When is Superior Capsular Reconstruction Surgery Utilized?
In rotator cuff repair surgery, a torn rotator cuff tendon is surgically mobilized and then anchored to its normal bony attachment site. However, some patients present having severely torn most or all of their rotator cuff tendons. These massive tears did not happen overnight. These massive rotator cuff tears are severely retracted from where the tendon normally attaches. These massive tears are usually “acute on chronic” tears, wherein a patient has had a rotator cuff tendon tear and often never knew it as they lost strength very slowly over time and were able to compensate. However, usually there is then a small incident, such as a ground level fall, where the patient tears away some remaining tendon and the patient can no longer compensate. These patients present with severe shoulder pain and weakness. Many patients cannot even lift their arm overhead. An MRI of the shoulder often shows most of the rotator cuff tendons to be torn. Moreover, the supraspinatus (rotator cuff tendon on the top of the shoulder) is often severely retracted from its normal attachment site, being pulled back 3 inches or so. Historically, nothing could be done for these severely retracted supraspinatus tears as they would not stretch back to where they belong, and a surgeon could only repair those tendon tears that could be adequately mobilized and reattached to their attachment site. However, Superior Capsular Reconstruction (SCR) is a newer shoulder surgical technique that Dr. Cunningham has utilized in many patients who had a massive, severely retracted supraspinatus and/or infraspinatus rotator cuff tear that was not repairable.
What is done in Superior Capsular Reconstruction Surgery?
The rotator cuff normally holds the humeral head down in the glenoid or socket and powers the shoulder. However, in massive, retracted rotator cuff tears, the humeral head migrates upward partially out of the socket. In superior capsular reconstruction, a piece of donor tissue is anchored in the shoulder in place of the irreparable rotator cuff tendons. This piece of donor tissue helps hold the ball (humeral head) down in the socket (glenoid) of the shoulder, thus giving mechanical advantage to the remaining repairable or intact rotator cuff tendons. This along with repairing the other rotator cuff tendons can result in great pain relief as well as improvements in shoulder strength, usually restoring a patient’s ability to once again lift their arm overhead. In addition, SCR helps to slow the progression of glenohumeral arthritis.
Superior Capsular Reconstruction Surgical Technique
A superior capsular reconstruction is performed arthroscopically through small incisions called portals. A thick dermal allograft is fixated to the superior aspect of the glenoid as well as to the greater tuberosity, which is where the supraspinatus and infraspinatus normally attach to the humeral head. Biocomposite anchors and strong suture are used to fix the graft in place. The allograft then grows into the bony attachment sites and acts as a “trampoline” to reduce superior migration and restore anatomic function and maximize rotator cuff biomechanics.
What is the Goal of a Superior Capsular Reconstruction and Who is a Candidate?
Chronic massive rotator cuff tendon tears present a difficult orthopaedic problem, and until recently the only other solution was reverse total shoulder replacement. SCR is a biological alternative to replacing the shoulder joint with metal and plastic. This biological procedure is a great alternative for active patients or younger patients who would prematurely wear out a shoulder replacement.
Recovery from a Superior Capsular Reconstruction
Patients will find the recovery from superior capsular reconstruction surgery to be slower than that of a traditional rotator cuff tendon repair surgery, as it takes longer for the donor tissue to heal to the bone. Patients are placed in a sling for the first 10 weeks postoperatively and are only allowed to do passive shoulder range of motion during this time. Physical therapy is not typically initiated until after the 6 week postoperative appointment. The goal during the initial phase is to protect the surgical site and to allow for the allograft to start to heal to the bone. The patient will only perform pendulum exercises outside of the sling to reduce the risk of postoperative stiffness in the first 6 weeks. At 6 weeks, we allow the patient to do passive range of motion (PROM) under the supervision of a physical therapist. The physical therapist will take the arm and move it to improve motion without having the patient engage their shoulder musculature. At 10 weeks, the patient may begin slightly activating their muscle during PROM exercises, doing active assisted range of motion (AAROM). At 12 weeks postoperatively, they patient may discontinue the sling and begin active shoulder range of motion (AROM), lifting the arm under their own power. From this point, they may increase their motion actively as tolerated. They will begin gentle strengthening exercises at 14-16 weeks from surgery. Patients often have less pain than they had prior to surgery at 3 months from surgery. However, patients have lost strength in their shoulder over many years, so to get good strength back may take 1 year from the date of surgery.