18 Arthroscopic Repair of Subscapularis Tear Based on the Tear Types

Chris Hyunchul Jo and Jeong Yong Yoon

Summary

With the advancement of magnetic resonance imaging (MRI) and arthroscopy, the diagnosis of subscapularis tears has become more and more common for arthroscopic surgeons. Nonetheless, arthroscopic technique for subscapularis tendon still remains challenging especially for under-experienced arthroscopists. In this chapter, the authors provide step-by-step approach for arthroscopic repair of subscapularis tear based on the tear types. In addition, we described biological augmentation with platelet-rich plasma and multiple channeling for the enhancement of healing.

Keywords: subscapularis repair, isolated subscapularis tear, platelet-rich plasma, multiple channeling

18.1 Patient Positioning

? The patient is positioned in a beach chair or lateral decubitus position based on surgeon preference.

? The authors prefer to position the patient in the lateral decubitus position.

? Evaluation under anesthesia: the amount of passive shoulder range of motion (ROM) in all directions.

? Gentle manipulation is performed if needed.

? Proper placement of stabilizing devices on the operating table and setup of lateral traction device.

? Rolling patient into a lateral decubitus position.

? Inflation of beanbag device and securing patient with table strap and tape.

? Placement of operative arm in lateral traction device with Spider (Smith & Nephew, Andover, MA).

? Standard sterile prepping and draping.

18.2 Portal Placement

? Anticipated portal sites are drawn out using bony landmarks, including the acromion, clavicle, acromioclavicular joint, and coracoid process.

? Posterior viewing portal: palpated in the ?soft spot? of the glenohumeral joint.

? Anterior portal: lateral to the tip of the coracoid process (inside-out and outside-in techniques).

? Lateral subacromial portal: anterior to the usual 50-yard line.

? Posterolateral portal (which provides the Grand Canyon view): 1 cm lateral and anterior to the posterolateral corner of the acromion.

18.3 Surgical Technique (Step-by-Step Approach)

18.3.1 Partial Tear in the Leading Edge

? The arthroscope is introduced through a standard posterior portal.

? Anterior portal: just lateral to the coracoid process under arthroscopic visualization.

? The partial-thickness articular-sided tear is debrided with a mechanical shaver through the anterior portal.

? To visualize the subscapularis footprint better, the assistant can hold the arm in internal rotation and perform a posterior lever push.1

18.3.2 Articular-Sided Tear

? The intraarticular approach is appropriate for upper one-third tears.2

? The glenohumeral joint was entered and explored through a primary posterior portal.

? If the subscapularis lesion is isolated, without bicipital involvement, repair is performed only if biceps stability is not threatened.

? Frayed partial thickness articular-sided tears were debrided carefully.

? Tendon insertion is reassessed.

? Lesser tuberosity (LT) preparation: the most medial side of the footprint.

? Tissue penetrator is used to pass suture through the upper one-third of the intact tendon.

? The anchor is placed in the previously prepared hole on the LT.

? The sutures are gently tensioned and then impacted, and the anchor?suture construct is screwed into place.

18.3.3 Concealed Bursal-Sided Tear

? Examination of glenohumeral joint and subscapularis tendon insertion: posterior portal as entry portal.

? Debridement: articular side of the subscapularis tendon.

? Reassessment of the tendon.

? Move to bursal side of rotator cuff.

? Removing the biceps tendon away from the groove.

? Arthroscopic exploration: bursal side of the subscapularis tendon.

? If the subscapularis tendon is torn: repair of the tendon.

? In case of associated supraspinatus tendon tear: subscapularis tendon repairs are performed before supraspinatus tendon repair.

18.3.4 Subscapularis Tendon Tear with Supraspinatus Tendon Tear

? Standard posterior portal: status of the rotator cuff (including the subscapularis) and the presence of other intraarticular lesions.

? The retracted subscapularis tendon: comma sign.3

? The biceps should be examined along its intraarticular length.

? Biceps instability: tenotomy or tenodesis.

? Detachment of the biceps from its origin enables improved visualization of the subscapularis insertion on the LT.

? The coracoid tip is identified and exposed, the conjoint tendon is identified, and the undersurface of the coracoid is skeletonized with a shaver and electrocautery.

? Coracoplasty: subcoracoid stenosis (coracohumeral distance is < 6 mm).4

? The medial sling of the biceps and the superior glenohumeral ligament should be preserved laterally.

? Coracohumeral ligament release around the coracoid.

? Retracted subscapularis tendon tear: anterior, superior, and posterior surfaces are released(three-sided release).1

? Three-sided release, using a combination of shaver and electrocautery to release the tendon from the coracoid neck and coracoid base.

? As work proceeds inferiorly in this location, care must be taken to protect the axillary nerve.

? Prepare the LT and greater tuberosity bone bed to a bleeding base.

? For complete tears, two medial anchors were used, and for tears of the upper half of the tendon, one anchor was used.

? The anchors are placed along the medial aspect of the footprint starting inferiorly.

? Sutures are then tied with a slippage-proof(SP) knot, reducing the medial aspect of the subscapularis tendon insertion to bone.5

? After the subscapularis tendon is repaired, repair of concomitant rotator cuff tears is performed.

? Depending on the size of the tear, either two or three anchors were applied for the medial row.

? In all tears that have a full-thickness component, we used double-row fixation with a suture bridge technique.

18.3.5 Isolated Subscapularis Tendon Tear

? Standard posterior portal: examination of glenohumeral joint.

? Either tenotomy or tenodesis of the biceps tendon could be performed, depending on the age, gender, and functional requirements of the patient.

? Move to the bursal side of the rotator cuff.

? Subscapularis tendon tear: measure the dimensions and check the excursion.

? Lesion of the retracted subscapularis tendon: releasing the adhesions (three-sided release).

? Traction suture (medial to the comma tissue): facilitates tendon exposure.

? In tears that are still under significant tension after release: a medialization of the bone bed of approximately 5 mm.6

? When medialization is necessary, a bur is used to abrade 5 mm of the articular surface to create the new site of tendon attachment.

? Prepare the bone bed of the LT.

? A double-row suture bridge technique was routinely performed for a complete restoration of the footprint (? Video 18.1).

18.3.6 Biological Augmentation with Platelet-Rich Plasma (PRP)7,8,9 and Multiple Channeling10,11

PRPGel Application

? One day before surgery using a platelet pheresis system.

image

Video 18.1 Arthroscopic repair of subscapularis tear based on the tear types and biological augmentation of rotator cuff repair with platelet rich plasma and multiple channeling.

? Three PRP gels in place, medial row sutures are tied using SP knot if necessary.

? Lateral row was then secured using suture anchors.

Multiple Channeling

? Perform after LT bone bed preparation.

? Thin and long tip bone punch: holes were 4?5 mm apart and 10 mm deep.

? After multiple channeling, suture anchors are placed in the usual manner.

18.4 Surgeon Tips and Tricks (Use of Specific Instrumentation)

? An adequate three-sided soft-tissue release may improve tendon excursion and allow fixation without excessive tension in most repairs.

? The use of an additional 70�arthroscope may also improve the joint view.

? ?Hand-on-face? position: achieve an appropriate angle to insert suture anchors

? into the LT.

? We recommend starting with the subscapularis tendon if there are several rotator cuff tendons.

? To produce a gel form of PRP: 0.3 mL of 10% calcium gluconate + 3 mL of PRP.

? The multiple channeling procedure: a kind of the bone marrow stimulation technique.

? Bone punch: thin and long tip is preferred to create channels.

18.5 Pitfalls/Complications

? Well-tolerated procedure with minimal number of complications.

? Small upper border subscapularis tears are often missed on magnetic resonance imaging and definitive diagnosis can be made upon arthroscopy.

? Extreme care should be taken not to pass instruments medial to the coracoid base.

18.6 Rehabilitation

? Immobilized for 4?6 weeks using an abduction brace.

? Immediate post-op: shrugging, protraction, retraction of shoulder girdles, and intermittent exercise of the elbow, wrist, and hand.

? After 4?6 weeks: passive ROM exercise.

? After 3 months: begin strengthening exercise, light sports.

? After 6 months: full return to sports.

References

[1] Denard PJ, Burkhart SS. Arthroscopic recognition and repair of the torn subscapularis tendon. Arthrosc Tech. 2013; 2(4):e373?e379

[2] Denard PJ, Burkhart SS. A new method for knotless fixation of an upper subscapularis tear. Arthroscopy. 2011; 27(6):861?866

[3] Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon. Arthroscopy. 2003; 19(3):334?337

[4] Lo IK, Burkhart SS. The etiology and assessment of subscapularis tendon tears: a case for subcoracoid impingement, the roller-wringer effect, and TUFF lesions of the subscapularis. Arthroscopy. 2003; 19(10):1142?1150

[5] Jo CH, Yoon KS, Lee JH, Kang SB, Lee MC. The slippage-proof knot: a new, nonstacking, arthroscopic, sliding locking knot with a lag bight. Orthopedics. 2007; 30(5):349?350

[6] Denard PJ, Burkhart SS. Medialization of the subscapularis footprint does not affect functional outcome of arthroscopic repair. Arthroscopy. 2012; 28(11):1608?1614

[7] Jo CH, Shin JS, Lee SY, Shin S. Allogeneic platelet-rich plasma for rotator cuff repair. Acta Ortop Bras. 2017; 25(1):38?43

[8] Jo CH, Shin JS, Shin WH, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of medium to large rotator cuff tears: a randomized controlled trial. Am J Sports Med. 2015; 43(9):2102?2110

[9] Jo CH, Shin JS, Lee YG, et al. Platelet-rich plasma for arthroscopic repair of large to massive rotator cuff tears: a randomized, single-blind, parallel-group trial. Am J Sports Med. 2013; 41(10):2240?2248

[10] Jo CH, Shin JS, Park IW, Kim H, Lee SY. Multiple channeling improves the structural integrity of rotator cuff repair. Am J Sports Med. 2013; 41(11):2650?2657

[11] Jo CH, Yoon KS, Lee JH, et al. The effect of multiple channeling on the structural integrity of repaired rotator cuff. Knee Surg Sports Traumatol Arthrosc. 2011; 19(12):2098?2107