Arthroscopic Superior Capsule Reconstruction Failed Rotator Cuff Repairs

Failed rotator cuff repairs present a unique and frustrating problem for both patients and surgeons. An in depth review of the rotator cuff and massive rotator cuff tears is available here.

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More on Superior Capsule Reconstruction

Patients with large, massive and previously failed rotator cuff repairs that have enough rotator cuff available for successful mobilization and anatomic repair to the footprint have been helped greatly utilizing an arthroscopic reinforcement graft technique. Patients with tears that involve significant loss of rotator cuff tissue (infection, atrophy, fatty infiltration, rotator cuff repairsmultiple surgeries, etc.) are faced with a difficult problem. Historically, depending on other associated individual patient factors, techniques to address this circumstance have included partial repair with bridging graft, partial repair alone or combined with a tendon transfer, and reverse total shoulder replacement among others. A recent study by Dr. Teruhisa Mihata and colleagues sheds some new light on shoulder anatomy and function and offers an alternative option for patients with an irreparable supraspinatus rotator cuff tear. Dr. Mihata noted that in Japan the reverse total shoulder replacement was not approved for use until April 2014 so it was important to try and find an alternative solution for this debilitating problem. One of the crucial roles of the superior rotator cuff and capsule is to limit the amount of superior or proximal translation of the humerus. This depressor function allows the other muscles of the shoulder girdle, particularly the deltoid muscle, to work more effectively.

Humerus Migration

In other words, as the humerus migrates or translates proximally the deltoid muscle shortens, thereby losing its mechanical advantage, which weakens it significantly and results in the patient not being able to raise the arm up overhead. In an elegant experiment, Mihata and colleagues tested the amount of humerus translation at different positions with the supraspinatus and superior capsule intact and then also tested this parameter again with these cut and with different reconstruction parameters, including a bridging graft, a superior capsule reconstruction, and a combined bridging graft and superior capsule reconstruction.

Superior Capsule Reconstruction Surgery

The bridging graft scenario did improve the translation towards normal, but only slightly. Interestingly, both the superior capsule reconstruction and the combined superior capsule reconstruction and bridging graft scenarios restored the translation parameters to nearly the intact situation. This sheds exciting and welcome new information on the crucial role of the superior capsule in preventing superior translation of the humerus and preserving the mechanical advantage for the deltoid. In our experience, patients always do better if the native anatomy can be preserved and restored. So in our practice, when previously we may have considered a bridging graft technique, as a result of this new information, we now believe patients will regain more functional benefit by instead choosing an arthroscopic superior capsule reconstruction technique combined with repair of the anterior and posterior rotator cuff. There are many possible options available for patients facing the daunting situation of a failed shoulder surgery. Patients are increasingly traveling across the country – and around the world – to seek out the best solutions for their surgery. The solution to your failed arthroscopic shoulder surgery is no longer limited by your location. Contact us for a second opinion.

Author
Vivek Agrawal, MD

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