11 Superior Capsule Reconstruction with Fascia Lata Autograft

10.1055/b-0039-167660

11 Superior Capsule Reconstruction with Fascia Lata Autograft

Teruhisa Mihata

Abstract

In 2007, we developed a new surgical treatment, “superior capsule reconstruction,” to restore superior stability and muscle balance in the shoulder joint without repairing supraspinatus and infraspinatus tendon tears, consequently improving shoulder function—particularly deltoid muscle function—and relieving pain. The presence of indications for this surgery is determined by preoperative MRI. Goutallier grades 3 and 4 (fatty infiltration equal to, or more than, the muscle volume) are absolute indications. Moreover, in Goutallier grade 2, if the torn tendon is severely atrophied, degenerated, and thin, we recommend superior capsule reconstruction. During arthroscopy, the quality and mobility of the torn tendon are examined. If the tendon cannot be made to reach its original footprint (i.e., if the tear is irreducible), a preoperative decision is made for superior capsule reconstruction. If, after mobilization, the tendon can be made to reach the original footprint (i.e., if the tear is reducible), superior capsule reconstruction followed by rotator cuff repair over the reconstructed superior capsule is chosen. Factors prognostic of clinical outcome are the degree of graft healing and the level of deltoid function. Re-tear of the graft of the repaired infraspinatus tendon causes shoulder pain or decreased active elevation. In some patients, concomitant cervical spinal (C5) palsy or axillary nerve palsy worsens clinical outcomes after surgery, resulting in poor shoulder function despite graft healing.

11.1 Goals of Procedure

In 2007, we developed a new surgical treatment, “superior capsule reconstruction” ( Figs. 11.1–11.3 ), to restore superior stability and muscle balance in the shoulder joint without repairing supraspinatus and infraspinatus tendon tears, ¹ ^– ⁴ consequently improving shoulder function—particularly deltoid muscle function—and relieving pain. ⁵

**Fig. 11.1** Superior capsule reconstruction. The graft is attached medially to the superior glenoid and laterally to the greater tuberosity. This is followed by side-to-side suturing between the graft and the infraspinatus or teres minor tendon. **(a)** The compression double-row repair technique. **(b)** The SpeedBridge repair technique (Arthrex).

**Fig. 11.2** Arthroscopic findings before and after superior capsule reconstruction. **(a)** Before surgery. **(b,c)** Just after surgery.

**Fig. 11.3** MRI findings before and after superior capsule reconstruction. **(a)** Before surgery. The torn supraspinatus tendon is severely retracted, and the supraspinatus muscle is severely atrophied and infiltrated with fat. **(b)** One year after surgery.

11.2 Advantages

Superior capsule reconstruction restores shoulder function and results in high rates of return to work and to recreational sport, including overhead sports, with relatively low rates of postoperative complications. Furthermore, the native glenohumeral joint can be kept in the superior capsule reconstruction, resulting in better shoulder range of motion, especially external rotation and internal rotation, compared with reverse shoulder arthroplasty.

11.3 Indications

Patient suitability for superior capsule reconstruction is determined by preoperative MRI. Goutallier grades 3 and 4 (fatty infiltration equal to, or more than, muscle volume) are absolute indications. In Goutallier grade 2, if the torn tendon is severely retracted, degenerated, and thin, we also recommend superior capsule reconstruction.

Irreparable rotator cuff tears of Hamada grades 1 to 3 are an absolute indication for arthroscopic superior capsule reconstruction (ASCR). Whereas young patients with Hamada grade 4 are recommended for ASCR, elderly patients with Hamada grade 4 and all patients with Hamada grade 5 should have total shoulder arthroplasty with open surgical superior capsule reconstruction.

During arthroscopy, the quality and mobility of the torn tendon are examined. If the torn tendon cannot be made to reach the original footprint (i.e., if the tear is irreducible), a preoperative decision is made to perform superior capsule reconstruction alone. If the torn tendon can reach the original footprint after mobilization (i.e., if the tear is reducible), superior capsule reconstruction followed by rotator cuff repair over the reconstructed superior capsule is recommended.

11.4 Contraindications

When patients already have severe deltoid atrophy and weakness from concomitant cervical spinal palsy (at the C5 level) or axillary nerve palsy, we do not recommend superior capsule reconstruction because we cannot expect functional improvement after surgery, even when the graft is healed. However, we sometimes do superior capsule reconstructions in patients with slight or moderate deltoid weakness, to decrease shoulder pain.

11.5 Preoperative Preparation/Positioning

Preoperative preparation for superior capsule reconstruction is the same as for rotator cuff repair. The surgery can be performed either arthroscopically or by an open approach, and both the lateral decubitus position and the beach-chair position are suitable.

11.6 Operative Technique

11.6.1 Measurement of Defect Size

Subacromial bursal tissue around the torn tendons is completely removed before measurement of the defect size. The defect is then measured in the mediolateral (5–6 cm in most cases: from “the superior glenoid,” not the edge of the torn tendon, to the lateral edge of the greater tuberosity) and anteroposterior (from the anterior edge to the posterior edge of the torn tendon) directions ( Fig. 11.4 ).