The Superior Capsular Reconstruction

Lessons Learned and Future Directions

John M. Tokish, MD; Justin L. Makovicka, MD


J Am Acad Orthop Surg. 2020;28(13):528-537. 

In This Article


The treatment of chronic, massive rotator cuff tears remains a challenge. Although success has been seen with many approaches, few valid options are available when this problem arises in a younger, active cohort. Research has demonstrated the importance of the superior capsule in shoulder stability, with increased glenohumeral translation in all directions with a defect in the capsule.[18] Biomechanical work has determined that superior translation could be completely restored by reconstructing the superior capsule, reestablishing stability of the shoulder.[13] This has led to an evolution in treatment approach in these patients.

Reconstruction of the superior capsule using fascia lata autograft has shown promising early results with notable increases in both ASES scores and AHD distances. Owing to concerns of donor site morbidity, SCR techniques using dermal allografts instead of fascia lata have gained popularity. The choice of graft and corresponding thickness continue to be analyzed in search for the option that provides the best results. In addition, alterations to the original technique, such as incorporation of the remnant cuff over the patch, or the addition of an acromial spacer, have been proposed as potential improvements (Figures 3 and 4).

Figure 3.

Incorporation of the native remnant rotator cuff into the patch. This image of the remnant cuff tied into the patch is viewed from the lateral portal. This incorporation is done lateral to the glenoid and separately from the side to side incorporation done anteriorly and posteriorly. If this medial to lateral incorporation is done, firing of whatever muscle is left will transfer forces across the patch and to the humerus.

Figure 4.

The SCR "Plus" Procedure. A, A second graft is fashioned from the remainder of the human dermal allograft not used for SCR. It is fashioned as a resurfacing graft on the undersurface of the acromion. B, The finished SCR "Plus" demonstrating the SCR graft (below), and the acromial resurfacing side (above), effectively doubling the width of the graft construct.

Although more than 15,000 SCRs have been done worldwide, there remains a paucity of outcome data and one must be vigilant to not allow enthusiasm to overtake critical evaluation. Although short-term clinical outcomes from SCR have been promising, results are still early, and it remains to be seen if these reconstructions will be durable over time. It must also be kept in mind that the vast majority of biomechanical and clinical literature has been published by a small group of surgeons, including the developer of the technique. The potential mechanisms of action, including a tenodesis effect, a force coupler, or a subacromial spacer, need further elucidation. Furthermore, whether the young patient who presents with pseudoparalysis and grade 3 or 4 Goutallier changes in their rotator cuff will regain functional strength after SCR remains an unanswered question.

Despite these questions, SCR has shown to be a promising approach to the irreparable rotator cuff tear. Further research is necessary to further define the indications, optimal technique, and limitations of this procedure.