Hamburger Technique: Augmented Rotator Cuff Repair With Biological Superior Capsular Reconstruction

Abstract

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).

Fig 1

Cuff tear and prepared footprint. Diagram is of right shoulder.

Fig 2

Suture passed through tenotomized LHB stump. The arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position. (LHB, long head of the biceps.)

Fig 3

LHB secured to footprint. The arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position. (ECM, extracellular matrix; LHB, head of the biceps.)

Fig 4

Standard medial row repair of the tendon tear using either 1 or 2 medial row anchors. The arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.

Fig 5

Patch preparation and suture passage into the patch. The patch is prepared outside the body by making2holes in the augment, through which the anchor suture limbs are passed, and a third hole more medially (approximately 5 mm from the medial edge of the patch and in between the other 2 holes). In addition, the corners of the rectangular patch are cut in order to leave an octagon.

Fig 6

ECM patch secured over rotator cuff repair. The medial edge of the patch is secured to the medial aspect of the cuff by tying the 2 limbs of the free FiberWire suture with arthroscopic knots through the Neviaser port. Lateral stabilization of the patch is achieved by a transosseous equivalent technique incorporating the augment into the construct. Two lateral row anchors (are inserted (laterally), one anterior and one posterior, thus securing the augment. The arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position. (ECM, extracellular matrix.)

Fig 7

Hamburger construct with ECM patch on top, RC repair in middle and LBH tendon underneath. Diagram is of right shoulder. (ECM, extracellular matrix; LHB, head of the biceps; RC, rotator cuff.)