Written by:
Thais Rondini Nucci | PT, CHT, B.Sc.PT
VHSF Fellow 2023
Despite significant advancements in technology and surgical procedures, there are instances where rotator cuff repairs cannot be successfully completed. Managing this subset of patients presents challenges as the available treatment options (anterior deltoid exercises, debridement, tuberoplasty, partial rotator cuff repair, amongst others) all come with their own set of difficulties.
In an effort to address irreparable rotator cuff tears, a new surgical technique known as Superior Capsule Reconstruction (SCR) was introduced by Mihata et al in 2012. Mihata initially utilized a fascia lata allograft patch, which was utilized to bridge the gap between the superior capsule and the greater tuberosity of the humerus, ultimately providing structural support and aiding in restoring shoulder function. This approach was later further promoted in the Western world by Hirahara and Burkhart, who adopted the use of extracellular matrix patches in the procedure.
Anatomy & function of the normal superior capsule
The normal superior capsule involves a thin sheet of collagen fibrils that span from the glenoid labrum to the humerus. It can cover a substantial portion of the greater tuberosity, potentially playing a crucial role in passive glenohumeral joint stability. Studies indicate that a tear or defect in the superior capsule can lead to increased humeral translation in various directions and heightened contact pressures at the coracoacromial arch.
Indications
Mihata's original paper outlines the indications for SCR, which include patients with an irreparable rotator cuff tear without severe bone deformity, significant superior migration of the humeral head, nerve or deltoid dysfunction, and infection. It is generally agreed among authors that SCR is suitable for individuals with symptomatic irreparable rotator cuff tears and a relatively normal glenohumeral joint, along with a functional deltoid. Some experts suggest that optimal outcomes are seen in patients with an intact subscapularis or a repairable tear in this muscle.
Techniques
There are various methods reported for conducting a Superior Capsule Reconstruction, which depend on factors such as the type of graft used, whether the procedure is done via open surgery or arthroscopically, the method of fixation on the glenoid and greater tuberosity, as well as the timing of anchor insertion in relation to graft passage. In the initial arthroscopic approach outlined by Mihata, a fascia lata autograft was employed, with a medial attachment to the glenoid using suture anchors, a lateral attachment to the greater tuberosity through a double-row technique and suture bridge, as well as an additional stabilization through suturing of the remaining infraspinatus and subscapularis.
Post-Op Protocol
Many authors follow a rehabilitation regimen akin to that used for large and massive rotator cuff repairs, typically involving a sling or abduction wedge for 4 to 6 weeks. While some may introduce passive motion early, the majority opt to delay this until after the removal of the sling to initiate progressive range of motion. Furthermore, most surgeons commence strengthening exercises around the 12-week mark, although some may opt to start this process as early as 8 weeks.
Over the last 7 years of my career, I had the pleasure of collaborating with Dr. Ian K. Y. Lo, a world-class surgeon who dedicates his practice solely to the treatment of shoulder conditions. Here in Alberta, he is one of the few - if not the only physician - who performs Superior Capsule Reconstructions thus my practice treating such patients has exclusively revolved around his specific post-protocol.
His approach is very conservative for approximately 4-9 months. This is due to the nature of the surgery and the time required for healing/remodeling of the free human dermal allograft utilized. When discussing his protocol with unfamiliarized therapists, I always like to remind them that these patients usually have had previous Rotator Cuff surgery (possibly a few of them) and that the expected outcomes are quite different than the traditional repairs.
In summary, his patients will be immobilized in a sling for 8 weeks, only being allowed elbow/ wrist/hand range of motion exercises. At 2 months, patients can be initiate on gradual passive ER, never pushing into pain. Other closed chain stretching is allowed at that time, including table slides & walk backs. Between 3-6 months, AAROM is started for flexion and ER. At that time, pulleys can be introduced as well as progressive supine forward elevation & punch program. Between 4-8 months, these patients are started on periscapular resistance training as well as biceps & triceps strengthening. Specific rotator cuff work is only initiated at 8-9 months post-op.
Outcomes
Mihata et al were the first to publish their clinical results on Superior Capsule Reconstruction, reporting outcomes in 24 shoulders with fascia lata grafts over a follow-up averaging 34 months, demonstrating notable enhancements in active abduction, external rotation, and American Shoulder and Elbow Surgeon (ASES) scores. Similarly, Hirahara et al presented findings from a study of 9 patients who underwent SCR with dermal allograft, showing improved ASES and VAS pain scores after a mean follow-up of 32.4 months. Recently, Pennington et al presented outcomes from 86 SCR patients using dermal allograft, indicating marked improvements in ASES and VAS scores after at least one year of follow-up (ranging from 16-28 months).
Summary
In conclusion, Superior Capsule Reconstruction has emerged as a valuable surgical technique for addressing irreparable rotator cuff tears, instability and overall dysfunction. Studies have shown promising outcomes, demonstrating improvements in range of motion, pain scores, and functional status. While SCR offers substantial benefits in restoring shoulder stability and function, the need for careful patient selection and ongoing research to optimize outcomes and minimize revision surgeries remains paramount in the field of shoulder reconstruction.
References:
Dimock, R. A. C., Malik, S., Consigliere, P., Imam, M. A., & Narvani, A. A. (2019). Superior Capsule Reconstruction: What Do We Know? Arch Bone Jt Surg, 7(1), 3-11
Hirahara, A. M., & Adams, C. R. (2015). Arthroscopic Superior Capsular Reconstruction for Treatment of Massive Irreparable Rotator Cuff Tears. Arthrosc Tech, 4(6), e637-e641
Mihata, T., McGarry, M. H., Pirolo, J. M., Kinoshita, M., & Lee, T. Q. (2012). Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med, 40(10), 2248-2255