12.1 Goals of Procedure

The goal of a superior capsular reconstruction (SCR) is to anatomically reconstruct the superior capsule to allow increased function and decreased pain in a patient with a large, irreparable rotator cuff tear. The SCR functions as a humeral head depressant, thereby centering the humeral head on the glenoid and allowing the deltoid to elevate the arm. ¹ Other options for these patients include a simple debridement (+ biceps tenotomy/tenodesis), partial rotator cuff repair, bridging patch graft, latissimus dorsi transfer, lower trapezius transfer, and reverse total shoulder arthroplasty. However, the SCR anatomically reconstructs the superior capsule using dermal allograft, which restores the biomechanical fulcrum of the shoulder and thereby restores function in a way that these other procedures do not. ^{1 , 2}

12.2 Advantages

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  The SCR can be performed arthroscopically with a similar setup to a rotator cuff repair and accurately restores the superior stability of the shoulder. ¹

  
  
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  The SCR is a reliable technique that produces excellent clinical outcomes in patients with irreparable rotator cuff tears. ³

12.3 Indications

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  Large, irreparable rotator cuff tears involving the supraspinatus and/or the infraspinatus in young patients without significant glenohumeral arthritis.

12.4 Contraindications

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  Significant glenohumeral arthritis.

  
  
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  Irreparable rotator cuff tears involving either the subscapularis or teres minor in addition to the supraspinatus/infraspinatus (having all these tendons involved disrupts the balanced transvers plane force couple).

  
  
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  Nonfunctioning deltoid.

  
  
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  Significant bone loss or bony deformity of the glenohumeral joint.

  
  
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  Previous reaction to dermal allograft tissue or religious beliefs prohibiting implantation of this allograft tissue.

12.5 Preoperative Preparation/Positioning

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  This procedure can be performed in the beach-chair or lateral decubitus position:

  
  
  
  
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    The authors prefer the beach-chair position, so this technique is for the beach-chair position.

  
  
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  Nonoperative arm at side and taped with a pillow around it, padding all bony prominences and the head secured.

  
  
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  An arm positioner (Trimano; Arthrex, Naples, FL) is helpful to maintain various arm rotations throughout the case.

  
  
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  Prep and drape in the usual sterile fashion.

12.6 Operative Technique

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  Mark out shoulder:

  
  
  
  
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    Acromion, clavicle, scapular spine, acromioclavicular joint, and soft spot for Neviaser portal between clavicle and scapular spine.

  
  
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  Mark portals:

  
  
  
  
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    Posterior, lateral, anterosuperolateral, Neviaser.

  
  
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  A no. 11 blade to make posterior portal skin incision, introduce trocar into glenohumeral joint.

  
  
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  Perform a complete diagnostic arthroscopy:

  
  
  
  
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    In the setting of a potential SCR, there should be a large rotator cuff tear allowing visualization of both the glenohumeral joint and subacromial space simultaneously.

  
  
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  Move the arthroscope subacromial in the posterior portal and make the lateral portal under direct visualization, coming in at the 50-yard line of the lateral acromion:

  
  
  
  
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    Debride the subacromial bursa to improve visualization of the rotator cuff ( Fig. 12.1 ):

    
    
    
    
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      Mobilize the tear using electrocautery, shaver, Bankart’s elevator, arthroscopic scissors, etc., and attempt to reduce the rotator cuff to the greater tuberosity:

      
      
      
      
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        i. If the tendon reduces without significant tension, perform an arthroscopic rotator cuff repair.

        
        
        
        
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           If part of the rotator cuff can be repaired, this can be done after the SCR is secured. ⁴

        
        
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        ii. If it does not reduce, proceed with the SCR.

  
  
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  Use a combination of the electrocautery device, shaver, and burr to expose and prepare the superomedial glenoid rim and greater tuberosity:

  
  
  
  
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    Do not go too medial on the glenoid, as the suprascapular nerve can be injured. ⁵

    
    
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    Do not take too much bone when preparing the glenoid and greater tuberosity as this can compromise fixation of the anchors.

  
  
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  Now place in two passport cannulas (Arthrex; one is a lateral and one is an anterosuperolateral portal).

  
  
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  There are now two options as to how to proceed:

  
  
  
  
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    The surgeon may place both the glenoid and humeral anchors before passing the graft into the joint, or he or she may place the glenoid anchors, pass the graft, and then place the humeral anchors.

    
    
    
    
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      This technique will be for placing the glenoid anchors, passing the graft, and then placing the humeral anchors.

  
  
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  Place two single-loaded SutureTak anchors loaded with FiberWire (Arthrex) in the glenoid:

  
  
  
  
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    Make the previously marked out Neviaser portal and place a switching stick in there to help retract tissues to better expose the glenoid:

    
    
    
    
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      A small stab incision may be needed to obtain the ideal trajectory for the anchors on the glenoid rim ( Fig. 12.2 ):

      
      
      
      
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        i. Do not compromise anchor placement because of inability to access the glenoid rim with the current portals—make additional percutaneous stab incisions to place anchors as needed.

    
    
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    Anchors should be placed at least 1 cm away from one another.

  
  
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  Now use the arthroscopic measuring tool to measure the distance between the anchors on the glenoid, and the proposed spots for the anchors on the humeral head, and then measure the distance between the anchors on the glenoid rim:

  
  
  
  
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    Then, use this tool to measure the distance from the posterior anchor on the glenoid to the proposed spot for the posterior anchor on the humeral head, and then measure the distance from the anterior anchor on the glenoid rim to the proposed spot for the anterior anchor on the humeral head:

    
    
    
    
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      Write all these measurements down:

      
      
      
      
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        i. Ensure accurate recording of all measurements.

  
  
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  Once all measurements are obtained, roll out the piece of dermal allograft matrix on a blue towel.

  
  
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  Mark the allograft at all the measurements, and cut the allograft to be 1 cm longer in all directions from what you measured:

  
  
  
  
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    Then mark with a marking pen on the cut piece of collagen exactly where the anchors are.

    
    
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    One by one, use an arthroscopic suture passing device (author’s preference is the Scorpion [Arthrex]) to pass the suture from the corresponding glenoid anchor on the piece of collagen:

    
    
    
    
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      Maintain tension on the sutures as they are passed to avoid tangling of the sutures.

    
    
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    Tie the two glenoid-side sutures (FiberWire) coming out of the superior aspect of the graft to each other.

    
    
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    Retrieve the glenoid sutures that were not passed through the graft out Neviaser portal.

  
  
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  Once the sutures from the glenoid anchor are passed (you will have two pieces coming through the collagen), insert the collagen piece into the shoulder via the passport cannula.

  
  
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  Gently roll this up and put it in through the cannula:

  
  
  
  
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    When placing this through the cannula, push it in rather than twisting as this can lead to the sutures becoming tangled.

    
    
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    Make sure not to drag the collagen along the patient’s skin to avoid dragging skin flora into the shoulder ( Fig. 12.3 ).

  
  
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  Use the two strands of suture coming out Neviaser portal to help parachute the tendon graft into place on the glenoid.

  
  
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  Unroll the allograft with a probe once inside the shoulder and lay it flat ( Fig. 12.4 ).

  
  
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  Now retrieve the glenoid sutures coming out Neviaser portal through the lateral portal and tie arthroscopic knots to secure the graft to the glenoid ( Fig. 12.3c). Do not cut these sutures after tying. Instead, to increase the load to failure of the construct and help flatten the graft over the glenoid, we incorporate these strands into a PushLock Anchor (Arthrex) posteriorly on the glenoid.

  
  
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  Next, place the punches for two SwiveLock anchors loaded with either FiberTape or FiberWire in the humeral head just lateral to the articular margin ( Fig. 12.5 ):

  
  
  
  
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    The anchors should be placed far enough apart so that when the graft is secure to them, it will cover the defect appropriately from anterior to posterior.

  
  
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  The humeral fixation will be treated like a SpeedBridge double-row rotator cuff repair ( Fig. 12.6 ):

  
  
  
  
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    Use an electrocautery to clean off an area on the lateral humerus.

    
    
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    Place two unloaded SwiveLock anchors in the lateral humeral head:

    
    
    
    
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      First, with the shoulder in internal rotation, place the posterior anchor:

      
      
      
      
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        i. Pass the posterior suture of each of the two humeral head anchors through this SwiveLock, and pull tension on the sutures once the anchor is seated into bone before it is malleted and screwed in to get any slack out of the system, and mallet the anchor into place.

      
      
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      Then place the anterior anchor in a similar manner.

  
  
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  The allograft is now secured.

  
  
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  The remaining posterior rotator cuff is now sutured to the allograft:

  
  
  
  
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    Typically there will be some posterior cuff left to sew the collagen to:

    
    
    
    
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      Anteriorly, the subscapularis should not be included in the repair, but rotator interval tissue or any anterior supraspinatus that is present should be sewn to the collagen.

    
    
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    Place two to three sutures between the collagen and cuff using a suture passing device and tie standard arthroscopic knots. This is done in a similar fashion to what is used for margin convergence sutures in massive rotator cuff repairs ( Fig. 12.7 ).

Related posts:

Part I Rotator Cuff/Biceps Part I Rotator Cuff/Biceps 7 Arthroscopic Subscapularis Repair 14 Open Suprapectoral Biceps Tenodesis 5 Arthroscopic Rotator Cuff Repair 2 Arthroscopic Acromioclavicular Joint Resection

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