Superior Capsular Reconstruction
What is it?
The shoulder joint is stabilized by the joint capsule and rotator cuff. Tears to the rotator cuff can cause severe pain and impairment. When defects in the underlying upper joint capsule add to the instability caused by rotator cuff tears, it cannot be repaired with conventional treatments. Superior capsular reconstruction is a surgical procedure performed to restore shoulder stability in irreparable rotator cuff tears.
The shoulder is made up of the humerus (upper arm bone), scapula (shoulder blade) and the clavicle (collarbone). The articulation between these bones to move the shoulder in all possible directions is supported by a group of four muscles called the rotator cuff, which surround the shoulder joint.
A fall on an outstretched arm, repetitive stress, abnormal bone growth or a sudden jerk while lifting a heavy object can cause the rotator cuff to tear. A rotator cuff tear can be treated with non-surgical or surgical repair. However, irreparable rotator cuff tears are massive tears that cannot be easily repaired. They may be asymptomatic or present with severe pain and disability.
Superior capsule reconstruction is indicated for massive rotator cuff tears that cannot be repaired. Such tears are characterized by the size and extent of retraction of the tears. Superior capsule reconstruction is suggested when:
- Initial attempt at repairing the tears by immobilization and soft-tissue release fails
- Arthritis of the glenohumeral joint (chondromalacia)
- Presence of sufficient amount of healthy bone to allow fixation of anchors
- Minimal migration of the humerus
- Intact teres minor and subscapularis muscles of the rotator cuff
Superior capsule reconstruction can be performed through arthroscopy, a minimally invasive technique. You will be positioned in a beach chair position. The top of the glenoid and the head of the humerus are first prepared. Drill holes are created. Two suture anchors are introduced at the medial glenoid. Two anchors loaded with fiber tape are inserted into the greater tuberosity of the humerus.
The fascia lata graft is extracted from your own thigh region. The spaces between these anchors are measured and a graft prepared according to size. The sutures are extracted through the incision and threaded through corresponding holes that are created in the graft. The graft is then passed through the incision and into the joint space. The sutures are pulled appropriately to accurately position the suture anchors. The sutures and fiber tape are then tied to fix the graft medially to the top of the glenoid and laterally to the greater tuberosity of the humerus head. Side-to-side sutures may also be used.
Once the procedure is complete, the skin incisions are closed.
Superior capsule reconstruction is usually performed as an outpatient procedure. Your doctor will prescribe medication to reduce post-surgical pain and inflammation. You will be encouraged to gradually move your affected arm.
For the first few weeks after the surgery, you will be instructed to avoid:
- Lifting heavy objects
- Excessive working on the computer
Rehabilitation will be initiated in phases to include certain exercises that will help heal the shoulder, lower muscle stiffness and spasms, strengthen, improve range of motion, and return to work and sports activities.
Advantages & disadvantages
The advantages of superior capsule reconstruction are:
- Shoulder stability is restored by structurally replacing the superior capsule of the shoulder.
- Improved shoulder flexibility Improved muscle strength
- No progression of arthritis
- No tears in graftImprovement in night pain
- Minimal complications
Risks and complications
As with any surgery, superior capsule reconstruction is associated with some complications, which may include:
- Severe stiffness
- Severe synovitis (inflammation)
Rotator Cuff Tear Symptoms
The rotator cuff is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor). The rotator cuff surrounds the ball and socket joint (glenohumeral joint) and provides stability to the joint as well as movement. Because the shoulder is a shallow joint and the most mobile joint in the body, it requires the rotator cuff for stability. If let untreated tears can lead to arthritis of the shoulder (rotator cuff arthropathy). This doesn’t mean that good function can’t be maintained with a tear. In fact, many people are able to maintain function despite a tear because the shoulder remains balanced with the remaining rotator cuff and other muscles that control shoulder movement.
Muscle inserts into bone via tendon. In the vast majority of cases, when a tear occurs the tendon pulls away from the bone. Broadly speaking, tears are classified as partial or full-thickness. Partial tears go part way through the tendon while full-thickness tears represent complete detachment. Frequently, an MRI will report “partial-tearing.” Since most people over the age of 40 to 50 have some changes within the rotator cuff, partial tears usually not a problem. The distinction with partial tears is when the tears are considered “high-grade,” meaning that they go almost all the way through the tendon.
Rotator cuff tears may occur after an injury or repetitive activity over time, but most cases occur without an injury. As we age the rotator cuff tendon degenerates and age and genetics are the greatest risk factors for a tear. Studies show that about 50% of people over the age of 65 have a full-thickness rotator cuff tears. Most of these people don’t even know they have a tear!
Treatment for rotator cuff tears is based on age, health, and response to conservative treatment. The rotator cuff tendon is not capable of repairing itself. Rather then tear will stay the same size or enlarge over time. In people under the age of 60, the risk of progression is about 50% in a two-year period. The ability to get healing with a surgical repair depends upon age, the tear size, muscle atrophy, associated arthritis, and health (smoking and diabetes for instance). One must also consider timing of repair. Traumatic tears have a better outcome if fixed within 6 months of injury. Additionally, after about six months of symptoms atrophy may occur. Unfortunately, atrophy of the rotator cuff is not considered reversible. Based on this, if someone desires repair, I typically recommend performing this within six months of beginning treatment.
Guidelines for surgery are general and must be individualized as noted above. But, as a general guideline, I recommend repair for all full-thickness tears in people under the age of 60 given the risk of increase in tear size. For people between the ages of 60 and 70, treatment is based on the above factors with health and activity expectations being the most important factors. For people over the age of 70, I nearly always recommend an attempt at conservative treatment. Surgery is then considered if one does not respond to conservative treatment.
For partial tears, conservative treatment should almost always be attempted first since these tears progress slowly or may not progress at all. Then surgery is considered if one does not respond to 4 to 6 months of conservative treatment.
Treatment options include:
Anti-inflammatories such as ibuprofen (Motrin or Advil) and naproxen (Aleve) are used to reduce pain and inflammation. The max does for ibuprofen is 800 mg three times per day. The max does for naproxen is 500 mg twice daily. Prolonged usage should be avoided and these should be taken with food since they can affect the stomach lining. If one experiences an upset stomach these should be stopped.
Injection of a steroid (cortisone) may be used to provide pain relief and facilitate physical therapy. I perform these injections with an ultrasound machine. This allows direct visualization of the joint and improved accuracy of the injection. Up to 3 injections over a 2 year period are allowed. Beyond this there are typically diminishing returns and excessive injections may be detrimental to the rotator cuff.
Alternative injections include Toradol (an anti-inflammatory agent similar to ibuprofen), prolotherapy, or platlet-rich plasma (PRP). ). I use Toradol in people who do not tolerate steroids. Prolotherapy involves injecting a substance such as sugar into tissue to “stimulate a healing response.” I do not perform prolotherapy as it has not been shown to improve symptoms in rotator cuff tears. PRP involves taking a small amount of blood from a patient, spinning in a centrifuge to separate the growth factors from the red blood cells, and then injecting the growth factors back into the shoulder to potentially decrease pain. While PRP has anti-inflammatory properties, it has not been shown to heal the rotator cuff. Therefore, it is not covered by insurance and is an out-of-pocket expense. Typically a series of 3 injections are performed at weekly intervals for 3 weeks.
Physical therapy with strengthening is one of the mainstays of treatment of rotator cuff tears. Long-term studies show that despite not healing the rotator cuff, therapy can lead to substantial improvements in function with good patient satisfaction. The core exercises in strengthening the rotator cuff are provided at the end of this handout. These exercises can be performed twice per day, 5 days a week.
Most tears, regardless of size can be repaired. I perform all my rotator cuff repairs arthroscopically. This is less invasive and therefore less painful than an open incision. It also allows a better view of the rotator cuff. This procedure requires general anesthesia, takes about 60 to 90 minutes to perform, and patients go home the same day. Small incisions are made in the shoulder, a scope is inserted, and the rotator cuff is repaired with anchors. Anchors are essentially headless screws which are placed flush with the bone. These anchors have sutures that are used to bring the tendon done to the bone so that the tendon can heal to the bone. The long-term outcome of this procedure is very good (>90% success in most cases) and the risk of complication is very low (1/5000 chance of infection). However, repair requires a long recovery period and the tendon takes about 12 weeks to heal into the bone. Therefore, a sling is worn for 6 weeks after surgery. Specific motion exercises afterwards are tailored to the tear pattern (patient-specific). The sling is removed at 6 weeks and motion is progressed. Strengthening is allowed at 12 weeks, followed by gym activities at 4 months. Full recovery takes 6 months for small tears and 12 months for large or massive tears.