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Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears

The superior capsule reconstruction is a novel treatment option for massive, irreparable posterosuperior rotator cuff tears. Treatment goals of such tears are to reduce pain, restore shoulder function and delay the development of advanced cuff tear arthropathy. Current non-prosthetic treatment options include debridement and partial rotator cuff repair, bridging rotator cuff reconstruction with a graft and latissimus dorsi transfer, although each has different factors which limit their clinical applicattion.

Superior capsule reconstruction (SCR) is a promising alternative treatment for irreparable posterosuperior rotator cuff tears (Figure 1). It utilizes a graft from the superior glenoid to the greater tuberosity to stabilize the humeral head. In a study by Mihata and colleagues of 23 patients who underwent SCR with a fascia lata autograft at a minimum of 2 years follow-up, the American Shoulder and Elbow Surgeons (ASES) score improved significantly from 23.5 preoperatively to 92.9. Postoperative MRI showed 83% of patients had intact reconstructions with no progression of muscle atrophy.

This Surgical Technique describes an arthroscopic SCR using a human dermal allograft and absorbable suture anchors as described by Petri and colleagues. The patient is placed in beach-chair position under general anesthesia with an interscalene nerve block. A glenohumeral diagnostic arthroscopy is performed with a standard 30° arthroscope in the posterior viewing portal.

The remaining rotator cuff tissue is debrided to stable margins and the dimensions of the rotator cuff defect are measured in sagittal and coronal planes. An arthroscopic ruler facilitates this (Arthroscopic Measurement Probe, 220 mm, 60°, Arthrex.) so the exact measurements for the patch can be obtained.

Preoperative MRI shows full-thickness supraspinatus tear
Pictured is the right shoulder of a 60-year-old male patient. Preoperative MRI (T2 coronal plane) shows full-thickness supraspinatus tear retracted to the glenoid (arrow) (L = lateral; M = medial) (a). Preoperative AP radiograph shows superior translation of the humeral head with beginning cuff tear arthropathy Hamada grade 2 (b).

Images: Millett PJ

The greater tuberosity and superior glenoid are prepared. To enhance graft-to-bone healing all soft tissue is removed with a shaver from the greater tuberosity and the superior glenoid and microfracture perforations are made using a motorized shaver (PowerPick, Arthrex). To place anchors in the glenoid, a Neviaser portal is established in the supraclavicular fossa using a spinal needle to localize the trajectory. Knotted or knotless anchors can be used. Typically, our preference is for 3 anchors on the glenoid side. For larger tears, a 3.5-mm knotless anchor loaded with tape (Labral SwiveLock anchor loaded with FiberTape, Arthrex) is inserted at the 12 o’clock position of the glenoid. This is repeated with two further anchors, one inserted in the anterosuperior (10 o’clock position) and the other in the posterosuperior (2 o’clock position) glenoid (Figure 2).

For humeral fixation, knotless anchors and suture tape are used (SpeedBridge kit, Arthrex). For the medial row, two or three 4.75-mm bioabsorbable knotless anchors (BioComposite SwiveLock anchors loaded with Fibertape, Arthrex) are inserted at the anteromedial and posteromedial aspects of the rotator cuff footprint adjacent to the articular cartilage margin. Medial row anchors are placed at 1-cm to 1.5-cm intervals in the sagittal plane.

Tear size measurement
Shown is the measurement of tear size in the sagittal plane with an arthroscopic ruler during arthroscopic superior capsule reconstruction, posterolateral viewing portal. A massive, irreparable posterosuperior rotator cuff tear (stars) is shown. Three anchors with fiber tape are placed in the posterosuperior, superior and anterosuperior glenoid (arrows) (G = glenoid, H = humeral head).

A 3-mm thick human acellular dermal patch (ArthroFlex, Arthrex) is prepared and shaped according to the measured coronal and sagittal dimensions of the rotator cuff defect. Typically, it is about 30 mm to 35 mm in anterior to posterior and 35 mm to 40 mm medial to lateral. The suture strands can be shuttled through the patch ex vivo with a suture shuttling device (Suture Lasso, Arthrex) at appropriate intervals according to the intra-articular measurements. The edges of the graft are secured with additional cinching sutures (FiberLink, Arthrex) passed with a direct passing instrument (FastPass Scorpion suture passer, Arthrex).

An arthroscopic knot pusher is used to introduce the patch into the shoulder via the anterolateral portal. The sutures are retrieved through the corresponding portals. The graft is first secured on the superior glenoid. The anterosuperior anchor on the glenoid is loaded with the cinching sutures and tape (FiberLink, Arthrex) from the anteromedial aspect, the posterosuperior anchor with cinching sutures and tape from the posteromedial aspect of the graft. The graft is then secured with knotless anchors on the glenoid, tensioning the graft. Alternatively, simple sutures can be passed and tied from each of the anchors on the glenoid to secure the graft medially.

Intraoperative view after superior capsule reconstruction
Intraoperative view after superior capsule reconstruction with acellular human dermal patch graft is shown. There is medial side fixation on the superior glenoid (arrows), margin convergence with teres minor and subscapularis (#) and lateral side interlinked double-row fixation (stars) (p = posterior, a=anterior, s=superior).

The infraspinatus or the teres minor are secured to the patch posteriorly in the coronal plane with side to side sutures. The subscapularis is secured anteriolaterally although the rotator interval is typically left open. Laterally, these coronal edges of the graft can be secured in margin convergence to bone configurations using the no. 2 Fiberwire tip retention sutures from the medial row anchors on the humeral side. More medial side-to-side margin convergence sutures are utilized posteriorly.

The graft is secured laterally using a bridging double row construct of four or more commonly six anchors. Also, 4.75-mm bioabsorbable knotless anchors are used for the lateral row fixation each connecting the tape strands from the medial row. To better compress the graft and to prevent dog ears, the lateral cinching sutures are incorporated into the lateral anchors. The final construct is best visualized via the posterolateral portal (Figure 3). Stability of the graft is assessed from both the bursal and articular side with a probe during a dynamic examination of the shoulder. Schematic illustrations of the graft fixation are shown in Figure 4.

In patch fixation for superior capsule reconstruction
In patch fixation for superior capsule reconstruction technique, the patch is fixed with an interlinked double-row technique onto the supraspinatus footprint on the greater tuberosity plus additional margin convergence stitches to infraspinatus/ teres minor and subscapularis. A single row anchor fixation is used to fix the graft to the superior glenoid. The patch is connected to the anchors using additional fiber links.

Rehabilitation

Patients are typically immobilized in an abduction pillow for 6 weeks postoperatively. Full passive range of motion is started at approximately 4 weeks, with active motion at 6 weeks and strengthening at 8 weeks.

Early outcomes in our series have been promising and we now have cases greater than 18 months from surgery with continued excellent clinical and structural results. Pain relief is typically marked and occurs surprisingly early. Functional returns have also reliably been noted by 3 months postoperatively. There have been no complications or adverse sequelae. We have also seen cases of re-centering of the humeral head on postoperative radiographs.

MRI shows intact graft
In a right shoulder of a 60-year-old male patient, the MRI (T2 coronal plane) 6 months after superior capsule reconstruction shows intact graft (arrows) (L = lateral, M = medial, star = anchors in glenoid).

Examples of postoperative MRI with an intact graft (Figure 5) and a re-centering of the humeral head (Figure 6) are shown.

Discussion

Mihata and colleagues used a fascia lata autograft for SCR. The human acellular dermal patch used in this technique as a bridging graft has shown promising early results. The technique has been described in greater detail by Petri and colleagues. The allograft is strong and safe and has been used previously as an augmentation scaffold for revision rotator cuff repair as was shown by Petri and colleagues. The allograft tissue is easy to use, strong and obviated donor site morbidity. We have not seen any immunologic reaction to these grafts.

Proximal migration of the humeral head
In the right shoulder of a 56-year-old female patient, there was proximal migration of the humeral head (cuff tear arthropathy Hamada grade 2) following massive irreparable rotator cuff tear (a). Re-centering of the humeral head 6 weeks after superior capsule reconstruction is shown (b).

Biomechanical studies from our lab by van der Meijden and colleagues and others have shown human acellular dermal grafts are strong and biocompatible. The concept of using the SCR to restore shoulder kinematics is supported by a biomechanical study from Mihata and Lee who showed attaching the graft medially to the superior glenoid (as done with the SCR) restores the superior translation of the humeral head better than when the graft is attached to the native supraspinatus tendon remnants as had been done in previous bridging interposition reconstruction techniques. These biomechanical laboratory advantages are now being translated into promising clinical results like those recently reported by Gupta et al in 24 patients with an average 3-year follow-up after bridging interposition reconstruction using an allograft patch. All bridging techniques are currently considered off-label uses as collagen scaffolds are not FDA-approved to bridge a gap in a rotator cuff repair greater than 1 cm.

Superior capsule reconstruction theoretically improves function by re-centering the humeral head and improving glenohumeral kinematics. With a stable fulcrum, the deltoid and remaining cuff can function more effectively. From our early results, pain relief has been dramatic and we believe the interposition effect of the graft may also play a role in decreasing pain. Patient selection and long-term benefits need to be investigated in further clinical trials.

Disclosures: Millett reports he receives royalties from and is a consultant for Arthrex, is a consultant for Myos, has stock options with GameReady and VuMedi, and receives research and institutional support from The Steadman Philippon Research Institute, a 501(c)(3) non-profit institution supported financially by private donations and corporate support from Smith & Nephew, Arthrex and Ossur. Katthagen and Tahal report they receive research and institutional support from The Steadman Philippon Research Institute.

The superior capsule reconstruction is a novel treatment option for massive, irreparable posterosuperior rotator cuff tears. Treatment goals of such tears are to reduce pain, restore shoulder function and delay the development of advanced cuff tear arthropathy. Current non-prosthetic treatment options include debridement and partial rotator cuff repair, bridging rotator cuff reconstruction with a graft and latissimus dorsi transfer, although each has different factors which limit their clinical applicattion.

Superior capsule reconstruction (SCR) is a promising alternative treatment for irreparable posterosuperior rotator cuff tears (Figure 1). It utilizes a graft from the superior glenoid to the greater tuberosity to stabilize the humeral head. In a study by Mihata and colleagues of 23 patients who underwent SCR with a fascia lata autograft at a minimum of 2 years follow-up, the American Shoulder and Elbow Surgeons (ASES) score improved significantly from 23.5 preoperatively to 92.9. Postoperative MRI showed 83% of patients had intact reconstructions with no progression of muscle atrophy.

This Surgical Technique describes an arthroscopic SCR using a human dermal allograft and absorbable suture anchors as described by Petri and colleagues. The patient is placed in beach-chair position under general anesthesia with an interscalene nerve block. A glenohumeral diagnostic arthroscopy is performed with a standard 30° arthroscope in the posterior viewing portal.

The remaining rotator cuff tissue is debrided to stable margins and the dimensions of the rotator cuff defect are measured in sagittal and coronal planes. An arthroscopic ruler facilitates this (Arthroscopic Measurement Probe, 220 mm, 60°, Arthrex.) so the exact measurements for the patch can be obtained.

Preoperative MRI shows full-thickness supraspinatus tear
Pictured is the right shoulder of a 60-year-old male patient. Preoperative MRI (T2 coronal plane) shows full-thickness supraspinatus tear retracted to the glenoid (arrow) (L = lateral; M = medial) (a). Preoperative AP radiograph shows superior translation of the humeral head with beginning cuff tear arthropathy Hamada grade 2 (b).

Images: Millett PJ

The greater tuberosity and superior glenoid are prepared. To enhance graft-to-bone healing all soft tissue is removed with a shaver from the greater tuberosity and the superior glenoid and microfracture perforations are made using a motorized shaver (PowerPick, Arthrex). To place anchors in the glenoid, a Neviaser portal is established in the supraclavicular fossa using a spinal needle to localize the trajectory. Knotted or knotless anchors can be used. Typically, our preference is for 3 anchors on the glenoid side. For larger tears, a 3.5-mm knotless anchor loaded with tape (Labral SwiveLock anchor loaded with FiberTape, Arthrex) is inserted at the 12 o’clock position of the glenoid. This is repeated with two further anchors, one inserted in the anterosuperior (10 o’clock position) and the other in the posterosuperior (2 o’clock position) glenoid (Figure 2).

For humeral fixation, knotless anchors and suture tape are used (SpeedBridge kit, Arthrex). For the medial row, two or three 4.75-mm bioabsorbable knotless anchors (BioComposite SwiveLock anchors loaded with Fibertape, Arthrex) are inserted at the anteromedial and posteromedial aspects of the rotator cuff footprint adjacent to the articular cartilage margin. Medial row anchors are placed at 1-cm to 1.5-cm intervals in the sagittal plane.

Tear size measurement
Shown is the measurement of tear size in the sagittal plane with an arthroscopic ruler during arthroscopic superior capsule reconstruction, posterolateral viewing portal. A massive, irreparable posterosuperior rotator cuff tear (stars) is shown. Three anchors with fiber tape are placed in the posterosuperior, superior and anterosuperior glenoid (arrows) (G = glenoid, H = humeral head).

A 3-mm thick human acellular dermal patch (ArthroFlex, Arthrex) is prepared and shaped according to the measured coronal and sagittal dimensions of the rotator cuff defect. Typically, it is about 30 mm to 35 mm in anterior to posterior and 35 mm to 40 mm medial to lateral. The suture strands can be shuttled through the patch ex vivo with a suture shuttling device (Suture Lasso, Arthrex) at appropriate intervals according to the intra-articular measurements. The edges of the graft are secured with additional cinching sutures (FiberLink, Arthrex) passed with a direct passing instrument (FastPass Scorpion suture passer, Arthrex).

An arthroscopic knot pusher is used to introduce the patch into the shoulder via the anterolateral portal. The sutures are retrieved through the corresponding portals. The graft is first secured on the superior glenoid. The anterosuperior anchor on the glenoid is loaded with the cinching sutures and tape (FiberLink, Arthrex) from the anteromedial aspect, the posterosuperior anchor with cinching sutures and tape from the posteromedial aspect of the graft. The graft is then secured with knotless anchors on the glenoid, tensioning the graft. Alternatively, simple sutures can be passed and tied from each of the anchors on the glenoid to secure the graft medially.

Intraoperative view after superior capsule reconstruction
Intraoperative view after superior capsule reconstruction with acellular human dermal patch graft is shown. There is medial side fixation on the superior glenoid (arrows), margin convergence with teres minor and subscapularis (#) and lateral side interlinked double-row fixation (stars) (p = posterior, a=anterior, s=superior).

The infraspinatus or the teres minor are secured to the patch posteriorly in the coronal plane with side to side sutures. The subscapularis is secured anteriolaterally although the rotator interval is typically left open. Laterally, these coronal edges of the graft can be secured in margin convergence to bone configurations using the no. 2 Fiberwire tip retention sutures from the medial row anchors on the humeral side. More medial side-to-side margin convergence sutures are utilized posteriorly.

The graft is secured laterally using a bridging double row construct of four or more commonly six anchors. Also, 4.75-mm bioabsorbable knotless anchors are used for the lateral row fixation each connecting the tape strands from the medial row. To better compress the graft and to prevent dog ears, the lateral cinching sutures are incorporated into the lateral anchors. The final construct is best visualized via the posterolateral portal (Figure 3). Stability of the graft is assessed from both the bursal and articular side with a probe during a dynamic examination of the shoulder. Schematic illustrations of the graft fixation are shown in Figure 4.

In patch fixation for superior capsule reconstruction
In patch fixation for superior capsule reconstruction technique, the patch is fixed with an interlinked double-row technique onto the supraspinatus footprint on the greater tuberosity plus additional margin convergence stitches to infraspinatus/ teres minor and subscapularis. A single row anchor fixation is used to fix the graft to the superior glenoid. The patch is connected to the anchors using additional fiber links.

Rehabilitation

Patients are typically immobilized in an abduction pillow for 6 weeks postoperatively. Full passive range of motion is started at approximately 4 weeks, with active motion at 6 weeks and strengthening at 8 weeks.

Early outcomes in our series have been promising and we now have cases greater than 18 months from surgery with continued excellent clinical and structural results. Pain relief is typically marked and occurs surprisingly early. Functional returns have also reliably been noted by 3 months postoperatively. There have been no complications or adverse sequelae. We have also seen cases of re-centering of the humeral head on postoperative radiographs.

MRI shows intact graft
In a right shoulder of a 60-year-old male patient, the MRI (T2 coronal plane) 6 months after superior capsule reconstruction shows intact graft (arrows) (L = lateral, M = medial, star = anchors in glenoid).

Examples of postoperative MRI with an intact graft (Figure 5) and a re-centering of the humeral head (Figure 6) are shown.

Discussion

Mihata and colleagues used a fascia lata autograft for SCR. The human acellular dermal patch used in this technique as a bridging graft has shown promising early results. The technique has been described in greater detail by Petri and colleagues. The allograft is strong and safe and has been used previously as an augmentation scaffold for revision rotator cuff repair as was shown by Petri and colleagues. The allograft tissue is easy to use, strong and obviated donor site morbidity. We have not seen any immunologic reaction to these grafts.

Proximal migration of the humeral head
In the right shoulder of a 56-year-old female patient, there was proximal migration of the humeral head (cuff tear arthropathy Hamada grade 2) following massive irreparable rotator cuff tear (a). Re-centering of the humeral head 6 weeks after superior capsule reconstruction is shown (b).

Biomechanical studies from our lab by van der Meijden and colleagues and others have shown human acellular dermal grafts are strong and biocompatible. The concept of using the SCR to restore shoulder kinematics is supported by a biomechanical study from Mihata and Lee who showed attaching the graft medially to the superior glenoid (as done with the SCR) restores the superior translation of the humeral head better than when the graft is attached to the native supraspinatus tendon remnants as had been done in previous bridging interposition reconstruction techniques. These biomechanical laboratory advantages are now being translated into promising clinical results like those recently reported by Gupta et al in 24 patients with an average 3-year follow-up after bridging interposition reconstruction using an allograft patch. All bridging techniques are currently considered off-label uses as collagen scaffolds are not FDA-approved to bridge a gap in a rotator cuff repair greater than 1 cm.

Superior capsule reconstruction theoretically improves function by re-centering the humeral head and improving glenohumeral kinematics. With a stable fulcrum, the deltoid and remaining cuff can function more effectively. From our early results, pain relief has been dramatic and we believe the interposition effect of the graft may also play a role in decreasing pain. Patient selection and long-term benefits need to be investigated in further clinical trials.

Disclosures: Millett reports he receives royalties from and is a consultant for Arthrex, is a consultant for Myos, has stock options with GameReady and VuMedi, and receives research and institutional support from The Steadman Philippon Research Institute, a 501(c)(3) non-profit institution supported financially by private donations and corporate support from Smith & Nephew, Arthrex and Ossur. Katthagen and Tahal report they receive research and institutional support from The Steadman Philippon Research Institute.