Editorial Commentary: Superior Capsular Reconstruction with Achilles Allograft Can Reverse Pseudoparalysis While Improving Functional Patient Outcomes.

Massive irreparable rotator cuff tears (MIRCTs) represent a vexing problem, particularly in the physiologically young patient with no glenohumeral arthritis and high functional expectations. Not even the last line of defense, the reverse shoulder arthroplasty can help all of our patients with MIRCTs and resultant pseudoparalysis, and in younger patients, joint preservation could be a preferable first line intervention. Superior capsular reconstruction (SCR) shares the joint preservation arena with an evolving multitude of options, including arthroscopic debridement, partial rotator cuff repair, biologic tuberoplasty, interposition balloon spacer, and lower trapezius tendon transfer. SCR shows promising biomechanical and clinical outcomes, including restoration of native glenohumeral biomechanics and contact pressures, achievement of humeral head depression, reduction of pain, and improved patient reported outcome measures (PROMs) and range of motion (ROM), despite a high rate of graft re-tear or discontinuity. Yet, comparable results may be achieved via simpler procedures including debridement, partial repair, tuberoplasty, and/or spacer. Ultimately, the true value of SCR, or any other technique, would be proven improvement in strength or survivorship from subsequent surgery, particularly reverse arthroplasty. Optimizing indications for these constantly evolving techniques is a moving target and essential for selecting the highest value procedures for patients based on their individual needs.