Arthroscopic Superior Capsular Reconstruction and Over-the-Top Rotator Cuff Repair Incorporation for Treatment of Massive Rotator Cuff Tears

Abstract

Massive rotator cuff tears pose significant clinical and surgical challenges for orthopaedic surgeons and increased morbidity to the patient. Left untreated, this pathology can lead to inability to perform daily activities, weakness, pain, and eventual cuff tear arthropathy. Several treatment options exist for irreparable cuff tears, such as reverse shoulder arthroplasty and tendon transfers. However, there exists significant concern for high complication rates and unpredictable clinical outcomes following such treatments. Superior capsular reconstruction (SCR) represents a viable alternative in treating irreparable cuff tears, providing biomechanical stability and improving pain related to this pathology by reducing superior humeral instability and subacromial impingement. Over-the-top repair of the native rotator cuff tendons with incorporation of the SCR allograft may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. The authors present a surgical technique with associated pearls and pitfalls for their preferred procedure of SCR with incorporation of the native rotator cuff in transosseous equivalent double-row repair for the treatment of massive, irreparable rotator cuff tears.

Superior Capsular Reconstruction With Arthroscopic Rotator Cuff Repair in a “Functional Biologic Augmentation” Technique to Treat Massive Atrophic Rotator Cuff Tears

“…Recently, Cabarcas et al. 21 reported a similar technique in Arthroscopy Techniques that they termed “over-the-top repair” of native rotator cuff tissue over an SCR graft in accordance with our view. We believe that decreasing the superior capsular distance through placement of the SCR graft decreases tension on the repair by decreasing the length that the rotator cuff has to be stretched to reach the native attachment site.…”

“…When repair of the native superior capsular tissue is not possible, we use this technique to restore superior stability to theoretically decrease stress on the repair. Recently, Cabarcas et al 21 . reported a similar technique in Arthroscopy Techniques that they termed “over-the-top repair” of native rotator cuff tissue over an SCR graft in accordance with our view.…”

Arthroscopic Superior Capsule Reconstruction and Rotator Cuff Repair to Restore Static and Dynamic Stability of the Shoulder

“…The technique has been referred to as "functional biologic augmentation" or "over-the-top repair". This procedure has been described as having the goal of decreasing the AHI to allow the rotator cuff to be stretched to reach the native attachment site 14,15 . However, we noticed the phenomenon that, in some cases, after the release technique and even SCR was performed, the remnant cuff tissue could not be reapproximated to its native footprint.…”

“…In addition, in some cases, the humeral head migrated superiorly again because of the "creep" (graft get stretched) phenomenon, which results in increased joint laxity, and may lead to SCR failure 13 . Although the importance of restoring the remnant rotator cuff tissue to maximize clinical outcomes when performing SCR has been highlighted 14,15 , problems such as extreme tension at the suture site, high re-tear rates, and incomplete dynamic function recovery after SCR still exist.…”

Technique for Double Row Superior Capsule Reconstruction with Dermal Allograft

“…Reverse total shoulder arthroplasty also offers surgeons an opportunity to aid patients with irreparable rotator cuff tears, but may not be the best option for younger and active patients or patients with little to no arthritis. 6 The superior capsule reconstruction procedure is technically demanding and has a steep learning curve, 7 which is why we limited our practice to patients unwilling or unable to proceed with tendon transfers and or shoulder arthroplasty ( Table 2). We offer our technique for superior capsule reconstruction as a surgical option for the younger, higher demand patient without significant degenerative changes for the management of irreparable rotator cuff tears.…”