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Superior capsular reconstruction – an up to date perspective

In the normal shoulder the rotator cuff articulates with the undersurface of the coracoacromial arch, the interposed thickness of the cuff stabilizing the humeral head against the upwards pull of the deltoid.

When the cuff deteriorates, the humeral head can translate superiorly because of the loss of this interpositional effect. This can result in an arthritic humeroacromial articulation.

In some cases of irreparable cuff tears, the humeral head remains centered in the glenoid as shown below (see this link).

In such cases, interposition of a fascia lata autograft (also known as a superior capsular reconstruction) can serve as a durable fascial arthroplasty between the humeral head and the acromion as shown in these 5 year followup images. In this recent report, 27 of 30 autografts healed (see this link).

However when the humeral head is superiorly decentered preoperatively as shown below

a superior capsular reconstruction is prone to failure as shown below

Support of the interpositional arthroplasty mechanism is provided by a paper presented at the recent ASES meeting (Functional and MRI outcomes of Superior Capsule Reconstruction with Acellular Dermal Matrix by Raffy Mirzayan et al.) Followup MRI revealed that 38% had a completely intact graft, 33% had a tear from the glenoid, 12% had a mid-substance tear, 14% tear from the tuberosity, and 2% had complete graft absence. There was no difference between pre-op and post-op acromiohumeral distance (7.3 mm vs 6.9mm, P=0.57). There was no difference in post-operative ASES score when the graft was completely intact or torn from the glenoid (P=0.39), but graft tear from the tuberosity resulted in a significantly lower ASES score (P=0.013). The authors interpreted these results as demonstrating that the graft functioned as an interposition between the proximal humerus and acromion.

In another ASES paper (Short Term Comparative Imaging and Clinical Analysis of Superior Capsular Reconstruction by Brian L. Badman et al), postoperative MRI’s showed graft failure at the glenoid or mid substance) in 40% of the cases. As in the prior report, as long as the graft remained intact to the tuberosity, the results were not different for those with and without graft failure – a result again supporting the interpositional arthroplasty mechanism.

In a third ASES paper (Evaluating the Role of Graft Integrity on Outcomes: Clinical and Imaging Results Following Superior Capsular Reconstruction by Mark W. LaBelle et al) the rate of graft failure was 59%, but functional outcomes were improved regardless of radiographic evidence of graft healing. Again, failures occurred on the glenoid side (see below left).

Comment: While there is much yet to be learned about the role that superior capsular reconstruction plays in the management of irreparable cuff tears, we interpret the evidence available so far as showing (1) fascial autografts appear to have a higher healing rate than acellular dermal matrix, (2) superior capsular reconstruction is more likely to be successful if the head is not superiorly displaced relative to the glenoid before surgery, (3) clinical improvement can be realized in cases of graft failure as long as the graft remains intact to the tuberosity, and (4) the most likely mechanism for the successes of superior capsular reconstruction is through the creation of a fascial arthroplasty between the proximal humerus and glenoid. While other mechanisms have been proposed (see this link), at this point the evidence supporting them does not seem compelling.

A video of our approach to shoulders with irreparable cuff tears can be seen by clicking this link.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit “Ream and Run – the state of the art” regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the “Search” box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis , total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the ‘ream and run essentials’

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