Do data support the continued use of SCR for massive rotator cuff treatment?
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Click here to read the Cover Story, "Surgeons navigate options for massive rotator cuff tears."
Narrow indications with SCR
The most common procedures for the surgical management of irreparable cuff tears include partial repair, SCR, the subacromial balloon, reverse shoulder arthroplasty and tendon transfers, particularly lower trapezius transfers.
The indication for each of these procedures is substantially affected by surgeons’ preferences, but most would agree that RSA is preferred in the presence of clear evidence of associated arthritis (Hamada 2 or higher) or when an irreparable posterosuperior (PS) tear is associated also with subscapularis insufficiency. Subscapularis insufficiency is also considered a contraindication for both SCR and the subacromial balloon. Finally, many favor RSA in the presence of true pseudoparalysis.
For irreparable PS tears with an intact or repairable subscapularis, lower trapezius transfer and the subacromial balloon are increasing in popularity, whereas the popularity of SCR is decreasing. Lower trapezius transfer is of choice when restoration of strength in external rotation is critical, such as in patients with pseudoparalysis in external rotation or a profound external rotation lag sign; SCR does not restore motion or strength in external rotation. The subacromial balloon is of choice in older patients (older than 65 years) with no arthritis, good preoperative motion and an intact subscapularis. Thus, the indications for SCR today remain limited to the active individual without arthritis and without subscapularis insufficiency who does not desire more strength in external rotation or when the only tendon that is irreparable is the supraspinatus.
To further confuse matters, a recent prospective randomized study reported an approximately 85% success rate at 2 years when a partial cuff repair is performed; because most surgeons who perform SCR also repair the cuff tear as much as possible in the same procedure, it is difficult to determine how much of the improvement these patients experience is due to the partial repair vs. the additional SCR. In addition, adequate pain relief has been reported when SCR failure occurs on the glenoid side, and not on the tuberosity side. Thus, biologic resurfacing of the greater tuberosity has been recently reported as an alternative to both SCR and the subacromial balloon.
What do the data show? Teruhisa Mihata, MD, PhD, and colleagues reported satisfactory 5-year outcomes in a cohort of 30 patients who underwent SCR performed with fascia lata autograft. However, his results have not been reproduced with SCR performed using dermal allograft. For shoulders with advanced fatty infiltration of the infraspinatus, one study found lower trapezius transfer to be superior to SCR. Finally, SCR is substantially more expensive than lower trapezius transfer or RSA.
In my opinion, even though some data support the continued use of SCR in select patients, current indications for SCR are so narrow that I rarely see a patient who would be a candidate and, as such, I no longer perform SCR. RSA, the subacromial balloon and lower trapezius transfer provide an answer for all patients I see in my practice with an irreparable PS cuff tear.
Joaquin Sanchez-Sotelo, MD, PhD, is a consultant and professor of orthopedic surgery and chair of the division of shoulder and elbow surgery at Mayo Clinic in Rochester, Minnesota.
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More research needed
The surgical treatment of massive PS rotator cuff tears remains a challenge. These tears are commonly found to be irreparable due to their chronicity and associated characteristics, including tendon retraction, loss of tendon substance/mobility and development of associated muscle atrophy. While multiple surgical options are available to treat irreparable tears, no single approach has proven to be superior, with management tailored to patients’ symptoms, function and expectations.
SCR was developed as an arthroscopic technique to restore more normal shoulder biomechanics in patients with massive, irreparable PS rotator cuff tears and, as its clinical use has grown, also likely has a beneficial subacromial spacer effect. SCR has been most commonly indicated in patients with tear-related pain and weakness, but without significant glenohumeral arthritis, irreparable subscapularis tear or external rotation lag sign; indications supported by recent clinical data also suggest better outcomes in younger patients. Systematic reviews have reported good to excellent clinical outcomes as measured by short-term patient-reported outcome measures (PROMs) with SCR that further support its use, but more clinical data are needed. Nearly all of the studies in the systematic reviews are level 3 or 4 evidence. Outcomes can vary substantially across individual studies, particularly with regard to graft healing and complications. This likely relates to the variability with regard to surgical technique for SCR, including choice of graft (autograft vs. allograft), graft thickness, graft fixation methods, position of the shoulder during graft fixation and concomitant procedures. Multiple recent systematic reviews have examined outcomes between the two most common SCR grafts — tensor fascia lata autograft and human dermal allograft and noted comparable outcomes with regard to PROMs, shoulder function, graft healing and complications between grafts, but again, substantial variability was found across the individual studies. For example, Garrett R. Jackson, MD, and colleagues reported graft failure rates of 4.5% to 38.2% with dermal allograft vs. 4.5% to 86.4% with tensor fascia lata autograft.
More well-controlled prospective and comparative studies with longer-term follow-up are needed to continue to evaluate the clinical benefits of SCR, including determining its optimal indications for use and the surgical technique and graft choice that produces the highest healing rates and most durable outcomes. Such higher-level evidence will help refine the treatment algorithm for massive, irreparable PS rotator cuff tears and where SCR fits into the surgical management of this challenging clinical problem.
Eric T. Ricchetti, MD, is the vice chair of research at the Orthopaedic and Rheumatologic Institute, director of the Shoulder Center and director of the Shoulder and Elbow Surgery Fellowship in the department of orthopedic surgery at the Cleveland Clinic in Cleveland, Ohio.
- References:
- Atlintas B, et al. Am J Sports Med. 2020;doi:10.1177/0363546520904378.
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May improve pain, functional outcomes
Massive rotator cuff tears have low rates of healing and high rates of retear as they are typically associated with fatty degeneration of the rotator cuff muscle and may require advanced mobilization techniques for tendon reduction to the footprint. SCR was developed and biomechanically validated by Teruhisa Mihata, MD, PhD, and colleagues to reconstruct the superior capsule and prevent proximal humeral migration, which is the typical pathologic mechanism leading to shoulder pseudoparalysis (inability to independently lift the arm under its own power). Early clinical outcomes of SCR were excellent; however, this clinical superiority did not reach the same level of clinical efficacy with later studies in the U.S. There are no level 1 or 2 studies evaluating SCR, and a recent meta-analysis showed improvements in pain and function with a 76% healing rate. SCR still has a role in treating complex massive rotator cuff tears as a joint-preserving option, especially when glenohumeral involvement is minimal. In a comparative study between SCR and RSA for irreparable cuff tears without glenohumeral arthritis, pain and functional improvements between the procedures were similar.
Additionally, one should consider that SCR is typically not done in isolation. Partial rotator cuff repair may be attempted, and a partially repaired tendon can restore the force-couples, leading to improved shoulder mechanics. Reconstructing the superior capsule can have additional benefits, especially done with rotator cuff repair. However, there have been no matched comparative studies evaluating efficacy and outcomes of alternative treatments, such as tendon transfer, balloon interposition, partial repair and debridement. Although there has been some thought that SCR does not “burn bridges,” this notion has been unsettled in the literature. One study showed only modest improvements in range of motion and worse clinical outcomes for RSA for failed SCR. SCR can still result in reproducible improvements in pain and functional outcomes, especially when considering joint-preserving solutions for massive rotator cuff tears.
Michael A. Stone, MD, is an orthopedic surgeon at Cedars-Sinai Medical Center in Los Angeles, California.
- References:
- Cusano A, et al. J Shoulder Elbow Surg. 2022;doi:10.1016/j.jse.2021.12.044.
- Degan TJ, et al. Arthroscopy. 2022;doi:10.1016/j.arthro.2021.11.008.
- Lacheta L, et al. J Shoulder Elbow Surg. 2020;doi:10.1016/j.jse.2020.04.002.
- Mihata T, et al. Arthroscopy. 2013;doi:10.1016/j.arthro.2012.10.022.
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