■ Trending in Orthopedics
Superior Capsular Reconstruction
ROBERT U. HARTZLER, MD, MS; STEPHEN S. BURKHART, MD
abstract
Orthopedics.
C
urrently, arthroscopic superior
capsular reconstruction (SCR)
is arguably the “hottest topic” in
shoulder surgery. Orthopedic surgeons
have adopted SCR at an amazingly fast
pace, as evidenced by more than 10,000
cases worldwide from 2014 to the present
being reported by a single implant ven-
dor for this procedure (T. Dooney, Group
Product Manager, Upper Extremity, Ar-
threx, Inc, personal communication, July
2017). This is similar in magnitude (ie, a
few thousand per year) to the estimated
number of revision shoulder replacements
SEPTEMBER/OCTOBER 2017
or total elbow replacements that were per-
formed annually in the United States dur-
ing the previous decade.1 The enthusiasm
for SCR as a novel procedure testifies to
the difficulty of the problem it is intended
to address: an irreparable rotator cuff tear
in the patient poorly suited for alterna-
tive procedures, especially reverse shoul-
der arthroplasty. Additionally, anecdotal
evidence, early published clinical results,
and anatomical and biomechanical basic
science studies support SCR as a viable
surgical option for many patients who pre-
viously had few good choices. Yet, SCR
represents an important additional tool for
the shoulder surgeon and not a panacea for
every challenging rotator cuff tear. Many
questions remain about the best indica-
tions and techniques, the risks and com-
plications, and the cost-effectiveness of
this operation. In this article, the authors
review the available evidence concerning
arthroscopic SCR and attempt to place
this knowledge into the broader context of
the current state of shoulder surgery.
WHAT IS AN “IRREPARABLE” ROTATOR
CUFF TEAR?
In rotator cuff surgery, the term “irrep-
arable” has had an inconsistent definition
during the past few decades. For example,
when the authors2 previously published
about the results of partial rotator cuff
repair, they used the term irreparable to
mean “operatively irreparable,” indicat-
ing that an operative repair had been at-
tempted and no or only partial repair was
possible. Prior to around the year 2000,
the term irreparable was used similarly
The authors are from The San Antonio Or-
thopaedic Group, Burkhart Research Institute for
Orthopedics, San Antonio, Texas.
Dr Hartzler is a paid presenter for Arthrex,
Inc. Dr Burkhart is a paid consultant for and re-
ceives royalties from Arthrex, Inc.
Correspondence should be addressed to:
Robert U. Hartzler, MD, MS, The San Antonio Or-
thopaedic Group, Burkhart Research Institute for
Orthopedics, 150 E Sonterra Blvd, Ste 300, San
Antonio, TX 78258 (rhartzler@tsaog.com).
doi: 10.3928/01477447-20170920-02
271
■ Trending in Orthopedics
Figure 1: Superior capsular reconstruction was
performed in a right shoulder. A piece of fascia lata
folded into 4 layers was made rectangular in shape
for the graft. The graft was sutured superiorly to
the glenoid margin through the labrum and bony
rim. Subsequently, it was sutured to the stump of
the subscapularis anteriorly and to the stump of
the infraspinatus posteriorly. Finally, the proximal
stump of the long head of the biceps brachii was
sutured to the inferior margin of the fascial sheet
to avoid inversion of the grafted fascia Iata. The
procedure was performed to prevent superior mi-
gration of the humeral head, stabilize the humeral
head in the anteroposterior plane, and rely on the
deltoid for shoulder elevation. [Reprinted from the
Journal of Shoulder and Elbow Surgery, 21(7), A
Nimura, A Kato, K Yamaguchi, et al, The superior
capsule of the shoulder joint complements the
insertion of the rotator cuff, 867-872, Copyright
2012, with permission from Elsevier.]
by other authors.3-5 Subsequently, a subtle
change in meaning was adopted for the
term, and irreparable began being used to
describe a rotator cuff that was either (1)
predicted to be irreparable based on pre-
operative characteristics or (2) predicted
to have a poor outcome from rotator cuff
surgery, regardless of the possibility of
achieving actual intraoperative repair.6-8
The important point is the likelihood of
many patients with bad looking cuff tears
(primarily by imaging but also by history
or examination) being denied the chance
to improve with nonprosthetic operations,
272
particularly attempted arthroscopic repair.
The authors’9-12 intraoperative experience
has been that many seemingly irreparable
tears turn out to be easily reparable with
the right combination of reduction and/
or mobilization techniques. Thus, the
authors advocate that surgeons avoid the
term irreparable unless this determination
has been made intraoperatively.
How common are intraoperatively ir-
reparable rotator cuff tears? In 2004, of all
rotator cuff repairs performed by a single
surgeon (S.S.B.), 95% of tears were com-
pletely reparable (unpublished data). In
revision rotator cuff surgery13 and in mas-
sive cuff tears,14 the authors have found
that approximately 85% of tears are com-
pletely reparable. With the advent of SCR,
the authors’ referral practice for difficult
rotator cuff tears has greatly expanded.
So, it seemed reasonable to determine, in
the current era, how many primary, mas-
sive rotator cuff tears were operatively
irreparable with arthroscopic techniques
and whether irreparability actually could
be predicted with confidence based on
preoperative imaging. Of 86 massive,
primary rotator cuff tears, 76 (88%) were
fully reparable.15 Preoperative tangent
sign and Goutallier 3-4 fatty infiltration
of the supraspinatus were associated with
irreparability; however, most of the tears
with these preoperative characteristics
(70% and 57%, respectively) were fully
reparable intraoperatively. Thus, surgeons
should be cautious about presuming the
ability to correctly predict the intraopera-
tive irreparability of rotator cuff tears.
HISTORICAL ASPECTS OF SCR
Hanada et al16 first described a “supe-
rior capsular reconstruction” of the gle-
nohumeral joint (Figure 1) as a revision
operation in a paraplegic patient with an
irreparable supraspinatus tendon tear. De-
spite its stated rationale, the operation in
this original report failed to restore su-
perior stability, provide pain relief, or re-
store shoulder range of motion, and its re-
sult was deemed “unsatisfactory.” Nearly
20 years later, Mihata et al17-19 presented
both excellent clinical results and biome-
chanical data to support the previously
described concept of a fascia lata allograft
patch for the irreparable supraspinatus at-
tached medially to the glenoid—as a re-
construction of the superior capsule—in-
stead of to the irreparable tendon stump.
Subsequently, a variety of allograft tech-
niques20-25 have been described as modi-
fications of the arthroscopic procedure of
Mihata et al. In the authors’ practice, SCR
essentially has never been performed as
an isolated procedure. Rather, SCR repre-
sents an additional reconstruction that can
be added to one or more of the following:
partial rotator cuff repair, biceps tenotomy
or tenodesis, modified subacromial de-
compression, and coracoplasty.
SCR CLINICAL RESULTS
Published and unpublished early clini-
cal results for SCR have been promis-
ing.18,26-28 The original series by Mihata
et al17 with a fascia lata autograft showed
amazingly good clinical outcomes at
minimum 2-year follow-up in 24 shoul-
ders with irreparable large and massive
posterosuperior cuff tears that underwent
partial cuff repair and SCR. Improve-
ments in clinical outcome scores and
range of motion were dramatic (mean
American Shoulder and Elbow Surgeons
score: 24 preoperative to 93 postopera-
tive, P<.00001; mean elevation: 84° pre-
operative to 148° postoperative, P<.001),
particularly for the 83% of patients with
healed grafts on postoperative magnetic
resonance imaging. Perhaps of most in-
terest, of 5 patients who had severe loss
of active forward elevation (20° to 30°),
4 (80%) regained active overhead motion.
In the senior author’s (S.S.B.) person-
al, unpublished series of 97 arthroscopic
SCRs using dermal allograft (Arthroflex
301; Arthrex, Inc, Naples, Florida), 34
shoulders have minimum 1-year follow-
up. Only 2 patients (6%) have had further
surgery, both after traumatic reinjury. One
patient had revision SCR, and the other
COPYRIGHT © SLACK INCORPORATED
 ■ Trending in Orthopedics

was revised to a reverse shoulder arthro-

plasty. The remaining 32 patients have
all reported satisfaction with the surgery,
and there have been no complications.
The mean visual analog scale pain score
(0 to 10) decreased from 4.6 preoperative
to 0.7 postoperative (P<.0001). The mean
American Shoulder and Elbow Surgeons
score improved from 51 preoperative to 88
postoperative (P<.001). The mean subjec-
tive shoulder value score improved from
37% preoperative to 87% postoperative
(P<.001). The mean active forward eleva- A B
tion improved from 140° preoperative to Figure 2: The attachment area of the articular capsule. The articular capsule has been removed from the
168° postoperative (P<.001). Six patients humerus. The area outlined by white dotted lines indicates the attachment area of the articular capsule.
with the most severe dysfunction (in the The area outlined by black dotted lines indicates the insertion area of the supraspinatus (star), infraspina-
tus (circle), tendinous portion (square), and muscular portion of the teres minor (arrowheads). Superior
authors’ opinion, unarguable true pseudo-
aspect (A) and posterior aspect (B) of the humerus. Abbreviations: Ant, anterior; HH, humeral head; Lat,
paralysis) had a mean forward elevation lateral; Sup, superior. [Reprinted from the Journal of Shoulder and Elbow Surgery, 21(7), A Nimura, A
of 26° preoperative and 157° postopera- Kato, K Yamaguchi, et al, The superior capsule of the shoulder joint complements the insertion of the rota-
tive, with all regaining active overhead tor cuff, 867-872, Copyright 2012, with permission from Elsevier.]
use of the arm at 1 year postoperatively.

ANATOMICAL AND BIOMECHANICAL
RATIONALE FOR SCR
In the authors’ practice, strong justifica-
tion for early adoption of SCR has come
from basic science research that supports
the operation as an anatomical and biome-
chanically sound shoulder reconstruction.
In fact, the role of the superior capsule of
the shoulder was likely underappreciated
by surgeons in the past.29 The superior cap-
sular complex30 has intricate anatomical
features.31,32 Blending of fibers occurs both
between the cuff tendons and from tendon
into the superior capsule.31,33 Thus, the su-
perior capsule serves to transmit force from
the cuff musculature to bone and to rein-
force the tendon insertions. In this manner,
the superior capsular complex contributes
to active glenohumeral stability.
Careful anatomical studies have re-
vealed a larger insertional footprint of
the superior capsule (Figure 2) than had
previously been recognized—up to 5 to 9
mm in medial–lateral width at the anterior
and posterior margins.34,35 The footprint
of direct supraspinatus and infraspina-
tus tendinous insertion to tuberosity cor-
respondingly is smaller (and of different
geometry) than has been traditionally de-
scribed.34-36 The origin and midsubstance
(including cable vs crescent dominant37)
patterns of the fibers of the superior com-
plex also exhibit significant variability.30,31
The important point is that the superior
capsular complex is a robust structure
that contributes to passive glenohumeral
stability.38 Reconstruction of the superior
capsule restores superior stability more
effectively than tendon patch grafting.39
CLINICAL RATIONALE FOR SCR,
INDICATIONS, AND ALTERNATIVES
Previously described open and ar-
throscopic procedures for irreparable
posterosuperior rotator cuff tears have in-
cluded debridement, biceps tenotomy or te-
nodesis, partial rotator cuff repair, subacro-
mial decompression, tuberoplasty, tendon
reconstruction with bridging graft, tendon
transfer, and reverse shoulder arthroplasty.
With the emergence of SCR as an addi-
tional option for the irreparable cuff, it is
necessary to address the question of when
SCR should be clinically indicated.
One strong indication for SCR is in the
patient with pseudoparalysis with supe-
rior instability who is a poor candidate for
a reverse shoulder arthroplasty because of
age or desired activity level. The authors
have found revision and partial rotator cuff
repair without SCR to be less reliable in
reversing pseudoparalysis than complete,
primary repair or partial repair in conjunc-
tion with SCR.40 Therefore, an irreparable
cuff tear with pseudoparalysis (especially
when less than 6 months in duration) with
or without a failed prior repair has become
a key indication for SCR in the authors’
practices, especially for younger patients.
Because a low rate of complications has
been reported for SCR, it can be viewed
as a salvage option that does not “burn any
bridges” for the typical patient with this
challenging problem.
Partial rotator cuff repair (and associ-
ated procedures, such as biceps tenotomy)
remains a good option for elderly patients
desiring pain relief who have preserved
overhead function of the shoulder. Many
of these patients have medical comor-
bidities or poor bone stock, which would
make adding SCR an unwise choice with
limited marginal benefit for the patient.
On the other hand, the authors have found

SEPTEMBER/OCTOBER 2017 273

■ Trending in Orthopedics
that patients who have radiographic or ar-
throscopic evidence of proximal humeral
migration and a chronic acromiohumeral
fulcrum (with preserved motion) will have
excellent pain relief with SCR. The au-
thors suspect that, in these cases, the graft
provides an improvement in pain relief
over partial cuff repair, a topic that is cur-
rently under study in their group.
Reverse total shoulder arthroplasty as
a planned, primary procedure in lieu of
arthroscopy for massive rotator cuff tears
without glenohumeral arthritis has a role
in specific cases with a combination of pa-
tient and disease factors. These factors in-
clude older age (preferably older than the
seventh decade), sedentary lifestyle, mul-
tiple failed cuff repairs, chronic pseudo-
paralysis (>6 months), recurrent shoulder
instability or frank anterosuperior escape
(subcutaneous), inflammatory arthritis,
and extensive fatty infiltration of multiple
cuff muscles on magnetic resonance im-
aging. When several of these are present,
particularly with chronic pseudoparalysis,
reverse shoulder replacement (with or
without tendon transfer) presents a reli-
able option for pain relief and restoration
of overhead function.41-43
PREOPERATIVE ASSESSMENT IN
MASSIVE CUFF TEARS
Physical Examination
The definition and the management of
severe shoulder dysfunction (pseudopa-
ralysis or pseudoparesis) continue to be
contentious topics in shoulder surgery.44
For many, a commonly used definition of
pseudoparalysis—inability to raise the arm
above shoulder level (90°) with full passive
range of motion and pain eliminated—is
too broad because it includes shoulders
that have limited elevation because of
painful weakness (ie, pseudoparesis).44,45
The debate over the terminology of severe
dysfunction (elevation pseudoparalysis
vs pseudoparesis) may seem trivial, but it
does highlight one important concept about
the shoulder: variable combinations of in-
stability and weakness (and pain) may lead
274
to the inability to raise the arm. It has been
proposed by expert opinion44 that a dys-
functional shoulder with predominance of
anterosuperior instability has no option ex-
cept reverse shoulder arthroplasty but that
a centered and weak shoulder remains a
candidate for other procedures (an opinion
with which the authors disagree).
In considering this matter, two impor-
tant questions arise. First, what degree of
irreparable cuff pathology can be salvaged
with joint-preserving surgery (arthroscopic
reconstruction with SCR), and what degree
requires prosthetic reconstruction (reverse
shoulder arthroplasty with or without ten-
don transfer)? Second, should this deter-
mination be made by physical examination
alone? For the sake of argument, assume
that the physical examination can inform
the surgeon that superior instability is the
main factor leading to severe dysfunction
(in this case, true pseudoparalysis). Does it
then follow that a reverse shoulder arthro-
plasty is the only way to restore stability?
Is it impossible (or so unlikely as to be im-
possible) that a soft tissue reconstruction
could serve the same function—the resto-
ration of superior restraint?
In the authors’ opinion, it is a mistake
to try to simplify the surgical decision-
making process such that a straight line
can be drawn from physical examination
to choice of operation.44 It may be the
case that severe shoulder dysfunction (eg,
shoulder shrug with minimal active mo-
tion, anterosuperior escape, lag signs) is
associated with other factors (advanced
age, poor tissue quality, large tear size,
tear chronicity) that would discourage
joint-preserving surgery. However, the au-
thors have successfully restored function
(Video) using an arthroscopic reconstruc-
tion for many patients with severe dys-
function who had been told by shoulder
surgeons that they had no option except
for a reverse total shoulder arthroplasty.
Thus, the authors have seen that adequate
passive, superior stability can be restored
by SCR in clinical practice and in the bio-
mechanics laboratory.19 Therefore, there
is no one physical examination finding
that can substitute for thorough consid-
eration of all patient and disease factors
in considering a difficult rotator cuff tear,
which in large part makes the entire de-
bate over the terminology of the physical
examination an exercise in futility.
Imaging
Preoperative radiographs are required
in the assessment of massive cuff tears for
several reasons. Evidence of significant
joint arthrosis (large osteophytes and joint
space narrowing) should prompt consider-
ation for reverse total shoulder arthroplas-
ty. However, the authors have performed
SCR with good results for patients with
only early signs of arthrosis (small margin-
al osteophytes and preserved joint space).
Loss of the greater tuberosity (proximal
humeral femoralization) from a chronic
acromiohumeral fulcrum often indicates
an irreparable supraspinatus. On the other
hand, proximal humeral migration is in no
way a contraindication to attempting an ar-
throscopic repair, in the authors’ opinion.46
In fact, SCR has been shown to increase
the acromiohumeral interval.
As discussed, magnetic resonance im-
aging poorly predicts the intraoperative
reparability of massive cuff tears. Further-
more, the authors have shown good clinical
results in repairing cuffs with high-grade
fatty infiltration.47 Because the repaired
tendons in these patients had poor-quality
muscles, perhaps the mechanism for im-
provement was the restoration of passive
restraint of the joint via the capsule, similar
to SCR.21 Thus, although it is incontrovert-
ible that poor muscle quality should be
a factor in the decision-making process
when treating rotator cuff tears, the authors
discourage surgeons from using this as-
sessment as the primary factor or as a con-
traindication to an arthroscopic repair.
SURGICAL TECHNIQUES FOR SCR
Repair or reconstruction of the massive
rotator cuff tear, with or without SCR, re-
quires a significant amount of surgical
COPYRIGHT © SLACK INCORPORATED

time, patience, and technical skill. The au-
thors usually allow 2 to 4 hours for these
operations, and they ensure that an expe-
rienced team (first assistant, lead surgical
technician, and secondary technician) will
be present for each case. The anesthesiol-
ogy team and the patient should be pre-
pared for the significant swelling that can
occur intraoperatively and in the immedi-
ate postoperative period.
As discussed above, proper intraopera-
tive assessment of the massive rotator cuff
tear will guide the surgeon as to which
type of reconstruction to perform. Some
manner of partial repair (subscapularis
and infraspinatus–teres minor) is almost
always possible in the massive cuff tear,
and this should not be neglected even
though it adds time to the case. With SCR,
the surgeon now has an additional option
for reconstruction of a cuff that will just
barely reach the bone bed—and likely
also has tissue loss, stiffness, or poor
quality. When to add SCR in the setting of
what otherwise would have been a tenu-
ous repair (Video) is currently an unan-
swered question. However, the authors’
early experience with SCR leads them to
suspect that reconstruction of the capsule
will prove to be beneficial as a supplement
to tenuous cuff repairs in the future.
Surgical Sequence
The authors consider the sequencing of
steps in complex rotator cuff surgery to be
a critical part of performing a successful
reconstruction. In particular, the specific
technical steps of the graft (SCR proper)
are performed as part of the final portion
of the reconstruction. The overall order of
steps in the operation is as follows: (1) di-
agnostic arthroscopy; (2) treatment of the
biceps and subscapularis repair; (3) sub-
acromial work (bursectomy, acromioplas-
ty, tuberosity preparation); (4) assessment
of the posterosuperior cuff and interval
slides; (5) partial repair of the posterosu-
perior cuff; (6) SCR proper; (7) side-to-
side repair of the graft to the posterior cuff
and to the rotator interval comma tissue
SEPTEMBER/OCTOBER 2017
(if present) anteriorly; and (8) side-to-side
repair of the remnant of the supraspinatus
tendon to infraspinatus over the top of the
graft, if feasible.
Setup and Materials
Lateral decubitus remains the authors’
preferred position for complex shoulder
arthroscopic procedures, primarily because
they have found that visualization is im-
proved in this position. Coincidentally, the
best arm position for graft sizing and fixa-
tion during the SCR proper48 is equivalent to
the authors’ standard position during lateral
arthroscopic shoulder surgery (20° of for-
ward flexion and 20° to 30° of abduction),
thus helping to prevent the surgeon from
inadvertently performing the reconstruction
with an inadequately tensioned graft.
Although Mihata et al17 originally per-
formed SCR with autograft approximate-
ly 6 to 8 mm thick, the authors49 prefer a
dermal allograft reconstruction. Allograft
lowers the morbidity of the operation for
the patient and reduces operative time.
The authors’ preferred graft (Arthroflex
301) has a 3.0-mm nominal thickness
and excellent biocompatibility and me-
chanical strength. A thick graft has certain
biomechanical and structural advantages
(spacer effect).48 However, the authors
have seen excellent results with a 3.0-mm
dermal graft, which has other advantages
such as being readily available, having
no morbidity, being easier to shuttle, and
more easily accommodating a cuff repair
over the top of the SCR when feasible.
Treatment of the Biceps
The authors prefer a high biceps teno-
desis at the articular margin50 for younger
patients and a tenotomy for older, more
sedentary patients. A high tenodesis anchor
can be used for subscapularis repair or as
an anterior medial row humeral SCR an-
chor (SwiveLock Tenodesis; Arthrex, Inc).
Management of the Subscapularis
The subscapularis should be repaired if
its tendon fibers have been detached from
■ Trending in Orthopedics
the bone. The subscapularis has a criti-
cal role in both passive and active shoul-
der stability, and neglected subscapularis
tears can cause persistent pain after rota-
tor cuff surgery. Subscapularis tears are
particularly critical to repair in the setting
of pseudoparalysis and proximal humeral
migration.46 A variety of arthroscopic re-
pair techniques have been described and
should be familiar to the surgeon who
would undertake an SCR reconstruction.
Subacromial Work
After any necessary work on the biceps
and subscapularis, the authors proceed
with preparation of the subacromial space.
The authors preserve the coracoacromial
ligament in massive cuff surgery, but lim-
ited anterior and lateral acromioplasties
often help to smooth the undersurface,
relieve impingement on the graft, and im-
prove visualization. Bony landmarks such
as the spine of the scapula and acromio-
clavicular joint should be clearly exposed.
Bursectomy should proceed until the mus-
cle tendon units are clearly seen.
Intraoperative Assessment in Massive
Cuff Tears
The surgeon should take care in every
posterosuperior rotator cuff repair to as-
sess the mobility of the entire length of
the lateral margin of the tear in multiple
directions.51 The authors perform this as-
sessment using a tendon grasper through
a lateral portal while viewing from a pos-
terior or posterolateral portal with a 70°
arthroscope. Again, this step is not per-
formed until the space has been cleared
of the bursa and “bursal leaders,” or bands
of fibrous scar tissue between the cuff and
the internal deltoid fascia. Often, massive
L-shaped or reverse-L cuff tears seem ir-
reparable when attempting to reduce the
tear from medial to lateral but reach the
bone easily simply by finding and reduc-
ing the corner of the L in an oblique direc-
tion.52
Once a tear has been determined to be
massive and contracted (immobile),52 the
275
■ Trending in Orthopedics
A B
Figure 3: A FiberWire (Arthrex, Inc, Naples, Florida) suture placed into the irreparable supraspinatus
(SS) tendon is retrieved through Nevaiser’s portal (A). Exposure of the superior glenoid (G) (B) is greatly
improved by pulling the tendon superiorly (blue arrows) (C).
Figure 4: Correct anterior glenoid anchor place-
ment ensures that the graft will constrain the hu-
meral head by creating a “monk’s hood” effect. This
anchor position is at the coracoid base, anterior to
the vertex of the superior glenoid. (Reproduced
with permission from Burkhart SS, Brady PC, De-
nard PJ, Adams CR, Hartzler RU. The Cowboy’s
Conundrum: Complex and Advanced Cases in
Shoulder Arthroscopy. Philadelphia, PA: Wolters
Kluwer; 2017.)
surgeon should perform anterior and pos-
terior interval slides,10,12 as this can often
dramatically improve tendon mobility. In
particular, a posterior interval slide can
improve the partial repair of the infraspi-
natus, even if the supraspinatus remains
irreparable. Finally, after a posterior in-
terval slide, retrieval of a supraspinatus
traction suture through Nevaiser’s portal
can accomplish retraction of the supraspi-
natus stump (Figure 3) and dramatically
improve the visualization of the superior
glenoid when SCR will be performed
(Video).
Partial Posterior Rotator Cuff Repair
Rarely will the surgeon encounter a
posterior cuff tear without any achiev-
276
C be “debulked” with electrocautery to al-
able partial repair or advancement of
the remaining infraspinatus–teres minor
tendon. Superior capsular reconstruction
has been proposed to improve the func-
tion of intact muscle tendon units in the
shoulder by stabilizing the glenohumeral
fulcrum via passive constraint. However,
SCR adds no motor function, per se, to the
shoulder. Therefore, to maximize external
rotation function, the surgeon should not
neglect partial repair of the posterior cuff.
Poor-quality tissue is commonly encoun-
tered in this setting; when it is found, the
surgeon should consider a load-sharing
rip-stop construct53,54 for the partial repair.
Glenoid Preparation and Anchor
Placement
Work on the glenoid side represents a
technical challenge during SCR proper and
has certain pitfalls. Anterosuperolateral,
modified Nevaiser, and accessory anterior
and posterolateral portals may be neces-
sary and should be created outside-in using
a spinal needle.55 A good angle of approach
for the anterior glenoid anchor can usually
be obtained using the anterosuperolateral
portal. As long as it has not been placed
too medially, Nevaiser’s portal may have
a good angle for the middle or posterior
glenoid anchors. Dangers of using this
portal for anchor placement include intra-
articular penetration (middle) or skiving
posteriorly. A posterolateral portal is often
necessary for posterior anchor placement.
The superior glenoid bone should be
cleared of soft tissue using electrocautery
and then lightly freshened with a burr on
reverse or ring curette to provide a heal-
ing surface for the graft. Nevaiser’s portal
can be helpful for performing this work.
When the superior labrum remains well
attached and does not technically impede
the glenoid work, it can be left attached.
However, a hypertrophic labrum should
low better apposition of the graft to bone.
The anterior anchor should be placed
anteriorly enough to ensure a “monk’s
hood” effect of the graft. This anchor po-
sition is at the coracoid base, anterior to
the vertex of the superior glenoid (Figure
4). The posterior anchor is placed at the
anterior margin of the intact (or repaired)
posterior cuff. When the length of the gle-
noid side of the graft will be greater than
30 to 35 mm, the authors recommend add-
ing a third anchor. Usually, the quality of
glenoid bone allows push-in anchors (eg,
SutureTak; Arthrex, Inc). Double-pulley,
knotted mattress, or knotless mattress su-
ture patterns have all been employed suc-
cessfully for glenoid fixation.
Humeral Preparation and Anchor
Placement
The greater tuberosity should be metic-
ulously prepared to maximize the chances
of allograft to bone healing in SCR. Elec-
trocautery is used to remove all soft tis-
sue remnants, and then light burring on
reverse freshens the surface and removes
any “charcoal” appearance of the bone.
The use of cannulated suture anchors and
microfracture of the tuberosity allows
marrow elements to reach the graft–bone
interface. Two humeral anchors (4.75-mm
SwiveLock) are placed medially just off
the articular surface at the anterior and
posterior margins of the planned graft.
Three anchors are required for very large
grafts (>35 mm on the lateral, or humeral,
dimension of the graft).
Graft Sizing and Preparation
After all anchors have been placed (typi-
cally 2 to 3 glenoid and 2 to 3 humeral), the
dimensions between anchors are measured
COPYRIGHT © SLACK INCORPORATED
 ■ Trending in Orthopedics

and recorded as a template on the back

table (Video, Figure 5). The final graft
size should have 5 mm of extra tissue on 3
sides (medial, anterior, and posterior) and
10 mm extra laterally to cover the greater
tuberosity. Small holes can be punched for
the humeral sutures (FiberTape and Fiber-
Wire safety sutures; Arthrex, Inc) using the
anchor inserter (Video, Figure 5).

Graft Shuttling and Glenoid Fixation

Placing the prepared graft into the
shoulder and achieving initial fixation is
best accomplished by using the glenoid
anchor sutures for shuttling. This strategy
has several variations that the authors have
used successfully depending on the choice
of glenoid anchor and the size of the graft.
Several technical pearls can help to pre-
vent complications during this technically
challenging portion of the case.
First, a 10- to 12-mm flexible can-
nula (PassPort; Arthrex, Inc) should be
placed through the lateral portal to facili-
tate suture management and graft passage
through the skin and deltoid. Often, the
authors cut the cannula along one side so
that it can be removed during graft pas-
sage, if necessary. Second, the humerus
anchor sutures are retrieved sequentially
and held in the “inferior” quadrants of
the cannula by the assistant. Third, the
glenoid sutures are retrieved sequentially
and held in the “superior” quadrants of the
cannula by the assistant.
Next, the glenoid sutures are sequen-
tially passed through the graft, usually
using a Scorpion suture passer (Arthrex,
Inc). If the glenoid anchors are knotless
SutureTaks, the sutures are passed as
horizontal mattress sutures. If standard
double-loaded SutureTaks are used, the
FiberWires can be placed as simple su-
tures using mulberry knots on the sub-
acromial side of the graft or as a medial
double-pulley suture (Video).56 The hu-
meral sutures are then brought through the
prepunched holes in the graft (Figure 6).
Finally, the graft is brought into the
shoulder either through the cannula or
A B
Figure 5: The allograft is prepared on a back table (A). The distances between anchors (X1, X2, Y1, and
Y2) and the size of the graft are recorded on a template (B) to ensure that the graft is cut precisely and in
the correct orientation.
A B
Figure 6: A double-pulley technique allows the graft to be pulled into the shoulder (blue arrows) (A). A
ZipLine pushing instrument (Arthrex, Inc, Naples, Florida) (green arrow) can be slid along the sutures
behind the graft to push the graft into the shoulder. A percutaneous suture can be used to pull the graft
(red arrow) into the shoulder (B). (Reproduced with permission from Burkhart SS, Brady PC, Denard PJ,
Adams CR, Hartzler RU. The Cowboy’s Conundrum: Complex and Advanced Cases in Shoulder Arthros-
copy. Philadelphia, PA: Wolters Kluwer; 2017.)
percutaneously following cannula re- seated and the sutures have been finally
moval around the sutures (via the pre- tensioned (Video). In a knotted glenoid
placed split). A combination of pushing technique (simple sutures or double-pul-
and pulling of the graft helps to deliver ley suture), the surgeon must sequentially
this atraumatically. The graft can be retrieve and tie these sutures.
pushed via the ZipLine pushing instru-
ment (Arthrex, Inc) (Figure 6). The Humeral Fixation
surgeon slides the instrument along the Once graft shuttling and medial fixa-
sutures (glenoid and humeral) behind tion have been completed, the graft is
the graft. The graft can be pulled inward fixed on the humeral side. Mihata et al17
via the medial double-pulley suture (if mentioned only one graft tear in their ini-
present) (Figure 6) or via a luggage tag tial series of SCR, and the mode of failure
suture retrieved out of Nevaiser’s portal was not reported. Early results from the
(Figure 6). Burkhart Research Association of Shoul-
In the knotless glenoid technique, the der Specialists group28 indicate that the
graft is secured as soon as it has been fully humerus is the most common site of graft

SEPTEMBER/OCTOBER 2017 277

■ Trending in Orthopedics
Figure 7: A medial double-pulley construct (ar-
row) should be routinely created for fixation of the
graft to the humerus. The safety sutures are tied
together between the 2 medial humeral SwiveLock
anchors (Arthrex, Inc, Naples, Florida) to increase
the strength of the humeral fixation of the allograft.
failure. The authors hypothesize that shear
forces between the humerus and the acro-
mion place the humeral side at greater risk
than the glenoid. Thus, although straight-
forward in comparison to the glenoid, hu-
meral fixation is a technically important
part of SCR. To increase the mechanical
strength of the construct, the authors rec-
ommend routinely tying a humeral medial
double-pulley using the SwiveLock safety
sutures (Figure 7) in addition to fixing the
criss-crossed FiberTape sutures laterally
to 2 knotless SwiveLocks. Furthermore,
for grafts greater than 35 mm in length
on the lateral side (humeral dimension),
3 SwiveLock anchors should be used for
fixation to the humerus.
Side-to-Side Graft Suturing
Routine suturing of the posterior mar-
gin of the SCR graft to the intact posterior
cuff using 2 or 3 free No. 2 FiberWire su-
tures should be performed to improve the
biomechanical stability of the construct.57
Commonly, some rotator interval capsular
tissue (comma tissue58) remains anteriorly
and should be used for anterior side-to-
side suturing. The authors do not recom-
mend suturing the SCR graft anteriorly to
the subscapularis tendon.
Platelet-Rich Plasma
Autologous conditioned plasma (plate-
let-rich plasma) (ACP; Arthrex, Inc) is
278
injected into the joint at the graft–bone
junction prior to closing the arthroscopy
portals. Although the authors are unaware
of specific evidence to support its use in
SCR, it helps to reduce postoperative pain
after rotator cuff repair and has a theoreti-
cal benefit for graft healing.
POSTOPERATIVE REHABILITATION
The authors base their rehabilitation
protocol after SCR on the following ob-
servations: (1) stiffness after arthroscopic
rotator cuff repair requiring reoperation
is uncommon59,60; (2) when postopera-
tive stiffness does require reoperation,
the repair typically is healed and restora-
tion of motion with a capsular release is
routinely successful60; (3) tendon to bone
healing cannot be assumed until approxi-
mately 3 months postoperatively61; and
(4) the strength of the allograft cannot be
assumed to be adequate to withstand even
low loads until at least 3 months postop-
eratively.62
For the first 6 weeks after surgery, the
authors employ sling immobilization with
a small abduction pillow. After 6 weeks,
active assisted range of motion begins
with rope and pulley exercises.60 Critical-
ly, active overhead motion and strength-
ening are not allowed until 4 months
postoperatively, when adequate time for
allograft incorporation and cuff healing
has passed. High-demand (acceleration)
activities such as throwing, golfing, and
weight lifting are restricted for 1 year
postoperatively.
For many patients undergoing SCR, the
operation will be their last opportunity for
joint preservation. Thus, the authors pri-
oritize healing of the reconstruction over
achieving early range of motion. From
both psychological and practical points
of view, reoperation for stiffness with a
healed construct is a much easier problem
to handle than a failed reconstruction.
CONCLUSION
Superior capsular reconstruction should
be thought of as a complex but highly use-
ful tool for the shoulder surgeon to use in
treating selected patients with irreparable
rotator cuff tears. Rotator cuff tear irrepa-
rability cannot be accurately predicted,
should not routinely be assumed by the
surgeon, and should only be diagnosed
after a careful diagnostic arthroscopy. Pa-
tients with risk factors for irreparability
and who might benefit from reconstruction
of the superior capsule should be counseled
about the operation as an additional, joint-
preserving procedure that can be added if
complete rotator cuff repair is not possible
intraoperatively. Superior capsular recon-
struction adds biological, passive, supe-
rior constraint to the glenohumeral joint,
thereby optimizing the rotator cuff force
couples and improving joint kinematics.
Superior capsular reconstruction is techni-
cally demanding, but early adopters of the
procedure are supported by its excellent
anatomical, biomechanical, and short-term
clinical results.
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