Superior Capsular Reconstruction (SCR): The New Gold Standard for the Irreparable Cuff Tear in Activ

I'm Steve Burkhardt from San Antonio Texas and today I'm going to talk to you about

superior

capsular

reconstruction

and why I think it's the new

gold

standard

for

irreparable

cuff

tear

s in

activ

e patients in these

activ

e patients who don't have Glen arthritis smoke I think our goal It should be joint preservation, we don't necessarily want to put in a reverse total shoulder with all the restrictions that would entail and all the potential complications, so we're trying to do something that's arthroscopic and preserve your own natural joint the background behind it.

superior

capsule

reconstruction

or SCR are from dr.

Mahara and Japan, who reported good clinical results with SCR using fascia lata as an autograft, more recently in the United States we have been using dermal allograft as a graft source and we have done so for several reasons, one is that we thought it would reduce operative time compared to fascia lata would certainly reduce donor site morbidity compared to a signed fascia lata and there is a long history of good results using dermal allograft for

cuff

augmentation. The Brass group is my group of former colleagues and I who have been in Multicenter studies in the past and looked at patients with scr which we all did in 2015.

The surgeons were myself, Dr. Adams dr. Dan our dr. Brady and Dr. toke ish and we had 62 patients combined with a 75% satisfactory outcome in that group. Lessons learned in that initial pilot study. First of all, we need to use a three millimeter thick dermal allograft from that series. We had 5 1 millimeter grafts and of those 5 3 or 60% of those who failed the second lesson do not do the SDR in patients with significant arthritis, particularly Hamada 4, where there is bone-on-bone articulation because we had a failure rate of more than 90 percent in those patients with significant glenohumeral arthritis, lesson number three.

If the graft was healed by MRI, we had a 100 percent success rate, so I think it is necessary to do everything possible to achieve strong mechanical fixation which will then improve the healing potential with this graphic lesson, since the Most of the graphical glitches occurred on the human side. It was a little unexpected for us, but I think it now emphasizes that we need to pay attention to humoral graft fixation. We use a quick bridge and usually a double pulley medial mattress to reinforce that as well and if there is a front to back gap. you're closing, that's more than 30 millimeters.

I will add a third twist lock on the medial row of the humerus for those larger defects. The results of lesson number five varied by surgeon and I think a lot of that was indications and some of the surgeons would put them in if there was more arthritis than others and they had worse results, and for each surgeon, later patients had better results, so there is a learning curve and there is improvement in both choosing the right patients and performing the procedure. Over time, what are the indications? Who should get the SCR right? These should be active patients with a posterior representation generally of the superspinatus and/or the infraspinatus.

They should have minimal or no glenohumeral arthritis. They need to have a functional deltoid and trapezius. need an intact or repairable subscab another subgroup would be active patients with previous failed cuff repairs and a very thin capsule deficient capsule even though they could still be repairable my personal clinical results at the end of August of this year represent 97 patients Over a period of 3 years, I had two failures, one revision surgery required, one of them was revised to a total inverted shoulder ten months post-op after a fall and the other was revised for a second SCR and this particular patient was a younger than we had had a fall in the early postoperative period at one year we had a significant improvement in all parameters a significant improvement in range of motion from a preoperative 142° to a postoperative 167 degrees aces scores improved from 51 to 89, so almost up to 90 in our aces scores, the VAF scores were very little pain and the same scores are the percentage of normal that the patient felt his shoulder was about 86%, so there are some technical tips that I want to give them.

One of them would be that for a large chart that is more than 30 millimeters in the ap dimension, use three medial anchors in the superior glenoid and that will prevent both of them from chaining through that vertex of the glenoid if you use the chord of the arch and you will lose contact with the middle portion of your graft and you don't want to maintain that solid contact, you want to place your actual medial anchor anterior to the root of the biceps and you will place it at the junction of the coracoid base and the coracoid neck. and by doing that anterior to the apex of the glenoid, so that you basically have this kind of monk's hood that will prevent superior escape, you can improve visualization of the superior glenoid where the postern will slide and a super smooth extraction. suture through the device or portal, can an SCR reverse pseudoparalysis?

The answer is yes. I'll show you a couple of examples. This was a 72-year-old rancher, he had had two failed rotator cuff repairs in his left shoulder and was in constant pain from Souter's paralysis. Two different orthopedic surgeons had advised that he undergo a reverse total shoulder replacement. He said no, I don't want that because I can't restrict my activities. I have to do heavy work on the ranch. He did not do it. He has some flash of arthritis, but you see here, he definitely had pseudoparalysis. He could not raise his arm more than 30 degrees against gravity a year after the operation.

He rated his shoulder above 90%. He regained full active elevation with excellent external appearance. rotational force, so here he is a year after the operation and he sees that he completely recovered, he is doing all his work on the ranch and now he is very happy with this result. Here's another case, a 58-year-old man, a certified public accountant, has a desk job. but he has this deep pseudoparalysis. They recommended that he also undergo a reverse total shoulder replacement even though he is under 60 years old. If you look at his exam, you see this profound paralysis. He has a top exhaust from Andros.

He has lost physical condition. He was deltoid. so even though it's at about 30 degrees it starts to go down and sink again once you get to six months post op SCR had improved significantly and could easily raise the arm to about ninety degrees and then a year later Next, Op, again rated his shoulder above ninety percent, had an active elevation of about one hundred and fifty degrees. This was a little home movie that his wife made and sent to me, but she'll see that he can very functionally raise his arm above his head, but he had good strength. even staying at 90 degrees as you will see here, so he lays it horizontal and rock steady, what about the MRI after SCR?

This is a 56 year old man who suffered an injury two months after the operation, so I had an MRI which showed a very robust graft and then we had an MRI a year after the operation which again showed this very robust graft. robust, so this is what we like to see interestingly and a lot of these people in the younger age groups will see it. improvement in the transverse muscle, so if you look at the preoperative parasagittal skin section of the MRI on the left, you will see that there are grade three or four goutles, changes in fatty fatty infiltration and these have partially reverted to gotiles from grade one to two. a on the right hand a year after the operation, so this doesn't happen in everyone, but it happens in a good percentage of people, so it's been very impressive and very encouraging, so think about SCR as an alternative effective biological to reverse arthroplasty and these.

Younger, more active people and I think it works because it provides a stable point of support and optimizes our power couples.