Update 2016: Reinforcement Grafting versus Superior Capsule Reconstruction

Arthroscopic superior capsule reconstruction has become a valuable addition to our arsenal as patients with complex shoulder problems continue to value and seek out the best possible treatment options regardless of distance.

The Evolution of Arthroscopic Rotator Cuff Repair: from Reinforcement Grafting to Superior Capsule Reconstruction 

Click here to watch a video about Superior Capsular Reconstruction Shoulder Surgery - How To + Review.

After reviewing Dr. Mihata’s publication and having a chance to meet him to discuss the results, we added Arthroscopic Superior Capsular Reconstruction to our arsenal and wrote about our indications and early results (less than 2 years). While we have written extensively on rotator cuff tearsarthroscopic rotator cuff repair, and failed rotator cuff repair, our current technique for arthroscopic rotator cuff repair including superior capsular reconstruction really represents lessons learned from performing thousands of arthroscopic rotator cuff repairs, including superior capsule reconstruction, glenoid bone grafting and reinforcement grafts, for our own patients combined with the research, successes and failures of the worldwide community of shoulder surgery. Dr. Stephen Burkhart, one of the pioneers of arthroscopic shoulder surgery, recently reviewed the history and future of arthroscopic rotator cuff repair from his perspective. In that article, Dr. Burkhart made some excellent points that every patient considering shoulder surgery should ponder:

“An irony related to technological advancement in surgery is that the more technically advanced the surgery becomes, the more skill is required. This fact is completely at odds with the public’s perception that technological advances make procedures easier. In arthroscopic rotator cuff repair, the surgeon must look, feel, and be aware to a greater degree than in open surgery.

Edward Tenner, in his book Why Things Bite Back, described the burden of the practitioner of any advanced technology as the burden of craft. The burden of craft is the inherent demand on all craftspeople, but particularly surgeons, to “up our game” if we are to be successful in our craft. For arthroscopic rotator cuff repair, the burden of craft requires patience, attention to detail, and the ability to work in a virtual space. Not everyone has these skills. But anyone who wants to practice in this discipline has an obligation to learn the skills required, and then to teach them to others and assess how well they are being applied.

Amazingly enough, there are still rotator cuff repair “deniers” who confidently assert from the podium that a large percentage of massive cuff tears cannot be repaired and that, even if they can be repaired, they do not have the biological potential to heal. Given the disparity in surgeons’ skills and results, however, one must ask whether poor results are a consequence of a biological deficit in the patient, or of a skill deficit in the surgeon…But the reason for choosing a specific type of surgery for a given problem should not be that it is easiest for the surgeon; it should be that it is best for the patient. The surgeon should start by asking what procedure he or she would want if the roles were reversed—if the surgeon were the patient with the massive rotator cuff tear. If a surgeon does not have the skill set for the best procedure for a particular patient, he or she is obligated to send that patient to a surgeon who does have the skills…Patients vastly prefer the minimally invasive arthroscopic approach, and through online searches can easily identify who can offer an arthroscopic solution.

To reproducibly achieve successful arthroscopic repair of massive rotator cuff tears, the surgeon must know advanced techniques, including subscapularis repair techniques, interval slides, and self-reinforcing constructs.

“It’s a poor carpenter who blames his tools.” This 18th-century English proverb is as true today as it was 300 years ago. The tools for arthroscopic cuff repair exist, and they are excellent. The burden of craft is the surgeon’s burden and obligation. As surgeons, we must accept that obligation and the responsibility of that burden.”

Reinforcement Grafts and Bridging Grafts

Superior Capsular Reconstruction represents a natural evolution from the techniques we have been using for reinforcement grafts and bridging grafts for complex rotator cuff tears for many years. Benjamin Franklin’s advice that “an ounce of prevention is worth a pound of cure” is as true today as in 1736 when he was speaking about fire safety in Philadelphia. This also has direct application for shoulder surgery, because, as Dr. Burkhart outlined, every new technique creates a new burden for orthopedic surgeons to improve and adapt or refer the patient to the best surgeon possible. Because advanced arthroscopic techniques like superior capsule reconstruction are very difficult to learn, many implant companies have attempted to help surgeons by designing implants that no longer require learning the skills required to tie arthroscopic knots. Unfortunately, as we all know “There ain’t no such thing as a free lunch.

Advanced Shoulder Arthroscopy

In this context, this means that without learning the detailed anatomy and techniques that advanced shoulder arthroscopy requires, including the ability to restore and repair multiple areas of the shoulder with precision and balance, the necessary judgement and skill to reliably achieve the best outcomes with superior capsule reconstruction also cannot be gained. Furthermore, each new device and technique introduces additional new possible complications.

Dr. Ernest Amory Codman performed and popularized rotator cuff repairs more than a century ago, and until the advent of advanced arthroscopic techniques, rotator cuff repairs were performed with bone tunnels, sutures, and knot tying. This is why Dr. Burkhart also noted:

“My initial bias toward arthroscopic cuff repair was that a transosseous bone tunnel technique not only would be possible but would be superior to suture anchor fixation. In fact, my first 2 patents with Arthrex were for instrumentation for an arthroscopic transosseous repair technique. I tested my hypothesis with 2 successive biomechanical studies. The first examined cyclic loading of bone tunnel repairs, and the second examined cyclic loading of anchor-based repairs. Evaluating the data from these 2 studies, I was surprised to find that anchor-based repairs were significantly stronger than bone tunnel repairs. In addition, anchors shifted the weak link from the bone–suture interface to the tendon-suture interface; in essence, anchors optimized bone fixation by shifting the weak link in the construct to the tendon. I was then completely convinced of the superiority of suture anchors over bone tunnels, and that conviction has become even stronger over the years.”

This has been the conviction that has driven a significant growth in the shoulder surgery implant industry with literally hundreds of different types of suture anchor devices available in the marketplace today. However, after starting in practice in 2001 and quickly developing a shoulder surgery practice treating many failed and complex rotator cuff repairs, I began to have doubts about using an ever increasing number of anchors. Whether metal as shown in the figure, or later with resorbable anchors, these devices take up significantly valuable real estate in that they reduce the amount of available bone for rotator cuff healing and footprint restoration. So the first natural break from convention towards my own personal technique for arthroscopic rotator cuff repair was to utilize triple loaded anchors and place them well beyond the rotator cuff footprint in order to better neutralize the pull of the rotator cuff tendons as well as preserve the valuable space for rotator cuff healing.

Arthroscopic Rotator Cuff Repair

Empirically, I have always believed that suture number determines the strength of rotator cuff repair and this was ultimately confirmed with this study. So the next step was to find a way to increase the number of sutures needed for the most secure arthroscopic rotator cuff repair without having to use a large number of anchors. This pursuit led me back to the gold standard technique of drilling bone tunnels to increase the number of sutures and combine it with the placement of one or two distal anchors to restore the rotator cuff pattern and neutralize the pull of the rotator cuff tendons. This hybrid technique which we call the trans-osseous tension band technique of arthroscopic rotator cuff repair now has more than 10 years of experience and outstanding results. The next step was to gradually develop a way to utilize this technique for arthroscopic rotator cuff repair with graft reinforcement . One of the additional benefits we realized with this hybrid technique is that unlike the now most widely recommended double row or similar techniques that create spot welds, the true transosseous technique is load sharing and avoids the risk of medial rotator cuff failure.

Subscapularis Tears

So in our practice, arthroscopic superior capsule reconstruction, arthroscopic rotator cuff repair with reinforcement graft, and arthroscopic rotator cuff repair, including subscapularis tears , all require the same level of attention to detail and surgical steps utilizing our hybrid transosseous tension band technique of arthroscopic rotator cuff repair. Patients are increasingly traveling across the country – and around the world – to seek out the best solutions for their healthcare problems. The solution to your shoulder problem is no longer limited by your location. Do your research and choose a shoulder surgeon with extensive expertise and experience with arthroscopic superior capsule reconstruction.

 

Author
Vivek Agrawal, MD

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