15 Double-Row Subscapularis Repair for Full-Thickness Subscapularis Tears

Grant Garcia, Hailey Casebolt, and Anthony Romeo

Summary

The subscapularis is the strongest rotator cuff muscle in the shoulder and, until this recent decade, most surgical repairs were performed through an open approach. In contrast, the reporting of arthroscopic repair techniques and outcomes is relatively limited. This is likely a result of the difficulty in all-arthroscopic repairs and the relative rarity of this injury in comparison to the supraspinatus and infraspinatus tendon. Even when arthroscopic repair is attempted, it can be challenging for an expert surgeon, and attempting a double-row repair adds further levels of complexity. Given these issues, we will provide our technique to improve potential complications that allow for a successful arthroscopic double-row supscapularis repair. This video chapter outlines background on double-row repair, portal placement, surgical technique, and tricks to avoid potential pitfalls.

Keywords: arthroscopy subscapularis, double-row, rotator cuff

15.1 Patient Positioning

? Beach chair position is our preferred technique (? Fig. 15.1).

? Lateral decubitus position can be used based on surgeon preference.

? The patient is placed on the edge of the table and secured.

? Two folded towels are placed behind the scapula.

? The head is secured with a towel and tape. Care is taken to avoid excess flexion or extension of the neck.

? The shoulder is positioned in an orientation familiar to the surgeon.

? We ensure the shoulder can move freely without blockage by the table. This is paramount, as maneuverability during the procedure facilitates easier surgical repair.

? Note: If unable to achieve adequate arthroscopic fixation, the beach chair position facilitates simple conversion to an open procedure.

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Fig. 15.1 This demonstrates our standard beach chair set-up. In addition, a mobile arm holder is used throughout the case as seen in this image.

15.2 Portal Placement (? Video 15.1, Part 1)

? Bony landmarks are drawn on the skin.

? The acromion-clavicular articulation, clavicle, acromion, spine of the scapula, and coracoid process are identified and marked.

? The posterior portal is placed in the soft spot.

? 2 cm inferior and 1 to 2 cm medial to the posterior lateral corner of the acromion.

? The anterior portal is just lateral to the coracoid.

? Directly below the coracoacromial ligament.

? The lateral portal is placed 3 cm inferior to the lateral edge of the acromion.

? In line with the midpoint of the anteroposterior distance on the acromion.

? An anterosuperior-lateral working portal is placed last.

? This is two fingerbreadths off the edge of the anterolateral corner of the acromion.

? In reference to the anterior portal, it is 1?2 cm superior and 2 cm lateral. This portal greatly improves the speed and ease of repair.

? The anterior and anterosuperior-lateral portals are the main working portals.

? The posterior portal is used for viewing.

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Video 15.1 The patient was placed in the beach chair position. A standard posterior portal was established followed by anterior, direct lateral, and anterosuperior under direct visualization. If significant adhesions are present, dissection of the axillary nerve may be necessary. To improve visualization, the biceps tendon was amputated and coracoplasty is performed with a 4.0-mm arthroscopic burr. The subscapularis was mobilized and the tendon approximated with an arthroscopic grasper. The footprint was prepared with an electrothermal device and 4.0-mm arthroscopic burr. The inferior medial-row anchor was placed. The suture was passed with a suture-passing device through the subscapularis in a medial to lateral angle. The superior medial anchor was placed next. Superior sutures were passed in a similar fashion. A superior mattress stitch may be placed. The bicipital groove was prepared with an electrothermal device and arthroscopic burr. A superior and inferior lateral row anchor was placed in the bicipital groove approximately 1 cm apart. Final fixation was performed through arthroscopic knot tying.

15.2.1 Portal Placement Technique

? All portal sites are injected with 0.25% bupivacaine and epinephrine.

? The posterior portal is placed with a blunt trocar.

? The anterior portal is established with an inside-out technique.

? The anterosuperior lateral portal localized with a spinal needle to allow optimization for repair.

? Care is taken to avoid its convergence with the anterior portal.

15.3 Surgical Technique (Step-by-Step Approach)

? Basic principles of rotator cuff repair should be followed.

? This pertains to both a primary and revision setting. This includes tendon mobilization, tear pattern recognition, footprint preparation, and a tension-free repair.

? We prefer a 30� scope throughout the procedure.

? If there is difficulty with visualization a 70� scope can be used.

? Note: The subscapularis repair is performed first when involved with supraspinatus tear.

? This is done because swelling can limit visualization and decrease appropriate working space in the anterior shoulder.

15.3.1 Steps

1. A systematic evaluation of the entire glenohumeral joint is performed (? Video 15.1, Part 2).

? Any additional pathology requiring surgical repair is noted and will be added to the operative plan at this time.

2. A dynamic exam is performed of all rotator cuff tendons while viewing from the posterior portal.

3. Advancing the posterior scope to the anterior humeral margin improves visualization of the subscapularis.

? A thorough evaluation of the anterior shoulder is performed.

? Subscapularis retraction, subluxation of long head of the biceps and conjoint tendon involvement are often present.

? An arthroscopic evaluation of the axillary nerve may be performed when there is significant retraction of the subscapularis tendon (? Video 15.1, Part 3).

4. Long head of the biceps tendon removal (? Video 15.1, Part 4).

? The long head of the biceps tendon is frequently involved with supscapularis tears.

? Generally, the medial sling is disrupted and there is subluxation (? Fig. 15.2).

? Often there is preexisting pathology in the tendon as well. This is represented by either tendon fraying or edema.

? Before the subscapularis mobilization, the tendon is amputated with arthroscopic scissors (? Fig. 15.3).

? The intra-articular portion is debrided to the superior labrum.

? The distal portion will later be tenodesed. The type of tenodesis is determined by the age and pathology of the patient. This will be discussed later in the chapter.

? Removal of the biceps tendon from the groove improves visualization and mobilization of the subscapularis.

? The proximal bicipital groove is the insertion point for our lateral row.

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Fig. 15.2 This is a representative drawing of the subscapularis tear allowing for instability of the biceps tendon.

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Fig. 15.3 This is a representative drawing of the removal of long head of the biceps tendon that allows for the mobilization of the subscapularis tendon.

5. The rotator interval is resected.

? This allows better visualization of the coracoid.

? Additional capsular tissue is also removed.

6. A coracoidplasty is performed from the anterior portal (? Video 15.1, Part 5).

? Staying lateral?all fatty tissues are removed until the coracoid is reached.

? An electrothermal device is used to clear the periosteum on the posterior coracoid (? Video 15.1, Part 6).

? A 4.0-mm bur is then used to remove bone from the posterolateral aspect of the coracoid

? This allows for more space anterior to the subscapularis. This is analogous to the subacromial decompression for the supraspinatus.

Note: After debridement, there should be 5?10 mm of space between the coracoid and subscapularis.

7. Subscapularis tendon mobilization (? Video 15.1, Part 7).

? A 360� release is performed.

? Superior margin from coracoid.

? Posterior from anterior capsule and scapular neck.

? Inferior from axillary nerves and vessels.

? Anterior from conjoined tendon.

Note: Care should be taken not to debride the tendon.

? This can be difficult in chronic retracted tears where the tendon morphology is distorted.

? Additional release of the coracohumeral ligament structures is often needed for mobilization.

? Attention is turned to the medial edge of the tendon to allow for further mobilization.

? A 5.0 shaver is introduced, and all loose tissue is debrided.

? The tendon edges are also freshened up at this time.

? The middle glenohumeral ligament is identified and separated from the tendon.

? This is done with our electrothermal cutting device.

8. Tendon approximation (? Video 15.1, Part 8).

? The anterosuperior lateral portal is introduced.

? An arthroscopic grasper is used from the anterolateral portal to identify maximal excursion of the tendon (? Fig. 15.4). This can help define the previously distorted anatomy of the tendon.

? Also, this ?excursion test? best defines the repair footprint.

? A traction stitch can be used if needed.
Note: If there is good quality tendon tissue without significant retraction, we prefer a double-row repair.

? If there is significant retraction and tendon tissue loss, we proceed with a tension-free, single-row repair or augment the tendon,

9. Preparation of the footprint (? Video 15.1, Part 9).

? This can be performed from an anterosuperior lateral or anterior portal.

? The arm is internally rotated and abducted to deliver the tuberosity to the bur.

? A 4.0 bur is used to clear the appropriate footprint.

? This is performed down to bleeding bone.

? Bone marrow stimulation is also performed prior to the placement of anchors.

10. Medial row anchor placement.

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Fig. 15.4 This drawing demonstrates an arthroscopic grasper mobilizing the subscapularis tendon to reapproximate the footprint of the subscapularis.

15.3.2 Tips

? Suture anchors designed for cancellous bone are ideal for repair.

? The anterior portal is used for inserting the suture anchors.

? Anchors are inserted 5 mm away from the articular surface.

? 4.75 mm SwiveLock anchors (Arthrex, Naples, FL) loaded with FiberTape (Arthrex) are used.

? The first anchor is placed at the inferior portion of the tear.

? All subsequent medial row anchors are placed further superiorly.

? The number of medial row anchors varies with the size of tear. Generally, two are used.

? We place one anchor per 1 cm of exposed footprint.

15.3.3 Inferior Medial Anchor Placement (? Video 15.1, Part 10)

? The anchor is placed after using a punch to facilitate insertion.

? All sutures are then pulled through the anterior cannula.

? Using a switching stick, the cannula is removed and the sutures are pulled outside of the cannula through the same portal.

? The cannula is reinserted with the sutures on the outside.

? Suture passage is performed with a 30�SutureLasso (Arthrex) or a Penetrator (Arthrex) (? Video 15.1, Part 11).

? A FastPass Scorpion (Arthrex) can greatly improve ease of passage and may be used in more difficult cases.

? The suture should be passed at an angle medial to lateral through the entire tendon thickness. The articular side is more medial then the bursal side.

? This is usually 1 cm from the medial edge and 1 cm from the inferior portion of the tendon.

? A crochet hook is used to retrieve the shuttle suture from the lasso and the associated anchor sutures.

? These are passed outside the shoulder through the anterosuperior lateral portal.

? The anchor suture is secured with a loop by the shuttle suture and passed back into the joint through the tendon and outside the cannula of the anterior portal (by a similar technique as previously described).

? All inferior sutures are passed outside of the anterior cannula to prevent tangling and to prepare for passage of the superior medial row.

15.3.4 Superior Medial Suture Placement (? Video 15.1, Parts 12 and 13)

? Once all inferior sutures are passed, the same process is repeated for the superior sutures.

? This is done using a second 4.75 SwiveLock anchor (Arthrex) loaded with Fiber Tape (Arthrex).

? The superior suture once passed is taken out though the anterosuperior lateral portal (? Fig. 15.5).

? This separates the medial row sutures and prevents tangling.

1. Superior mattress stitch (? Video 15.1, Part 14).

? Added fixation for the superior limb of the supscapularis is often needed.

? Using a suture passage device, an inverted mattress suture is passed at the most superior portion of the tendon.

? This stitch reapproximates the rotator interval.

? The mattress stitch is retrieved through the lateral portal (? Fig. 15.6).

? Once passage is completed, this stitch can be secured with a 4.75 SwiveLock (Arthrex) separately. This is placed in the superior lateral row just medial to the bicipital groove (? Fig. 15.7).

? In most cases, this stitch is secured with the superior lateral row fixation along with one limb from each medial row of FiberTape (Arthrex) (? Video 15.1, Part 15).

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Fig. 15.5 Demonstrates placement of two medial row anchors and then passing these sutures from posterior to anterior through the subscapularis tendon. We typically used FiberTape that is wedged together, making it easier for single passage of both suture limbs.

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Fig. 15.6 Demonstrates an inverted mattress repair for the upper border of the subscapularis in which the FiberTape suture has been passed anterior to posterior and retrieved through the lateral cannula.

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Fig. 15.7 This demonstrates an alternative use of the mattress suture in which the anchor is placed medial to the bicipital groove. Routinely, we place this suture with the superior lateral row anchor.

1. Lateral row fixation (? Video 15.1, Parts 15 and 16).

? Once the all medial row sutures have been passed and separated, final fixation is performed.

? One suture limb from each medial row anchor is retrieved from the lateral portal (? Fig. 15.8).

? These are then loaded onto a 4.75-mm SwiveLock (Arthrex).

? The bicipital groove is prepared with a bur and electrothermal device.

? The loaded SwiveLock is then placed into the empty bicipital groove for the superior lateral row (? Video 15.1, Part 15).