We're talking about SCR, are we getting what we think? What's the evidence and what are my indications and technique? And so no disclosures. So a case, as always, starting out with a case. So you have this hockey player checked into the boards. He's had some pain for years, but he got checked two years ago, didn't come in, and now here's his weighted abduction showing some humeral head elevation, but really no arthrosis. You get an MRI and you see some atrophy of the cuff muscle, not a lot of fatty infiltration, and I can assure you the subscapularis is intact, but his infra and supra have massive tears and it's been two years old. So you've got some, then you, let's say you get to arthroscopy, you're really seeing this normal cartilage, but a retracted scarred cuff. And so you've got some options here. This is not reparable, so we'll leave that out today. In the irreparable, you've got debridement, partial repair, potentially tendon transfers, and then this SCR, shoulder arthroplasty, we're gonna try to avoid, he's 41 with no arthrosis. So SCR, are we getting what we think? Well, you know, there's a lot of literature, in fact, much of the literature, especially early, was on the fasciolata, but that's not used quite so much in the US, and allograft dermis is more popular. We're hearing about the biceps, as you just heard today from Dr. Tokish, and you could do this arthroscopic or open, that's what that might look like with fasciolata. The fasciolata is, on average, gonna be up to eight millimeters thick, but usually between four and eight, you get an MRI and you look at the thickness and the interposition effect of that, which is quite different than what we're doing in the US, where if you have a three millimeter, which is probably the average, you have a fairly thin, and the interposition effect is certainly far less, and you're probably, as you see on the right picture, they're getting some ruptures there at the glenoid because they're thin. Well, what about the biceps? Are we getting what we think? So on the pictures here at the bottom of the screen on the right, you're seeing some different configurations tested by Berthold and that group, and you can see in the picture labeled B, second one over, that the V shape seems to resist the superior migration of the head better than a box construct or a single strand, and so as we're learning more about bio-SCR, probably thinking about the biomechanics and what may get us some success, and we'll hear more about Dr. Tokish's technique with the meshing here shortly. So fasciolata, are we getting what we think? So four to eight millimeters, and definitely more than the four millimeters resists, the eight millimeter thick resists translation superiorly and decreases contact pressures. In a head-to-head comparison with dermal allograft, the fasciolata resisted humeral head migration and those contact pressures, but interesting, a group out of HSS looked at, if you use fasciolata six millimeters versus human dermal allograft six millimeters, then instead they're actually quite equal. So it may be that it's the thickness and the interposition effect that's really more successful, and so this is something to think about, that the thinner grafts may not be the answer. SCR versus bridge grafting, when you've got this humeral head elevations, certainly anchoring to the glenoid makes a difference, that the interposition in the tendon only does not resist superior translation so well. If we look at some other biomechanics, graft tensioning seems to be important, so putting the, abducting the arm to 10 to 30 degrees resists, or tensions that better, and side-to-side suturing, we see in several studies of biomechanics that attaching your SCR to the anterior and posterior soft tissues is important, and in fact resists, it makes the shoulder more stable. Some clinical evidence, Mahada's probably got most of the work in this area with fasciolata, and one of the things we can see, if we look at the table on the right, that's improvement, so when I say active elevation is 53 degrees, that means improvement of 53 degrees, these are all improvements over even five years that patients still have an improvement of 66 degrees elevation, and improved 4.7 millimeters on their humeral head elevation, and at specialty day this past year in March, we finally saw some 10-year follow-up on SCR, and though this has not been published yet, we could see graft survival with fasciolata up to 89% at five to 10 years, and as long as the tear stayed healed, the chromohumeral distance was maintained at almost eight millimeters, which is pretty impressive in a low complication rate, and in Lisa Mahada's work, he's able to show improvement of pseudoparalysis at quite a high level, but what do we see with systematic reviews now getting away from fasciolata, and looking at nine studies here in 2020, 13% of grafts had a tear with some 15 patients needing revisions and 432 patients in seven reverses, but the further out we start going, now 51 studies, we see now even comparing to balloon partial repair that partial repairs and massive tears were failing 45% of the time, and graft interposition or superior capsule failing 21% of the time, and in 14 studies we're seeing higher rates of failure, and so finishing up with my indications, so generally younger patients with no arthrosis, if you don't have an intact subscapularis, you should think about not doing this, and like you see some other things like good forward elevation, I don't use it for pseudoparalysis, and lastly, looking at the types of patients, I think thinking about Colin's work in 2014 showing the pattern, if you've got an upper and lower subscap tear, you probably shouldn't be doing SCR, it's really for the superior tears, and finally I would just emphasize that I use a thick graft, I don't use one less than five millimeters in my practice, and I do this mini open site contention better, and always pay attention to the biceps, thank you.

SCR

shoulder injury

treatment options

grafts

clinical evidence