Abstract
The recent study published in the American Journal of Sports Medicine titled “Arthroscopic Superior Capsule Reconstruction With Combined Fascia Lata Autograft Augmented With Either LARS Ligament or Polypropylene Mesh Synthetic Scaffold Patch Graft: A Comparison of Techniques With a Minimum 2-Year Follow-up for the Treatment of Irreparable Rotator Cuff Tears” by Bi et al, 2 which focuses on the hybrid sandwich graft (Fascia lata autografts + synthetic scaffold) and its 2-year follow-up data, which demonstrate superior functional outcomes and graft healing rates in the Ligament Augmentation and Reconstruction System (LARS) group, providing valuable insights for optimizing arthroscopic superior capsular reconstruction (ASCR) techniques. However, we also highlight three methodological and clinical considerations that we believe are crucial for interpreting the study’s conclusions and guiding future research in this field.
First, the nonrandomized retrospective design and temporal bias in stent allocation raise questions about whether the 2 patient groups were truly comparable beyond the reported baseline characteristics. The authors note that LARS ligaments were used from December 2016 to June 2019, after which polypropylene (PP) mesh was substituted due to LARS unavailability. This temporal separation introduces potential confounding effects from surgical learning curves or protocol evolution during the extended 6-year study period (2016-2022). For instance, surgical teams may have refined graft preparation techniques or postoperative rehabilitation protocols between these periods—factors known to influence ASCR outcomes. While the authors report no significant differences in preoperative patient characteristics (eg, age, Hamada grading, or Goutallier grading) or graft size between groups, they do not address whether other variables (eg, surgeon experience or variations in operative time) differed across time periods. Such unmeasured confounders may have inadvertently amplified the observed superiority of the LARS ligament, as the PP mesh cohort may have reflected an earlier phase of the team adapting to the new scaffold.
Second, the definition and assessment of graft failure require further clarification, as this definition forms the key conclusion regarding healing rate differences. Authors classified grafts as fully intact, partial tear, or complete tear based on coronal magnetic resonance imaging scans (4-mm slice thickness) and citing Burkhart and Hartzler’s criteria. 3 However, they did not explicitly state whether a partial tear or stretched graft (3 cases in the LARS group, 8 cases in the PP mesh group) was defined consistently among different radiologists. It remains unclear whether stretching was quantified, such as by percentage reduction in graft thickness, or based on subjective visual assessment. This ambiguity is critical because the 9% failure rate in the LARS group included only 1 case of graft stretching, whereas the 28% failure rate in the mesh group included 8 such cases.
Third, the subgroup analysis of healed versus non-healed grafts highlighted the importance of patient-specific factors that were not fully explored in the primary analysis. The authors noted that patients with graft healing demonstrated significantly superior functional outcomes and acromiohumeral distance (AHD) compared with those with graft failure. However, they did not investigate which preoperative factors, beyond graft type, predict graft healing—such as fascia lata thickness or tendon retraction grading. The authors mention that “inappropriate fascia lata” is “commonly encountered” in clinical practice, leading to “patch creep.” 1 Yet the study did not report whether fascia lata quality (eg, donor site complications or thickness variability) differed between the LARS and PP mesh groups. Similarly, although deltoid dysfunction was an exclusion criterion, the authors did not preoperatively assess deltoid strength—a factor influencing postoperative active forward flexion and graft stress. Incorporating these variables into multivariate models would help identify patients most likely to benefit from LARS ligament augmentation, thereby optimizing clinical decision-making.
In summary, this study makes a valuable contribution to the treatment of irreparable massive rotator cuff tears, highlighting the potential of the LARS ligament as a superior synthetic scaffold. Addressing temporal bias through a randomized controlled trial design, standardizing definitions of graft failure, and exploring patient-specific healing predictors are crucial for validating these findings and translating them into clinical practice. We encourage the authors to incorporate these considerations into their planned long-term follow-up studies and future investigations.
Footnotes
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
