20 Four-Anchor Repair of Massive Subscapularis Tear with Subcoracoid Decompression

Colin P. Murphy, Colin M. Robbins, Connor G. Ziegler, Anthony Sanchez, and Matthew T. Provencher

Summary

Tears involving the muscles of the rotator cuff demonstrate significant variation in severity. Depending on the type of tear, location, muscle quality, and extent of retraction, management of the rotator cuff tear can also differ considerably from patient to patient. In cases where surgical management is indicated, the surgeon has many options, including debridement, arthroscopic repair, mini-open repair, and open repair. At times, surgery may be performed in combination with other procedures, such as a total shoulder arthroplasty. In this chapter, we will describe the surgical management of a massive subscapularis tendon tear, including a subcoracoid decompression. The preparation, technique, and rehabilitation for this unique surgical case will be described in detail and demonstrated through a video presentation.

Keywords: coracoid, rotator cuff, shoulder, subcoracoid decompression, subscapularis

20.1 Patient Positioning1

? Beach chair position.

? All bony prominences well padded.

? Operative extremity prepped and draped in usual sterile orthopedic fashion.

? Pneumatic arm positioner to assist with manipulating and holding extremity during the procedure.

20.2 Portal Placement

? Posterior portal.

? Midglenoid anterior portal.

? Midlateral portal placed near midpoint of lateral acromion 1 cm inferior to the acromial edge.

? Accessory anterior portal as needed.

20.3 Surgical Technique2,3,4

? Diagnostic arthroscopy.

? Synovectomy and debridement.

? Performed through anterior portal in the rotator interval.

? Assess labrum for any degeneration or tears.

? Take note of any frayed ligaments, tendons, or sheaths.

? Debride any significant synovitis using a mechanical shaver and radiofrequency (RF) device.

image

Fig. 20.1 Arthroscopic view of the completed subcoracoid decompression. The arm can be put through full range of motion to ensure that the coracoid will no longer impinge on the subscapularis tendon. Subscap, subscapularis; HH, humeral head.

? Subcoracoid decompression (? Fig. 20.1).

? Arthroscope positioned in the posterior portal and the midlateral portal as needed to perform a complete and thorough decompression.

? Debride any scar tissue, synovitis, and/or inflammation using the combination of an arthroscopic shaver and RF device.

? Make an indentation in the capsule under the coracoid base medial to the middle glenohumeral ligament (MGHL) with an RF device.

? Skeletonize coracoid base using an RF or shaver, removing any inflamed bursa.

? Gently elevate coracoacromial (CA) ligament using an RF device; this preserves the CA ligament.

? Using an arthroscopic shaver/bur, perform decompression of the coracoid base overlying the subscapularis tendon.

? A high-speed bone-cutting bur is generally used to remove osteophytes from the coracoid.

? Subscapularis tendon repair.

? 8 mm cannula inserted into an anterior portal.

? Debride scar tissue and adhesions along the tendon to maximize tendon excursion.

? Extend releases medially to the musculotendinous junction as needed but take care superiorly where the subscapular nerve innervates the muscle.

? Lesser tuberosity bone bed is prepared with a combination of high-speed bone-cutting bur and motorized rasp, which creates a bleeding bed optimal for healing.

? If a longitudinal tear is present, No. 2 FiberTape suture (Arthrex, Naples, FL) is passed through the tear in a horizontal mattress technique using a Scorpion suture-passing device (Arthrex) to reduce the tear prior to double-row repair (? Fig. 20.2).

? Double-row repair using 4.75-mm SwiveLock (Arthrex) anchors.

1. Suture-loaded anchor placed at the inferomedial aspect of the lesser tuberosity footprint.

2. Suture-loaded anchor placed at the superomedial aspect of the lesser tuberosity footprint.

image

Fig. 20.2 Arthroscopic view showing the FiberTapes from the superomedial (SM) and inferomedial (IM) SwiveLock anchors passed through the subscapularis tendon. The tapes were passed by using a Scorpion suture-passing device. Subscap, subscapularis; HH, humeral head.

image

Fig. 20.3 Arthroscopic view showing the placement of the inferolateral (IL) anchor. One end of FiberTape from both the inferomedial and superomedial anchors are placed in the eyelet of the IL anchor. This anchor is placed at the IL aspect of the lesser tuberosity footprint. The FiberTapes for the superolateral (SL) anchor can be seen superior to the IL tapes and anchor.Subscap, subscapularis.

3. One suture strand from each medial row anchor is passed through the eyelet of an unloaded SwiveLock, which is then placed at the inferolateral aspect of the lesser tuberosity footprint. (? Fig. 20.3).

4. Each remaining suture strand from the medial row anchors is passed through the eyelet of another unloaded SwiveLock, which is then placed at the superolateral aspect of the lesser tuberosity footprint (? Fig. 20.4).

? Sutures are cut flush to anchor with an arthroscopic suture cutter.

? Assess final repair with probe.

image

Fig. 20.4 Arthroscopic view showing the placement of the superolateral(SL) anchor. One end of FiberTape from both the inferomedial, and superomedial anchors are placed in the eyelet of the SL anchor. This anchor is placed at the SL aspect of the lesser tuberosity footprint. The FiberTapes for the inferolateral (IL) anchor can be seen inferior to the IL tapes and anchor.-Subscap, subscapularis.

? Wound closure.

? Copiously irrigate all wounds.

? Close portal sites with 3?0 Monocryl.

? Apply sterile gauze and Tegaderm dressings.

? Place patient in padded abduction sling.

20.4 Surgeon Tips and Tricks

? Proper position of cannulas and use of soft cannulas, such as the PassPort(Arthrex).

? Adequate visualization from the lateral portal.

? Completely release all adhesions from the subscapularis tendon to ensure proper excursion.

? Inferiorly, superiorly, and laterally.

? Be careful with release of tendon medially as innervation enters subscapularis muscle from superior aspect.

? Consider turning down RF intensity when working medially.

? Careful and thorough subcoracoid decompression is recommended.

? First skeletonize coracoid prior to using shaver/bur.

? A 70� scope can sometimes be helpful.

? The coracoid base is located medial to the glenoid and at the level of the superior aspect of the glenoid.

? Capsular window to access coracoid base for decompression should be made medial to the MGHL.

? Double-row repair using SwiveLock anchors.

? FiberTape to load anchors and/or may use anchors preloaded with FiberTape.

? The author prefers knotless and tape construct.

? May tie two knots with medial row with tape if preferred.

? Place lateral row of SwiveLock anchors at the lateral aspect of the anatomic insertion of the subscapularis tendon.

? Use of suture-passing device.

? Understand the equipment and devices you are using prior to using them on your patient, as there are nuances to every device.

? Creating an accessory anterior portal may be necessary and aid in ease of anchor placement.

20.5 Pitfalls/Complications

? Inadequate soft-tissue release of scarred and retracted subscapularis.

? Incomplete capsular/bony releases off the glenoid.

? It is essential to perform a complete inferior release.

? Incomplete or inadequate subcoracoid decompression.

? Inadequate exposure/debridement of subscapularis footprint and subsequent suboptimal, nonanatomic repair.

? Inadequate tensioning of lateral row.

? Ensure the arm is in 20�?30� abduction when tensioning lateral row.

? Poor suture management.

? Use tape graspers to avoid tangles.

? Leaving proud ?dog ears,? especially anteriorly.

20.6 Rehabilitation5

? Phase I (weeks 1?6): maximal protection, passive range of motion (ROM).

? Sling (weeks 1?6).

? No resisted elbow flexion (weeks 1?6).

? Exercises.

? Cervical ROM exercises.

? Elbow/hand/wrist ROM.

? Ball squeeze.

? Pendulums.

? Ankle pumps.

? Scapular retraction/depression.

? Aquatherapy for active assist ROM (beginning week 3).

? Passive ROM (full ROM beginning week 5).

? External rotation (ER): 30� (weeks 1?2), 60� (weeks 3?4).

? Forward elevation and scaption: 90� (weeks 1?2), 150� (weeks 3?4).

? Abduction: 60� (weeks 1?2), 120� (weeks 3?4).

? Internal rotation: 30� (weeks 1?2), 45� (weeks 3?4).

? Activities of daily living.

? Eating/drinking (use uninvolved arm only weeks 7?13).

? Dressing (use uninvolved arm only weeks 7?13).

? Washing/showering (use uninvolved arm only weeks 7?13).

? Computer with supported arm (weeks 1?8).

? Driving (weeks 3?13).

? Phase II (beginning weeks 6?7): minimal protection, active ROM.

? Active assist ROM.

? Internal/ER (weeks 6?8).

? Flexion/abduction (weeks 6?8).

? Isometrics.

? Internal/ER (weeks 6?8).

? Flexion/abduction (weeks 6?8).

? Active ROM.

? Bench press series (weeks 7?13).

? Modified military press (weeks 8?13).

? Side-lying ER (weeks 7?13).

? Salutes (weeks 7?13).

? Full can (weeks 8?13).

? Prone row progression (weeks 7?13).

? Prone ER90� (weeks 8?13).

? Prone Ys (weeks 8?13).

? Prone lift off (weeks 8?13).

? Open-chain proprioception (weeks 7?13).

? Low load prolonged stretches.

? Door jamb series (weeks 7?13).

? Towel internal rotation (weeks 7?13).

? Cross arm stretch (weeks 7?13).

? Sleeper stretch(weeks 7?13).

? TV watching stretch (weeks 7?13).

? 90�/90�ERstretch (weeks 7?13).

? Activities of daily living.

? Eating/drinking (weeks 7?8).

? Dressing (weeks 7?8).

? Washing/showering (weeks 7?8).

? Lifting up to 5 lb (weeks 7?13).

? Phase III (beginning week 9): initial resistance, strengthening, and proprioception.

? Exercises.

? ER (weeks 9?25).

? Internal rotation (weeks 9?25).

? Double arm ER (weeks 9?25).

? Full can (weeks 9?25).

? Forward punch w/plus (weeks 9?25).

? Rows (weeks 9?25).

? Bicep curl (weeks 9?25).

? Triceps extension (weeks 9?25).

? Lat pulldown (weeks 9?25).

? Initial closed-chain stability (weeks 10?25).

? Activities of daily living.

? Overhead activity (weeks 9?13).

? Phase IV (beginning week 10): advanced resistance, strengthening, and proprioception.

? Exercises.

? Bear hugs (weeks 10?25).

? ER at 45� (weeks 10?25).

? ER at 90� (weeks 10?25).

? Rhythmic stabilization/neuromuscular control (weeks 10?25).

image

Video 20.1 Preparation, technique, and rehabilitation for the management of a massive subscapularis tendon tear, including a subcoracoid decompression.

? Advanced closed-chain stability (weeks 17?25).

? Plyometrics (weeks 21?25).

? Decelerations (weeks 21?25).

? Activities of daily living.

? Lifting > 5 lb (weeks 10?13).

? Phase V (beginning week 17): return to sports.

? Criteria.

? Functional, pain-free active ROM.

? Maximized strength.

? Proper scapulothoracic mechanics.

? Skiing (week 17).

? Swimming (week 17).

? Throwing progression (week 25).

? Overhead and serving sports (week 25).

? Contact sports (week 25).

20.7 Rationale and/or Evidence for Approach6

? Excellent bony purchase achieved with SwiveLock anchors.

? Double-row repair provides excellent compression and anatomic restoration of the subscapularis tendon. Please see ? Video 20.1 for demonstration.

References

[1] Provencher MT, Mcintire ES, Gaston TM, Frank RM, Solomon DJ. Avoiding complications in shoulder arthroscopy: Pearls for lateral decubitus and beach chair positioning. Tech Shoulder Elbow Surg. 2018; 11(1):1?3

[2] Kennedy NI, Sanchez G, Mannava S, Ferrari MB, Frangiamore SJ, Provencher MT. Arthroscopic rotator cuff repair with mini-open subpectoral biceps tenodesis. Arthrosc Tech. 2017; 6(5):e1667?e1674

[3] Sanchez G, Chahla J, Moatshe G, Ferrari MB, Kennedy NI, Provencher MT. Superior capsular reconstruction with superimposition of rotator cuff repair for massive rotator cuff tear. Arthrosc Tech. 2017; 6(5):e1775?e1779

[4] Sanchez G, Rossy WH, Lavery KP, et al. Arthroscopic superior capsule reconstruction technique in the setting of a massive, irreparable rotator cuff tear. Arthrosc Tech. 2017; 6(4):e1399?e1404

[5] Ghodadra NS, Provencher MT, Verma NN, Wilk KE, Romeo AA. Open, mini-open, and all-arthroscopic rotator cuff repair surgery: indications and implications for rehabilitation. J Orthop Sports Phys Ther. 2009; 39(2): 81?89

[6] Arce G, Bak K, Bain G, et al. Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting. Arthroscopy. 2013; 29(11):1840?1850