Combined Cuff Repair And superior Capsular Reconstruction reinforcement (CRACR) in patients with massive rotator cuff (re)tears. A Minimum 2-year clinical and radiological follow-up.

Abstract

Background: Due to the aging population, the number of symptomatic degenerative rotator cuff tears has increased substantially and some are challenging to repair due to poor tendon quality with significant retraction. In order to optimize repair integrity and function, rotator cuff repair reinforcement with a superior capsule reconstruction has been proposed. This study presents the results of a technique combining cuff repair and capsular reconstruction (CRACR) using acellular dermal allograft in patients with massive rotator cuff tears and retears.

Methods: From December 2017 to July 2019 50 consecutive patients with previous failed rotator cuff repairs or primary surgery on poor tendon quality defined as massive rotator cuff tear (full thickness rotator cuff tears with 2 or more tendons involved), were treated with the CRACR technique and enrolled prospectively. Contraindications for the CRACR procedure were Hamada stage ≥ 3 cuff tear arthropathy and patient's preference for reverse total shoulder arthroplasty. Patients were reviewed at 3, 6, 12 and 24 months (American Shoulder and Elbow Surgeons (ASES) scores, Constant Murley Scores (CMS), Visual Analogues Scores (VAS), Oxford Shoulder Score (OSS), QuickDASH (QD)). Postoperative MRI scans were requested at 6 weeks, 3 months, 6 months, 12 months, and 24 months postoperatively to assess repair integrity.

Results: Mean age at surgery was 58.0 years (SD 8.1, range 41-79). Of the 50 patients, 14 patients (28.0%) had previous failed rotator cuff repair. From the 36 primary cases, 28 (77.8%) had massive rotator cuff tears and one (2.8%) a perioperative irreparable tear, while 28 (77.8%) patients had a subscapularis tear. At 2 years of follow-up all scores improved significantly (VAS 6.3 to 1.5; ASES 34.0 to 79.0; CMS 30.9 to 68.0; OSS 23.3 to 40.1; QD 56.2 to 20.3; all p<0.001). MRI scans were conducted at a mean of 14.4 months (SD 7.0, range 3-26) after surgery showing 6 isolated SCR failures and 5 isolated rotator cuff retears.

Conclusion: In the short term the rotator cuff repair and superior capsular reconstruction reinforcement (CRACR) technique is a valid option for patients with massive rotator cuff tears and retears with a high chance of a postoperative retear due to poor tendon quality. Clinical results and repair integrity is promising. Longer term follow-up is ongoing to establish the efficacy of this procedure.