Arthroscopic Rotator Cuff Repair With Superior Capsule Reconstruction for Irreparable Supraspinatus Tears

Abstract

Background:

Irreparable rotator cuff tears represent approximately 12% of all presenting cuff tears, and multiple surgical techniques have been described for treatment, including allograft/bridge augmentation, debridement, partial repair, subacromial balloon, tendon transfer, and superior capsule reconstruction (SCR). SCR has demonstrated durable improvement in range of motion (ROM) and outcome scores at 2 and 5 years.

Indications:

Surgical indications for SCR include an irreparable tear of the supraspinatus and/or infraspinatus with a preserved or reparable subscapularis and preserved glenohumeral joint cartilage.

Technique Description:

Diagnostic arthroscopy is performed to identify and characterize the rotator cuff tear. Thorough debridement of the greater tuberosity is performed. Two all-suture FiberTak anchors are placed in the superior aspect of the glenoid. Two 2.6-mm FiberTak suture anchors are placed in the humeral head at the chondral margin. After measuring, the dermal allograft is cut to size with 15-mm overhang left on the far lateral edge. A 12-mm passport cannula is inserted laterally and the sutures from the glenoid and humeral head anchors are brought out through the cannula maintaining their position and orientation. The sutures are passed through the graft outside the cannula. The graft is introduced into the shoulder via the passport cannula with a back grasper. A cannula-in-cannula technique is used to tie the glenoid anchors first and then the medial row anchors. Two lateral row swivel lock anchors are used to complete a standard double row repair. Margin convergence is performed between the dermal allograft and remaining rotator cuff anterior and posterior. Postoperatively, patients are kept in a sling for 6 weeks, with no shoulder ROM. From weeks 6 to 12, patients discontinue sling and begin passive progression to active ROM. Strengthening is initiated at 12 weeks, and return-to-sport or work is at approximately 6 months.

Results:

Irreparable rotator cuff tears treated with arthroscopic rotator cuff repair and SCR show durable improvement in patient-reported outcomes at 2 and 5 years. Re-tear rates did not differ between athletes and non-athletes.

Discussion/Conclusion:

Arthroscopic rotator cuff repair with SCR is a durable and reliable surgical option for patients presenting with preserved glenohumeral joint and irreparable supraspinatus and/or infraspinatus tear.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we will demonstrate our preferred technique for arthroscopic rotator cuff repair with superior capsular reconstruction for irreparable supraspinatus tears. As an overview, we will present some background literature on superior capsule reconstruction (SCR), provide a case presentation, demonstrate the surgical technique, and then discuss tips and tricks, postoperative management, return to sport guidelines, and patient outcomes.

Irreparable rotator cuff tears represent approximately 12% of all tears, ⁴ and multiple surgical techniques for addressing these have been described. ³ SCR has demonstrated a reduced superior translation of the humeral head,^1,8,9 decrease of acromion contact pressures, ⁷ and improved patient range of motion (ROM) and functional outcomes.^2,5,6

This patient is a 51-year-old right-hand-dominant man who sustained a traumatic rotator cuff tear 10 months prior. He initially underwent a surgical repair at an outside institution and ultimately failed, and he now presents with persistent shoulder weakness and limited motion. Radiographs demonstrate a well-preserved glenohumeral joint space and relatively well-preserved subacromial space. Magnetic resonance imaging demonstrates a massive rotator cuff tear at the muscle-tendon junction with severe retraction of the supraspinatus. In this sagittal view of the humeral head, the supraspinatus tendon is completely absent and the upper border of the infraspinatus is also torn.

SCR is generally considered after failure of nonoperative treatment for the irreparable supraspinatus tears in the absence of rotator cuff arthopathy. The absence of rotator cuff arthropathy, the required equipment and implants are listed here. This patient will be positioned in the beach-chair position utilizing a mechanical arm holder.

A standard posterior portal is used to access the shoulder, and a thorough diagnostic arthroscopy is performed. Any previous loose sutures or anchors can be removed. It is important to remove these in order to directly visualize the greater tuberosity and prepare the surface for adequate healing. Electrocautery and a shaver or bur are then used to remove any remaining tissue and to get down to a nice surface of cancellous bone on the greater tuberosity. Electrocautery is used to remove the scar tissue above the glenoid and to expose the superior surface of the glenoid. In this case, as you can see, the supraspinatus is completely scarred in and medially retracted and unable to be mobilized. A shaver is then used to repair the bony surfaces. When viewing from this lateral portal, you can see the remnant of the infraspinatus that is retracted inferiorly and medially, so we will plan to repair this as well. Anteriorly, there is still some comma tissue and subscapularis that will be utilized in the repair.

A total of 2 all-suture FiberTak anchors are placed in the superior aspect of the glenoid. One is placed at the anterior margin, and the other is placed at the posterior aspect of the glenoid. These are each placed about 8 mm off the articular surface, and a 2.6-mm FiberTak suture anchor is placed in the posterior aspect of the humeral head. This will be used to secure the infraspinatus as well as the posterior aspect of the dermal allograft. An additional anchor is placed anteriorly, and both of these are placed just off the chondral margin of the humeral head. Here you can see our 4-anchor configuration, which will be used to fix and secure the 4 corners of our dermal allograft. Posterior humeral head anchor contains both suture tapes and fiber tapes. The suture tapes will be loaded onto a scorpion and passed through the infraspinatus individually. After they are passed, they are tied using an arthroscopic knot pusher. This repairs the infraspinatus in a lateralized and superiorized position and brings it closer to where the dermal allograft will be located.

Afterward, measurements for the dermal allograft are taken. This is done by grabbing one of the sutures at the corner, zeroing in the measuring device, and then measuring the posterior length, followed by the lateral length. Then, the diagonally opposite anchor is grabbed and the sutures are zeroed in and used to measure the medial length and the anterior length of the graft. All 4 measurements are noted.

A flexible passport cannula with a diameter of 12 mm is then inserted into the lateral portal. Attention is turned to the back table for graft preparation. Once the graft is open, the dimensions representing the 4 anchors are then marked on the allograft. The periphery of the graft is marked so as to leave approximately 15 mm at the far lateral edge to cover the greater tuberosity during our double row repair. Excess graft is then excised using a scalpel. Because the graft is so thick and robust, it can be difficult to pass fiber tapes through it, so a punch is used to punch holes in the 2 lateral holes representing our anchors in the medial row of the greater tuberosity.

Attention is then turned back to the shoulder. Blue towels are placed over the skin, so the dermal allograft is not contaminated. The 4 sutures are then retrieved and sequentially tensioned. As they are being retrieved, it is important to maintain appropriate tension and orientation of the sutures coming from our 4 anchors. The posterior fiber tapes are then passed through the posterior lateral hole in the dermal allograft. The anterior fiber tapes are passed through the anterior hole and then the 4 sutures from our glenoid anchors are passed in an individual fashion. As they are being passed, tension in the entire system is maintained to prevent tangling of sutures. A reverse biting grasper is then used to grasp the medial border of the graft and pass it through the 12-mm cannula, all while maintaining appropriate tension on the sutures. While holding the graft in place, all the slack is taken out of the sutures.

A cannula-in-cannula technique is used to retrieve and tie the knots for the glenoid fixation. So in this demonstration, the 2 sutures from the posterior glenoid anchor were passed through the 5-mm cannula, which was then tunneled down into the 12-mm cannula. The tip of the cannula is advanced beyond all the other sutures. This allows knot tying in an isolated fashion, so that these 2 sutures do not get tangled with any of the other sutures coming out of the cannula. The small inner cannula is then removed, and the 2 remaining glenoid sutures from the anterior glenoid anchor are passed through in the same fashion. These are then tied and cut using the same cannula-within-cannula technique. Using a knot pusher here can be quite helpful as it allows you to advance and secure the graft immediately.

The smaller cannula is then removed and attention is turned to fixing the lateral aspect of the graft, and this is done in a standard double row technique. One fiber tape from each of the anchors is retrieved and loaded onto a swivel lock suture anchor. The first is fixed anteriorly with the arm to the side and in neutral rotation. The 2 remaining sutures are loaded on to a second swivel lock anchor, which is then fixed in the posterior aspect of the humeral head to complete our lateral row fixation. Here, we can see the greater tuberosity and humeral head are completely covered.

Next, we’ll turn our attention to margin convergence. When possible, margin convergence is performed both anteriorly and posteriorly. A free suture tape is passed through the subscapularis and comma tissue anteriorly and the anterior border of the dermal allograft. This is then tied using a standard arthroscopic knot, and the excess sutures are cut. The same process is then repeated posteriorly through the infraspinatus and the posterior edge of the dermal allograft. This is securely tied, and excess suture is cut. And here you can see our final construct that goes from the glenoid to the great tuberosity, completely covers the human head, and has both posterior and anterior margin convergence.

When performing superior capsular reconstruction, it is important to perform a thorough debridement in preparation of the greater tuberosity and glenoid. It is also critical to align the graft and pass sutures through the graft outside the shoulder to prevent tangling as the graft is inserted. Utilization of a cannula-within-cannula technique can be extremely helpful for tying the graft down immediately and preventing suture entanglement. Finally, convergence repair both anteriorly and posteriorly is important to help restore force couples and support the graft.

Postoperatively, patients are placed in a sling with an abduction pillow, and no shoulder ROM is performed in the first 6 weeks. From weeks 6 to 12, the sling is discontinued and ROM is initiated and advanced. Strengthening typically begins around week 12, and return to work or play generally occurs around 6 months postoperatively, but it can be quite variable depending on their progression through rehabilitation. ¹⁰

Studies have analyzed the ability of these patients to return to sporting activity, and these studies have demonstrated reasonable rates of return to sport that are maintained up to 2 years and that retear rates tend to be similar between patients participating in sports and non-athletes. There have been a number of clinical, biomechanical, and systematic review type studies that have been published on the outcomes of superior capsular reconstruction, most of which support improved biomechanics, improved patient outcomes, and improved functional scores that are maintained at 2 to 5 years postoperatively.^2,5,6,9