Arthroscopic management of massive rotator cuff tears: Superior capsule reconstruction

The goal of this chapter is to discuss the indications, operative technique, and rehabilitation protocol for arthroscopic superior capsular reconstruction (SCR) using an acellular dermal allograft

Arthroscopic SCR provides significant pain relief and improvement in functional outcomes in appropriately selected patients

Arthroscopic SCR with an acellular dermal allograft is safe and effective using the described technique

A thorough subacromial decompression with clearance of any remaining tendon and bursa, especially medial for glenoid graft placement, is critical for surgical efficiency and visualization

If necessary, repair subscapularis and/or infraspinatus prior to SCR

Confirmation that anchors are fully seated with appropriate resistance to pullout strength is important for graft delivery and fixation

Careful measurement of the graft with additional length added is necessary to prevent graft-size mismatch

Slow and controlled graft passage with the assistance of team members is crucial to prevent insertion problems

Appropriate arm positioning and suture tension for the lateral row anchors is important prior to final anchor insertion

Antegrade suture passage with a Scorpion (Arthrex, Naples, FL) or similar instrument via the lateral portal provides an efficient means of performing margin convergence

Excessive debridement of the subscapularis and infraspinatus remnants may limit the ability for margin convergence at the cuff-graft intervals

Smaller glenoids may not accommodate three anchors and may accommodate the use of only two anchors (this can be appreciated on preoperative imaging)

Malpositioning of the anchors can result in damage to the articular cartilage and insufficient pullout strength

Graft thickness should be selected carefully as thin grafts are predisposed to tearing

Medial row sutures should stay below the glenoid sutures at all times in order to avoid entanglement while passing the graft

If resistance is high during graft passage, avoid applying force, rather reverse your action and reassess

Suture over-tightening may result in “dog-ears” in case of a large graft or stiffness and predisposition for graft tearing with smaller grafts