Superior Capsular Reconstruction With Acellular Dermal Allograft Improves Midterm Clinical Outcomes but Is Associated With High Rates of Graft Failure and Progression of Cuff Tear Arthropathy

PURPOSE: To evaluate the midterm clinical and radiographic outcomes of arthroscopic superior capsular reconstruction (SCR) using acellular human dermal allograft. METHODS: The study period was from December 2022 to May 2024. Patients were eligible if they underwent SCR with dermal allograft for operatively irreparable posterosuperior rotator cuff tears by a single surgeon between 2013 and 2017. Exclusion criteria included SCR used as augmentation to complete rotator cuff repair, conversion to arthroplasty, inability to consent/participate, and practice administrative dismissal. Enrolled patients completed patient-reported outcomes, radiographs, and magnetic resonance imaging at a minimum of 5-year follow-up. Imaging was independently assessed by a musculoskeletal radiologist. RESULTS: Of 136 SCRs (132 patients), 33 were excluded (augmentation to complete repair (n = 21), revision to arthroplasty (n = 3)) and 44 were lost to follow-up. Final analysis included 59 SCRs (57 with patient-reported outcomes, 32 with complete imaging), with minimum 5-year follow-up (median 6 years (range: 5.0-8.1)). Final American Shoulder and Elbow Surgeons (median 83 (interquartile range (IQR) 77, 93)) and Single Assessment Numeric Evaluation scores (median 85 (IQR 75, 95)) were improved compared with preoperative values (American Shoulder and Elbow Surgeons: 48 (IQR 35, 64) P < .001; Single Assessment Numeric Evaluation scores: 40 (IQR 21, 50), P < .001), with 81% and 91% of patients exceeding the minimum clinically important difference for the respective measures. Radiographs revealed 63% (n = 20) of patients were Hamada grade 4 at final follow-up (preoperative: Hamada 1: 66% (n = 21); 2: 16% (n = 5); 3: 16% (n = 5); 4: 3% (n = 1)), with a decreased acromiohumeral interval (median 3.5 mm (IQR 2.0, 5.0) compared with preoperative values (6.2 mm (IQR 4.2, 7.5)). Major graft discontinuity (Hasegawa V) was observed in 66% (n = 21) of patients. CONCLUSIONS: Arthroscopic SCR with acellular dermal allograft substantially improves patient-reported outcomes at midterm follow-up, with a low overall reoperation rate. However, structural deterioration, including decreased acromiohumeral distance and a high graft failure rate, suggests that SCR may not significantly alter the natural history of massive rotator cuff tears. LEVEL OF EVIDENCE: Level IV, retrospective case series.