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Arthroscopic Superior Capsular Reconstruction for Massive Irreparable Rotator Cuff Repair

Open AccessPublished:December 12, 2016DOI:https://doi.org/10.1016/j.eats.2016.08.024

      Abstract

      We have been performing arthroscopic superior capsular reconstruction (SCR) with acellular dermal allograft for almost 2 years. Our techniques are based on Mihata's original concept for SCR, in which he used fascia lata autograft. In this report, we describe our standard arthroscopic technique as well as 2 variations of a “zip-line” technique, which we have found particularly useful for large dermal allografts (grafts that are ≥40 mm in any dimension).

      Technique Video

      See video under supplementary data.

      For many years, we have been strong advocates of arthroscopic repair for massive rotator cuff tears, and we have reported superior results with this approach.
      • Denard P.J.
      • Lädermann A.
      • Brady P.C.
      • et al.
      Pseudoparalysis from a massive rotator cuff tear is reliably reversed with an arthroscopic rotator cuff repair in patients without preoperative glenohumeral arthritis.
      • Denard P.J.
      • Lädermann A.
      • Jiwani A.Z.
      • Burkhart S.S.
      Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
      • Denard P.J.
      • Jiwani A.Z.
      • Lädermann A.
      • Burkhart S.S.
      Long-term outcome of arthroscopic massive rotator cuff repair: The importance of double-row fixation.
      The vast majority of massive tears have been fully reparable in our hands. In the small percentage of tears that have not been fully reparable, we have done partial repairs.
      • Denard P.J.
      • Jiwani A.Z.
      • Lädermann A.
      • Burkhart S.S.
      Long-term outcome of arthroscopic massive rotator cuff repair: The importance of double-row fixation.
      • Burkhart S.S.
      • Nottage W.M.
      • Ogilvie-Harris D.J.
      • Kohn H.S.
      • Pachelli A.
      Partial repair of irreparable rotator cuff tears.
      Mihata introduced the concept of superior capsular reconstruction (SCR) with fascia lata graft, a procedure that reversed proximal humeral migration, thereby optimizing the force couples about the shoulder.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      • Mihata T.
      • McGarry M.H.
      • Pirolo J.M.
      • Kinoshita M.
      • Lee T.Q.
      Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears.
      For the past 2 years, we have used a modification of Mihata's technique of SCR, in which we use acellular dermal allograft
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      rather than fascia lata. This technique will be described below.

      Objective Diagnosis

       Physical Examination

      Rotator cuff strength is assessed initially by testing resisted external rotation (to detect tears of the supraspinatus, infraspinatus, and teres minor). A positive Hornblower test indicates involvement of the teres minor. In addition, subscapularis function is tested by means of the Bear Hug, Belly Press, and Lift-Off tests.
      Inspection of the shoulder may reveal atrophy in the supraspinatus and/or infraspinatus fossa. Active dynamic assessment will demonstrate the presence or absence of pseudoparalysis and/or anterosuperior escape.

       Imaging

      Plain radiographs are very helpful. There is a group of patients who have adaptive changes on the greater tuberosity (femoralization of the proximal humerus) and on the undersurface of the acromion, who have irreparable rotator cuff tears yet do not have significant arthritis of the glenohumeral joint. Some of these patients will have maintained active overhead motion because they have developed an acromiohumeral fulcrum whereby the deltoid can actively elevate the shoulder.
      On the MRI, the rotator cuff tear pattern is assessed in addition to the degree of fatty infiltration and muscle atrophy. However, we do not consider fatty infiltration of ≥50% to be a contraindication to either rotator cuff repair or SCR.

      Surgical Technique

       General

      We perform the SCR in the lateral decubitus position. We use the same portals as those we use for arthroscopic repair: posterior, anterior, lateral, and accessory lateral. The arm is held in 20° to 30° of abduction
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      combined with 20° forward flexion, with 5 to 10 pounds of lateral weight suspended from a standard arthroscopic boom (Star Sleeve Suspension System; Arthrex, Naples, FL). General anesthesia is used along with a supplementary suprascapular nerve block.

       Procedure

      A posterior viewing portal is used, starting with a 30° arthroscope while doing a limited subacromial decompression that preserves the coracoacromial arch (Video 1). After the decompression, bony landmarks (scapular spine, undersurface of acromion, undersurface of acromioclavicular [AC] joint) are dissected so that they are fully visualized. Good visualization of the scapular spine is particularly important in order to see the raphé between the supraspinatus and the infraspinatus.
      Most tears that are not fully reparable have involvement of the subscapularis. However, the subscapularis itself is virtually always reparable. We typically repair the subscapularis before addressing the rest of the cuff, along with performing coracoplasty and biceps tenodesis or tenotomy when indicated. Then we evaluate the supraspinatus and infraspinatus.
      Every effort is made to obtain a complete repair of the cuff, including careful excavation of the cuff, excision of bursal leaders, and interval slides when indicated. During this phase of the procedure, we have found that a 70° arthroscope is particularly useful because of the expanded field of view that it offers.
      If, after mobilizing the cuff to its fullest extent by the above techniques, we find that the cuff is still not fully reparable, then the decision is made to proceed with SCR using acellular dermal allograft
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      (Table 1).
      Table 1Order of Steps
      Sequential Steps in Performing Superior Capsular Reconstruction
      Subscapularis repair ± coracoplasty
      Biceps tenodesis or tenotomy as indicated
      Partial repair of posterosuperior rotator cuff
      Bone bed preparation (glenoid and greater tuberosity of humerus)
      Insertion of anchors into superior glenoid neck
      Insertion of anchors for medial row of greater tuberosity
      Extracorporeal passage of sutures through dermal allograft
      Shuttling of dermal allograft into shoulder
      Securing medial end of graft to glenoid with sutures
      Securing lateral end of graft with double-row fixation
      Side-to-side fixation of graft to posterior tissue (infraspinatus) and anterior tissue (comma tissue) if present; do not suture graft directly into subscapularis

       Placement of Suture Anchors

      After performing a partial cuff repair, we next place the suture anchors for the dermal graft. Usually 2 anchors are placed in the superior glenoid neck for medial fixation, and 4 anchors will be used to secure the graft laterally to the humerus (in a linked bridging configuration). However, only 4 of the anchors (the 2 glenoid anchors and the 2 most medial humeral anchors) will be preplaced before the introduction of the dermal allograft.
      The bone bed on the superior glenoid is prepared to a bleeding bone by means of motorized shaver blades, electrocautery ablation, and ring curettes. If soft tissue is obscuring the superior glenoid neck, a posterior interval slide will greatly increase visualization of the bone bed on the superior glenoid neck. If a meniscoid superior labrum has a firm attachment at the corner of the glenoid, we leave the meniscoid portion intact, but if it detaches from the bone, we completely debride the superior labrum. We also routinely do a biceps tenodesis or tenotomy when we perform SCR, because debridement of the superior labrum removes most of the meaningful bone attachments of the long head of the biceps tendon and creates an unstable biceps root.
      The anterosuperior glenoid anchor is placed at the base of the coracoid, just anteromedial to the origin of the long head of the biceps tendon. We prefer a low-profile biocomposite anchor (BioComposite SutureTak; Arthrex). This anchor is placed through a modified anterosuperior portal, which is often made just anterior to the acromion. The posterosuperior glenoid anchor is placed through either a modified Neviaser portal or an accessory portal along the posterior margin of the acromion. Care must be taken that the trajectory of anchor placement is from lateral to medial so that the anchor does not penetrate the articular surface. We prefer to place the anchors 2 to 3 mm medial to the corner of the glenoid in order to optimize the contact area between graft and bone, yet still maintain anchor placement far enough laterally that it does not jeopardize the suprascapular nerve.
      If a tendon bridge is overlying and obscuring the superior glenoid neck, a posterior interval slide may significantly improve the exposure of the superior glenoid neck (Fig 1). After the glenoid anchors have been placed, we prepare the bone bed on the greater tuberosity of the humerus down to a bleeding base by means of motorized shaver, electrocautery, and ring curettes. The 2 medial anchors for the greater tuberosity are preplaced at the junction of the bone bed with the articular cartilage. Each of the medial humerus anchors is a cannulated threaded anchor (4.75 mm BioComposite SwiveLock; Arthrex) that has been preloaded with a braided suture tape (FiberTape; Arthrex). The anterior anchor is placed just posterior to the bicipital groove, and the posterior anchor is placed at the posterior aspect of the cuff defect. Anchor placement is performed through percutaneous punctures adjacent to the lateral acromion. At this point, 4 anchors (2 in the glenoid and 2 in the humerus) have been preplaced.
      Fig 1
      Fig 1(A) Right shoulder, posterolateral viewing portal. Supraspinatus (SS) and infraspinatus (IS) obscure visualization of superior glenoid neck and impedes bone bed preparation. (B) Right shoulder, posterolateral viewing portal. After posterior interval slide, there is increased working space between the SS and IS to allow bone bed preparation to be performed more easily. (C) Right shoulder, posterolateral viewing portal. Anterior and posterior anchors (*) have been placed in the superior glenoid neck after performing posterior interval slide. Note that the exposure is much better than in (A), before the posterior interval slide was performed. Placement of anterior and posterior anchors into superior glenoid neck has been expedited by the expanded exposure afforded by posterior interval slide.

      Dermal Allograft Preparation

      The acellular dermal allograft that we prefer to use (ArthroFlex; Arthrex) is a thick (3.0-mm) dermal allograft that requires only 1 minute of hydration time. A calibrated probe is used to precisely measure the size of the defect to be spanned as well as the distance between each pair of suture anchors (both the anterior-to-posterior distances and the medial-to-lateral distances). Based on these measurements, the graft is cut to size and the exact positions of the 4 anchors relative to the graft are marked on the graft. The graft is oversized 5 mm medial, anterior, and posterior to the anchor locations in order to ensure some overhang of the graft for suturing into the adjacent intact cuff and to minimize the chance of suture cutout; it is also oversized 10 mm lateral to the humeral anchors in order to establish a 10-mm footprint contact interface between the graft and the greater tuberosity. The SwiveLock anchor inserter is used as a punch (after the anchors have been placed) to create 2 holes in the graft corresponding to the anchor positions on the medial row of the greater tuberosity. Alternatively, a 1.5-mm biopsy punch (or 14-gauge spinal needle) may be used. These larger punched holes enable the FiberTape sutures to pass through the graft and slide during insertion of the graft into the shoulder. Alternatively, the FiberTapes may be passed with an antegrade suture passer (FastPass Scorpion; Arthrex) recognizing that the tapes will not slide as easily through the graft and that a pusher or grasper will need to be used to move the graft relative to the tapes. We have found that it is not necessary to create holes for the FiberWire sutures from the glenoid anchors, as they will slide easily through the graft. Even so, we sometimes punch 2 holes in the medial part of the graft in order to pass 4 suture limbs from double-loaded SutureTak anchors, thereby enabling us to complete 2 double pulley suture constructs for greater medial fixation.
      The sutures from the 4 anchors are then retrieved through a lateral flexible cannula (PassPort; Arthrex), being careful to keep the sutures in their corresponding quadrant as they are removed and keeping tension on all sutures as they are retrieved, so that sutures will not become crossed and tangled during retrieval and placement into the graft. Each suture tail is then individually passed through its corresponding premarked spot on the dermal allograft with an antegrade suture passer (FastPass Scorpion; Arthrex) for each of the medial suture pairs (from the glenoid anchors), and a mulberry interference knot is tied to facilitate graft passage (Fig 2).
      Fig 2
      Fig 2Right shoulder, exterior view. Dermal allograft lying on top of lateral portal, just before passage into joint. Small arrows show sutures from glenoid anchors after mulberry knots have been tied; heavy arrow shows one FiberTape from medial row humeral anchors as another FiberTape is being passed.

      Passing and Securing the Graft

      The eyelets of the medial anchors are used as pulleys to deliver the dermal allograft into the shoulder. By pulling on the free ends of the 2 suture pairs, the mulberry knots push the medial portion of the graft down until it touches the glenoid. Once the graft is in contact with the superior glenoid, an open-section pusher (FiberChain retriever; Arthrex) is used to slide sequentially down each FiberTape, tensioning the FiberTape as the nose of the instrument pushes the dermal graft down to the humeral bone bed, thereby eliminating the redundancy in the FiberTapes.
      Finally, the medial portion of the graft is secured to the glenoid by means of a double-pulley technique. The 2 mulberry knots are retrieved out of the lateral portal, and those 2 suture limbs are tied securely together under tension over a metal post with a 6-throw surgeon's knot. Then the 2 corresponding limbs (to those that were tied) are tensioned, pulling the surgeon's knot down tightly over the medial part of the graft. The 2 free limbs are then tied together in a 6-throw static surgeon's knot using a static double-diameter knot pusher (Surgeon's Sixth Finger; Arthrex). This completes the fixation of the medial portion of the graft.
      Next, we turn our attention to fixation of the lateral portion of the graft. This portion of the procedure is performed with the arm in its standard arthroscopy position of 20° to 30° abduction
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      combined with 20° of forward flexion, and neutral rotation. The previously passed FiberTapes from the medial humerus suture anchors are sequentially tensioned while an open-section pusher slides down each FiberTape to push the dermal graft against bone and remove any residual redundancy from the tapes. Then the FiberTapes are criss-crossed in a SpeedBridge (Arthrex) configuration, and the tapes are fixed laterally in the humeral metaphysis with 2 BioComposite SwiveLock-C suture anchors (Fig 3A). At this point in the procedure, additional glenoid anchors can be placed both anterior and posterior to the superior glenoid anchors if additional glenoid fixation is desired.
      Fig 3
      Fig 3(A) Right shoulder, posterolateral viewing portal. Suture tapes from medial row of humeral fixation have been tensioned and have been secured by a lateral row of suture anchors. (B) Final construct of superior capsular reconstruction showing medial sutures (thin arrow); lateral fixation with FiberTapes (heavy arrows); and side-to-side fixation of dermal graft to infraspinatus (asterisk).
      Finally, side-to-side sutures are placed between the graft and the intact posterior cuff (Fig 3B). Anteriorly, if there is some intact rotator interval tissue (comma tissue), the anterior margin of the graft is sutured to this tissue with side-to-side sutures. If there is no rotator interval tissue, the anterior margin of the graft is left as a free margin, without suturing it to anything. The graft should never be directly sutured to the subscapularis, as that would deform and overly constrain the graft, thereby restricting shoulder motion. If possible, partial side-to-side repair of the supraspinatus to the infraspinatus is performed over the top of the dermal allograft.

      Zip-Line Technique for Reliably Shuttling Dermal Allografts Into the Shoulder for SCR

       Large and Massive Grafts

      As our experience with SCR has increased, we have used the technique on some massive cuff tears that had very large residual defects after partial repair, requiring “oversized” dermal allografts.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears.
      When the dermal allograft is more than 35 mm in the anterior-to-posterior dimension, there are 2 potential problems that may occur as the graft is shuttled into the shoulder:
      • 1.
        The graft may be so large that it becomes “captured” in the cannula, even in a 10-mm PassPort cannula (Arthrex), so that it cannot be passed all the way through the cannula; and/or
      • 2.
        The high resistance encountered as the graft is shuttled through the cannula can create enough force on the glenoid anchors (whose eyelets are being used as “pulleys” for the shuttling sutures) to dislodge the glenoid anchors from the bone.
      We have overcome these 2 problems by devising a zip-line shuttle technique. This technique avoids graft entrapment within the cannula so it can either be expanded or removed. Furthermore, the tensile forces on the glenoid anchors are dramatically reduced by
      • 1.
        placing a third glenoid anchor centrally between the anterior and posterior glenoid anchors and
      • 2.
        using a FiberTape retriever (Arthrex) to sequentially push the graft along 2 zip-lines (the 4 sutures from the anterior glenoid anchor; and the 4 sutures from the posterior glenoid anchor which have been prepassed through oversized holes punched in the graft) while the 2 sutures from the middle glenoid anchor are used to pull the graft into the shoulder. Tension is reduced in these middle-anchor sutures by having their direction of pull through the modified Neviaser portal rather than through the lateral portal. Then, after helping to shuttle the graft to its final location, these sutures from the middle anchor are tied as simple sutures to further strengthen the medial fixation of the graft.
      Following are the steps in the zip-line technique:
      • 1.
        Determine that the cuff tear is not fully reparable (Fig 4).
        Fig 4
        Fig 4Residual defect in a right shoulder after repairing as much of the rotator cuff as possible.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 2.
        Prepare the recipient bone beds on the glenoid and the greater tuberosity of the proximal humerus (Fig 5).
        Fig 5
        Fig 5Right shoulder. Bone bed preparation on the superior glenoid and the greater tuberosity has been performed with a combination of ring curettes, motorized shavers, and motorized burrs.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 3.
        Three glenoid anchors are placed (BioComposite SutureTak; Arthrex). In general, we use an anterosuperolateral portal to place the anterior anchor, a posterosuperior portal for the posterior anchor, and a modified Neviaser portal for the central anchor (Fig 6). In placing the central anchor, the surgeon must be sure that the anchor's bone socket is begun far enough medially that it will not penetrate into the joint, yet not so far medially as to jeopardize the suprascapular nerve. Then 2 SwiveLock-C suture anchors with FiberTape (Arthrex) are placed at the articular margin of the proximal humerus.
        Fig 6
        Fig 6Right shoulder. Three glenoid suture anchors (BioComposite SutureTaks; Arthrex) are placed. In addition, 2 BioComposite SwiveLock-C suture anchors (Arthrex) are placed into the greater tuberosity at the articular margin of the proximal humerus.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 4.
        A flexible calibrated probe (Arthrex) is used to size the graft, measuring the distance between all 5 suture anchors (Fig 7A). A 5-mm border is added to each side of the graft except the lateral side, where a 10-mm border is added (to give a greater contact area with the large bone bed on the greater tuberosity), then the SwiveLock-C inserter is used as a punch to create 4 holes in the graft corresponding to the positions of the suture anchors at the 4 corners of the SCR (Fig 7B).
        Fig 7
        Fig 7Right shoulder. (A) A flexible calibrated probe (Arthrex) is used to size the graft by measuring the distance between all 5 suture anchors. (B) The inserter for a SwiveLock-C suture anchor (Arthrex) is used as a punch to make 4 punch-holes for passage of the sutures from the 4 corners of the anchor construct.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 5.
        One end of each suture from the middle glenoid anchor is withdrawn from the lateral portal and passed through the graft. Then a mulberry knot is tied near the end of both of these sutures so that the corresponding free ends of these sutures can be tensioned to aid in pulling the graft into the shoulder. The 4 sutures from the posterior glenoid anchor are passed through the oversized hole in the posteromedial corner of the graft, and the 4 sutures from the anterior glenoid anchor are placed through the oversized hole in the anteromedial corner of the graft. A cinch-loop suture is placed through each of the 2 lateral punch holes in the graft for later shuttling of the FiberTapes from the lateral anchors. The fact that we do not prepass the FiberTapes greatly reduces the chance of tangling or fouling the sutures from separate anchors during shuttling of the graft (Fig 8).
        Fig 8
        Fig 8Right shoulder. Medial sutures have been passed through the graft extracorporeally. Cinch-loops have been placed in the 2 lateral punch-holes for later shuttling of the FiberTapes.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 6.
        The PassPort cannula (Arthrex) is split along one side so that it can either expand enough to accommodate passage of the large dermal graft, or else the split cannula can be removed to allow the graft to be shuttled directly through the skin puncture, without a cannula. Then a calibrated Zip Line pusher (Arthrex) is to used to alternately push the graft along the posteromedial and anteromedial suture groups (the 2 zip-lines) as the sutures from the middle glenoid anchor are tensioned, thereby shuttling the graft along the 2 zip-lines to its final position over the superior glenoid (Figs 9 and 10).
        Fig 9
        Fig 9Right shoulder. The PassPort cannula has been split (dotted red line) to allow for expansion or removal of the cannula in order to accommodate the oversized graft. The 2 zip-lines are the anterior and posterior groups of glenoid sutures. A calibrated Zip Line pusher (Arthrex) is used to alternately push the graft down the tensioned anterior and posterior zip-lines. At the same time, the sutures from the middle glenoid anchor are tensioned in order to pull the graft into place over the superior glenoid.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
        Fig 10
        Fig 10Right shoulder. The calibrated Zip Line pusher (Arthrex) is pushing the graft down the posterior zip-line as the middle glenoid sutures pull the graft into position over the superior glenoid.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 7.
        Then the sutures from the middle glenoid anchor are tied as simple sutures. The sutures from the anterior and posterior glenoid anchors are used to create a double mattress suture by means of the double-pulley technique. Once medial fixation of the dermal allograft has been achieved, the 2 lateral cinch-loops are “un-cinched” and used to shuttle the 2 sets of FiberTapes through the 2 lateral punch-holes (Fig 11).
        Fig 11
        Fig 11Right shoulder. The lateral cinch-loops (FiberLink; Arthrex) have been “un-cinched,” and are used to shuttle the FiberTapes through the lateral punch-holes in the graft.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 8.
        The FiberTapes are criss-crossed and then secured laterally on the greater tuberosity with 2 SwiveLock-C suture anchors (Arthrex) (Fig 12). The graft is then sutured to the posterior cuff as well as to any residual comma tissue anteriorly.
        Fig 12
        Fig 12Right shoulder. Lateral fixation of the graft has been achieved by criss-crossing the FiberTapes and securing them with 2 BioComposite SwiveLock-C suture anchors (Arthrex) in a SpeedBridge configuration.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      We have found this technique to be extremely helpful in shuttling large dermal allografts (>35 mm) without having them become captured or hopelessly tangled, and without risking pullout of the glenoid anchors.

       Small to Medium-Sized Grafts

      Although we originally used the zip-line technique to shuttle large and massive dermal allografts into the shoulder, we have modified the zip-line procedure for small and medium-sized dermal allografts. The simplicity and reliability of this technique has greatly reduced our operating time and has turned the SCR into a very reproducible procedure. For the small to medium-sized grafts, the main difference from the previously described zip-line procedure (for large and massive grafts) is that we only use 2 suture anchors in the superior glenoid, rather than 3. We still have a “pulling suture” in the mid-medial aspect of the graft, which exits through a modified Neviaser portal, but is it is not associated with a suture anchor; it simply helps to pull the graft into place as the surgeon tensions this suture. We still use a second-stage shuttling of the FiberTapes through the graft after medial fixation has been completed.
      Following are the steps for the 2-medial-anchor zip-line:
      • 1.
        The tear is assessed arthroscopically (Fig 13). Then the glenoid and humeral bone beds are prepared (Fig 14).
        Fig 13
        Fig 13Right shoulder. Residual defect in the rotator cuff after repairing all reparable elements of the rotator cuff tear.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
        Fig 14
        Fig 14Right shoulder. The bone beds on the superior glenoid and the greater tuberosity have been prepared.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 2.
        Suture anchors are placed (2 SutureTaks in the superior glenoid and 2 SwiveLocks, preloaded with FiberTape, at the articular margin of the greater tuberosity of the proximal humerus) (Fig 15).
        Fig 15
        Fig 15Right shoulder. Two suture anchors (BioComposite SutureTaks; Arthrex) have been placed in the superior glenoid, and 2 additional anchors (BioComposite SwiveLocks preloaded with FiberTape) have been placed at the articular margin of the greater tuberosity of the proximal humerus.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 3.
        The graft is sized using a flexible calibrated probe (Fig 16A). Four holes are punched in the dermal graft corresponding to the locations of the underlying suture anchors (Fig 16B).
        Fig 16
        Fig 16Right shoulder. (A) A flexible calibrated probe is used to size the graft by measuring the distances between all 4 suture anchors. (B) The SwiveLock Inserter (Arthrex) is used as a punch to create 4 holes in the graft corresponding to the locations of the underlying suture anchors.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 4.
        Sutures (both for shuttling and for graft fixation) are passed (Fig 17).
        Fig 17
        Fig 17Right shoulder. Shuttling sutures and graft fixation sutures are passed through the graft extracorporeally. Tapes are not passed through the graft at this stage; they will be shuttled after medial fixation has been completed.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 5.
        A calibrated Zip Line pusher (Arthrex) pushes down each of the zip-lines sequentially, as the central “pulling suture” is tensioned (Figs 18 and 19).
        Fig 18
        Fig 18Right shoulder. A calibrated Zip Line pusher (Arthrex) is used to push the graft through the cannula by alternately pushing the graft down the 2 zip-lines as the medial “pulling suture” is tensioned. Note that the PassPort cannula has been split (red dotted line) and may either be expanded or removed to permit graft passage.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
        Fig 19
        Fig 19Right shoulder. Once the graft is inside the shoulder, the Zip Line pusher (Arthrex) again pushes the graft down the 2 zip-lines as the “pulling suture” is tensioned.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 6.
        After medial graft fixation has been achieved by means of a double-pulley technique, the sutures and tapes from the greater tuberosity are shuttled through the lateral punch-holes in the graft (Fig 20).
        Fig 20
        Fig 20Right shoulder. Medial fixation of the graft to the superior glenoid is achieved by using a modified double-pulley technique to create a double mattress construct. At the lateral side of the graft, the FiberTapes are shuttled through the 2 punch-holes.
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      • 7.
        Lateral fixation is obtained by means of a SpeedBridge construct (Fig 21).
        Fig 21
        Fig 21Right shoulder. Lateral fixation of the graft is accomplished by means of a FiberTape SpeedBridge construct (Arthrex).
        Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press.
      The 2 zip-line techniques illustrated here have been extremely valuable to us in rapidly creating secure dermal allograft fixation when performing SCRs.

      Discussion

      In patients without glenohumeral arthritis yet with massive cuff tears, some surgeons are investigating surgical treatment with reverse total shoulder arthroplasty (rTSA).
      • Mulieri P.
      • Dunning P.
      • Klein S.
      • Pupello D.
      • Frankle M.
      Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis.
      • Hartzler R.U.
      • Steen B.M.
      • Hussey M.M.
      • et al.
      Reverse shoulder arthroplasty for massive rotator cuff tear: Risk factors for poor functional improvement.
      However, we are philosophically opposed to that approach, and we believe that joint preservation should be the guiding principle in dealing with such patients. We have previously reported that massive cuff tears are usually completely reparable,
      • Denard P.J.
      • Lädermann A.
      • Jiwani A.Z.
      • Burkhart S.S.
      Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
      and that even in patients with massive tears associated with pseudoparalysis, the pseudoparalysis is reversible in >90% of cases after cuff repair.
      • Denard P.J.
      • Lädermann A.
      • Brady P.C.
      • et al.
      Pseudoparalysis from a massive rotator cuff tear is reliably reversed with an arthroscopic rotator cuff repair in patients without preoperative glenohumeral arthritis.
      However, we freely admit that some tears are not fully reparable. In such cases, the surgical choices are partial cuff repair versus rTSA. In the past, we have chosen partial repair because of our philosophic preference for joint preservation. In the case of pseudoparalysis patients, however, we found that reversal of pseudoparalysis was not as predictable with partial repair as with complete cuff repair. Therefore, SCR with dermal allograft was a very appealing option in such patients because of its potential for reversing proximal humeral migration by means of a “reverse trampoline” effect from the dermal graft on the humeral head, thereby restoring a stable fulcrum of glenohumeral motion. Maintenance of a stable fulcrum would provide the added benefit of optimizing the remaining intact force couples, thereby increasing objective measures of strength.
      Mihata et al.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      were the first to report using fascia lata autograft for SCR. In their series of 24 shoulders, 83% had intact grafts by postoperative imaging at an average follow-up of 34 months. Furthermore, the acromiohumeral distance increased from an average of 4.6 to 8.7 mm, indicating reversal of proximal humeral migration. In addition, restoration of superior glenohumeral stability by means of SCR has been demonstrated in several elegant biomechanical studies,
      • Mihata T.
      • McGarry M.H.
      • Pirolo J.M.
      • Kinoshita M.
      • Lee T.Q.
      Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: A biomechanical cadaveric study.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effect of thickness and tension of fascia lata graft on glenohumeral stability for superior capsule reconstruction in irreparable supraspinatus tears.
      • Mihata T.
      • McGarry M.H.
      • Kahn T.
      • Goldberg I.
      • Neo M.
      • Lee T.Q.
      Biomechanical effects of acromioplasty on superior capsule reconstruction for irreparable supraspinatus tendon tears.
      thus showing that a graft is much more effective at resisting superior translation of the humerus if the graft is anchored medially to the superior glenoid as opposed to simply suturing it medially into the rotator cuff stump.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      Pseudoparalysis probably is the result of an inability to establish a stable fulcrum of glenohumeral joint motion. However, many patients with proximal migration will establish a stable fulcrum of motion by means of an acromiohumeral fulcrum, once the humeral head has begun to articulate against the acromion. These patients maintain active overhead motion but still have weak external rotation. And they often have significant pain, which may be due in large part to the abrasive effect of the rough undersurface of the acromion articulating against the humeral head. We have found that many patients with proximal migration of the humerus, even though they have adaptive changes on the greater tuberosity and the acromion, do not have glenohumeral arthritis and still maintain a normal glenohumeral joint space. Therefore, a joint-preserving procedure would be preferable to rTSA in such patients (Table 2).
      Table 2Advantages and Disadvantages of SCR
      AdvantagesDisadvantages
      1. Very low infection rate1. Slightly longer rehab than rTSA
      2. Restores stable fulcrum2. If SCR fails, rTSA will usually be necessary
      3. Does not preclude future rTSA if necessary3. Technically demanding, moreso than rTSA
      4. Lower cost than rTSA4. Will not usually restore normal strength
      5. Reversal of pseudoparalysis is common
      6. Low morbidity compared to rTSA
      rTSA, reverse total shoulder arthroplasty; SCR, superior capsular reconstruction.
      As discussed in the Surgical Technique section, SCR is a technically demanding procedure. A knowledge of surgical pearls and pitfalls is invaluable (Table 3).
      Table 3Surgical Pearls and Pitfalls
      PearlsPitfalls
      1. Posterior interval slide enhances exposure of superior glenoid.1. Failure to manage sutures at 4 corners of graft will lead to fouling and tangling of sutures.
      2. Traction suture through supraspinatus from Neviaser portal enhances exposure of superior glenoid.2. In doing medial double-pulley fixation on superior glenoid, observe closely that sutures do not bowstring over the edge of the glenoid.
      3. Place anteromedial glenoid anchor at base of coracoid, anterior to biceps root.3. If graft is >35 to 40 mm in any dimension, it can become “captured” in cannula during shuttling; remove cannula before passing sutures and shuttling graft in such cases.
      4. Use curette to thoroughly prepare superior glenoid to bleeding base.4. Do not go fast with rehab. If SCR fails, patient will likely need rTSA.
      5. Repair posterior margin of graft to infraspinatus.5. Must stay at least 5 mm lateral to base of scapular spine during anchor placement to avoid damage to the suprascapular nerve.
      6. Repair anterior margin of graft to comma tissue, if it is present.
      7. Do double-row SpeedBridge fixation on humeral side using FiberTape.
      8. Use cinch-loop suture on medial edge of graft to shuttle it into place.
      9. After dermal graft fixation, do partial repair of cuff over the top of graft.
      rTSA, reverse total shoulder arthroplasty; SCR, superior capsular reconstruction.
      We became interested in SCR with acellular dermal allograft after Alan Hirahara, MD, presented his initial experience in adapting the dermal allograft to Mihata's original SCR technique.
      • Hirahara A.M.
      • Adams C.R.
      Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears.
      Over the past 2 years, we have collectively performed more than 100 SCRs with dermal allograft in patients with massive irreparable cuff tears. The 2 categories of patients in which we have performed this procedure are
      • 1.
        those with massive irreparable cuff tears and pseudoparalysis; and
      • 2.
        those with massive irreparable cuff tears with proximal humeral migration, an acromiohumeral fulcrum allowing active overhead motion, preservation of the glenohumeral joint, but with significant pain and weakness despite active overhead motion.
      We will report our results with longer-term follow-up as we continue to observe the progress of these patients. However, our early results give us reason to be optimistic that SCR with dermal allograft may be a joint-preserving alternative that is preferable to rTSA for patients with massive irreparable rotator cuff tears.

      Supplementary Data

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