Rotator cuff repair using Arthroscopic Superior Capsular Reconstruction (SCR) of the Shoulder Using Dermal Allograft
Mr Daoud Makki, Consultant Upper Limb Surgeon wins a Blue Ribbon Article Award for his article Arthroscopic Superior Capsular Reconstruction (SCR) of the Shoulder Using Dermal Allograft, an innovative surgical technique used for rotator cuff repair.
In this interview with Mary Wolff-Ingham, LSO Marketing Manager, he explains what the award was for; the success he’s had in repairing massive rotator cuff tears (of the supraspinatus tendon) using this technique and the enhancements he’s introduced to increase its effectiveness.
What was your Blue Ribbon Article Award for?
It was for an article that reported on the 2-year clinical outcomes for patients who had undergone arthroscopic SCR using an acellular dermal allograft to treat irreparable rotator cuff tears. We received the award because our study was consistent, with very few variables. For all patients, we used one technique, one graft, the same assessment measures, the same assessor, and the same group of surgeons, which means the results are more reliable. Our paper was regarded as the single most important contribution to the literature on this subject, this year. You can read the extract here.
What exactly is arthroscopic SCR and when was it first introduced?
Arthroscopic SCR was first introduced in the USA about 8 to 9 years ago to treat rotator cuffs tears when the supraspinatus tendon is irreparable. Superior capsular reconstruction simply means that you are recreating a superior restraint over the humeral head. The supraspinatus tendon keeps the ball contained in the socket: if the supraspinatus tendon is irreparable, then you try and substitute it with something else. We take a piece of tissue and we anchor it over the ball and over the socket, so when the humeral head wants to migrate upwards during arm elevation, this piece of tissue holds it down and stops it from going upwards.
Initially, the tissue used for this kind of procedure used to be the patient’s own fascia lata (taken from the hip). However, it was found that this wasn’t actually strong enough to hold and support the humeral head. Consequently, we therefore moved on to using dermal allografts, which were found to be stronger, much more effective and less likely to stretch with time and tear.
Over time, we hope that the patient’s own tissues will grow over the dermal allograft and create a thick membrane that will stay there for a long time. At the moment, we don’t have any long-term outcomes; however, our study has shown that patients are still doing well at two-year follow-up.
What was the success rate evidenced by the study?
Our study showed between an 80 to 85% success rate at 2 years follow-up. This is considered significant and extremely promising. We don’t know yet what will happen in 3 – or 4 years’ time, because this technique is so new. If by 5 years patients are still doing reasonably well, then I would be very happy, because we’ll then have been able to change somebody’s quality of life for 5 years with minimally-invasive keyhole surgery that is often just day-case surgery. If a patient is in less pain, can carry out simple daily activities (like reaching up to hang clothes in their wardrobe, or holding a kettle), and they are able to do what they like with no struggle, then for me, that is a success. Even now, knowing that SCR surgery has improved a patient’s quality of life for 2 years is rewarding.
What were the options for patients prior to the introduction of Arthroscopic SCR surgery?
Prior to the introduction of arthroscopic SCR surgery, the only option for a patient who had an irreparable supraspinatus tendon was physiotherapy and / or to just put up with the pain, or else opt for a reverse shoulder replacement. However, a reverse shoulder replacement is a big operation, with high risks. In my view, it should be a last resort and only offered to patients who are in significant pain from arthritis. It shouldn’t be offered to patients who have a torn tendon but with a healthy shoulder joint. For these patients, arthroscopic SCR surgery offers a good interim bridging option and does not make doing a reverse shoulder replacement any more difficult at a later stage, if this is ever required.
How did you become involved in pioneering the use of dermal allografts in SCR in the UK?
I undertook my Fellowship Training in Manchester, under the guidance of Mr Matt Ravenscroft, who is an outstanding arthroscopist. Arthroscopic SCR using dermal allograft was just being introduced, and we received many referrals. At the time, there was only a small handful of surgeons in the UK doing this procedure, and we were one of the few centres involved.
This is where I learned my arthroscopic SCR technique and where the cohort of patients came from for the study that received the Blue Ribbon Article Award.
Is that true to say that you are one of the most experienced surgeons in the UK using this technique to treat patients?
In the past few years, there’s been lots of seminars and workshops for surgeons to learn about this technique, so more of us are now using it to repair supraspinatus tears. For any surgeon, the more times you do an operation, the more skilled and expert you become in it. Over the last two years, I’ve performed this technique on 19 patients, whereas many other surgeons based in my NHS patch in North West London may only have done between 0 to 7 in the last 2 to 3 years. My 19 patients are coming up to their 2-year post-surgery review, so I will be publishing my own independent series of patient clinical outcomes, which will evidence my expertise and success in treating patients using this technique.
What’s the enhanced surgical technique you’ve introduced to increase the effectiveness of Arthroscopic SCR?
The more times you do an operation, you more you start thinking: ‘what’s the best way to get this better and better?’ So, I’ve changed the technique slightly, using what I learned from Matt during my Fellowship, and have moved it forward. I’ve simplified the technique. By using better suture management, I’ve reduced the risk of entanglement. If you are doing keyhole surgery and get entanglement in your sutures, this is a big problem! If you’re not having to untangle your sutures, your surgery time is kept to a minimum, which is big advantage to the patient. My technique also differs from others in that I only put part of the anchors in initially, and I only fix the graft partially. I leave the other end free (i.e. simulating a tendon repair). This means that I can ensure that I can easily get the right tension in the reconstruction.
I’ve recently submitted an article on my enhanced technique to one of the American journals (Orthopaedics), and it has been accepted and will be published later this year.
When would you normally offer patients Arthroscopic SCR surgery?
I never push patients towards surgery, and will only offer it when we’ve exhausted every other appropriate option first. If the patient has tried physiotherapy (but without improvement) and if their range of movement is severely limited, and if the pain is severe and we don’t have any other options, then that is when I would normally tend to suggest surgery.
What’s the rehab protocol for this surgery?
In the first 6 weeks post-op it’s the same as a tendon repair (i.e. avoid stiffness by moving the arm forwards, up 70° and rotating the arm in 30°). After 6 weeks, the aim is to get all the movement back, but without loading and putting pressure on the shoulder, because we need to encourage new tissues to grow over the dermal allograft. The theory is that this is likely to take longer than normal tendon repairs, so ideally, I like the patient to wait longer before they try and lift anything heavy. The longer they wait, the stronger the tissue that is building there will be likely to be.
That said, my first arthroscopic SCR patient was a nurse who couldn’t really avoid lifting or pushing in her job, so she ended up pushing her shoulder harder than I would have liked; however, it worked for her, and within 6 months she was back to doing her normal job. Other patients who proved quite challenging (in terms of following rehab protocols) were two builders, a carpenter and a weight-lifter, but thankfully they also all had good outcomes!
Where can patients have this operation with you?
My NHS practice is in North London, although due to the COVID pandemic, waiting times will most likely be 12 to 15 months now. If patients are seeing me privately, then I operate at London Bridge Hospital & The Spire Harpenden Hospital.
With NHS waiting list times being so long, can patients pay for themselves to have this operation with you.
Yes, of course. This can be arranged via my medical secretary by calling 020 7496 3552 or email: makki.admin@sportsortho.co.uk .
Mr Daoud Makki, Upper Limb & Trauma Surgeon. For more information visit:
https://sportsortho.co.uk/specialist/mr-daoud-makki/
https://sportsortho.co.uk/self-pay-patients-and-access-to-private-healthcare/
