of Superior Capsular Reconstruction

Fig. 9.1

Arthroscopic view of the retracted supraspinatus tendon in a right shoulder

Table 9.1

Indications for superior capsular reconstruction

Indications
Author’s indication	Initially described indication [1]
– Postero-superior tear pattern (Bateman grade 3) – Advanced retraction (Patte grade 3) – Advanced fatty infiltration (Goutallier grade 3 or more) Failed conservative management Intolerable shoulder pain	Non-reparable RC tear: “torn tendon cannot reach to the original footprint” during shoulder arthroscopy
Contraindications
– Advanced arthritis – Significant bone defects – Axillary nerve palsy – Shoulder stiffness – External rotation lag sign >20° – Concomitant non-repairable subscapularis tear – Pseudoparalysis of the shoulder	– Every bone deformity (Mihata grade 5) – Severe superior migration of the humeral head that does not move by traction of the arm – Cervical or axillary nerve palsy – Deltoid muscle dysfunction – Infection

9.3 Intraoperative Complications

As for all arthroscopic surgeries, patient positioning, blood pressure, pump pressure can be possible sources of complications (see chaps. 1 and 2).

In the following the authors will focus on technique specific complications:

9.3.1 Preparation of Glenoid and Humerus

The patient is positioned in the beach-chair position. The arm is maintained comfortably at the patient’s side (“neutral abduction”) and in neutral rotation. At the beginning of the operation, arthroscopic portals are established to evaluate the status of the glenohumeral joint and to confirm clinical and MRI findings.

An attempt is made to repair as much of the rotator cuff as possible, i.e. the infraspinatus and subscapularis tendons. Since the long head of the biceps tendon or pulley complex is usually involved, a biceps tenodesis or tenotomy is performed.

First, the superior scapular bone medial to the superior glenoid rim is debrided using the shaver and the burr in order to create a bony bed for medial fixation of the patch graft. Second, the insertion zone of the torn rotator cuff tendons of the major tuberosity is debrided and prepared.

Possible complications can be an injury to the suprascapular nerve while debriding the superior scapular bone. Care must be taken to visualize the instruments during debridement and to avoid to be to medial in order to protect the nerve.

Excessive bony debridement in combination with poor bone quality can lead to later anchor pull out and should be avoided.

According to the anatomy of the scapula, patient-individual approaches are used for placing two 3.0 double loaded suture anchors in the superior scapular bone in front of the base of the coracoid and at the medial border of the still intact posterior rotator cuff. According to the patients’ individual anatomy, the ideal approaches can be an anterosuperior approach, the Neviaser portal or a posterosuperior portal.

Possible complications can be anchor malpositioning and pull out. The authors recommend to simulate each Portal with a spinal needle and to check for later anchor insertion angle in order to prevent these complications. Care must be taken to place the drill holes of the anchors in a medial towards the bone of the scapula directed way in order to prevent perforation of the cartilaginous surface of the glenoid (Fig. 9.2).

../images/437034_1_En_9_Chapter/437034_1_En_9_Fig2_HTML.png — Fig. 9.2

Perforation of the cartilaginous surface of the glenoid due to drilling in a too much lateral directed way for the glenoidal anchors

Then two 4.75-mm Anchors loaded with both, FiberTapes and 2.0 Fibre wires are placed at the cartilage bone junction of the greater tuberosity both anteriorly and posteriorly. The anterior anchor is placed posterior to the biceps groove. After evaluation of the flexibility of the remaining posterior cuff, the posterior anchor is placed in the posterior part of the greater tuberosity in order to allow repair and shift of the upper part of the remaining infraspinatus tendon. The Fibre wire of this anchor is then used to partially repair and shift the infraspinatus tendon to the greater tuberosity and thereby decrease the size of the tear.

By use of an intra-articular measurement device the distance between each of the anchors is measured (Fig. 9.3a–c). The individual anchors serve hereby as landmarks to determine the size of the patch in coronal plane and in sagittal plane both medially and laterally. Laterally 1.0 cm patch length is added in order to cover the footprint of the major tuberosity.