Abstract
Arthroscopic superior capsular reconstruction (ASCR) is an option to treat irreparable rotator cuff tear. Different techniques have been used for ASCR. In this Technical Note, we use autogenous peroneus longus tendon to build a bridge for ACSR. Our technique is back-and-forth folding and fixation of the autogenous peroneus longus tendon under arthroscopy. This technique provides a simple and efficient method to repair irreparable rotator cuff tear.
Technique Video
Irreparable rotator cuff tears (IRCTs) in relatively young patients are a tricky problem for joint surgery and sports medicine surgeons.1 Treating IRCTs is full of challenges and has motivated experts to conduct more in-depth studies.2 Before resorting to reverse total shoulder arthroplasty, several methods to treat IRCTs can be attempted,3 such as arthroscopic debridement and partial repair with residual rotator cuff, transition of the long head of the biceps patch or balloon implantation, and arthroscopic superior capsular reconstruction (ASCR).4
Mihata et al.5 first reported the superior capsular reconstruction (SCR) technique for the treatment of IRCTs. The reconstructed superior capsule provides a spacer and fulcrum to stabilize the upwardly humeral head.6 The results showed significantly improved function and range of motion of the shoulder. The described autograft sources for SCR include fascia lata autograft, human acellular dermal allograft, allogeneic tendon, autologous hamstring, and biological patch.7,8 We harvest autologous peroneus longus tendon to avoid the limitation of lateral recumbent position during autologous graft preparation. In this Technical Note, we introduce a technique for ASCR using autologous peroneus longus tendon (APLT) (Video 1).
Surgical Technique
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (the institutional review board of Sun Yet-sun University, No. SYSU-2022528) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Preoperative Evaluation and Surgical Indications
The indications for ASCR with APLT include patients with IRCTs, nonresponse to conservative treatment after 3 to 6 months, no obvious osteoarthritis in the glenoid humeral joint (Hamada grade I or II), and intact structure and strength of the deltoid muscle.
Patient Positioning, Arthroscopic Portal Preparation, Exploration, and Debridement
After the preoperative safety check, the patient is placed in a lateral recumbent position on the operating table under general anesthesia and nerve block. The operative side is sterilized and draped in the conventional way. Mark the locations of the scapular spine, acromion, clavicle, coracoid process, and acromioclavicular joint on the patient′s skin.
For this Technical Note, we establish 6 arthroscopic portals: posterior, posterolateral, anterior, anterior inferior, anterolateral, and Neviaser (Fig 1). First, a standard posterior portal is established, and a 30° arthroscope (Smith & Nephew) is introduced into the glenohumeral joint. Diagnostic exploration of the glenohumeral joint is performed. Under careful arthroscopic evaluation, we should confirm the IRCT, cartilage condition glenohumeral joint, and the pully structure of the long head of the biceps tendon (LHBT). The anterior portal is established by the outside-in technique. The low-temperature plasma and shaver blades are accessed for debridement. The treatment of the LHBT (resection or tenodesis) mainly depends on the injury and inflammation, patient age, and their occupation. Spontaneous rupture or poor quality of the LHBT cannot be transposed.
Fig 1.
The portals used for arthroscopic superior capsular reconstruction (ASCR) are shown. We create 6 arthroscopic portals: posterior (P), posterolateral (PL), anterior (A), anterior inferior (AI), anterolateral (AL), and Neviaser (N), which are used for exploration, introducing tendon, and implantation of anchors.
The anterior inferior portal is applied in reserve. The rotator cuff interval is widely released. Decompression of the subacromial bursal tissue is necessary. We need to ensure sufficient subacromial space and a clear operative field of view. The posterolateral portal is established by the outside-in technique for the observation of rotator cuff tears. The Neviaser portal is used for implantation of anchor (3.0 mm; DePuy) at the 10-o'clock and 11-o'clock positions of the superior scapular glenoid. The assisted portal is established by the outside-in technique for the implantation of 4 anchors (4.75 mm; Arthrex) around the rotator cuff footprint.
Preparation of APLT
We make a 2- to 3-cm skin incision on the posterior lateral ankle styloid process. Separate the deep fascia and expose the peroneus longus tendon. Cut the tendon as close to the distal side as possible. Use a 6-mm diameter tendon stripper (Smith & Nephew) to extract the tendon towards the proximal end of peroneus longus tendon. The autogenous peroneus longus tendon is prepared with No. 2 ETHIBOND Suture (Johnson & Johnson) full-length weaved (Fig 2). The APLT graft is approximately 25 cm long and 6 to 10 mm in diameter, It is fully woven with a high strength suture of approximately 10 cm at both ends.
Fig 2.
The autogenous peroneus longus tendon is prepared with a No. 2 ETHIBOND full-length woven suture. The autogenous peroneus longus tendon graft is approximately 25 cm long and 6 to 10 mm in diameter. It is fully woven with a high-strength suture of approximately 10 cm at both ends.
Arthroscopic Superior Capsular Reconstruction
The footprint of rotator cuff and superior scapular glenoid are debrided to a fresh cancellous bone bed. Two suture anchors (3.0 mm; DePuy) are implanted at the 10-o'clock and 11-o'clock positions of the superior scapular glenoid (right shoulder) with Neviaser portal (Fig 3). The thick end of the tendon is clamped from the posterior approach and pulled to the 10-o'clock position of the superior scapular glenoid for fixation with the suture anchors (Fig 4). Thread the suture around the tendon and use a knotter to push it to the 10-o'clock position for temporary fixation. At 1 cm from the lateral side of cartilage of the humeral head, 2 anchors (4.75 mm; Arthrex) is implanted into the footprint of the greater tuberosity of the humerus (Fig 5). Fix the temporarily fixed end with the suture of a 10-o'clock anchor. Translate the free tendon to the anchor at the 11-o'clock position and fix it with suture. Refer to the previous method, the 2-strand tendon fixed between the superior scapular glenoid and the greater tuberosity. We use a suture hook (Spectrum-I; Conmed) and PDS-II (Ethicon) to pass the suture. The segment of the APLT graft is placed at the scapular glenoid with arthroscopic SMC knot fixation. The APLT graft is shuttled back and forth and fixated at the anchors of tuberosity footprint (Fig 6). Finally, side-to-side fixation of infraspinatus muscle and APLT graft (Fig 7). Most patients can meet clinical needs after 2 folds of the APLT graft. Suture the posterior tendon side to side with the posterior rotator cuff and remove redundant free tendons.
Fig 3.
The arthroscopic screenshot of a right shoulder in the lateral decubitus position. Two suture anchors (3.0 mm; DePuy) are implanted at 10-o'clock and 11-o'clock of superior scapular glenoid (right shoulder) with the Neviaser portal.
Fig 4.
The view from posterolateral arthroscopic portal (right shoulder, with patient in lateral recumbent position) showing the thick end of the tendon is clamped from the posterior approach and pulled to the 10 o'clock of the superior scapular glenoid for fixation with the suture anchors (arrow).
Fig 5.
The view from posterolateral arthroscopic portal (right shoulder, with patient in lateral recumbent position) showing 1 cm from the lateral side of cartilage of the humeral head, two anchors (4.75 mm; Arthrex) are implanted into the footprint of the greater tuberosity of the humerus (arrow).
Fig 6.
The view from posterolateral arthroscopic portal (right shoulder, with patient in lateral recumbent position) showing the APLT graft is shuttle back and forth and fixated at the anchors of tuberosity footprint (arrow).
Fig 7.
The view from posterolateral arthroscopic portal (right shoulder, with patient in lateral recumbent position) showing side-to-side fixation of infraspinatus muscle and APLT graft (arrow).
Postoperative Rehabilitation
After the operation, the patient follows an SCR-to-repair-the-IRCT rehabilitation plan. The shoulder is placed into an abduction brace at 60° and maintained for 6 weeks. One day after the operation, elbow, wrist, hand exercises, and pendulum exercises are allowed. Gradual passive mobilization of the shoulder is implemented under the limitation of 45° abduction, 90° forward elevation, and external rotation 15 days after operation. At 6 weeks after surgery, the abduction brace is removed. Full range of motion of active movement and daily activities gradual recovery. Strengthening or resistance exercises begin 12 weeks after surgery.
Discussion
The treatment of IRCTs in younger patients presents a challenge for orthopaedic surgeons.9 ASCR has become popular to treat IRCT.10, 11, 12 Good clinical outcomes have been reported after ASCR surgery.13 Popular grafts for ASCR are dermal, fascia lata autograft, and others.14, 15, 16
In our technique, we use an APLT graft. The advantages and disadvantages of our technique are listed in Table 1. Compared with dermal allograft or different allogeneic grafts, using autologous tendons can reduce costs. APLT grafts are available and cheaper than several allografts. The surgical procedure is relatively simple compared with that of the fascia lata autograft or dermal allograft. There is no need to measure the size of the graft during surgery. It avoids a limitation of lateral recumbent position during autologous graft preparation. The expenses related to this technique include the 6 anchors used for fixation of the APLT. Despite several methods and grafts used, ASCR still has a certain learning curve.
Table 1.
Advantages and Disadvantages of APLT Transposition for ASCR
| Advantages |
| The surgical procedure of ASCR techniques is relatively simple compared with fascia lata autograft or dermal allograft |
| Using autologous APLT graft can save graft costs |
| There is no need to measure the size of the graft during surgery |
| It avoids a limitation of lateral recumbent position during autologous graft preparation. |
| Disadvantages |
| Donor-site morbidity compared with autograft |
| Costs of suture anchors (6 anchors) |
| Still has a certain learning curve |
APLT, autogenous peroneus longus tendon; ASCR, arthroscopic superior capsular reconstruction.
The APLT graft is 6- to 7-mm thick. It is adequate to restore the stability of the superior glenohumeral joint. It also is easy to adjust the suture of the graft intraoperatively. The LHBT for ASCR also is used to reconstruct the partial superior capsular.17 However, it is difficult to adequately cover the superior capsular defect in massive, IRCTs.18 Some authors reports the biomechanical and clinical outcomes of this “shuttle back-and-forth” graft suturing for SCR.19 Although the transposition of the LHBT is effective in treating massive rotator cuff tears, spontaneous biceps tendon rupture or poor quality restricts the use of LHBT. By using this technique, the length of the free tendon can be adjusted as needed, without relying on precise measurement, greatly simplifying the procedure of SCR. This technique has achieved excellent postoperative results through follow-up.
In conclusion, we describe a technique for ASCR using APLT to build a bridge for ASCR to repair IRCT. The procedure of this technique is intuitive, simple, and controllable.
Disclosures
All authors (J.W., Y.H., H.L, J.L., Y.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Funding
This research was supported by the Joint Funds of the Zhejiang Provincial Natural Science Foundation of China under grant no. LBY21H170001; Basic research project of Shenzhen Science and technology innovation Commission under grant no. JCYJ20210324122807021; and Guangxi key Laboratory of Basic and Translational Research of Bone and joint Degenerative Disease (21-220-06/ 202202).
Footnotes
J.W., Y.H., H.L., and J.L. contributed equally to the manuscript.
Supplementary Data
In this Technical Note, we establish 6 arthroscopic portals: posterior, posterolateral, anterior, anterior inferior, anterolateral and Neviaser. First, a standard posterior portal Is established and a 30° arthroscope introduced into the glenohumeral joint. Diagnostic exploration of glenohumeral joint is performed. Under careful arthroscopic evaluation, we should confirm the existence of the irreparable rotator cuff tear, cartilage condition of the glenohumeral joint, and the pully structure of long head biceps tendon. The autogenous peroneus longus tendon is prepared with a No. 2 full-length ETHIBOND woven suture. The APLT graft is approximately 25 cm long and 6 to 10 mm in diameter. It is fully woven with a high strength suture of approximately 10 cm at both ends. The footprint of rotator cuff and superior scapular glenoid are debrided onto a fresh cancellous bone bed. Two suture anchors (3.0 mm; DePuy) are implanted at 10-o'clock and 11-o'clock of superior scapular glenoid (right shoulder) with Neviaser portal. The thick end of the tendon was clamped from the posterior approach and pulled to the 10 o'clock of the superior scapular glenoid for fixation with the suture anchors. One centimeter from the lateral side of cartilage of the humeral head, 2 anchors (4.75 mm; Arthrex) are implanted into the footprint of the greater tuberosity of the humerus. Translate the free tendon to the anchor at the 11-o'clock position and fix it with the suture. Refer to the previous method, 2-strand tendon fixed between the superior scapular glenoid and the greater tuberosity. The ALPT graft is shuttled back and forth and fixated at the anchors of tuberosity footprint. Finally, side-to-side fixation of infraspinatus muscle and ALPT graft is completed.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
In this Technical Note, we establish 6 arthroscopic portals: posterior, posterolateral, anterior, anterior inferior, anterolateral and Neviaser. First, a standard posterior portal Is established and a 30° arthroscope introduced into the glenohumeral joint. Diagnostic exploration of glenohumeral joint is performed. Under careful arthroscopic evaluation, we should confirm the existence of the irreparable rotator cuff tear, cartilage condition of the glenohumeral joint, and the pully structure of long head biceps tendon. The autogenous peroneus longus tendon is prepared with a No. 2 full-length ETHIBOND woven suture. The APLT graft is approximately 25 cm long and 6 to 10 mm in diameter. It is fully woven with a high strength suture of approximately 10 cm at both ends. The footprint of rotator cuff and superior scapular glenoid are debrided onto a fresh cancellous bone bed. Two suture anchors (3.0 mm; DePuy) are implanted at 10-o'clock and 11-o'clock of superior scapular glenoid (right shoulder) with Neviaser portal. The thick end of the tendon was clamped from the posterior approach and pulled to the 10 o'clock of the superior scapular glenoid for fixation with the suture anchors. One centimeter from the lateral side of cartilage of the humeral head, 2 anchors (4.75 mm; Arthrex) are implanted into the footprint of the greater tuberosity of the humerus. Translate the free tendon to the anchor at the 11-o'clock position and fix it with the suture. Refer to the previous method, 2-strand tendon fixed between the superior scapular glenoid and the greater tuberosity. The ALPT graft is shuttled back and forth and fixated at the anchors of tuberosity footprint. Finally, side-to-side fixation of infraspinatus muscle and ALPT graft is completed.