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Shoulder surgeon techniques and preferences in treatment of massive rotator cuff tears: current practices for rotator cuff repair and superior capsule reconstruction

Open AccessPublished:August 10, 2022DOI:https://doi.org/10.1016/j.jseint.2022.07.007

      Background

      Massive rotator cuff tears can be difficult to manage and consensus regarding treatment is debated. The purpose of this questionnaire study was to examine surgeon techniques and considerations for treatment of massive rotator cuff tears including how they implement superior capsule reconstruction (SCR), when indicated.

      Methods

      A 21-item questionnaire was sent to members of the American Shoulder and Elbow Surgeons and the American Orthopedic Society for Sports Medicine. Questions covered management preferences for massive rotator cuff tears, rotator cuff repair and SCR techniques, beliefs about SCR, implant choices, use of augments, demographics, and patient management scenarios.

      Results

      The questionnaire had 230 respondents. In rotator cuff repair of massive rotator cuff tears, preferred responses were long head biceps tendon preservation (when asymptomatic, 45.3%), routine subacromial decompression (62.1%), solid threaded anchors (71.1%), double row configuration (65.1%), and bone marrow stimulation of the footprint (55.6%). For providers that perform SCR (n = 166), preferred strategies included long head biceps tenodesis (55.4%), human dermal allograft tissue (93.2%), glenoid fixation with 3 implants (71.2%) using solid threaded anchors (42.3%), and humeral fixation with 2 solid threaded anchors medially (71.0%), and 2 solid threaded anchors laterally (46.9%). Other highly recommended strategies were side-to-side repair to the posterior rotator cuff if able (97.6%) and to use the thickest graft available (62.2%).

      Conclusion

      Despite improved techniques and growing interest in SCR, many questions still remain. This study identifies the significant variability in repair constructs and methodology with SCR; further investigation into these variables could be analyzed to identify best practice guidelines.

      Level of evidence

      Keywords

      Pathology involving the rotator cuff is an incredibly common reason for referral to a shoulder surgeon.
      • Ishihara Y.
      • Mihata T.
      • Tamboli M.
      • Nguyen L.
      • Park K.J.
      • McGarry M.H.
      • et al.
      Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
      ,
      • Jeong J.
      • Shin D.C.
      • Kim T.H.
      • Kim K.
      Prevalence of asymptomatic rotator cuff tear and their related factors in the Korean population.
      ,
      • Mirzayan R.
      • Otarodifard K.A.
      • Singh A.
      Arthroscopic superior capsule reconstruction with a doubled-over (6 mm) dermal allograft.
      ,
      • Saridakis P.
      • Jones G.
      Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review.
      ,
      • Yamamoto A.
      • Takagishi K.
      • Osawa T.
      • Yanagawa T.
      • Nakajima D.
      • Shitara H.
      • et al.
      Prevalence and risk factors of a rotator cuff tear in the general population.
      Treatment paradigms can vary from provider to provider depending on several factors including surgeon training or level of experience; patient factors such as age, activity level, or medical comorbidities; or characteristics of the cuff including tear size, tendon retraction, muscle quality, or chronicity. Massive rotator cuff tears can be difficult to manage and consensus regarding treatment is debated. Many strategies exist including nonoperative management, partial or total rotator cuff repair (RCR), interval slide, tendon transfers, superior capsule reconstruction (SCR), and reverse total shoulder arthroplasty.
      • Greenspoon J.A.
      • Petri M.
      • Warth R.J.
      • Millett P.J.
      Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes.
      ,
      • Yoon J.P.
      Patch augmentation for massive rotator cuff tears.
      Additionally, for joint preserving techniques such as RCR surgeon preferences can vary widely, such as when and how to repair each tendon, how to manage the long head biceps (LHB) tendon, implant and fixation strategies, and augment or graft usage. For patients with irreparable tears, especially those who are younger and more physically active, the decision-making process can be challenging. The presence of a significant functional deficit or pseudoparalysis further complicates the clinical scenario.
      SCR has been described as an effective treatment modality in patients with massive or irreparable rotator cuff tears.
      • Frank R.M.
      • Cvetanovich G.
      • Savin D.
      • Romeo A.A.
      Superior capsular reconstruction: indications, techniques, and clinical outcomes.
      ,
      • Tokish J.M.
      • Makovicka J.L.
      The superior capsular reconstruction: lessons learned and future directions.
      Mihata initially described SCR as a means to restore superior stability, thus decreasing the superior migration of the humeral head.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • Fukunishi K.
      • Ohue M.
      • Tsujimura T.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      ,
      • Mihata T.
      • McGarry M.H.
      • Pirolo J.M.
      • Kinoshita M.
      • Lee T.Q.
      Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study.
      The restoration of the superior capsule helps to improve the dysfunctional rotator cuff force couples and to reestablish the concavity compression effect.
      • Ishihara Y.
      • Mihata T.
      • Tamboli M.
      • Nguyen L.
      • Park K.J.
      • McGarry M.H.
      • et al.
      Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
      Initial clinical results following SCR have shown promising pain relief, patient satisfaction, and return of functional deficit.
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      ,
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • Fukunishi K.
      • Ohue M.
      • Tsujimura T.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Patient selection and indications for SCR continue to evolve with time and growing surgeon familiarity. While SCR continues to gain in popularity as a treatment option, debate exists as to the optimal fixation methods or techniques, graft choice, and concomitant procedures.
      The purpose of this study was to examine surgeon techniques and considerations for treatment of massive rotator cuff tears, including how they implement the use of SCR using a questionnaire. We chose to survey surgeons with expertise in the field; we targeted members of orthopedic professional societies, namely the American Shoulder and Elbow Surgeons (ASES) and the American Orthopedic Society for Sports Medicine (AOSSM). This cross-sectional descriptive study aimed to give observations about provider management preferences and opinions. We hypothesized that the management of massive rotator cuff tears and the usage of SCR would vary widely in terms of technical preferences and indications.

      Methods

      We designed and implemented a survey for members of the ASES and AOSSM. The survey was administered as a one-time, anonymous link sent via primary contact email for participants from August to December 2019. Prior to study initiation, the protocol was approved by the institutional review board at the institution of the principal investigator.

      Study population

      Participants were members of either (or both) the ASES or the AOSSM. Membership within these professional societies is exclusive to orthopedic surgeons and includes providers that focus on sports medicine and/or shoulder and elbow primarily. All participants were over 18 years old.

      Survey design

      We constructed a 21-item questionnaire which included: 2 questions on surgeon practice and experience, 5 questions on management preferences for treatment of massive rotator cuff tears, 2 questions on treatment choice for patient scenarios, 2 questions on implant choices and augmentation in massive rotator cuff tears, and 3 questions of beliefs about SCR. The last section was specific only to providers that perform SCR as part of their practice; this included 7 questions on SCR specifics regarding technique, implants, and augments. The questions were developed based upon expert opinion at the discretion of the principal investigator.

      Results

      A total of 230 participants responded to the survey (Fig. 1). The providers represented a wide spectrum of years in practice: 0-5 years (21.9%), 6-10 years (21.9%), 11-20 years (27.2%), and >20 years (29.0%). Polled providers reported performing a number of yearly RCRs ranging from: 0-20 (3.5%), 20-50 (21.0%), 50-100 (28.0%), and 100+ (47.6%).
      Figure thumbnail gr1
      Figure 1Flow chart demonstrating study participants. ASES, American Shoulder and Elbow Surgeons; AOSSM, American Orthopedic Society for Sports Medicine; SCR, superior capsule reconstruction.

      Massive RCR

      Polled providers were asked how many massive RCRs (2+ tendon tear) they performed per year; results were as follows: 0-10 (10.9%), 10-20 (23.9%), 20-30 (24.8%), 30-50 (20.4%), and 50+ (20.0%). Respondents were asked about percentage of subscapularis repair performed in massive RCRs, percentage of massive RCRs where interval slides were performed, percentage of massive RCRs where subacromial decompression (SAD) was performed, preferences for LHB tendon management in massive RCR, instrumentation preferences in massive RCR, and strategies employed outside of standard repair in massive RCR. These data are shown in Table I.
      Table ISurvey results for management preferences for massive rotator cuff repair (RCR) and associated pathology.
      ResponsePercentageN in group
      In what percentage of massive RCR surgery (2+ tendons) do you perform a subscapularis tendon repair?
       0-25%33.9178
       26-50%36.5284
       51-75%19.1344
       76-100%10.4324
      In what percentage of massive RCR surgery do you perform an interval slide to mobilize tissue?
       0%24.3556
       1-25%42.1797
       26-50%13.0430
       51-75%11.3026
       76-100%9.1321
      In what percentage of massive RCR surgery do you perform some form of SAD (CA ligament release, acromioplasty, etc.)?
       0%7.3917
       1-25%15.6536
       26-50%14.7834
       51-75%16.9639
       76-100%45.22104
      What is your preferred treatment of the LHB during massive RCR if the patient has no bicipital symptoms and the tendon is relatively healthy?
       Tendon preservation45.22104
       Tenotomy13.4831
       Tenodesis41.3095
      Which implants and strategies do you prefer in massive RCR? (please check all that apply)
       Solid threaded anchor (eg, Corkscrew, SwiveLock, etc.)71.18163
       Soft-anchor (eg, FiberTak)19.6545
       Knotless techniques40.6193
       Knot-tying technique59.39136
       Double-row repair65.07149
       Transosseous equivalent repair49.34113
       Single-row repair24.8957
       High-strength suture45.41104
       High-strength tape51.09117
      Do you ever employ any of the following strategies outside of standard repair when performing massive RCR? (please check all that apply)
       Platelet-rich plasma (PRP)11.2321
       Bone-marrow aspirate concentrate (BMAC)8.5616
       Bone marrow stimulation of the footprint55.61104
       Synthetic material patch (non-tissue)4.819
       Human allograft augmentation (non-SCR)29.4155
       SCR66.84125
       Xenograft collagen implant (Regeneten)32.0960
      SAD, subacromial decompression; CA, coracoacromial; LHB, long head biceps; SCR, superior capsule reconstruction.
      N = 230, however, not all participants answered every question.

      SCR

      When asked about how many SCRs polled providers performed over the previous 6 months, responses were 0 (33.6%), 1-5 (45.4%), 5-10 (14.0%), 10-20 (6.1%), and 20+ (0.9%). For those providers that did not perform an SCR in the last 6 months, 73.6% said they were planning to perform one within the next year if a patient met their indications. For those providers who said they would not perform an SCR in the next year, reasons for choosing against SCR included (multiple answers permitted): I do not believe that this procedure will help my patients (33.7%), I have concerns about the use of human dermal allograft for this surgery (4.6%), I would not perform enough SCRs to feel comfortable doing so occasionally (10.5%), the technique is too technically demanding (1.2%), I prefer performing arthroplasty in this population (17.4%), I prefer performing partial repair and débridement (32.6%).
      For providers that performed SCR, respondents were asked about preferred treatment of the LHB tendon during SCR if no bicipital symptoms were present and the tendon is relatively healthy, preferred treatment of the superior labrum when performing SCR, preferred graft choice for SCR, preferred glenoid fixation strategies (multiple responses allowed), preferred humeral fixation strategies (multiple responses allowed), preferred techniques in SCR (multiple responses allowed), and SCR beliefs/pearls (multiple responses allowed). These data are shown in Table II.
      Table IISurvey results of participants that perform superior capsule reconstruction (SCR) including their treatment strategies, fixation methods, and graft choices.
      ResponsePercentageN in group
      What is your preferred treatment of the LHB during SCR if the patient has no bicipital symptoms and the tendon is relatively healthy?
       Tendon preservation30.1250
       Tenotomy14.4624
       Tenodesis55.4292
      What is your preferred treatment of the superior labrum when performing SCR?
       Complete preservation12.2020
       Debridement enough to allow for bone preparation78.05128
       Completely excise for bone preparation9.7616
      What is your preferred graft choice for SCR?
       Fascia lata autograft3.115
       Human dermal allograft tissue93.17150
       Other human allograft tissue1.863
       Synthetic patch (no tissue or combined)1.863
      What are your preferred glenoid fixation strategies (please check all that apply)
       2 implants28.2246
       3 implants71.17116
       4 implants (if necessary)2.454
       Solid-punched anchor (eg, SutureTak)42.3369
       Solid threaded implant (eg, Corkscrew)17.1828
       Soft anchor (eg, FiberTak)22.7037
       All-knotless technique39.8865
       Knot-tying technique35.5858
       Combined knotless and knot-tying technique11.0418
      What are your preferred humeral fixation strategies (please check all that apply)
       2 solid threaded implants medially (eg, SwiveLock, Corkscrew)70.99115
       3 solid threaded implants medially (eg, SwiveLock, Corkscrew)14.2023
       2-3 soft implants medially (eg, FiberTak)8.0213
       2 solid threaded implants laterally (double-row)44.4472
       3 solid threaded implants laterally (double-row)5.569
       2 solid threaded implants laterally (trans-osseous equivalent)46.9176
       3 solid threaded implants laterally (trans-osseous equivalent)8.0213
      Which of the following techniques do you try to include in SCR surgery? (Please check all that apply)
       Side-to-side repair to the intact/repaired posterior rotator cuff97.56160
       Side-to-side repair to the subscapularis tendon or anterior interval tissue54.8890
       Incorporate partial repair of the rotator cuff into the SCR69.51114
       Incorporate complete repair of the rotator cuff along with the SCR21.3435
       Acromioplasty51.8385
      Which of the following statements do you agree with regarding SCR surgery? (please check all that apply)
       I just approximate the graft size8.5414
       I accurately measure the distance between sutures to size the graft88.41145
       I add load-bearing sutures between the glenoid and humerus to protect the graft4.888
       I believe the SCR functions as a dynamic trampoline53.6688
       I believe the SCR functions as a subacromial spacer59.1597
       I intentionally pretension the graft by measuring the graft in relative abduction or decreasing the medial-lateral dimensions32.3253
       I try to use the thickest graft available62.20102
      LHB, long head biceps.
      N = 166, however, not all participants answered every question.

      Clinical scenarios

      Providers were asked about their decision-making in the clinical scenario of early stage rotator cuff arthropathy (Hamada stage 1-2) with a rotator cuff that cannot be completely repaired in either a 1) 60-year-old patient and a 2) 70-year-old patient. For the 60-year-old patient scenario, responses were as follows: partial repair and débridement (42.0%), isolated SCR (5.73%), combined repair and SCR (45.4%), reverse arthroplasty (4.0%), partial repair and biceps augmentation (4.0%), and subacromial balloon (0.0%). For the 70-year-old patient scenario, responses were as follows: partial repair and débridement (28.4%), isolated SCR (4.4%), combined repair and SCR (20.1%), reverse arthroplasty (41.9%), partial repair and biceps augmentation (5.24%), and subacromial balloon (0.0%).

      Discussion

      This study highlights some interesting trends among sports medicine and shoulder specialists that treat a high number of rotator cuff tears. The vast majority of surgeons in this study (75.6%) perform 50-100 or more RCRs per year. However, only a small number of surgeons (20.0%) perform 50+ massive RCR (2+ tendon) repairs per year. Even fewer surgeons regularly perform SCR; from this cohort of specialists 79.0% of surgeons had performed 5 or fewer SCRs in the past 6 months. Thus despite improved techniques and growing interest in SCR, many questions still remain for optimal usage. When asked about a patient with early stage rotator cuff arthropathy with a rotator cuff that cannot be completely repaired, polled providers favored partial repair and débridement (42.0%) or combined repair and SCR (45.4%) over reverse arthroplasty (4.0%) in a 60-year-old patient. For a 70-year-old patient, reverse arthroplasty (41.9%) was favored over partial repair and débridement (28.4%), or combined repair and SCR (20.1%). As indications for surgery for RCR vs. SCR vs. reverse arthroplasty vary widely and consensus treatment algorithms have not been established, the goal of this study was to report on preferences and attitudes among current practicing experts.
      Management of patients with massive rotator cuff tears remains a complicated issue. The decision-making process must consider a variety of factors including tear pattern, chronicity, and tissue quality. Additionally, tears must be considered in light of patient factors such as demographics (age, comorbidities, etc) and associated pain, weakness, or disability secondary to their condition. Descriptive classifications of rotator cuff tears have been described however currently no consensus exists for which is best.
      • Rho J.Y.
      • Kwon Y.S.
      • Choi S.
      Current concepts and recent trends in arthroscopic treatment of large to massive rotator cuff tears: a review.
      For those patients who have a massive rotator cuff tear that is deemed amenable to repair, many factors still need to be considered surgically. Consensus regarding these factors has not been established though the present study identifies some trends. In the management of clinically asymptomatic LHB which intraoperatively appears healthy, providers were split between tendon preservation (45.3%) and tenodesis (41.2%) with minimal role for tenotomy (13.5%). In the setting of massive rotator cuff tear, Boileau et al reported positive outcomes and no significant difference between tenodesis and tenotomy for LHB lesions.
      • Boileau P.
      • Baqué F.
      • Valerio L.
      • Ahrens P.
      • Chuinard C.
      • Trojani C.
      Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears.
      The scenario of an asymptomatic LHB tendon with massive rotator cuff tear has minimal published data. Performing SAD in the setting of massive rotator cuff tear has been deemed controversial because of the importance of maintaining the coracoacromial ligament to prevent superior escape of the humeral head in rotator cuff insufficiency. If the coracoacromial arch and the acromion are kept intact, SAD for massive rotator cuff tears can be performed effectively with good clinical results.
      • Verhelst L.
      • Vandekerckhove P.J.
      • Sergeant G.
      • Liekens K.
      • Van Hoonacker P.
      • Berghs B.
      Reversed arthroscopic subacromial decompression for symptomatic irreparable rotator cuff tears: mid-term follow-up results in 34 shoulders.
      For providers in this study, the majority perform SAD routinely in massive RCR; 45.2% perform SAD in almost all cases (75-100%) while 17.0% of providers perform SAD in 50-75% of cases. The use of interval slides for mobilizing cuff tendons in RCR was historically a common technique.
      • Lo I.K.Y.
      • Burkhart S.S.
      Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results.
      Interval slides appear to be decreasing in their popularity; the present study showed that 66.5% of providers used the technique in 25% or less of their cases. The preferences for implants for the participants varied widely; the most common implant choice was solid threaded anchors such as Corkscrew or SwiveLock (Arthrex Inc., Naples, FL, USA) (71.1%). The most preferred method of fixation was a double row repair (65.1%). A recent systematic review reported that double row fixation constructs may be associated with better patient-reported outcomes in massive rotator cuff tears.
      • Saridakis P.
      • Jones G.
      Outcomes of single-row and double-row arthroscopic rotator cuff repair: a systematic review.
      For method of repair, knotless technique (59.4%) was preferred over knot-tying technique (40.6%). Meta-analysis by Paramasivam Meenakshi Sundaram in 2020 reported no difference in clinical outcomes scores over 8 studies comparing knotless and knot-tying techniques.
      • Paramasivam Meenakshi Sundaram P.
      • Lee W.W.B.
      • Sayampanathan A.A.
      • Tan H.C.A.
      Comparison of clinical outcomes between knotted and knotless double-row arthroscopic rotator cuff repairs: a meta-analysis.
      Similarly, Nemirov et al showed no difference in outcome scores, repair failure rates or complications at 2 years postoperatively.
      • Nemirov D.
      • Herman Z.
      • Paul R.W.
      • Clements A.
      • Beucherie M.
      • Brutico J.
      • et al.
      Knotted versus knotless medial-row transosseous-equivalent double-row rotator cuff repairs have similar clinical and functional outcomes.
      Preferences between use of high-strength tape (51.1%) and high-strength suture (45.4%) were similar for respondents. Previous biomechanical studies have shown higher footprint contact pressure, load to failure, and stiffness with high-strength tape.
      • Borbas P.
      • Fischer L.
      • Ernstbrunner L.
      • Hoch A.
      • Bachmann E.
      • Bouaicha S.
      • et al.
      High-strength suture Tapes are biomechanically stronger than high-strength sutures used in rotator cuff repair.
      ,
      • Liu R.W.
      • Lam P.H.
      • Shepherd H.M.
      • Murrell G.A.C.
      Tape versus suture in arthroscopic rotator cuff repair: biomechanical analysis and assessment of failure rates at 6 months.
      Liu et al reported that clinically retear rates remain similar at 6 months postoperatively, however.
      • Liu R.W.
      • Lam P.H.
      • Shepherd H.M.
      • Murrell G.A.C.
      Tape versus suture in arthroscopic rotator cuff repair: biomechanical analysis and assessment of failure rates at 6 months.
      Strategies for adjuncts to RCR in massive rotator cuff tear were varied; the most commonly cited augments were bone marrow stimulation of the footprint (55.6%) and SCR (66.8%). Kim et al examined RCR with or without bone marrow stimulation of the footprint and reported no significant differences in outcomes or imaging studies looking at structural integrity of the cuff postoperatively.
      • Kim C.
      • Lee Y.J.
      • Kim S.J.
      • Yoon T.H.
      • Chun Y.M.
      Bone marrow stimulation in arthroscopic repair for large to massive rotator cuff tears with incomplete footprint coverage.
      SCR remains a growing area of interest in the management of massive and irreparable rotator cuff tears. The use of SCR has had positive results clinically with promising pain relief, patient satisfaction and recovery of functional deficit in short-term and medium-term follow-up.
      • Burkhart S.S.
      • Denard P.J.
      • Adams C.R.
      • Brady P.C.
      • Hartzler R.U.
      Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair.
      ,
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      ,
      • Frank R.M.
      • Cvetanovich G.
      • Savin D.
      • Romeo A.A.
      Superior capsular reconstruction: indications, techniques, and clinical outcomes.
      ,
      • Ishihara Y.
      • Mihata T.
      • Tamboli M.
      • Nguyen L.
      • Park K.J.
      • McGarry M.H.
      • et al.
      Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
      ,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • Fukunishi K.
      • Kawakami T.
      • Fujisawa Y.
      • et al.
      Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      ,
      • Tokish J.M.
      • Makovicka J.L.
      The superior capsular reconstruction: lessons learned and future directions.
      In a medium-term follow-up clinical study at 5 years patients had high rates of satisfaction, return to recreational sport, and return to physical work.
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • Fukunishi K.
      • Kawakami T.
      • Fujisawa Y.
      • et al.
      Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      The present study identified 166 providers out of 230 that perform SCR in their clinical practice. For providers that perform SCR (n = 166), management of clinically asymptomatic LHB that appears healthy was associated with a greater preference for tenodesis (55.4%) than preservation (30.1%) or tenotomy (14.5%). In preparation of the superior labrum for SCR fixation, the majority of providers débrided only enough superior labrum to allow for bone preparation (78.8%). Human dermal allograft tissue was the overwhelming preference for graft choice in SCR (93.2%). The initial clinical description by Mihata utilized tensor fascia lata autograft.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • Fukunishi K.
      • Ohue M.
      • Tsujimura T.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Dermal allograft for SCR was described by Hirahara as a viable graft option which obviated the surgical time and risks associated with autograft harvest.
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      Other graft options such as LHB rerouting have also been described.
      • Kim Y.S.
      • Lee H.J.
      • Park I.
      • Sung G.Y.
      • Kim D.J.
      • Kim J.H.
      Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon.
      The strategies for graft fixation in SCR have been quite variable; glenoid fixation is typically with 2-3 anchors sized between 1.8 mm to 3.5 mm using biocomposite, suture-based, and titanium anchors.
      • Altintas B.
      • Scheidt M.
      • Kremser V.
      • Boykin R.
      • Bhatia S.
      • Sajadi K.R.
      • et al.
      Superior capsule reconstruction for irreparable massive rotator cuff tears: does it make sense? A systematic review of early clinical evidence.
      ,
      • de Campos Azevedo C.I.
      • Ângelo A.C.L.P.G.
      • Vinga S.
      Arthroscopic superior capsular reconstruction with a minimally invasive harvested fascia lata autograft produces good clinical results.
      ,
      • Hirahara A.M.
      • Andersen W.J.
      • Panero A.J.
      Superior capsular reconstruction: clinical outcomes after minimum 2-year follow-up.
      ,
      • Lee S.J.
      • Min Y.K.
      Can inadequate acromiohumeral distance improvement and poor posterior remnant tissue be the predictive factors of re-tear? Preliminary outcomes of arthroscopic superior capsular reconstruction.
      ,
      • Lim S.
      • AlRamadhan H.
      • Kwak J.M.
      • Hong H.
      • Jeon I.H.
      Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome.
      ,
      • Mihata T.
      • Lee T.Q.
      • Fukunishi K.
      • Itami Y.
      • Fujisawa Y.
      • Kawakami T.
      • et al.
      Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
      ,
      • Pennington W.T.
      • Bartz B.A.
      • Pauli J.M.
      • Walker C.E.
      • Schmidt W.
      Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: short-term clinical outcomes and the radiographic parameter of superior capsular distance.
      Humeral sided fixation in most cases has been reported as double row fixation with biocomposite anchors sized 3.9 mm to 5.0 mm.
      • Altintas B.
      • Scheidt M.
      • Kremser V.
      • Boykin R.
      • Bhatia S.
      • Sajadi K.R.
      • et al.
      Superior capsule reconstruction for irreparable massive rotator cuff tears: does it make sense? A systematic review of early clinical evidence.
      ,
      • de Campos Azevedo C.I.
      • Ângelo A.C.L.P.G.
      • Vinga S.
      Arthroscopic superior capsular reconstruction with a minimally invasive harvested fascia lata autograft produces good clinical results.
      ,
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      ,
      • Hirahara A.M.
      • Andersen W.J.
      • Panero A.J.
      Superior capsular reconstruction: clinical outcomes after minimum 2-year follow-up.
      ,
      • Lim S.
      • AlRamadhan H.
      • Kwak J.M.
      • Hong H.
      • Jeon I.H.
      Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome.
      ,
      • Mihata T.
      • Lee T.Q.
      • Fukunishi K.
      • Itami Y.
      • Fujisawa Y.
      • Kawakami T.
      • et al.
      Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
      ,
      • Pennington W.T.
      • Bartz B.A.
      • Pauli J.M.
      • Walker C.E.
      • Schmidt W.
      Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: short-term clinical outcomes and the radiographic parameter of superior capsular distance.
      In this study, for glenoid fixation, the preferred strategy was 3 implants (71.2%), with solid threaded anchors being the most common response (42.3%). For humerus fixation, the preferred strategy was 2 solid threaded anchors medially (71.0%) and 2 solid threaded anchors laterally (46.9%). Other highly recommended strategies in SCR surgery were to perform side-to-side repair to the intact/repaired posterior rotator cuff if able (97.6%), to accurately measure the distances between sutures when sizing the graft (88.4%), and to use the thickest graft available (62.2%). Side-to-side repair of the remnant rotator cuff to the graft has been recommended in previous studies.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon.
      ,
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      ,
      • Sutter E.G.
      • Godin J.A.
      • Garrigues G.E.
      All-arthroscopic superior shoulder capsule reconstruction with partial rotator cuff repair.
      The addition of the partial repair to the posterior cuff has been theorized to aid in postoperative external rotation strength.
      • Sutter E.G.
      • Godin J.A.
      • Garrigues G.E.
      All-arthroscopic superior shoulder capsule reconstruction with partial rotator cuff repair.
      Graft thickness has been variably reported; most studies using acellular dermal allograft reported a thickness of 1 to 3.5 mm.
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      ,
      • Hirahara A.M.
      • Andersen W.J.
      • Panero A.J.
      Superior capsular reconstruction: clinical outcomes after minimum 2-year follow-up.
      ,
      • Pennington W.T.
      • Bartz B.A.
      • Pauli J.M.
      • Walker C.E.
      • Schmidt W.
      Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: short-term clinical outcomes and the radiographic parameter of superior capsular distance.
      Studies using tensor fascia lata autografts reported a range of 5 to 8 mm.
      • de Campos Azevedo C.I.
      • Ângelo A.C.L.P.G.
      • Vinga S.
      Arthroscopic superior capsular reconstruction with a minimally invasive harvested fascia lata autograft produces good clinical results.
      ,
      • Lim S.
      • AlRamadhan H.
      • Kwak J.M.
      • Hong H.
      • Jeon I.H.
      Graft tears after arthroscopic superior capsule reconstruction (ASCR): pattern of failure and its correlation with clinical outcome.
      ,
      • Mihata T.
      • Lee T.Q.
      • Fukunishi K.
      • Itami Y.
      • Fujisawa Y.
      • Kawakami T.
      • et al.
      Return to sports and physical work after arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears.
      Clinical studies have favored the use of thicker grafts for both allograft and autograft if possible, with the reasoning that thicker grafts increase the superior restraint and decrease the risk of graft tearing.
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      ,
      • Frank R.M.
      • Cvetanovich G.
      • Savin D.
      • Romeo A.A.
      Superior capsular reconstruction: indications, techniques, and clinical outcomes.
      ,
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • Fukunishi K.
      • Ohue M.
      • Tsujimura T.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Strategies for obtaining a thicker graft have been described, including folding the graft or adding two grafts, though no gold standard exists.
      • Li H.
      • Zhou B.
      • Tang K.
      Advancement in arthroscopic superior capsular reconstruction for irreparable massive rotator cuff tear.
      ,
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      ,
      • Mirzayan R.
      • Otarodifard K.A.
      • Singh A.
      Arthroscopic superior capsule reconstruction with a doubled-over (6 mm) dermal allograft.

      Limitations

      This study has several limitations to discuss. The first limitation is the survey nature of the study protocol. The use of a survey as a primary means of polling our cohort of surgeons has some inherent bias. Additionally, the format of our study allowed participants to skip questions which resulted in decreased and variable numbers throughout the survey. The choice to only poll members of the ASES and AOSSM limits the generalizability of our findings. Given the descriptive nature of the study, statistical analyses could not be performed. This limited the ability of the study to go beyond making observations of trends. This study intentionally did not define what made the difference between reparable and irreparable rotator cuff tear. As such, much of the decision-making on techniques and preferences in this article was subjective to the respondents. This vagueness in the “irreparability” component of RCR limited this study’s ability to report clearly on indications for SCR despite the expert cohort. Providers in this poll were not asked to differentiate whether they would use SCR only in irreparable tears or also in massive RCRs in certain clinical scenarios. This may have resulted in some confusion among respondents who did not understand whether questions about SCR (Table II) were being specifically asked about reparable or irreparable cuff tears. Further clarification on SCR indications is needed with future studies, including whether providers consider it to be solely a salvage option in setting of irreparable cuff tears or whether it can or should be employed as a supplement in reparable massive tears. Additionally, aside from the techniques and preferences for RCR and SCR, many other viable options for joint preserving procedures (such as tendon transfers and subacromial balloon) were not investigated with separate questions in the questionnaire. This limited the scope of the study and did not reflect the variety of individualized options surgeons can implement in this difficult patient cohort.

      Conclusions

      This survey is the first major compilation of provider preferences for management of massive rotator cuff tears with SCR. This study illustrates the varying thoughts and preferences of expert shoulder and sports medicine surgeons across the country. As indications for surgery for RCR vs. SCR vs. reverse arthroplasty vary widely for massive rotator cuff tears and consensus treatment algorithms have not been established, the goal of this study was to report on current practice standards. In the setting of RCR of massive rotator cuff tear, respondents in this study preferred LHB preservation when asymptomatic, routine SAD, double row repair with solid threaded anchors, and bone marrow stimulation, and/or SCR as indicated for augmentation. Preferences for respondents in this study that perform SCR include LHB tenodesis, superior labral preparation only as much as necessary, human dermal allograft tissue, 3 solid threaded anchors in the glenoid, and double row solid threaded anchors on the humeral side. This study identifies the significant variability in repair constructs and methodology with SCR; further investigation into these variables could be analyzed to identify best practice guidelines.

      Disclaimers

      Funding: This study did not receive any outside funding or grants.
      Conflicts of interest: Thomas Dooney: The author is a senior group product manager at Arthrex Inc. Thay Q. Lee: The author is a consultant for Arthrex inc. Orr Limpisvasti: The author is a consultant for Arthrex Inc. and Linvatec. The other author, his immediate families, and any research foundation with which he are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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