What is Superior Capsule & Anterior Rotator Cable Repair: Recouplage?
Recouplage, a French term meaning recoupling, is the act of connecting or joining things that have become separated. Superior capsule and anterior rotator cable repair is a surgical procedure to treat massive rotator cuff tears and involves reconstruction of the superior capsule and anterior rotator cable of the shoulder joint using an autograft (tissue from the same person) or an allograft (tissue from a donor).
The upper part of the capsular lining of your shoulder joint is the superior capsule. A rotator cuff is a group of 4 muscles in the shoulder joint including the supraspinatus, infraspinatus, teres minor, and subscapularis. These muscles originate in the scapula and attach to the head of the humerus through tendons. The rotator cuff forms a sleeve around the humeral head and glenoid cavity, providing stability to the shoulder joint while enabling a wide range of movements.
The anterior cable of the rotator cuff is the main ligamentous load-bearing structure deep to the supraspinatus tendon. Ruptures involving this anterior cable section of the supraspinatus have been shown to amplify rotator cuff tendon ruptures through the tendon strain of the infraspinatus. The anterior attachment of the rotator cuff cable is crucial for preserving rotator cuff function, superior capsule function, and shoulder kinematics.
The shoulder joint is stabilized by the joint capsule and rotator cuff. Tears to the rotator cuff can cause severe pain and impairment. When defects in the underlying upper joint capsule add to the instability caused by rotator cuff tears, it cannot be repaired with conventional treatments, requiring superior capsule and anterior rotator cable repair.
Anatomy of the Shoulder
The shoulder joint, also referred to as the glenohumeral joint, is a ball and socket joint, formed by the bone of the upper arm (humerus), which articulates with the shoulder blade (scapula) in a cavity called the glenoid fossa. The glenoid cavity is surrounded by a raised ridge of cartilage called the labrum that deepens the cavity, and a ligamentous structure called the shoulder capsule that centers the humerus in the cavity. A group of four tendons and muscles called the rotator cuff maintain stability of the shoulder joint, preventing the humerus from sliding out of the socket bone (dislocation). The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.
Indications for Superior Capsule & Anterior Rotator Cable Repair: Recouplage
Superior capsule and anterior rotator cable repair are mainly indicated for massive rotator cuff tears (MRCTs) of the shoulder joint. MRCTs are defined as cuff tears involving two or more cuff tendons or a retraction of greater than or equal to 5 centimeters. Reconstruction of the anterior rotator cable and superior capsule will help restore stability to the shoulder and minimize dysfunction.
Preparation for Superior Capsule & Anterior Rotator Cable Repair: Recouplage
Preparation for superior capsule and anterior rotator cable repair may involve the following steps:
- A review of your medical history and a physical examination to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to stop taking blood-thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Superior Capsule & Anterior Rotator Cable Repair: Recouplage
The surgery is usually performed arthroscopically, a minimally invasive technique that uses small incisions, an arthroscope, a slender tubular instrument with a light and camera on the end that projects images onto a monitor for your surgeon to view inside your shoulder joint, and thin surgical instruments to carry out the required repair.
In general, arthroscopic superior capsule and anterior rotator cable repair will involve the following steps:
- The procedure is performed under general and/or regional anesthesia with you lying either in a beach chair or lateral decubitus position.
- Your surgeon makes a few small incisions (arthroscopic portals), about half-inch in length, over your shoulder joint.
- An arthroscope is inserted through one of the incisions into your shoulder joint.
- The arthroscope transmits the image of the inside of your shoulder joint onto a television monitor for your surgeon to evaluate the defects.
- Your surgeon then passes miniature surgical instruments through the other incisions into the shoulder joint.
- Damaged soft tissue from the superior capsule and anterior cable is removed.
- Partial repair of the rotator cuff is then performed.
- The bones of the shoulder joint are then prepared for placement of the graft.
- The local proximal biceps tendon can be used as a graft for reconstruction of the anterior cable and superior capsule.
- Suture anchors are placed on the glenohumeral joint structures.
- The graft tissue is then passed and secured with sutures.
- The suture strands are further secured using lateral anchors (double row technique).
- Your surgeon ascertains that the graft is appropriately secured to the humeral head and superior glenoid.
- A final shoulder assessment is performed to confirm satisfactory repair and graft placement.
- Once the procedure is complete, the instruments are withdrawn, and the skin incisions are closed and bandaged.
Post-Operative Care and Recovery
In general, postoperative care and recovery after superior capsule and anterior rotator cable repair will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs.
- Following the surgery, your arm will be placed in a shoulder sling for 2 to 4 weeks to rest the shoulder and promote healing.
- You may experience pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed to address these.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You may also apply ice packs on the shoulder area to help reduce swelling and pain.
- You are encouraged to move around in bed and walk as frequently as possible to prevent the risk of blood clots.
- Instructions on incision site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities and lifting heavy weights for at least a couple of months. A gradual increase in activities is recommended.
- An individualized physical therapy protocol is designed to help strengthen your shoulder muscles and optimize shoulder function.
- You will be able to resume your normal daily activities in 3 to 4 weeks, but with certain activity restrictions. Return to sports may take 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
As with any surgery, superior capsule and anterior rotator cable repair are associated with some complications, which may include:
- Synovitis (inflammation of the synovial membrane)
- Allergic/anesthetic reactions
- Damage to adjacent soft tissue structures