Clinical Importance of Graft Integrity in Arthroscopic Superior Capsular Reconstruction Using a Minimally Invasively Harvested Midthigh Fascia Lata Autograft: 3-Year Clinical and Magnetic Resonance Imaging Outcomes

Abstract

Background: The clinical importance of graft type and integrity in arthroscopic superior capsular reconstruction (ASCR) remains controversial. Purpose: To assess 3-year clinical and magnetic resonance imaging (MRI) outcomes of ASCR using a minimally invasively harvested fascia lata autograft (FLA) for irreparable rotator cuff tears (IRCTs) and to determine the clinical importance of graft integrity and whether the results change from year 2 to 3. Study Design: Case series; Level of evidence, 4. Methods: A total of 22 consecutive patients who underwent ASCR with a minimally invasively harvested FLA were enrolled in a prospective single-arm study. At 3 years, the patients answered a satisfaction questionnaire and underwent a clinical examination and MRI. The MRI scans were independently reviewed by 3 raters to determine the graft integrity, acromiohumeral interval, supraspinatus atrophy, and fatty degeneration of the rotator cuff muscles. Reliability statistics were calculated, and the outcomes were compared across subgroups of patients with and without complete graft tears. Results: Overall, 21 patients (95.5%) answered the questionnaire, 20/21 (95.2%) were satisfied, 4/20 (20.0%) reported donor site pain, and 19 patients (86.4%) underwent examinations. From preoperatively to 3 years, the mean improvement was 73.68° in elevation (95% CI, 47.59°-99.77°), 89.21° in abduction (95% CI, 66.56°-111.86°), 24.74° in external rotation (95% CI, 4.72°-34.75°), 3.00 in internal rotation (95% CI, 2.36-3.64), 2.61 kg in abduction strength (95% CI, 1.76-3.45 kg), 50.79 on the Constant score (CS; 95% CI, 41.99-59.58), 7.47 on the Simple Shoulder Test (SST; 95% CI, 5.19-9.75), and 36.05% on the subjective shoulder value (SSV; 95% CI, 23.19%-48.92%), which were all significant ( P < .05). From 2 to 3 years, the mean improvement in abduction was 20.26° (95% CI, 5.44°-35.09°), which was significant ( P = .010). At 3 years, the raters perfectly agreed (kappa = 1; P = .000013) that 4 patients (21.1%) had complete graft tears; this subgroup of patients had decreased external rotation strength at 90° of abduction (1.77 ± 0.17 vs 4.45 ± 2.55 kg, respectively; P = .027) and increased grades of infraspinatus (3.50 ± 0.58 vs 2.20 ± 1.01, respectively; P = .030) and teres minor fatty degeneration (3.25 ± 0.96 vs 1.53 ± 0.64, respectively; P = .005) compared with those without a complete graft tear, but the mean CS, SST, and SSV scores did not differ from those of the overall group (69.50 ± 5.20 vs 69.63 ± 18.25; 9.00 ± 2.31 vs 9.74 ± 4.73; and 72.50 ± 15.00 vs 71.58 ± 26.70, respectively). Conclusion: The 3-year clinical outcomes of ASCR using a minimally invasively harvested FLA for IRCTs were good, despite donor site morbidity. Active abduction improved significantly from 2 to 3 years. Complete graft tears were correlated with significantly decreased external rotation strength at 90° of shoulder abduction and increased grades of infraspinatus and teres minor fatty degeneration. Registration: NCT03663036 (ClinicalTrials.gov identifier)

Proximal and mid-thigh fascia lata graft constructs used for arthroscopic superior capsule reconstruction show equivalent biomechanical properties: an in vitro human cadaver study

“…ASCR using either the openly harvested proximal thigh FL autograft 13 , 15 or the minimally invasively harvested mid-thigh FL autograft 2 , 5 has been shown to produce good clinical outcomes, and the present study validates the biomechanical equivalence of the 2 types of FL graft constructs with regard to the stiffness and Young’s modulus. Orthopedic surgeons and patients may find the mid-thigh harvesting of the graft advantageous versus the open harvesting technique because the mid-thigh FL autograft can be minimally invasively harvested using a reproducible technique, 3 , 25 with a low donor site morbidity.…”

“…The clinical studies on ASCR using either the proximal thigh– or mid-thigh–harvested FL autograft reported good shoulder outcomes in IRCTs. 2 , 5 , 13 , 15 However, the morphological characteristics and elastic properties of the FL have been shown to be site dependent. 21 The lateral FL has been shown to be significantly thicker than other sites (0.8 ± 0.2 mm versus 0.2 – 0.3 mm in other sites), 21 and the proximal region of the lateral FL is capable of undergoing elongation that is significantly greater than that of the middle and distal regions.…”

Shoulder Positioning during Superior Capsular Reconstruction: Computational Analysis of Graft Integrity and Shoulder Stability

“…During this procedure, a concomitant tenotomy or tenodesis of the long head of the biceps (LHB) tendon may be performed, which has been shown to contribute to the relief of shoulder pain [ 18 , 19 , 20 ]. ASCR has been shown to produce excellent clinical outcomes [ 21 ]; however, graft tear rates can range from 4.2% to 75% [ 16 , 17 , 22 , 23 , 24 ]. ASCR using a human dermal allograft presents higher tear rates than ASCR using a fascia lata autograft [ 23 , 24 ].…”

“…ASCR has been shown to produce excellent clinical outcomes [ 21 ]; however, graft tear rates can range from 4.2% to 75% [ 16 , 17 , 22 , 23 , 24 ]. ASCR using a human dermal allograft presents higher tear rates than ASCR using a fascia lata autograft [ 23 , 24 ]. Graft tears of larger dimensions have been correlated with decreased functional outcomes compared to functionality in the intact graft condition [ 25 ].…”

SCR 2021

“…In recent years, other surgical groups have also reported the results of autograft SCR, often with their own modifications. 2,3,12,16 Azevedo et al, 2 for example, utilized a fascia lata autograft harvested with a minimally invasive technique. Kholinne et al 12 reported that reinforcing a fascia lata autograft SCR with polypropylene mesh yielded improved results in graft integrity and several clinical parameters.…”