reconstruction versus bridge grafting a prospective randomized controlled trial. My name is Yohei Ono from Japan giving this talk on behalf of Dr. Low. Massive calf tears are difficult to treat with a variety of surgical options such as partial repair, bridging rafts, superior capsule reconstruction, tendon transfer, and reverse. Among those, partial repair is commonly performed and classically, a graft has been utilized to bridge the gap or to fill the hole. As you know, Dr. Mihata introduced an idea to recreate superior capsule by proximally fixing the graft to the glenid bone rather than to the tendon tissue which is called SCR. He demonstrated excellent clinical and radiographical outcomes following SCR, however, it's never been directly compared to the conventional bridging graft technique. Therefore, the purpose of the study was to compare the outcomes of SCR with bridging graft for massive irreparable calf tears. This is a prospective randomized controlled trial where both patients and evaluators were blinded. Human dermal allograft was utilized as a graft. Both primary and revisionally irreparable calf tear cases without arthritic changes were included. Interoperatively, if the tear was confirmed irreparable, partial repair was performed followed by randomization to one of the two procedures. The graft utilized was the Artoflex, which has its thickness over 3 mm. Postoperatively, patients followed the same rehab program and the AACS work and death scores were assessed at every visit. X-rays were taken for acromiohumeral interval and Hamada classification and graft integrity was evaluated by MRI at 1-year post-op. Power analysis according to MCID of the AACS score revealed 13 per group, which was inflated up to 25 per group, 50 in total. Results Among the 72 patients recruited and screened, 50 patients were randomized and allocated to either bridging or SCR. 84% was male with the mean age of 60 years. Mean pre-op duration of symptom was about 5 years and the majority was with Hamada 1 and 2. There was no difference in the patient population between groups. No major complications were observed. Graft size was about an inch in width and length. AACS score improved over time with no difference between groups. Same for the work score and the death score. There were no significant differences in acromiohumeral interval between groups. Passive forward elevation range was better in the SCR group at 3 months post-op, but otherwise there was no difference. Same for passive abduction, better in SCR group only at 3 months post-op. For external rotation range, there was no difference at any time points. Risk healing was obtained at 64% for bridging and 75% for SCR with no significant difference. There was no significant difference in the distribution of irreparable service gap or posterior calf between bridging and SCR. If service gap or posterior calf was irreparable, healing rate decreased significantly. AACS and work scores were greater in the intact group at 24 months, whether bridging or SCR Intact groups demonstrated greater acromiohumeral interval at all time points. Discussion Both groups improved passive range and SCR was better than bridging only at 3 months. Although the follow-up was too short to conclude, this might indicate the important role of partial repair. Overall, healing rate was about 70% while it significantly dropped if service gap or posterior calf was irreparable, and healing was positively correlated with outcome scores and ACH. The question is, how can we improve healing? While patient selection should be critical, achieving better fixation will help, and slow down rehab program may be another thing to consider. In the original case series by Mihata, the results were actually surprisingly good in comparison to others including our study. The most significant difference may be the fact that they utilized fasciolata autograft. Mihata later reported in a biomechanical study that human dermal autografts elongated during testing and fasciolata provided greater superior stability in comparison to human dermis. In conclusion, both bridging and SCR improved clinically although there was no difference between the groups. Overall healing rate was about 70% and the cases with intact grafts performed better in passive range and acromio-humeral interval. Future research is planned to determine longer-term outcomes, ideal graft types, better fixation methods, and adequate patient selection. Thank you very much.

randomized controlled trial

reconstruction

bridge grafting

calf tears

clinical outcomes