Name: Superior Capsular Reconstruction (SCR)
Uploaded: 2017-01-12T00:00:00Z
Channel: Arthrex

Stephen S. Burkhart, MD, (San Antonio, TX) performs a live Superior Capsular Reconstruction (SCR) in a patient with a massive irreparable supraspinatus tear, but no glenohumeral arthritis. He shares numerous pearls on patient positioning, portal placement, recognizing and excavating any remaining rotator cuff tissue, and bone bed preparation on both the superior glenoid and humerus. Dr. Burkhart details the measurement, preparation, insertion and fixation of an ArthroFLEX®* acellular dermal matrix, including side‐to‐side fixation to the remaining infraspinatus posteriorly and to the comma tissue anteriorly. Lastly, he shares his rehab protocol.
*ArthroFLEX is a registered trademark of LifeNet Health.

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VID1-00875-EN | A | Superior Capsular Reconstruction (SCR)

Stephen S. Burkhart

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Surgical Technique Videos

Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

Vídeos de técnicas cirúrgicas

Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

Videos de técnicas quirúrgicas

Superior Capsular Reconstruction (SCR)

This patient is a 56 year old man who has been having severe left shoulder pain on a chronic basis, with limited range of motion only up to about 90 degrees. About a year and a half earlier, we did a superior capsular reconstruction on his opposite right side, which has done very well. He's very happy with it. And now he's come back to have the same procedure done on his left side. So here you can see up here where he is getting an acromial fulcrum as well. He's getting adaptive changes on his greater tuberosity. And it looks like his cuff is going to be scarred in up against the acromion. Okay, so let's look at his glenoid. His articular surfaces are reasonable. Certainly at age 56. You know, you don't want to be doing a reverse total shoulder on him. Well, that's interesting because it looks like his scap is intact. He's It's been kind of inconsistent on having a bear hug belly press. So he was negative this morning on testing. So but he's got some biceps tension signs. So we're going to go ahead and we're going to do a tenodesis. Now most of the time if we're going to do an SCR, which I think we'll have to do on this guy, most of the time we end up doing a tenodesis anyway because of the fact that you end up with kind of a poor labral attachment if you try to leave it and then you're cleaning up around the labrum, then usually you end up having a poor labral attachment at the biceps root there is this screw is right beside it. Okay, here's our sub scap right there. Now I need to see though where the edge of the articular margin should be. So I'm having to make now a new footprint for the greater tuberosity here. So I'm running the burrow in reverse so that it doesn't skip and get out of control on me. Internal more. And then we're back over here to that bear area that we were beginning to prepare earlier. So that's good. I want to be sure and get all that soft tissue off. I think that's real important to have a good, consistent bleeding bone surface. I like to kind of refine that margin a little bit during Curettes are good for that. Now I want to try to dissect whatever cuff he has and preserve whatever there is. He's obviously scarred in Against the Acromion, and there's not going to really be too much there. But so, so what I do is I bring my shaver in from a posterior portal. I hit the scapula spine, I sweep out laterally, and then I'm going to see my shaver start to come through these soft tissues here. And that's how I know that I'm in the right place. Now, there's not going to be much cuff there, I can guarantee you that. Okay, so now once we have that little hole where we can see up in that space, we can use our cautery switch back between cautery and and shaver if we need to. So there's a good view of scapular spine. But you've got to be able to see that to know which part of the cuff you're dealing with. So basically there's no supraspinatus. Here's the biceps root. Here's the labrum. This little layer of trash tissue is kind of what would have been supraspinatus. There's really nothing there to speak of. So I think there's no question he'll need a super capsular reconstruction on his plain x rays. He's already got chronic proximal migration, but he doesn't have any significant glenohumeral arthritis. So that's the key here. Now internally rotate the arm. Now that I'm getting back a little more posterior, what I want to do is to see where the intact rotator cuff is. And it's right there. Okay. So you see, this part of cuff is coming into the bone, into the humerus. So this part here is a Bursa leader. It goes from the subacromial space over to the internal deltoid fascia. This is not rotator cuff. So we might as well just go ahead and split through that. So now we're getting into posterior gutter here. So this is the type of cuff excavation you've got to do to see what cuff is left and what you need to substitute for with your superior capsular reconstruction. So we have it. What? Looks like some infraspinatus here. You see, here's some intact cuff coming across here. So the next thing I'm going to do is get all the soft tissues off from the undersurface of the acromion. That's just going to help me to visualize things better. Help me to do any acromial plasty that I might need to do. So we'll just do sort of a subacromial smoothing here, running it on reverse again, keep it from skipping. So I just want to see if there's any mobility to this posterior leaf. So really. Nothing meaningful there at all. Wow. So he has nothing repairable over there on that big span. So I want to see I want to prepare my superior glenoid. So I'm going to have to have a really big graft again it looks like here. So I'm coming in through this BioSurge portal chamber. We're just making some space here so we can see just to get that fatty tissue out, see if there's any muscle here to speak of. Now, we still want to stay away from the suprascapular nerve, because it does wind around to innervate the part of the infraspinatus. It's still intact. So basically, there's not any meaningful supraspinatus at all. I mean, this is what would have been capsule here, but he has nothing preventing him from proximal migration. So in this case I'm not doing a posterolateral slide because there's really no capsular bridge or anything meaningful there. So I'm just taking this little weak capsular bridge out of there so I can come right down onto the to the bone and prepare it. So I'm going to come down anteriorly so that I can see the base of the coracoid where it joins up with coracoid neck. That's ideally the area I like to place my anterior anchor. Okay. So I'm coming in through this antero-superolateral portal. It's just off of the anterolateral corner of the acromion, which is the portal that I use to do my tenodesis through my biceps. Tenodesis. And that usually is a pretty good shot for putting in your more anterior anchor into the superior glenoid. Okay, now let's have a spear for SutureTak. So what I'd like to do is see about placing my more anterior anchor. I'm going to see if perhaps this might give me a better angle. Sometimes in a BioSurge can be good, and it looks like that's about where I'd like it to go. So let's drill right about there. Okay, so we haven't penetrated into the into the glenoid. I always like to look at the glenoid. So we're okay there. And now we want to look over here. And I want to prepare that maybe a little better. Give me a curette. So very important. Again, run the burr on reverse. Get rid of the soft tissue. But you don't decorticate. So now let's see where our posterior anchor is going to go. Let's have that spear again. Let's just see what happens through the bias or aiming the other direction. Bad angle. What about here? Bad angle. Let's have a needle okay. It looks like that's going to be about right. Just posterior to the scapular spine. So the suprascapular nerve is right at the base of scapular spine. I'm still about a centimeter away from that. That helps you not to slip if you're drilling on a real oblique surface. And now we're going to put the greater tuberosity anchors on. The medial aspect of the tuberosity is such an overhang to his acromion, it's hard to find a spot to get the angle we need. We're rather close to the tenodesis screw. So I'll just show you a little precautionary trick. Here is we'll start out drilling a pinhole, so we'll go in like this. That way we're not going to crack out into that adjacent bone socket. Okay. So we use the green handle punch. And you can just in order to avoid risking anything, you can just take this down by hand and we'll take our SwiveLock punch. Okay, so now you can see we've gotten very close to that screw without blowing it out. We tapped to the first threads, hit stop. Turn. We'll leave all the stitches in, including the safety stitch for now. Then we're going to want to put one toward the back. Before we measure for our graft, we should be sure that the arm is in the correct position to adequately tension our graft, which is about 20 to 30 degrees of abduction and 20 to 30 degrees of forward elevation. So let's just measure everything. So we're measuring guide. As I measure between the four anchors, I call out the measurements to my assistant who marks them on a template on the back table. So we've measured the measurements between all four anchors on this inner rectangle here. So it's 25 between the medial anchors on the glenoid. 23 on the lateral Anchors on the humerus and then 30 and 35 anterior. Posterior. I use a five millimeter flap of tissue all the way around. Anterior, median and posterior. Except for lateral, I use a ten millimeter extra flap so I get better coverage on the greater tuberosity. So we'll go ahead here. Go ahead. So we're going to just punch a hole and go to the next spot and punch a hole. We have a 35 millimeter span which is kind of a big span over here. So what I want to do is I'm going to look back and see if it looks like we have room for a third anchor medially. So that's a pretty good distance between those two. And what can happen if you have that longer span. Is the middle part of your graph. Can slip over the edge of the glenoid medially Immediately and bowstring across there. And that's not so good. So so I would like to go about midway between. I want to be sure we're not penetrating into the glenoid as we go. Tell me when you bottomed out. Okay. So you can see we've not penetrated the glenoid. Okay. Now let's put our anchor in. So long. Okay, so we're just close to midway between, but not quite. So I'm going to cut this passport longitudinally here. Because what I want to do is to be able to pass my sets of sutures through it and then just peel it off and out without having my sutures trapped within it. But this will still allow me a nice little channel to bring them through. So that's going to allow me to pull these out in sequence. So lateral sutures and tapes come out first. Posterolateral. So we're keeping these all in their respective quadrants. Anteromedial comes here. Posteromedial comes here. Now, my pulling sutures are going to be these two in the middle. So I want to take one of each. I want to take a blue one and a white one. And we'll leave the other two out the portal. And that's how we do it there. I want to just kind of zip line down and be sure that everything's still okay, and we'll just push down and be sure that we're not crossing anything else. Okay. So that one's okay okay. So that's clear okay. So these are all clear okay. So now I'm just going to take the cannula out. And now we have these all in the proper alignment okay. These are the two inferior ones with the tapes. And then these are the medial ones. Now what I want to do is bring our graph over here. We're going to put down this towel so we don't get contamination from skin bacteria potentially on it. So this is from our middle glenoid. Anchor got oriented correctly. So here's M. This is medial. And we're going to want to go two thirds of the way posterior. So it's 15mm here because that's basically what we measured. Okay. So we'll pass this one. And now we want to do a mulberry. Not the easiest way to do a mulberry. Not as far as I'm concerned. You hold this under some tension. You do two wraps around a hemostat, and then you bring that down and make a little cinch loop. It's a slip loop there. Then you come back and you get the end of it, and you pull through. And simple little mulberry. Not like that. That's not going to pull through. So that's the other end of this one. So we'll pull the slack out like so Okay, now we'll do the blue one. These are our delivery sutures. We'll deliver the graft in rather by tensioning these. So I like these mulberry knots because this actually will pull at a very advantageous angle. So you're actually with that middle suture. These sutures are pulling sutures that are going to pull the graft in instead of having to just simply push it in. So now what we need to do is then pass our other medial sutures. So we go posteromedial. And these are going to be I call these our zip line sutures. That's our posterior zip line. Here's our anterior zip line. Because we use that little zip line pusher to push to push the graft down. So so you can see what's going to happen. I'll show you before I put my tapes in. We're going to be able to push this graft this way while we're pulling this way. It's just a very efficient way to get it in where you can get it to go in every time that way. So now what I'm going to do is bring our lateral lateral ones through tapes plus the safety sutures. And then we'll do the same with these. So our anterolateral tapes and then we're going to just zip things down while we pull here. Go from the anterior zip line to the posterior zip line. Push it in. So Joe is pulling on the central ones and there it is. Now I'm pushing on that posterior zip line. So there's our posteromedial corner right there. So now what I want to do is to get a cannula over the top of the graft. That helps me to control the graft. All right. So now I'm over the top of the graft. And now it makes it easy for me to work on the medial side on the glenoid side here. I'm going to fix this central part. Retriever. So I'm going to have two simple sutures here. So now what I want to do is kind of a modified double pulley. We're going to tie blue to blue. So we'll do the same over here. Then I'll get the matching blues. The two other blue limbs out here. Okay. So now to do a true double pulley, which we'll do here. First of all I want to be sure this is going to slide easily. So that one matches that one matches. They slide very easily. So now we're going we're going to do a six throw surgeons not three, four five, six. Now before I cut that come out. And I just want to be sure it's not going to slip in either direction. And it doesn't. Okay. So then we're going to pull that down. Now I just want to be sure that this is up over the top of my glenoid. I don't want it bow strung across the medial side of our glenoid rim. Okay. And it is. Okay. So now I'm going to get these two other limbs out. All right. So now I want to set this not pusher right down on this corner. Be sure there are no twists as I come down. All right. So now we're secured medially. Now just because I like to have belt and suspenders and I have those other two sutures, I'm going to do the same with them. So now we've got a really good secure medial fixation there. So that looks good. Now we need to come here. Lateral. And what I want to do is kind of fix my graft laterally where those SwiveLock anchors are that we placed. So I can do a double pulley with my safety stitches, which is what I'm going to do. Okay. Now we'll complete our lateral SpeedBridge repair by using two SwiveLock C anchors to fixate our lateral FiberTape. So we retrieve two FiberTape one from the anterior anchor and one from the posterior anchor. Pull them to an anterolateral SwiveLock anchor. Fixate that with a SwiveLock. Next, we take the other two FiberTape and pull them posterior laterally, where we fix those with another SwiveLock C anchor posted laterally. Okay. Good looking graft. Now we need to put some side to sides back here. It's very important that you link up your graft to your remaining cup, particularly posteriorly. You need to link it up to your infraspinatus. So that's what I'm doing here is we're putting these side to side margin convergent sutures. I think we're going to need probably a second one as well. So that's our posterior repair into Infraspinatus. Now let's see what we have anterior that we can repair. If anything I've got my 70 degree scope. So I'm kind of looking over the corner. So let's see if we have some comma tissue. Let's have the. And what we do have is we have those sutures. And you know, I did intentionally save those sutures from Bio-Tenodesis. If there is some comma tissue I like to tie anteriorly to that, because I think it adds another restraint to keep the humeral head from buttonholing up past the anterior margin of the graft. However, you don't want to repair your graft to the subscapularis. That would be pulling it down too far. If there is no comma tissue, then you don't repair the anterior margin. Okay, so there's our medial fixation up onto the glenoid of two double mattress with double pulleys. Then laterally we have one double mattress with double pulleys. We've got a SpeedBridge Criss-Cross with tapes. And then we've got. Side to sides into the infraspinatus back here. And then we have anterolaterally. We have fixation to the tenodesis screw and then to this remnant of comma tissue. People ask a lot about the post-op rehab. So what I'll do with this guy is I'll have him in a sling for six weeks. I'll only allow elbow motion, flexion, extension of the elbow. No shoulder motion, no pendulums, nothing at the end of six weeks. We'll start on passive motion. He'll come out of his sling. We'll do passive overhead with a rope and pulley. We'll do table slides. But we're not going to do any active motion at all overhead. We'll also do passive external rotation at about 30 degrees. I don't do any any internal rotation at that point. At four months the graft should be healed enough. Then it can withstand forces of strengthening. So at four months I start some theraband strengthening. I'll also allow him, as his strength improves, to do active overhead motion. So and then we'll also start at four months internal rotation as well.

Superior Capsular Reconstruction (SCR)

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