Superior capsular reconstruction using human acellular dermal allograft has emerged as a promising surgical treatment option for massive irreparable rotator cuff tears. The reconstructed superior capsule acts as a restraint to superior humeral migration during active shoulder abduction. It also helps to balance the force couples necessary for overhead shoulder function. In this chapter, we describe our all-arthroscopic surgical technique for performing a superior capsular reconstruction utilizing a dermal allograft. We find the superior capsular reconstruction most useful in relatively younger, symptomatic patients with chronic massive irreparable rotator cuff tears who are deemed not to be candidates for a reverse total shoulder arthroplasty. Furthermore, we reserve this procedure for those patients with an intact or repairable subscapularis tendon, in addition to Hamada 1 or 2 changes to the glenohumeral joint.
Keywords: dermal allograft, massive irreparable cuff tear, superior capsular reconstruction
? The patient is positioned in the beach chair position.
? All the bony prominences are adequately padded.
? A pneumatic arm holder is utilized during the procedure.
The procedure can be performed with standard anterior, posterior, and lateral subacromial portals. Percutaneous stab incisions are utilized for anchor insertion as well as for docking sutures. Specifically, the Neviaser portal can be useful for placement of the glenoid anchors.
? The shoulder joint is entered via a standard midglenoid posterior portal. A diagnostic arthroscopy is performed. We typically release the long head biceps tendon at its insertion on the glenoid with a biter and perform a subpectoral biceps tenodesis. The subscapularis is repaired if it is torn. All other intraarticular pathology is addressed as needed.
? The subacromial space is then initially entered from the posterior portal. A midlateral portal is then established. A subacromial decompression is performed. Bursal- and articular-sided releases of the rotator cuff are performed. The mobility of the cuff is evaluated after the releases are performed. We make every effort to repair the native rotator cuff if possible.
? If the tear is determined to be irreparable, we proceed to perform a superior capsular reconstruction. Even in this case, we make every effort to balance the joint and minimize the amount of graft required by repairing the posterior rotator cuff using standard anchor repair techniques.
? The superior glenoid neck immediately medial to the labrum is prepared. We elect not to resect the superior labrum, but to create a bleeding bony bed medially using cautery and a burr. Care is taken not to go more than 1 cm medial to the glenoid edge to avoid injury to the suprascapular nerve.
? Two 3-mm glenoid anchors bio-composite or PEEK (Suture-Tak, Arthrex, Naples, FL) are inserted either through the standard anterior, posterior, or Neviaser portals. Alternatively, knotless Suture-Tak anchors may be utilized to reduce the risk of suture entanglement. Care is taken to direct the anchors away from the glenoid to avoid inadvertent penetration into the joint.
? The greater tuberosity is prepared in a standard fashion using a burr. Two 4.75 mm anchors (SwiveLock anchors with FiberTape sutures, Arthrex) are inserted through stab incisions into the medial aspect of the rotator cuff footprint on the greater tuberosity. It is critical to place the anchor as anteriorly as possible to maximize the coverage of the humeral head and reduce the risk for humeral superior escape. The anterior anchor is inserted just posterior to the biceps groove. The posterior anchor is inserted close to the infraspinatus insertion.
? A measuring device is utilized to measure the medial-to-lateral as well as anterior-to-posterior distances between each of the sets of anchors. Prior to measurement, the shoulder should be placed in 20-30 degrees of abduction, neutral flexion and neutral rotation to appropriately tension the graft.
? A 10 mm cannula (PassPort, Arthrex) is inserted through the midlateral portal.
? The sutures from the four anchors are brought out through the midlateral portal. The sutures are held separately and clamped to avoid tangling.
? The graft (ArthroFLEXacellular dermal allograft, Arthrex, 3 mm thickness) is prepared on the back table. The distances previously measured are marked on the graft material using a marking pen. The dimensions are extended by 5 mm over the medial, anterior, and posterior aspects to prevent suture cut-through. The dimension is extended 10-15 mm over the lateral aspect to recreate the anatomical lateral footprint. The graft is then cut based on these dimensions.
? Utilizing a suture passer device, the sutures limbs from the anchors are passed through the graft. This can be facilitated by using the empty anchor driver for the SwiveLock anchor (Arthrex, Naples, FL) to punch the holes in the graft.
? A double-pulley technique is then utilized. One limb from each of the glenoid anchors is tied over a switching stick. The leading edge of the graft is grasped with a tissue grasper. The graft is advanced into the lateral cannula by pulling on the two untied suture ends from the glenoid anchor and by pushing it in through the cannula with a grasper. Tension is held on the remaining sutures as the graft is shuttled into the cannula.
? Viewing from the posterior portal, a switching stick is inserted through the lateral portal to flatten out the graft.
? The sutures from the individual medial greater tuberosity anchors are retrieved via their respective stab incisions through which they were initially inserted. This reduces the risk for suture entanglement.
? The remaining sutures from the two glenoid anchors are tied down to secure the medial edge of the graft.
Video 24.1 Surgical demonstration of all-arthroscopic superior capsular reconstruction with dermal allograft.
? A extraneousness-equivalent technique is then utilized to secure the graft to the greater tuberosity.
? The suture limbs from the medial tuberosity anchors are tied in a double-pulley fashion to further secure the graft to the medial aspect of the greater tuberosity. Alternatively, these sutures may be used to close the respective intervals between the graft material and the native intact rotator cuff.
? Side-to-side sutures are placed between the posterior aspect of the graft and the remaining infraspinatus and tied down. Similarly, the interval between the graft material and the subscapularis tendon should be closed (? Video 24.1).
? Care should be taken during preparation of the glenoid to prevent injury to the suprascapular nerve.
? Care should be taken while inserting the glenoid anchors to prevent inadvertent penetration into the joint.
? During retrieval of glenoid and medial tuberosity sutures through the lateral cannula as well as during the passage of the graft into the shoulder, the suture limbs are held separately and clamped. This prevents tangling of the sutures.
? Anchor pull-out can sometimes be encountered during this procedure especially during the passage of the graft. Care is taken to be gentle during graft insertion.
? An abduction sling is utilized in the postoperative period.
? Initial rehabilitation focuses on protected range of motion (ROM) with an aim to prevent stiffness and to improve glenohumeral and scapulothoracic biomechanics.
? Progressive active and active-assisted ROM from the supine position is begun at 6 weeks postoperatively.
? Progressive strengthening is started at 3 months postoperatively.
? The first biomechanical studies on the superior capsule of the shoulder were performed by Ishihara et al1 They found that sectioning of the superior capsule resulted in increased humeral translation in all directions.
? Mihata et al2 in their biomechanical studies found that reconstructing the superior capsule of the shoulder resulted in complete restoration of the superior translation of the humerus.
? These studies formed the basis of performing superior capsular reconstruction in patients with massive irreparable rotator cuff tears. The reconstructed superior capsule was believed to act as a superior restraint to the humerus in these patients.
? Mihata et al3 reported their clinical findings on 24 patients treated with a superior capsular reconstruction with an average follow-up period of 34 months. The mean age of the patients in their study was 65 years. They found that forward elevation in their patients increased from 84to 148. External rotation increased from 26 to 40. The American Shoulder and Elbow Surgeons scores increased from 23 to 92.
? Other studies4,5,6,7,8 on superior capsular reconstruction with acellular dermal allograft showed similar results at 2- to 4-year follow-up with significant improvement in patient-reported outcome measures, decrease in pain, as well as improvement in ROM. More recent clinical studies have focused on the patient-related factors such as the degree of glenohumeral arthritis that can adversely affect clinical outcomes.9
? Histological studies performed by Snyder et al10 suggest that there was host cellular infiltration as well as organization of new tissue along the margins of the graft in the postoperative period. This forms the basis of performing a margin convergence of the native infraspinatus to the edge of the graft.
? Mihata et al11 determined the effect of acromioplasty on superior capsular reconstruction in their biomechanical studies. They found that performing an acromioplasty in the superior capsular reconstruction decreased the subacromial contact area and had no effect on the subacromial contact pressures. They concluded that acromioplasty may help to decrease the postoperative risk of abrasion and tearing of the graft beneath the acromion. Hence, acromioplasty can be safely performed in patients undergoing a superior capsular reconstruction.
? Recent cadaveric studies have reported on the use of 3 glenoid-sided anchors to reduce the ultimate load-to-failure of the graft on the glenoid.12
? In conclusion, superior capsular reconstruction can be utilized as an option for relatively younger patients with symptomatic massive irreparable cuff tears who are deemed not to be candidates for a reverse total shoulder arthroplasty.
 Ishihara Y, Mihata T, Tamboli M, et al. Role of the superior shoulder capsule in passive stability of the glenohumeral joint. J Shoulder Elbow Surg. 2014; 23(5):642?648
 Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012; 40(10): 2248?2255
 Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013; 29(3):459?470
 Bond JL, Dopirak RM, Higgins J, Burns J, Snyder SJ. Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: technique and preliminary results. Arthroscopy. 2008; 24(4): 403?409.e1
 Gupta AK, Hug K, Berkoff DJ, et al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012; 40(1):141?147
 Wong I, Burns J, Snyder S. Arthroscopic GraftJacket repair of rotator cuff tears. J Shoulder Elbow Surg. 2010; 19(2) Suppl:104?109
 Modi A, Singh HP, Pandey R, Armstrong A. Management of irreparable rotator cuff tears with the GraftJacket allograft as an interpositional graft. Shoulder Elbow. 2013; 5:188?194
 Petri M, Greenspoon JA, Moulton SG, Millett PJ. Patch-augmented rotator cuff repair and superior capsule reconstruction. Open Orthop J. 2016; 10:315?323
 Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft. Arthroscopy. 2018;34(1):93?99
 Snyder SJ, Arnoczky SP, Bond JL, Dopirak R. Histologic evaluation of a biopsy specimen obtained 3 months after rotator cuff augmentation with GraftJacket Matrix. Arthroscopy. 2009; 25(3):329?333
 Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical effects of acromioplasty on superi- or capsule reconstruction for irreparable supraspinatus tendon tears. Am J Sports Med. 2016; 44(1):191?197
 Pogorzelski J, Muckenhirn KJ, Mitchell JJ, et al. Biomechanical comparison of 3 glenoid-side fixation techniques for superior capsular reconstruction. Am J Sports Med. 2018;46(4):801?808