**9. Future direction and conclusion**

Large irreparable rotator cuff tears in younger and active patients continue to pose a significant clinical challenge to orthopedic surgeons. Arthroplasty treatment option with a reverse shoulder replacement is not ideal in this patient population. Mihata et al. [33] have shown in biomechanical cadaveric studies that a graft reconstruction can restore superior glenohumeral translation when the graft is attached to the glenoid medially and humeral head laterally. However, many technical aspects of this procedure have not been well studied, such as ideal suture and anchor configuration medially or laterally, ideal graft tissue (allograft versus autograft), ideal graft thickness, or ideal tensioning technique.

In the immediate future, we will need larger clinical studies with short, medium, and longterm outcome data demonstrating the effectiveness of superior capsular reconstruction. Radiographic follow-up studies are needed to document graft incorporation or deterioration after this surgery, as well as to monitor the acromiohumeral distance in this patient population. Clinical indications and contraindications, as well as the ideal patient population, for this procedure need be better defined.

Superior capsular reconstruction is a novel technique that may provide a potentially promising solution to a tough problem in the shoulder region. The procedure should be considered for active and physiologically young patients with high functional demand on their upper extremity, and an irreparable rotator cuff tear, and should be performed by surgeons experienced in treating shoulder pathology. More clinical studies are needed before we can advocate widespread use of this procedure in general orthopedic practice.
