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59-year-old female with pseudoparalysis due to massive, irreparable supra- and infraspinatus tears and radiographic findings shown in Figure A
52%
968/1878
75-year-old male with pseudoparalysis due to massive, irreparable supraspinatus tear and radiographic findings showing Figure B
5%
99/1878
65-year-old mechanic with pseudoparalysis due to massive, irreparable supra- and infraspinatus tears with radiographic findings showing Figure B
10%
190/1878
59-year-old mechanic with pseudoparalysis due to massive, irreparable supraspinatus and subscapularis tears and radiographic findings shown in Figure A
191/1878
45-year-old female with pseudoparalysis due to massive, irreparable supraspinatus and subscapularis tears with radiographic appearance showing in Figure A
23%
423/1878
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Of the choices, the 59-year-old with massive, irreparable supra- and infraspinatus tears without significant arthritic change (Figure A) would be the most ideal candidate. Irreparable rotator cuff tears in the middle-aged patient pose a significant problem for both the patient and physician. Without an intact rotator cuff the shoulder mechanics are distorted and create significant disability and disuse. Multiple procedures have been proposed over the years to restore the rotator cuff force-couples. Mihata et al. described the superior capsular reconstruction, which used autograft fascia lata graft to reconstruct the superior shoulder capsule and act as both a space-occupier and tether of the humeral head. This has subsequently undergone many technical variations but has been widely adopted. While long-term outcomes are yet to be demonstrated, early outcomes show promise in the ideal patient population. Frank et al. provide a review of indications and technique for SCR. The ideal patient is one who has intolerable pain from a massive, irreparable supra- and/or infraspinatus tear that is unresponsive to conservative treatment, has minimal arthritis change graded less than 2 on the Hamada scale, has an intact or reparable subscapularis tendon, and intact deltoid muscle. Contraindications are patients with significant arthritic changes (Hamada 3 or greater) and irreparable subscapularis tears. Pennington et al. conducted a retrospective case series of 86 patients with average age of 59 years, who underwent an SCR. At average follow-up of 12 months, significant improvements were shown in acromiohumeral distance (7 to 9mm), strength (4.8 to 9.0 lbs in forward flexion), range of motion (abduction from 103 to 159 degrees), and patient-reported outcomes (ASES 52 to 81). This shows excellent early outcomes following SCR. Figure A shows a shoulder without superior migration and a normal acromiohumeral interval. Figure B shows a shoulder with Hamada grade 4 changes: superior migration, narrowing of the acromiohumeral interval to less than 5mm, and a "goat's beard" osteophyte forming on the inferior humeral head. Illustration A is a depiction of the SCR procedure with the graft in place with multiple sutures. Illustration B is an intra-operative image from the lateral portal of a completed SCR. Illustration C depicts the Hamada classification. Incorrect Answers: Answers 2 and 3: Arthritic changes graded Hamada 3 or above are contraindications for SCR. Additionally, elderly patients with these findings would be ideal candidates for reverse shoulder arthroplasty. Answers 4 and 5: Irreparable subscapularis tears are contraindications for SCR, regardless of the arthritic changes seen.
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