Superior capsular augmentation for massive rotator cuff tears

2.1 Patients with rotator cuff tears may have shoulder pain and weakness accompanied by functional limitation leading to a reduced quality of life. Rotator cuff tears can be caused by an injury or can develop gradually. They can be minor or severe depending on the degree of damage to the tendon. Minor tears to the rotator cuff are very common and may not cause any symptoms at all. Diagnosis is usually by ultrasound or MRI.

2.2 Conservative treatment may include physiotherapy, pharmacological treatments (including pain relief and topical or oral non-steroidal anti-inflammatory drugs) and corticosteroid injections. If the tear is severe or has not responded to other treatments, surgical interventions such as debridement, rotator cuff repair, bridging rotator cuff reconstruction, subacromial smoothing, tendon transfer, or shoulder arthroplasty may be needed.

2.3 Superior capsular augmentation aims to improve pain symptoms and shoulder function in patients with massive and otherwise irreparable rotator cuff tears. The intention is to reduce superior gleno-humeral translation and restore superior stability with minimal re-tear rates. The optimal repair uses the patient's own rotator cuff muscles and tendons, but if the tear is too large augmentation with other tissue may be needed.

2.4 Superior capsular augmentation is done arthroscopically or by open surgery, with the patient either in the lateral decubitus position, or the 'beach-chair' position, and under general anaesthesia. It involves using a fascia lata autograft, an allograft or a regenerative tissue matrix. The arm of the patient is kept in neutral abduction and in neutral rotation. The supraspinatus and infraspinatus are repaired as much as possible and a biceps tenotomy or tendonesis are done on any biceps tear or instability. The superior glenoid and greater tuberosity are debrided to prepare for reconstruction. Using suture anchors, the graft is attached medially to the glenoid superior tubercle and laterally to the greater tuberosity. Side-to-side sutures between the graft and the infraspinatus tendon, as well as between the graft and the residual anterior supraspinatus or subscapularis may also be added to improve force coupling. Post-operative rehabilitation is essential and can be long and difficult.