Anterior Capsular Reconstruction for Irreparable Subscapularis Tears

Authors:

Jonas Pogorzelski, Zaamin B Hussain, George F Lebus, Erik M Fritz, Peter J Millett

Abstract:

The shoulder capsule and rotator cuff are the most important static and dynamic stabilizers of the glenohumeral joint. More precisely, anterior glenohumeral stability is maintained by the anterior shoulder capsule and the subscapularis muscle. Concomitant tearing of these structures with progression to irreparable capsular insufficiency is commonly understood as a major contributor to “end-stage” shoulder instability, which can cause devastating functional deficits. It predominantly affects young patients after multiple failed prior instability procedures, especially after previous thermal capsulorrhaphy. In addition, the presence of a hereditary collagen disorder further increases the risk of chronic severe anterior shoulder instability. Patients with prior open shoulder procedures in which the subscapularis muscle is detached may also be at risk.

In general, successful management of these patients is extremely challenging for the surgeon given the inadequate or poor-quality capsular, labral, and rotator cuff tissue, as well as the possible undiagnosed connective tissue disorders that may coexist. In cases in which a repair is not possible, few options remain for the treatment of these patients. Several surgical techniques, both nonanatomic and anatomic, have attempted to reconstruct the anterior glenohumeral capsule and the subscapularis muscle in this context. The results have varying rates of success and may be associated with altered biomechanics, high retear rates, and complications such as nerve injury. Optimal graft choices, techniques for graft placement and fixation, and rehabilitation protocols are all controversial.

The purpose of this article and Video 1 is to describe our preferred surgical technique for anterior capsular reconstruction using a human acellular dermal patch to treat irreparable subscapularis tears; advantages and disadvantages of the technique are outlined in Table 1. The allograft used in this procedure may offer additional benefits such as superior mechanical strength compared with the smaller, thinner tendon allografts used previously. Moreover, in patient groups with generalized tissue laxity or collagen disorders, allografts from nonaffected donors have the additional benefit of avoiding the pathology inherent to the donor’s autograft tissue.

For the complete study: Anterior Capsular Reconstruction for Irreparable Subscapularis Tears

Peter Millett, MD

Average rating:

39 reviews

Alexandra Thompson

Mar 23, 2024

by Alexandra Thompson on Peter Millett, MD

110%

Dr. Millett and his team did a SLAP tear repair and bicep tenodesis on my left shoulder. I use my arms as an artist, and love to swim in the ocean, surf, paddle, and telemark ski. So regaining full use of my shoulder and keeping my bicep attached was very important to me. Now, over two years later, my shoulder has the equivalent range of motion as my other arm and as before the injury, and no pain. After the first three months it felt so good and was so strong that - to my horror - I completely forgot my six-month follow-up.

Not only did Dr. Millett and his team make my arm as good as new, but having had the experience of such kindness and expertise throughout the process of surgery and recovery is like an added shoulder superpower.

Thank you Rita, Brooke, Jason, Sarah, Camille, Olivia, Dr. Millett and everyone! And see you soon when my husband comes in for his knee...

Jeff Chandler

Jan 31, 2022

by Jeff Chandler on Peter Millett, MD

Flawless procedure, Easy recovery

Dr. Millet's repaired my knee and tibia, following a botched operation by a different surgeon. That procedure was virtually pain free and I was weight bearing within a few days. That was 18 years ago and the knee is still strong. A few years after the knee incident, Dr Millet repaired my shoulder. My insurance company approved me for 3 months of disability following that surgery. I was off pain medication in 2 days and had 90% range of motion within a week. I withdrew my disability claim and returned to work within two weeks of surgery. I’m not a famous athlete—just a regular guy. Nonetheless, I was treated like an NFL at the Steadman clinic. Most notable was the time for recovery. Other surgeons perform their hour-long task in the OR and don’t involve themselves in the other functions. Peter and his team manages the entire process from diagnosis, anesthesia, nursing care, and therapy. He takes a holistic approach to patient care and doesn’t skip any steps.

Jenn West

Jul 2, 2021

by Jenn West on Peter Millett, MD

Saved My Life

I went to Dr. Millett after 7 knee surgeries (6 on my right and 1 on my left) and had seen 11 different surgeons who all refused to remove femur metal from my right leg. I am highly allergic to metal and the chronic pain was leaving me bedridden for 3.5wks out of a month. He personally wrote me back on my inquiry, listened to my concerns, scheduled my surgery within a week (due to insurance issues) and personally followed up with my recovery. The level of patient care from Dr. Millett and his ENTIRE team is above any care I have ever received in my 20 years of dealing with orthopedic surgeons. There are not enough words to describe the level of care, dedication and professionalism you receive from Dr. Millett and his staff.
My only disappointment is that I did not find him sooner!!!

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