**5. Treatment options for irreparable rotator cuff tears**

Therefore, due to poor healing potential and low likelihood of restoration of good cuff function, chronic large (3–5 cm) and massive (>5 cm) tears, especially those with Goutallier 2 or greater atrophy, may be considered irreparable. Other types of tears that are considered irreparable include tears with significant retraction of the tendon (medial to the glenoid), poor tendon quality for repair, and poor bone quality at the greater tuberosity attachment site (**Figure 4**). Attempts at repair of tears with these features should be approached with guarded expectations.

Those rotator cuff tears that fail to heal or are irreparable frequently go on to a clinical condition called cuff tear arthropathy (CTA) (**Figure 2**). This is a specific form of shoulder arthritis resulting from rotator cuff deficiency. Due to the failure and absence of superior restraint, the humeral head typically migrates superiorly, and eventually articulates with the acromion. Over time this leads to wear of the acromion, destruction of the humeral head cartilage, and eventually the glenoid cartilage as well. Patients typically present with significant pain, weakness, and crepitus with range of motion, and sometimes even pseudoparalysis—severe inability to elevate the shoulder. Once advanced CTA develops, the only surgical solution available to treat it (other than fusion of the shoulder joint) is a reverse total shoulder replacement (**Figure 5**).

**Figure 5.** Reverse shoulder replacement in a 60 year-old man, performed for symptomatic advanced cuff-tear arthropathy.

**Figure 4.** Massive tear of the superior rotator cuff, not amenable to repair. (A) Note poor tissue quality of the tendon stump, and retraction medial to the glenoid rim. (B) Despite extensive releases, this tendon stump could not be mobilized

even to the medial margin of the greater tuberosity.

134 Advances in Shoulder Surgery

The treatment of massive and irreparable rotator cuff tears is challenging. Surgical options include partial repair with marginal convergence, debridement with biceps tenotomy, graft interposition, tendon transfer, reverse total shoulder, and now superior capsular reconstruction. Partial repair of the inferior half of the infraspinatus was originally described by Burkhart et al. in 1994, with the goal restoring a balanced anterior-posterior force couple in the shoulder [27]. Multiple studies which analyzed surgery for massive cuff tears with combinations of partial repair, marginal convergence, debridement, and biceps tenotomy have shown mixed results, typically with good outcomes early on, but persistent strength deficit in elevation, and deterioration of clinical results over time. For example, Shon et al. performed partial repair and marginal convergence techniques in 31 patients and found initial improvement in clinical outcome scores, whereas 2-year follow-up showed a dissatisfaction rate of 50% [28]. Fatty infiltration of the infraspinatus was found to be a negative predictor of outcome in these patients.

Graft interposition techniques to bridge irreparable rotator cuff defects have been described using autograft, allograft, xenograft, and synthetic materials. A systematic review of these techniques found a lack of high quality comparative studies. The limited studies available show improvement in clinical outcomes in all graft types [29], with allograft, xenograft, and synthetic grafts having the appeal of no harvest site morbidity, compared to autograft. On the other hand, significant inflammatory reactions have been reported with the use of xenografts as well as allografts [30], and therefore caution must be used. Just as with other surgeries for massive cuff tear, significant fatty atrophy leads to significantly lower healing rates after graft interposition repairs. Finally, interpositional grafts may need to be placed through an open approach, which runs the increased disk of damage to the deltoid muscle, potentially making subsequent revision surgery more difficult and less successful. In summary, due to lack of high quality comparative studies on the use of graft interposition for cuff repair, the potential benefits of this procedure must be weighed against the cost, risks, and potential future complications of this approach.

Several tendon transfer procedures have been described for the treatment of massive irreparable rotator cuff tears. Tendon transfers are typically performed in younger patients without glenohumeral arthritis and good range of motion. The most common transfers used for posterosuperior tears are latissimus dorsi and lower trapezius transfers. Clinical studies show latissimus dorsi transfer provides significant pain relief after tendon transfer, whereas functional results are more unpredictable [31]. Lower trapezius transfer anatomically provides a more direct line of pull compared to latissimus dorsi transfer; however, limited clinical evidence is available to show improvement in pain and function.

Reverse total shoulder arthroplasty (RTSA) is a semiconstrained reverse ball and socket prosthesis which helps improve the biomechanical efficiency of the deltoid muscle by lengthening its lever arm. The design provides inherent glenohumeral stability and lowers the humeral head to increase deltoid tension, which allows this muscle to elevate the arm without a functional rotator cuff. While elevation is typically restored after RTSA, active rotation of the shoulder is not as easily recovered as it relies on presence of the anterior-posterior components of the cuff. Overall, clinical studies have shown significant improvements in pain, motion, and functional scores in patients treated for cuff-tear arthropathy. However, implant longevity is a concern, as are functional limitations imposed by this surgery. Due to these limitations, reverse shoulder arthroplasty is typically reserved for patients in their 60s, 70s, and older [32].

way occupying the space above it. Biomechanical cadaveric studies by Mihata and colleagues have shown that SCR does restore superior translation to physiologic conditions [33]; and also that increased thickness of the graft improves stability [34]. These studies lend credence to both

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

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

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Indications for this surgery currently include physiologically young (absolute age has not been determined) and relatively active patients with symptomatic irreparable superior rotator cuff, with intact anterior-posterior force couples, and no or minimal glenohumeral arthritic wear. Young patients with moderate cartilage wear and symptoms primarily related to cuff function may be considered for SCR, in lieu of RTSA, but guarded expectation are warranted with more severe arthritic wear. SCR may also be an attractive option for previous failed cuff repair, in a setting of poor tissue quality, fatty infiltration, and other factors that may result in

Absolute contraindications include infection, neuropathic disease of the shoulder, and neurologic disorders significantly affecting function of the deltoid muscle. Relative contraindications include advanced arthritis, tears of the anterior/posterior rotator cuff, as well as unwillingness or inability to comply with postoperative immobilization and rehabilitation

Arthroscopic reconstruction using tensor fascia lata was initially proposed by Mihata et al. [2]. Several other authors have reported SCR using acellular dermal allograft [35–39]. An arthroscopic technique is typically used for this procedure, but an open technique may be used in cases of difficult arthroscopic exposure or for surgeons less familiar with arthroscopic techniques. We describe our preferred technique for arthroscopic superior cap-

Surgery is typically performed in an ambulatory setting, under combination general and regional anesthesia. After induction of anesthesia, and prior to positioning (with the patient supine on the operating table), the shoulder should be examined for passive motion and stability. Manipulation of the shoulder to regain motion should be performed as needed. We prefer a beach-chair position with the arm supported by a hydraulic arm positioner device,

Standard posterior portal is used to enter the glenohumeral joint, and an anterior portal is established in the rotator interval. A thorough diagnostic arthroscopy of the glenohumeral joint is performed, and pathologic lesions are addressed as needed. Particular attention must be paid to the integrity of the subscapularis tendon, which needs to be repaired if significantly

but a lateral decubitus with balanced suspension-traction may also be used.

**7.2. Diagnostic arthroscopy and associated procedures**

theories regarding biomechanical function of SCR; indeed both factors may be at play.

tear irreparability.

protocol.

**7. Technique**

sular reconstruction.

**7.1. Surgical positioning**
