Arthroscopic Supraspinatus Tendon Reconstruction Using Hybrid LARS-Fascia Lata Graft for Irreparable Posterosuperior Massive Rotator Cuff Tears.

BACKGROUND: Conventional techniques for repairing an irreparable posterosuperior massive rotator cuff tear (MRCT) typically fail1,2. The supraspinatus tendon reconstruction (STR) technique offers a systematic approach to achieve both anatomic restoration and functional recovery of the supraspinatus tendon1. The use of autografts for reconstruction is challenged by their limited availability, inadequate dimensions, and donor site morbidity. The Ligament Augmentation and Reconstruction System (LARS; MovMedix) is a synthetic ligament consisting of fibers made of polyethylene terephthalate that is used as an alternative to autograft; however, concerns remain regarding inadequate graft integration with bone3. In contrast, fascia lata autografts demonstrate enhanced interface healing with both the supraspinatus muscle and the bone at the footprint4-6. The present article describes a unique arthroscopic STR approach involving a hybrid LARS-fascia lata graft for irreparable posterosuperior MRCTs. DESCRIPTION: The patient is placed in the lateral decubitus position, with lateral traction applied to the operative arm. Following diagnostic arthroscopy and subacromial decompression, the dimensions of the rotator cuff defect are measured arthroscopically. The width of the LARS artificial ligament is matched to the defect size, and the length is determined by the distance from the greater tuberosity to the most medial aspect of the scapular spine. A 5-cm autogenous fascia lata graft is harvested from the ipsilateral proximal thigh (distal to a point 2 cm above the greater trochanter). The graft is then circumferentially wrapped around one end of the LARS ligament and sutured in a mattress suture pattern. Two absorbable anchors are placed on the medial line of the footprint. The anchors are sutured through the lateral end of the hybrid LARS-fascia lata graft. The guide pin is passed through the subacromial region from the lateral portal, running along the supraspinatus muscle to the most medial part of the spine of the scapula and penetrating the dorsal skin. The traction wire is pulled medially and fixed with use of a double-row anchor technique. A transverse incision approximately 3 cm in length is made at the most medial side of the scapular spine to expose the medial end of the patch and the spine of the scapula. A suture anchor is implanted at the most medial part of the scapular spine, and the fascia lata is sutured to maintain the graft under as much tension as possible7-9. ALTERNATIVES: Surgical alternatives for the treatment of irreparable posterosuperior MRCTs include partial repair, superior capsular reconstruction (SCR), tendon transfers (such as latissimus dorsi or pectoralis major transfer), and reverse shoulder arthroplasty. RATIONALE: Compared with SCR and its modified approaches such as the "sandwich" technique, the STR technique for irreparable posterosuperior MRCTs offers distinct histological, biomechanical, and functional advantages, making it preferable in select clinical scenarios. Histologically, unlike SCR and its sandwich modification-which rely solely on graft-to-bone healing-STR incorporates dual healing interfaces, which involve graft-to-bone healing at the lateral end and graft-to-muscle integration at the medial end. Additionally, fascia lata healing to the native bone tends to recapitulate the normal biological tendon-bone interface5,6. STR with the hybrid LARS-fascia lata technique selectively applies the fascia lata at the footprint to optimize graft fixation and its healing to the bone. Biomechanically, SCR primarily restores passive stability by reconstructing the static superior capsule. STR and bridging techniques uniquely restore dynamic stability through reconstruction of the supraspinatus tendon's functional stretching mechanism, closely mimicking native shoulder kinematics6. Functionally, STR and bridging techniques actively recreate supraspinatus muscle function, whereas SCR does not restore dynamic tendon excursion. A reduction in fatty infiltration within the supraspinatus muscle has been observed following STR8, suggesting muscle revitalization potential. EXPECTED OUTCOMES: In a retrospective cohort study of 43 patients with irreparable posterosuperior MRCTs undergoing STR8, STR resulted in significant improvements in active shoulder range of motion. Additionally, outcome scores substantially improved compared with the preoperative baseline scores. The fascia lata enhances interface healing between the LARS ligament and bone, whereas the LARS component reduces the risk of graft failure. The hybrid LARS-fascia lata graft technique might achieve better long-term outcomes for patients with irreparable posterosuperior MRCTs. IMPORTANT TIPS: Subacromial decompression is critical for graft passage.Graft trajectory must follow a 30° to 45° angle to avoid impingement.Mattress sutures (2 cm) are used between the LARS artificial ligament and fascia lata to enhance the interface healing between the LARS artificial ligament and bone in the footprint.Maintain moderate tension in the LARS artificial ligament when its end is fixed to the scapular spine.Fractures of the medial scapular spine may easily occur during LARS artificial ligament fixation with a 2.9-mm LUPINE (DePuy Mitek) suture anchor. ACRONYMS AND ABBREVIATIONS: VAS = visual analog scale scoreASES = American Shoulder and Elbow Surgeons scoreUCLA = University of California Los Angeles scoreROM = range of motionAHD = acromiohumeral distancePP = posterior portalAP = anterolateral portalLP = lateral accessory portalMRI = magnetic resonance imagingPDS = polydioxanone sutureBMI = body mass indexFF = forward flexionSBD = subacromial bursal decompressionER = external rotationIR = internal rotation.