Arthroscopic Superior Capsular Reconstruction for Massive Irreparable Rotator Cuff Repair  Stephen S. Burkhart, M.D., Patrick J. Denard, M.D., Christopher R. Adams, M.D., Paul C. Brady, M.D., Robert U. Hartzler, M.D.  Arthroscopy Techniques  Volume 5, Issue 6, Pages e1407-e1418 (December 2016) DOI: 10.1016/j.eats.2016.08.024 Copyright © 2016 Terms and Conditions

Fig 1 (A) Right shoulder, posterolateral viewing portal. Supraspinatus (SS) and infraspinatus (IS) obscure visualization of superior glenoid neck and impedes bone bed preparation. (B) Right shoulder, posterolateral viewing portal. After posterior interval slide, there is increased working space between the SS and IS to allow bone bed preparation to be performed more easily. (C) Right shoulder, posterolateral viewing portal. Anterior and posterior anchors (*) have been placed in the superior glenoid neck after performing posterior interval slide. Note that the exposure is much better than in (A), before the posterior interval slide was performed. Placement of anterior and posterior anchors into superior glenoid neck has been expedited by the expanded exposure afforded by posterior interval slide. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 2 Right shoulder, exterior view. Dermal allograft lying on top of lateral portal, just before passage into joint. Small arrows show sutures from glenoid anchors after mulberry knots have been tied; heavy arrow shows one FiberTape from medial row humeral anchors as another FiberTape is being passed. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 3 (A) Right shoulder, posterolateral viewing portal. Suture tapes from medial row of humeral fixation have been tensioned and have been secured by a lateral row of suture anchors. (B) Final construct of superior capsular reconstruction showing medial sutures (thin arrow); lateral fixation with FiberTapes (heavy arrows); and side-to-side fixation of dermal graft to infraspinatus (asterisk). Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 4 Residual defect in a right shoulder after repairing as much of the rotator cuff as possible. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 5 Right shoulder. Bone bed preparation on the superior glenoid and the greater tuberosity has been performed with a combination of ring curettes, motorized shavers, and motorized burrs. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 6 Right shoulder. Three glenoid suture anchors (BioComposite SutureTaks; Arthrex) are placed. In addition, 2 BioComposite SwiveLock-C suture anchors (Arthrex) are placed into the greater tuberosity at the articular margin of the proximal humerus. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 7 Right shoulder. (A) A flexible calibrated probe (Arthrex) is used to size the graft by measuring the distance between all 5 suture anchors. (B) The inserter for a SwiveLock-C suture anchor (Arthrex) is used as a punch to make 4 punch-holes for passage of the sutures from the 4 corners of the anchor construct. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 8 Right shoulder. Medial sutures have been passed through the graft extracorporeally. Cinch-loops have been placed in the 2 lateral punch-holes for later shuttling of the FiberTapes. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 9 Right shoulder. The PassPort cannula has been split (dotted red line) to allow for expansion or removal of the cannula in order to accommodate the oversized graft. The 2 zip-lines are the anterior and posterior groups of glenoid sutures. A calibrated Zip Line pusher (Arthrex) is used to alternately push the graft down the tensioned anterior and posterior zip-lines. At the same time, the sutures from the middle glenoid anchor are tensioned in order to pull the graft into place over the superior glenoid. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 10 Right shoulder. The calibrated Zip Line pusher (Arthrex) is pushing the graft down the posterior zip-line as the middle glenoid sutures pull the graft into position over the superior glenoid. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 11 Right shoulder. The lateral cinch-loops (FiberLink; Arthrex) have been “un-cinched,” and are used to shuttle the FiberTapes through the lateral punch-holes in the graft. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 12 Right shoulder. Lateral fixation of the graft has been achieved by criss-crossing the FiberTapes and securing them with 2 BioComposite SwiveLock-C suture anchors (Arthrex) in a SpeedBridge configuration. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 13 Right shoulder. Residual defect in the rotator cuff after repairing all reparable elements of the rotator cuff tear. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 14 Right shoulder. The bone beds on the superior glenoid and the greater tuberosity have been prepared. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 15 Right shoulder. Two suture anchors (BioComposite SutureTaks; Arthrex) have been placed in the superior glenoid, and 2 additional anchors (BioComposite SwiveLocks preloaded with FiberTape) have been placed at the articular margin of the greater tuberosity of the proximal humerus. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 16 Right shoulder. (A) A flexible calibrated probe is used to size the graft by measuring the distances between all 4 suture anchors. (B) The SwiveLock Inserter (Arthrex) is used as a punch to create 4 holes in the graft corresponding to the locations of the underlying suture anchors. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 17 Right shoulder. Shuttling sutures and graft fixation sutures are passed through the graft extracorporeally. Tapes are not passed through the graft at this stage; they will be shuttled after medial fixation has been completed. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 18 Right shoulder. A calibrated Zip Line pusher (Arthrex) is used to push the graft through the cannula by alternately pushing the graft down the 2 zip-lines as the medial “pulling suture” is tensioned. Note that the PassPort cannula has been split (red dotted line) and may either be expanded or removed to permit graft passage. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 19 Right shoulder. Once the graft is inside the shoulder, the Zip Line pusher (Arthrex) again pushes the graft down the 2 zip-lines as the “pulling suture” is tensioned. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 20 Right shoulder. Medial fixation of the graft to the superior glenoid is achieved by using a modified double-pulley technique to create a double mattress construct. At the lateral side of the graft, the FiberTapes are shuttled through the 2 punch-holes. Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions

Fig 21 Right shoulder. Lateral fixation of the graft is accomplished by means of a FiberTape SpeedBridge construct (Arthrex). Reproduced with permission from: Burkhart SS. The cowboy's conundrum: Complex and advanced cases in shoulder arthroscopy. Philadelphia: Wolters Kluwer, 2017, in press. Arthroscopy Techniques 2016 5, e1407-e1418DOI: (10.1016/j.eats.2016.08.024) Copyright © 2016 Terms and Conditions