Arthroscopic Subscapularis Repair: Surgical Tips and Pearls A to Z

doi:10.1016/j.arthro.2006.07.020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 22, Issue 9, September 2006, Pages 1014-1027

https://doi.org/10.1016/j.arthro.2006.07.020 Get rights and content

Abstract

Arthroscopic subscapularis repair can be technically challenging. This article summarizes a number of technical tips that can greatly simplify and expedite what otherwise might be a daunting surgical procedure. Specific tips and pearls include the following:

1
A description of a new clinical test—the bear-hug test—for detecting subscapularis tears on physical examination.
2
How to accurately place portals for precise subscapularis repair.
3
How to safely and accurately perform a coracoplasty.
4
How to identify and mobilize a retracted subscapularis tear.
5
How the comma sign can be used to simplify arthroscopic subscapularis repair.
6
How to securely repair all sizes of subscapularis tear.
7
A description of postoperative immobilization and rehabilitation to optimize results of arthroscopic subscapularis repair.

Section snippets

Safety of approach

The key to success with this procedure is to know the arthroscopic anatomy around the coracoid. The anatomy at risk includes the axillary nerve, the axillary artery, the musculocutaneous nerve, and the lateral cord of the brachial plexus. All of these are greater than 25 mm from the coracoid on anatomic cadaveric dissections.⁴

The safety of mobilization of the subscapularis tendon has been called into question because of the potential for neurovascular injury with subscapularis release, a

Before You Begin (Preoperative Planning)

The clinician should be suspicious of a torn subscapularis based on preoperative physical examination. Recently, the senior author (S.S.B.) examined the sensitivity and specificity of several physical examination techniques in terms of identifying a torn subscapularis and confirmed the following correlations.⁶ The lift-off test⁷ is not positive until at least three fourths of the subscapularis tendon is detached and, therefore, is not a good test for upper subscapularis tears. The Napoleon test¹

Does fatty degeneration of the subscapularis matter?

There has been some suggestion in the orthopaedic literature that fatty degeneration of the rotator cuff might be a contraindication to rotator cuff repair and that muscle-tendon units with fatty degeneration do not have an ability to heal.10, 11 In the case of the subscapularis, this does not seem to hold true. The subscapularis appears to be unique among the rotator cuff tendons in that a significant part of its function is a tenodesis function and it is needed as an anterior restraint.¹²

What if the subscapularis is not repairable?

First of all, the subscapularis is almost always repairable through meticulous mobilization techniques and through medialization of the bone footprint. Occasionally, there may be a subscapularis that is not repairable. In such a case one may consider an Achilles tendon allograft or a subcoracoid pectoralis major transfer.¹³

Proximal humeral migration

Proximal humeral migration can occur with massive anterosuperior tears (combined subscapularis, supraspinatus, and infraspinatus tears). When proximal humeral migration occurs as a result of these large tears, there is frequently loss of overhead function. In our series of subscapularis repairs, 10 of 25 patients had anterosuperior rotator cuff tears with proximal humeral migration.1, 2 All of these had lost overhead function. With subscapularis repair combined with repair of the residual tear

Postoperative protocol

After repair of the subscapularis, with or without associated repair of other rotator cuff tendons, the patient’s extremity is placed in a sling for 6 weeks. In the case of a complete subscapularis tear, external rotation beyond 0° is not allowed for 6 weeks. With partial subscapularis tears, we allow passive external rotation to approximately 30°. No overhead motion is allowed for 6 weeks. However, the patient may use the hand in the straight-ahead position for writing or for eating. The sling

Conclusions

1
Arthroscopic subscapularis repair, even with retracted tears, can reliably be done.
2
The surgeon must understand the anatomy around the coracoid.
3
The surgeon must remember that the comma sign is the key to locating the superolateral corner of the subscapularis.
4
Secure fixation into the lesser tuberosity and adequate postoperative immobilization are essential for successful repair.

References (13)

S.S. Burkhart et al.
Arthroscopic subscapularis tendon repair: Technique and preliminary results
Arthroscopy
(2002)
W.F. Bennett
Subscapularis, medial, and lateral coracohumeral ligament insertion anatomyArthroscopic appearance and incidence of “hidden” rotator interval lesions
Arthroscopy
(2001)
J.J. Warner et al.
Diagnosis and treatment of anterosuperior rotator cuff tears
J Shoulder Elbow Surg
(2001)
S.S. Burkhart et al.
Loop security as a determinant of tissue fixation security
Arthroscopy
(1998)
S.S. Burkhart et al.
The disabled throwing shoulder: Spectrum of pathologyPart I: Pathoanatomy and biomechanics
Arthroscopy
(2003)
I.K.Y. Lo et al.
Subscapularis tears: Arthroscopic repair of the forgotten rotator cuff tendon
Tech Shoulder Elbow Surg
(2002)

There are more references available in the full text version of this article.

Cited by (141)

Combined, Single-Anchor Subscapularis Tendon Repair and Proximal Biceps Tenodesis Leads to Improved Function and Decreased Pain at 1 Year
2024, Arthroscopy, Sports Medicine, and Rehabilitation
To evaluate the 1-year clinical outcomes of patients treated with combined proximal biceps tenodesis and repair of type II to III subscapularis tendon (SST) injuries according to Lafosse et al., using the Loop ‘N’ Tack (LNT) technique.
All patients undergoing proximal biceps tenodesis and rotator cuff repair between March 1, 2020, and January 30, 2022, were retrospectively identified. Only patients undergoing combined proximal biceps tenodesis and repair of grade II or III SST injuries with a minimum follow-up of 1 year were included. All patients underwent combined single-anchor proximal biceps tenodesis and SST repair using the LNT technique. The following outcome scores were recorded at a final follow-up of 1 year postoperatively and compared with baseline, preoperative values: American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), Veterans Rand 12 Item Health Survey (VR-12), and visual analog scale (VAS). The minimal clinically important difference (MCID) for all outcome indices was determined with a distribution-based method.
A total of 41 consecutive patients were included. The MCID values for VAS pain, ASES, SANE, and VR-12 mental scores were 0.97, 8.5, 10.9, and 6.0 respectively. At 1-year final follow-up, approximately 95% (39/41) of patients exceeded the MCID for VAS pain scores, 90% (37/41) of patients for ASES scores, 85.4% (34/41) of patients for SANE scores, and 75.6% (31/41) of patients for VR-12 mental health scores. On average, ASES and SANE scores improved by 37 (preoperatively: 45.2, 1 year: 82.4, P < .001) and 38 points (preoperatively: 38.0, 1 year: 75.7, P < .001), respectively, while VAS scores decreased by 4 points (preoperatively: 5.49, 1 year: 1.48, P < .001). Approximately 88% (36/41) of patients were satisfied at 1 year postoperatively. Treatment failure was observed in 1 patient (2.4%).
Patients treated with combined, single-anchor SST repair and LNT proximal biceps tenodesis achieved significant improvements in function, high satisfaction, and low rates of reoperation at 1 year postoperatively. Additionally, 76% to 95% of patients met the MCID for VAS pain, ASES, SANE, and VR-12 mental health scores.
Level IV, retrospective case series.
Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes
2024, Journal of Shoulder and Elbow Surgery
Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon.
Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded.
In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear.
Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.
Arthroscopic subscapularis repair using the subscapularis interlocking (SICK)-stitch technique leads to restoration of clinical function with low complication and revision rates
2024, JSES International
The purpose of this study is to determine the mid-term outcome after arthroscopic subscapularis tendon (SCP) reconstruction using the subscapularis interlocking (SICK)-stitch technique. The hypotheses are that arthroscopically repaired SCP lesions using the SICK-stitch show a good restoration of shoulder function with low complication and failure rates.
This is a retrospective monocentric study of n = 199 patients (n = 106 female) with arthroscopically treated SCP tears with the interlocking (SICK) stitch technique from July 2013 to October 2018. Inclusion criteria: minimum follow-up of 2 years. Exclusion criteria: irreparable and massive cuff tears, osteoarthritis, and fractures. The postoperative assessment consisted of the range of motion, constant score, simple shoulder test, simple shoulder value, disability of the shoulder and arm score, short form 12, and patient satisfaction.
Mean age was 61 years (25-83); n = 4 (2%) patients were lost to follow-up with mean follow-up time of 63.6 months (36-96). Additional supraspinatus tendon lesions (n = 147) were repaired in n = 101 cases. SCP grading (n = 69) (35% traumatic) (Fox/Romeo): n = 113 grade II, n = 71 grade III, n = 11 grade IV. A positive preoperative lift-off test (n = 132, 68%) was corrected in n = 124 (94%) of cases. Ninety seven percent of patients would undergo surgery again with a mean satisfaction score of 14.4/15. Results at final follow-up (data: mean pre; post; P value): lexion (130; 166; .001), abduction (123;159; .001), external rotation (35;82; .001), internal rotation (52; 68; .07), constant score (50; 82; .001), disability of the shoulder and arm score (40; 19; .001), simple shoulder test (5; 10; .001), and simple shoulder value (44; 83; .001) significantly improved. The mean physical health scale short form 12 was 46 (24-63) and 51 (15-66) for mental health. Age, body mass index, SCP-grading, and supraspinatus tendon repair did not significantly affect any outcome parameter. Three (1.5%) patients underwent revision surgery, of which 1 (0.5%) had an infection.
Two years after arthroscopic SCP repair using the SICK-stitch technique, we observed excellent restoration of clinical function with low complication and revision rates. The SICK-stitch technique thus represents a good and reliable therapeutic option for the arthroscopic repair of SCP lesions.
Arthroscopic Subscapularis Repair With Preserved Biceps Anatomy
2023, Arthroscopy Techniques
Arthroscopic subscapularis repair continues to improve with the advancement of surgical technique and critical focus on careful intraoperative evaluation. As identification of these tears increases, there is an expected increase in repair rates as well. Anatomically, the upper border of the subscapularis and the long head of the biceps (LHB) tendon are in close relation. Many surgeons have advocated concomitant LHB tenotomy versus tenodesis in conjunction with operative subscapularis tears. We hypothesized that in the setting of a preserved anatomic biceps pulley and no LHB pathology, isolated subscapularis repair would result in excellent clinical outcomes when compared with subscapularis repair and biceps tenotomy or tenodesis.
Relationship between rotator cuff posterior delamination and subscapularis tear: a large cross-sectional analysis
2023, JSES International
Rotator cuff posterior delamination and subscapularis tear are commonly observed in rotator cuff injuries. However, there are very few studies on the relationship between posterior delamination and subscapularis tendon tear. This study aimed to investigate the relationship between posterior delamination and subscapularis tendon tear.
The study was conducted from March 2018 to June 2021 with 553 patients who underwent rotator cuff repairs at two institutions. The age and gender, size of rotator cuff tear, duration of symptoms, range of motion of shoulder joint, visual analog scale score, Korean Shoulder Scale score, gap and width of rotator cuff tear, and fatty degeneration of the supraspinatus and infraspinatus muscles were compared to confirm the differences between a delaminated and nondelaminated rotator cuff tear. Moreover, the proportions of the subscapular tendon rupture and subscapularis tendon rupture according to the size of the rotator cuff tear were analyzed in both the delaminated and nondelaminated rotator cuff tear groups.
Compared to the nondelaminated rotator cuff tear group, the age of the delaminated rotator cuff tear group was significantly higher, and as the size of the rotator cuff tear increased, the proportion of delaminated tear increased (P < .001). Furthermore, the duration of symptoms was longer, visual analog scale score was higher, Korean Shoulder Scale score was lower, gap and width of rotator cuff as well as fatty degeneration of the supraspinatus and infraspinatus were more severe in the group with posterior delamination than that without. In the nondelaminated rotator cuff tear group, 212 subjects (84.46%) had no subscapularis tear, and 39 subjects (15.54%) had subscapularis tear. In the delaminated rotator cuff tear group, 103 subjects (34.11%) had no subscapular tendon tear while 199 subjects (65.89%) had a subscapular tendon tear (P < .001). Furthermore, as the size of the rotator cuff tear increased, the rate of subscapular tendon tear increased in both the delaminated and nondelaminated rotator cuff tear groups.
The results suggest that there is a high probability of concomitant rupture of the subscapularis tendon in the patient group with posterior delamination tear. Therefore, it should be noted that if a posterior delamination is confirmed during surgery, it is necessary to carefully check for rupture of the scapular tendon.
The Digitation Sign Facilitates Diagnosis of Shoulder Subscapularis Lesions on Preoperative Magnetic Resonance Imaging
2022, Arthroscopy, Sports Medicine, and Rehabilitation
The purposes of this study were to investigate a radiographic sign found on coronal magnetic resonance imaging (MRI) sequences in subscapularis (SSC) pathology, reporting interobserver reliability data and sensitivity and specificity; and to correlate the preoperative assessment of SSC pathology with intraoperative assessment of the SSc during shoulder arthroscopy.
A consecutive series of patients undergoing arthroscopic rotator cuff repair from January 2020 to December 2020 were examined. The positive diagnosis of a subscapularis tendon tear was prospectively determined and confirmed by arthroscopy. The “digitation sign” was assessed by 3 independent shoulder-trained fellows when evaluating the SSC in the coronal plane on T2-weighted images.
Of the 132 patients included, 74 (56%) had SSC tendon tears confirmed during arthroscopy. Interobserver agreement for digitation sign was substantial (k= 0.640). Sensitivity for digitation sign only was 74.3%; for criteria of Adams et al. (Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy; Arthroscopy 2010;26:1427-1433) only, 83.8%; and for the combination of the 2 methods, 89.2%. Specificity was 84.5% for digitation sign only, 77.6% for Adams et al. criteria only, and 67.2% for the combination of the 2 methods. Sensitivity is statistically better when the digitation sign is added to the Adams et al. criteria for detection of SSC lesions. As expected, specificity is statistically lower. SSC tears are significantly associated with biceps lesions.
Preoperative systematic MRI evaluation by shoulder surgeons can diagnose subscapularis lesions by using the digitation sign in the coronal plane along with Adams et al. criteria, leading to good sensitivity. This easy-to-apply sign can be helpful in the initial MRI evaluation in the coronal plane, with improved sensitivity when combined with a systematic approach.
II, study of diagnostic test.

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¹: S.S.B. is a consultant for and receives inventor’s royalties from Arthrex, Inc., Naples, Florida.

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Technical noteArthroscopic Subscapularis Repair: Surgical Tips and Pearls A to Z

Abstract

Section snippets

Safety of approach

Before You Begin (Preoperative Planning)

Does fatty degeneration of the subscapularis matter?

What if the subscapularis is not repairable?

Proximal humeral migration

Postoperative protocol

Conclusions

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Subscapularis tears: Arthroscopic repair of the forgotten rotator cuff tendon

Tech Shoulder Elbow Surg

Technical note
Arthroscopic Subscapularis Repair: Surgical Tips and Pearls A to Z