Dermal Tuberoplasty for Irreparable Supraspinatus Tears Using Self-Punching, Knotless Fixation

Abstract

Superior capsular reconstruction has become an accepted treatment option for the irreparable rotator cuff tear in the nonarthritic shoulder. Widespread adoption of this technique has been limited, however, because of the technical difficulty of performing this procedure. Recently, allograft interpositional grafting of the greater tuberosity has gained popularity as a simpler alternative to superior capsular reconstruction and provides similar joint preservation advantages. We describe a technique for allograft interpositional tuberoplasty that simplifies graft delivery, graft fixation, and suture management by using a graft inserter and self-punching, knotless soft anchors.

Fig 1

A 3-mm-thick dermal allograft (asterisk) is prepared for loading onto a retractable graft inserter (C). The arrow indicates the medial edge of the graft, which has been prepared by pre-punching 2 holes and loading a No. 0 FiberWire (A) through each of its medial corners. A closed-loop suture passer (B) can be used to help pass the No. 0 FiberWire through the holes at the distal end of the graft inserter.

Fig 2

The 3-mm-thick dermal allograft (asterisk) is assembled on the graft inserter. The No. 0 FiberWire sutures (arrowhead) are crossed over the front of the inserter and cleated onto the opposite-side handle slot to maintain tension and control of the graft as it is inserted into the subacromial space.

Fig 3

Left shoulder in lateral decubitus position. Dermal allograft is inserted through a 10-mm flexible cannula placed through a low-lateral portal (A) and held in place against the greater tuberosity. The posteromedial anchor is being inserted through a percutaneous portal (B) just off of the lateral edge of the acromion. The anteromedial anchor has already been inserted percutaneously through a more anterior percutaneous portal (C); the anchor inserter has been removed and the repair sutures are seen exiting the portal (D).

Fig 4

Arthroscopic view of left shoulder through standard posterior portal. The dermal allograft is being held over the greater tuberosity with the graft inserter (asterisk). The posteromedial anchor (arrow) is inserted through the posteromedial pre-punched hole in the graft.

Fig 5

Left shoulder in lateral decubitus position. With the anteromedial (A) and posteromedial (B) anchors in place, the graft is fixated medially over the greater tuberosity. The graft can then be disengaged from the graft inserter by uncleating the No. 0 FiberWire tag sutures (C) from the handle and pulling 1 end of each of the sutures.

Fig 6

Arthroscopic view of left shoulder through posterior portal. The dermal graft (asterisk) is compressed by the crossing FiberTapes (arrows), which originate from the anteromedial (A) and posteromedial (B) anchors and are fixated by the anterolateral (C) and posterolateral (D) SwiveLock anchors.