Surgical Technique

Arthroscopic superior capsule reconstruction for rotator cuff tears improves shoulder function

Superior capsule reconstruction is a new treatment option for massive, irreparable posterosuperior rotator cuff tears (Figure 1). The treatment goals for massive tears are to reduce pain, restore shoulder function and delay the development of cuff tear arthropathy. Superior capsule reconstruction is an exciting and promising new procedure that can achieve these goals. Moreover, superior capsule reconstruction can be performed arthroscopically, which minimizes the complication risk. Superior capsule reconstruction uses a bridging graft that is attached at the superior glenoid and at the greater tuberosity to re-stabilize and re-center the humeral head. Teruhisa Mihata, MD, who is credited with inventing the procedure, recently reported on 100 patients who underwent superior capsule reconstruction with fascia lata autografts at a minimum of 2-years follow-­up. In that series, the American Shoulder and Elbow Surgeons score improved significantly from 36 preoperatively to 92 postoperatively and MRI follow-up showed 95% of patients had intact capsule reconstructions.

This article describes an arthroscopic superior capsule reconstruction (SCR) using an acellular human dermal allograft (DA) that is fixed with suture anchors, as described by Maximilian Petri, MD, 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 subacromial and subdeltoid spaces are cleared of bursal tissues using two additional lateral portals.

The rotator cuff is assessed and, if it is repairable, the tendons are repaired. In cases in which the rotator cuff is not repairable, SCR is performed. The remaining rotator cuff tendons are debrided to stable margins and the dimensions of the rotator cuff defect are measured in sagittal and coronal planes. An arthroscopic ruler facilitates exact measurements so the appropriate size DA patch can be fashioned.

The greater tuberosity and superior glenoid are prepared. To enhance graft­-to-­bone healing, all soft tissues are removed from the greater tuberosity and superior glenoid. To place the superior anchor 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. Our preference is to use three anchors on the glenoid side. A 3-­mm SutureTak suture anchor (Arthrex) is inserted at the 12 o’clock position of the glenoid. A second anchor is inserted in the anterosuperior (10 o’clock position) and the other is inserted in the posterosuperior (2 o’clock position) glenoid, using the anterior and posterior portals, respectively.

Suture anchors for humeral fixation

For humeral fixation, the SpeedBridge kit (Arthrex) knotless suture anchors and suture tapes are used. For the medial row, two or three 4.75­-mm bioabsorbable knotless anchors 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. Prior to inserting the lateral row anchors, perforations are made on the greater tuberosity using the Powerpic (Arthrex) motorized microfracture device to enhance healing.

Arthroscopic superior capsule reconstruction
Figure 1. The left shoulder with a retracted and irreparable posterosuperior rotator cuff tear, as viewed from the posterolateral portal, is shown.
Figure 2. DA preparation according to the intra-articular measured size with additional 7-mm to 8-mm coverage medially on the glenoid and 15-mm to 18-mm coverage laterally over the anatomical footprint of the rotator cuff on the humerus. Lines are placed on the superior surface. The most lateral line is placed 15 mm from the lateral edge to provide a visual reference for where the sutures should be passed for the fixation on the greater tuberosity.
Figure 3. The first suture strand (12 o’clock glenoid anchor) can be passed through the DA ex vivo with a FastPass suture passing device (Arthrex).
Figure 4. Subacromial view via the posterolateral portal after superior capsule reconstruction with DA. Note how the graft covers the footprint on the greater tuberosity and how the infraspinatus and graft are closed posteriorly.
Figure 5. A 3-month postoperative coronal MRI view of the left shoulder shows an intact and incorporated graft (*).

Source: Peter J. Millett, MD, MSc

An Arthroflex (Arthrex) 3-mm thick human acellular DA is prepared accordingly, taking care to make the correct measurements in the coronal and sagittal dimensions, and leaving an additional 7 mm to 8 mm for coverage medially on the glenoid, and 15-mm to 18-mm coverage laterally over the anatomical footprint of the rotator cuff on the greater tuberosity (Figure 2). Both sutures from the 12 o’clock glenoid anchor are passed in a mattress configuration through the patch ex vivo with a FastPass (Arthrex) suture passing device (Figure 3). The graft is then shuttled into the shoulder through the anterolateral portal with a knot pusher. After ensuring the graft has unfolded and is in the correct orientation, the medial glenoid anchor is retrieved out the Neviaser portal and tied to secure the graft. The graft is then fixed on the glenoid side with two additional sutures from the medial anchors, at the 10 o’clock and the 2 o’clock positions. The sutures from each anchor are passed through the medial edge of the graft and tied to complete fixation of the graft medially to the superior glenoid surface.

The graft is secured laterally using a SpeedBridge (Arthrex) bridging, double-row construct of four anchors. For large tears that exceed 50 mm in sagittal plane dimension, a six-anchor extended bridging construct is used. For the medial and lateral rows, 4.75-mm bioabsorbable knotless anchors are used with interconnected tape bridging between the two rows of anchors. To better compress the graft and prevent dog ears, lateral cinching sutures are also incorporated into the lateral anchors. The final construct is best visualized via the posterolateral portal (Figure 4).

The graft is also secured using margin convergence to bone sutures using the No. 2 eyelet sutures from the medial row anchors. Anteriorly, the lateral subscapularis is secured to the graft, although the rotator interval is typically left open. Posteriorly, the infraspinatus or teres minor are secured to the patch with the margin convergence to bone suture. Additional medial side­-to-­side margin convergence sutures are used posteriorly to close the interval between the graft and remaining rotator cuff tendon.

Stability of the graft is then assessed from both the bursal and articular side with a probe during a dynamic examination of the shoulder.

Rehabilitation

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

Early outcomes in our series have been promising. We now have patients who are more than 24 months from surgery with 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. Complications or adverse sequelae have been minimal. Postoperative MRI shows intact and incorporated grafts postoperatively (Figure 5).

Discussion

SCR is among the most exciting new developments in shoulder surgery. Although Mihata and colleagues used a fascia lata autograft for SCR, the human acellular DA used in this SCR technique has shown promising early short-term results. We have described the technique in greater detail by Petri and colleagues. The allograft tissue, which has been used as an augmentation scaffold in revision rotator cuff repair, is easy to use, safe, strong and has obviated donor site morbidity. We have not seen any immunologic reaction to these grafts.

Biomechanical studies from our lab by Olivier A. van der Meijden, MD, and colleagues, and others, have shown human acellular DAs are strong and biocompatible. The concept of using the SCR to restore shoulder kinematics is supported by a biomechanical study from Mihata and Thay Q. Lee, PhD, who showed attaching the graft medially to the superior glenoid, as is done during SCR, restores superior translation of the humeral head better than when the graft is attached to the native supraspinatus tendon remnants, as was done in earlier bridging interposition rotator cuff reconstruction techniques. These advantages in the biomechanical laboratory are now being translated into promising clinical results like those reported by Patrick J. Denard, MD, and colleagues and William T. Pennington, MD, and colleagues using DAs.

SCR 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. We believe the interposition effect of the graft may also play a role in decreasing pain. Although early results are promising, patient selection and long-­term benefits need to be investigated in further clinical trials.

Disclosures: Lacheta reports his position at Steadman Philippon Research Institute is funded by Arthrex. Millett reports he receives IP royalties and research support from and is a paid consultant for Arthrex.

Superior capsule reconstruction is a new treatment option for massive, irreparable posterosuperior rotator cuff tears (Figure 1). The treatment goals for massive tears are to reduce pain, restore shoulder function and delay the development of cuff tear arthropathy. Superior capsule reconstruction is an exciting and promising new procedure that can achieve these goals. Moreover, superior capsule reconstruction can be performed arthroscopically, which minimizes the complication risk. Superior capsule reconstruction uses a bridging graft that is attached at the superior glenoid and at the greater tuberosity to re-stabilize and re-center the humeral head. Teruhisa Mihata, MD, who is credited with inventing the procedure, recently reported on 100 patients who underwent superior capsule reconstruction with fascia lata autografts at a minimum of 2-years follow-­up. In that series, the American Shoulder and Elbow Surgeons score improved significantly from 36 preoperatively to 92 postoperatively and MRI follow-up showed 95% of patients had intact capsule reconstructions.

This article describes an arthroscopic superior capsule reconstruction (SCR) using an acellular human dermal allograft (DA) that is fixed with suture anchors, as described by Maximilian Petri, MD, 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 subacromial and subdeltoid spaces are cleared of bursal tissues using two additional lateral portals.

The rotator cuff is assessed and, if it is repairable, the tendons are repaired. In cases in which the rotator cuff is not repairable, SCR is performed. The remaining rotator cuff tendons are debrided to stable margins and the dimensions of the rotator cuff defect are measured in sagittal and coronal planes. An arthroscopic ruler facilitates exact measurements so the appropriate size DA patch can be fashioned.

The greater tuberosity and superior glenoid are prepared. To enhance graft­-to-­bone healing, all soft tissues are removed from the greater tuberosity and superior glenoid. To place the superior anchor 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. Our preference is to use three anchors on the glenoid side. A 3-­mm SutureTak suture anchor (Arthrex) is inserted at the 12 o’clock position of the glenoid. A second anchor is inserted in the anterosuperior (10 o’clock position) and the other is inserted in the posterosuperior (2 o’clock position) glenoid, using the anterior and posterior portals, respectively.

PAGE BREAK

Suture anchors for humeral fixation

For humeral fixation, the SpeedBridge kit (Arthrex) knotless suture anchors and suture tapes are used. For the medial row, two or three 4.75­-mm bioabsorbable knotless anchors 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. Prior to inserting the lateral row anchors, perforations are made on the greater tuberosity using the Powerpic (Arthrex) motorized microfracture device to enhance healing.

Arthroscopic superior capsule reconstruction
Figure 1. The left shoulder with a retracted and irreparable posterosuperior rotator cuff tear, as viewed from the posterolateral portal, is shown.
Figure 2. DA preparation according to the intra-articular measured size with additional 7-mm to 8-mm coverage medially on the glenoid and 15-mm to 18-mm coverage laterally over the anatomical footprint of the rotator cuff on the humerus. Lines are placed on the superior surface. The most lateral line is placed 15 mm from the lateral edge to provide a visual reference for where the sutures should be passed for the fixation on the greater tuberosity.
Figure 3. The first suture strand (12 o’clock glenoid anchor) can be passed through the DA ex vivo with a FastPass suture passing device (Arthrex).
Figure 4. Subacromial view via the posterolateral portal after superior capsule reconstruction with DA. Note how the graft covers the footprint on the greater tuberosity and how the infraspinatus and graft are closed posteriorly.
Figure 5. A 3-month postoperative coronal MRI view of the left shoulder shows an intact and incorporated graft (*).

Source: Peter J. Millett, MD, MSc

An Arthroflex (Arthrex) 3-mm thick human acellular DA is prepared accordingly, taking care to make the correct measurements in the coronal and sagittal dimensions, and leaving an additional 7 mm to 8 mm for coverage medially on the glenoid, and 15-mm to 18-mm coverage laterally over the anatomical footprint of the rotator cuff on the greater tuberosity (Figure 2). Both sutures from the 12 o’clock glenoid anchor are passed in a mattress configuration through the patch ex vivo with a FastPass (Arthrex) suture passing device (Figure 3). The graft is then shuttled into the shoulder through the anterolateral portal with a knot pusher. After ensuring the graft has unfolded and is in the correct orientation, the medial glenoid anchor is retrieved out the Neviaser portal and tied to secure the graft. The graft is then fixed on the glenoid side with two additional sutures from the medial anchors, at the 10 o’clock and the 2 o’clock positions. The sutures from each anchor are passed through the medial edge of the graft and tied to complete fixation of the graft medially to the superior glenoid surface.

PAGE BREAK

The graft is secured laterally using a SpeedBridge (Arthrex) bridging, double-row construct of four anchors. For large tears that exceed 50 mm in sagittal plane dimension, a six-anchor extended bridging construct is used. For the medial and lateral rows, 4.75-mm bioabsorbable knotless anchors are used with interconnected tape bridging between the two rows of anchors. To better compress the graft and prevent dog ears, lateral cinching sutures are also incorporated into the lateral anchors. The final construct is best visualized via the posterolateral portal (Figure 4).

The graft is also secured using margin convergence to bone sutures using the No. 2 eyelet sutures from the medial row anchors. Anteriorly, the lateral subscapularis is secured to the graft, although the rotator interval is typically left open. Posteriorly, the infraspinatus or teres minor are secured to the patch with the margin convergence to bone suture. Additional medial side­-to-­side margin convergence sutures are used posteriorly to close the interval between the graft and remaining rotator cuff tendon.

Stability of the graft is then assessed from both the bursal and articular side with a probe during a dynamic examination of the shoulder.

Rehabilitation

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

Early outcomes in our series have been promising. We now have patients who are more than 24 months from surgery with 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. Complications or adverse sequelae have been minimal. Postoperative MRI shows intact and incorporated grafts postoperatively (Figure 5).

Discussion

SCR is among the most exciting new developments in shoulder surgery. Although Mihata and colleagues used a fascia lata autograft for SCR, the human acellular DA used in this SCR technique has shown promising early short-term results. We have described the technique in greater detail by Petri and colleagues. The allograft tissue, which has been used as an augmentation scaffold in revision rotator cuff repair, is easy to use, safe, strong and has obviated donor site morbidity. We have not seen any immunologic reaction to these grafts.

Biomechanical studies from our lab by Olivier A. van der Meijden, MD, and colleagues, and others, have shown human acellular DAs are strong and biocompatible. The concept of using the SCR to restore shoulder kinematics is supported by a biomechanical study from Mihata and Thay Q. Lee, PhD, who showed attaching the graft medially to the superior glenoid, as is done during SCR, restores superior translation of the humeral head better than when the graft is attached to the native supraspinatus tendon remnants, as was done in earlier bridging interposition rotator cuff reconstruction techniques. These advantages in the biomechanical laboratory are now being translated into promising clinical results like those reported by Patrick J. Denard, MD, and colleagues and William T. Pennington, MD, and colleagues using DAs.

PAGE BREAK

SCR 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. We believe the interposition effect of the graft may also play a role in decreasing pain. Although early results are promising, patient selection and long-­term benefits need to be investigated in further clinical trials.

Disclosures: Lacheta reports his position at Steadman Philippon Research Institute is funded by Arthrex. Millett reports he receives IP royalties and research support from and is a paid consultant for Arthrex.