Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears: Technique and Associated Considerations

Abstract

Background:

Massive rotator cuff tears lead to superior humeral head translation and may prevent successful repair. Superior capsular reconstruction (SCR) can overcome this by improving the compression and depressor effects of the rotator cuff and joint capsule simultaneously.

Indications:

SCR is indicated in young, active patients with massive rotator cuff tears or a functional cuff deficiency from a failed previous rotator cuff repair without significant arthritis, articulation of the humeral head with the acromion, or dysfunctional deltoid.

Technique Description:

During the procedure, repair of the subscapularis is performed using a polydioxanone (PDS) suture shuttling device to pass suture through the subscapularis in an inverted mattress knotless configuration. Posterior infraspinatus tendon fibers are reduced and the tuberosity is abraded and decorticated followed by completion of the partial repair of the posterior cuff. Anchors are placed on the glenoid and articular margins followed by preparation of the dermal allograft with luggage tags medially and perforation laterally. The graft is passed and secured in a double row configuration laterally with apposition of the graft to the remnant, repaired rotator cuff posteriorly.

Results:

Passive range of motion (ROM) is begun at week 4, followed by progressive active ROM at weeks 6 to 12, and advancement of full ROM and advanced strengthening begun at 3 months. With SCR, a patient can expect maximal strength and function to be regained at 1 year postoperatively. Significant clinical improvement following SCR has been seen in visual analog scale (VAS) and American Shoulder and Elbow Surgeons Shoulder Score (ASES) scores for most patients, although there is a varied degree of return to sport following this procedure.

Discussion/Conclusion:

Clinical evidence suggests that SCR is a beneficial therapeutic intervention for short to medium term outcomes in younger patients with massive, irreparable rotator cuff tears. More studies are needed to identify the optimal thickness of the graft.

Graphical Abstract

This is a visual representation of the abstract.

Video transcript

SCR is indicated with young, active patients with massive rotator cuff tears, have a functional cuff deficiency from a failed a previous rotator cuff repair (Hamada Grade 1 or 2), and no significant glenohumeral arthritis.^3-5

The indications for the InSpace balloon (Stryker; Kalamazoo, Michigan) are similar to SCR, although the balloon can be used in patients who may not be able to partake in the extensive SCR rehabilitation. Tendon transfer is utilized in young, non-arthritic, heavy laboring patients who require improved strength. Lastly, reverse total shoulder arthroplasty is employed for older patients with cuff arthropathy or arthritis with diminished range of motion.

This 56-year-old male patient was involved in a work-related incident while moving a heavy pallet and had significant pain and weakness to the right shoulder. On examination, he had full active forward flexion, as well as internal and external rotation with shoulder abduction at 90°. There were significant strength deficits with external rotation at 0° of abduction. He had 4 out of 5 strength, a positive empty can test, and noticeable popeye deformity. Magnetic resonance imaging (MRI) showed a massive posterior-superior rotator cuff tear with degeneration of the supraspinatus and infraspinatus, and radiographs revealed minimal arthritis with no proximal migration of the humeral head.

Anatomical landmarks were marked in addition to standard posterior, anterior, lateral, and anterolateral portals. A massive, irreparable, retracted tear of the supraspinatus and infraspinatus is appreciated, in addition to a tear of the subscapularis. Anterior interval tissue around the subscapularis is gently released with arthroscopic cautery to improve visualization and mobilization of the tendon to accommodate subscapularis repair. With cannulas placed in the lateral and anterior portals, repair of the subscapularis is performed using a polydioxanone (PDS) suture shuttling device to pass suture through the subscapularis in an inverted mattress knotless configuration.

These sutures are then loaded into a 4.75 mm PEEK anchor (Arthrex; Naples, Florida), and the anchor is placed at the footprint of the subscapularis. The remaining core suture from the anchor is subsequently shuttled through the upper border of the subscapularis in a simple configuration and tied to complete the repair.

In the subacromial space, a thorough bursectomy is completed to improve visualization. Posterior infraspinatus tendon fibers are reducible, and a 4.75 mm double loaded corkscrew anchor is inserted. Using a penetrator device from the posterior portal, sutures are passed in a simple configuration. The sutures are subsequently tied and cut flush to complete the partial repair of the posterior rotator cuff.

To set up for anchor placement, the medial glenoid rim is exposed and gently decorticated while leaving the labrum intact. Pilot holes for two 2.4 mm knotless anchors are placed on the glenoid anteriorly, at the base of the coracoid, and posteriorly, just anterior to the repaired posterior rotator cuff. Then, percutaneous pilot holes are placed at the articular margin of the glenoid anteriorly and posteriorly with subsequent placement of 4.75 mm PEEK anchors loaded with suture tape.

These sutures will serve as medial row fixation of the graft on the humerus. Core sutures are left in place for subsequent graft measurement. Finally, using Nevaisier portal, a 2.9 mm all-suture anchor is percutaneously drilled and placed at the 12 o’clock position on the glenoid.

Next, the distance from the anterior and posterior glenoid pilot holes to the medial row sutures is measured using the core sutures left in the medial row anchors, respectively. An arthroscopic ruler is then inserted through the anterolateral portal and pulled with a grasper coming from the posterior portal to measure the anterior-posterior distance between the 2 pilot holes on the glenoid.

An additional 10 mm is added to the medial-lateral distance of the graft, and 5 mm is added to the anterior and posterior borders to ensure adequate coverage of the greater tuberosity and facilitate fixation to the partially repaired posterior cuff.

Luggage tag suture tapes are passed through the medial edge and the lateral edge is perforated with a 4.75 mm PEEK anchor inserter, 5 mm from the anterior and posterior borders, respectively.

While maintaining graft orientation, the anterior luggage tag suture on the medial aspect of the graft is passed through the lateral cannula and retrieved out the anterior portal.

Next, each limb of the all-suture anchor at the 12 o’clock position on the glenoid is retrieved out of the lateral cannula and passed using a self-catching suture passing device in a mattress configuration at the middle of the medial aspect of the graft. Awareness of the orientation of suture passage is necessary here to prevent suture entanglement.

The posterior luggage tag suture at the medial aspect of the graft is then introduced into the shoulder through the lateral cannula and retrieved out the posterior cannula.

Next, attention is turned to the medial row sutures on the humerus. Both anterior and posterior sutures are retrieved out the lateral portal and passed through the perforations previously placed on the lateral edge of the graft with a self-catching suture passage device.

The graft is delivered through the lateral cannula, while pulling tension on the anterior and posterior luggage sutures. Once the graft is in the joint, a grasper is used to assist with proper graft positioning.

The graft is initially secured by retrieving and tying the 12 o’clock all-suture glenoid anchor in a mattress fashion. Suture limb tails are left intact for later incorporation into the anterior and posterior glenoid anchors.

Next, the anterior luggage tag suture and 1 suture limb from the tied 12 o’clock anchor are retrieved from the anterior portal and loaded into knotless 2.4-mm anchor inserted into the previously created anterior glenoid pilot hole. The sutures are cut flush, and the same process is performed for the posterior glenoid anchor.

Pilot holes for lateral row knotless anchors are created, and reduction of the graft is again approximated to ensure adequate coverage of the greater tuberosity footprint. One limb of each suture from the medial row humeral anchors is retrieved from the lateral portal and loaded into a 4.75-mm knotless PEEK anchor. As the sutures are tensioned through the anchor, attention is paid to ensure adequate graft reduction with the help of a grasper through the anterolateral portal.

This step is repeated for the posterior lateral row anchor and sutures are cut flush.

Lastly, using a free suture, a self-catching suture passing device, and a penetrator device is used through the posterior portal to pass side-to-side sutures and reinforce the infraspinatus repair to the graft. We can appreciate successful placement and fixation of the dermal allograft in a double row configuration lateral with apposition of the graft to the remnant, repaired rotator cuff posteriorly.

Complications of this technique pertain to suture management, incorrect allograft sizing and difficulty with graft delivery. These complications can be avoided with adequate debridement of subacromial bursa and remnant rotator cuff tissue for necessary visualization, maintaining systematic approach to anchor placement, graft passage and knot tying.

A sling is used for the first 6 to 8 weeks and passive range of motion is begun only at week 4 where supine elevation in the scapular plane is allowed to 140° and external rotation to 40°. The sling is discontinued during weeks 6 to 12 and progressive active range of motion of the shoulder is initiated. At 3 months, advancement of full range of motion and advanced strengthening is the focus, and maximal strength and function may take as long as 1 year postoperatively to regain.

Burkart et al ¹ evaluated outcomes following SCR with a dermal allograft and found significant improvement in American Shoulder and Elbow Surgeons Shoulder Score (ASES) and visual analog scale (VAS) reduction at 1 year with improvement in active forward elevation and external rotation. There was no deterioration in outcomes from year 1 to year 2, however, there was a 5% reduction in the subjective patient rating during the same time period.

Gilat et al ² found that the major factors influencing SCR clinical failure was a higher body mass index, lower pre-operative acromiohumeral distance, presence of a subscapularis tear, female gender, and lower preoperative forward elevation.