**7.2. Diagnostic arthroscopy and associated procedures**

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 torn. If the biceps tendon is still present in the joint (more often than not there is a chronic tear and absence of the long head), it needs to be removed from the superior glenoid, so that it does not block graft placement; a tenotomy or tenodesis is performed. Any loose bodies should be removed, and synovectomy is performed as needed. Chondroplasty may be performed for frayed and unstable cartilage flaps on the humeral head and glenoid.

The camera is then repositioned into the subacromial space. Subacromial portals are created, typically one anterolaterally and one posterolaterally. A bursectomy is performed, and the rotator cuff tear is then carefully evaluated, characterized and mobilized, ensuring that a repair is not possible or not advisable. A superior capsular reconstruction is considered if there is a massive full-thickness tear of the supraspinatus, without or without infraspinatus tear, that cannot be repaired, and the glenohumeral joint does not show severe degenerative changes (**Figure 7**).

Once a decision is made to perform a SCR, an acromioplasty should be performed, to increase working space for graft placement and fixation, and also to decrease the risk of graft tissue abrasion postoperatively [40]. Any osteophytes off the inferior aspect of the AC joint need to be resected as well (**Figure 8**). We always attempt to preserve the CA ligament, if possible, so as not to disrupt the coracoacromial arch.

We also prefer at this time to place #2 braided sutures into the upper borders of the intact cuff posteriorly (teres minor or infraspinatus) and anteriorly (subscapularis or intact anterior fibers of the supraspinatus); these are used, after graft fixation, to repair the native cuff to the patch, side to side. Additionally, if there is any significant cuff tissue remaining medially, overlying the glenoid rim, it can be tagged with a #2 suture through a Neviaser portal, and pulled up for better visualization of the superior glenoid (**Figure 9**).

**7.3. Bony preparation, anchor placements**

of the graft postoperatively.

instrumentation on the glenoid neck.

Any residual soft tissue on the superior glenoid neck and greater tuberosity is removed using a motorized shaver and/or electrocautery wand. To maximize healing potential, the superior

**Figure 8.** An inferior osteophyte (OP) is being resected off the distal clavicle (DC), to avoid impingement and abrasion

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

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

139

Medial anchors are placed on the superior glenoid, approximately 2–4 mm medial to the rim, taking care to ensure good bone purchase and avoid intraarticular penetration. Anchors are placed as far anterior and posterior as possible to provide adequate spread and coverage for

**Figure 9.** (A) A penetrating suture passer is inserted through the Neviaser portal and is used to pass a tagging suture through the rotator cuff tendon stump. (B) The rotator cuff can then be pulled up, to allow better visualization of and

glenoid neck and greater tuberosity are burred down to bleeding bone.

**Figure 7.** Massive and irreparable rotator cuff tear in the left shoulder of a 70 year old active male (view from posterolateral portal). (A) Note severely retracted massive tear of the superior cuff (SS and IS), with relatively normal articular cartilage both on the glenoid and the humeral head. (B) Even after extensive releases, the tendon stump is not adequately mobile for primary repair (HH—humeral head; G—glenoid).

Superior Capsule Reconstruction: Review of a Novel Operative Technique for Management... http://dx.doi.org/10.5772/intechopen.70049 139

**Figure 8.** An inferior osteophyte (OP) is being resected off the distal clavicle (DC), to avoid impingement and abrasion of the graft postoperatively.

#### **7.3. Bony preparation, anchor placements**

torn. If the biceps tendon is still present in the joint (more often than not there is a chronic tear and absence of the long head), it needs to be removed from the superior glenoid, so that it does not block graft placement; a tenotomy or tenodesis is performed. Any loose bodies should be removed, and synovectomy is performed as needed. Chondroplasty may be per-

The camera is then repositioned into the subacromial space. Subacromial portals are created, typically one anterolaterally and one posterolaterally. A bursectomy is performed, and the rotator cuff tear is then carefully evaluated, characterized and mobilized, ensuring that a repair is not possible or not advisable. A superior capsular reconstruction is considered if there is a massive full-thickness tear of the supraspinatus, without or without infraspinatus tear, that cannot be repaired, and the glenohumeral joint does not show severe degenerative

Once a decision is made to perform a SCR, an acromioplasty should be performed, to increase working space for graft placement and fixation, and also to decrease the risk of graft tissue abrasion postoperatively [40]. Any osteophytes off the inferior aspect of the AC joint need to be resected as well (**Figure 8**). We always attempt to preserve the CA ligament, if possible, so

We also prefer at this time to place #2 braided sutures into the upper borders of the intact cuff posteriorly (teres minor or infraspinatus) and anteriorly (subscapularis or intact anterior fibers of the supraspinatus); these are used, after graft fixation, to repair the native cuff to the patch, side to side. Additionally, if there is any significant cuff tissue remaining medially, overlying the glenoid rim, it can be tagged with a #2 suture through a Neviaser portal, and

**Figure 7.** Massive and irreparable rotator cuff tear in the left shoulder of a 70 year old active male (view from posterolateral portal). (A) Note severely retracted massive tear of the superior cuff (SS and IS), with relatively normal articular cartilage both on the glenoid and the humeral head. (B) Even after extensive releases, the tendon stump is not

pulled up for better visualization of the superior glenoid (**Figure 9**).

adequately mobile for primary repair (HH—humeral head; G—glenoid).

formed for frayed and unstable cartilage flaps on the humeral head and glenoid.

changes (**Figure 7**).

138 Advances in Shoulder Surgery

as not to disrupt the coracoacromial arch.

Any residual soft tissue on the superior glenoid neck and greater tuberosity is removed using a motorized shaver and/or electrocautery wand. To maximize healing potential, the superior glenoid neck and greater tuberosity are burred down to bleeding bone.

Medial anchors are placed on the superior glenoid, approximately 2–4 mm medial to the rim, taking care to ensure good bone purchase and avoid intraarticular penetration. Anchors are placed as far anterior and posterior as possible to provide adequate spread and coverage for

**Figure 9.** (A) A penetrating suture passer is inserted through the Neviaser portal and is used to pass a tagging suture through the rotator cuff tendon stump. (B) The rotator cuff can then be pulled up, to allow better visualization of and instrumentation on the glenoid neck.

the medial graft fixation on the glenoid. Typically two anchors, each double loaded with a #2 braided suture, are placed, in the region between the 10 and 2 o'clock positions (**Figure 10A** and **B**), but a third anchor may need to be added for very large defects (**Figure 10C**). Appropriate trajectory for anchor placement should be confirmed prior to drilling, and can typically be achieved from the anterior, posterior and Neviaser portals.

On the humeral head, graft fixation is accomplished using a double row transosseous equivalent technique. Prior to graft passage, medial row greater tuberosity anchors placed, just lateral to the articular margin (**Figure 11**). We prefer to use anchors preloaded with #2 suturetape, non-sliding. As on the glenoid, two anchors are typically used, but a third one may be needed in large shoulders with large defects.

**7.4. Graft sizing and preparation**

the anterolateral portal).

been decorticated down to bleeding bone.

the measurement, and during subsequent graft fixation.

Once all the anchors are placed, distances between them are measured. First the anteriorposterior distance is measured for the glenoid anchors and tuberosity anchors. Then the medial-lateral distance is measured between the glenoid and tuberosity anchors, obtaining one measurement anteriorly, and one posteriorly. A calibrated probe is used to make these measurements (**Figure 12**). In our opinion, in order to obtain the graft size that will provide appropriate stabilizing affect without overtightening the glenohumeral articulation, the shoulder should be positioned in neutral rotation and approximately 20–30° of abduction for

**Figure 12.** Measuring distances between the anchors using a calibrated probe. (A) Distance between the glenoid anchors. (B) Distance between the medial GT anchors. (C) Distance between the glenoid and GT anchors (posterior, viewing from

**Figure 11.** Medial row greater tuberosity (GT) anchors are inserted. The anterior anchor is placed just posterior to the bicipital groove, and the posterior anchor is at the posterior-most extent of the exposed tuberosity. Both are pre-loaded with a suture-tape, and placed adjacent to the articular margin of the humeral head. Note how the surface of the GT has

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

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

141

**Figure 10.** Glenoid anchors. Each one is double-loaded with a #2 braided suture. Note the anchor position approximately 2–4 mm medial to the rim, and the trajectory of insertion (away from the articular cartilage). The spread between the anchors can be narrow (A) for smaller defects, or wide (B) for larger ones. Sometimes three anchors may need to be placed (C), for massive tears involving both the SS and IS. In this case, a Neviaser portal helps with proper trajectory for the middle anchor, as shown by the spinal needle.

**Figure 11.** Medial row greater tuberosity (GT) anchors are inserted. The anterior anchor is placed just posterior to the bicipital groove, and the posterior anchor is at the posterior-most extent of the exposed tuberosity. Both are pre-loaded with a suture-tape, and placed adjacent to the articular margin of the humeral head. Note how the surface of the GT has been decorticated down to bleeding bone.

#### **7.4. Graft sizing and preparation**

the medial graft fixation on the glenoid. Typically two anchors, each double loaded with a #2 braided suture, are placed, in the region between the 10 and 2 o'clock positions (**Figure 10A** and **B**), but a third anchor may need to be added for very large defects (**Figure 10C**). Appropriate trajectory for anchor placement should be confirmed prior to drilling, and can

On the humeral head, graft fixation is accomplished using a double row transosseous equivalent technique. Prior to graft passage, medial row greater tuberosity anchors placed, just lateral to the articular margin (**Figure 11**). We prefer to use anchors preloaded with #2 suturetape, non-sliding. As on the glenoid, two anchors are typically used, but a third one may be

**Figure 10.** Glenoid anchors. Each one is double-loaded with a #2 braided suture. Note the anchor position approximately 2–4 mm medial to the rim, and the trajectory of insertion (away from the articular cartilage). The spread between the anchors can be narrow (A) for smaller defects, or wide (B) for larger ones. Sometimes three anchors may need to be placed (C), for massive tears involving both the SS and IS. In this case, a Neviaser portal helps with proper trajectory for

typically be achieved from the anterior, posterior and Neviaser portals.

needed in large shoulders with large defects.

140 Advances in Shoulder Surgery

the middle anchor, as shown by the spinal needle.

Once all the anchors are placed, distances between them are measured. First the anteriorposterior distance is measured for the glenoid anchors and tuberosity anchors. Then the medial-lateral distance is measured between the glenoid and tuberosity anchors, obtaining one measurement anteriorly, and one posteriorly. A calibrated probe is used to make these measurements (**Figure 12**). In our opinion, in order to obtain the graft size that will provide appropriate stabilizing affect without overtightening the glenohumeral articulation, the shoulder should be positioned in neutral rotation and approximately 20–30° of abduction for the measurement, and during subsequent graft fixation.

**Figure 12.** Measuring distances between the anchors using a calibrated probe. (A) Distance between the glenoid anchors. (B) Distance between the medial GT anchors. (C) Distance between the glenoid and GT anchors (posterior, viewing from the anterolateral portal).

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 marking pen (**Figure 13**).

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 Arthex Passport) can be helpful.

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

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 posterior portals, while the graft is being passed.
