Clinical Sports Medicine Update

Superior Capsule Reconstruction

for Irreparable Massive Rotator
Cuff Tears: Does It Make Sense?
A Systematic Review of Early Clinical Evidence
Burak Altintas,*y MD, Michael Scheidt,z BS, Victor Kremser,* BS, Robert Boykin,§ MD,
Sanjeev Bhatia,|| MD, Kaveh R. Sajadi,{ MD, Scott Mair,* MD, and Peter J. Millett,#** MD, MSc
Investigation performed at the University of Kentucky, Lexington, Kentucky, USA

Background: Treatment of irreparable massive rotator cuff tears (MRCTs) in patients without advanced glenohumeral osteoar-
thritis remains a challenge. Arthroscopic superior capsule reconstruction (SCR) represents a newer method for treatment with
increasing popularity and acceptance.
Purpose: To analyze the clinical evidence surrounding SCR and determine the current clinical outcomes postoperatively.
Study Design: Systematic review.
Methods: A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines. Electronic databases of PubMed, MEDLINE, Cochrane, and Google Scholar were used
for the literature search. The study quality was evaluated according to the Modified Coleman Methodology Score. Studies in
English evaluating SCR outcomes were included.
Results: Seven studies were reviewed, including 352 patients (358 shoulders) treated with arthroscopic SCR with the mean duration
of follow-up ranging from 15 to 48 months (range, 12-88 months). Fourteen patients were lost to follow-up, leaving 338 patients (344
shoulders) with clinical outcome data. Graft types included dermal allografts (n = 3 studies), fascia lata autografts (n = 3), or both (n =
1). Most commonly, a double-row technique was utilized for humeral graft fixation. The most common complication included graft
tears in 13% of patients, resulting in 15 SCR revisions and 7 reverse shoulder arthroplasties. Postoperatively, improvements in visual
analog scale (2.5 to 5.9), American Shoulder and Elbow Surgeons (20 to 56), Japanese Orthopaedic Association (38.0), Subjective
Shoulder Value (37.0 to 41.3), and Constant (11.6 to 47.4) scores were observed. Three studies reported respective satisfaction
rates of 72.9%, 85.7% and 90%. Increases in external rotation, internal rotation, and abduction with improved strength in external
rotation were observed postoperatively. Improvement of pseudoparalysis was also observed in 3 studies. One study reported return
to sports in 100% of patients (2 competitively, 24 recreationally) with no adverse outcomes.
Conclusion: SCR showed good to excellent short-term clinical outcomes with adequate pain relief and functional improvement.
The current evidence suggests that the procedure is an alternative for symptomatic patients with irreparable MRCT; however, the
included studies were fair to poor in quality, and there were some notable complications. Long-term follow-up will determine the
longevity and ultimate role of this new method in the treatment of irreparable MRCT.
Keywords: massive rotator cuff tear; irreparable; superior capsule reconstruction; arthroscopy

The management of massive rotator cuff tears (MRCTs)
presents a treatment dilemma, especially in young
patients with preserved glenohumeral cartilage. While
most tears can be mobilized and repaired with adequate
releases and modern surgical techniques, there is a subset
of MRCT that is not amenable to repair. While the
The American Journal of Sports Medicine
1–11
DOI: 10.1177/0363546520904378
Ó 2020 The Author(s)
definition of ‘‘irreparable’’ may vary, the ability for
MRCT to heal remains a challenge, as chronic tears are
commonly complicated by cranial migration of the humeral
head,14,20,46 tendon inelasticity,37 fatty infiltration of the
musculature,1,24 and subsequent development of osteoar-
thritis.47 The rate of retear has been shown to be higher
with an acromiohumeral distance (AHD) \7 mm,46 limit-
ing the utility of primary repair. Historically, proposed
treatment options for irreparable MRCT have ranged
from nonoperative measures4,40 to surgical procedures,
such as debridement19,23; debridement with biceps tenot-
omy19,21; tear augmentation or bridging of the tendon

1
2 Altintas et al The American Journal of Sports Medicine

defect from tendon to bone with xenograft, allograft, and
synthetic patch grafts13,34; latissimus dorsi transfer
(LDT)11; partial rotator cuff repair7; and reverse total
shoulder arthroplasty (RTSA).1,8 Positive clinical outcomes
in MRCT have been observed with interventions including
RTSA,8,43 LDT,11 and lower trapezius transfer.9 However,
incomplete return of muscle strength and range of motion
after tendon transfers9,35 and higher failure rates of RTSA
in younger populations8,43 may limit full recovery.
In the irreparable MRCT, the lack of a superior
restraint to humeral migration32 may lead to secondary
subacromial impingement, weakness owing to a lack of
power from the rotator cuff and loss of appropriate
mechanics, and impaired range of motion associated with
loss of superior stability.7,12,32 Biomechanically, defects in
the superior capsule lead to significant increases in supe-
rior glenohumeral translation and subacromial contact.18
In 2013, superior capsule reconstruction (SCR) with a ten-
sor fascia lata (TFL) graft was proposed by Mihata
et al28,32 as an alternative treatment for patients with
MRCT to restore the loss of superior stability. In biome-
chanical and clinical studies performed by Mihata
et al,29,31 SCR was reported to decrease the superior migra-
tion of the humeral head, preventing subacromial impinge-
ment and preserving the AHD. An alternative acellular
dermal allograft for SCR was described by Hirahara and
Adams,16 as use of TFL may yield potential donor-site mor-
bidity and increased surgical time.6
The goal of this systematic review was to evaluate all
relevant clinical evidence associated with SCR in patients
with irreparable MRCT to provide physicians with
improved insight on how to provide better care for this dif-
ficult condition.
METHODS
The systematic review of the literature was performed per
the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) guidelines.33
Search Strategy
PubMed, MEDLINE, Cochrane Library, and Google Scholar
were used to conduct an electronic search of the literature
with the keywords ‘‘superior capsule reconstruction’’ and
‘‘superior capsular reconstruction.’’ The final search was
performed on December 22, 2018. Two independent
reviewers (M.S., V.K.) screened all of the resulting titles
and abstracts. After this initial search, the citations of
included articles were carefully examined to locate further
studies.
Selection Criteria
Studies in English comprising levels 1 to 4 evidence that
reported outcomes after SCR in patients with irreparable
MRCTs were included. Excluded were level 5 studies, tech-
nique descriptions, and case reports.
Evaluation of the Study Quality
Each study’s methodological quality and bias were evalu-
ated with the 10-item Modified Coleman Methodology
Score as described by Øiestad et al.38 Its scaled potential
score ranges from 0 to 100 (85-100, excellent; 70-84, good;
55-69, fair; \55, poor).
Extraction of Data and Synthesis
The two independent reviewers separately extracted data
from the included studies. Study characteristics, clinical
and radiographic follow-up intervals, patient demographics,
and complications with clinical and radiographic outcomes
were noted. Clinical outcomes measures were variable and
included visual analog scale (VAS), American Shoulder
and Elbow Surgeons (ASES), Constant-Murley (Constant),
Subjective Shoulder Value, and Japanese Orthopaedic Asso-
ciation scores. Graft tears were included if reported by post-
operative imaging (magnetic resonance imaging [MRI] or
ultrasound) or if found postoperatively in conjunction with

**Address correspondence to Peter J. Millett, MD, MSc, The Steadman Clinic, 181 West Meadow Drive, Suite 400, Vail, CO 81657, USA (email:
drmillett@thesteadmanclinic.com).
*Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA.
y
Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA.
z
Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA.
§
EmergeOrtho, Blue Ridge Division, Asheville, North Carolina, USA.
||
Department of Orthopaedic Surgery, Northwestern Medicine, Warrenville, Illinois, USA.
{
Kentucky Bone & Joint Surgeons, Lexington, Kentucky, USA.
#
The Steadman Clinic, Vail, Colorado, USA.
Submitted May 21, 2019; accepted December 12, 2019.
One or more of the authors has declared the following potential conflict of interest or source of funding: Steadman Philippon Research Institute received
research support from Arthrex, Smith & Nephew, Ossur, and Siemens. P.J.M. has received royalties from Arthrex Inc, Medbridge, and Springer; consulting
fees from Arthrex; research support from Arthrex Inc, Ossur, Siemens, and Smith & Nephew; and hospitality payments from Arthrosurface Inc, Gemini
Mountain Medical LLC, Stryker Corp, and Sanofi-Aventis; and holds stock in VuMedi. B.A. has received research support from Arthrex, education and hos-
pitality payments from Smith & Nephew, and a grant from the ON Foundation. S.B. has a commercial affiliation with Graymont Medical LLC, Edge Surgical,
and Joint Preservation Innovations LLC. R.B. has received consulting fees from Smith & Nephew and compensation for services other than consulting from
Arthrex and Smith & Nephew and is on the scientific advisory board for Avadim Technologies. K.R.S. has received consulting fees from DePuy/Mitek and
Exactech and education fees from Arthrex. S.M. has received education funding from Smith & Nephew and Arthrex and hospitality payments from Zimmer
Biomet. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the
OPD and disclaims any liability or responsibility relating thereto.
AJSM Vol. XX, No. X, XXXX Outcomes of Superior Capsule Reconstruction 3

TABLE 1
Study Characteristics

Study Year Design Level of Evidence Follow-up, mo, Mean 6 SD or Range Coleman Score

de Campos Azevedo et al5 2018 Retrospective case series 4 24 57

Denard et al6 2017 Retrospective case series 4 17.7 (12-29) 58
Hirahara et al17 2017 Retrospective case series 4 32.4 (25-39) 53
Lee and Min20 2018 Retrospective case series 4 24.8 6 6.9 52
Lim et al22 2019 Retrospective case series 4 15 (12-24) 55
Mihata et al26 2018 Comparative cohort study 3 48 (24-88) 58
Mihata et al27 2018 Retrospective case series 4 60 (35-110) 57
Pennington et al39 2018 Retrospective case series 4 12a (16-28) 63

a
Minimum.

Figure 1. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) flow diagram. SCR, superior capsule reconstruction.

other pathology. The AHD was measured pre- and postoper-
atively with standard anteroposterior radiographs.
RESULTS
Study Selection
A total of 8 clinical studies were included for systematic
review. Figure 1 summarizes the process for study selec-
tion. Literature searches of the Ovid MEDLINE,
Cochrane, Google Scholar, and PubMed databases with
query of major orthopaedic journals revealed 313 individ-
ual titles and abstracts, including duplicates. After initial
screening of the titles and abstracts and removal of dupli-
cates, 257 studies were excluded, leaving 56 articles for
full-text review. After a thorough review of these articles
and their citations with a repeated search of the litera-
ture, 8 studies were included in the systematic review.
The study by Burkhart and Hartzler3 was excluded as it
represented a subset of patients from separate studies
conducted by Denard et al.6 Of the 8 included studies,
there were 7 level 4 retrospective case series and 1 level
3 study (Table 1).
4 Altintas et al The American Journal of Sports Medicine

TABLE 2
Patient Characteristicsa

Shoulders Age, y,
(Patients) Mean 6 SD Sex, Male: Dominant Previous
Study Included, n (Range) Female, n Arm, n RCR, n (%) Torn Tendons

de Campos Azevedo et al5 22 (22) 63.8 (47-72) 7:15 15 8 complete, 7 SSP and ISP, 7 SSP
Denard et al6 59 (59) 62.0 6 8.7 39:20 25 (42.4) 59 complete SSP, 56 ISP, 33 SSC
Hirahara et al17 8 (8) 61.3 (47-78) 7 7 8 SSP
Lee and Min20 36 (32) 60.9 6 6.2 22:10 (37.5) 2 SSP only; 12 SSP and ISP;
2 SSP and SSC; 20 SSP, ISP, and SSC
Lim et al22 31 (31) 65.3 (44-85) 9:22 25
Mihata et al26 100 66.9 (43-82) Undefined 25 SSC (23 reparable,
2 irreparable); rest not listed
Mihata et al27
No PS 45 66.2 (43-78) 25 SSP and ISP; 18 SSP, ISP, and SSC;
2 SSP, ISP, and TM
Moderate PS 28 68.3 (45-82) 19 SSP and ISP; 8 SSP, ISP, and SSC;
1 SSP, ISP, SSC, and TM
Severe PS 15 62.3 (45-80) 7 SSP and ISP; 8 SSP, ISP, SSC
Pennington et al39 88 (86) 59.4 (27-79) 59:27 ISP, and SSP; no SSC or TM

a
Blank cells indicate not available. ISP, infraspinatus; PS, pseudoparalysis; RCR, rotator cuff repair; SSC, subscapularis; SSP, supraspi-
natus; TM, teres minor.

Study Characteristics and Quality
The baseline information for each study is documented in
Table 1. Table 2 depicts patient characteristics, while
Table 3 details surgical procedures.
Although the interventions and study aims were similar
in the included studies, there were major differences in
population characteristics, follow-up interval, tear size,
repair type, and outcome measures. The studies of Mihata
et al26 and Mihata et al27 represent the same patient pop-
ulation. Thus, only the study of Mihata et al26 was used for
the majority of the analysis, as it was the only one report-
ing the outcome scores of the entire group. The study of
Mihata et al27 was used for the analysis of the radiographic
outcomes, however because Mihata et al26 did not report
radiographic findings. The 2013 Mihata et al28 study was
not used in the review, because the latter studies by
Mihata et al26,27 included the same patient population
and had longer follow-up.
According to the Modified Coleman Methodology Score,
2 studies17,20 were poor (\55), 6 studies5,6,22,26,27,39 were
fair (55-69), and none of the studies were good (70-84) or
excellent (85-100). The median Modified Coleman Method-
ology Score was 57 (range, 52-63) of a possible 100. The
mean duration of follow-up ranged from 15 to 48 months
(range, 12-88 months). The study by Pennington et al39
did not indicate a mean follow-up value and was, therefore,
excluded for the mean follow-up analysis.
Patient Characteristics
A total of 352 patients (358 shoulders), including 136 men and
94 women, were included in the 7 studies, with a mean age
from 59.4 to 68.3 years (range, 27-85 years).5,6,17,20,22,27,39
Studies by Hirahara et al17 and Mihata et al26 did not include
patients’ sex. Fourteen patients were lost to follow-up, leaving
338 patients (344 shoulders) for analysis. One patient from
the de Campos Azevedo et al5 study was included in the pre-
operative evaluation and radiographic analysis at 6 months
but was lost to follow-up at 2 years and was not included in
the study. Twenty-six (7.7%) patients identified themselves
as athletes: 2 competitive and 24 recreational.26 Three stud-
ies5,17,22 reported on arm dominance, with 76.67% of the
injured shoulders (46 of 60) involving the dominant arm. A
total of 126 patients from 4 studies, including the study by
Mihata et al,26 were also noted to experience preoperative
pseudoparalysis.5,22,27,39
Graft Type and Technique
Three studies6,17,39 exclusively used acellular dermal allo-
graft with thicknesses ranging from 1 to 3.5 mm, while 3
studies5,22,26 used TFL autografts with thicknesses rang-
ing from 5 to 8 mm. Lee and Min20 used TFL autografts
unless patients had sarcopenia, had previous high-level
surgery, or preferred an allograft to an autograft. Lee
and Min did not specify the graft thickness used.
While all studies utilized arthroscopic SCR, only 3 stud-
ies5,20,26 stated the position of the shoulder at the time of
graft tensioning. de Campos Azevedo et al5 reported graft
fixation at 70° elevation, 10° abduction, and neutral rota-
tion. Lee and Min20 fixed the graft at 30° of abduction,
while Mihata et al26 fixed it at an abduction angle of 30°
to 45°.
The numbers and types of anchors used on the glenoid
side were variable as well. Pennington et al39 cited the
use of three 2.9-mm biocomposite anchors. Hirahara
et al17 used two 3.0-mm biocomposite anchors and one
3.5-mm biocomposite anchor. Lee and Min20 used one
3.0-mm biocomposite anchor anteriorly and one 2.4-mm
biocomposite anchor posteriorly. Mihata et al26 utilized
AJSM Vol. XX, No. X, XXXX Outcomes of Superior Capsule Reconstruction 5

TABLE 3
Surgical Proceduresa
Type of Humeral No. and Location of Graft
Graft No. and Type Fixation; No. and Type Concomitant Tears (% Total Grafts per
Study Graft Type Thickness, mm Fixation Angle of Glenoid Anchors of Humeral Anchors Procedures, n (%) Study)

de Campos Azevedo et al5 TFL autograft 5-8 70° elevation, 10° ABD, Two 1.8-mm all-suture DR, Two 4.5-mm BT 2 (9.1)
neutral rotation knotless PEEK
anchors
Denard et al6 ADA 1 (5 cases), NA 2.3 (2-4) BC DR, 3.9 (2-5) 4.75-mm Anterior interval slide, 7 (11.9) humeral side,
2 (2 cases), BC 27 (45.8); posterior 3 (5.1) intrasubstance,
3 (52 cases) interval slide, 18 1 (1.7) glenoid side
(30.5); limited
acromioplasty, 48
(81.4); distal clavicle
excision, 3 (5.1);
biceps tenodesis, 25
(42.4); BT, 9 (15.3);
coracoplasty, 16
(27.1)
Hirahara et al17 ADA 1.5 (1 case), Neutral ABD, neutral Two 3-mm BC and one DR, 4.75-mm BC BT, SSC repair, ISP 1 (12.5) intrasubstance, 1
3.5 (7 cases) rotation 3.5-mm BC anchors repair (12.5) glenoid side
20
Lee and Min TFL autograft NA 30° ABD Two 3-mm BC and one SR, two 5.0-mm If SSC tear, then SR 11 (30.6) humeral side, 2
or allograft 2.4-mm BC Corkscrew anchors with 5.5-mm BC. If (5.6) glenoid side
posterior remnant,
then side-to-side
Lim et al22 TFL autograft 6 NA 2-3 DR BT, acromioplasty 9 (29): 2 (6.5) lateral row of
greater tuberosity and 7
(22.6) medial row of
greater tuberosity
Mihata et al26 TFL autograft 6-8 30°-45° ABD Two 5-mm titanium DR, Corkscrew II NA 5 (5)
anchors or
SwiveLocks
Mihata et al27 30°-45° ABD Two 5-mm titanium DR, Corkscrew II
anchors or
SwiveLocks
No PS TFL autograft 6-8 Tenodesis for 1 (2.2)
dislocated biceps in
4, acromioplasty in
45
Moderate PS TFL autograft 6-8 Tenodesis for 1 (3.6)
dislocated biceps in
3, acromioplasty in
28
Severe PS TFL autograft 6-8 Tenotomy for 2 (13.3)
dislocated biceps in
1, acromioplasty in
15
Pennington et al39 ADA 3.0 (2.75-3.25) NA Three 2.9-mm BC DR, two 4.75-mm BC Glenohumeral 4 (4.5) (3 radiographically)
medially, 2 screw-in debridement or BT
anchors laterally on all; both
acromioplasty and
distal clavicle
excision on 23
patients

a
Values are presented as mean (range) where indicated. ABD, abduction; ADA, acellular dermal allograft; BC, biocomposite; BT, biceps tenotomy; DR, double
row; ISP, infraspinatus; NA, not available; PEEK, polyetheretherketone; PS, pseudoparalysis; SR, single row; SSC, subscapularis; TFL, tensor fascia lata.

two 5-mm titanium anchors. de Campos Azevedo et al5
chose two 1.8-mm all-suture anchors. Denard et al6 used
a mean 2.3 (range, 2-4) biocomposite anchors, and Lim
et al22 did not indicate the type of anchor utilized, although
a range of 2-3 anchors were used. The technique by Denard
et al was adapted from anchoring techniques described by
Burkhart et al.2
For the humeral fixation, 6 studies documented the use
of a double-row technique,5,6,17,22,26,39 while 1 study20
chose a single-row technique with two 5.0-mm suture
anchors. Lim et al22 used a knotless double-row technique
and did not indicate the type of anchors. Mihata et al26 also
did not state the number of anchors. Pennington et al39
used two 4.75-mm biocomposite anchors in the medial
row and 2 screw-in anchors laterally. The study by Denard
et al6 used a mean 3.9 (range, 2-5) 4.75-mm biocomposite
anchors. Another study cited using a knotless double-row
construct with 4.75-mm biocomposite anchors.17
Complications and Retears
Seven studies reported on postoperative complica-
tions.5,6,17,20,22,26,39 Sixty-seven total postoperative compli-
cations out of 338 patients (344 shoulders, 19%
complication rate) were noted from all included studies,
with the highest rate of complication consisting of 46 graft
tears (13%),5,6,17,20,22,26,39 including 4 tears as a result of 3
6 Altintas et al The American Journal of Sports Medicine

Figure 2. Superior capsule reconstruction outcomes. Values are presented as mean 6 SD. ASES, American Shoulder and Elbow
Surgeons score; Constant, Constant-Murley score; f/u, follow-up; JOA, Japanese Orthopaedic Association score; PS, pseudo-
paralysis; SSV, Subjective Shoulder Value; VAS, visual analog scale.

unspecified traumas and 1 motor vehicle accident,17,20 4
isolated cases of trauma without graft tearing (1%; 3 falls
and 1 motor vehicle accident),6,17,20 4 cases of anchor or
suture pullout or loosening (1%),26 4 infections (1%),5,6,26
3 instances of severe fatty degeneration of the infraspina-
tus (1%),26 and 2 cases of shoulder stiffness or contracture
(1%).26
All 7 studies performed a dedicated structural evaluation
with MRI after surgery at a range of 6 to 88
months.5,6,17,20,22,26,39 In addition, Hirahara et al analyzed
the postoperative status of the graft between 2 weeks and
2 months, between 4 and 10 months, at 12 months and
between 25 and 36 months with ultrasound. However, 5
studies outlined the location of the graft tears, which
included 30 humeral-sided tears, 4 intrasubstance tears,
and 4 glenoid-sided tears.6,17,20,22,39
A total of 30 procedures were performed after initial
SCR secondary to complications.5,6,20,26 These consisted
of 15 revisions of the torn SCR grafts,6,20 7 RTSAs,6 4
debridement procedures for infections,5,6,26 2 arthroscopic
releases for contracted or stiff shoulders,26 1 open subpec-
toral tenodesis for biceps pain,6 and 1 unspecified addi-
tional surgery.6 The SCR graft was retained after
procedures for arthroscopic release, infection debridement,
and subpectoral tenodesis.6,26
Patient Satisfaction and Functional Outcomes
The details of patient-reported outcomes (PROs) are listed
in Figure 2. The rate of patient satisfaction was noted in 3
studies via postoperative surveys and ranged from 72.9%
to 90%.5,6,39 Pain according to VAS was evaluated in 5
studies6,17,20,22,39 and showed preoperative means between
4.0 and 6.25 and postoperative means between 0.8 and 2.5.
There was a high degree of heterogeneity in other func-
tional outcome reporting. Six studies6,17,20,22,26,39 including
316 patients utilized the ASES score, with pre- to
AJSM Vol. XX, No. X, XXXX
Figure 3. Range of motion. Values are presented as mean 6 SD. f/u: follow-up; PS, pseudoparalysis.
postoperative changes including 43.6 to 77.5,6 41.75 to
86.5,17 50.9 to 85.1 (for intact grafts),20 54.1 to 74.1 (for
intact grafts),22 36.0 to 92.0,26 and 49.5 to 85.3 at 2-year
follow-up.39 Three studies5,20,22 documented Constant
scores from 85 patients, with pre- to postoperative changes
from 17.5 to 64.9,5 56.3 to 84.3 (for intact grafts),20 and
51.8 to 63.4 (for intact grafts).22 Two studies5,6 including
81 patients utilized the Subjective Shoulder Value. Pre-
to postoperative changes in mean values were 33.0 to
70.0 (de Campos Azevedo et al5) and 35.0 to 76.3 (Denard
et al6). Mihata et al26 also reported the Japanese Orthopae-
dic Association score of 100 patients, with a change in pre-
to postoperative mean from 53 to 91. Overall, significant
improvements in VAS (2.5 to 5.9), ASES (20.0 to 56),
JAO (38.0), SSV (37.0 to 41.3), and Constant (11.6 to
47.4) scores were observed postoperatively.
Additionally, functional outcomes were reported through
analysis of range of motion and strength (Figure 3). The
degree of elevation was cited by 6 studies,5,6,20,22,26,39 with
preoperative means ranging from 74.8° to 133.0° and postop-
erative means from 106.7° to 160.0°. Four studies5,20,22,27
Outcomes of Superior Capsule Reconstruction 7
measured external rotation of the affected shoulders, with
means ranging from 13.2° to 40.8° preoperatively and 30°
to 58.2° postoperatively. Analysis of internal rotation was
conducted by 4 studies5,6,20,26 and was more heterogeneous,
given the different methods of measurement.
Three studies5,22,39 reported on shoulder strength
before and after SCR, with 2 studies22,39 on external rota-
tion strength and 2 studies5,22 on supraspinatus strength.
Lim et al22 and Pennington et al39 documented strength of
external rotation, with preoperative means of 2.1 kg and
7.7 lb and postoperative means of 2.2 kg and 12.3 lb,
respectively. De Campos Azevedo et al5 and Lim et al
reported on strength of the supraspinatus, with preopera-
tive means of 2.1 and 1.8 kg and postoperative means of
8.6 and 1.9 kg. Lim et al noted no significant differences
of external rotation or supraspinatus strength in either
the intact or the torn SCR group.
Three studies, including Mihata et al,27 reported on
reversal of pseudoparalysis at postoperative follow-up.5,22
de Campos Azevedo et al5 and Lim et al22 reported on
reversal of pseudoparalysis in 93% (13 of 14) and 100% (5
8 Altintas et al The American Journal of Sports Medicine

of 5) of patients, respectively. Mihata et al27 classified TABLE 4

patient pseudoparalysis as moderate and severe, with post- Radiographic Outcomesa
operative reversal rates of 96% (27 of 28) and 93% (14 of
15), respectively. Follow-up Patients for
for MRI/ Follow-up
Study Radiograph, mob MRI, n

Return to Sports de Campos Azevedo et al5 6 21 of 22

Denard et al6 12 20 of 59
26
Only 1 study assessed the level of activity achieved after Hirahara et al17 24c 5 of 8 (3 US only)
SCR in patients participating in competitive and recrea- Lee and Min20 12
tional sports. A total of 26 patients with a mean age of Intact graft 23 of 23
65.5 years (range, 43-82 years) who participated in golf, Graft tear 13 of 13
table tennis, swimming, martial arts, baseball, yoga, ten- Lim et al22 12.8 (12-24)
nis, badminton, skiing, mountain climbing, and park golf Total 31 of 31
Intact graft 22 of 22
were included.26 Two patients participated in their sports
Graft tear 9 of 9
competitively, while the other 24 participated recreation-
Mihata et al26 48 (24-88) 100 of 100
ally. Follow-up showed that all 26 patients returned with- Mihata et al27 60 (35-110)
out complications or limitations to their sports.26 No PS 45 of 45
Moderate PS 28 of 28
Severe PS 15 of 15
Radiographic Outcomes
Pennington et al39
1y 12 4 of 86d
Figure 4 depicts the radiographic outcomes after SCR. For
2y 24 NA
the purpose of analyzing the AHD, the study by Mihata
et al27 was used in place of the one by Mihata et al,26 which a
MRI, magnetic resonance imaging; NA, not available; PS,
lacked AHD reporting (ie, these studies contained the same pseudoparalysis; US, ultrasound.
patient population). Therefore, 7 studies were included for b
Mean (range) where indicated.
analysis,5,6,17,20,22,27,39 and all reported on the range of radio- c
Used ultrasound between 2 weeks and 2 months, between 4
logic follow-up time, from 6 to 110 months.5,6,17,20,22,27,39 and 10 months, at 12 months and between 25 and 36 months.
However, only 4 of the 7 studies6,17,22,27 indicated their MRI was used only when there was concern about graft failure.
d
mean follow-up time, which ranged from 12.8 to 60 months. MRI was conducted only if patients were unsatisfied.
All patients received radiographic imaging at follow-up,
although there was variability among studies in terms of
whether MRI was obtained (Table 4). In total, 205 of 330 supraspinatus, with 3 studies reporting the mean,5,17,22 2
(62%) patients received postoperative MRI. Three stud- reporting individual patient grades,6,27 and 1 reporting Gou-
ies20,22,27 stated that MRI was obtained for all patients at tallier score range.39 Three studies cited the mean preopera-
follow-up. As previously mentioned, 1 patient in the de Cam- tive supraspinatus Goutallier grades, ranging from 2.7 to
pos Azevedo et al5 study was lost to 2-year follow-up, and 3.3.5,17,22 Individual preoperative supraspinatus Goutallier
MRI was not obtained. Denard et al6 stated that 20 of 59 scores for each patient were indicated by Denard et al6 and
patients were willing to undergo MRI, and imaging was Mihata et al,27 with significant portions of each population
obtained at 1-year follow-up. Hirahara et al17 utilized ultra- reporting grades of 3 or 4. A range of 3 to 4 for preoperative
sound as the imaging modality of choice, although MRI supraspinatus Goutallier scores was also noted by Pennington
was ordered for 5 of 8 patients owing to concerns of graft fail- et al.39 Four studies analyzed preoperative Goutallier scores
ure. According to Pennington et al,39 MRI was ordered for for the infraspinatus, with 2 reporting mean scores,5,22 1
only 4 of 86 patients for either patient dissatisfaction or con- reporting individual patient scores,6 and 1 reporting the score
cern of poor outcomes. range.39 de Campos Azevedo et al5 and Lim et al22 docu-
All 7 studies reported on the mean AHD.5,6,17,20,22,27,39 Six mented mean preoperative Goutallier grades for the infraspi-
articles cited the mean AHD of their overall patient popula- natus, with means of 2.3 and 2.5, respectively. Denard et al
tion, with differences between the pre- and postoperative indicated individual patient scores, with 19 patients grading
AHD ranging from 0.1 to 3.2 mm.5,6,17,22,27,39 Lee and Min20 a 1 or 2 and 37 patients grading a 3 or 4. Pennington et al
noted that the patient population with an intact graft had cited a range of 3 to 4 for preoperative infraspinatus Goutal-
an improvement in AHD of 4.8 mm, while the cohort that lier scores. Three studies reported on preoperative subscapu-
had a torn graft improved by only 2.2 mm. One study consist- laris Goutallier scores, with 2 reporting the mean score5,22
ing of 88 shoulders (86 patients) reported the superior capsule and 1 reporting individual scores.6 de Campos Azevedo et al
distance (defined as the arc length between the superior and Lim et al cited mean scores of 1.7 and 1.1, respectively.
aspect of the glenoid and the medial aspect of the greater Denard et al indicated individual preoperative subscapularis
tuberosity of the humerus), which included a preoperative Goutallier scores, with 34 patients grading 0 or 1 and 23
mean of 52.9 mm and a postoperative mean of 46.2 mm.39 patients grading 2 to 4. Postoperative Goutallier grades for
Fatty degeneration analysis based on Goutallier grading all 3 muscles were determined only by Lim et al, with means
was conducted by 6 of the 7 studies.5,6,17,22,27,39 All 6 aforemen- of 2.9, 2.6, and 1.2 for the supraspinatus, infraspinatus, and
tioned studies analyzed preoperative Goutallier scores of the subscapularis, respectively.
AJSM Vol. XX, No. X, XXXX
Figure 4. Radiographic outcomes. Values are presented as mean 6 SD. f/u, follow-up; PS, pseudoparalysis.
DISCUSSION
The results of this study demonstrated that regardless of
the type of graft used, SCR provided significant improve-
ment in PRO scores and VAS5,6,17,20,22,27,39 with high post-
operative satisfaction.5,6,39 Given the limited options for
treatment of patients with irreparable MRCT, the SCR pro-
cedure was developed from an understanding of the dys-
functional mechanics of the rotator cuff–deficient
shoulder. Biomechanical studies have validated the ability
of a static graft to reduce acromiohumeral impingement,
decrease superior humeral migration, and improve gleno-
humeral contact forces. TFL autograft, acellular dermal
allograft, and long head of the biceps tendon autograft
appear to be biomechanically viable options, but further
clinical study is clearly needed.10,15,25,29-32,41,42
The ultimate question remains whether these clinical
improvements in PRO and VAS scores are comparable
with alternative treatments, such as RTSA or LDT, and
whether these early positive outcomes will remain consis-
tent in medium- and long-term studies. A systematic review
on RTSA for irreparable MRCT showed an ASES score
improvement of 30.8 to 42.1 and a Constant score gain of
28.4 to 35.9.44 A similar trend with higher overall scores
in ASES was seen after SCR (20-56).6,17,20,22,26,39
The Constant score improvement after SCR was less in
the Lim et al22 study (11.6 for intact grafts) but similar in
the Lee and Min20 (28.0 for intact grafts) and de Campos
Azevedo et al5 (47.4) studies. In comparison, a systematic
review on LDT showed improvement in Constant score
ranging from 14 to 36, with a single study reporting an
ASES improvement of 24.9.36 The SCR provided higher
overall ASES score improvement and similar Constant
Outcomes of Superior Capsule Reconstruction 9
score gain. While the studies reported short midterm
follow-up after SCR, the improvements in PROs are prom-
ising and comparable with, if not better than, those after
RTSA and LDT. It should be noted that SCR does not pre-
clude future revision to either of these procedures and does
not require as extensive a rehabilitation program as LDT.
The complications of RTSA ranged from 4.1% to 20%
and included major complications, such as acromial frac-
ture, dislocation, and baseplate failures.44 The complica-
tion rate after LDT was 9.5%, with a revision surgery
rate of 6.9%.36 The most common complication after SCR
was tearing of the graft at a rate of 13%,5,6,17,20,22,26,39
with revision surgery reported in 6.4%.6,20 Denard et al6
showed poorer outcomes with thin grafts. Mihata et al29
showed in a cadaveric model that a 8-mm graft was better
at reducing superior translation than a 4-mm TFL graft;
however, all acellular dermal allografts in the market are
thinner than 8 mm. Interestingly, patients with postoper-
ative graft tears also showed significant improvement in
PROs, albeit not as good as patients with intact grafts.20,22
MRCT may lead to a pseudoparesis, which can be debilitat-
ing. There has been much debate in the literature regarding
the influence of SCR on this.45 Interestingly, Burkhart and
Hartzler3 showed reversal of severe pseudoparesis (active
elevation \45°) in 90% of patients after SCR with acellular
dermal allograft. While Mihata et al27 defined severe pseudo-
paresis slightly differently (\90° of active elevation with pos-
itive drop arm sign), they also demonstrated reversal in 93%
of the patients after SCR with TFL graft. This may be
explained through the restoration of a stable fulcrum via the
addition of the graft, which may improve the force couples.3
A number of biomechanical studies have been per-
formed that have helped shape the current recommended
10 Altintas et al
techniques.10,15,25,29-32,41,42 In summary, biomechanical
data have suggested that thickness of the graft does play
a role in time-zero effectiveness. Posterior side-to-side
suturing is recommended in all SCR procedures, with the
addition of anterior side-to-side suturing if acellular der-
mal allograft is used.25,29,31 Other biomechanical evidence
has suggested that 3.5-mm knotted suture anchors provide
a biomechanically superior construct for glenoid fixation,
while the majority of studies have used a type of double-
row fixation on the humeral side.41 Further studies are
needed to most effectively optimize SCR efforts and deter-
mine areas in which biomechanical improvements can be
translated to improved clinical results. In addition, future
studies should consider a cost analysis relative to outcomes
in determining the overall value of the procedure.
Limitations
The level of evidence of the majority of the included studies
was low (3 and 4). According to the Modified Coleman Meth-
odology Score, the quality of most studies was fair (because
all of them had a retrospective design), whereas no studies
were rated good or excellent and 2 were rated poor. The vari-
ety of patient populations, return-to-sport metrics, and clini-
cal outcome measurements created a heterogeneous study
cohort, limiting the amount of comparative analyses that
could be performed. The wide range of clinical follow-up
and limited postoperative MRI (62% of patients). To further
analyze clinical efficacy, studies of greater scientific merit
and longer follow-up will be required.
CONCLUSION
SCR showed good to excellent early clinical outcomes,
with adequate pain relief and functional improvement.
The current evidence suggested that the procedure is an
alternative for symptomatic cases of irreparable MRCT;
however, there were some notable complications. Long-
term follow-up will determine the longevity and ultimate
role of this new method in the treatment of irreparable
MRCT.
REFERENCES
1. Bedi A, Dines J, Warren RF, et al. Massive tears of the rotator cuff.
J Bone Joint Surg Am. 2010;92(9):1894-1908.
2. Burkhart SS, Denard PJ, Adams CR, et al. Arthroscopic superior cap-
sular reconstruction for massive irreparable rotator cuff repair.
Arthrosc Tech. 2016;5(6):e1418.
3. Burkhart SS, Hartzler RU. Superior capsular reconstruction reverses pro-
found pseudoparalysis in patients with irreparable rotator cuff tears and
minimal or no glenohumeral arthritis. Arthroscopy. 2019;35(1):22-28.
4. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, et al. Partial repair of
irreparable rotator cuff tears. Arthroscopy. 1994;10(4):363-370.
5. de Campos Azevedo CI, Angelo ACLPG, Vinga S. Arthroscopic supe-
rior capsular reconstruction with a minimally invasive harvested fas-
cia lata autograft produces good clinical results. Orthop J Sports
Med. 2018;6(11):2325967118808242.
6. Denard PJ, Tokish J, Brady PC, et al. Preliminary results of arthro-
scopic superior capsule reconstruction with dermal allograft. Arthros-
copy. 2017;33(10):e107.
The American Journal of Sports Medicine
7. Duralde XA, Bair B. Massive rotator cuff tears: the result of partial
rotator cuff repair. J Shoulder Elbow Surg. 2005;14(2):121-127.
8. Ek ET, Neukom L, Catanzaro S, et al. Reverse total shoulder arthro-
plasty for massive irreparable rotator cuff tears in patients younger
than 65 years old: results after five to fifteen years. J Shoulder Elbow
Surg. 2013;22(9):1199-1208.
9. Elhassan BT, Wagner ER, Werthel JD. Outcome of lower trapezius
transfer to reconstruct massive irreparable posterior-superior rotator
cuff tear. J Shoulder Elbow Surg. 2016;25(8):1346-1353.
10. El-Shaar R, Soin S, Nicandri G, et al. Superior capsular reconstruc-
tion with a long head of the biceps tendon autograft: a cadaveric
study. Orthop J Sports Med. 2018;6(7):2325967118785365.
11. Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the
treatment of irreparable rotator cuff tears. J Bone Joint Surg Am.
2006;88(1):113-120.
12. Gerber C, Wirth SH, Farshad M. Treatment options for massive rota-
tor cuff tears. J Shoulder Elbow Surg. 2011;20(2)(suppl):20.
13. Gillespie RJ, Knapik DM, Akkus O. Biologic and synthetic grafts in
the reconstruction of large to massive rotator cuff tears. J Am
Acad Orthop Surg. 2016;24(12):823-828.
14. Gruber G, Bernhardt GA, Clar H, et al. Measurement of the acromio-
humeral interval on standardized anteroposterior radiographs: a pro-
spective study of observer variability. J Shoulder Elbow Surg.
2010;19(1):10-13.
15. Hast MW, Schmidt EC, Kelly JD 4th, et al. Computational optimiza-
tion of graft tension in simulated superior capsule reconstructions.
J Orthop Res. 2018;36(10):2789-2796.
16. Hirahara AM, Adams CR. Arthroscopic superior capsular reconstruc-
tion for treatment of massive irreparable rotator cuff tears. Arthrosc
Tech. 2015;4(6):637.
17. Hirahara AM, Andersen WJ, Panero AJ. Superior capsular recon-
struction: clinical outcomes after minimum 2-year follow-up. Am J
Orthop (Belle Mead NJ). 2017;46(6):266-278.
18. Ishihara Y, Mihata T, Tamboli M, et al. Role of the superior shoulder
capsule in passive stability of the glenohumeral joint. J Shoulder
Elbow Surg. 2014;23(5):642-648.
19. Lee BG, Cho NS, Rhee YG. Results of arthroscopic decompression
and tuberoplasty for irreparable massive rotator cuff tears. Arthros-
copy. 2011;27(10):1341-1350.
20. Lee SJ, Min YK. Can inadequate acromiohumeral distance improve-
ment 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(7):
2205-2213.
21. Liem D, Lengers N, Dedy N, et al. Arthroscopic debridement of mas-
sive irreparable rotator cuff tears. Arthroscopy. 2008;24(7):743-748.
22. Lim S, AlRamadhan H, Kwak JM, et al. Graft tears after arthroscopic
superior capsule reconstruction (ASCR): pattern of failure and its cor-
relation with clinical outcome. Arch Orthop Trauma Surg. 2019;
139(2):231-239.
23. Lo IK, Burkhart SS. Arthroscopic repair of massive, contracted,
immobile rotator cuff tears using single and double interval slides:
technique and preliminary results. Arthroscopy. 2004;20(1):22-33.
24. Melis B, Wall B, Walch G. Natural history of infraspinatus fatty infiltra-
tion in rotator cuff tears. J Shoulder Elbow Surg. 2010;19(5):757-763.
25. Mihata T, Bui CNH, Akeda M, et al. A biomechanical cadaveric study
comparing superior capsule reconstruction using fascia lata allograft
with human dermal allograft for irreparable rotator cuff tear. J Shoul-
der Elbow Surg. 2017;26(12):2158-2166.
26. Mihata T, Lee TQ, Fukunishi K, et al. Return to sports and physical
work after arthroscopic superior capsule reconstruction among
patients with irreparable rotator cuff tears. Am J Sports Med. 2018;
46(5):1077-1083.
27. Mihata T, Lee TQ, Hasegawa A, et al. Arthroscopic superior capsule
reconstruction can eliminate pseudoparalysis in patients with irrepa-
rable rotator cuff tears. Am J Sports Med. 2018;46(11):2707-2716.
28. Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic
superior capsule reconstruction for irreparable rotator cuff tears.
Arthroscopy. 2013;29(3):459-470.
AJSM Vol. XX, No. X, XXXX
29. Mihata T, McGarry MH, Kahn T, et al. Biomechanical effect of thick-
ness and tension of fascia lata graft on glenohumeral stability for
superior capsule reconstruction in irreparable supraspinatus tears.
Arthroscopy. 2016;32(3):418-426.
30. Mihata T, McGarry MH, Kahn T, et al. Biomechanical effects of acro-
mioplasty on superior capsule reconstruction for irreparable supra-
spinatus tendon tears. Am J Sports Med. 2016;44(1):191-197.
31. Mihata T, McGarry MH, Kahn T, et al. Biomechanical role of capsular
continuity in superior capsule reconstruction for irreparable tears of
the supraspinatus tendon. Am J Sports Med. 2016;44(6):1423-1430.
32. Mihata T, McGarry MH, Pirolo JM, et al. Superior capsule reconstruc-
tion to restore superior stability in irreparable rotator cuff tears: a bio-
mechanical cadaveric study. Am J Sports Med. 2012;40(10):
2248-2255.
33. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for
Systematic Reviews and Meta-Analyses: the PRISMA statement.
PLoS Med. 2009;6(7):e1000097.
34. Mori D, Funakoshi N, Yamashita F. Arthroscopic surgery of irrepara-
ble large or massive rotator cuff tears with low-grade fatty degener-
ation of the infraspinatus: patch autograft procedure versus partial
repair procedure. Arthroscopy. 2013;29(12):1911-1921.
35. Moursy M, Forstner R, Koller H, et al. Latissimus dorsi tendon transfer
for irreparable rotator cuff tears: a modified technique to improve ten-
don transfer integrity. J Bone Joint Surg Am. 2009;91(8):1924-1931.
36. Namdari S, Voleti P, Baldwin K, et al. Latissimus dorsi tendon transfer
for irreparable rotator cuff tears: a systematic review. J Bone Joint
Surg Am. 2012;94(10):891-898.
37. Oh JH, Kim SH, Kang JY, et al. Effect of age on functional and struc-
tural outcome after rotator cuff repair. Am J Sports Med. 2010;
38(4):672-678.
38. Øiestad BE, Engebretsen L, Storheim K, et al. Knee osteoarthritis
after anterior cruciate ligament injury: a systematic review. Am J Sports
Med. 2009;37(7):1434-1443.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
Outcomes of Superior Capsule Reconstruction 11
39. Pennington WT, Bartz BA, Pauli JM, et al. Arthroscopic superior cap-
sular 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(6):1764-1773.
40. Piper CC, Hughes AJ, Ma Y, et al. Operative versus nonoperative
treatment for the management of full-thickness rotator cuff tears:
a systematic review and meta-analysis. J Shoulder Elbow Surg.
2018;27(3):572-576.
41. Pogorzelski J, Muckenhirn KJ, Mitchell JJ, et al. Biomechanical com-
parison of 3 glenoid-side fixation techniques for superior capsular
reconstruction. Am J Sports Med. 2018;46(4):801-808.
42. Schon JM, Katthagen JC, Dupre CN, et al. Quantitative and com-
puted tomography anatomic analysis of glenoid fixation for superior
capsule reconstruction: a cadaveric study. Arthroscopy. 2017;33(6):
1131-1137.
43. Sershon RA, Van Thiel GS, Lin EC, et al. Clinical outcomes of reverse
total shoulder arthroplasty in patients aged younger than 60 years.
J Shoulder Elbow Surg. 2014;23(3):395-400.
44. Sevivas N, Ferreira N, Andrade R, et al. Reverse shoulder arthro-
plasty for irreparable massive rotator cuff tears: a systematic review
with meta-analysis and meta-regression. J Shoulder Elbow Surg.
2017;26(9):e277.
45. Tokish JM, Alexander TC, Kissenberth MJ, et al. Pseudoparalysis:
a systematic review of term definitions, treatment approaches, and
outcomes of management techniques. J Shoulder Elbow Surg. 2017;
26(6):e187.
46. Walch G, Marechal E, Maupas J, et al. Surgical treatment of rotator
cuff rupture: prognostic factors. Rev Chir Orthop Reparatrice Appar
Mot. 1992;78(6):379-388.
47. Zingg PO, Jost B, Sukthankar A, et al. Clinical and structural out-
comes of nonoperative management of massive rotator cuff tears.
J Bone Joint Surg Am. 2007;89(9):1928-1934.