Purpose To investigate the effects of graft length and thickness on shoulder biomechanics after superior capsule reconstruction. Methods Subacromial peak contact pressure and glenohumeral superior ...translation were measured at 0°, 30°, and 60° of glenohumeral abduction in 8 fresh-frozen cadaveric shoulders under 5 conditions: (1) intact shoulder; (2) irreparable supraspinatus tendon tear, (3) superior capsule reconstruction with a fascia lata allograft 4-mm thick and 15 mm longer than the distance from the superior glenoid to the lateral edge of the greater tuberosity, as determined during placement at 30° of glenohumeral abduction; (4) superior capsule reconstruction with a fascia lata allograft 8-mm thick and with the same 15 mm relative length determined at 10° of glenohumeral abduction, and (5) superior capsule reconstruction with a fascia lata allograft 8-mm thick and with the 15-mm relative length determined at 30° of glenohumeral abduction. To investigate the effect of graft thickness, we compared the data from conditions 1, 2, 3, and 5. To assess the effect of graft length, we compared conditions 1, 2, 4, and 5. Results With superior capsule reconstruction using a 4-mm graft, subacromial peak contact pressure (but not superior translation) was significantly lower than with irreparable supraspinatus tears (at 0° abduction: 259% decrease; P = .0002; at 30° abduction: 113% decrease; P = .01). The superior capsule reconstruction using an 8-mm graft significantly decreased both subacromial peak contact pressure (at 0° abduction: 246% decrease, P = .0002; at 30° abduction: 158% decrease; P = .0008; at 60° abduction: 57% decrease; P = .04) and superior translation (at 0° abduction: 135% decrease; P = .02; at 30° abduction; 130% decrease; P = .004). Graft length with placement at 10° glenohumeral abduction was 5 mm greater than that at 30° abduction. The 8-mm superior capsule reconstruction performed at 10° or 30° of glenohumeral abduction significantly decreased subacromial peak contact pressure (placement at 10° and 30°: 0° abduction, P = .0002 and .0002, respectively; 30° abduction, P = .0004 and .0005, respectively; 60° abduction, P = .04 and .04, respectively) and superior translation (placement at 10° and 30°; 0° abduction, P =.04 and .02, respectively; 30° abduction, P = .02 and .004, respectively) compared with irreparable supraspinatus tears. Conclusions Superior capsule reconstruction normalized the superior stability of the shoulder joint when the graft was attached at 10° or 30° of glenohumeral abduction. An 8-mm-thick graft of fascia lata had greater stability than did a 4-mm-thick graft. Clinical Relevance Grafts 8-mm thick and attached at 15° to 45° of shoulder abduction (equal to 10° to 30° of glenohumeral abduction) biomechanically restore shoulder stability during superior capsule reconstruction using fascia lata.
Arthroscopic superior capsule reconstruction was developed to restore superior stability, muscle balance, and function in the shoulder joint after an irreparable rotator cuff tear. Our objective was ...to assess the functional and radiographic results of superior capsule reconstruction after 5 years of follow-up.
Thirty patients who underwent arthroscopic superior capsule reconstruction using fascia lata autograft were enrolled in this study. The inclusion criteria were an irreparable rotator cuff tear confirmed by shoulder arthroscopy and 5 years of postoperative follow-up. Shoulder range of motion, American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, rates of return to sport and physical work, acromiohumeral distance, Goutallier grade of all rotator cuff muscles, graft healing and thickness, and postoperative cuff tear arthropathy were investigated.
Compared with preoperative values, ASES and JOA scores, active elevation, and acromiohumeral distance increased postoperatively at both 1 year (p < 0.001) and 5 years (p < 0.001); the 1-year values increased by 54.0 points for the ASES score, 34.4 points for the JOA score, 53° for active elevation, and 5.7 mm for acromiohumeral distance, and the 5-year values increased by 63.3 points for the ASES score, 39.9 points for the JOA score, 66° for active elevation, and 4.7 mm for acromiohumeral distance. The ASES score was greater at 5 years postoperatively than it was at 1 year postoperatively (mean difference, 9.3 points; p = 0.03). At 5 years postoperatively, 11 of 12 patients returned to physical work, a rate of 92% (95% confidence interval CI, 73% to 100%), and 8 of 8 patients returned to sports, a rate of 100% (95% CI, 79% to 100%). None of the 27 patients who had graft healing showed progression of cuff tear arthropathy, but all 3 patients with a graft tear (10% 95% CI, 0% to 22%) had severe cuff tear arthropathy at 5 years postoperatively. In the 27 patients whose grafts remained intact, the graft thicknesses at 3 months, 1 year, and 5 years postoperatively did not differ (p = 0.67).
In this 5-year follow-up study, healed arthroscopic superior capsule reconstruction restored shoulder function and resulted in high rates of return to recreational sport and work. In patients with postoperative graft failure, severe cuff tear arthropathy was present at 5 years.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Background:
Patients with pseudoparalysis and irreparable rotator cuff tears have very poor function. The authors developed a superior capsule reconstruction (SCR) technique for irreparable rotator ...cuff tears that restores shoulder stability and muscle balance, improving shoulder function and relieving pain.
Purpose:
To evaluate whether arthroscopic SCR reversed preoperative pseudoparalysis in patients with irreparable rotator cuff tears.
Study Design:
Case series; Level of evidence, 4.
Methods:
One hundred consecutive patients with irreparable rotator cuff tears underwent arthroscopic SCR with fascia lata autografts; 7 patients with deltoid weakness from cervical or axillary nerve palsy and 5 with severe presurgical shoulder stiffness were excluded. The remaining 88 were allocated to 3 groups according to their preoperative active shoulder elevation: no pseudoparalysis (45 patients; mean age, 66.2 years; mean tear size, 3.5 cm), moderate pseudoparalysis (28 patients, 68.3 years, 3.5 cm), and severe pseudoparalysis (15 patients, 62.3 years, 4.9 cm). Clinical outcome, active shoulder range of motion, acromiohumeral distance, and healing rate were compared between patients with and without pseudoparalysis, as well as before surgery and at final follow-up (35-110 months).
Results:
American Shoulder and Elbow Surgeons score, active elevation, active external rotation, and acromiohumeral distance increased significantly after arthroscopic SCR among all patients. Graft healing rates did not differ among the groups (P = .73): 98% (44 of 45) for no pseudoparalysis, 96% (27 of 28) for moderate pseudoparalysis, and 87% (13 of 15) for severe pseudoparalysis. Pseudoparalysis was reversed in 96% (27 of 28) of patients with preoperative moderate pseudoparalysis and 93% (14 of 15) with preoperative severe pseudoparalysis. Both patients with residual pseudoparalysis postoperatively (1 of 28 with preoperative moderate pseudoparalysis, 1 of 15 with preoperative severe pseudoparalysis) had graft tears.
Conclusion:
Arthroscopic SCR restored superior glenohumeral stability and improved shoulder function among patients with or without pseudoparalysis who had previously irreparable rotator cuff tears. In the absence of postoperative graft tear, arthroscopic SCR reversed preoperative pseudoparalysis. Graft healing rates after arthroscopic SCR did not differ between patients with and without pseudoparalysis.
Background:
Although sports participation and heavy physical work can contribute to rotator cuff tears, many patients expect to return to these activities after surgery; however, irreparable rotator ...cuff tears can preclude this outcome. A new surgical treatment—arthroscopic superior capsule reconstruction (SCR)—restores shoulder stability and muscle balance in patients with irreparable rotator cuff tears; consequently, it improves shoulder function and relieves pain.
Purpose:
To evaluate the rates of return to sports and physical work among patients treated with arthroscopic SCR.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
From 2007 to 2014, we performed arthroscopic SCR in 105 patients with irreparable rotator cuff tears, 5 of whom were lost to follow-up. Consequently, 100 patients (mean age, 66.9 years; range, 43-82 years) were enrolled in the study. Before surgery, 26 patients had participated in sports (2 competitive, 24 recreational), and 34 patients had physical work. Rates of return to sports and physical work, the American Shoulder and Elbow Surgeons (ASES) score, active shoulder range of motion, and rate of graft tear were evaluated. The mean time to final follow-up was 48 months (range, 24-88 months).
Results:
All 26 patients who played sports before their injuries returned fully to them. In addition, 32 patients returned fully to their previous physical work, whereas the 2 remaining patients returned with reduced hours and workloads. As compared with the nonsports group, the sports group had significantly higher postoperative active elevation (160° ± 32° vs 146° ± 39°; P = .04) and higher postoperative ASES scores (97 ± 7 vs 91 ± 12; P = .02). The shoulder range of motion and ASES scores before and after surgery did not differ significantly between the physical and nonphysical work groups (P = .11-.99). The rate of graft tear did not differ between the sports group (4%) and nonsports group (5%) (P = .75) and between the physical work group (6%) and nonphysical work group (5%) (P = .77).
Conclusion:
Arthroscopic SCR restored shoulder function and resulted in high rates of return to recreational sports and physical work.
Background:
Patients with irreparable rotator cuff tears have a defect of the superior capsule, which creates discontinuity of the shoulder capsule in the transverse direction (anterior-posterior ...direction). This effect is one of the causes underlying shoulder instability after rotator cuff tears.
Purpose/Hypothesis:
The purpose of this study was to assess the effects of anterior and posterior continuity on shoulder biomechanics after superior capsule reconstruction (SCR). The hypothesis was that capsular continuity in the transverse direction would improve glenohumeral stability after SCR.
Study Design:
Controlled laboratory study.
Methods:
Seven fresh-frozen cadaveric shoulders were tested by using a custom shoulder testing system. Subacromial peak contact pressure, glenohumeral superior translation, glenohumeral compression force, and glenohumeral range of motion (ROM) were compared among 5 conditions: (1) intact shoulder, (2) simulated irreparable supraspinatus tendon tear, (3) SCR without side-to-side suturing, (4) SCR with posterior side-to-side suturing, and (5) SCR with both anterior and posterior side-to-side suturing.
Results:
The creation of an irreparable supraspinatus tear significantly increased glenohumeral superior translation (0° of abduction: 254% of intact P = .04; 30° of abduction: 200% of intact P = .04) and subacromial peak contact pressure (0° of abduction: 302% of intact P = .0001; 30° of abduction: 239% of intact P = .0006), decreased glenohumeral compression force (0° of abduction: 85% of intact P = .004; 30° of abduction: 87% of intact P = .0002; 60° of abduction: 88% of intact P = .0001), and increased total ROM (0° of abduction: 16° increase P = .008). SCR without side-to-side suturing significantly decreased subacromial peak contact pressure (0° of abduction: 79% of intact P = .0001; 30° of abduction: 91% of intact P = .001; 60° of abduction: 55% of intact P = .04) but did not inhibit glenohumeral superior translation. By adding posterior side-to-side sutures, both glenohumeral superior translation (0° of abduction: 93% of intact P = .02; 30° of abduction: 110% of intact P = .04) and subacromial peak contact pressure decreased significantly (0° of abduction: 56% of intact P = .0001; 30° of abduction: 83% of intact P = .0003; 60° of abduction: 46% of intact P = .04). Neither SCR with nor SCR without side-to-side suturing ameliorated the tear-associated decrease in glenohumeral compression force and increase in total ROM. Adding anterior side-to-side sutures did not change any measurements compared with SCR with posterior side-to-side suturing.
Conclusion:
SCR with side-to-side suturing completely restored the superior stability of the shoulder joint by establishing posterior continuity between the graft, residual infraspinatus tendon, and underlying shoulder capsule.
Clinical Relevance:
Side-to-side suturing between the graft, residual infraspinatus tendon, and underlying shoulder capsule is recommended for SCR in patients with irreparable supraspinatus tendon tears to restore superior stability after surgery.
C5 palsy is a major complication of cervical spine surgery, however, its exact pathogenesis remains unclear. Some studies have shown that the superficial layer of the posterior longitudinal ligament ...extends laterally and forms the periradicular fibrous sheath (PFS), and envelopes the nerve roots. However, the anatomical relationship between the PFS and nerve root at each cervical level has not been fully revealed.
To examine the difference of the PFS that covers the nerve root at each cervical level, and to consider its potential in the onset of postoperative C5 palsy.
Anatomical study of cervical dissection of 13 embalmed cadavers.
Thirteen human formalin-fixed cadavers were dissected from posterior approach, and were observed their cervical nerves bilaterally from C3 to C8 (the total number of nerves was 156). The bare area length (BAL), which is the distance between the medial posterior edge of the PFS and the bifurcation of the nerve and dura mater, was measured by using electronic calipers. Thus, BAL is the uncovered area of the nerve root by the PFS. We examined whether BAL significantly varied at each cervical level.
We confirmed the PFS macro- and/or microanatomically in all cadavers. The average BAL gradually increased craniocaudally, and there was a significant step between that of C5 and C6 level.
The average BAL of the C5 root was significantly shorter than that of C6, C7, and C8, suggesting that C5 root was more tightly anchored. This could be one reason for C5 palsy, making C5 nerve root vulnerable to the traction caused by the postoperative spinal cord shift.
This study provides clinicians an additional understanding of the anatomical factor of C5 palsy. Consideration of the anchoring effect of the PFS for nerve roots, release of the PFS could be a preventive procedure for C5 palsy.
Background:
Arthroscopic superior capsule reconstruction (SCR) was developed to restore shoulder superior stability, muscle balance, and function in patients with irreparable posterior-superior ...rotator cuff tears.
Purpose:
To assess the effects of concomitant subscapularis tendon tear, which may reduce glenohumeral stability and force coupling, on clinical outcomes of SCR for irreparable posterior-superior rotator cuff tears.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
In total, 193 patients with irreparable posterior-superior rotator cuff tears underwent arthroscopic SCR using fascia lata autograft between 2007 and 2015. They were allocated to 3 groups: group 1, no subscapularis tear (160 patients); group 2, reparable subscapularis tear, which underwent arthroscopic repair (26 patients); and group 3, irreparable subscapularis tear (7 patients). American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, visual analog scale (VAS) score for pain, active shoulder range of motion (ROM), muscle strength (manual muscle test), and acromiohumeral distance were evaluated before surgery and at final follow-up (mean, 3 years, 7 months; range, 2-11 years). Postoperative complications were assessed.
Results:
In groups 1 and 2, ASES, JOA, and VAS scores and shoulder ROM and muscle strength improved significantly after SCR with subscapularis repair (P < .001). SCR in group 3 significantly improved ASES, JOA, and VAS scores (P < .001), whereas shoulder ROM and muscle strength did not increase significantly. Postoperative acromiohumeral distance was significantly smaller in group 3 (5.7 ± 2.9 mm mean ± SD) than group 2 (9.1 ± 2.3 mm) (P = .002). Group 3 had a significantly higher rate of graft tear (P < .001) and postoperative infection (P < .001) than group 1.
Conclusion:
The presence of subscapularis tendon tear affects clinical outcomes and complication rates after SCR. The reparability of the subscapularis affects superior glenohumeral stability; therefore, an intact subscapularis or reparable subscapularis tendon tear is the best indication for arthroscopic SCR in patients with irreparable posterior-superior rotator cuff tendon tears.
Background:
Acromioplasty is increasingly being performed for both reparable and irreparable rotator cuff tears. However, acromioplasty may destroy the coracoacromial arch, including the ...coracoacromial ligament, consequently causing a deterioration in superior stability even after superior capsule reconstruction.
Purpose/Hypothesis:
The purpose of this study was to investigate the effects of acromioplasty on shoulder biomechanics after superior capsule reconstruction for irreparable supraspinatus tendon tears. The hypothesis was that acromioplasty with superior capsule reconstruction would decrease the area of subacromial impingement without increasing superior translation and subacromial contact pressure.
Study Design:
Controlled laboratory study.
Methods:
Seven fresh-frozen cadaveric shoulders were evaluated using a custom shoulder testing system. Glenohumeral superior translation, the location of the humeral head relative to the glenoid, and subacromial contact pressure and area were compared among 4 conditions: (1) intact shoulder, (2) irreparable supraspinatus tendon tear, (3) superior capsule reconstruction without acromioplasty, and (4) superior capsule reconstruction with acromioplasty. Superior capsule reconstruction was performed using the fascia lata.
Results:
Compared with the intact shoulder, the creation of an irreparable supraspinatus tear significantly shifted the humeral head superiorly in the balanced muscle loading condition (without superior force applied) (0° of abduction: 2.8-mm superior shift P = .0005; 30° of abduction: 1.9-mm superior shift P = .003) and increased both superior translation (0° of abduction: 239% of intact P = .04; 30° of abduction: 199% of intact P = .02) and subacromial peak contact pressure (0° of abduction: 308% of intact P = .0002; 30° of abduction: 252% of intact P = .001) by applying superior force. Superior capsule reconstruction without acromioplasty significantly decreased superior translation (0° of abduction: 86% of intact P = .02; 30° of abduction: 75% of intact P = .002) and subacromial peak contact pressure (0° of abduction: 47% of intact P = .0002; 30° of abduction: 83% of intact P = .0005; 60° of abduction: 38% of intact P = .04) compared with after the creation of a supraspinatus tear. Adding acromioplasty significantly decreased the subacromial contact area compared with superior capsule reconstruction without acromioplasty (0° of abduction: 26% decrease P = .01; 30° of abduction: 21% decrease P = .009; 60° of abduction: 61% decrease P = .003) and did not alter humeral head position, superior translation, or subacromial peak contact pressure.
Conclusion:
Superior capsule reconstruction repositioned the superiorly migrated humeral head and restored superior stability in the shoulder joint. Adding acromioplasty decreased the subacromial contact area without increasing the subacromial contact pressure.
Clinical Relevance:
When superior capsule reconstruction is performed for irreparable rotator cuff tears, acromioplasty may help to decrease the postoperative risk of abrasion and tearing of the graft beneath the acromion.
Purpose
To evaluate the association between the sagittal alignment of the pelvis and residual knee flexion contracture after total knee arthroplasty (TKA). This is important as a flexion contraction ...can be associated with the risk of poor outcomes and patient satisfaction after TKA.
Methods
This was a retrospective, case–control, study of 200 osteoarthritic knees, contributed by 200 patients, over a mean follow-up of 2.4 years. The following factors were compared between patients ‘with’ (46 knees) and ‘without’ (154 knees) a residual flexion contracture ≥ 10° after TKA: age, sex, pelvic incidence (PI), anterior femoral bowing, femoral component flexion angle (FFA), and patient-reported outcomes. Logistic regression and receiver operating characteristic curve analyses were used to identify predictive factors.
Results
The following factors were predictive of a residual flexion contracture ≥ 10°: a pelvic incidence ≥ 55° (odds ratio, 1.29; 95% confidence interval, 1.05−1.59;
P
= 0.031) and the FFA (odds ratio, 1.08; 95% confidence interval, 1.03−1.14;
P
= 0.044). A pelvic incidence cutoff of 55° yielded a significant between-group difference, with a sensitivity of 78.4% and specificity of 89.9% to differentiate a residual knee flexion contracture ≥ 10° (
P
= 0.001), patient satisfaction (
P
= 0.029), EuroQol 5-Dimension score (
P
= 0.028), anterior femoral curvature (
P
= 0.031), and Knee Injury and Osteoarthritis Outcome Score-Joint Replacement score (
P
= 0.046).
Conclusion
A pelvic incidence > 55° is associated with a residual knee flexion contracture ≥ 10° after TKA. The significance of the pelvic incidence measurement as a possible predictor of TKA outcome was highlighted, including its impact on patient satisfaction.
Level of evidence
III.
Background:
Retear of repaired rotator cuff tendons worsens patient outcome and decreases patient satisfaction. Superior capsule reconstruction (SCR) was developed to center the humeral head and thus ...restore the force couple for patients with rotator cuff tears.
Purpose:
To evaluate whether SCR for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Thirty-four consecutive patients (mean age, 69.1 years) with severely degenerated but reparable rotator cuff tears underwent SCR with fascia lata autografts for reinforcement before ARCR. All tears were medium (1-3 cm) or large (3-5 cm), and the number of torn tendons was 2 (supraspinatus and infraspinatus) in 29 shoulders and 3 (supraspinatus, infraspinatus, subscapularis) in 5 shoulders. To assess the benefit of SCR for reinforcement, all data were compared with those after ARCR alone among 91 consecutive patients with medium or large rotator cuff tears (mean age, 63.6 years). The American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopaedic Association (JOA) scores, active shoulder range of motion, and cuff integrity (Sugaya magnetic resonance imaging classification) were compared (t test and chi-square test) between ARCR with and without SCR, as well as before surgery and at final follow-up.
Results:
All 34 patients who underwent SCR before ARCR had neither postoperative retear nor type III cuff integrity, whereas those treated with ARCR alone had a 4% incidence (4 of 91) of retear and 8% incidence of type III cuff integrity. ASES and JOA scores, active elevation, active external rotation, and active internal rotation increased in both treatment groups (P < .001). Postoperative ASES score and active range of motion did not differ between groups, although the Goutallier grade of the supraspinatus was higher for ARCR with SCR (mean, 2.8) than ARCR alone (mean, 2.1; P < .0001).
Conclusion:
SCR for reinforcement prevented retear at 1 year after ARCR and improved the quality of the repaired tendon on magnetic resonance imaging. Functional outcomes were similar between groups, even though degeneration of the torn tendons was greater among patients who underwent ARCR with SCR.
