A new retrospective study from Hospital for Special Surgery (HSS) evaluated 72 patients who underwent arthroscopic SCR with dermal allograft to treat symptomatic irreparable rotator cuff tears. All patients were operated on at HSS between 2012 and 2017. Nearly 42% of the patients had a history of failed rotator cuff repair.

After surgery, the overwhelming majority of patients demonstrated significant improvements in forward elevation, abduction and external rotation through their pre- and post-operative active range of motion. At follow-up appointments, patients completed various patient-reported outcome surveys including Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES), and University of California at Los Angeles (UCLA). Patient scores were high, averaging 80%, 78% and 85%, respectively.

Five patients required a second operation – no other complications were recorded.

“This technique has proven to be effective for patients with irreparable tears,” said Joshua S. Dines, MD, HSS sports medicine surgeon and senior study author. “As we continue to do more outcomes research, we become more precise at predicting the best candidates for each technique. While not for everyone, this has emerged as a great option for patients who may not be right for a reverse shoulder replacement.”

The authors look to perform future research evaluating the long-term outcomes and results.

This study is available online as part of the AAOS 2020 Virtual Education Experience.

Abstract Title: Clinical Outcomes following Arthroscopic Shoulder Superior Capsular Reconstruction

Authors: Daniel Hurwit, MD, Justin Chan, Michael Fu, MD, John Apostolakos, MD, Stephen Fealy, MD, Frank Cordasco, MD, David Dines, MD, Lawrence Gulotta, MD, Joshua Dines, MD.

“I have always been a very active, outdoorsy nature lover, enjoying activities such as mountain climbing, biking, kayaking and rock-climbing all around the world with my family, as well as ballet dancing,” Ms. Hitchcock wrote on “Back in the Game,” the HSS patient blog. “By 2009 I was in constant pain and barely able to walk, much less dance or climb. Within a month of my total knee replacement I was back in the ballet studio doing my barre exercises and I climbed Mt Katahdin in Maine, crossing the ‘Knife’s Edge’ 11 months later. Dr. Westrich truly gave me back my life! With my new knee I was able to take a rock-climbing trip to Thailand in 2014 to celebrate our children’s’ PhDs! What fun!”

Over the years, Ms. Hitchcock has enjoyed numerous active vacations with her family. She has visited Zimbabwe, Botswana, Borneo and other exotic locales. In addition to climbing, she continues to go hiking, bicycling and has taken up snorkeling. She recently returned from an adventure vacation in New Zealand with her husband and daughter, which included mountain climbing and kayaking.

Ms. Hitchcock is among a growing number of baby boomers who refuse to slow down, despite joints worn out by years of activity, an injury or the passage of time. “I’m seeing more people in their 40’s and 50’s who refuse to be sedentary and, like Diane, will do what it takes to enjoy their active lives,” Dr. Westrich says. “Over the past few years, advances in joint implant design and surgical technique provide even more options for younger patients.” Robotic-assisted surgery and a newer cementless implant could lead to a longer-lasting knee replacement, he says.

Along with Dr. Westrich, Ms. Hitchcock credits two other highly specialized orthopedic surgeons at HSS with helping her maintain her active lifestyle. In addition to her knee replacement at age 56, she had a spinal fusion with Dr. Federico Girardi in 2017 and shoulder replacement surgery with Dr. Lawrence Gulotta in 2018.

She says each surgery has helped her enjoy life again. “Never once did any of my doctors at HSS express the notion that these goals were too extreme for someone my age,” she explains. Major surgery is never a walk in the park, but Ms. Hitchcock didn’t hesitate. She took each surgery and recovery very seriously, taking time off from work and vigorously adhering to her physical therapy regime after each procedure. She speaks very highly of all three of her HSS physicians, and says she had excellent outcomes after surgery.

 Her doctors applaud the motivation of Diane and others who wish to enjoy the physical and psychological benefits of exercise at every age. “Why give up years of an active lifestyle,” Dr. Westrich says, “when newer options are available to allow patients with arthritis or another orthopedic condition to live life to the fullest?”

Reconstruction is the current standard of care surgical treatment for tears of the anterior cruciate ligament (ACL). This procedure typically uses a graft, or a piece of tissue, placed in the knee minimally invasively, using small incisions. About 300,000 ACL reconstructions are performed annually in the United States with well documented rates of success.

ACL repair is an older technique that involved suturing (sewing) torn ACL tissue, not rebuilding it with a graft. ACL repair was performed in the 1970s at select institutions, including Hospital for Special Surgery, but was abandoned due to unacceptably high failure rates of up to 50%.

Today, ACL repair has been modernized and can be performed through a minimally invasive approach. Proponents suggest that modern ACL repair techniques may be performed safely and may lead to a quicker recovery than ACL reconstruction. However, the limited studies to date raise questions that must be discussed in detail with your surgeon.

1. It is critically important to get ACL surgery right the first time.

When ACL surgery fails, surgeons must do a revision procedure to correct or revise the problems that were not fully addressed the first time. Revision requires reconstructive ACL surgery with a graft. (ACL repairs cannot be done as revisions.) Redoing ACL surgery may result in higher rates of failure, lower rates of return to sports, and increased risk of osteoarthritis.

The importance of successful initial ACL surgery holds true for people of all ages, but it is particularly critical for young athletes, for whom a failed surgery can have devastating consequences, including years lost from sport in the short term as well as chronic pain and loss of function in the long term.

2. Failure rates for ACL repair appear to be significantly higher than those for ACL reconstruction in people of all ages.

Current studies suggest that modern ACL repair techniques have a failure rate that may be five to ten times higher than that of ACL reconstruction^1,2,3. One major recent study in a prominent sports medicine journal found that arthroscopic ACL repair has unacceptable outcomes in young athletes, with short-term failure rates of close to 50%².

It has been suggested that ACL repair may be appropriate for older adults who have a type of ACL tear called a proximal avulsion and who do not participate in “cutting and pivoting” sports such as basketball, volleyball, and soccer. For these patients, failure rates in the short term appear to be much higher than ACL reconstruction in this age group^1,2,3.

3. There is still much we don’t know about ACL repair.

There has been no scientific evidence that shows a difference in postoperative pain between ACL repair and reconstruction. Rehabilitation and return-to-play protocols for ACL repair have not yet been established. Proper guidelines for rehabilitation and return to sports are essential to keep people safe from re-injury.
 

Andrew D. Pearle, MD

Chief, HSS Sports Medicine Institute

Bryan T. Kelly, MD

HSS Surgeon-in-Chief and Medical Director

Answorth A. Allen, MD

David W. Altchek, MD

Struan H. Coleman, MD, PhD

Frank A. Cordasco, MD, MS

David M. Dines, MD

Joshua S. Dines, MD

Stephen Fealy, MD

Andreas H. Gomoll, MD

Lawrence V. Gulotta, MD

Jo A. Hannafin, MD, PhD

Anne M. Kelly, MD

John D. MacGillivray, MD

Robert G. Marx, MD, MSc, FRCSC

Michael J. Maynard, MD

Moira M. McCarthy, MD

Danyal H. Nawabi, MD, FRCS

Stephen J. O’Brien, MD, MBA

Anil S. Ranawat, MD

Scott A. Rodeo, MD

Howard Anthony Rose, MD

Beth E. Shubin Stein, MD

Sabrina M. Strickland, MD

Karen M. Sutton, MD

Samuel A. Taylor, MD

Russell F. Warren, MD

Thomas L. Wickiewicz, MD

Riley J. Williams III, MD

References

1. Jonkergouw A, van der List J, DiFelice G. Arthroscopic primary repair of proximal ACL tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc. 2019 Jan;27(1):21-28.

2. Gagliardi AG, Carry PM, Parikh HB, Traver JL, Howell DR, Albright JC. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019 Mar;47(3):560-566.

3. Wright RW et al. Risk of tearing the intact ACL in the contralateral knee and rupturing the ACL graft during the first 2 years after ACLR: A prospective MOON cohort study. Am J Sports Med. 2007 Jul;35(7):1131-4.

For more information visit https://www.hss.edu/condition-list_torn-acl.asp.