**8. Outcomes**

**7.7. Anterior and posterior convergence**

placed here.

146 Advances in Shoulder Surgery

Once the graft is secured medially and laterally, side-to-side margin convergence sutures are placed to secure the graft to the intact cuff (**Figure 18A** and **B** ). Pre-placed sutures are helpful for this, as discussed above. Typically two side-to-side sutures are used posteriorly, to connect the graft to the intact part of the infraspinatus or to the teres minor. Anteriorly, if the fixation is to the intact remaining supraspinatus, two sutures may be used as well (**Figure 18C**); however, if there is no supraspinatus left, and fixation is to the upper border of the subscapularis, no more than one suture should be used, as laterally as possible, to avoid over-constricting the rotator interval. If the distance between the anterior edge of the graft and the upper border of the subscapularis is too great, no margin convergence sutures are

**Figure 17.** Graft fixation to the humeral head. (A) Suture-tapes from the medial row greater tuberosity anchors are passed up through the graft, using the previously placed suture-loop (left shoulder, view from the anterolateral portal; AA—anterior anchor, PA—posterior anchor, GT—greater tuberosity); (B) Suture tapes are criss-crossed and secured just past the lateral margin of the tuberosity with knotless anchors, providing excellent compression of the graft over the tuberosity footprint. (C) If a small "dog-ear" is noted after lateral graft fixation, a suture preloaded into the lateral-row

anchor can be used to tie it down. (D) Model demonstration of graft fixation to the humeral head.

Published reports of clinical outcomes following superior capsular reconstruction thus far have been limited to one study, but more such studies are currently either in data collection or already in preparations to report outcomes. In 2013, Mihata et al. reported a case series of 24 shoulders (23 consecutive patients), treated with SCR using fascia lata autograft, with minimum 2-year follow-up [2]. At an average follow-up of 34 months (24–51 months), mean active elevation increased from 84 to 148° and mean external rotation increased from 26 to 40°. All clinical outcomes scores improved significantly, with American Shoulder and Elbow Surgeons score (ASES) score going up from an average of 23.5 to 92.9. Furthermore, imaging showed acromiohumeral distance increased from 4.6 to 8.7 mm, on average. No procedurerelated complications were reported [2].

In the United States, most surgeons prefer to use a dermal allograft (Arthrex Arthroflex), which is a thick (3 mm) and durable patch, which requires minimal preparation time and is relatively easy to handle. Several technical reports using this graft have been published, including those by Hirahara and Adams, Petri et al., Tokish and Beicker, and Burkhart et al. [36–39], but clinical data on the outcomes of this approach is lacking in the published literature. However, personal communication with a number of surgeons currently performing SCR using the dermal allograft patch produced reports of high patient satisfaction rates, excellent improvement in function and pain levels in the short term, and low risk of complications. One of our personal communications has been with a surgeon who now has data on 20 SCR procedures, with a minimum follow-up of 3 months and up to 1.5 years, and reports that Visual Analogue Scale (VAS) scores decreased on average from 6–9 to 0–3 range, while ASES scores went up from the 20–30 range to the 70–90 range. No complications were reported in this patient group (personal communication with Dr. Kevin Kaplan, Jacksonville Orthopedic Institute, Jacksonville, FL).

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