Superior Capsule Reconstruction for Reinforcement of Arthroscopic Rotator Cuff Repair Improves Cuff Integrity

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1 Superior Capsule Reconstruction for Reinforcement of Arthroscopic Rotator Cuff Repair Improves Cuff Integrity Teruhisa Mihata,* yz k MD, PhD, Thay Q. Lee, z PhD, Akihiko Hasegawa, y MD, PhD, Kunimoto Fukunishi, y MD, Takeshi Kawakami, y MD, PhD, Yukitaka Fujisawa, y MD, PhD, Mutsumi Ohue, k MD, Munekazu Doi, y MD, and Masashi Neo, y MD, PhD Investigation performed at the Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan Background: Retear of repaired rotator cuff tendons worsens patient outcome and decreases patient satisfaction. Superior capsule reconstruction (SCR) was developed to center the humeral head and thus restore the force couple for patients with rotator cuff tears. Purpose: To evaluate whether SCR for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-four consecutive patients (mean age, 69.1 years) with severely degenerated but reparable rotator cuff tears underwent SCR with fascia lata autografts for reinforcement before ARCR. All tears were medium (1-3 cm) or large (3-5 cm), and the number of torn tendons was 2 (supraspinatus and infraspinatus) in 29 shoulders and 3 (supraspinatus, infraspinatus, subscapularis) in 5 shoulders. To assess the benefit of SCR for reinforcement, all data were compared with those after ARCR alone among 91 consecutive patients with medium or large rotator cuff tears (mean age, 63.6 years). The American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, active shoulder range of motion, and cuff integrity (Sugaya magnetic resonance imaging classification) were compared (t test and chi-square test) between ARCR with and without SCR, as well as before surgery and at final follow-up. Results: All 34 patients who underwent SCR before ARCR had neither postoperative retear nor type III cuff integrity, whereas those treated with ARCR alone had a 4% incidence (4 of 91) of retear and 8% incidence of type III cuff integrity. ASES and JOA scores, active elevation, active external rotation, and active internal rotation increased in both treatment groups (P \.001). Postoperative ASES score and active range of motion did not differ between groups, although the Goutallier grade of the supraspinatus was higher for ARCR with SCR (mean, 2.8) than ARCR alone (mean, 2.1; P \.0001). Conclusion: SCR for reinforcement prevented retear at 1 year after ARCR and improved the quality of the repaired tendon on magnetic resonance imaging. Functional outcomes were similar between groups, even though degeneration of the torn tendons was greater among patients who underwent ARCR with SCR. Keywords: cuff integrity; reconstruction; reinforcement; rotator cuff; superior capsule; tear Symptomatic rotator cuff tear compromises shoulder function, even in daily life. When nonoperative treatment neither relieves shoulder pain nor recovers function, arthroscopic repair is a good option for reparable rotator cuff tears. In most cases, arthroscopic rotator cuff repair (ARCR) provides satisfactory clinical results. 8,14,33,38 However, postoperative retear of the repaired tendon significantly decreases postoperative strength, worsens patient outcome, and decreases patient satisfaction. 8,14,16,33,38 The American Journal of Sports Medicine 1 10 DOI: / Ó 2018 The Author(s) To improve clinical outcomes, factors that contribute to postoperative retear of repaired rotator cuff tendons have been investigated. { Reported risk factors for retear after rotator cuff repair include patient age, 3,5,19,21,34 sex, 3 bone mineral density, 3 initial tear size, 3,5,10,17,19,21,34,37 muscle atrophy 15,23 and fatty infiltration # of the supraspinatus or infraspinatus muscles, preoperative tendon length 24 and tendon thickness 19 of the torn rotator cuff, tendon retraction, 17-19,37 acromiohumeral distance, 3,18,37 duration of symptoms before surgery, 17 and repair method. 2,12,21,33,34 Surgeons can improve the repair technique to secure { References 1-3, 5, 10-12, 15, 17-19, 21, 23, 24, 33, 34, 37. # References 1, 3, 5, 11, 18, 21, 23, 24, 34, 37. 1

2 2 Mihata et al The American Journal of Sports Medicine fixation of the rotator cuff tendons; however, patient-related factors are difficult to control during and after treatment. Therefore, repaired rotator cuff tendons can retear even though repair techniques that improve biomechanical characteristics continue to be developed. Most risk factors for rotator cuff retear are related to tendon and muscle degeneration and are due to age, overuse before initial tear, and disuse after initial tear.** For the repair of severely degenerated rotator cuff tendons, high tension is needed to fix the torn tendons to the greater tuberosity, owing to the large defect of the torn tendons, the shortening of the tendon tissue, and severe retraction. 10,17,39 In addition, such degenerated tendons are weaker and thinner than native tendons, resulting in lower tensile strength. 7,35 Therefore, when tendinopathic tendons are repaired, the increased tension in the weakened tendon tissue leads to a high rate of retear in rotator cuffs. Superior capsule reconstruction (SCR) has been developed for the treatment of irreparable rotator cuff tears. 25,27-32 Biomechanical and clinical studies showed that SCR restores superior shoulder stability and improves shoulder function. 13,25,27-32 We recently modified the technique for SCR to provide reinforcement in tendinopathic but reparable rotator cuff tears. In this surgery, SCR for reinforcement may improve superior shoulder stability, thus decreasing the risk of subacromial abrasion after surgery, and it may increase tendon strength by increasing tendon thickness. Consequently, SCR for reinforcement may lower the retear rate of repaired rotator cuff tendons. In this study, we investigated whether SCR for reinforcement before ARCR improved cuff integrity, especially in cases of severely degenerated supraspinatus tendon tear. Our hypothesis was that SCR for reinforcement would prevent postoperative retear after ARCR. METHODS We retrospectively reviewed our database of rotator cuff tears, which was collected prospectively. All patients signed an informed consent form approved by the institutional review board of the Osaka Medical College (No. 2425). From 2013 through 2016, 452 consecutive shoulders with rotator cuff tears for which nonoperative treatment had failed underwent arthroscopic surgery by a single surgeon (T.M.). Since 2013, surgical indication for the treatment of rotator cuff tears has been determined with **References 1, 3, 5, 11, 15, 17-19, 21, 23, 24, 34, 37. preoperative magnetic resonance imaging (MRI) to assess the following: Muscle degeneration: mild fat area in the supraspinatus fossa is less than in muscle; severe fat area in the supraspinatus fossa is equal to or larger than that in muscle (Figure 1A) Tendon degeneration: mild slightly thinned or slight fatty degeneration in the tendon part; severe markedly thinned with fatty degeneration in the tendon part or no tendon (Figure 1B) Tendon retraction: mild the torn tendon edge is on the greater tuberosity or the lateral half of the humeral head; severe the torn tendon edge lies in the medial half of the humeral head or on the glenoid (Figure 1C) Patients with severe degeneration or retraction in only 1 category or in none received ARCR only (259 shoulders); the remaining 193 patients were classified with severe degeneration or retraction in 2 or 3 of the supraspinatus assessment categories and therefore underwent arthroscopic SCR. Reducibility of the torn rotator cuff tendons was assessed during diagnostic arthroscopy. For patients with severe degeneration or retraction of the supraspinatus in at most 1 category according to preoperative MRI, all torn tendons were reducible and underwent ARCR only (259 shoulders). For patients with severe degeneration or retraction of the supraspinatus in 2 or 3 categories based on preoperative MRI and who were judged as having irreducible tears during diagnostic arthroscopy, SCR only was performed (156 shoulders). When the torn tendon reached the original footprint for patients with severe degeneration or retraction in 2 or 3 categories according to preoperative MRI, arthroscopic SCR was performed for reinforcement, after which the torn tendon was repaired over a fascia lata graft (ARCR with SCR: 37 shoulders). To assess the benefit of SCR for reinforcement, the results of ARCR with SCR were investigated in this study. For personal reasons, 3 patients who underwent ARCR with SCR and had full range of motion (ROM) at 6 months after surgery elected to discontinue follow-up before 1 year after surgery. The remaining 34 shoulders were included in the study (Figure 2). Among these patients, the mean age was 69.1 years (range, years), the mean tear size was 2.2 cm (range, cm), and the number of torn tendons was 2 (supraspinatus and infraspinatus) in 29 shoulders and 3 (supraspinatus, infraspinatus, subscapularis) in 5 shoulders. The mean time to final follow-up was 36 months (range, months). For the control data, the results after ARCR alone for 91 consecutive patients (mean age, 63.6 years; range, *Address correspondence to Teruhisa Mihata, MD, PhD, Department of Orthopedic Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka , Japan ( tmihata@yahoo.co.jp, tmihata@osaka-med.ac.jp). y Department of Orthopedic Surgery, Osaka Medical College, Takatsuki, Japan. z Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, California, USA. Department of Orthopaedic Surgery, University of California, Irvine, California, USA. k Katsuragi Hospital, Kishiwada, Japan. Presented at the interim meeting of the AOSSM, New Orleans, Louisiana, March The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

3 AJSM Vol. XX, No. X, XXXX ARCR With Superior Capsule Reconstruction 3 years) with medium (1-3 cm) or large (3-5 cm) rotator cuff tears were used, because all ARCRs for the control population were performed from 2006 through 2009, before we had started SCR for reinforcement of ARCR. At that time, our surgical indication for rotator cuff tear was determined according to arthroscopic findings. For reducible tears, in which the torn tendon reached the original footprint, ARCR was performed regardless of the quality of the torn rotator cuff tendon and muscle. When the torn tendon failed to reach the original footprint (irreducible tear), we chose arthroscopic SCR without rotator cuff repair or arthroscopic partial repair. The mean tear size among the controls was 2.5 cm (range, cm), and the number of torn tendons was 1 (supraspinatus) in 32 shoulders, 2 (supraspinatus, infraspinatus) in 50 shoulders, 2 (supraspinatus, subscapularis) in 8 shoulders, and 3 (supraspinatus, infraspinatus, subscapularis) in 1 shoulder. All rotator cuff tears in the control group were repaired with a compression double-row technique, which is a combination of the conventional double-row technique and a suture bridge. 26,27,33 The average time to final follow-up was 37 months (range, months). Patient Assessment Shoulder elevation, external rotation at side, and internal rotation were measured actively before surgery; at 3, 6, and 12 months after surgery; and at the final follow-up. Internal rotation was measured as the highest vertebral body that the patient was able to reach with the thumb of the affected arm. All patients were assessed preoperatively with 2 scoring systems the shoulder indexes of the American Shoulder and Elbow Surgeons (ASES; a 100-point scoring system) and the Japanese Orthopaedic Association (JOA; a 100-point scoring system) and were reassessed at final follow-up; postoperative complications were recorded also. MRI was performed with a 1.5-T closed-type scanner (MRT-2000/V2; Toshiba) before surgery and at the final follow-up after surgery. Oblique coronal, oblique sagittal, and axial T2-weighted MRI scans were acquired for structural and qualitative assessment of the rotator cuff and repair integrity after surgery. Preoperative rotator cuff muscle quality was evaluated via Goutallier grading. 11 Repair integrity was classified into 5 categories according to Sugaya classification. 38 Type I indicated a repaired cuff that had sufficient thickness, with homogeneously low intensity in each image; type II cuffs had sufficient thickness associated with a partial high-intensity area; type III had insufficient thickness without discontinuity; type IV demonstrated a minor discontinuity in multiple slices of each image; and type V revealed a major discontinuity in each image. Types IV and V in the Sugaya classification scheme indicated postoperative retear. To eliminate observer bias, 3 experienced shoulder surgeons (T.M., A.H., T.K.) evaluated cuff repair integrity in all postoperative MRI scans. The Sugaya type, which was assigned through consensus of 2 or 3 of the evaluating surgeons, was determined according to the current integrity of the cuff repair on each MRI scan. There was no case in which all 3 shoulder surgeons selected different Sugaya types. Figure 1. Severity of degeneration in the torn supraspinatus tendon was evaluated with preoperative magnetic resonance imaging. (A) Muscle degeneration: mild fat area in the supraspinatus fossa is less than in muscle; severe fat area in the supraspinatus fossa is equal to or larger than that in muscle. (B) Tendon degeneration: mild slightly thinned or slight fatty degeneration in the tendon part; severe severely thinned with fatty degeneration in the tendon part or no tendon. (C) Tendon retraction: mild the torn tendon edge is located on the greater tuberosity or on the lateral half of the humeral head; severe the torn tendon edge is located on the medial half of the humeral head or on the glenoid.

4 4 Mihata et al The American Journal of Sports Medicine Rotator cuff tears: 452 shoulders Evaluate severity of supraspinatus degenera on using preopera ve MRI Severe degenera on in none or one category ARCR: 259 shoulders Arthroscopic finding All reducible tear Reducible tear Severe degenera on in two or three categories SCR: 193 shoulders Arthroscopic finding Irreducible tear ARCR alone: 259 shoulders SCR + ARCR: 37 shoulders SCR + ARCR: 34 shoulders Loss of followup:3 shoulders SCR alone: 156 shoulders Figure 2. Surgical indication. ARCR, arthroscopic rotator cuff repair; MRI, magnetic resonance imaging; SCR, superior capsule reconstruction. Surgical Technique of SCR for Reinforcement of ARCR Preparation. For all procedures, patients were under general anesthesia and in the lateral decubitus position. Three portals were typically required for arthroscopic SCR. A posterior portal was established for initial assessment of the glenohumeral joint. An anterior portal through the rotator interval was established as the working portal for the treatment of intra-articular lesions, such as labral tear and biceps tear, or subluxation. The arthroscope was then removed from the glenohumeral joint and redirected into the subacromial space. A lateral portal was also established. Any pathological bursal tissue that impeded clearance of the space was removed. Arthroscopic subacromial decompression was performed to create a flat acromial undersurface. Bony spurs in the inferior part of the acromioclavicular joint and at the distal end of the clavicle were removed. The superior glenoid and rotator cuff footprint on the greater tuberosity were debrided to expose cortical bone. If the subscapularis tendon tear was reparable, it was completely repaired with fully threaded titanium suture anchors (diameter, 4.5 mm; Corkscrew FT Suture Anchor, Arthrex). Choosing the Graft Size and Harvesting the Fascia Lata. Appropriate graft size was the most important factor in this surgical technique. The size of the so-called superior capsular defect is evaluated with a measuring probe in the anteroposterior direction (from the anterior edge to the posterior edge of the torn tendon) and the mediolateral direction (from the superior edge of the glenoid to the lateral edge of the greater tuberosity) at 30 of shoulder abduction. The optimal graft length in the anteroposterior direction was exactly the same as the length of the defect without partial repair of the torn infraspinatus tendon. To give a 15-mm footprint on the superior glenoid, the graft length in the mediolateral direction was 15 mm longer than the distance from the superior edge of the glenoid to the lateral edge of the greater tuberosity. A longitudinal skin incision was made over the lateral thigh, beginning at the greater trochanter of the femur. In SCR for reinforcement of ARCR, a single layer of autologous fascia lata was used (graft thickness, 1-3 mm). All fatty tissue should be removed from the graft. Graft Attachment. All soft tissues on the superior glenoid and greater tuberosity were removed to expose cortical bone. One or 2 fully threaded titanium suture anchors (diameter, 4.5 mm; Corkscrew FT Suture Anchor), each with 2 No. 2 polyester sutures with a long-chain polyethylene core (FiberWire; Arthrex), were inserted into the superior glenoid. All No. 2 polyester sutures from the superior glenoid were placed through the fascia lata in a mattress fashion outside the body. Then the graft was inserted through the lateral portal into the subacromial space (Figure 3A); for this manipulation, we used a 5-mL syringe as a cannula. When the medial edge of the graft reached the superior glenoid, all No. 2 polyester sutures were tied (Figure 3B). To attach the lateral side of the fascia lata to the rotator cuff footprint on the greater tuberosity, 1 or 2 fully threaded 5.6-mm titanium suture anchors were inserted at the medial edge of the footprint. All No. 2 polyester sutures from the medial row on the greater tuberosity were placed through the fascia lata graft in mattress fashion and tied with a nonsliding knot (RC knot 33 ) (Figure 3B). The sutures were not cut after the knots were tied so that the suture limbs could be used to repair the torn tendons over the graft (Figure 3B).

5 AJSM Vol. XX, No. X, XXXX ARCR With Superior Capsule Reconstruction 5 Figure 3. Arthroscopic rotator cuff repair with superior capsule reconstruction. (A) All No. 2 polyester sutures from the superior glenoid were placed through the fascia lata in mattress fashion outside the body. Then the graft was inserted through the lateral portal and into the subacromial space. (B) When the medial edge of the graft reached the superior glenoid, all No. 2 polyester sutures were tied. All No. 2 polyester sutures from the medial row on the greater tuberosity were placed through the fascia lata graft in mattress fashion and tied with nonsliding knots. Sutures were left cut after the knots were made so that the suture limbs could be used to repair the torn tendon over the graft. (C) The torn tendons were repaired on the fascia lata graft with the compression double-row technique or the transosseous equivalent rotator cuff repair. Torn tendons were repaired on the fascia lata graft with a compression double-row technique, which is a combination of the conventional double-row technique and a suture bridge, 27,33 or the transosseous equivalent rotator cuff repair (Figure 3C). The No. 2 polyester sutures of the medial anchors, which were used for graft fixation to the greater tuberosity, were placed approximately 10 to 15 mm medial to the lateral edge of the torn rotator cuff tendon in mattress fashion with a suture shuttle or suture-passing device and tied with a nonsliding knot (RC knot 33 ). For the compression double-row repair, 2 fully threaded 4.5-mm titanium suture anchors with 2 No. 2 polyester sutures were placed at 5 to 10 mm inferior to the highest tip of the greater tuberosity. The No. 2 polyester sutures of the lateral anchors were placed approximately 10 mm medial to the lateral edge of the rotator cuff tear with a suture shuttle or suture-passing device and tied with simple stitches before knot tying in the medial row. Then, the conventional double-row repair was completed with knot tying of the medial row. The No. 2 polyester sutures in the medial row were not cut so that the suture limbs could be used to create suture bridges. One limb from the medial row anchor was fixed at the lateral row anchor by tying the medial limb with a No. 2 polyester suture from the lateral anchor. Next, the other suture limb from the medial row anchor was tied with a nonsliding knot to the first medial suture limb, which had been fixed at the lateral row anchor, thereby completing suture bridges with 2 medial suture limbs. Suture bridges were generated from the remaining medial and lateral suture limbs in the same way used to create the first suture bridges. For the transosseous equivalent rotator cuff repair, the limbs from medial row anchors were fixed with 2 Swive- Locks (Arthrex), which were inserted at 5 to 10 mm inferior to the highest point of the greater tuberosity. Postoperative Protocol. The postoperative protocols for both ARCR only and SCR for reinforcement of ARCR were the same. An abduction sling (Block Shoulder Abduction Sling; Nagano Prosthetics and Orthotics) was used for 4 weeks after surgery. After the immobilization period, passive and active assisted exercises were initiated to promote scaption. At 8 weeks after surgery, patients began to perform exercises to strengthen the rotator cuff and scapular stabilizers. Full activity was allowed at 6 months postoperatively, when patients had sufficient ROM and muscle strength. Physical therapists assisted all patients. Statistical Analysis Using t tests and chi-square tests, we compared the ASES score, active shoulder ROM, and cuff tear integrity (Sugaya MRI classification) between ARCR with and without SCR as well as before surgery and at final follow-up. A significant difference was defined as P \.05. RESULTS Cuff Integrity At 3 months after ARCR with SCR, MRI showed type I cuff integrity in 27 of the 34 shoulders (79%) (Figure 4, Table 1) and type II cuff integrity in the remaining 7 shoulders (21%). Three of the 7 shoulders that were type II at 3 months after ARCR with SCR became type I at 6 months, and 3 type II shoulders at 3 months changed to type I at 1 year and 1 remained type II at 1 year. Overall, at 1 year after ARCR with SCR, 33 of the 34 shoulders (97%) demonstrated type I cuff integrity, which represents a torn tendon that has healed with good thickness and quality. Neither type III cuff integrity, which represents thin tendon part or partial-thickness retear, nor type IV/V, indicative of retear, occurred after ARCR with SCR.

6 6 Mihata et al The American Journal of Sports Medicine TABLE 1 Change in Cuff Integrity Until 1 Year After Surgery by Sugaya Classification a ARCR 1 SCR ARCR Type 3 mo 6 mo 1 y 3 mo 6 mo 1 y I 27 (79) 30 (88) 33 (97) 42 (46) 60 (66) 68 (75) II 7 (21) 4 (12) 1 (3) 38 (42) 20 (22) 12 (13) III (7) 6 (7) 7 (8) IV (2) 1 (1) 0 V (3) 4 (4) 4 (4) a Values are presented as n (%). ARCR, arthroscopic rotator cuff repair; SCR, superior capsule reconstruction. TABLE 2 Comparison of Shoulder Range of Motion and Functional Outcome Between ARCR With and Without SCR a ARCR 1 SCR ARCR P Value b Figure 4. Magnetic resonance imaging. (A) Coronal image and (B) sagittal image before surgery. (C) Coronal image and (D) sagittal image at 3 months after arthroscopic rotator cuff repair with superior capsule reconstruction. For ARCR alone, 4 of the 91 shoulders (4%) revealed retear (type V) at 1 year after surgery. Three type V shoulders had large tears (Goutallier grade 3 or 4), and the remaining type V shoulder had very thin and degenerated tissue in the torn tendon before surgery. One shoulder with type IV cuff integrity at 6 months after surgery became type III at 1 year; in contrast, the other type IV at 3 months became type V at 6 months. In addition, 7 of the 91 shoulders (8%) had type III cuff integrity, and 12 shoulders (13%) were classified as type II at 1 year after ARCR. The remaining 68 shoulders (75%) had type I cuff integrity after ARCR at 1 year after surgery. Functional Outcome ASES and JOA scores increased significantly after ARCR with SCR (ASES, 46 preoperatively to 92 postoperatively; ASES score Preoperative Postoperative P value c \.0001 \.0001 JOA score Preoperative Postoperative P value c \.0001 \.0001 Active elevation, deg Preoperative Postoperative P value c \.0001 \.0001 Active external rotation, deg Preoperative Postoperative P value c Active internal rotation Preoperative L4 L2.01 Postoperative L1 T11 \.0001 P value c \.0001 \.0001 a Values are expressed as mean 6 SD ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons; JOA, Japanese Orthopaedic Association; SCR, superior capsule reconstruction. b ARCR 1 SCR vs ARCR. c Pre- vs postoperative. JOA, 60 to 94) and without SCR (ASES, 41 to 91; JOA, 58 to 96; P \.0001) (Table 2). ASES and JOA scores did not differ significantly between ARCR with and without SCR before or after surgery. Postoperative ASES and JOA scores in the groups with a healed repair (ARCR with SCR: ASES, 92; JOA, 94; ARCR alone: ASES, 92; JOA, 97) were significantly better than in patients with a retear after ARCR (ASES, 60; JOA, 80; P \.0001). The shoulders with retear after ARCR had significantly lower postoperative ASES and JOA scores than the healed cases after ARCR (P \.0001 for both scores) and ARCR with SCR (ASES, P \.0001; JOA, P =.0002).

7 AJSM Vol. XX, No. X, XXXX ARCR With Superior Capsule Reconstruction 7 Shoulder ROM Shoulder ROM improved significantly after ARCR with and without SCR. Specifically, shoulder ROM after ARCR with SCR improved by 34 for active elevation (P \.0001), by 10 for active external rotation (P =.0002), and by 3 vertebral bodies of active internal rotation (P \.0001) (Tables 2 and 3). Improvements after ARCR alone were 36 in active elevation (P \.0001), 8 for active external rotation (P =.006), and 3 vertebral bodies of active internal rotation (P \.0001). Postoperative active ROM did not differ significantly between ARCR with and without SCR. Postoperative active elevation in the shoulders with a healed repair (ARCR with SCR, 163 ; ARCR alone, 171 ) was significantly better than that in the shoulder with a retear after ARCR (120 ; P =.003 and P \.0001, respectively). Fatty Infiltration, Tear Size, and Acromiohumeral Distance The Goutallier grade of the supraspinatus tendon was significantly higher for ARCR with SCR (mean, 2.8) than for ARCR alone (mean, 2.1) (P \.0001). There was no significant difference in the number of torn tendons (P =.45), tear size (P =.10), or preoperative (P =.06) and postoperative (P =.23) acromiohumeral distance (Table 4). In addition, the Goutallier grades of the infraspinatus (P =.16), teres minor (P =.07), and subscapularis (P =.24) did not differ between ARCR with SCR and ARCR alone. Acromiohumeral distance significantly increased after surgery in both groups (P \.0001) (Figure 5). Concomitant Injury and Surgery The numbers of subscapularis repair (P =.45) and biceps pathology and treatment (P =.26) did not differ significantly between ARCR with SCR and ARCR alone. Acromioplasty was performed for all patients (Table 5). Complications There were no surgical complications, including nerve injury, infection, or suture anchor problems, after ARCR with SCR or ARCR alone. At the final follow-up, no patient who underwent ARCR with SCR had any adverse symptoms at the harvest site. DISCUSSION To improve clinical outcomes after ARCR, postoperative retear of the repaired rotator cuff tendons needs to be prevented. 8,14,16,33,38 Severe degeneration and retraction of the torn rotator cuff tendon correlated with the retear rate after rotator cuff repair. yy For example, Gladstone yy References 1, 3, 5, 11, 15, 17-19, 21, 23, 24, 34, 37. et al 10 reported that preoperative muscle atrophy and fatty infiltration of the supraspinatus were significantly correlated with postoperative cuff integrity, and Kim and Kim 17 showed that the severity of torn tendon retraction is correlated with the retear rate after ARCR. For severely degenerated and retracted rotator cuff tears, we developed a technique for SCR for reinforcement of the repaired tendon. In the current study, 97% of shoulders treated with SCR before ARCR achieved type I cuff integrity, indicating that the torn tendon healed with good thickness and quality. In addition, these patients showed no partial or complete retear of the repaired tendon, even though all shoulders had severe degeneration or retraction or both before repair. These rates were significantly better than those after ARCR alone. Therefore, we believe that SCR with ARCR is an excellent option for rotator cuff repair to improve tendon quality and prevent postoperative retear. For severely degenerated rotator cuff tears, patch augmentation is one potential surgical option to prevent postoperative rotator cuff retear. However, several studies investigating cuff integrity after rotator cuff repair with patch augmentation found that the retear rate is relatively high (10%-62%), 6,9,20,22,36,40 and some reports showed no improvement of postoperative cuff integrity after patch augmentation as compared with rotator cuff repair alone. 6,36 Flury et al 6 concluded that repairing supraspinatus tears with patch augmentation does not benefit patients in terms of reducing the risk of a recurrent tendon defect or improving shoulder function within 24 months after surgical repair. The reason why the clinical outcome after patch augmentation for ARCR was inconsistent may be the location of the graft attachment. In all previous studies, 6,9,20,22,36,40 the patch graft was attached on the rotator cuff tendons, which is severely degenerated and has a poor healing response, whereas we attached the patch graft under the repaired rotator cuff tendons to reconstruct the superior capsule. Previous biomechanical studies showed that SCR improved the stability of the shoulder superior to preinjury levels. 32 In addition, the current study showed no retear among patients who underwent ARCR with SCR for reinforcement, meaning that we have not seen a retear since Therefore, we recommended attaching the patch graft through SCR to prevent retear after rotator cuff repair, especially for severely degenerated, reducible tears. We developed the SCR technique to improve shoulder function and pain relief after irreparable rotator cuff tears. 25,27-32 For cases in which the tear is irreparable, we recommend using a thick graft (6-8 mm) to prevent graft tear after surgery. 29 However, in SCR for reinforcement of rotator cuff repair, the graft is a single layer of fascia lata that is just 2 to 3 mm thick because the torn tendon is repaired on the graft. For thick grafts, autografted fascia lata is a good material because it accommodates the harvest of large grafts and because multiple pieces of fascia lata can be united between layers to generate a graft of necessary thickness. In contrast, for SCR reinforcement of rotator cuff repair, other materials, such as human or porcine dermal grafts, may be good candidates because a thickness of 2 to 3 mm is sufficient.

8 8 Mihata et al The American Journal of Sports Medicine TABLE 3 Comparison of Shoulder Range of Motion and Functional Outcome Between Healed and Retear Cases a Healed Cases ARCR 1 SCR ARCR Retear Cases: ARCR b P Value c P Value d ASES score Preoperative Postoperative \.0001 \.0001 P value e \.0001 \ JOA score Preoperative Postoperative \.0001 P value e \.0001 \ Active elevation, deg Preoperative Postoperative \.0001 P value e \.0001 \ Active external rotation, deg Preoperative Postoperative P value e Active internal rotation Preoperative L4 L2 L Postoperative L1 T11 T P value e \.0001 \ a Values are expressed as mean 6 SD. ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Surgeons; JOA, Japanese Orthopaedic Association; SCR, superior capsule reconstruction. b There were no cases of retear among patients undergoing ARCR 1 SCR. c Healed ARCR 1 SCR vs retear ARCR. d Healed ARCR vs retear ARCR. e Pre- vs postoperative. TABLE 4 Severity of Rotator Cuff Tear a ARCR 1 SCR ARCR P Value b Tear size in anterior-posterior direction, cm 2.2 (2-4) 2.5 (1.5-5).10 Torn tendons: shoulders.45 2: supraspinatus and infraspinatus : supraspinatus, infraspinatus, and subscapularis 5 9 Acromiohumeral distance, mm Before surgery 6.4 ( ) 7.4 ( ).06 At 1 y after surgery 9.6 ( ) 10.1 ( ).23 Goutallier classification Supraspinatus 2.8 (2-4) 2.1 (1-4) \.0001 Infraspinatus 0.6 (0-3) 0.4 (0-2).16 Teres minor 0.1 (0-1) 0.1 (0-2).07 Subscapularis 0.4 (0-4) 0.3 (0-3).24 a Values are expressed as mean (range) or n. b ARCR 1 SCR vs ARCR. Retear of the repaired tendon led to poorer ASES and JOA scores and decreased active elevation as compared with healed ARCR in the control group of 91 shoulders. This result is compatible with previous studies 8,14,16,33,38 and highlights the necessity of carefully considering how to prevent retear after ARCR. In the current study, the addition of SCR completely prevented retear after ARCR, and postoperative functional outcome, including ASES and JOA scores and active elevation, among patients treated with ARCR with SCR reinforcement was significantly better than among those with retear after ARCR. Therefore, we recommend the addition of SCR to ARCR, especially for severely degenerated rotator cuff tears. In SCR, the graft is attached medially to the superior glenoid and laterally to the greater tuberosity to improve superior stability in the glenohumeral joint. However,

9 AJSM Vol. XX, No. X, XXXX ARCR With Superior Capsule Reconstruction 9 TABLE 5 Concomitant Injury and Surgery a ARCR 1 SCR (n = 34) ARCR (n = 91) P Value b Subscapularis.45 Intact or partial tear (no treatment) 29 (85) 82 (90) Repair for complete tear 5 (15) 9 (10) Biceps.26 Intact (no treatment) 17 (50) 58 (64) Partial tear (no treatment) 12 (35) 24 (26) Complete tear (no treatment) 2 (6) 7 (8) Tenodesis for dislocated biceps 2 (6) 2 (2) Tenotomy for dislocated biceps 1 (3) 0 Acromioplasty 34 (100) 91 (100) a Values are presented as n (%). ARCR, arthroscopic rotator cuff repair; SCR, superior capsule reconstruction. b ARCR 1 SCR vs ARCR. Figure 5. Plain radiographs. (A) Before surgery. (B) At 1 year after arthroscopic rotator cuff repair with superior capsule reconstruction. this surgical technique may decrease shoulder ROM when the graft tension is too tight. A previous biomechanical study showed that SCR decreased total rotational ROM (the sum of external rotation and internal rotation) by 5 to 20 as compared with the intact condition. 32 In comparison, the current study showed significantly decreased ROM only in internal rotation after ARCR with SCR versus ARCR alone. However, the actual decrease in internal rotation was only 2 vertebral bodies, and all patients had no restriction in any activity. Furthermore, neither active elevation nor external rotation differed significantly between ARCR with and without SCR. Therefore, SCR for reinforcement does not cause shoulder stiffness after ARCR, although it may cause slightly decreased internal rotation, which has no influence on any activity. The current study had several limitations. First, despite the widespread use of the Sugaya classification in previous studies, this system relies on subjective evaluation of postoperative cuff integrity. Therefore, we assigned the Sugaya classification through consensus among 3 experienced shoulder surgeons, and we believe that the Sugaya classification results in this study are reliable. Second, the data for the 2 groups in this study were collected from different periods to eliminate patient selection bias, but doing so might have influenced the clinical results. However, all surgical procedures were performed by the same experienced shoulder surgeon, who had already performed many shoulder procedures before the first one included in this study. In addition, the postoperative protocol did not change throughout the study, and postoperative physical therapy was performed by the same physical therapy team. Therefore, we believe that the different periods of data collection had no noteworthy effect on the results. Third, our evaluation system for severity of degeneration in the torn supraspinatus tendon has not been validated yet. However, this evaluation has been made by combining and simplifying previously validated classifications. Therefore, we believe that the current evaluation should be reasonable to determine surgical indication. Fourth, the final follow-up of MRI was only 1 year after SCR however, in previous reports, most retear after ARCR or graft tear after SCR occurred at 3 to 6 months after surgery. 2,4,28,33 Therefore, we believe that the follow-up period in the current study is reasonable. CONCLUSION SCR for reinforcement prevented postoperative retear after ARCR and improved the quality of the repaired tendon according to MRI. Furthermore, postoperative functional outcomes were similar between patients treated with ARCR alone and those who also underwent SCR, even though the degeneration of the torn tendons was greater in the latter group. REFERENCES 1. Barry JJ, Lansdown DA, Cheung S, Feeley BT, Ma CB. The relationship between tear severity, fatty infiltration, and muscle atrophy in the supraspinatus. J Shoulder Elbow Surg. 2013;22: Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique. Am J Sports Med. 2010;38: Chung SW, Oh JH, Gong HS, Kim JY, Kim SH. Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med. 2011;39:

10 10 Mihata et al The American Journal of Sports Medicine 4. Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft. Arthroscopy. 2018;34: Deniz G, Kose O, Tugay A, Guler F, Turan A. Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate? Arch Orthop Trauma Surg. 2014;134: Flury M, Rickenbacher D, Jung C, Schneider MM, Endell D, Audige L. Porcine dermis patch augmentation of supraspinatus tendon repairs: a pilot study assessing tendon integrity and shoulder function 2 years after arthroscopic repair in patients aged 60 years or older. Arthroscopy. 2018;34: Frisch KE, Marcu D, Baer GS, Thelen DG, Vanderby R. The influence of partial and full thickness tears on infraspinatus tendon strain patterns. J Biomech Eng. 2014;136: Gazielly DF, Gleyze P, Montagnon C. Functional and anatomical results after rotator cuff repair. Clin Orthop Relat Res. 1994;304: Gilot GJ, Alvarez-Pinzon AM, Barcksdale L, Westerdahl D, Krill M, Peck E. Outcome of large to massive rotator cuff tears repaired with and without extracellular matrix augmentation: a prospective comparative study. Arthroscopy. 2015;31: Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med. 2007;35: Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures: pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304: Hantes ME, Ono Y, Raoulis VA, et al. Arthroscopic single-row versus double-row suture bridge technique for rotator cuff tears in patients younger than 55 years: a prospective comparative study. Am J Sports Med. 2018;46: Hirahara AM, Adams CR. Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears. Arthrosc Tech. 2015;4:e637-e Huijsmans PE, Pritchard MP, Berghs BM, van Rooyen KS, Wallace AL, de Beer JF. Arthroscopic rotator cuff repair with double-row fixation. J Bone Joint Surg Am. 2007;89: Jo CH, Shin JS. Cross-sectional area of the supraspinatus muscle after rotator cuff repair: an anatomic measure of outcome. J Bone Joint Surg Am. 2013;95: Kim HM, Caldwell JM, Buza JA, et al. Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear. J Bone Joint Surg Am. 2014;96: Kim IB, Kim MW. Risk factors for retear after arthroscopic repair of full-thickness rotator cuff tears using the suture bridge technique: classification system. Arthroscopy. 2016;32: Kim JR, Cho YS, Ryu KJ, Kim JH. Clinical and radiographic outcomes after arthroscopic repair of massive rotator cuff tears using a suture bridge technique: assessment of repair integrity on magnetic resonance imaging. Am J Sports Med. 2012;40: Le BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff retears: an analysis of 1000 consecutive rotator cuff repairs. Am J Sports Med. 2014;42: Lederman ES, Toth AP, Nicholson GP, et al. A prospective, multicenter study to evaluate clinical and radiographic outcomes in primary rotator cuff repair reinforced with a xenograft dermal matrix. J Shoulder Elbow Surg. 2016;25: Lee YS, Jeong JY, Park CD, Kang SG, Yoo JC. Evaluation of the risk factors for a rotator cuff retear after repair surgery. Am J Sports Med. 2017;45: Lenart BA, Martens KA, Kearns KA, Gillespie RJ, Zoga AC, Williams GR. Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study. J Shoulder Elbow Surg. 2015;24: Liem D, Lichtenberg S, Magosch P, Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair. J Bone Joint Surg Am. 2007;89: Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med. 2012;40: Mihata T, Bui CNH, Akeda M, et al. A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear. J Shoulder Elbow Surg. 2017;26: Mihata T, Fukuhara T, Jun BJ, Watanabe C, Kinoshita M. Effect of shoulder abduction angle on biomechanical properties of the repaired rotator cuff tendons with 3 types of double-row technique. Am J Sports Med. 2011;39: Mihata T, Lee TQ, Fukunishi K, et al. Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears. Am J Sports Med. 2018;46: Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;29: Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears. Arthroscopy. 2016;32: Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears. Am J Sports Med. 2016;44: Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon. Am J Sports Med. 2016;44: Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40: Mihata T, Watanabe C, Fukunishi K, et al. Functional and structural outcomes of single-row versus double-row versus combined double-row and suture-bridge repair for rotator cuff tears. Am J Sports Med. 2011;39: Park JS, Park HJ, Kim SH, Oh JH. Prognostic factors affecting rotator cuff healing after arthroscopic repair in small to medium-sized tears. Am J Sports Med. 2015;43: Sano H, Wakabayashi I, Itoi E. Stress distribution in the supraspinatus tendon with partial-thickness tears: an analysis using twodimensional finite element model. J Shoulder Elbow Surg. 2006; 15: Sears BW, Choo A, Yu A, Greis A, Lazarus M. Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation. Orthopedics. 2015;38:e292-e Shin YK, Ryu KN, Park JS, Jin W, Park SY, Yoon YC. Predictive factors of retear in patients with repaired rotator cuff tear on shoulder MRI. AJR Am J Roentgenol. 2018;210: Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89: Thompson WO, Debski RE, Boardman ND 3rd, et al. A biomechanical analysis of rotator cuff deficiency in a cadaveric model. Am J Sports Med. 1996;24: Yoon JP, Chung SW, Kim JY, et al. Outcomes of combined bone marrow stimulation and patch augmentation for massive rotator cuff tears. Am J Sports Med. 2016;44: For reprints and permission queries, please visit SAGE s Web site at

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