Superior Capsular Reconstruction: An Alternative for a Recurrent Irreparable Supraspinatus Tendon Tear
A 61-year-old male patient is still in pain 6 months after surgery for a rotator cuff tear. Will a new type of procedure offer pain relief and restore the function of his left shoulder?
Eric Secrist, BS; Max Greenky, MD; and Sommer Hammoud, MD
The authors have no disclosures relevant to this article.
Rotator cuff muscles compress the humeral head against the glenoid. This is the primary source of dynamic stability in the glenohumeral joint, with additional static support provided by the glenohumeral ligaments, labrum, and negative intra-articular pressure.
Chronic rotator cuff tears result in: 
- Tear enlargement
- Tendon retraction
- Tendon shortening
- Fatty infiltration of the muscle body
This complicates future attempts to repair the defect.
Between 6.5% and 22.4% of rotator cuff tears are irreparable, meaning that even with the use of advanced arthroscopic mobilization techniques, they cannot be repaired back to the rotator cuff footprint on the greater tuberosity of the humerus in a tension-free manner. 
Patients with irreparable rotator cuff tears and concomitant glenohumeral arthritis (and even some without arthritis) commonly undergo reverse total shoulder arthroplasty.  Positive results have been achieved with this procedure in older patients, but have not been replicated in younger patients. 
There are other surgical options involving attempts to partially restore the functionality of the rotator cuff, but they do not have a high success rate in patients with irreparable tears. 
A 61-year-old male patient presents for his 6-month follow-up visit after undergoing arthroscopic primary rotator cuff repair with biceps tenodesis to treat a left rotator cuff injury. He sustained the injury at work when he opened a coin press machine.
The patient had initially made progress with physical therapy, but it has not been sustained. At 6 months after surgery, he has persistent pain and weakness.
- Active forward elevation: 140° external rotation in neutral position of 60°; internal rotation of T10
- 4/5 strength in supraspinatus and infraspinatus muscles
- Negative belly press
- Rotator cuff re-tear
- Impingement syndrome
- No superior migration of humeral head
Magnetic Resonance Imaging
- Progressive areas of high-grade partial-thickness glenoid cartilage loss, with focal full-thickness cartilage loss and associated subchondral marrow edema at the superior glenoid
- No significant degenerative changes in the humeral head
- Grade 2 fatty infiltration of supraspinatus muscle based on the Goutallier Classification
- Operative changes related to the rotator cuff repair (Figure 1)
- Failure of the supraspinatus tendon repair, with retraction to the level of the glenoid
- Intact infraspinatus and subscapularis tendons
Figure 1. MRI showing a 15.5- mm defect at the greater tuberosity footprint (top). The arrow shows the anchor eyelet embedded within the lateral edge of the supraspinatus tendon (bottom).
- Full-thickness, retracted, recurrent rotator cuff tear of the left shoulder
After the diagnosis and treatment options were explained to him, the patient agreed to undergo a left shoulder arthroscopic superior capsular reconstruction with allograft patch.
- The patient was placed in the beach-chair position on the shoulder table. He received an interscalene nerve block and general anesthesia.
- A posterior portal was established 2 cm distal and 1 cm medial to the posterolateral acromial border. Additional anterior arthroscopic portals were established under direct visualization.
- Diagnostic arthroscopic examination revealed prior biceps tendonesis; intact subscapularis, infraspinatus, and teres minor tendons; and a full-thickness retracted tear of the supraspinatus tendon to the level of the glenoid.
- Sutures and suture anchors remained in the humeral head, while an eyelet of the SwiveLock anchor was embedded in the supraspinatus tendon edge at the level of the glenoid (Figure 2).
- The old suture and suture anchors were removed and the greater tuberosity footprint was prepared for repair using an arthroscopic burr.
- Traction was placed on the supraspinatus tendon, revealing very little medial-to-lateral mobility. At this point, it was determined that the supraspinatus tendon could not be repaired. A superior capsular reconstruction was planned.
- The glenoid rim was prepped by removing soft tissue with radiofrequency ablation and using a burr to abrade the area, creating a bed of bleeding bone. This area was then used as the medial attachment of the allograft.
- Two single-loaded Bio-SutureTak anchors were placed in a typical spread along the superior glenoid, just medial to the superior labrum. Nevaiser’s portal was utilized to place these anchors (Figure 3).
- Two double-loaded 5.5-mm anchors were placed in the medial aspect of the greater tuberosity footprint.
- To plan for the appropriate graft size, an arthroscopic measuring probe was used to measure the distance between the anchors placed in the superior glenoid, the distance between the anchors placed in the medial aspect of the greater tubersity footprint, and the distance between the greater tuberosity and superior glenoid (Figure 4). The arm was in a natural resting position at side in the McConnell shoulder positioner.
- The measurements acquired arthroscopically were used to cut an appropriately sized patch of decellularized dermis allograft.
- Small holes were made in the corresponding portions of the allograft.
- The sutures were systematically retrieved and passed through the allograft.
- One suture limb from each glenoid anchor were tied together outside of the joint. The free limbs were used to shuttle the graft into the joint and reduce the graft to the glenoid.
- A King-Fisher grasper was used to advance the graft into the glenohumeral space.
- The 2 remaining medial glenoid sutures were tied, completing fixation to the glenoid.
- The graft was fixed to the greater tuberosity using a knotted suture bridging repair technique.
- Using a suture passer, FiberWire suture was passed through the anterior edge of the infraspinatus and the allograft patch to create a side-to-side repair posteriorly (Figure 5).
- Good tension was achieved on the superior capsule reconstruction allograft. The shoulder was internally and externally rotated, revealing excellent coverage.
Figure 2. Arthroscopic image from the posterior viewing portal shows the bare footprint left by the supraspinatus tendon re-tear (top). The intact infraspinatus tendon (IS) is also shown here. Arthroscopic image from the posterior viewing portal shows the anchor eyelet embedded in the lateral edge of the supraspinatus tendon at the level of the glenoid (bottom).
Figure 3. Arthroscopic image through the lateral viewing portal shows a spinal needle (red arrow) placed through Nevaiser’s portal to determine the appropriate trajectory for insertion of the glenoid anchors.
Figure 4. Arthroscopic image from the lateral viewing portal shows the glenoid anchors (red arrows) in place. The edge of the supraspinatus tendon (SS) is seen medial to the anchors. The anterior border of the infraspinatus tendon (IS) can also be seen to the right of the image.
Figure 5. Arthroscopic image from the lateral viewing portal shows the acellular dermal allograft sewn to the anterior edge of the infraspinatus (red star). The graft and infraspinatus are demarcated by dashed line.
Postoperative Rehabilitation Protocol (abbreviated)
Phase 1: Protected range of motion (ROM), 0 to 8 weeks
- Sling utilized when not performing exercises
- Immediate elbow, forearm, and finger ROM out of sling
- Passive external rotation and supine forward flexion at 6 weeks
Phase 2: Progressive ROM, 8 to 12 weeks
- Discontinue sling
- Start progressive active assisted ROM and active ROM
- Avoid resisted training or strengthening
Phase 3: After 12 weeks
- Progressive rotator cuff strengthening; advance as tolerated
Most Recent Follow-up
- Full passive and active ROM of the left shoulder at the 6-month follow-up visit
- Strength graded as 5/5
Surgeons currently have many options to treat irreparable rotator cuff tears. Reverse total shoulder arthroplasty is commonly performed in older patients or in patients with glenohumeral arthritis. In younger patients without glenohumeral arthritis, however, this operation results in decreased functionality and a high complication rate. 
Other surgical options for these patients include:
- Partial repair of the rotator cuff
- Arthroscopic debridement with a biceps tenotomy or tenodesis
- Patch augmentation
- Patch bridging
- Tendon transfer
Each of these surgical options has unique issues, however. 
A new surgical option for patients with irreparable rotator cuff tears is superior capsular reconstruction, which involves attaching an allograft from the greater tuberosity of the humeral head to the superior glenoid neck.
With this procedure, the surgeon is able to: 
- Anatomically replace the superior capsule, which is damaged in irreparable rotator cuff tears
- Reduce superior humeral translation
- Restore force couples necessary for dynamic shoulder function
- Preserve the patient’s ability to undergo future operations
Superior capsular reconstruction was originally developed Dr. Terihusa Mihata.  In the original study of 23 patients, the average ASES score improved from 23.5 to 92.9 following the operation. At 2 years of follow-up, 83.3% of patients had not suffered a graft tear or rotator cuff re-tear. 
Mihata et al  used a fascia lata autograft in their study. For the patient in this case report, we used an acellular dermal allograft instead, as it is: 
- Thicker than a fascia lata autograft
- Does not involve graft harvest or donor site morbidity
- Provides a scaffold for neovascularization
- Carries minimal immunologic risk
Cadaveric research on the biomechanical effects of superior capsular reconstruction conducted by Mihata et al  revealed that superior capsular reconstruction decreased subacromial peak contact pressure, although it did not restore the glenohumeral compression force lost due to rotator cuff tear.
The addition of side-to-side suturing between the allograft, the anterior edge of the infraspinatus tendon, and the underlying shoulder capsule increased the superior stability of the shoulder joint by decreasing superior glenohumeral translation, Mihata et al found.  This side-to-side suturing technique was used in our case report.
Superior capsular reconstruction is less invasive than reverse shoulder arthroplasty, and short-term results indicate it may allow patients with an irreparable rotator cuff tear to maintain shoulder function with their native joint without compromising future surgical options. Mid-term and long-term clinical results are still needed to confirm these positive results.
Eric Secrist, BS; Max Greenky, MD; and Sommer Hammoud, MD, are from The Rothman Institute, Philadelphia, Pennsylvania.
Sports Medicine Section Editor, Rothman Institute Grand Rounds
- Goutallier D, Postel J, Bernageau J, Lavau L, Voisin M. Fatty muscle degeneration in cuff ruptures: Pre-and postoperative evaluation by CT scan. Clin Orthop. 1994;304:78-83.
- Anley CM, Chan SK, Snow M. Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder. World J Orthop. 2014;5(5):557-565.
- Harreld KL, Puskas BL, Frankle M. Massive rotator cuff tears without arthropathy. J Bone Joint Surg Am. 2011;93(10):973-984.
- Ek E, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: Results after 5 to fifteen years. J Shoulder Elbow Surg 2013;22:1199-1208.
- Berth A, Neumann W, Awiszus F, Pap G. Massive rotator cuff tears: Functional outcome after debridement or arthroscopic partial repair. J Orthop Traumatol 2010;11:13-20.
- Mihata T, Lee TQ, Watanabe C, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2013;29(3):459-470.
- Tokish JM, Beicker C. Superior capsule reconstruction technique using an acellular dermal allograft. Arthroscopy Techniques. 2015;4(6):e839.
- Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon. Am J Sports Med. 2016;44(6):1423-1430.