I'm Patrick Dennard from Medford, Oregon, and I'm going to talk about superior capsule reconstruction, how to do it, and how to optimize your outcomes. We've evolved our technique over time from preoperatively to our indications, technically how we do the procedure, and then postoperatively how we rehab the patients. We learned a lot on the way. Much of this comes from our experience that we published a couple of years ago in the Arthroscopy Journal, and if you look at this paper, keep in mind that we had very broad indications in this series, and many of these patients were revision patients. I looked at my learning curve in the early experience, which was 2015, to the two years subsequently, and by adapting my technique, I had better improvement in my SANE scores of my patients, and the few patients I looked at in MRI healing data, I had improved healing rates. but definitely a trend that I observed. My top tip for you is respect the indication, okay? I think the ideal indication is a young patient, less than 70, they have minimal to no arthritis, they obviously have advanced atrophy because they're not going to have a high healing rate otherwise, and they have a repairable or intact subscapularis tendon. What I mean by that is a tear of less than 50% of the superior to inferior width and minimal to no atrophy. Relative contraindications, if they're over 70 in particular, I pretty much, for the most part, will go to reverse if they have functional compromise, or I'll accept a partial repair if they have maintained overhead function. Absolute contraindications, to me, I don't think you can improve external rotation with this procedure more than a few degrees, so if you have less than 10 degrees of ER, I do not perform SCR on those patients, and if they have arthritis, I do not think that's a good indication. This is what our indications look like graphically, so the hematocrit classification, stage one is a normal joint, stage two, they're superiorly migrated, but have a normal tuberosity, so no adaptive changes. Stage three, you see adaptive changes of the tuberosity, and stage four, you get arthritis. So one and two is your go zones, and that's what we found in our paper, and if you look close at the indications, that's also what Mahada used early on. Stage three, you really need to be very careful, perhaps you can consider it in a very young patient, but if they're an older patient, I would be cautious about SCR, and I would avoid it in patients with arthritis. This is an example of an ideal indication, this is a 70-year-old gentleman, but he's very active and healthy, he's a hematotube, because he's got a normal tuberosity, but he's superiorly migrated, and you can see he's got grade three atrophy of his supra and infra with an intact subscap, you can tell the subscap's intact based on the lack of atrophy there. So we do an SCR, and you can see postoperatively, his improvement is a chromohemal distance, and this is maintained at six months postoperatively, so an ideal indication there. And I think the single biggest thing I can tell you with anything with SCR is the indication. If you don't get the indication right, it doesn't matter how well of a procedure you do from a technical standpoint, you're not going to get a good result. Let's move on to the surgical tips. First, I like to use independent medial anchors on the glenoid. Initially, we did just two anchors and used a double pulley construct to pull the graft into the joint. With this technique, we had some cases of suture pullout, sorry, anchor pullout, and the problem with using a double pulley technique is that if you have one knot failure because you're linking the two anchors, you get failure of the entire construct. So currently, I'll use three anchors that are independent fixation medially on the glenoid. I use knotless anchors, but you can use any anchor you want. This independent type of construct has the highest load to failure from a biomechanical standpoint. Here's what it looks like right shoulder. First anchor, I place off the AC joint percutaneously. Posterior anchor, I want to go right in front of the scapula spine. I do that through a portal that is medial to my posterior viewing portal. And then I use an advisor portal to place my middle anchor, and I want to go slightly medial to my other anchors, so I'm not converging my other two anchors. You got to size the graft properly. Make sure you get adequate and accurate measurements, and really make sure you account for the curvature of the glenoid because the glenoid is obviously curved. So you can't use a straight instrument. You either have to use a measuring device like this or make marks on your sutures to really ensure you're accounting for that curvature and measure in whatever position you're going to secure it. Because if you don't do that, you're not going to have it placed properly when you go down. For me, because the graft is elastic, and Mahada and Lee have shown this where the dermalografts elongate 15%, I make sure that if anything I will slightly undersize my position. So for instance, if I measure 22 millimeters, I may place them 20 millimeters apart knowing that they're going to have some stretching of the graft. Graft prep, I like to put five millimeters anterior-posterior immediately, and then I go 10 millimeters to cover the tuberosity in a case where I have no cuff at all. Suture management is key. I pull all the sutures out laterally. If you're going to do a technique like this, make sure that you run the suture line, go back down, ensure you have no tangles, and then make sure you keep them separated on the outside. It's really helpful to have a good assistant who knows what's going on here. You can also consider clipping the sutures to the cannula laterally with a hemostat to keep them from sliding over each other. Then we want to shuttle the graft in. I'll pre-punch holes for the tuberosity sutures, pass those first to get those out of the way, and then I'll work immediately because I'm doing these independent medium mattress sutures. I'll pass up and back down with a scorpion because this is a number two suture, and then I'm going to link it into its knotless anchor. I'll grab the loop of this knotless anchor and shuttle that mattress suture into the joint, pulling it back through the percutaneous portal which it's been placed through. I do a double pulley technique on the tuberosity that helps the graft sit down on the tuberosity and gives some enhanced fixation, and then you want to push the graft into the joint. You don't want to pull it in. Push it in, and then once it's into the joint, then you can start removing the slack. It's going to look like this at first, but if you've ensured that you run the suture line, you're not going to have tangles once you start removing all the slack, and you just need to work back and forth. Get that pulley set down on the tuberosity, and then ensure that all the slack is out of your medial anchors if you're using a knotless technique like this. Alternative is to place the medial anchors first and just shuttle that portion in, and then essentially do a cuff type of repair, pulling the graft over, but I really like this technique. I just think it's easier to handle for the graft inside. I don't really like passing sutures to the graft on the inside of the joint. Next, you want to repair the cuff over the graft if possible, so the first step is repair the cuff over the graft, and then do margin convergence posteriorly. Margin convergence is important, but I like to do the cuff part first because you don't want to lock in the mobility by sewing the infra to the graft and not be able to advance it over the graft if that would have been possible. Again, we know margin convergence is important, and we also know from Mahata's work that doing a combined procedure can be very effective, especially in patients who have poor muscle and have a lot of retraction. He does this if two of these three factors are important. I'll typically do it in a patient who's under the age of 60 and has a repairable cuff, but advanced atrophy or is revision, so I know I might be able to get them repaired, but their healing rate is low, so that's when I'll use dermal allograft. This is an example of a patient where I would do this. This is a patient who had grade three atrophy. Actually, the cuff, though, is fairly mobile here. If we do some releases, I can get the cuff over the top, but there's going to be a short tenon length and some tension here, so I'll do an SCR underneath. In this case, I'll just do two anchors in the glenoid, two on the upper side of the glenoid, and one on the lower side of the glenoid, and then I'll do an SCR here, so I'll do an SCR underneath. In this case, I'll just do two anchors in the glenoid, two on the tuberosity, and then I'll repair the cuff over, and that's how I'll do my augmented procedures. Last tip is go slow on the rehab. Scott Steinman did a study several years ago looking at dermal allografts in a canine model, and he found that the strength of the graft decreased at six weeks and then only got back to baseline at three months, but then continued to improve out later until six months. So our protocol is this, six weeks in a sling, passive motion only until or beginning at six weeks. We delay strength until four months because of that graft integration issue, and then we avoid heavy activity up to six months to avoid late failures. Summary. Respect the indication. Again, that's the single biggest tip. Three medial anchors for independent fixation on the glenoid. Properly size the graft. Be very careful with your suture management. Run the suture line. Repair the cuff over the graft if possible, and go slow on your rehab. If you want a full-length video, I have this. I have several videos actually on Vumedi that you can take a look at. Thank you, and good luck.

superior capsule reconstruction

postoperative rehabilitation

biomechanical performance

surgical tips

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