Dermal Allograft and Biceps Superior Capsule Reconstruction for Massive Irreparable Rotator Cuff Tears

Resumen

Here, we describe a modified technique for dermal allograft and long head of the biceps tendon superior capsule reconstruction for massive irreparable rotator cuff tears.

Resumen

Since the use of autologous fascia lata for superior capsule reconstruction of massive irreparable rotator cuff tears (MIRCTs), the technique has evolved into various modifications, including dermal allografts, long head of the biceps tendon (LHBT), and combinations of both, which will be discussed in this article. After making sure the remnant cuff cannot be restored to the anatomical footprint of the supraspinatus, a double-loaded or triple-loaded, suture-based anchor is inserted 5-8 mm posterior to the bicipital groove to secure the long head of the biceps (LHBT) initially. A bone trough is made 5 mm posterior to the bicipital groove. One or two lasso loops are created through the LHBT before the complete release of the transverse humeral ligament without tenotomy of the LHBT distal to the fixation point, resulting in a posteriorly rerouted LHBT.Preservation of the proximal attachment of the biceps on the glenoid side is maintained, ensuring a native fixation.

Subsequently, a 3 x 3 cm dermal allograft of 2 mm thickness is utilized to cover the rerouted LHBT, enhancing its strength and providing a tensile effect. Four anchors are then employed for fixation: two double-loaded anchors at the glenoid side and two lateral row anchors at the greater tuberosity. Following the introduction of the dermal allograft into the joint, the sutures from the glenoid anchors are secured, and the optimal tension of the allograft is gauged during the insertion of the lateral row anchors at 45° shoulder abduction. The dermal allograft can cover the LHBT to increase the spacer effect. Medial row anchors are not necessary. The remaining portions of the supraspinatus and infraspinatus can be repaired using sutures passed through the lateral row anchors or repaired with the dermal allograft together to enhance stability.

Introducción

Since Mihata et al.¹ published their technique using autologous fascia lata to reproduce the superior capsule of the shoulder, the idea of superior capsule reconstruction (SCR) became very popular in treating massive irreparable rotator cuff tears (MIRCTs). There were many modifications of SCR, including the use of dermal allografts^2,3,4,5, gracilis and semitendinosus tendons⁶, long head of the biceps tendon (LHBT)^7,8,9, as well as combinations of dermal allografts and autologous LHBT¹⁰.

Each technique has its pros and cons regarding the coverage of the footprint, the thickness of the graft, and the different biomechanical properties. Based on Mihata's original article¹¹, a 5 mm-thick graft was created by folding the fascia lata two or three times and suturing around the edge of the folds. In contrast, Denard et al. achieved an 80% successful rate with a 19% short-term revision rate using 1-3 mm-thick acellular dermal allografts instead of autologous fascia lata.

Barth et al. posteriorly rerouted autologous LHBT inMIRCTs and found that it could prevent infraspinatus retears⁷. Kim et al. compared the results of SCR using autologous LHBT or dermal allografts and found no differences between the two groups at 2 years postoperatively, except for the autograft being thicker¹², since the average thickness was 6 mm, which was similar to the 6-8 mm autologous fascia lata used by Mihata et al⁹. This paper presents our technique of combining a 2 mm-thick dermal allograft and autologous LHBT to treat MIRCTs.

Protocolo

This technique was approved by our institution's Ethics Committee (IRB 20230107080), and informed consent was obtained from all patients.

1. Patient selection

1. Select patients for the following indications: MIRCTs less than Hamada grade 2 rotator cuff arthropathy (Figure 1A, B), supraspinatus tendon retraction at Patte stage III ( Figure 1C), no preoperative pseudoparesis, supraspinatus muscle fatty infiltration (FI) equal to or more than Goutallier stage 2 ( Figure 1D), and the presence of LHBT¹³.
2. Set the following exclusion criteria: patients with severe capsular tightness, motion restriction defined as passive internal or external rotation less than 30°, previous ipsilateral shoulder surgery, subscapularis tear > Lafosse type 3¹⁴, fractures, infection-related pathologies, a partial or complete tear of LHBT, severe glenohumeral joint osteoarthritis, and deformity of the humeral head on preoperative X-ray.

2. Surgical procedure

1. Put the patient in a beach chair position with an arm holder.
2. Perform a thorough arthroscopic release of the remnant rotator cuff.
3. Define the subscapularis tear according to Lafosse classification (Figure 2A)¹⁴ and repair accordingly (Figure 2B).
4. Release all vertical fibers beneath the supraspinatus arthroscopically.
5. Insert a double-loaded or triple-loaded, suture-based anchor 5 mm posterior to the bicipital groove to secure the LHBT initially (Figure 2C).
6. Create one lasso loop through the LHBT (Figure 2D).
7. Make a bone trough 5 mm posterior to the bicipital grove (Figure 2E).
8. Complete release of the transverse humeral ligament.
9. Tie the lasso loops passed through the LHBT and posteriorly rerouted the LHBT by the lasso loop just made (Figure 2F).
   NOTE: Do not perform a tenotomy to preserve the integrity of the LHBT.
10. Maintain the proximal attachment of the LHBT on the glenoid side, ensuring native fixation.
11. Use the other suture from the anchor to repair the remnant anterior cuff, providing more soft tissue coverage on top of the rerouted LHBT (Figure 2G).
12. Insert two double-loaded suture-based anchors through the Naviaser portal at the top of the glenoid, allowing for four pairs of sutures (Figure 2H), and shuttle them through the anterolateral portal for further use.
13. Pass all eight sutures (four pairs of sutures) from the two anchors through one side of a 3 x 3 cm dermal allograft with a thickness of 2 mm, outside the shoulder.
14. Tie one suture from each anchor together to provide a double-pulley fashion (Figure 2I). The other 2 pairs of sutures through the dermal allograft work with a mattress suture fashion.
15. Use a half-cut 10 mL syringe as a hand-made cannula long enough to approach approximately the glenoid, facilitating the double-pulley and the two mattress sutures fixing the dermal allograft on top of the medial glenoid (Figure 2J).
16. Pass the two limbs of free sutures or a FiberTape suture from the lateral side of the graft, which is used for lateral row fixation (Figure 2K).
17. Introduce and fix the dermal allograft onto the glenoid.
18. Insert one anchor at the greater tuberosity.
19. Fix the lateral part of the dermal allograft with the pre-passed sutures.
20. Cover the supraspinatus footprint by the graft, which is determined by where to fix the dermal allograft by the lateral row anchor.
21. Optimize the tension of the allograft during the insertion of the lateral anchor at 45° shoulder abduction (Figure 2L)¹⁵.
22. Cover the dermal allograft on top of the LHBT to increase the spacer effect.
    NOTE: There is no need for medial row anchors.
23. Make additional side-to-side sutures between the fixed dermal allograft and infraspinatus (Figure 2M, N).
24. Repair the remaining portions of the supraspinatus and infraspinatus using sutures passed through the anchor to enhance stability.
    NOTE: No suture is needed between the subscapularis and the fixed dermal allograft. All of the exposed footprint of the proximal humerus is covered by LHBT, dermal allograft, and remnant rotator cuff (Figure 2O).

Resultados

A total of 39 patients met the inclusion criteria; four were excluded, leaving 8 males and 27 females for the study. The patient demographics are listed in Table 1. There was no significant change regarding active shoulder range of motion (ROM) and acromiohumeral distance (AHD) before and after the surgery (Table 2). There was a significant improvement in pain scales and functional outcomes at the 2-year follow-up. The visual analogous score (VAS) demonstrated substantial improvements, decreasing from 8.2 ± 0.6 to 1.3 ± 0.6, subjective shoulder value (SSV) improved from 23.1 ± 9 to 79.3 ± 11.6, Constant-Murley score (CMS) from 37 ± 7.6 to 81.1 ± 8.1, and American shoulder, and elbow surgeons (ASES) scores from 38.7 ± 10.6 to 80.7 ± 5.3 at the final follow-up (all P < 0.001) (Table 2). Thirty-three patients demonstrated a healed dermal allograft on the supraspinatus footprint during the 1-year follow-up MRI exam (Figure 3). Two (5.7%) patients experienced a retear of the humeral side. Both underwent reverse total shoulder arthroplasty (RSA) during the revision surgery, leading to an uneventful recovery.

Figure 1: Preoperative radiological assessment. (A,B) The patients who undergo this technique should have less than Hamada grade 2 rotator cuff tear arthropathy. (C) Supraspinatus tendon retraction at Patte stage III, and (D) Supraspinatus muscle fatty infiltration equal to or more than Goutallier stage 2. Please click here to view a larger version of this figure.

Figure 2: Right shoulder, viewed from the lateral portal in a beach chair position. (A,B) Any subscapularis tear is defined and repaired. (C) A double-loaded or triple-loaded, suture-based anchor is inserted 5 mm posterior to the bicipital groove. (D) One lasso loop is used to secure the LHBT. (E) A bone trough is made 5 mm posterior to the bicipital grove. (F) After the complete release of the transverse humeral ligament, the lasso loop passed through the LHBT is tied, and the LHBT is rerouted posteriorly. No distal tenotomy is done to preserve the integrity of the LHBT. (G) The other suture can be used to repair the remnant anterior cuff if necessary, providing more soft tissue coverage on top of the rerouted LHBT. (H) Two double-loaded suture-based anchors are inserted at the top of the glenoid, allowing four sutures. (I) One pair of sutures of each glenoid anchor is passed through one side of a 3 x 3 cm dermal allograft with a thickness of 2 mm, providing a double-pulley fashion. The other two pairs of sutures are passed through the dermal allograft in a mattress fashion. (J) A half-cut 10 mL syringe can be used as a hand-made cannula long enough to approach approximately the glenoid, facilitating the double-pulley and the two mattress sutures fixing the dermal allograft on top of the medial glenoid. (K) Two limbs of free sutures or sutures are passed from the lateral side of the graft, which is used for lateral row fixation. (L) By inserting one lateral row anchor at the greater tuberosity, the lateral part of the dermal allograft is fixed with the pre-passed sutures. (M, N) The additional side-to-side sutures can be done between fixed dermal allograft and infraspinatus. (O) Finally, all exposed footprint of the proximal humerus is covered by LHBT, dermal allograft, and remnant rotator cuff. The asterisks indicate LHBT; black arrowheads point to the dermal allograft. Abbreviations: SSC = subscapularis; FP = footprint; LHBT = long head of the biceps; GL = glenoid; SSP = supraspinatus; ISP = infraspinatus. Please click here to view a larger version of this figure.

Figure 3: Preoperative and postoperative images of a patient receiving this technique. (A) A 70-year-old female patient with previously failed rotator cuff repair presented with Hamada type 1 rotator cuff arthropathy. The anteroposterior X-ray revealed an acromiohumeral distance of more than 7 mm, (B) and a Patte stage III rotator cuff retraction. (C) The supraspinatus muscle fatty infiltration was Goutallier stage 2. (D) The postoperative anteroposterior X-ray presented with a preserved acromiohumeral distance. (E,F) Coronal and sagittal view MRI revealed a healed dermal allograft on the supraspinatus footprint at the 1 year follow-up MRI exam. The arrowhead points to the dermal allograft. Please click here to view a larger version of this figure.

No. of patient	35
Age (yr)	63.8 ± 7.7
Male /female	8 / 27
Body mass index (kg/m2)	24.2 ± 4.4
Follow up duration (months)	24.2 ± 5.3
Side of surgery, right/left	14 / 21
Systematic disease, (diabetes, hypertension), n / %	22, 9%
Preoperative X-ray
AHD (mm)	7.8 ± 2.2
Preoperative MRI
SSP retraction Patte classification
(I/II/III, n)	0 / 0 / 35
Fatty change grade (0 / 1 / 2 / 3 / 4)
SSC	18 / 13 / 3 / 1 / 0
SSP	0 / 0 / 2 / 23 /10
ISP	4 / 23 / 8 / 0 / 0
Preoperative, shoulder Active ROM
FF (°)	132.9 ± 34.6
ER 1 (°)	56.3 ± 15.2
IR (1~18)	11.4 ± 3.4

Table 1: Characteristics of patients. Abbreviations: ROM = range of motion; AHD = acromiohumeral distance; SSC = subscapularis; SSP = supraspinatus; ISP = infraspinatus; FF = forward elevation; ER1 = external rotation; IR = internal rotation.

	Preoperative	Postoperative	P-value
X-ray
AHD (mm)	7.8 ± 2.2	7.2 ± 2.5	0.296
Active ROM
FF (°)	132.9 ± 34.6	148.6 ± 19.4	0.022
ER 1(°)	56.3 ± 15.2	60.3 ± 12	0.225
IR	11.4 ± 3.4	10.7 ± 3.2	0.43
Pain intensity
VAS	8.2 ± 0.6	1.3 ± 0.6	<0.001
Functional score
SSV	23.1 ± 9	79.3 ± 11.6	<0.001
CMS	37 ± 7.6	81.1 ± 8.1	<0.001
ASES	38.7 ± 10.6	80.7 ± 5.3	<0.001

Table 2: Postoperative outcomes. Abbreviations: ROM = range of motion; AHD = acromiohumeral distance; FF = forward flexion, ER = External rotation; IR = internal rotation; VAS = visual analog scale; SSV = Subjective Shoulder value; ASES = American shoulder and elbow surgeons; CMS = Constant-Murley Score.

Discusión

The critical step in this protocol is that we do not insert medial row anchors as in the conventional SCR technique proposed by Mihata et al.¹¹ According to the original technique, a precise measurement of the size of the graft is important to provide adequate tension. Instead, we shuttle the Fibertape suture from a Swivelock anchor to make a reverse mattress suture at the lateral side of the dermal allograft, which is used to fix the graft onto the footprint when the Swivelock anchor is inserted at the greater tuberosity at 45° shoulder abduction. The fixation angle of 45° shoulder abduction maintains appropriate tension at 90° of shoulder abduction and prevents graft tears at 0° of shoulder abduction¹¹. In this way, maximum tension can be achieved when tightening up during the Swivelock anchor insertion, and it will not be affected by the position of the medial row anchor.

This modified technique provides flexibility in dermal allograft fixation because the actual position of the dermal allograft fixation depends on the position to cover the most exposed part of the footprint determined by the inserted position of the lateral anchors. If the infraspinatus can be reduced to its anatomical position, the dermal allograft can be fixed more anteriorly, on top of the posterior rerouted LHBT to create a greater spacer effect, because the anterosuperior part of the anatomical capsule is thicker, with an average of 2.3 mm. After all, it includes the superior glenohumeral ligament¹⁶. If the infraspinatus cannot be pulled back to cover its footprint, the author will fix the allograft more posteriorly, covering the most exposed footprint. As Mirzayan et al. reported, a graft tear leaving the tuberosity covered has lower pain and higher functional scores than those in whom the torn graft leaves the tuberosity uncovered¹⁷. Thus, covering as much footprint might be as important as providing a strong spacer effect. Further, the remaining portions of the supraspinatus and infraspinatus can be repaired using sutures passed through the Swivelock anchor to enhance stability. The dermal allograft can also serve as a biological bridge when the remnant supraspinatus and infraspinatus are sutured with it.

There are two limitations to this technique. First, the quality of LHBT cannot be controlled preoperatively. We only excluded patients in whom LHBT was absent before the surgery. If the LHBT was present, we considered it a biological augmentation and performed the bio-SCR technique regardless of biceps tendon size or quality, as reported by McClatchy et al.¹⁸. Second, we have no control group, such as partial repair of the rotator cuff or biceps SCR alone, since this is a report for a surgical protocol.

The significance of the method is that it combines the advantages of biceps and dermal SCR and avoids the complication of fascia lata harvest. Moreover, this technique allows footprint coverage without using medial row anchors, which may lead to a more cost-effective procedure. We do not cut the proximal part of the LHBT that is already secured to the glenoid through the native anchor site, which obviates the need for anchor fixation and another interface for potential failure. We also do not cut the distal part of the LHBT but make a new trough as Kim et al.¹⁹ proposed to secure the posteriorly rerouted LHBT, leaving the intact LHBT to provide a space effect.

This technique can potentially be applied to all MIRCTs when the LHBT is present, and the patient is without external rotation lag. There is still debate between the biomechanics of SCR and lower trapezius transfer (LTT) for MIRCTs. While both SCR and LTT decrease glenohumeral superior translation and contact pressure compared with posterosuperior MIRCT conditions, the LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle. In contrast, the SCR showed more advantageous subacromial contact characteristics compared with LTT²⁰. Further study should focus on the correct position of graft attachment and the thickness of the graft. In summary, the combined SCR technique using a 2 mm dermal allograft and autologous LHBT for MIRCTs significantly improves the patient-reported outcomes.

Materiales

Name	Company	Catalog Number	Comments
3 x 3 cm dermal allograft of 2 mm thickness	Megaderm; L&C BIO Inc., Seongnam, Korea
BioComposite SwiveLock C anchor	Arthrex, Naples, FL		anchor
FiberTape	Arthrex, Naples, FL		suture