All right, thanks very much. We're going to spend the final 15 minutes of this session describing or discussing some of the technical aspects regarding superior capture reconstruction. As you heard, we can probably spend hours debating what are the indications for each of the procedures to manage chronic rotator cuff or massive rotator cuff pathology, but at least when it comes to SCR, one of the difficulties of the operation is the technical portion of it. And so we're going to spend the next 15 minutes going over that. We fortunately have with us an expert panel, Alan Curtis, Scott Trenhill, and Chris Camp are going to help us. Please make sure that if you have questions, you either come to the mics and or text the questions in. So guys, I put together about a 15-minute video just showing the technique that I use and highlighting, I think, what are some of the challenges and how we navigate those in managing superior capture reconstruction in the operating room. So our patient today is a 56-year-old male. He works at a paper plant. He's got a work-related injury. His main complaint is pain, but also weakness. You can see that he has relatively maintained range of motion, but he's weak on isolated cuff testing, particularly with an empty can test, and he does have a chronic Popeye deformity as well, indicating biceps pathology. He does have some limitations in external rotation, but no lag sign. His x-rays are shown here. Despite the presence of a small inferior osteophyte, he has relative maintenance of his joint space. His humeral head position shows slight elevation, a fairly significant osteophyte on the undersurface of the acromion, and a chronic retracted rotator cuff tear with at least grade two, three changes in the supra and infraspinatus. My preference is to do this in a beach chair position. We've got our standard portals that we would use, an anterior working portal, a posterior viewing portal, and then at least two to four lateral portals, which are used for a combination of suture management as well as for graft passage. So the first thing we're going to do is just take care of the bicep stump. Alan, is there any indication in your mind for leaving the biceps in these procedures or is it gone 100% of the time? No, actually, it's a good question. So I've evolved a lot in dealing with the biceps with SCRs. So obviously in this case here, you don't have any choice. It's already gone. But what I started doing a few years ago, similar to what Steve Snyder did with his graft jackets, is I tenodese the biceps in situ, and I leave it, and I use it as an extension of the graft. So I'll tie the graft to the biceps anteriorly. That way I don't have to touch the interval. And in essence, it's just an extension of that graft material, and it's actually worked extraordinarily well to the point now that I do a lot of revisions, and I'm actually doing less SCRs because I've found that by using the native biceps, almost like a mini-SCR, I can tie remnant of cuff to that, fix the infraspinatus, get a balanced repair, and avoid putting a graft in. So the answer is, if I have the biceps, I never waste it. So Chris, you know, Tony showed us a very nice double row repair technique. In this case, he had an upper border subscap tear, kind of a pasta delamination, if you will. He had an anchor with an inverted mattress, and then took our retention suture to repair the rest of the subscap. Is this an absolute for SCR? Do you have to have a functional subscap in order to perform the procedure? I think it is for me. So for me, my indications for an SCR are irreparable supra, but an either intact or repairable subscapularis and infraspinatus. So for me, almost every time, it either has to be intact or repairable for the subscap. So Scott, we just did a necromioplasty, and now we're working on repairing the posterior aspect of the cuff. You know, some would argue that we shouldn't be doing necromioplasties in these situations because of anterior superior escape. Do you think that that's a relevant part of the procedure and something that we should do? I think I commonly do a subacromial decompression because it assists with visualization, graft passage, and also potential biologic healing. So for me, I typically do it, and that's assuming that you've got a good sound subscapularis and enough containment that you won't get into an anterior superior escape situation. Yeah, I think that's a key point. If the subscap is intact, I think it's very difficult to end up with anterior superior escape. So we used one anchor to repair the posterior superior cuff. Here we're working on the glenoid, and this first anchor goes basically at the base of the coracoid process, and when I first started doing these procedures, I would place anchors with sutures and use them to shuttle the graft into the joint, and what I found is that based on the nature of the bone in this area, as well as sometimes a significant force that's required to get that graft through the cannula, I would end up pulling out my anchors on the glenoid, which can make for somewhat of a miserable situation. So now what I do is I use basically a knotless anchor construct at the front and the back, and you'll see how we use sutures to shuttle it into the joint that don't involve a pulling mechanism into the joint itself. Guys, do you have any comments on what you use, medial row, two anchors, three anchors? You shuttle through sutures? I use two anchors as a minimum, very commonly do three, and I've gone to all soft anchors, so I try to go as small as possible, because I do worry if this patient ends up with a reverse at some point, you may have compromised that glenoid bone loss. Too much stuff in the bone. I still tie knots medially, but I like your thought, because I do worry about using those medial anchors to shuttle your graft in can cause a lot of problems. Once you get the graft in, if that anchor comes out, that can be pretty difficult to fix. Suture management here I think is critical, and we put in our lateral row anchors on the medial side, so just off the edge of the tuberosity, and then I actually make two additional portals, a far anterior lateral and a far posterior lateral, and I take those tapes, the back to the back and the front to the front, and what this does is opens up the alley in the middle of the shoulder for you to be able to introduce the graft without having to worry about those tapes getting in your way, and you can see here we're using an advisor portal for placement of a central all suture anchor the way that Chris just described. So, the measurement here is you've got to measure the four sides of the graft, basically anterior medial to anterior lateral, anterior on the lateral side from anterior to posterior, on the medial side from anterior posterior, and then on the posterior side from lateral to medial. Alan, do you think it matters what position the arm is here when we measure? How do we want to make sure we get this graft into the right tension? Well, I think it matters depending on, you do them in the beach chair position, so arm in position could be easily affect your measurements. I do them in the lateral decubitus position in about 20 degrees of abduction, so that's more or less a fixed point, so for me, I don't think it really matters when you're doing the lateral decubitus position, I think you have to be careful otherwise, and after you do a lot of these, you realize that the measurements are relatively similar all the time, so you have something to go by. So here you can see our measurements, the actual measurements and the fact that we've got to add a little bit of extra graft, particularly on the lateral aspect. Because I'm not shuttling and using point-to-point fixation medially, I use a point-to-point measurement medially, but on the lateral side, because I'm measuring from my medial row, I've got to add 10 to 12 millimeters to accommodate coverage of the footprint and my lateral row, and about 3 to 5 millimeters on each side of the graft to be able to incorporate my repair into the remaining posterior and anterior cuff. I then basically use a suture tape that's placed in a cinch configuration at the two medial corners of the graft. This will be how I introduce the graft into the joint, as well as how I fix the graft on the medial points, both anteriorly and posteriorly, and then we pre-punch some holes in order for us to be able to more easily pass the lateral tapes when we get to that point. So now you can see we've got the joint opened up, we've got all of our anchors ready into view, and now this is the part where you've really got to pay attention. You need a minimum of three hands, somebody's got to hold the graft, somebody's got to maintain the sutures, and somebody's got to be doing the work and holding the camera. So what we're going to do is we're going to take that first anterior stitch, we're going to shuttle it into the joint, and we're going to retrieve it through a far medial anterior cannula. Then we're going to take the next posterior stitch, which is the all suture, we're going to bring those out one by one through our lateral anchor and use a direct penetrating device in order to pass those through the graft. What I make sure to do is that my assistant at all times is maintaining suture tension as you see here, and we're always working from front to back, medial to lateral, so that we avoid any suture tangles. So you'll see that as I go to grab the next suture, all of my existing sutures stay to the front, and I go behind them to grab the next suture, and then that goes through the graft and then gets attached to the drapes using a hemostat under tension. And then finally, we'll take the posterior stitch, pass it into the joint, and retrieve it from a posterior medial portal so that we can shuttle this in. Any other tips that anyone has on suture management? Because of course, this is the part of the procedure where everybody's blood pressure is up, and until you get that graft in, it can become pretty tricky. Also on the cannula device they're using there, they come in a 10 and a 12. The 12 usually is no problem sliding the graft through, and even with that, you can slice the outer aspect to make it a little easier, but don't slice all the way through it, otherwise the graft can get trapped in the slice as you pass it in. And there are now some cannulas that actually have divisions that are removable so you can keep sutures in different quadrants and then remove the inner portion. So as you see here, as we're retrieving the medial row, or excuse me, the medial portion of our lateral row, we're now bringing all of the sutures anteriorly. So we've got our medial row staying to the top of the cannula, and our lateral row will stay to the bottom of the cannula, and we retrieve those out and pass them through the graft outside. Everybody using dermal allografts, Scott, I know you mentioned earlier that you've kind of more techniques to a hamstring. I've kind of done this every way you can do it, and I think we all struggle to some degree with this. And it's gotten to the point where I'm converting over to using hamstring, and basically taking passes back and forth, I'll bring the whole hamstring in across, fix it in the middle, and then go back and forth until my hole is filled. And there's no measuring, and there's no entanglements and things. But I'm just starting to do that, so we'll see. Potentially a thicker graft as well, I would assume, depending on what the hamstring that you get. So at this point, I basically have my anterior medial suture out in anterior portal, my poster medial suture out of poster portal. Each of my assistants pulls on one end while I deliver the graft into the joint, and this makes sure that I'm pulling directly onto the graft, and there's no concern about pulling out sutures on the medial side. Once you get the graft in, you can actually use a grasper on the medial corners to be able to reduce the graft into place. I then use those accessory portals that I've already created to be able to retrieve the suture tapes, so the suture tapes come out of my working portal. And now at this point, the only suture remaining in that working portal is the medial row suture, which is the first one that I'm going to tie. So my assistants then use a grasper to be able to reduce the graft into place, and the next thing we do is just to tie our sutures medially to get our provisional fixation of the graft at the 12 o'clock position on the glenoid. Once these sutures are tied, I can then take one limb of that suture along with the anterior tapes into my anterior knotless anchor, one limb of the suture with my posterior tapes into the posterior prepared hole for the anchor, and that way we get not only apposition of the graft, but we get some compression of the graft over the top. So there's the retrieval of the medial stitch as well as the remaining stitches. We use these with a knotless anchor construct that goes right up to the base of the coracoid, and this gives us compression over the top as well as our medial fixation. Chris, you said you use all sutures. Do you just pass them through and tie on the medial row? How do you do that? I do, yeah. It's the same step after you had passed your graft, and we still have the sutures from the glenoid as well as the medial row humeral head sutures all coming out through the cannula. So I take my anterior glenoid sutures, and I pull them out and I actually put them in a five millimeter cannula, and I slide that into my 12 millimeter cannula. So it's a cannula in cannula technique. And then I actually use that cannula, I push it down on the sutures and use that to reduce the graft to the glenoid, and then I tie them and cut them in that cannula, and then do the same thing for the other glenoid. So you literally have the cannula over the corner of the graft holding it in place while you're tying your suture. Correct, correct. For some mechanical just pressure. And it helps keep me from getting the rest of them tangled, and I don't have to pull them all out separate cannulas. Nice. Got it. So basically now that we have the medial fixation done, then you're left with what would be a standard transosseous repair on the lateral side, and this is the part of the case where you can finally exhale. So we're essentially now going to retrieve one limb of our anterior tape, one limb of our poster tape, we're going to bring those over the top. We can use spinal needles that actually go through, Scott taught me this, that actually go through percutaneously, you can actually pin the graft into place if you need to, or you can just have your assistants use graspers at the corner of the graft to hold it down. Again, we get back to the tensioning question, guys. There's been some recent evidence that suggests that maybe we should put these grafts in at 20 or 30 newtons of tension, rather than just laying them over the top. Chris, any comments on how you get the right tension here? I tend to think this is acellular material, that it's tough, it's durable, but it will stretch over time. So I tend to put it pretty tight. I usually put the arm at 30 to 45 degrees of abduction and fix it about as tight as I can. Yeah, so for me, it's 30 degrees of abduction, 30 degrees of forward flexion, neutral rotation, and hopefully when you get down into the zero position, this will impart some tension on your graft. But admittedly, it's an inexact science. So now we're putting in our standard lateral row anchors to fix those tapes. With many of the lateral row devices, you have some extra stay sutures that can then be used to deal with dog ears or other, if you want to make sure that the graft is sitting flush on the medial side. So in this case, we're going to pass one of those stay sutures through a corner of the graft in order to reduce it properly into place. And then we've got to close the intervals. I would assume that everybody closes the remaining cuff to the posterior aspect of the graft, correct? And would you say that you're more often than not repairing some portion of the posterior cuff, Alan? Oh, I mean, I think that's critical to get anything back from the infraspinatus, gives you some external rotation. And there's no question that the patients that do well with this operation are the ones that you can establish some of their native cuff. So I think the anterior part is a little bit more controversial, right? And should we close the anterior intervals? Do we leave it open? Do we have to go all the way down to the edge of the subscap? Because the reality is that many of these patients are revision or previously operated situations. You might not have interval tissue there. Chris, do you make an effort to try to close the anterior portion? Yeah, I do. And I don't know if it's right or wrong, but every time when I'm repairing the infra in the back or the subscap in the front, I try to cheat both of those up superiorly when I repair them. So I try to intentionally bring that subscap up and lateral to get it closer to where the anterior edge of my graft is going to be. And so I think that that may help prevent anterior escape. It helps with the forced couples. And it makes it easier for me to margin converge the graft to the subscap as well. So I'll try to do that in both front and back. What do you think about if we're starting to go far forward on our glenoid insertion and we're creating two fixed points? Any concern about risking external rotation loss if you're closing down that anterior interval? Yeah, I think so. But I think for me, the bigger concern is that superior escape. So I would tend to err on the side of being a little too tight in the front rather than too loose and allowing them to escape. But that's a great concern. So that's our completed reconstruction. Scott, I'm going to give you the last word, rehabilitation. How slow do you go with these people? Pretty slow. Six weeks in a sling. Minimum. No motion, no therapy? Nothing. And then out of the sling maybe eight weeks or so and then slow advance from there. And I don't do any strengthening until at least 14 to 16 weeks. Probably 12 for me. But yeah, I agree. All right. Thanks very much, gentlemen and ladies. I appreciate your assistance.

superior capture reconstruction

surgical procedure

chronic rotator cuff

massive pathology

work-related injury