Reinforcement Techniques in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears: A Comparative Study of Superior Capsule Reconstruction and Patch Graft Augmentation

Abstract

Background: Large-to-massive rotator cuff tears (LMRCTs) present challenges in achieving successful repair due to factors such as muscle atrophy and tendon retraction. Arthroscopic rotator cuff repair (ARCR) with reinforcement techniques like superior capsule reconstruction (SCR) or patch graft augmentation (PGA) has emerged as a less invasive option to improve shoulder joint stability and prevent retear. This study aimed to compare the clinical and radiological outcomes of SCR and PGA as reinforcement techniques for the arthroscopic repair of LMRCTs. Methods: A single-center retrospective study was conducted on patients undergoing LMRCT repair between January 2019 and December 2021. Patients were divided into two groups: those receiving SCR (Group 1) and those receiving PGA (Group 2). Various clinical parameters including range of motion, functional scores, and radiological assessments were evaluated preoperatively and six months postoperatively. Results: Both SCR and PGA techniques demonstrated significant improvements in the range of motion and clinical scores postoperatively. However, Group 2 showed higher postoperative SST and UCLA scores compared to Group 1. Radiologically, there was a slightly higher retear rate in Group 2, although this was not statistically significant. Group 2 also had a shorter mean duration of surgery compared to Group 1. Conclusions: In the arthroscopic repair of LMRCTs, both SCR and PGA techniques exhibit favorable clinical and radiological outcomes. Despite the simplicity of PGA compared to SCR, it offers comparable results with a shorter surgical duration, making it a feasible reinforcement option for surgeons.

Keywords: arthroscopic rotator cuff repair; patch graft augmentation; reinforcement; rotator cuff tears; superior capsule reconstruction.

Figure 1

Patient flowchart. LMRCTs, large-to-massive rotator cuff tears; MRI, magnetic resonance imaging; A/S, arthroscopy; SCR, superior capsule reconstruction; PGA, patch graft augmentation.

Figure 2

Preoperative MRI and A/S images. (a,b) LMRCTs are shown in a preoperative MRI image of a patient who underwent PGA reinforcement. Reparable LMRCTs were confirmed using A/S. (c,d) LMRCTs are shown in a preoperative MRI image of a patient who underwent SCR reinforcement. Reparable LMRCTs were confirmed using A/S. LMRCTs, large-to-massive rotator cuff tears; MRI, magnetic resonance imaging; A/S, arthroscopy; SCR, superior capsule reconstruction; PGA, patch graft augmentation.

Figure 3

External images of the right shoulder that underwent SCR reinforcement before ARCR in the beach chair position. (a) The patient’s arm was placed in a fully adducted and internally rotated position. (b) An appropriately sized allogenic dermal patch. A lateral-to-medial arrow was marked to avoid confusion. (c) Using an EXPRESSEW^® Flexible Suture Passer, all four strands were passed to the medial side of the allogenic dermal patch. Mega knots, also known as Mulberry knots, were made with the most anterior and posterior strands. (d) The allogenic dermal patch was pulled into the patient’s shoulder through the accessory anterolateral portal incision site. SCR, superior capsule reconstruction; ARCR, arthroscopic rotator cuff repair.

Figure 4

A/S images of the patients who underwent ARCR and SCR reinforcement. (a,b) This patient underwent SCR and was partially repaired with the remnants of the supraspinatus and infraspinatus muscles. (c,d) This other patient underwent SCR and the supraspinatus and infraspinatus muscles over the patch graft were completely repaired. SSP, supraspinatus muscle; ISP, infraspinatus muscle; GT, greater tuberosity; A/S, arthroscopy; ARCR, arthroscopic rotator cuff repair; SCR, superior capsule reconstruction; Ant., anterior; Post., posterior; Med., medial; Lat., lateral.

Figure 5

External images of the right shoulder that underwent PGA reinforcement after ARCR in the beach chair position. (a) BellaCell HD™ (Hans BioMed Corp., Seoul, Republic of Korea); (b) An appropriately sized allogenic dermal patch. A lateral-to-medial arrow was marked to avoid confusion. (c) Using an EXPRESSEW^® Flexible Suture Passer, two strands were passed to the medial side of the allogenic dermal patch. Mega knots were made anteriorly and posteriorly. (d) The allogenic dermal patch was pulled into the patient’s shoulder through the accessory anterolateral portal incision site. PGA, patch graft augmentation; ARCR, arthroscopic rotator cuff repair.

Figure 6

A/S images of the patients who underwent ARCR and PGA reinforcement. (a) The supraspinatus and infraspinatus muscles were repaired as much as possible using the suture-bridge technique. (b) Using the PGA technique, reinforcement was done over the defect to cover the greater tuberosity. SSP, supraspinatus muscle; ISP, infraspinatus muscle; GT, greater tuberosity; A/S, arthroscopy; ARCR, arthroscopic rotator cuff repair; PGA, patch graft augmentation; Ant., anterior; Post., posterior; Med., medial; Lat., lateral.

Figure 7

Preoperative and postoperative MRI images. (a,b) LMRCTs are shown in the preoperative MRI image. In the postoperative MRI image, LMRCTs have been repaired, and the patch (yellow arrows) fully covers the defect and the greater tuberosity using PGA reinforcement. (c,d) LMRCTs are shown in the preoperative MRI image. In the postoperative MRI image, SCR using a patch (yellow arrows) was performed, and this fully covered the greater tuberosity. LMRCTs were well repaired over the patch. LMRCTs, large-to-massive rotator cuff tears; MRI, magnetic resonance imaging; SCR, superior capsule reconstruction; PGA, patch graft augmentation.