Advertisement

Partial Rotator Cuff Repair Provides Improved Patient-Reported Outcome Measures Following Superior Capsule Reconstruction (SCR)

Open AccessPublished:June 08, 2022DOI:https://doi.org/10.1016/j.asmr.2022.03.004

      Purpose

      To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).

      Methods

      Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months’ follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.

      Results

      Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (P < .001). When we compared the 2 groups, SCR+RCR provided significantly improved ASES Index (87.6 vs 78.2, P = .048) and ASES Function (25.5 vs 21.7, P = .02). There was no statistically significant difference in SANE scores (75.5 vs 64.2, P = .07) at 24 months’ follow-up.

      Conclusions

      SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

      Level of Evidence

      III, retrospective cohort study.
      Irreparable rotator cuff tears represent a treatment challenge for shoulder surgeons. Chronic tears with high-grade fatty infiltration,
      • Gerber C.
      • Schneeberger A.G.
      • Hoppeler H.
      • Meyer D.C.
      Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: A study in thirteen patients.
      • Kim J.Y.
      • Park J.S.
      • Rhee Y.G.
      Can preoperative magnetic resonance imaging predict the reparability of massive rotator cuff tears?.
      • Meyer D.C.
      • Wieser K.
      • Farshad M.
      • Gerber C.
      Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair.
      short tendon length,
      • Meyer D.C.
      • Wieser K.
      • Farshad M.
      • Gerber C.
      Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair.
      ,
      • Meyer D.C.
      • Farshad M.
      • Amacker N.A.
      • Gerber C.
      • Wieser K.
      Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears.
      and a high degree of retraction
      • Kim J.Y.
      • Park J.S.
      • Rhee Y.G.
      Can preoperative magnetic resonance imaging predict the reparability of massive rotator cuff tears?.
      ,
      • Meyer D.C.
      • Wieser K.
      • Farshad M.
      • Gerber C.
      Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair.
      demonstrate high rates of clinical failure or retear.
      • Henry P.
      • Wasserstein D.
      • Park S.
      • et al.
      Arthroscopic repair for chronic massive rotator cuff tears: A systematic review.
      In those patients who are nonresponsive to conservative management,
      • Zingg P.O.
      • Jost B.
      • Sukthankar A.
      • Buhler M.
      • Pfirrmann C.W.
      • Gerber C.
      Clinical and structural outcomes of nonoperative management of massive rotator cuff tears.
      common surgical options can be categorized into palliative interventions (debridement, biceps tenotomy/tenodesis,
      • Boileau P.
      • Baque 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.
      suprascapular nerve release
      • Mallon W.J.
      • Wilson R.J.
      • Basamania C.J.
      The association of suprascapular neuropathy with massive rotator cuff tears: A preliminary report.
      ), attempted restoration of native force couples (partial rotator cuff repair,
      • Cuff D.J.
      • Pupello D.R.
      • Santoni B.G.
      Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: Midterm outcomes with a minimum 5 years of follow-up.
      bridging techniques
      • Ono Y.
      • Davalos Herrera D.A.
      • Woodmass J.M.
      • Boorman R.S.
      • Thornton G.M.
      • Lo I.K.
      Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review.
      ), or reconstruction (superior capsule reconstruction [SCR],
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      tendon transfers
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      • Warner J.J.
      • Parsons IMt
      Latissimus dorsi tendon transfer: A comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
      • Elhassan B.T.
      • Wagner E.R.
      • Werthel J.D.
      Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.
      • Elhassan B.T.
      • Sanchez-Sotelo J.
      • Wagner E.R.
      Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears.
      • Elhassan B.T.
      • Alentorn-Geli E.
      • Assenmacher A.T.
      • Wagner E.R.
      Arthroscopic-assisted lower trapezius tendon transfer for massive irreparable posterior-superior rotator cuff tears: surgical technique.
      • Wagner E.R.
      • Woodmass J.M.
      • Welp K.M.
      • et al.
      Novel arthroscopic tendon transfers for posterosuperior rotator cuff tears: Latissimus dorsi and lower trapezius transfers.
      • Wagner E.R.
      • Elhassan B.T.
      Tendon transfers for rotator cuff pathologies.
      ).
      • Woodmass J.M.
      • Wagner E.R.
      • Chang M.J.
      • et al.
      Arthroscopic treatment of massive posterosuperior rotator cuff tears: A critical analysis review.
      Partial rotator cuff repair (pRCR) is proposed to re-establish the rotator cable to provide a “suspension bridge” effect, thus restoring normal force–couple mechanics.
      • Burkhart S.S.
      • Esch J.C.
      • Jolson R.S.
      The rotator crescent and rotator cable: An anatomic description of the shoulder's "suspension bridge.".
      Although pRCR can improve pain and function,
      • Chen K.H.
      • Chiang E.R.
      • Wang H.Y.
      • Ma H.L.
      Arthroscopic partial repair of irreparable rotator cuff tears: Factors related to greater degree of clinical improvement at 2 years of follow-up.
      deteriorating results in longer-term follow-up are noted, with up to 50% of patients not being satisfied at 2 years’ postoperatively.
      • Shon M.S.
      • Koh K.H.
      • Lim T.K.
      • Kim W.J.
      • Kim K.C.
      • Yoo J.C.
      Arthroscopic partial repair of irreparable rotator cuff tears: Preoperative factors associated with outcome deterioration over 2 years.
      In an attempt to improve outcomes, an incorporation of grafts has been observed including repair augmentation,
      • Ono Y.
      • Davalos Herrera D.A.
      • Woodmass J.M.
      • Boorman R.S.
      • Thornton G.M.
      • Lo I.K.
      Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review.
      bridging techniques,
      • Ono Y.
      • Davalos Herrera D.A.
      • Woodmass J.M.
      • Boorman R.S.
      • Thornton G.M.
      • Lo I.K.
      Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review.
      and more recently SCR.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      SCR, as described by Mihata et al.,
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      is designed to provide a static restraint to superior migration of the humeral head.
      • 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.
      Excellent clinical outcomes were reported in the original patient cohort, in whom partial repair of the infraspinatus tendon was performed whenever possible,
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      thus restoring force–couple mechanics. Subsequent articles have reported variability in patient selection and surgical technique, including the concomitant pRCR.
      • 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      The inability to restore normal biomechanics in patients with an irreparable infraspinatus tendon may be a factor contributing to the high variability in patient-reported outcome measures, graft retear rates, and reoperations following SCR.
      • 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      The purpose of this study was to evaluate the role of concomitant pRCR (i.e., infraspinatus) on patient-reported clinical outcomes following SCR. We hypothesized that patients who underwent concomitant pRCR of the infraspinatus with SCR would have improved outcomes (American Shoulder and Elbow Surgeons [ASES] Function, ASES Index, and Single Assessment Numeric Evaluation [SANE] scores) when compared with those who underwent SCR alone.

      Methods

      Study Design

      The duration of the study was 2 years. Inclusion criteria consisted of if a patient had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they lacked at least 6 months of follow-up and/or they did not complete the preoperative baseline questionnaire.

      Surgical Outcomes System Database

      After approval from the institutional review board (protocol number 2011P002663), a retrospective analysis of a multicenter, prospective outcomes registry database (Surgical Outcomes System) was performed (Arthrex, Naples, FL). After they provided consent for participation, patients received 7 surveys via e-mail over the course of 2 years at select time intervals assessing patient-reported outcome measures regarding pain, range of motion, and functional scores. Operative details from each surgery were entered into the patient’s Surgical Outcomes System record by the care team. Aside from a preoperative survey, patients received questionnaires at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years. Outcomes measured included patients’ visual analog scale (VAS) on a scale of 0 to 10, ASES Functional, ASES Index, and SANE score. Patients were excluded if they did not complete a preoperative baseline surgery questionnaire or did not have at least 6 months of follow-up in the database. Response compliance is summarized in Table 1.
      Table 1Response Compliance
      Preoperative6 Months1 Year2 Years
      VAS Pain Score
       SCR only99% (161)94% (153)84% (137)74% (121)
       SCR+RCR100% (17)100% (17)88% (15)88% (15)
      ASES Shoulder Function score
       SCR only99% (161)93% (152)82% (134)74% (121)
       SCR+RCR100% (17)100% (17)82% (14)88% (15)
      ASES Shoulder Index score
       SCR only99% (161)93%82%74% (121)
       SCR+RCR100% (17)100% (17)82% (14)88% (15)
      SANE score
       SCR only99% (161)93%83%74% (121)
       SCR+RCR100% (17)100% (17)82% (14)88% (15)
      NOTE. Number in parenthesis next to percentage is n.
      ASES, American Shoulder and Elbow Score; RCR, infraspinatus rotator cuff repair; SANE, Single Assessment Numeric Evaluation; SCR, superior capsule reconstruction; VAS, visual analog score.

      Patient Demographics

      There were no significant differences between the demographics of the 2 cohorts for sex, ethnicity, race, smoking status, diabetes diagnosis, insurance coverage, age, or body mass index. The demographic information is summarized in Table 2.
      Table 2Study Population Demographics
      SCR Only (n = 163)SCR+RCR (n = 17)
      Sex
       Male61% (99)59% (10)
       Female35% (57)18% (3)
       Unlisted4% (7)24% (4)
      Tobacco use
       Nonsmoker48% (78)71% (12)
       Smoker10% (16)0% (0)
       Unlisted42% (69)29% (5)
      Diabetes
       Nondiabetic54% (87)65% (11)
       Diabetic4% (7)12% (2)
       Unlisted42% (69)24% (4)
      Worker’s compensation
       No worker’s compensation45% (73)76% (13)
       Worker’s compensation13% (21)0% (0)
       Unlisted42% (69)24% (4)
      BMI (P > .05)30.7 (SD 6.9)31.2 (SD 9.5)
      Age, y (P > .05)59.8 (SD 8.4)59.4 (SD 8.1)
      NOTE. Number in parenthesis next to percentage is n.
      BMI, body mass index; RCR, infraspinatus rotator cuff repair; SCR, superior capsule reconstruction; SD, standard deviation.

      Surgical Details

      Procedural information is summarized in Table 3.
      • Cofield R.H.
      Rotator cuff disease of the shoulder.
      In both groups, the majority of patients had chronic rotator cuff tears, poor rotator cuff quality, and massive tears per Cofield classification.
      • Cofield R.H.
      Rotator cuff disease of the shoulder.
      The group that received concomitant infraspinatus repair had a significantly greater number of torn tendons than compared with the group that just underwent SCR alone.
      Table 3Concomitant Procedures and Rotator Cuff Description
      SCR Only (n = 163)SCR+RCR (n = 17)
      Concomitant procedures
       Unaltered biceps or debridement6% (10)18% (4)
       Tenotomy or tenodesis10% (16)41% (7)
       Suprascapular nerve release1% (2)6% (1)
       Subacromial decompression67% (109)41% (7)
       Subscapularis repair0% (0)24% (4)
      Rotator cuff quality
       Poor49% (80)59% (10)
       Fair5% (8)35% (6)
       Good2% (3)0% (0)
       Unlisted44% (72)6% (1)
      Cofield tear size classification
      • Cofield R.H.
      Rotator cuff disease of the shoulder.
       Medium1% (2)0% (0)
       Large4% (7)12% (2)
       Massive40% (65)76% (13)
       Unlisted55% (90)12% (2)
      Number of tendons torn (P < .001)2.2 (SD 0.61)2.75 (SD 0.44)
      NOTE. Number in parenthesis next to percentage is n.
      RCR, infraspinatus rotator cuff repair; SCR, superior capsule reconstruction; SD, standard deviation.

      Statistical Analysis

      Descriptive statistics were used for overall outcomes and relevant comparisons between the SCR alone and concomitant SCR+RCR. For dichotomous variables and continuous variables, the Fisher exact test and the Student t test with unequal variances were used, respectively. P value <.05 was considered statistically significant. A sample size calculation was performed using standard deviation for 1-year post-SCR ASES scores (22.0),
      • 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.
      substantial clinical benefit (SCB) for 1-year post-RCR ASES scores (17.5),
      • Cvetanovich G.L.
      • Gowd A.K.
      • Liu J.N.
      • et al.
      Establishing clinically significant outcome after arthroscopic rotator cuff repair.
      power of 0.80, and alpha of 0.05. The resulting sample size was identified as 15 participants per group. Subanalyses assessing the association between surgical group and proportion of participants meeting SCB for ASES and SANE was performed using either χ2 tests for association or Fisher exact tests.

      Results

      Outcome Measures

      A total of 180 patients were included in the study. There were 163 patients who underwent SCR alone and 17 patients who underwent SCR+RCR. Compared with the respective preoperative values, both procedures had significant improvements at 2 years in VAS pain, ASES Shoulder Function, ASES Shoulder Index, and SANE score (Table 4).
      Table 4Preoperative Versus Postoperative (Two-Year) PROMs in all SCR and SCR With RCR (SCR+RCR) Groups
      SCR OnlySCR+RCR
      VAS Pain Score
       Preoperative4.74.8
       Postoperative1.61.0
      P value6.2 × 10–20
      P < .001.
      1.2 × 10–5
      P < .001.
      ASES Shoulder Function score
       Preoperative13.113.6
       Postoperative21.725.5
      P value1.1 × 10–24
      P < .001.
      2.1 × 10–7
      P < .001.
      ASES Shoulder Index score
       Preoperative49.948.6
       Postoperative78.287.6
      P value9.4 × 10–28
      P < .001.
      3.6 × 10–8
      P < .001.
      SANE score
       Preoperative32.037.9
       Postoperative64.275.5
      P value4.8 × 10–24
      P < .001.
      2.6 × 10–5
      P < .001.
      ASES, American Shoulder and Elbow Score; RCR, infraspinatus rotator cuff repair; SANE, Single Assessment Numeric Evaluation; SCR, superior capsule reconstruction; SD, standard deviation; VAS, visual analog score.
      P < .001.
      For VAS pain scores, both groups demonstrated a trend of decreasing over the study’s 2 years (Fig 1). There was no difference in pain scores preoperatively or at 3 months and 6 months (Table 5). However, patients with a concomitant infraspinatus repair had lower pain scores at 6 months, 1 year, and 2 years, with scores significantly lower at 1 year (P = .04).
      Figure thumbnail gr1
      Fig 1VAS Pain Score for SCR only versus SCR and RCR. Error bars indicate 95% confidence intervals. (RCR, infraspinatus rotator cuff repair; SCR, superior capsule reconstruction; VAS, visual analog score.)
      Table 5Comparison of PROMs in SCR Versus SCR with RCR (SCR+RCR) Groups
      Preoperative3 Months6 Months1 Year2 Years
      VAS Pain Score
       SCR only4.42.21.72.01.6
       SCR+RCR4.82.41.30.91.0
      P value.24.35.21.04
      P < .05.
      .14
      ASES Shoulder Function score
       SCR only13.114.818.820.321.7
       SCR+RCR13.612.119.223.825.5
      P value.36.05.41.03
      P < .05.
      .02
      P < .05.
      ASES Shoulder Index score
       SCR only49.963.772.874.378.2
       SCR+RCR48.659.475.585.087.6
      P value.39.17.29.03
      P < .05.
      .048
      P < .05.
      SANE score
       SCR only32.045.657.962.764.2
       SCR+RCR37.935.963.672.875.5
      P value.13.050.18.09.07
      ASES, American Shoulder and Elbow Score; PROMs, patient-reported outcome measures; RCR, infraspinatus rotator cuff repair; SANE, Single Assessment Numeric Evaluation; SCR, superior capsule reconstruction; SD, standard deviation; VAS, visual analog score.
      P < .05.
      For ASES Shoulder Function and Shoulder Index scores, both groups increased over time (Fig 2). Compared with those who only underwent SCR, patients who also received an infraspinatus repair had significantly greater ASES Shoulder Function and Shoulder Index scores at both 1 year (P = .03) and 2 years (P = .02) (Table 5).
      Figure thumbnail gr2
      Fig 2ASES Function (A) and Index (B) scores for SCR only versus SCR and RCR. Error bars indicate 95% confidence intervals. (ASES, American Shoulder and Elbow Score; RCR, infraspinatus rotator cuff repair; SCR, superior capsule reconstruction.)
      SANE score increased over 2 years (Fig 3). Patients who underwent the additional infraspinatus repair had no significant improvement in SANE score at 6 months, 1 year, and 2 years when compared with SCR alone (Table 5).
      Figure thumbnail gr3
      Fig 3SANE for SCR only versus SCR and RCR. Error bars indicate 95% confidence intervals. (RCR, infraspinatus rotator cuff repair; SANE, Single Assessment Numeric Evaluation; SCR, superior capsule reconstruction.)
      A greater proportion of patients who underwent SCR+RCR (92.9%) met or exceeded SCB for ASES scores at 1-year postoperatively compared with SCR alone (60.4%; P = .017), with no differences identified at 2 years (P = .520) postoperatively. Moreover, no differences were noted between surgical groups in the proportion of patients meeting or exceeding SCB for SANE scores 12 months (P = .222) and 2 years (P = .112) postoperatively.

      Discussion

      This study demonstrates that SCR provides postoperative improvement in pain and function at 1 and 2 years. Patients who underwent concomitant infraspinatus repair demonstrated significantly greater ASES Index (87.6 vs 78.2, P < .05) and ASES Function (25.5 vs 21.7, P = .02) scores than compared with those who underwent SCR alone. SANE scores showed a nonsignificant difference between SCR+RCR and SCR alone (75.5 vs 64.2, P = .07).
      Although SCR can provide significantly improved pain and functional outcomes, there has been considerable variability in the success of this intervention.
      • 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      ,
      • Woodmass J.M.
      • Wagner E.R.
      • Chang M.J.
      • et al.
      Arthroscopic treatment of massive posterosuperior rotator cuff tears: A critical analysis review.
      ,
      • 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.
      ,
      • Hirahara A.M.
      • Andersen W.J.
      • Panero A.J.
      Superior capsular reconstruction: Clinical outcomes after minimum 2-year follow-up.
      A multitude of factors are likely contributing to this variability, including patient selection, surgical technique, and concomitant procedures. As this technique gains popularity, so too does the need to accurately identify and define the factors predictive of an improved and reliable outcome. In this study, SCR was shown to provide modest improvement in pain and function in patients with irreparable rotator cuff tears. However, patients who underwent concomitant repair of the infraspinatus tendon demonstrated significantly improved patient-reported outcome measures at 2 years postoperatively when compared with patients who underwent SCR alone. This is despite the cohort of patients undergoing infraspinatus repair having a statistically larger tear size.
      SCR was first described by Mihata et al.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      in 2003 as a means to treat irreparable rotator cuff tears. In the initial series of 24 patients, 87.3% of patients demonstrated an intact graft at a mean of 34.1 months follow-up with significantly improved forward elevation, external rotation, and ASES scores. The authors recommended repair of the infraspinatus tendon followed by SCR using a thick fascia lata autograft with side-to-side sutures to the infraspinatus. Biomechanical evaluation of SCR for isolated supraspinatus tendon defects has validated the aforementioned technique to prevent superior migration of the humeral head (similar to the intact supraspinatus tendon),
      • 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.
      particularly when performed combined with an infraspinatus partial repair.
      • 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.
      Subsequent clinical studies have supported the need for the infraspinatus repair and integrity of the posterosuperior rotator cuff.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      ,
      • 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.
      ,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      In recent years, surgeons have evolved this technique to use allograft, thinner grafts, and variability in concomitant procedures.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      ,
      • 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.
      ,
      • Catapano M.
      • de Sa D.
      • Ekhtiari S.
      • Lin A.
      • Bedi A.
      • Lesniak B.P.
      Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature.
      ,
      • Sochacki K.R.
      • McCulloch P.C.
      • Lintner D.M.
      • Harris J.D.
      Superior capsular reconstruction for massive rotator cuff tear leads to significant improvement in range of motion and clinical outcomes: A systematic review.
      Many of these factors have likely contributed to the large variability in clinical outcomes and failure rates.
      • 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.
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      • 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.
      ,
      • Catapano M.
      • de Sa D.
      • Ekhtiari S.
      • Lin A.
      • Bedi A.
      • Lesniak B.P.
      Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature.
      • Sochacki K.R.
      • McCulloch P.C.
      • Lintner D.M.
      • Harris J.D.
      Superior capsular reconstruction for massive rotator cuff tear leads to significant improvement in range of motion and clinical outcomes: A systematic review.
      • Badman B.L.
      • Baessler A.M.
      • Moor M.
      Short-term clinical outcomes and comparison of ultrasound versus magnetic resonance imaging of superior capsular reconstruction.
      The first large multicenter study on the dermal allograft demonstrated these considerations. Denard et al.
      • 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.
      analyzed 59 patients undergoing SCR with dermal allografts, demonstrating improvements in the patients’ pain and functional outcomes measures. However, there was a 19% rate of revision surgery and only 45% of grafts demonstrated complete healing. Although some studies have shown promising outcomes,
      • 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.
      others have shown clinical failure rates up to 65%
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      and retear rates up to 70%.
      • Badman B.L.
      • Baessler A.M.
      • Moor M.
      Short-term clinical outcomes and comparison of ultrasound versus magnetic resonance imaging of superior capsular reconstruction.
      As with the autografts, the infraspinatus integrity played an important role, with a clinical failure rate of 84% in patients with infraspinatus tendons grade II-IV fatty infiltration based on Goutallier grade.
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      Given that SCR is a static restraint designed to depress the humeral head, its inability to restore the posterior force couple may limit the effectiveness of SCR in managing massive tears where the infraspinatus is truly irreparable. These findings are supported in the current study, with improved outcomes in patients who underwent SCR in combination with infraspinatus repair and a greater proportion of patients reaching SCB for ASES scores at 1 year postoperatively compared with SCR alone.
      Repair of the infraspinatus as a treatment for massive irreparable rotator cuff tears is a well-accepted and widely adopted intervention first described by Burkhart et al.
      • Burkhart S.S.
      • Nottage W.M.
      • Ogilvie-Harris D.J.
      • Kohn H.S.
      • Pachelli A.
      Partial repair of irreparable rotator cuff tears.
      in 1994. The intervention was proposed to restore the anteroposterior force couples, thus restoring the “suspension bridge” effect to the shoulder resulting in improved biomechanics.
      • Burkhart S.S.
      • Esch J.C.
      • Jolson R.S.
      The rotator crescent and rotator cable: An anatomic description of the shoulder's "suspension bridge.".
      ,
      • Burkhart S.S.
      • Nottage W.M.
      • Ogilvie-Harris D.J.
      • Kohn H.S.
      • Pachelli A.
      Partial repair of irreparable rotator cuff tears.
      Several studies have demonstrated significantly improved pain, range of motion, and functional outcomes following partial rotator cuff repair supporting the force–couple theory.
      • Cuff D.J.
      • Pupello D.R.
      • Santoni B.G.
      Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: Midterm outcomes with a minimum 5 years of follow-up.
      ,
      • Chen K.H.
      • Chiang E.R.
      • Wang H.Y.
      • Ma H.L.
      Arthroscopic partial repair of irreparable rotator cuff tears: Factors related to greater degree of clinical improvement at 2 years of follow-up.
      ,
      • Shon M.S.
      • Koh K.H.
      • Lim T.K.
      • Kim W.J.
      • Kim K.C.
      • Yoo J.C.
      Arthroscopic partial repair of irreparable rotator cuff tears: Preoperative factors associated with outcome deterioration over 2 years.
      ,
      • Moser M.
      • Jablonski M.V.
      • Horodyski M.
      • Wright T.W.
      Functional outcome of surgically treated massive rotator cuff tears: A comparison of complete repair, partial repair, and debridement.
      In the current study, dynamic restoration of the anteroposterior force–couple (i.e., pRCR) was combined with static restraint to superior migration (i.e., SCR) resulting in continuously improving outcomes at 2 years postoperatively, contradicting the deteriorating outcomes observed following partial repair alone.
      • Shon M.S.
      • Koh K.H.
      • Lim T.K.
      • Kim W.J.
      • Kim K.C.
      • Yoo J.C.
      Arthroscopic partial repair of irreparable rotator cuff tears: Preoperative factors associated with outcome deterioration over 2 years.
      Thus, these seemingly independent interventions may have a synergistic effect with the humeral head depression imposed by SCR acting to recenter the humeral head and detension the infraspinatus repair, protecting its function and integrity over time. This concept has also been demonstrated in biomechanical
      • 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.
      and clinical
      • Woodmass J.M.
      • Wagner E.R.
      • Borque K.A.
      • Chang M.J.
      • Welp K.M.
      • Warner J.J.P.
      Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
      ,
      • 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.
      ,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      studies of SCR. In the setting of an irreparable infraspinatus alone or in combination with teres minor, surgeons should potentially consider other salvage procedures, such as arthroscopic-assisted tendon transfers
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      • Warner J.J.
      • Parsons IMt
      Latissimus dorsi tendon transfer: A comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
      • Elhassan B.T.
      • Wagner E.R.
      • Werthel J.D.
      Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.
      • Elhassan B.T.
      • Sanchez-Sotelo J.
      • Wagner E.R.
      Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears.
      • Elhassan B.T.
      • Alentorn-Geli E.
      • Assenmacher A.T.
      • Wagner E.R.
      Arthroscopic-assisted lower trapezius tendon transfer for massive irreparable posterior-superior rotator cuff tears: surgical technique.
      • Wagner E.R.
      • Woodmass J.M.
      • Welp K.M.
      • et al.
      Novel arthroscopic tendon transfers for posterosuperior rotator cuff tears: Latissimus dorsi and lower trapezius transfers.
      • Wagner E.R.
      • Elhassan B.T.
      Tendon transfers for rotator cuff pathologies.
      or reverse shoulder arthroplasties.
      • Boileau P.
      • Watkinson D.
      • Hatzidakis A.M.
      • Hovorka I.
      Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty.
      • Hartzler R.U.
      • Steen B.M.
      • Hussey M.M.
      • et al.
      Reverse shoulder arthroplasty for massive rotator cuff tear: Risk factors for poor functional improvement.
      • Wagner E.R.
      • Houdek M.T.
      • Schleck C.D.
      • et al.
      The role age plays in the outcomes and complications of shoulder arthroplasty.
      Recovery curves are becoming increasingly important in understanding the process of recovery following shoulder surgery. Interestingly, the postoperative recovery curves referenced in this study demonstrate a delayed early recovery when a concomitant infraspinatus repair was performed. However, patients who underwent infraspinatus repair demonstrated greater patient-reported outcome measures for all variables by 6 months postoperatively with statistically significant values being observed for VAS, ASES Function, and ASES Index by 1-year postoperatively. This delayed early recovery with improved long-term prognosis when infraspinatus repair is performed is important for both surgeons and patients to understand.

      Limitations

      Several limitations should be considered when interpreting the data presented in this study. First, factors relating to surgical technique, intra or postoperative complications, reoperations, revision surgery, radiographic outcomes, or range of motion were not captured and reported. Second, the lack of a physical follow-up is a major limitation. Third, there were a disproportionate number of concomitant procedures and worker’s compensation patients between the 2 groups. Fourth, the number of patients in the SCR+RCR group was limited to 17 patients. Although this met the intended sample size for the primary outcome (ASES), it may have been underpowered for the secondary outcomes evaluated. This may explain the failure to reach a statistical significance for SANE scores. Finally, as is inherent to all database studies, the accuracy of the information reported is depended on the completeness of data entry, the accuracy of the coding of each surgical procedure, the surgeries were performed by multiple surgeons, and the surgical technique was not standardized throughout the patient cohort.

      Conclusions

      SCR provides modest improvements in pain and function at 1 and 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

      Supplementary Material

      References

        • Gerber C.
        • Schneeberger A.G.
        • Hoppeler H.
        • Meyer D.C.
        Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: A study in thirteen patients.
        J Shoulder Elbow Surg. 2007; 16: 691-696
        • Kim J.Y.
        • Park J.S.
        • Rhee Y.G.
        Can preoperative magnetic resonance imaging predict the reparability of massive rotator cuff tears?.
        Am J Sports Med. 2017; 45: 1654-1663
        • Meyer D.C.
        • 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: 2242-2247
        • Meyer D.C.
        • Farshad M.
        • Amacker N.A.
        • Gerber C.
        • Wieser K.
        Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears.
        Am J Sports Med. 2012; 40: 606-610
        • Henry P.
        • Wasserstein D.
        • Park S.
        • et al.
        Arthroscopic repair for chronic massive rotator cuff tears: A systematic review.
        Arthroscopy. 2015; 31: 2472-2480
        • Zingg P.O.
        • Jost B.
        • Sukthankar A.
        • Buhler M.
        • Pfirrmann C.W.
        • Gerber C.
        Clinical and structural outcomes of nonoperative management of massive rotator cuff tears.
        J Bone Joint Surg Am. 2007; 89: 1928-1934
        • Boileau P.
        • Baque 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.
        J Bone Joint Surg Am. 2007; 89: 747-757
        • Mallon W.J.
        • Wilson R.J.
        • Basamania C.J.
        The association of suprascapular neuropathy with massive rotator cuff tears: A preliminary report.
        J Shoulder Elbow Surg. 2006; 15: 395-398
        • Cuff D.J.
        • Pupello D.R.
        • Santoni B.G.
        Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: Midterm outcomes with a minimum 5 years of follow-up.
        J Shoulder Elbow Surg. 2016; 25: 1803-1809
        • Ono Y.
        • Davalos Herrera D.A.
        • Woodmass J.M.
        • Boorman R.S.
        • Thornton G.M.
        • Lo I.K.
        Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review.
        Arthroscopy. 2017; 33: 673-680
        • Mihata T.
        • Lee T.Q.
        • Watanabe C.
        • et al.
        Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
        Arthroscopy. 2013; 29: 459-470
        • 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.
        Arthroscopy. 2018; 34: 1764-1773
        • Woodmass J.M.
        • Wagner E.R.
        • Borque K.A.
        • Chang M.J.
        • Welp K.M.
        • Warner J.J.P.
        Superior capsule reconstruction using dermal allograft: Early outcomes and survival.
        J Shoulder Elbow Surg. 2019; 28: S100-S109
        • 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.
        Arthroscopy. 2018; 34: 93-99
        • Gerber C.
        • Vinh T.S.
        • Hertel R.
        • Hess C.W.
        Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
        Clin Orthop Relat Res. 1988; : 51-61
        • Warner J.J.
        • Parsons IMt
        Latissimus dorsi tendon transfer: A comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
        J Shoulder Elbow Surg. 2001; 10: 514-521
        • Elhassan B.T.
        • Wagner E.R.
        • Werthel J.D.
        Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.
        J Shoulder Elbow Surg. 2016; 25: 1346-1353
        • Elhassan B.T.
        • Sanchez-Sotelo J.
        • Wagner E.R.
        Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears.
        J Shoulder Elbow Surg. 2020; 29: 2135-2142
        • Elhassan B.T.
        • Alentorn-Geli E.
        • Assenmacher A.T.
        • Wagner E.R.
        Arthroscopic-assisted lower trapezius tendon transfer for massive irreparable posterior-superior rotator cuff tears: surgical technique.
        Arthrosc Tech. 2016; 5: e981-e988
        • Wagner E.R.
        • Woodmass J.M.
        • Welp K.M.
        • et al.
        Novel arthroscopic tendon transfers for posterosuperior rotator cuff tears: Latissimus dorsi and lower trapezius transfers.
        JBJS Essent Surg Tech. 2018; 8: e12
        • Wagner E.R.
        • Elhassan B.T.
        Tendon transfers for rotator cuff pathologies.
        Curr Orthop Pract. 2019; 30: 192-199
        • Woodmass J.M.
        • Wagner E.R.
        • Chang M.J.
        • et al.
        Arthroscopic treatment of massive posterosuperior rotator cuff tears: A critical analysis review.
        JBJS Rev. 2018; 6: e3
        • Burkhart S.S.
        • Esch J.C.
        • Jolson R.S.
        The rotator crescent and rotator cable: An anatomic description of the shoulder's "suspension bridge.".
        Arthroscopy. 1993; 9: 611-616
        • Chen K.H.
        • Chiang E.R.
        • Wang H.Y.
        • Ma H.L.
        Arthroscopic partial repair of irreparable rotator cuff tears: Factors related to greater degree of clinical improvement at 2 years of follow-up.
        Arthroscopy. 2017; 11: 1949-1955
        • Shon M.S.
        • Koh K.H.
        • Lim T.K.
        • Kim W.J.
        • Kim K.C.
        • Yoo J.C.
        Arthroscopic partial repair of irreparable rotator cuff tears: Preoperative factors associated with outcome deterioration over 2 years.
        Am J Sports Med. 2015; 43: 1965-1975
        • 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.
        Am J Sports Med. 2016; 44: 1423-1430
        • Cofield R.H.
        Rotator cuff disease of the shoulder.
        J Bone Joint Surg Am. 1985; 67: 974-979
        • Cvetanovich G.L.
        • Gowd A.K.
        • Liu J.N.
        • et al.
        Establishing clinically significant outcome after arthroscopic rotator cuff repair.
        J Shoulder Elbow Surg. 2019; 28: 939-948
        • 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.
        Arthrosc Tech. 2016; 5: e1407-e1418
        • Hirahara A.M.
        • Andersen W.J.
        • Panero A.J.
        Superior capsular reconstruction: Clinical outcomes after minimum 2-year follow-up.
        Am J Orthop (Belle Mead NJ). 2017; 46: 266-278
        • 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.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2205-2213
        • Mihata T.
        • Lee T.Q.
        • Hasegawa A.
        • et al.
        Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
        J Bone Joint Surg Am. 2019; 101: 1921-1930
        • Catapano M.
        • de Sa D.
        • Ekhtiari S.
        • Lin A.
        • Bedi A.
        • Lesniak B.P.
        Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature.
        Arthroscopy. 2019; 35: 1243-1253
        • Sochacki K.R.
        • McCulloch P.C.
        • Lintner D.M.
        • Harris J.D.
        Superior capsular reconstruction for massive rotator cuff tear leads to significant improvement in range of motion and clinical outcomes: A systematic review.
        Arthroscopy. 2019; 35: 1269-1277
        • Badman B.L.
        • Baessler A.M.
        • Moor M.
        Short-term clinical outcomes and comparison of ultrasound versus magnetic resonance imaging of superior capsular reconstruction.
        Arthrosc Sports Med Rehabil. 2020; 2: e229-e235
        • Goutallier D.
        • Postel J.M.
        • Bernageau J.
        • Lavau L.
        • Voisin M.C.
        Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
        Clin Orthop Relat Res. 1994; : 78-83
        • Burkhart S.S.
        • Nottage W.M.
        • Ogilvie-Harris D.J.
        • Kohn H.S.
        • Pachelli A.
        Partial repair of irreparable rotator cuff tears.
        Arthroscopy. 1994; 10: 363-370
        • Moser M.
        • Jablonski M.V.
        • Horodyski M.
        • Wright T.W.
        Functional outcome of surgically treated massive rotator cuff tears: A comparison of complete repair, partial repair, and debridement.
        Orthopedics. 2007; 30: 479-482
        • Boileau P.
        • Watkinson D.
        • Hatzidakis A.M.
        • Hovorka I.
        Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty.
        J Shoulder Elbow Surg. 2006; 15: 527-540
        • Hartzler R.U.
        • Steen B.M.
        • Hussey M.M.
        • et al.
        Reverse shoulder arthroplasty for massive rotator cuff tear: Risk factors for poor functional improvement.
        J Shoulder Elbow Surg. 2015; 24: 1698-1706
        • Wagner E.R.
        • Houdek M.T.
        • Schleck C.D.
        • et al.
        The role age plays in the outcomes and complications of shoulder arthroplasty.
        J Shoulder Elbow Surg. 2017; 26: 1573-1580