Name: The Superior Capsular Reconstruction: What Have We Learned?
Uploaded: 2017-10-09T00:00:00Z
Channel: Arthrex
Description: Chris Adams, MD, (Naples, FL) lists the top 10 lessons he has learned about Superior Capsular Reconstruction over the last few years. He also shares the preliminary clinical results gathered by the BRASS group.

<p>Chris Adams, MD, (Naples, FL) lists the top 10 lessons he has learned about Superior Capsular Reconstruction over the last few years. He also shares the preliminary clinical results gathered by the BRASS group.</p>

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VPT1-00934-EN | B | The Superior Capsular Reconstruction: What Have We Learned?

Christopher Adams

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The Superior Capsular Reconstruction: What Have We Learned?

So this is going to be a summary of all the key points that we've learned over the last few years regarding the superior capsular reconstruction. So where did it all come from? Well, it was originally described by Miyata in Japan. And this is a classic example of necessity is the mother of invention in Japan. As of it wasn't until three years ago where the reverse shoulder replacement was available for them, so they didn't have any other options, let's say five, six years ago. What is it? Well, it's an anatomic reconstruction of the superior capsule, the glenohumeral joint that biomechanically restores the normal fulcrum of the shoulder. Now there's an anatomic distinction between a bridging patch graft and a superior capsule reconstruction. It has to do with the medial attachments. You'll notice on the medial side with the bridging patch graft it's attached to the remnant cuff, whereas a superior capsular reconstruction it's attached directly to the glenoid. Now there has been over the last three last three years, over 10,000 skiers performed with a tremendous buzz in the news of what Steve Burkhart calls this biologic reverse. Now, here are some of the key points. Starting with number one, it's very important to mobilize the cuff, which is a good investment to make. You see here I'm freeing up the scar tissue in the lateral gutter. But you want to free up all this scar tissue to see. First and foremost, can you fix the rotator cuff? Because in a lot of cases you're able to to fix it. This one we're not able to. We're freeing up the scar tissue. This is with the Apollo RF right on top of the cuff, freeing it up. And it's a little bit of sculpting here, sculpting it out. But this can take a lot of time. Sculpting it out, getting it freed up. Now we're on the undersurface of the cuff again, freeing up the scar tissue. So it's a tremendous amount of time here. Now we're looking through a lateral portal. You can see here we got a bleeding Bursa leader, which is connecting the scar tissue from the internal deltoid fascia to the to the cuff. We're removing that and again continuing to free it up. But very important to free up that scar tissue. Number two superior labrum in the biceps will the biceps is often gone from the index procedure. However, it's not that it's typically torn or unstable. Then you have to decide do you want to do either a biceps? Tenodesis or a tenotomy. In most cases, you want to leave the superior labrum. You can see in this case we're preparing the footprint just medial to the superior labrum. However, if it's a big bulky labrum, you can certainly debride it. Number three, about ten years ago, Nicole Polier published her article on the superior capsule. And we found that after removal, the rotator cuff, the superior capsule is indeed a distinct anatomic structure, which is very important to the normal function of the shoulder. Now, Peter Millett was the lead author in this study, where we looked at the safety of glenoid anchors for the CRx. What we did was inserted three beef pins arthroscopically into 12 cadaveric shoulders, and all three anchor positions were safe with respect to the suprascapular nerve. And we noticed that the minimum distance to the suprascapular nerve was that posterior superior anchor and was at least ten millimeters away. So so they're safe using those three anchors at anchors at ten, 12 and two. And you see, when this demonstration were arthroscopically confirming it, in this case, the 12:00 anchor, that's the suprascapular nerve at the tip of that probe. It's about 15mm away. So that was just a cadaveric demonstration, just showing how far away the suprascapular nerve is. Now, typically all the anchors and this is interesting are rotated when you insert them. They tend to be rotated posteriorly on a clock face. So instead of this is a left shoulder instead of being ten, 12 and two, they're more at 11, 1230 and three. So you have to resist that urge. You have to go into the case knowing that, especially that anterior superior anchor, that 10:00 anchor, so to speak, in this case, because you don't want anterior superior escape. So you really have to make sure that you come down as low as you can on the front there. And then arguably the most important point from, from this study, other than the safety, was this superior anchor trajectory. And we found this in the lab that that's the that's the one that's most at risk for glenoid face perforation. So if you stare at the red arrow Just a suggestion. Go a little bit more medial. And as you can see in this live patient we moved the anchor position more medial not only decrease the chance of glenoid face perforation but also decrease the chance of converging on the other two anchors. So just a nice important pearl there. Number four, we all know with every construct there's a weak link with the superior capsular reconstruction. It's on the glenoid. Now, we've all done all different types of ways of fixing it. On the glenoid side. You just saw Peter demonstrate one way. Double pulley. Suturetak, LabralTape and PushLock. We've done them all. But we wanted to show you a relatively new advancement in glenoid fixation. So there's a cadaveric demonstration, a left shoulder. You can see we made a large rotator cuff tear. We placed the three spinal needles in representing the ten, 12 and 2:00 positions prepared the bone bed, as you can see there on the glenoid and also on the greater tuberosity. And what we're going to be doing is showing you three knotless suture tax. So we've inserted the drill guide here. I like to tap it with a mallet. Kind of keeps it nice and stable. And I do that for that for all my instability. Decrease the chance of it skiving inserting the knotless SutureTak take the little black tab away here, and then you just pull it straight out. Now to speed things up, we're now going to show you the 12 inch. The 2:00 anchors magically are done. And now we're going to go over to the greater tuberosity side and place in either a 4.75 or 5.5 Biocomposite SwiveLock anchor preloaded with either FiberTape or TigerTape. So the beauty of this technique is you're placing all five anchors ahead of time. You're going to pass all the sutures through the graft later on. And in my opinion, I just think it makes it much easier. So number five is the CRx just a spacer? Well, this is a study that true Mahata did in Tylee's lab that was published in Agsm in 2012. And they looked at this, they looked at superior translation. And if you look at one, that's the intact state. There's normally three millimeters of superior translation with proximally loading the humerus with a massive rotator cuff tear. It's off the charts. Bridging patch graft did not restore the normal superior restraint, whereas the superior capsule reconstruction did. And biomechanically. That's what we're doing. The CRx restores the fulcrum back to the glenohumeral joint so that you go from this preoperatively to this postoperatively. Now, this is a follow up to the first study looking at anatomic safety of placing the three anchors in the superior glenoid. Peter Millett again took the lead on this study, where we looked at different fixation techniques at the superior glenoid. And this particular technique. We found that with the three knotless, suture techs had very good ultimate load to failure with minimal variation, which is obviously very important. Number six, we know that proper tension in the graft is arguably the most important step in the operation. This is something that Gus and I have been studying at UConn, trying to figure out that optimal arm position. Can't tell you that right now. However, I can tell you, most surgeons seem to be when they're measuring between the anchors with a dermal graft or tensioning the graft in about 30 to 40 degrees of abduction. However, from our own SOS AWS data. This is patient reported outcome data. In the short term, it doesn't seem to make a clinically a difference at this point. But again, we're still very early on in this process. Now back to the demonstration. So now we're going to be using the CRx measuring device. And this makes it very convenient for measuring the distances between the anchors. So you've got to have first the proper arm position. Once you've got the proper arm position you calibrate it to zero on the guide there as you see there, we did with a snap. And then you could bring it over to that anterior anchor on the greater tuberosity. It's nice because you can go across an arc with this measuring device. We measure it 20mm. In this case mark it on the back table. Then we go to that posterior superior anchor on the glenoid. And you can see in this particular case it's 30mm. Now we're done with that anchor. Now we're going to go to that anterior superior anchor. This is the knotless SutureTak. Calibrate it back to zero again and then go over to the greater tuberosity. Happens to be in this case 30mm again. And now we can go across the arc of the glenoid. We're going to measure 15 and 15 again, so 15 between each of the anchors on the glenoid side. But again, the most important measurements are medial, lateral, measuring the distances here, 15 between each of them, adding in 5 to 10mm of extra graft all the way around. Now we're putting the little poke holes where the greater tuberosity, that medial row, those anchors, the sutures are going to go through. And then adding on on the greater tuberosity side where you're going to do the SpeedBridge, just adding an extra centimeter, 12mm of extra tissue. Little A for anterior. And then we're going to cut the excess graft away. Now where the FiberTape are going to slide through, you take that SwiveLock driver. And that's where you can make it easier on yourself so that the tape slide nice and easy. Just you can put little two little poke holes. Now you can see anterior is the front. They're also showing the sterile towels so you don't drag the skin flora into the shoulder. Another very important pearl for you guys is and I've done this I've tangled sutures in the past. Is have your assistant really pull tension on those sutures. Really crank on them to make sure that when you're going to grab the grab the sutures, that you don't tangle up the sutures, so have them really pull tension on them while you're doing this. Now we're going to go over to the glenoid side, and we're going to grab the little looped end in the knotless SutureTak suture, take it out. And we're going to we're going to do is it's going to be a horizontal inverted mattress. So we're going to go up. Then we're going to go down. And then we're going to pass that same suture through the little passing loop of the Knotless SutureTak. And then you're going to see your assistant with the little arrow there. You just pull on that suture right there and you can see how it loads it in. And then again, just for the sake of time, we're going to speed it up. Now we've done the 12:00 and the 10:00 anchors in this case too. So now we've have it all passed and ready to go. You fold it over like a cigar, and you just push it straight in. Don't rotate your forearm. I've done that before. And you flip it upside down. It's really embarrassing and a pain to get that untangled. So just go straight in. You'll feel a pop once it goes in, and then you're all set. Little Pearl here with the 12 millimeter passport. Before you load the sutures in there. I there. I just want to point this out. You can fold it over and ahead of time so you know you won't get stuck, because that's always a concern. If you get stuck. It's one way with those knotless suture, Tex. You can't reverse them, so you just take it ahead of time and make sure you can go right through the passport. Great. Now you know you're going to be in good shape when you're doing it. You don't have any worries. However, let's say you're struggling a little bit there. Then what you can do is what Steve Burkhart has taught us a bivalve, the cannula, you bivalve it and then you can stick it right back into the shoulder. Number seven. So we're fixating the graft here. I'd love to see you just pulling on each of those sutures from the knotless suture. Tex. On the. I love the 12:00 one. See how it goes, pops? Right over the top. It even makes that noise. And so you get it right over there, and you just keep pulling on each of those sutures and secure it in place. So there's no tying knots. That's the beauty of this. So all the work was done outside the body for me. I like to make the procedure as simple as possible. And so it's nice with this procedure because now all you're doing is the SpeedBridge on the lateral row. So you get the SpeedBridge you can do some side to side to side posteriorly and a side to side anteriorly. As you can see here. So that's the final construct there. Now a little word on side to side sutures. We used to always say posteriorly every time for stability and augmentation. Keep in mind these are pedicles. See all the bleeding that was occurring there. So for the remodeling process is very helpful but also for that anteriorly. Now we're realizing because of Poisson's ratio. We could talk about that in the panel discussion. It's probably important to also be doing anterior side to side sutures especially lateral. So the final construct, if you tension it properly you get what we call that reverse trampoline effect when everything's tensioned properly. And what you find is even when you remove the deltoid, you can see as we're pushing on it here, we're not faking this. We're really pushing on this. When you tension it properly, it doesn't hit the undersurface of the acromion. When you have it with the arm at the side, and you have to transect the graft. And not only then is it unstable superiorly, but it's also unstable inferiorly as well, so it becomes completely unstable at that point. Number nine, we know there's numerous studies over the years that have shown that dermal allografts in the shoulder are safe, including MRI studies demonstrating no complications and numerous ultrasound studies. And this is a case report of Evan Letterman's of a patient who had an SCR. But unfortunately, two months after surgery fell and tore his construct. Then it was explanted at one year, and you can see there's already neoangiogenesis in tendinous remodeling of the ArthroFLEX. Now, I prefer the three millimeter ArthroFLEX. The one millimeter is just not thick enough. The three millimeter. And because it has the MatrACELL processing, which removes over 97% of the DNA, so less chance of an immunogenic response. It's also sterile and very strong. Finally, last one, number ten. Numerous people in this room can tell you that most these patients clinically do very well. Including tumor study 24 patients had significant improvements in acromial humeral distance and ASCs scores. So most of these patients do very well. We also have the prelim data that we've now submitted to the Journal of Arthroscopy with the brass group. And you can see that most of our patients in our study had very large rotator cuff tears, all sorts of wide variation for harmonic classification of arthritis. And a lot of these patients had significant atrophy of their, of their muscles. But what we found was 75% patient satisfaction at one year. We're happy with this. I mean, you think about this, the a the learning curve and B, this very difficult patient population. We didn't really have any other great options before this other than maybe a reverse. So 75% satisfaction was great. We think the number will be even higher in the future. Maybe 80, 85, maybe more than 90%. If you learn from some of the some of our observations. So some of our early observations was graph size very important. The thicker the graph, the better the outcome. Three out of the five patients with a one millimeter graph went on to reverse shoulder. So very important using the three millimeter graft. Next one is arthritis. The less arthritis, the better the outcome. Think of a traffic light, Hamada one and two. And that just has to do with migration. With the Hamada classification one and two, it's a green light. Go ahead, do the Hamada three, where you start to have adaptive changes on the undersurface of the acromion. That's where you get the caution. That's the yellow light. Just be careful because the results aren't as good, at least in our study. And then when you get to red where they have arthritis, that's the stop and think. Maybe that's not the best option. So that's the stop at the traffic light. And finally the size of the tear. The larger the tear the lower the success rate. And there's SOS data which is also shown that these patients feel better rather soon. So if you ask somebody who's done a lot of these, they'll tell you, these patients feel great, but be careful because you'll your patients will send you videos like this. This is one of my patients I did maybe six months ago who's four months post-op, and he's sending me this video four months post-op. I'm like, are you kidding me? What happened to all those conversations we had? So just try and tell them that. Because that's another thing we learned is you got to slow these people down. And arguably the most important slide I have for you, this entire presentation, I've presented this in the past, but it's worth mentioning one more time. This is a histologic study that Julie Adams and Scott Steinman did at the Mayo Clinic canine model. They looked at four different time points. Time zero, six weeks, three months and six months. And what they found was at time zero. It's just a collagen sponge. Six weeks. There's already native cellular infiltration and development at three months. This is where it gets interesting. The graphs were completely disorganized with hyaline degeneration. We're going to go back to that in a moment. Whereas at six months there was normal tendon structure grossly and histologically in this canine model. Most important point though was when they looked at the load to failure testing at time zero and six months, all of the constructs failed at the attachment sites, both medial and lateral. However, at three months, over 75% of the constructs failed mid substance. So the graft gets weaker before it gets stronger. We know this with Allografts, just like you wouldn't have an ACL patient going back and playing soccer at two months. You don't have these patients have unrestricted activities at two months. Slow your patients down. Good. Good. Pearl, that may help with your outcomes too. So summary. Slide number one. Careful dissection of the scar tissue to see if you can repair it. Number two, address the biceps. Leave the superior labrum. Number three the superior capsule is critical for normal shoulder function. Number four glenoid anchors are safe. But that 12:00 anchor just go a little more. Medial. Number five glenoid three. Not less SutureTak and greater tuberosity. Speedbridge works really well. Number six proper tensioning. If you're going to towards the side of slightly over tensioning than under tensioning. Number seven. Side to side sutures increase stability. Number eight the scar restores the fulcrum back to the glenohumeral joint. Number nine dermal grafts, especially ArthroFLEX, are safe in the shoulder. And finally, number ten. Most patients do very well. But consider a conservative rehab program. Thank you.

The Superior Capsular Reconstruction: What Have We Learned?

Related Pages

Shoulder

Superior Capsular Reconstruction (SCR) Technique

Procedure