Okay, thank you very much. This next talk is on superior capsule reconstruction is it better than a bridging wrap. These are my disclosures. As we all know, when we are faced with a massive irreparable tear, there are a number of different treatment options which can be utilized. These can be as simple as a gun human debridement tuberoplasty and some sort of bicep tendon surgery to partial repair bridging grasp your capsule reconstruction, or even a reverse shoulder arthroplasty. And of course, it's really that superior capsule reconstruction, which has become popularized particularly over the last five years. And we know of course, Mihata was the first and the inventor of the superior capsule reconstruction. And this particular case when he was in Japan, he really needed a treatment option for his patients who had significant proximal humeral migration, as well as shoulder dysfunction. And at that time in Japan, there was really no availability for a reverse shoulder arthroplasty. So he discovered and invented really this unique procedure, where instead of attaching the graft from the end of the tendon to the bone, he decided to in fact repair the superior capsule. And that in fact, he attached a graph from the superior glenoid to the lateral aspect of the humerus. And because also in Japan, there was limited availability of allografts, he actually used fascia ladder autograft. And he also did a number of studies to look at the importance of the superior capsule. And what he discovered was that when you created a defect in the superior aspect of the capsule, this increased the translation in all directions, and also increased subacromial contact. However, he also did another study which showed that when you do have a massive tear of the supraspinatus tendon, this of course, again, increased superior translation and increased subacromial contact. But a bridging graft, which is a graft which only repairs the tendon to the bone, while it did somewhat improve superior translation and decreased subacromial contact, a graft which span between the glenoid and the humerus, that is so called superior capsule reconstruction, did this even better, with even more improved or decrease of the superior translation and as well as a decrease in the subacromial contact. And when he first presented his work on the first 24 shoulders, at an average of three months, sorry, three years, essentially, he got remarkable results. He had an increase in the American shoulder level surgery score from 24 to up to 93, and improvement in the forward elevation. 83% of his grafts were intact on MRI. But very interestingly, he had an improvement in the acromio-humeral interval, suggesting some sort of biomechanical improvement as well, from 4.6 to 8.7 millimeters. And in fact, this is quite durable. You can see in his longer term study, his five-year results, 30 patients again, he only had a 10% retail rate. And again, he had still a significant improvement in his acromio-humeral interval as well as improved clinical results. And you should know that this results or these results are extremely, extremely good. In fact, an ASES score of 93 is extremely high. You can see in this study of arthroscopic rotator cuff repair in just young patients. So this is what you might consider the ideal rotator cuff repair. Young patients with a rotator cuff with under these expert surgeons, the ASES score is 84. So 93 is actually extremely, extremely high. Well, what has been the experience of other authors using this technique? You can see here, Dr. Burkert's initial results, 59 patients, the average age was 62, a fall of a year. Again, very good clinical results as far as improvement in the forward elevation and proven in an external rotation and the ASES score up to 77, 78. So maybe not as high as 93, but still a significant improvement per se. But the anatomic results were really not as good. And of course, we know that Dr. Burkert and many of us US or North American surgeons utilizing human dermal allograft. And you can see here that only 45% of these grafts were actually healed on the MRI. The chromohumeral interval had a transient improvement, but did not stay persistently high. And in addition, what he noticed was that subscapularis atrophy was associated with healing of the graft. That is, you have to have an intact subscapularis for this human dermal allograft in particular to heal. That's been the experience of other authors. You can see in this study out of Rush, who they essentially looked at the factors associated with failure of a superior capsule reconstruction. So they defined superior capsule reconstruction failure as a patient who required a reverse shoulder arthroplasty or patients who actually thought they were worse after surgery or decreases in the patient reported outcome measurement tools. So out of their 54 patients, 11 of them were considered failure, about a failure rate of 20%, average follow-up of 24 months. And you can see, females were thought to have a higher risk of failure, but again, patients associated with a subscapularis tear. There were also trends with decreased forward elevation, decreased the chromohumeral interval, and increased BMI as well. But the two major factors were again, female and again, the subscapularis tear. In addition, you can see in the study, I believe out of Korea, where it's also associated failure of the graft with the residual rotator cuff tendon. You can see in these 36 shoulders, superior capsule reconstruction, a mean of about two months follow-up, 13 patients retore, that is 36%. You can see while there was significant improvements in all of their scores, the intact rate was associated with the integrity of the posterior rotator cuff. That is to say that if you did not have an intact posterior rotator cuff, that it tended to fail. So really, when you think about it, we're talking about intact subscapularis and intact posterior cuff as well as being important factors as far as the success of this type of surgery. So the question of course is, is it just really the partial repair that's really important in this type of procedure? Because we know of course that when we can balance the force couples about the shoulder, we can actually get a very functional shoulder in and of itself. And we know that when you just do a partial repair, you can have the significant improvement. You can see in this meta-analysis here, you again of course have improved in motion, excrementation, decrease in your visual analog scale for pain and improvement in ACS and constant score. And you can think of that, and that's actually quite close to what you might get from some of these superior capsule reconstruction results. The question of course is, does adding a graft improve results even over and above a partial repair? And you can see in this very large meta-analysis or a structured literature review here from the American Shoulder and Elbow Society, this is a special group within it called the Massive Cuff Evaluation and Research Initiative. Investigators, we looked at all the options related to massive irreparable rotator cuffs. And what they noted was that partial repair was definitely better than physical therapy. A bridging graft did have significant evidence for improvement over a partial repair. And the superior capsule reconstruction, particularly related to fascia latae, did have some improvement related to the partial repair, but not as much as in fact a bridging graft. Interestingly enough, they also felt that this was specifically related, more likely related to the fascia latae. There seemed to have more evidence per se. So is that part of the problem with the major, some of the U.S. experience? Is it actually the graft itself? And you can see here in this biomechanical study by Mihata comparing fascia latae autograft versus human dermal allograft, both grafts did improve superior stability. However, the fascia latae graft did it much better than the human dermal allograft. And the human dermal allograft tends to stretch quite a bit more and relied on suturing of the anterior and posterior aspect of the graft to allow it to function better, which of course is in part related to if you have an intact anterior and an intact posterior cuff as well. So the question really is, does that make a difference? That is using the graft, fascia latae autograft versus a human dermal allograft. And you can see in this structural review here from the arthroscopy journal in 2020, seven studies with 344 shoulders, both human dermal allograft and fascia latae autograft had an improvement in forward elevation constant score and ACPS score. However, you can see on the MRI, the re-tear rate for the fascia latae autograft was between five and 32%, where the re-tear rate in the human dermal allograft seemed to be higher between 20 and 75%. However, these studies were so heterogeneity, had significant heterogeneity that really they were unable to compare the results. However, finally, you can see in this meta-analysis here by Lin and AJSM in 2020, where they looked at 23 studies comparing superior capsule reconstruction versus a bridging graft. You can see the bridging graft actually has a significantly more number of patients as well as significantly longer follow-up. They also had, interestingly enough, similar healing rates, but you can see that the bridging graft had a significant improvement in the constant score, the ACS score, the visual analytic score for pain and active exhalation, which was actually significantly better than that of the superior capsule reconstruction that has been reported. And that actually favors the bridging graft. The difficulty, of course, when you have these types of meta-analysis studies is really are the indications for these two types of surgeries the same. It's a little bit unclear. Of course, all of them are related to essentially irreparable tears, but it's the severity of the tear worse. It's a little bit unclear because the indications may be slightly different between these two groups, per se. In addition, when we're looking at superior capsule reconstruction, almost always, they talk about fatty infiltration being greater than grade three, as well as a lot of these patients have significant pseudo-paralysis, whereas in the bridging graft patients, this is rarely mentioned. So we might be really talking about two different patient groups as well. So in conclusion, I think both of these types of procedures, of course, can improve patient reported outcomes as well as range of motion, but at least with the existing literature, the bridging graft seems to be still a very viable option and may, in fact, be somewhat better than superior capsule reconstruction when we strictly look at some of these results. But really, we need more clinical studies, particularly prospective randomized control studies where the indications are actually the same and we can compare the surgeries and also look at different graft types as well. Thank you very much.

superior capsule reconstruction

shoulder tears

fascia ladder autograft

clinical outcomes

graft material