Name: Anterior Capsular Reconstruction with Human Dermal Allograft for Irreparable Subscapularis Tears (Video) | JoVE Journal
Uploaded: 2025-05-09T14:40:00.000+00:00
Duration: 4 min 27 s
Description: Learn anterior capsular reconstruction using human dermal allograft for irreparable subscapularis tears. This technique provides structural support and improves shoulder function through precise graft fixation and rehabilitation.

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5 minutes

The authors have no acknowledgment.

The protocol follows the guidelines of our institution&#39;s human research ethics committee.
1. Patient positioning and preparation
<ol>
	<li>Position the patient in a beach-chair configuration (Table of Materials) under general anesthesia to ensure optimal access to the shoulder joint.</li>
	<li>Administer an interscalene block for postoperative pain management. 
	NOTE: An interscalene block is performed by the anesthesiologist injecting a local anesthetic near the brachial plexus at the level of the anterior and middle scalene muscles. The procedure is guided by ultrasound to ensure accurate placement, providing targeted nerve blockades for shoulder and upper arm surgeries.</li>
	<li>Prepare the surgical site using a standard sterile draping technique to expose the anterior shoulder region.</li>
</ol>
2. Surgical technique
<ol>
	<li>Approach and exposure
	<ol>
		<li>Make an 8-10 cm deltopectoral incision, starting at the coracoid tip and extending distally toward the deltoid tuberosity (Figure 1).</li>
		<li>Identify the deltopectoral interval and retract the cephalic vein medially or laterally to protect it from damage.</li>
		<li>Incise the clavicopectoral fascia using electrosurgical pencils to expose the anterior joint capsule (Figure 2).</li>
		<li>Use retractors to maintain a clear surgical field and minimize trauma to surrounding structures (Figure 3).</li>
	</ol>
	</li>
	<li>Subscapularis assessment and preparation
	<ol>
		<li>Use a curette to create a bleeding bone surface on the humeral lesser tuberosity to enhance allograft integration (Figure 4).</li>
		<li>Mobilize the SSc tendon with sharp and blunt dissection to release adhesions.</li>
		<li>Visually evaluate the feasibility of a tension-free repair by assessing tendon quality and retraction.</li>
		<li>Proceed with anterior capsular reconstruction5 if the tendon is severely retracted or of poor quality.</li>
	</ol>
	</li>
	<li>Glenoid preparation
	<ol>
		<li>Insert a Fukuda retractor (Table of Materials) to improve the visibility of the glenoid (Figure 5).</li>
		<li>Decorticate the anterior glenoid surface at the 2- and 4-o&#39;clock positions using a periosteal elevator, rasp, and curette to create a bleeding bone surface.</li>
		<li>Place two suture anchors (Table of Materials) at the prepared glenoid site for stable graft fixation (Figure 6).</li>
	</ol>
	</li>
	<li>Graft preparation
	<ol>
		<li>Select a human dermal allograft (Table of Materials) measuring approximately 50 mm &#215; 40 mm and 3-4 mm thick.</li>
		<li>If additional thickness is required, fold the graft in half to create a double-layer construct. Folding is optional and at the surgeon&#39;s discretion.</li>
		<li>Reinforce the edges of the graft with 1-0 silk sutures for stability and ease of handling during fixation (Figure 7).</li>
	</ol>
	</li>
	<li>Graft fixation
	<ol>
		<li>Place two additional suture anchors (Table of Materials) into the humeral lesser tuberosity to secure the graft (Figure 8).</li>
		<li>Thread sutures from the glenoid anchors through the graft and secure it to the anterior glenoid with firm knotting (Figure 9 and Figure 10). 
		NOTE: In this illustrated case, the graft is not folded to increase its thickness. However, depending on the surgeon&#39;s preference, the graft can be folded to create a thicker construct.</li>
		<li>Position the arm in neutral flexion with 30&#176; of abduction and 30&#176; of external rotation to ensure proper tensioning of the reconstructed capsule.</li>
		<li>Use sutures from the humeral lesser tuberosity anchors (Table of Materials) to pass through the graft (Figure 11). Secure the graft to the humeral side using a double-row suture bridge technique (Figure 12).</li>
	</ol>
	</li>
	<li>Completion and augmentation
	<ol>
		<li>If the SSc tendon stump is retracted but viable, suture it over the graft to augment the reconstruction.</li>
		<li>Close the rotator interval (Figure 13) and inferior capsule (Figure 14) using adjacent tissue sutures to restore the native soft tissue envelope.</li>
	</ol>
	</li>
</ol>
3. Postoperative rehabilitation
NOTE: First-generation cephalosporins were administered as antibiotics until postoperative day 1. For pain management, NSAIDs were provided alongside opioids on a PRN basis. Opioids were administered when the postoperative pain visual analog scale (VAS) score exceeded 7.
<ol>
	<li>Immobilization phase
	<ol>
		<li>Immobilize the shoulder in an abduction brace for 6 weeks to protect the reconstruction and facilitate initial healing.</li>
		<li>Initiate passive range-of-motion of forward flexion exercises during this period to prevent stiffness and maintain joint mobility without compromising graft fixation.</li>
	</ol>
	</li>
	<li>Early rehabilitation phase
	<ol>
		<li>At 6 weeks, begin a gradual rehabilitation program emphasizing passive and active-assisted range-of-motion exercises.</li>
		<li>Limit external rotation to 30&#176; initially to avoid excessive stress on the graft.</li>
	</ol>
	</li>
	<li>Strengthening phase
	<ol>
		<li>Introduce isometric strengthening exercises at three months to rebuild muscle strength gradually.</li>
		<li>Progress to full active range of motion and advanced strengthening exercises by six months.</li>
	</ol>
	</li>
	<li>Return to activity
	<ol>
		<li>Gradually transition patients to daily activities and athletic pursuits after achieving adequate strength and stability.</li>
	</ol>
	</li>
</ol>

<ol><li>Meshram, P., Rhee, S. M., Park, J. H., Oh, J. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+functional+and+radiological+outcomes+of+tears+involving+the+subscapularis%3A+Isolated+subscapularis+versus+combined+anterosuperior+rotator+cuff+tears%5BTitle%5D)+AND+%22Orthop+J+Sports+Med%22%5BJournal%5D)">Comparison of functional and radiological outcomes of tears involving the subscapularis: Isolated subscapularis versus combined anterosuperior rotator cuff tears.</a> Orthop J Sports Med. 8 (2), 2325967119899355(2020).</li>
<li>Su, W. -R., Budoff, J. E., Luo, Z. -P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+effect+of+anterosuperior+rotator+cuff+tears+on+glenohumeral+translation%5BTitle%5D)+AND+%22Arthroscopy%22%5BJournal%5D)">The effect of anterosuperior rotator cuff tears on glenohumeral translation.</a> Arthroscopy. 25 (3), 282-289 (2009).</li>
<li>Elhassan, B. T., Wagner, E. R., Kany, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Latissimus+dorsi+transfer+for+irreparable+subscapularis+tear%5BTitle%5D)+AND+%22J+Shoulder+Elbow+Surg%22%5BJournal%5D)">Latissimus dorsi transfer for irreparable subscapularis tear.</a> J Shoulder Elbow Surg. 29 (10), 2128-2134 (2020).</li>
<li>Luo, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcome+comparison+of+latissimus+dorsi+transfer+and+pectoralis+major+transfer+for+irreparable+subscapularis+tendon+tear%3A+A+systematic+review%5BTitle%5D)+AND+%22Am+J+Sports+Med%22%5BJournal%5D)">Outcome comparison of latissimus dorsi transfer and pectoralis major transfer for irreparable subscapularis tendon tear: A systematic review.</a> Am J Sports Med. 50 (7), 2032-2041 (2022).</li>
<li>Rhee, Y. G., Kyeong, T. H., Rhee, S. M., Kantanavar, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+capsular+reconstruction+in+irreparable+subscapularis+tear%3A+human+dermal+allograft%5BTitle%5D)+AND+%22J+Shoulder+Elbow+Surg%22%5BJournal%5D)">Anterior capsular reconstruction in irreparable subscapularis tear: human dermal allograft.</a> J Shoulder Elbow Surg. 32 (11), 2256-2263 (2023).</li>
<li>Baek, C. H., Kim, J. G., Baek, G. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Outcomes+of+combined+anterior+latissimus+dorsi+and+teres+major+tendon+transfer+for+irreparable+anterosuperior+rotator+cuff+tears%5BTitle%5D)+AND+%22J+Shoulder+Elbow+Surg%22%5BJournal%5D)">Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears.</a> J Shoulder Elbow Surg. 31 (11), 2298-2307 (2022).</li>
<li>Pogorzelski, J., Hussain, Z. B., Lebus, G. F., Fritz, E. M., Millett, P. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+capsular+reconstruction+for+irreparable+subscapularis+tears%5BTitle%5D)+AND+%22Arthrosc+Tech%22%5BJournal%5D)">Anterior capsular reconstruction for irreparable subscapularis tears.</a> Arthrosc Tech. 6 (4), e951-e958 (2017).</li>
<li>Omid, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biomechanical+analysis+of+anterior+capsule+reconstruction+and+latissimus+dorsi+transfer+for+irreparable+subscapularis+tears%5BTitle%5D)+AND+%22J+Shoulder+Elbow+Surg%22%5BJournal%5D)">Biomechanical analysis of anterior capsule reconstruction and latissimus dorsi transfer for irreparable subscapularis tears.</a> J Shoulder Elbow Surg. 29 (2), 374-380 (2020).</li>
<li>Mihata, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biomechanical+role+of+capsular+continuity+in+superior+capsule+reconstruction+for+irreparable+tears+of+the+supraspinatus+tendon%5BTitle%5D)+AND+%22Am+J+Sports+Med%22%5BJournal%5D)">Biomechanical role of capsular continuity in superior capsule reconstruction for irreparable tears of the supraspinatus tendon.</a> Am J Sports Med. 44 (6), 1423-1430 (2016).</li>
<li>Nuvoli, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Biological+patch+in+the+repair+of+rotator+cuff+tears%3A+Functional+and+clinical+evaluation+of+twenty-three+cases+with+a+mean+follow-up+of+six+years%5BTitle%5D)+AND+%22J+Clin+Med%22%5BJournal%5D)">Biological patch in the repair of rotator cuff tears: Functional and clinical evaluation of twenty-three cases with a mean follow-up of six years.</a> J Clin Med. 13 (18), 5596(2024).</li>
<li>Russo, M., Dirkx, G. K., Rosso, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patch+augmentation+in+arthroscopic+rotator+cuff+surgery-review+of+current+evidence+and+newest+trends%5BTitle%5D)+AND+%22J+Clin+Med%22%5BJournal%5D)">Patch augmentation in arthroscopic rotator cuff surgery-review of current evidence and newest trends.</a> J Clin Med. 13 (17), 5066(2024).</li>
<li>Mirzayan, R., Korber, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+capsular+reconstruction+with+acellular+dermal+allograft+for+subscapularis+deficiency%3A+a+report+of+two+cases%5BTitle%5D)+AND+%22Clin+Shoulder+Elb%22%5BJournal%5D)">Anterior capsular reconstruction with acellular dermal allograft for subscapularis deficiency: a report of two cases.</a> Clin Shoulder Elb. 27 (1), 126-130 (2024).</li>
<li>Shin, J. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pectoralis+major+transfer+for+treatment+of+irreparable+subscapularis+tear%3A+a+systematic+review%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthrosc%22%5BJournal%5D)">Pectoralis major transfer for treatment of irreparable subscapularis tear: a systematic review.</a> Knee Surg Sports Traumatol Arthrosc. 24 (6), 1951-1960 (2016).</li>
<li>Elhassan, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transfer+of+pectoralis+major+for+the+treatment+of+irreparable+tears+of+subscapularis%3A+does+it+work%5BTitle%5D)+AND+%22J+Bone+Joint+Surg+Br%22%5BJournal%5D)">Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work.</a> J Bone Joint Surg Br. 90 (8), 1059-1065 (2008).</li>
<li>Ruiz-Ibán, M. A., Murillo-González, J. A., Díaz-Heredia, J., Avila-Lafuente, J. L., Cuéllar, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pectoralis+major+transfer+for+subscapular+deficiency%3A+anatomical+study+of+the+relationship+between+the+transferred+muscle+and+the+musculocutaneous+nerve%5BTitle%5D)+AND+%22Knee+Surg+Sports+Traumatol+Arthrosc%22%5BJournal%5D)">Pectoralis major transfer for subscapular deficiency: anatomical study of the relationship between the transferred muscle and the musculocutaneous nerve.</a> Knee Surg Sports Traumatol Arthrosc. 21 (9), 2177-2183 (2013).</li>
<li>Komperda, K. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Anterior+Capsule+reconstruction+versus+pectoralis+major+transfer+for+irreparable+subscapularis+tears+involving+the+anterior+capsule%3A+A+comparative+biomechanical+cadaveric+study%5BTitle%5D)+AND+%22Arthroscopy%22%5BJournal%5D)">Anterior Capsule reconstruction versus pectoralis major transfer for irreparable subscapularis tears involving the anterior capsule: A comparative biomechanical cadaveric study.</a> Arthroscopy. 35 (11), 3002-3008 (2019).</li>
</ol>

The authors have nothing to disclose.

The success of ACR with human dermal allograft is contingent upon meticulous surgical technique and adherence to key procedural steps. Accurate preparation of the anterior glenoid and the lesser tuberosity of the humerus is crucial to achieve optimal fixation and facilitate graft integration. Proper tensioning of the reconstructed capsule is equally critical and is accomplished by positioning the arm in neutral flexion with 30&#176; of abduction and 30&#176; external rotation during the procedure. Postoperative rehabilit...

The subscapularis (SSc) is a critical component of the rotator cuff, responsible for maintaining shoulder stability, facilitating internal rotation, and acting as a restraint against anterior instability1. Damage or irreparable tears to the SSc can lead to significant pain, dysfunction, and progressive shoulder instability, often culminating in cuff tear arthropathy2. While surgical techniques such as tendon transfers are widely utilized to address these tears, they come with inherent limitations. Tendon transfers, including pectoralis major transfer, latissimus dorsi transfer, and latissimus dorsi with teres major transfers, are biomechanically non-anatomic and often fail to restore native shoulder kinematics, leading to high failure rates and complications3,4,5,6.
Anterior capsular reconstruction (ACR) with allograft has emerged as a promising alternative for managing irreparable SSc tears5,7. This technique offers a biomechanically anatomic solution by recreating the anterior capsule without compromising future surgical options8. It preserves shoulder biomechanics, providing a stable and functional joint environment8. The success of ACR has been inspired by the principles of superior capsule reconstruction, which have demonstrated improved outcomes in restoring shoulder stability in other rotator cuff pathologies9.
On the other hand, numerous studies have highlighted the effectiveness of human dermal allografts as augmentation in rotator cuff repair, with their clinical benefits also well-documented in superior capsular reconstruction9,10,11.
This technical note provides a comprehensive overview of the ACR technique using human dermal allografts to address irreparable SSc tears. By focusing on this specific technique, we aim to guide surgeons through the essential steps and considerations for successful ACR, emphasizing procedural nuances and the potential for improved clinical outcomes. This approach seeks to optimize functional recovery and pain relief for patients with severe SSc damage, offering a viable solution for those with limited treatment options.

<table><tbody><tr><td>Lift-Assist Beach Chair Positioner</td><td>Arthrex, Naples, FL, USA</td><td>AR-1627</td><td>Surgical bed</td></tr><tr><td>Universal Head Positioner</td><td>Arthrex, Naples, FL, USA</td><td>AR-1627-05</td><td>Head holder</td></tr><tr><td>SPIDER2</td><td>Smith &amp;amp; Nephew, Watford, UK</td><td>72203299</td><td>Pneumatic arm holder</td></tr><tr><td>HEALICOIL</td><td>Smith &amp;amp; Nephew, Watford, UK</td><td>72203707</td><td>Anchors for glenoid</td></tr><tr><td>Hi-Fi Tape</td><td>CONMED, Utica, NY, USA</td><td>YRC03</td><td>Anchors for humerus, medial row</td></tr><tr><td>CrossFT</td><td>CONMED, Utica, NY, USA</td><td>CFK-55DT</td><td>Anchors for humerus,</td></tr><tr><td>Knotless DT</td><td>CONMED, Utica, NY, USA</td><td>CFK-55DT</td><td>lateral row</td></tr><tr><td>Electrosurgical Pencils</td><td>CONMED, Utica, NY, USA</td><td>131307A</td><td>Electrocauterization</td></tr><tr><td>BellaCell HD</td><td>Hans, Daejeon, Korea</td><td>Not applicable</td><td>Human dermal allografts</td></tr><tr><td>Modified Fukuda-type Retractor</td><td>Innomed, Savannah, GA, USA</td><td>1930</td><td>Retractor for optimizing the surgical view of the glenoid</td></tr></tbody></table>

anterior capsular reconstruction with human dermal allograft for irreparable subscapularis tears

Anterior Capsular Reconstruction with Human Dermal Allograft for Irreparable Subscapularis Tears

Anterior capsular reconstruction (ACR) using human dermal allograft (HDA) is an innovative surgical technique for managing irreparable subscapularis (SSc) tears. This procedure begins with patient positioning in the beach-chair configuration under general anesthesia, combined with an interscalene block for postoperative pain control. A deltopectoral approach is utilized, with an 8-10 cm incision extending from the coracoid tip to the deltoid tuberosity. After identifying and retracting the deltopectoral interval, the anterior glenoid is prepared by decorticating the bone surface to promote graft integration. Two suture anchors are placed at the 2- and 4-o'clock positions of the anterior glenoid. The HDA, measuring 50 mm &#215; 40 mm and 3-4 mm in thickness, is folded into a double-layer configuration or used as a single layer based on the patient's requirements. The graft is secured with sutures to the glenoid anchors, with the arm positioned in neutral flexion, 30&#176; abduction, and 30&#176; external rotation for optimal tensioning. Additional fixation to the lesser tuberosity is achieved using a double-row suture bridge technique with anchors. For cases with a viable but retracted SSc tendon, augmentation over the graft is performed. Postoperative immobilization in an abduction brace is maintained for 6 weeks, followed by gradual rehabilitation. The precise graft fixation, tensioning, and structural support provided by this technique make ACR with HDA a valuable alternative to tendon transfers, preserving native shoulder biomechanics and offering a viable non-arthroplasty solution for severe anterior capsular deficiency.

This retrospective study5 was conducted with institutional review board approval patients who underwent open ACR with human dermal allograft for irreparable SSc tears between August 2020 and January 2022.
A total of 18 patients (mean age: 63.7 years) underwent open anterior capsular reconstruction (ACR) using human dermal allografts for irreparable subscapularis (SSc) tears, with a mean follow-up of 17 months. Inclusion criteria included Yoo-Rhee type 4 or 5 tears, Gout...

This article details an open anterior capsular reconstruction technique using human dermal allograft for irreparable subscapularis tears, providing structural support and enhancing functional outcomes through precise graft fixation and rehabilitation.

Anterior capsular reconstruction (ACR) using human dermal allograft (HDA) is an innovative surgical technique for managing irreparable subscapularis (SSc) ...

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Learn anterior capsular reconstruction using human dermal allograft for irreparable subscapularis tears. This technique provides structural support and improves shoulder function through precise graft fixation and rehabilitation.

Anterior Capsular Reconstruction with Human Dermal Allograft for Irreparable Subscapularis Tears

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