By Ryan A. Harrell, DO
Historically, the treatment of irreparable rotator cuff injuries has been a real challenge for orthopaedists and their patients.
Cases involving a torn and retracted tendon, significant muscle atrophy and fatty infiltration, impaired mobility, and chronic pain have not responded well to traditional procedures such as partial rotator cuff repair, patches, augments or tendon transfers.
Thankfully, there is another option besides reverse total shoulder replacement: Superior Capsule Reconstruction (SCR), which studies demonstrate delivers significant short- and long-term improvements in range of motion, pain relief and joint function in about 70 to 80 percent of appropriately indicated patients.
Acute or chronic rotator cuff injuries are among the most common reasons patients seek orthopaedic care, particularly after age 40 or 50. Shoulder pain and weakness can develop after a fall or other trauma, or as a result of gradual degeneration and repetitive motions.
Rest, physical therapy, anti-inflammatory medications, and/or cortisone or biologic injections can benefit some patients, while those who fail conservative treatments are candidates for a surgical repair.
The problem, however, arises in patients who suffer from pain and decreased range of motion but have poor tissue quality and tendon retraction, which can be secondary to a previously neglected rotator cuff tear or a re-tear following surgery.
This poses two concerns: reattaching the tendon to the humerus is not possible due to retraction, and the tissue overall has very limited healing potential.
In 2007, however, a Japanese doctor pioneered a new arthroscopic procedure in which a fascia lata autograft – a tendon transplanted from a patient’s own thigh – was secured to the superior glenoid and greater tuberosity, thereby reconstructing the superior capsule of the shoulder.
For patients with minimal arthritis, Dr. Teruhisa Mihata found the graft could effectively hold the humeral head in its normal position and create a fulcrum for the anterior and posterior rotator cuff to act like a cable suspension bridge.
The reverse trampoline effect of the graft, restoring humeral head anatomy, eased pain and restored natural shoulder mechanics to improve mobility and the ability of the deltoid muscle and remaining cuff to raise the arm. Surgeons since have revised the SCR technique to substitute dermal allograft tissue, sparing patients a second surgical site.
Short- and mid-term outcomes indicate that patients can see improved function at least five years after surgery, and I expect well beyond. SCR also can restore overhead motion in cases of pseudoparalysis secondary to a damaged rotator cuff, rather than due to true nerve paralysis.
As a joint preservation strategy, this procedure can help younger patients return to previous function and delay or avoid a shoulder replacement. Patients typically are immobilized in an abduction pillow for six weeks postoperatively, with a gradual return of motion and strengthening exercises over a six-month rehabilitation period.
The excellent clinical, structural and functional results that I have seen in my practice – and that studies to date confirm – should give these patients hope for a good recovery.
Dr. Harrell is a fellowship-trained orthopaedic surgeon, specializing in sports medicine, based at Hampton Roads Orthopaedics Spine & Sports Medicine’s Newport News office. hrosm.com
