**7.5. Graft passage**

The suture pulley system previously created on the medial side of the graft with the glenoid sutures is now tensioned. The graft may need to be partially folded to allow it to pass through the cannula, or the cannula may be removed (if it was pre-cut). Also, a blunt tissue grasper can be used to pinch the graft medially to ease the delivery and transport of the graft through the cannula. The graft is visualized entering the joint, and moving medially until it sits flush on the superior glenoid neck, covering the rim (**Figure 16A** and **B**). It may be necessary to help unfold the anterior and posterior edges of the graft once its fully inside, in case they get folded in.

## **7.6. Graft fixation**

The sutures from the glenoid anchors are then tied arthroscopically to secure the graft to the glenoid neck. The tails of those sutures may be passed up through the remnant of the native cuff, to bring it down to the medial edge of the graft, helping create a biologic seal over this area (**Figure 16C**).

**Figure 13.** Graft measurement. It is important not to cut the graft too short. 5 mm extra is left on the medial, anterior, and

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management...

http://dx.doi.org/10.5772/intechopen.70049

143

posterior edges, whereas laterally 10 mm extra distance is left to allow coverage over the GT footprint.

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management... http://dx.doi.org/10.5772/intechopen.70049 143

Next the graft if prepared. We use an acellular human dermal graft (Arthroflex by Arthex, Inc., Naples, FL), but an autograft, such as tensior fascia lata, may also be harvested and used. Whichever graft is used, it is now sized and prepared on the back table. The graft is cut to allow a 5 mm margin medially, anteriorly and posteriorly and a 10 mm margin laterally. The dimensions of the anchor configuration are then carefully marked on the graft using a mark-

At this point, all the sutures must be brought out through one of the subacromial portals in preparation for graft passage. We prefer to view from the posterior or posterolateral portal, and use the anterolateral portal for graft passage. Sometimes this portal must be slightly increased in size, and a flexible cannula, which can be cut along one of its sides (such as the

The graft is brought close to the shoulder, carefully supported on a sterile Mayo stand. The sutures from the glenoid anchors are passed through the medial edge of the graft. Simple configuration can be used, but we prefer to place each sets of sutures in a criss-crossing mattress configuration (one vertically and one horizontally), creating a Mason-Allen type configuration. One limb from each suture set is tied to a limb from another suture set (off a different color), and the knot tails are cut. This leaves two suture limbs (one of each color) on the anterior-medial and posterior-medial edges of the graft, which, when tensioned, create a pul-

At this time it is possible to either place the tuberosity medial row sutures through the graft, or instead place a suture loop (such as Arthrex Fiberlink) which would aide with the passage of those sutures later. The advantage of the latter approach is minimizing suture traffic in the lateral subacromial portal, and avoiding suture entanglement. We prefer this technique (**Figure 14**), and temporarily park the medial row tuberosity sutures in the anterior and pos-

The suture pulley system previously created on the medial side of the graft with the glenoid sutures is now tensioned. The graft may need to be partially folded to allow it to pass through the cannula, or the cannula may be removed (if it was pre-cut). Also, a blunt tissue grasper can be used to pinch the graft medially to ease the delivery and transport of the graft through the cannula. The graft is visualized entering the joint, and moving medially until it sits flush on the superior glenoid neck, covering the rim (**Figure 16A** and **B**). It may be necessary to help unfold the anterior and posterior edges of the graft once its fully inside, in case they get

The sutures from the glenoid anchors are then tied arthroscopically to secure the graft to the glenoid neck. The tails of those sutures may be passed up through the remnant of the native cuff, to bring it down to the medial edge of the graft, helping create a biologic seal over this

ley effect on the graft, allowing it to be drawn into the joint (**Figures 14** and **15**).

ing pen (**Figure 13**).

142 Advances in Shoulder Surgery

**7.5. Graft passage**

folded in.

**7.6. Graft fixation**

area (**Figure 16C**).

Arthex Passport) can be helpful.

terior portals, while the graft is being passed.

**Figure 13.** Graft measurement. It is important not to cut the graft too short. 5 mm extra is left on the medial, anterior, and posterior edges, whereas laterally 10 mm extra distance is left to allow coverage over the GT footprint.

**Figure 14.** Suture placement into the graft prior to shuttling. Glenoid sutures are placed in a horizontal and vertical mattress configurations, perpendicular to each other. Laterally, we prefer to place a suture-loop (Arthrex Fiberlink), for subsequent shuttling of suture-tapes from the GT medial row anchors.

Then the tuberosity medial row sutures are passed through the graft using the previously preloaded suture-loop, if they haven't been already placed outside the shoulder. Both limbs of the sutures from the medial GT anchors are passed through the graft, from inferior to superior, one at the anterior and one at the posterior pre-determined spots (**Figure 17A**). Finally, these suture-tapes are brought over the lateral-most extent of the graft in a criss-cross fashion, and secured just past the lateral margin of the tuberosity with knotless anchors (**Figure 17B–D**). Prior to setting final tension and fixating the graft laterally, proper shoulder position of neutral

**Figure 16.** Arthroscopic view of graft fixation to the glenoid. (A) The graft is pulled in using the double-pulley system, which is created by tying one limb of each suture to the other one from the same anchor (white arrows); the remaining limbs act as pulley sutures (black arrows), to cinch the graft onto the superior glenoid rim. (B) Note the ability to pull up the remnant of the superior cuff, with a previously placed free suture, via the Neviaser portal, for improved visualization. (C) After the sutures from the glenoid anchors are tied, securing the graft to the glenoid, the remnant cuff tissue can be tied down to the graft, using those suture tails. This creates a nice biologic seal over the medial part of the SCR construct.

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management...

http://dx.doi.org/10.5772/intechopen.70049

145

rotation and slight abduction (20–30°) needs to be ensured.

**Figure 15.** Model demonstration of the step-by-step process of glenoid suture placement and tying. (A) All suture limbs from each anchor are placed in a mattress configuration, perpendicular to each other. (B) One limb from each suture is tied to a limb from the other suture (different color), and this creates a double-pulley system, which helps shuttle the graft to its attachment points on the glenoid. (C) Final construct, with all glenoid sutures tied.

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management... http://dx.doi.org/10.5772/intechopen.70049 145

**Figure 14.** Suture placement into the graft prior to shuttling. Glenoid sutures are placed in a horizontal and vertical mattress configurations, perpendicular to each other. Laterally, we prefer to place a suture-loop (Arthrex Fiberlink), for

**Figure 15.** Model demonstration of the step-by-step process of glenoid suture placement and tying. (A) All suture limbs from each anchor are placed in a mattress configuration, perpendicular to each other. (B) One limb from each suture is tied to a limb from the other suture (different color), and this creates a double-pulley system, which helps shuttle the

graft to its attachment points on the glenoid. (C) Final construct, with all glenoid sutures tied.

subsequent shuttling of suture-tapes from the GT medial row anchors.

144 Advances in Shoulder Surgery

**Figure 16.** Arthroscopic view of graft fixation to the glenoid. (A) The graft is pulled in using the double-pulley system, which is created by tying one limb of each suture to the other one from the same anchor (white arrows); the remaining limbs act as pulley sutures (black arrows), to cinch the graft onto the superior glenoid rim. (B) Note the ability to pull up the remnant of the superior cuff, with a previously placed free suture, via the Neviaser portal, for improved visualization. (C) After the sutures from the glenoid anchors are tied, securing the graft to the glenoid, the remnant cuff tissue can be tied down to the graft, using those suture tails. This creates a nice biologic seal over the medial part of the SCR construct.

Then the tuberosity medial row sutures are passed through the graft using the previously preloaded suture-loop, if they haven't been already placed outside the shoulder. Both limbs of the sutures from the medial GT anchors are passed through the graft, from inferior to superior, one at the anterior and one at the posterior pre-determined spots (**Figure 17A**). Finally, these suture-tapes are brought over the lateral-most extent of the graft in a criss-cross fashion, and secured just past the lateral margin of the tuberosity with knotless anchors (**Figure 17B–D**). Prior to setting final tension and fixating the graft laterally, proper shoulder position of neutral rotation and slight abduction (20–30°) needs to be ensured.

The shoulder is then taken through a full range of motion to ensure no signs of impingement. And residual spurs on the acromion, or osteophytes off the inferior distal clavicle should be

**Figure 18.** Side-to-side repair to the intact cuff and completion of the SCR. (A) Sutures are passed through the graft and adjacent intact cuff. (B) Sutures are then tied, providing close approximation between the graft and native tissue. (C) Superior view from the Neviaser portal, showing a completed SCR, with excellent coverage of the joint by the graft and

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management...

http://dx.doi.org/10.5772/intechopen.70049

147

We follow the same protocol for our SCR cases as for our large rotator cuff repair cases. A shoulder immobilizer sling is worn for 6 weeks, with or without an abduction pillow. Passive range of motion exercises are started at 4–6 weeks postoperatively, active-assisted motion is allowed at 6–8 weeks, and full active motion is allowed after 8 weeks. Strengthening progresses after 12 weeks, and return to activities which require overhead lifting is allowed no earlier than 16 weeks. Typical full return to activities is allowed 6 months postoperatively.

Published reports of clinical outcomes following superior capsular reconstruction thus far have been limited to one study, but more such studies are currently either in data collection or already in preparations to report outcomes. In 2013, Mihata et al. reported a case series of 24 shoulders (23 consecutive patients), treated with SCR using fascia lata autograft, with minimum 2-year follow-up [2]. At an average follow-up of 34 months (24–51 months), mean active elevation increased from 84 to 148° and mean external rotation increased from 26 to 40°. All clinical outcomes scores improved significantly, with American Shoulder and Elbow Surgeons score (ASES) score going up from an average of 23.5 to 92.9. Furthermore, imaging showed acromiohumeral distance increased from 4.6 to 8.7 mm, on average. No procedure-

In the United States, most surgeons prefer to use a dermal allograft (Arthrex Arthroflex), which is a thick (3 mm) and durable patch, which requires minimal preparation time and is relatively easy to handle. Several technical reports using this graft have been published, including those

resected (**Figure 8**).

**8. Outcomes**

related complications were reported [2].

**7.8. Postoperative protocol**

native cuff, repaired to the graft.

**Figure 17.** Graft fixation to the humeral head. (A) Suture-tapes from the medial row greater tuberosity anchors are passed up through the graft, using the previously placed suture-loop (left shoulder, view from the anterolateral portal; AA—anterior anchor, PA—posterior anchor, GT—greater tuberosity); (B) Suture tapes are criss-crossed and secured just past the lateral margin of the tuberosity with knotless anchors, providing excellent compression of the graft over the tuberosity footprint. (C) If a small "dog-ear" is noted after lateral graft fixation, a suture preloaded into the lateral-row anchor can be used to tie it down. (D) Model demonstration of graft fixation to the humeral head.

## **7.7. Anterior and posterior convergence**

Once the graft is secured medially and laterally, side-to-side margin convergence sutures are placed to secure the graft to the intact cuff (**Figure 18A** and **B** ). Pre-placed sutures are helpful for this, as discussed above. Typically two side-to-side sutures are used posteriorly, to connect the graft to the intact part of the infraspinatus or to the teres minor. Anteriorly, if the fixation is to the intact remaining supraspinatus, two sutures may be used as well (**Figure 18C**); however, if there is no supraspinatus left, and fixation is to the upper border of the subscapularis, no more than one suture should be used, as laterally as possible, to avoid over-constricting the rotator interval. If the distance between the anterior edge of the graft and the upper border of the subscapularis is too great, no margin convergence sutures are placed here.

**Figure 18.** Side-to-side repair to the intact cuff and completion of the SCR. (A) Sutures are passed through the graft and adjacent intact cuff. (B) Sutures are then tied, providing close approximation between the graft and native tissue. (C) Superior view from the Neviaser portal, showing a completed SCR, with excellent coverage of the joint by the graft and native cuff, repaired to the graft.

The shoulder is then taken through a full range of motion to ensure no signs of impingement. And residual spurs on the acromion, or osteophytes off the inferior distal clavicle should be resected (**Figure 8**).
