Subacromial bursal tissue around the torn tendons is completely removed before measurement of the defect size. The defect is then measured in the mediolateral (4.0-4.5 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. Partial repair of the torn infraspinatus or teres minor tendon makes the defect size decrease. However, the partial repair causes inconsistent clinical results due to overtightening or possible retear of the repaired infraspinatus or teres minor tendon.² Therefore, the defect size should be measured without partial repair of the torn infraspinatus or teres minor, and partial repair is not recommended when SCR is performed.

The graft length in the anteroposterior direction is determined to be exactly the same as the length of the defect without partial repair of the torn infraspinatus or teres minor tendon. In the mediolateral direction, the graft (5.5-6.0 cm in most cases) should be 15 mm longer than the distance from the superior glenoid to the lateral edge of the greater tuberosity at 30° of shoulder abduction to make a 10-mm footprint on the superior glenoid and allow for 5 mm of latitude in graft size. A biomechanical study has indicated that the appropriate graft thickness for SCR using the fascia lata is 6 to 8 mm.³ SCR using a 4-mm-thick graft did not significantly restore superior translation. Therefore, the amount of fascia lata that we need to harvest will be at least double the estimated graft length or width to make sufficient thickness.

Fascia lata is harvested beginning at the tip of the greater trochanter, with care to include the posterior, thicker tissue. The average thickness of a single layer of autologous fascia lata is 1 to 3 mm. Therefore, a graft thickness of 6 to 8 mm is achieved by folding the fascia lata two or three times. Also, the fascia lata includes an intermuscular septum that consists of the tissues of two tendons and connects the fascia lata to the femur. To make a thicker graft, this intermuscular septum should be included in the graft (Figure 20-5). The fascia lata is mostly thinner at its anterior aspect than posteriorly; therefore, to make a flat graft of even thickness, the intermuscular septum is usually sutured to the anterior surface of the fascia lata after being completely detached from it. All fatty tissue should be removed from the graft. Finally, the layers of fascia lata are united very closely with nonabsorbable sutures to prevent delamination after surgery.

Acromioplasty makes improved visualization during SCR, improved control of bleeding in the subacromial space, and increased concentrations of growth factors in the subacromial space, potentially improving tendon healing.^{4, 5 and 6} The coracoacromial ligament, and spurs on the anterior, lateral, or medial side, should be resected to prevent subacromial impingement after surgery. Also, the inferior surface of the acromion is usually made flat. Biomechanical study showed that acromioplasty decreased the contact area between the graft and undersurface of acromion, suggesting that acromioplasty may help to decrease the postoperative risk of abrasion and tearing of the graft beneath the acromion when SCR is performed for irreparable rotator cuff tears.⁷ Although acromioplasty is performed in all cases of superior capsule reconstruction, we have had no cases of postoperative superior dislocation of the humeral head.

All soft tissue on the footprint of the superior glenoid should be removed to give a good bone bed before insertion of the suture anchors. Cortical bone should not be removed to prevent anchor pullout after surgery. Two 4.5- to 4.75-mm screw-type suture anchors (Table 20-1) are inserted, at the 10- or 11-o’clock position on the glenoid (Neviaser portal) and at the 1-o’clock position on the coracoid base (anterior portal) of the right shoulder, and at the 1- or 2-o’clock position on the glenoid and at the 11-o’clock position on the coracoid base on the left shoulder. Even for massive rotator cuff tear, two 4.5- to 4.75-mm screw-type suture anchors (Table 20-1) are enough to prevent suture anchor pullout or graft tear on the glenoid.

All soft tissue on the footprint of the greater tuberosity should be removed. Excessive resection of the cortical bone, which may lead to anchor pullout after surgery, is not recommended for SCR. Two 4.75-mm screw-type suture anchors with strong suture and tape (Table 20-1) are inserted on the medial footprint of the greater tuberosity to make a suture bridge.

A 10-mL syringe is used as a cannula. Strong sutures and tapes from the suture anchors on both superior glenoid and medial footprint of the greater tuberosity are placed through the fascia lata in a mattress fashion when the graft is still outside the body. After all strong sutures and tapes have been placed through the fascia lata, the graft is inserted in its appropriate place on the glenoid. All sutures on the superior glenoid are then tied in the subacromial space to fix the graft on the glenoid.

To complete the suture-bridge fixation using tapes from suture anchors on the medial footprint of greater tuberosity, the additional two 4.75- to 5.5-mm knotless suture anchors (Table 20-1) are inserted at 5 mm distal to the lateral footprint of the greater tuberosity. I recommend making additional medial mattress suturing using strong sutures from two 4.75-mm screw-type suture anchors (Table 20-1), which had been inserted on the medial footprint of the greater tuberosity.

In a dynamic observational study of cadaveric biomechanics,⁸ four of seven shoulders had posterior-superior subluxation during external and internal rotations in the absence of side-to-side suturing; after the addition of posterior side-to-side suturing, the glenohumeral joint was secure and stable and posterior-superior subluxation did not occur. Therefore, two or three sutures for posterior side-to-side suturing should be placed between the graft and the infraspinatus tendon or teres minor to increase superior shoulder stability and to prevent posterior-superior subluxation. Side-to-side suturing both anteriorly and posteriorly may cause postoperative shoulder stiffness, so anterior side-to-side suturing in superior capsule reconstruction using the fascia lata is not recommended. If dermal graft is used for SCR, both anterior and posterior side-to-side suturing is recommended.