Superior Capsular Reconstruction Combined With Latissimus Dorsi Transfer for Massive Irreparable Rotator Cuff Tears With Shoulder Hyperlaxity

Abstract

Massive rotator cuff injuries are a frequent and disabling shoulder disorder. Over the years, many treatment options have been proposed, including superior capsular reconstruction and latissimus dorsi transfer. However, in our experience, when these 2 approaches are performed individually, they have achieved suboptimal results in patients with massive cuff injury and concomitant shoulder hyperlaxity, as is most often the case in female patients with Beighton scores ≥4. Therefore, we considered the possibility of combining the 2 treatments, taking advantage of the dual stabilizing action of both approaches in cases of hyperlaxed shoulders with massive and irreparable rotator cuff lesions.

Fig 1

Lateral decubitus on the left side with the right shoulder at 70° abduction for the arthroscopic phase of the procedure.

Fig 2

View from the posterior portal of the subscapularis tendon (S) reinserted on the lesser tuberosity of the humerus and humeral head (H).

Fig 3

Glenoid (G) seen from the posterior portal during cleaning of the superior glenoid rim (red arrow).

Fig 4

View from the posterior portal of the glenoid (G), humeral head (H), and its anchors inserted on the upper edge of the glenoid. Anterior (red arrow) and posterior (blue arrow) anchorage.

Fig 5

View from the posterior portal of shaving and cleaning of the greater tuberosity of the humerus (T).

Fig 6

View from the posterior portal of the SwiveLock anchor insertion (red asterisk) in anterior position on the greater tuberosity of the humerus (T). The glena (G) appears in the background.

Fig 7

View from the posterior portal of the SwiveLock (Arthrex) anchor insertion (blue asterisk) in a posterior position on the greater tuberosity of the humerus (T). The glena (G) appears in the background.

Fig 8

Measurement of the length of the anterior margin of the patch with the dedicated Arthrex instrument (SCR Guide; Arthrex). View from the posterior portal, the glenoid (G) and humeral head (H) are appreciated.

Fig 9

Preparation of the patch and its doubling by suturing the 2 membranes together.

Fig 10

Full doubled patch. The upper side and the lateral and medial portions should be marked.

Fig 11

Detail of the passage of anchor wires over the patch using Scorpion suture passers (Arthrex).

Fig 12

Portals configuration. The PassPort cannula (Arthrex) (red arrow) is placed in posterolateral portal, arthroscope is placed in posterior portal (patient's right shoulder).

Fig 13

Arthroscopic detail of the patch passage through the PassPort cannula (Arthrex) as seen from the posterior portal.

Fig 14

View from the posterolateral portal of the patch (P) fixed to the glenoid rim (Gr).

Fig 15

Insertion of the second SwiveLock anchor (Arthrex) (red asterisk) on the distal part of the greater tuberosity of the humerus to complete the double-row suture for lateral patch fixation (P). View from the posterior portal.

Fig 16

Detail of the double-row suture as seen from the posterolateral portal.

Fig 17

View from the posterolateral portal of the suture between the patch (P) and the posterior cuff remnant (Pc) with a 2 mm TigerTape wire (Arthrex).

Fig 18

View from the posterolateral portal of the final patch configuration (P), attached to the glenoid rim (Gr) and sutured to the posterior cuff remnant (Pc).

Fig 19

Example of the positioning of the patient's arm with the shoulder at 90° of abduction and the elbow at 90° of flexion, during the withdrawal phase of the latissimus dorsi transfer (patient's right shoulder).

Fig 20

Latissimus dorsi tendon basted with different colors FiberWire threads (patient's right shoulder).

Fig 21

Surgical forceps indicate the space behind the long head tendon of the triceps (red asterisk) where the latissimus dorsi transfer will pass. Tendon of latissimus dorsi (LD) and teres major (TM) (patient's right shoulder).

Fig 22

Detail of the meniscus clamp passage (red arrow) with the 2 silicone tubes loaded for intra-articular transport. Teres major (TM), Latissimus dorsi (LD), and the long head of the triceps brachii (red asterisk) are shown. (patient's right shoulder)

Fig 23

Detail of the passage of latissimus dorsi tendon wires through silicone tubes using a wire loop (patient's right shoulder).

Fig 24

Detail of the passage of the latissimus dorsi (LD) transfer through the space posterior to the long head tendon of the triceps brachii by means of 2 transparent silicone suction tubes (patient's right shoulder).

Fig 25

View from the posterolateral portal of the latissimus dorsi (LD) transfer passing into the space between posterior cuff remnant and deltoid, and above the SCR membrane.

Fig 26

View from the anterolateral portal of the latissimus dorsi (LD) transfer passing over the SCR membrane, final surgery configuration.

Fig 27

Representation of SCR (in yellow) and LD transfer (in red) final configuration.