All Knot-less Arthroscopic Superior Capsular Reconstruction.

Irreparable rotator cuff tears are a complicated problem, and current treatment options include nonoperative rehabilitation, debridement with or without a biceps tenotomy, tuberoplasty, partial rotator cuff repair, patch augmentation, biodegradable spacers, tendon transfer, and reverse shoulder arthroplasty. Arthroscopic superior capsular reconstruction is a more recent technique that is gaining popularity for use in irreparable rotator cuff tears. However, this surgery can be technically complicated. The purpose of this technique is to increase reproducibility and simplify a complicated procedure by addressing the current challenges of previous techniques.

Injury to the rotator cuff can result in massive and irreparable tears. Current treatment options include nonoperative rehabilitation, debridement with or without a biceps tenotomy, tuberoplasty, partial rotator cuff repair, patch augmentation, biodegradable spacer, tendon transfer, and reverse shoulder arthroplasty.

A more recent technique, arthroscopic superior capsular reconstruction (ASCR), was first developed by Mihata et al. and showed promising and favorable short-term clinical outcomes.2, 3 In addition, there have been multiple studies showing the importance of the superior capsule in maintaining passive stability and preventing translation of the glenohumeral joint.4, 5

Despite the success of ASCR, it remains technically challenging, time consuming, and difficult to reproduce. A challenge in this procedure is suture placement and graft management after insertion into the joint space. This particular technique attempts to minimize this problem by doing the majority of the graft and suture preparation on the back table and then completing this procedure with a completely knotless repair while maximizing security and compression of the graft (Table 1, Video 1). The aim of the technique is to simplify, making a difficult procedure more reproducible and efficient.

Table 1

Surgical Steps in Knotless Arthroscopic Superior Capsular Reconstruction

1. Perform diagnostic arthroscopy.

2. Perform debridement and prepare bone.

3. Drill anchor holes.

4. Measure anchor dimensions and cut graft to size.

5. Pass sutures through graft on the back table.

6. Pull graft into shoulder capsule from lateral to medial.

7. Anchor medial graft to drilled superior glenoid holes.

8. Anchor graft to drilled medial row of the humeral head.

9. Anchor lateral graft to lateral row of the humeral head.

10. Secure graft to adjacent rotator cuff with side-to-side sutures.

11. Perform joint inspection and drainage.

Technique

Surgical Indications

General indications for ASCR include irreparable supraspinatus and/or infraspinatus tears confirmed by magnetic resonance imaging, conservative management failure, and intolerable shoulder pain. Surgery should be avoided in cases with moderate to severe arthropathy, significant bone defects, and dysfunction of deltoid, pectoralis, or latissimus dorsi.

Patient Positioning and Anesthesia

The procedure is performed with the patient under general anesthesia and positioned in the lateral decubitus position. All bony prominences should be well padded, including a pillow for the peroneal nerve at the knees and an axillary roll. A physical examination should be performed to demonstrate any instability with anterior superior, anterior middle, or anterior inferior zone load and shift as well as posteriorly.

Diagnostic Arthroscopy

Establish a midposterior glenoid portal, followed by an anterior rotator interval portal. Perform a diagnostic arthroscopy of the glenohumeral joint to examine the extent of the damage, and debride any labral fraying, arthritic changes, and chondromalacia. It may be necessary to repair some of the rotator cuff including the subscapularis and infraspinatus. Abrade the superior neck of the glenoid and the greater tuberosity. The greater tuberosity should also be microfractured to maximize healing of the graft to bone.

Surgical Technique

Create holes for the 2.9-mm footprint knotless glenoid anchors through percutaneous stab wounds. Place an anterior hole through an anterior clavicle approach into the superior glenoid and another posterior to the acromion. Do not place anchors; instead, leave spinal needles in anchor holes to help later identify anchor placement after graft insertion into the joint space. Punch holes for the medial and lateral row of the transosseous equivalent double-row portion of the superior capsular reconstruction on the medial footprint. Measure the distances between drilled anchor holes using a knotted suture.

Prepare the Allograft LifeNet patch (LifeNet Health, Virginia Beach, VA) on the back table. Stretch and restretch the graft using 4 corner clamps, and then cut to the appropriate length using the measurements (in millimeters) provided by the knotted suture. Create the medial border by measuring the distance from the anterior medial (AM) anchor hole to the posterior medial (PM) anchor hole and adding 5 mm to both sides of the holes (PM + AM + 5 + 5 = medial border). Create the lateral border by measuring the distance from the anterior lateral (AL) anchor hole to the posterior lateral (PL) anchor hole and adding 5 mm to both sides of the holes (PL+ AL + 5 + 5 = lateral border). Create the anterior border by measuring the distance from the AM anchor hole to the AL anchor hole and adding 5 mm for the medial border and 12 mm for the lateral border (AM + AL + 12 + 5 = anterior border). Create the posterior border by measuring the distance from the PM anchor hole to the PL anchor hole and adding 5 mm for the medial border and 12 mm for the lateral border (PM + PL + 12 + 5 = posterior border) (Fig 1).

Fig 1

Method (viewing from superior) for sizing the graft (in millimeters) used for superior capsular reconstruction in the right shoulder. PM, AM, PL, and AL are anchor locations. AM and PM are located on the superior glenoid. PL and AL are located on the medial row of the humeral head. The distance between each hole and the border is 5 mm. The 12 mm added to the posterior and anterior border is the distance between anchor placement in the medial row (PL and AL) and lateral border of the humeral head. (AL, anterior lateral; AM, anterior medial; PL, posterior lateral; PM, posterior medial.)

Next, pass No. 2 UltraBraid (Smith & Nephew, Andover, MA) on the medial border of the graft in an inverted fashion at the AM and PM locations. Pass inverted UltraTape sutures (Smith & Nephew) at the AL and PL locations. Pass an additional UltraTape under each inverted UltraTape on the bursal side of the graft at the AL and PL locations. Two limbs of UltraTape should exit inferiorly and 2 superiorly from the graft at these locations (Figs 2 and 3). Place a simple stitch midway on the graft both anteriorly and posteriorly with No. 2 UltraBraid to pass side-to-side sutures later to the native cuff adjacent to the graft. Place luggage tag No. 2 UltraBraid sutures in the anterolateral and posterolateral corners. When passing sutures, be sure to leave 5-mm borders from the edge of the graft. This is done to help ensure the sutures do not pull through the sides of the graft (Fig 4).

Fig 2

Suture placement (viewing from posterior and superior) in the graft used for superior capsular reconstruction in the right shoulder. Inverted No. 2 UltraBraid was passed along the medial border (AM and PM). Inverted UltraTape sutures were passed on the AL and PL locations. UltraTape (LS) is looped under each inverted UltraTape on the bursal side of the graft at the AL and PL locations. (AL, anterior lateral; AM, anterior medial; LS, looped suture; PL, posterior lateral; PM, posterior medial.)

Fig 3

Suture placement in the graft used for superior capsular reconstruction in the right shoulder. The figure (viewing from superior) shows the inverted No. 2 UltraBraid placed along the medial border (AM and PM) and the inverted UltraTape at the AL and PL locations. UltraTape (LS) is also looped under each inverted UltraTape on the bursal side of the graft at the AL and PL locations. The figure shows a limb from each LS UltraTape being combined with the UltraBraid luggage tag sutures located in the posterolateral corner (PLT). The other limb from each LS UltraTape will be combined with the UltraBraid luggage tag suture located in the anterolateral corner (ALT). The image (viewing from posterior and superior) also shows the No. 2 UltraBraid, which will be used for anterior and posterior side-to-side sutures (SSA and SSP). (AL, anterior lateral; ALT, anterior luggage tag; AM, anterior medial; LS, looped suture; PL, posterior lateral; PLT, posterior luggage tag; PM, posterior medial; SSA, side-to-side anterior; SSP, side-to-side posterior.)

Fig 4

Suture and graft orientation (viewing from superior) for superior capsular reconstruction in the right shoulder. The medial border (M) will be anchored to the superior glenoid. The anterior border (A) will be attached to the native cuff adjacent and anterior to the graft with side-to-side sutures. The posterior border (P) will be attached to the native cuff adjacent and posterior to the graft with side-to-side sutures. The lateral border (L) will be anchored to the humeral head via 2 anchor rows.

Place a passing stitch through the Neviaser portal and pull it out of the far lateral portal through a 10-mm cannula. Use this passing stitch to pull the folded graft through the 10-mm cannula from lateral to medial, pulling it through the Neviaser portal. Care must be taken to only “pull” the medial glenoid-based UltraBraid sutures while leaving behind the remaining sutures in the 10-mm portal.

Retrieve medial limbs from AM and PM individually through the respective anterior and posterior percutaneous stab wounds, and secure using 2.9-mm Bioraptor knotless peek anchors (Smith & Nephew) into the previously drilled superior glenoid holes. Visualization of the placement of these medial glenoid anchors may be improved by placing the camera into the Neviaser portal (Fig 5). Retrieve inverted UltraTape sutures from AL and PL locations on the inferior aspect of the graft, and anchor them into the previously drilled medial row on the greater tuberosity of the humeral head using MultiFix S Ultra anchors (Smith & Nephew). For the lateral row of the humeral head, combine 1 looped UltraTape from each of the anterior and posterior inverted sutures, AL and PL, with the posterior luggage tag posteriorly and the anterior luggage tag anteriorly. Secure these using MultiFix S Ultra anchors. The result should be 4 MultiFix S anchors in the humeral head, 2 medially and 2 laterally with a completely knotless transosseous equivalent double-row suture capsular reconstruction. Finally, place the side-to-side sutures anteriorly and posteriorly for added tension and stability (Figs 6 and 7).

Fig 5

Viewing medially from Neviaser portal, glenoid anchor placement and graft positioning for superior capsular reconstruction in the right shoulder. The bottom left image shows anchor placement into the superior glenoid posteriorly at the PM location using the inverted sutures in that location. The top right image shows the medial aspect of the graft with both knotless glenoid anchors secured at the PM and AM locations. (AM, anterior medial; PM, posterior medial.)

Fig 6

Graft placement for superior capsular reconstruction in the right shoulder (viewing lateral portion of graft from superior and lateral). PL and AL are the locations of the inverted UltraTape that make up the medial anchor row on the humeral head. A limb from each UltraTape (LS) looped under the inverted sutures at PL and AL was combined and anchored with the posterior luggage tag (not shown) in the posterolateral corner. The other limb from each UltraTape (LS) was then combined and anchored with the anterior luggage tag (not shown) in the anterolateral corner. The result is a knotless transosseous equivalent double-row suture capsular reconstruction with 4 MultiFix S anchors on the humerus. SSA and SSP are attached to adjacent native cuff anteriorly and posteriorly, respectively. (AL, anterior lateral; LS, looped suture; PL, posterior lateral; SSA, side-to-side anterior; SSP, side-to-side posterior.)

Fig 7

Graft placement for superior capsular reconstruction in the right shoulder (viewing medial portion of graft from superior and lateral). PM and AM show the locations of the inverted sutures that make up the knotless superior glenoid anchors. Additionally, SSA and SSP show the location of side-to-side sutures attached anteriorly and posteriorly to adjacent native cuff. (AM, anterior medial; PM, posterior medial; SSA, side-to-side anterior; SSP, side-to-side posterior.)

Inspect the joint for anatomic reconstruction of the superior capsule from the articular side. Drain the shoulder and close the portals with 3-0 nylon interrupted sutures. Apply sterile dressings and take the patient to the recovery room in a pillow sling.

Postoperative Rehabilitation

An abduction sling should be used at all times for the first 4 weeks except when showering and under guidance of physical therapy. Passive range of motion as the patient tolerates is allowed at this time. At 4 weeks, discontinue sling immobilization and start gentle passive stretching. Begin active-assisted and active range of motion at 6 weeks and strengthening exercises at 8 weeks.

Discussion

ASCR is a relatively new technique that has gained popularity in treating irreparable rotator cuff tears. Although there have been improvements in previous techniques, the procedure remains technically challenging, time consuming, and difficult to reproduce.

A key challenge addressed in this procedure is suture placement and graft management after insertion into the joint space. This particular technique attempts to minimize this problem by doing the majority of the graft preparation and suture placement on the back table. Advantages and disadvantages of this technique are listed in Table 2, whereas pearls and pitfalls are listed in Table 3. The limitations of this technique include increased time preparing and measuring the graft on the back table, as precise planning is needed before pulling the graft into the subacromial space; fixating the graft from medial to lateral without being able to adjust the implants; and difficulty visualizing the medial anchor insertion from standard portals in the subacromial space.

Table 2

Advantages and Disadvantages of the Surgical Technique

Advantages	Disadvantages
Knotless technique avoids passing sutures through a thick graft once in the subacromial space.	Precise planning of all measurements must be complete before pulling the graft into the subacromial space.
Passing the graft from medial to lateral allows for a controlled introduction of the graft and avoids twisting or entanglement of sutures.	Must fixate the graft from medial to lateral without the ability to adjust the implants as they have been predetermined for their location.
A Neviaser portal is an excellent way to pull the graft into the subacromial space and visualize the medial knotless anchors in the glenoid during insertion.	Visualizing the medial glenoid anchor insertion can be difficult from standard portals in the subacromial space.

Table 3

Pearls and Pitfalls of the Surgical Technique

Pearls	Pitfalls
Spinal needles left in anchor hole to easily identify location.	Drilling holes and then placing anchors later may cause difficulty with angle of anchor insertion.
Accurate measurements of all landmarks and perimeter of graft results in a reproducible perfect fit in the defect.	Precise measurements of the implant locations and graft preparation on the back table are the most time-consuming portion of the procedure that cannot be avoided.
Anterior, lateral, posterior, and Neviaser portals are necessary for the procedure.	Avoid attempting knotless fixation of the graft without first placing other sutures in alternative portals during suture management.

Ideally, the inverted sutures should streamline anchoring by decreasing graft twisting and material in the subacromial space while providing a low-profile construct. By doing more work outside the body and inverting sutures, this technique aims to simplify a difficult procedure and increase reproducibility as well as efficiency.