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Double-Row Arthroscopic Subscapularis Repair: A Surgical Technique


Abstract and Figures

The subscapularis is the strongest rotator cuff muscle in the shoulder. Until recently, most surgical repairs were performed through an open approach. Furthermore, the reporting of arthroscopic repair techniques and outcomes is fairly limited. This is likely due to the difficulty involved in all-arthroscopic repairs and the relative rarity of this injury compared with injuries of the other rotator cuff tendons. Arthroscopic subscapularis repair can be challenging, even for an expert surgeon, and attempting a double-row repair adds further complexity. Given these issues, this article provides techniques to allow for successful arthroscopic double-row subscapularis repair and avoid potential complications. The key features of an arthroscopic double-row repair include portal placement, surgical technique, and tips to avoid potential pitfalls, all of which are discussed.
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Technical Note
Double-Row Arthroscopic Subscapularis Repair:
A Surgical Technique
Brandon C. Cabarcas, B.S., Grant H. Garcia, M.D., Joseph N. Liu, M.D.,
Anirudh K. Gowd, B.S., and Anthony A. Romeo, M.D.
Abstract: The subscapularis is the strongest rotator cuff muscle in the shoulder. Until recently, most surgical repairs were
performed through an open approach. Furthermore, the reporting of arthroscopic repair techniques and outcomes is fairly
limited. This is likely due to the difculty involved in all-arthroscopic repairs and the relative rarity of this injury compared
with injuries of the other rotator cuff tendons. Arthroscopic subscapularis repair can be challenging, even for an expert
surgeon, and attempting a double-row repair adds further complexity. Given these issues, this article provides techniques
to allow for successful arthroscopic double-row subscapularis repair and avoid potential complications. The key features of
an arthroscopic double-row repair include portal placement, surgical technique, and tips to avoid potential pitfalls, all of
which are discussed.
The subscapularis comprises the anterior portion of
the rotator cuff and plays a major role in stabilizing
the shoulder in both the coronal and transverse planes.
Tears of the supraspinatus and even isolated upper ber
subscapularis tears have been shown to alter the
biomechanics of the glenohumeral joint, increasing
both anterior and superior humeral translation.
coracoid stenosis and impingement causing tensile
undersurface ber failure have been proposed as a
mechanism for the etiology of subscapularis tears.
Although the advent of arthroscopy has allowed for
signicant advancements in the diagnosis and
treatment of subscapularis tears, all-arthroscopic repair
of the subscapularis tendon remains a technically
demanding procedure. Double-row repair offers the
most secure xation and, therefore, provides an envi-
ronment that maximizes the potential for improved
functional outcomes and decreased rates of rerup-
This procedure has been shown to demonstrate
a signicant biomechanical advantage compared with a
single-row repair.
Our preference for an all-
arthroscopic double-row repair is motivated by both
clinical experience and an evidenced-based approach.
Surgical Technique
Patient Positioning
The beach chair position is the authorspreferred
technique for arthroscopic subscapularis repair. How-
ever, the lateral decubitus position can also be used. The
patient is placed on the edge of the table so that the arm
can be freely moved throughout the procedure.
The shoulder anatomy is positioned in an orientation
familiar to the surgeon, making the transition to an
open repair approach relatively easy if an all-
arthroscopic repair becomes unfeasible. This differs
from the orientation of the patient in the lateral decu-
bitus position, which can be more difcult to convert to
an open procedure.
Portal Placement
Portal placement and operative technique are out-
lined in Video 1. The following anatomic landmarks are
From the Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL, U.S.A.
The authors report the following potential conicts of interest or sources of
funding: A.R. receives nancial or material support from AANA and MLB;
research support grants from Aesculap/B. Braun, Histogenics, Medipost,
NuTech, OrthoSpace, Smith & Nephew, and Zimmer; grants, personal fees, IP
royalties, other nancial and material support, research support, and
consultant and presenter or speaker payments from Arthrex; and personal
fees, publishing royalties, and nancial or material support from Saunders/
Mosby-Elsevier and SLACK. Full ICMJE author disclosure forms are avail-
able for this article online, as supplementary material.
Received March 2, 2018; accepted March 28, 2018.
Address correspondence to Brandon C. Cabarcas, B.S., Rush University
Medical Center, Orthopaedic Surgery, 1611 W Harrison St, Suite 300, Chi-
cago, IL 60612, U.S.A. E-mail:
Ó2018 by the Arthroscopy Association of North America. Published by
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
Arthroscopy Techniques, Vol 7, No 8 (August), 2018: pp e805-e809 e805
identied and marked: acromion-clavicular articula-
tion, clavicle, acromion, spine of the scapula, and
coracoid process. The posterior portal is placed in the
soft spot, which is 2 cm inferior and 1 to 2 cm medial to
the posterior lateral corner of the acromion. The ante-
rior portal is placed just lateral to the coracoid. The
lateral portal placement is best conrmed with an
18-gauge needle through the skin when viewing from
the posterior portal and is often 3 cm inferior to the
palpable lateral edge of the acromion. A nal ante-
rosuperior lateral portal is then placed 2 ngerbreadths
off the edge of the anterolateral corner of the acromion
and initially localized with an 18-gauge needle through
the skin while viewing from the subacromial space. The
anterior and anterosuperior lateral portals are the main
working portals for subscapularis repair, whereas the
posterior and lateral portals are used for viewing.
Preparation and Evaluation of the Glenohumeral
The basic rotator cuff repair principles of tear pattern
recognition, tendon mobilization, footprint preparation,
and tension-free repair should be followed in both
primary and revision settings. A 30arthroscope
(Arthrex, Naples, FL) is preferred to obtain optimal
visualization, although a 70arthroscope can be very
useful when performing the procedure in the lateral
decubitus position. A subscapularis repair is performed
rst if a concomitant supraspinatus tear is present
because repair of the subscapularis can help to reduce
the supraspinatus to a more anatomic position. Also,
swelling may decrease the anterior shoulder working
space, leading to compromised visualization if the
subscapularis repair is performed later in the case.
A systematic evaluation of the entire glenohumeral
joint is performed, including dynamic examination of
rotator cuff tendons. Any subscapularis retraction or
subluxation of the long head of the biceps is noted.
When in the subacromial space, evaluation and
dissection of the axillary nerve may be necessary if
signicant subscapularis retraction is present.
The long head of the biceps tendon is frequently
involved with subscapularis tears. Generally, the medial
sling is disrupted and subluxation is present. Regardless
of disruption, before subscapularis mobilization, the
biceps tendon is amputated to improve visualization,
and a biceps tenodesis is performed after the repair. In
some cases, biceps tendon rupture can be the present-
ing symptom, in which retrieval and tenodesis are
performed after all rotator cuff tendons are repaired.
Following biceps amputation, the remaining rotator
interval tissues are debrided and a coracoplasty is per-
formed with an electrothermal device (Super Turbovac
90; Smith & Nephew, Andover, MA). This is done by
clearing periosteum from the posterior coracoid and
using a 4.0-mm arthroscopic burr to remove bone from
the posterolateral aspect (Fig 1). These steps are essential
for achieving adequate visualization and crucial for a
successful repair (Table 1). This step is analogous to an
acromioplasty for a supraspinatus repair.
Subscapularis Tendon Mobilization and
A 270release of the subscapularis tendon is per-
formed using the following approach:
Fig 1. Right-sided coracoplasty performed with a 4.0-mm
arthroscopic burr in the anterior portal allows for more
space anterior to the subscapularis. After coracoplasty, there
should be 5 to 10 mm of space between the coracoid and
subscapularis. Viewed from posterior portal.
Table 1. Surgeon Pearls and Pitfalls
Pearls Pitfalls
Coracoplasty is essential for adequate visualization and
appropriate working space.
Beware of partial tears, as they may make it difcult to assess the
lower edge of the subscapularis.
Use a 70arthroscope, if necessary, to improve visualization. Poor visualization may complicate the case, especially during a
surgeon training period.
Extend dissection to medial border of subscapularis for
complete removal of adhesions.
Overmobilization may lead to injury of the nearby neurovascular
Ensure proper suture management. Overdebridement of the rotator interval can cause increased
swelling, necessitating prompt xation.
Perform a posterior-level push for additional space, if needed. Failure to reapproximate the appropriate tendon tension or
anatomic footprint may increase the risk of failure.
-Superior margin from coracoid.
-Posterior from anterior capsule and scapular neck.
-Anterior from conjoined tendon.
Additional release of the coracohumeral ligament is
needed if further mobilization is required. Also, the
middle glenohumeral ligament is identied and sepa-
rated from the tendon with an electrothermal device.
The anterosuperior lateral portal is then established,
and an arthroscopic grasper (Kingsher; Arthrex) is
used to identify maximal tendon excursion (Fig 2). This
excursion testserves to dene the potential repair
footprint. The arm is internally rotated and abducted to
deliver the tuberosity, and a 4.0-mm arthroscopic burr
is used to clear the appropriate footprint down to
bleeding bone.
Anchor and Suture Placement
Medial-row suture anchors are placed 5 mm away
from the articular surface through the anterior portal.
The SwiveLock 4.75 mm anchors (Arthrex) loaded with
FiberTape (Arthrex) are preferred. The rst anchor is
placed at the tears inferior margin, and all subsequent
medial-row anchors are placed further superiorly. The
number of medial-row anchors varies with tear size.
Normally, 2 medial-row anchors are sufcient, with 1
anchor placed per every 1 cm of exposed footprint.
The inferior medial anchor is placed after using a
4.75-mm punch (Arthrex) to facilitate insertion. All
sutures are then pulled through the anterior cannula.
Using a switching stick to remove the cannula, the
sutures are pulled outside through the same portal or
through an accessory portal to aid in suture manage-
ment. The sutures are passed with a suture-passing
device (30SutureLasso or Penetrator Retriever;
Arthrex) at an angle medial to lateral through the full
thickness of the tendon, which best approximates the
anatomic footprint. An arthroscopic retriever (Fiber-
Tape Retriever; Arthrex) is used to retrieve the shuttled
sutures. A second medial anchor is generally used
(superior), which is passed in a similar manner (Fig 3).
Care is taken to separate the inferior and superior
sutures to prevent tangling.
In some cases, a separate inverted mattress suture is
passed at the most superior portion of the tendon to
properly reapproximate the uppermost portion of the
tendon and establish the lower edge of the rotator in-
terval (Table 1). The mattress stitch is retrieved through
the lateral portal and can be secured separately with a
4.75-mm anchor (SwiveLock; Arthrex) once passage is
completed or integrated into the nal lateral-row repair.
Fig 2. Right subscapularis (SS) tendon approximation and
excursion test performed with an arthroscopic grasper
(Kingsher; Arthrex) in the anterosuperior lateral portal. This
excursion test serves to help dene the previously distorted
anatomy of the tendon and characterize the repair footprint.
Viewed from posterior portal. (LT, lesser tuberosity of
Fig 3. (A) Orientation of
superior and inferior medial
suture anchors with suture
limbs. The number of medial-
row anchors varies with the
size of the tear. Generally, 2
are used with 1 anchor placed
per 1 cm of exposed footprint.
(B) Superior medial suture
(SMS) passage performed with
a suture passing device (30
SutureLasso; Arthrex) in the
anterosuperior lateral portal.
Viewed from posterior portal
on the right side. (ASLP, ante-
rosuperior lateral portal; AP,
anterior portal; LP, lateral
Achieving Adequate Fixation
Final lateral-row xation is performed once all
medial-row sutures have been passed and separated.
One suture limb from each medial-row anchor is
retrieved from the lateral portal and loaded onto a
4.75-mm anchor (SwiveLock; Arthrex). The bicipital
groove is prepared with a 4.0-mm arthroscopic burr
and electrothermal device, and the loaded 4.75-mm
anchor is placed into the empty bicipital groove to
form the superior lateral row. The remaining medial
suture limbs from each medial-row anchor are loaded
onto a second 4.75-mm anchor (SwiveLock; Arthrex),
and this is placed 1 cm below the superior anchor to
form the inferior lateral row (Fig 4).
Final Testing and Concomitant Procedures
Once the original tendon has been secured, the
shoulder is put through range-of-motion testing under
arthroscopic visualization to assess the integrity of the
repair (Fig 5). Any remaining pathology is addressed. A
biceps tenodesis is normally performed, with our
preferred technique being open subpectoral tenodesis.
The technical difculties associated with a double-row
repair may be a reason for the dearth of literature on
this topic. Studies reporting clinical outcomes following
this technique are scarce, with most combining single-
row repair patients in their cohorts. Grueninger et al.
performed a double-row repair on 11 patients with a
mean age of 45 years and a mean follow-up of
12 months. Constant scores improved from 43 to 89
postoperatively, and liftoff strength and belly press
improved from 2.9 to 4.8 (out of 5). No complications
were reported. Lafosse et al.
demonstrated good results
in 17 patients with a mean age of 47 years and mean
follow-up of 29 months. Their cohort was mixed, with
64.7% of these patients (11/17) receiving a double-row
repair. Constant scores improved from 52 to 85, and
belly press improved from 2.5 to 4.4 (out of 5).
Improved outcomes have also been reported in rela-
tively younger patients after arthroscopic subscapularis
repair. In 70 patients younger than 45 who underwent
single- or double-row repair, mean postoperative
American Shoulder and Elbow Surgeons and Constant
scores were reported at 84.6 and 81.7, respectively,
after an average of 35.8 months.
Additionally, forward
exion signicantly improved from 158.7to 168.4,
and a 4% failure rate was reported. Although these
studies are limited in their ability to solely evaluate
results after arthroscopic double-row repair, as a whole
they demonstrate a trend of favorable clinical outcomes
in a variety of patient populations.
Fig 4. Inferior lateral-row anchor placement in the bicipital
groove performed with 4.75-mm anchors (SwiveLock;
Arthrex) loaded with FiberTape (Arthrex) in the lateral portal.
Suture anchors designed for cancellous bone are ideal for this
technique. Viewed from posterior portal on the right side.
(SLR, superior lateral row; SS, subscapularis.)
Fig 5. (A) Orientation of
superior lateral row (SLR),
inferior lateral row (ILR), and
superior mattress stitch
(SMAT) after completion of
the subscapularis tendon
double-row repair. (B) Final
range-of-motion testing of the
integrity of the subscapularis
tendon repair is done viewing
from the posterior and lateral
(pictured) portals on the
right side. Once the sub-
scapularis tendon is repaired,
any remaining pathology
is addressed. Commonly, a
biceps tenodesis is also
A systematic review by Saltzman et al.
evaluated 8
arthroscopic subscapularis studies. Of the 8 studies that
met their criteria, only 3 used a double-row repair in a
portion of their patients. After subanalysis of the data,
they found a lower rerupture rate with a double-row
repair (0%) compared with a single-row technique
(5%-10%). In addition, they reported better Constant
strength scores improvements with double row
(a change of 14) compared with single row (a change of
9). Additionally, they found that patients treated with
the double-row technique often had higher grade pre-
operative tears, demonstrating a surgeon preference for
a more extensive repair with difcult cases. Positive
clinical outcomes were also reported by Lanz et al.
a case series of 52 patients who underwent arthroscopic
repair of Lafosse type III and IV subscapularis tears with
primarily double-row conguration at 2 to 4 years of
follow-up. Both mean Constant scores (46.4-79.9
points) and University of California, Los Angeles scores
(15.1-31.5 points) signicantly improved with an
associated strength restoration compared with the
contralateral shoulder up to 96%.
The body of literature regarding arthroscopic double-
row repair of the subscapularis tendon is generally
lacking. Although a potential explanation may be the
technical difculty associated with the procedure, the
available evidence demonstrates excellent clinical out-
comes after double-row repair.
Limitations of
the technique include the potential risk for iatrogenic
neurovascular injury upon anterior release of the
subscapularis tendon. The axillary nerve runs along
the inferior and lateral border of the subscapularis,
and the posterior circumex humeral artery courses
along with the axillary nerve to eventually enter the
quadrangular space.
These structures are not
routinely visualized; therefore, awareness of their
anatomic locations must be maintained to safely
achieve adequate tendon mobilization. Conversely, if
adequate mobilization and reapproximation of the
tendon are not achieved, the risk of failure may
increase. Poor visualization may complicate the case,
especially in cases of concomitant posterior and
superior tears of rotator cuff tendons. A thorough
arthroscopic examination is necessary to detect partial-
thickness subscapularis tears that may be difcult to
observe, as the prevalence of subscapularis tears in
patients undergoing arthroscopic rotator cuff repair has
been reported to be higher than 31%.
swelling may signicantly reduce the working space
and visualization in the anterior shoulder if the rotator
interval is overdebrided or the subscapularis tear is
addressed after concomitant rotator cuff tendon tears.
Nonetheless, success is likely with this technique if
these risks and limitations are properly kept in mind
and addressed throughout the case.
In this article, we have outlined our recommended
technique to perform an all-arthroscopic double-row
subscapularis repair. Our goal was to improve the
feasibility of this procedure to both maximize anatomic
repair integrity and potentially improve clinical out-
comes for this specic patient group.
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repair of isolated subscapularis tears: A systematic re-
view of technique-specicoutcomes.Arthroscopy
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repair for complete subscapularis tears. Knee Surg Sports
Traumatol Arthrosc 2009;17:1477-1484.
7. Grueninger P, Nikolic N, Schneider J, et al. Arthroscopic
repair of traumatic isolated subscapularis tendon lesions
(Lafosse type III or IV): A prospective magnetic resonance
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Arthroscopy 2014;30:665-672.
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Gobezie R. Structural integrity and clinical outcomes after
arthroscopic repair of isolated subscapularis tears. J Bone
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years. Arthroscopy 2013;29:811-817.
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Lafosse L. Arthroscopic repair of large subscapularis
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... There have been numerous techniques published regarding arthroscopic treatment of subscapularis pathology; however, we believe that this technique is both simple and reproducible with excellent results, as reported by Katthagen et al. and others. [9][10][11][12][13][14][15][16][17][18] Additionally, our stepwise approach with decompression of the subcoracoid space allows for safe manipulation of the subscapularis tendon in proximity to the neurovascular structures medially and inferiorly. ...
... 10 The spinal needle method avoids the cost of other high-end suture passing devices that some authors have advocated, and it also negates the need for establishment of an anterosuperolateral portal, as is described by Howlett et al. 13 Although most subscapularis tears associated with subcoracoid impingement can be treated with the technique described in this article, the same methods can be applied to larger tears, for which a double-row technique and multiple rows of linked anchors can be used. 11 Lastly, there is no need for knot-tying, which creates more consistency, 19 decreases the risk for soft tissue irritation, and reduces the risk for loss of repair tension. 17 Several other techniques have been presented; however, they have similar pitfalls as mentioned above. ...
Full-text available
Subscapularis tears have been found to occur in the setting of subcoracoid impingement and are related to the narrowing of the coracohumeral interval. The advancement of arthroscopic techniques has allowed for improved identification and treatment of this historically overlooked pathology. Challenges of arthroscopic subscapularis treatment include nearby neurovascular structures, tendon retraction, and adhesions, which are further complicated by diminished arthroscopic visualization, resulting from the concomitant subcoracoid impingement. The purpose of this Technical Note is to describe our preferred technique for arthroscopic management of subscapularis tears in the setting of subcoracoid impingement that is simple and reproducible, as well as cost-effective and efficient with limited additional morbidity to that of a standard diagnostic shoulder arthroscopy.
... The most common adverse events of RF use are thermal inju- Table 3. Continued ries due to high temperature of the fluid and surrounding tissue [3]. Many studies involve novel arthroscopic techniques with RF devices, yet parameters of its use such as safety, complications, and outcome profiles are poorly detailed within the majority of studies [16,[44][45][46][47][48][49]69]. All four studies reporting these adverse events specify second-degree burns as related to direct contact of the irrigation fluid from outflow tubing rather than from contiguous, elevated intraarticular temperatures [65][66][67][68]. ...
Background Radiofrequency has seen an increase in use in orthopedics including cartilage lesion debridement in the hip and knee as well as many applications in arthroscopic shoulder surgery. The purpose of this systematic review is to evaluate the safety and usage of radiofrequency in the shoulder.Methods This systematic review was registered with PROSPERO (international registry) and followed the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. Embase and PubMed were searched using: “shoulder,” “rotator cuff,” “biceps,” “acromion” AND “monopolar,” “bipolar,” “ablation,” “coblation,” and “radiofrequency ablation.” The title and abstract review were performed independently. Any discrepancies were addressed through open discussion.ResultsA total of 63 studies were included. Radiofrequency is currently utilized in impingement syndrome, fracture fixation, instability, nerve injury, adhesive capsulitis, postoperative stiffness, and rotator cuff disease. Adverse events, namely superficial burns, are limited to case reports and case series, with higher-level evidence demonstrating safe use when used below the temperature threshold. Bipolar radiofrequency may decrease operative time and decrease the cost per case.DiscussionShoulder radiofrequency has a wide scope of application in various shoulder pathologies. Shoulder radiofrequency is safe; however, requires practitioners to be cognizant of the potential for thermal burn injuries. Bipolar radiofrequency may represent a more efficacious and economic treatment modality. Safety precautions have been executed by institutions to cut down patient complications from shoulder radiofrequency. Future research is required to determine what measures can be taken to further minimize the risk of thermal burns.
... [6][7][8] Doublerow repairs have also been described for subscapularis tears, shoulder capsulolabral repair, medial epicondylitis, and hip abductor repair with varying results. [9][10][11][12] Conceptually, double-row repairs increase construct stiffness, better re-create broad anatomic footprints, and provide compression of tendon to bone via suture bridges. Despite this, there is a paucity of data describing significant clinical benefits to double-row repairs. ...
Full-text available
Quadriceps tendon ruptures compromise the knee extensor mechanism and cause an inability to ambulate and significant functional limitations. Therefore, the vast majority of quadriceps tendon ruptures are indicated for operative intervention to restore patient mobility and function. Although these injuries were traditionally repaired using a transosseous repair technique, recent literature has shown that suture anchor repair may offer biomechanical advantages. Additionally, research in other areas of orthopaedics has found that a double-row suture anchor construct can offer additional biomechanical strength to tendinous repair. This technical note describes a safe and effective quadriceps tendon repair using a double-row suture anchor construct.
Arthroscopic subscapularis repairs are becoming more common and outcomes are similar to those of open repairs. Many times, the tear is an upper border injury that can easily be addressed with arthroscopic techniques. This chapter outlines the preoperative assessment, technique, and/or outcomes of arthroscopic subscapularis repairs.
Purpose To systematically review the literature to 1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and 2) compare outcomes following single and double row subscapularis repair in both of these settings. Methods A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis re-tears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis. Results The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2,406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 + 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs utilized single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in five studies comparing isolated to combined tears. Subscapularis re-tear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and re-tear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (p > 0.05 for all). Conclusion Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless if tears were isolated or combined or if repairs were single or double row.
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Although the subscapularis has historically received less attention than posterosuperior rotator cuff tears, repair of a torn subscapularis tendon is critically important to restoring anatomy and achieving the best functional outcome possible. Arthroscopic repair begins with proper recognition of the tear. A systematic approach can then be used to arthroscopically repair all types of subscapularis tendon tears, from partial tears to full-thickness tears, as well as those which are retracted and have adhesions medially. Subscapularis footprint restoration can be accomplished with a variety of repair techniques that must be matched to the extent of the tear and mobility of the tendon.
Purpose: To systematically review the literature to identify all studies reporting outcomes of arthroscopically repaired isolated subscapularis tears, to (1) report outcomes across all repair techniques, (2) compare outcomes by arthroscopic technique, and (3) highlight the frequency and management of associated long head of biceps pathology, and the influence of these concomitant procedures on outcomes following arthroscopic subscapularis repair. Methods: A systematic literature review was conducted using the MEDLINE, Embase, and Scopus databases with the following term: ("isolated repair" AND "arthroscopic subscapularis tear"). Only studies evaluating the techniques and outcomes of isolated subscapularis repair were included. Data were extracted, including patient characteristics, surgical technique, and outcomes. Descriptive analysis was provided for the available literature. Results: Eight studies were included in this review. Uniformly, improvements in patient-reported outcome scores were substantial after arthroscopic subscapularis repair. Constant Total scores improved in each individual study from preoperative to postoperative (range, Δ18.8-Δ49.8 points), as did Strength (range, Δ1.3-Δ13.7 points), Pain (range, Δ7.6-Δ8.9 points), Range of Motion (range, Δ7.3-Δ13.3 points), and Activities of Daily Living (range, Δ8.7-Δ10.2 points) subscores. Significant improvements were seen in most individual studies for belly-press (Δ21.6 N or Δ1.9 out of 5) and lift-off strength (Δ24.3 N or Δ1.7-Δ1.9 out of 5), range of motion in forward flexion (29.1°-37.0°), external rotation (10.3°-16.0°), and internal rotation. Complications were relatively infrequent overall, with 5 studies reporting no complications, and the remaining 3 studies with rerupture rates between 4.8% and 11.8%. Studies that used only double-row repair reported fewer complications (0% vs 5%-10%) and better outcome scores than single-row repair, similar to those studies that uniformly performed biceps tenodesis compared with no biceps intervention. Conclusions: This descriptive study highlights that arthroscopic subscapularis repair appears to be a reasonable option for the treatment of isolated tears of the subscapularis to obtain successful functional and patient-reported clinical outcomes. Its findings also pose the question of whether future prospective, comparative studies will find double-row surgical fixation and concomitant biceps tenodesis surgery to be superior to single-row fixation and leaving the biceps alone. Level of evidence: Level IV, systematic review of Level IV studies.
The subscapularis represent the anterior portion of rotator cuff and it is very important to stabilize the shoulder on the coronal and on the transverse plane. Balancing the coronal and transverse plane force couple is essential in providing a stable fulcrum for glenohumeral joint motion [1]. In a cadaveric study, some authors noted that when an anterosuperior rotator cuff tear extends into the upper subscapularis, glenohumeral joint kinematics start to be altered [2]. Conversely, glenohumeral kinematics were not altered in presence of an isolated tear of the middle portion of supraspinatus tendon. The upper part of the subscapularis tendon, in fact, is the zone where the fibers of subscapularis fuse with the most anterior fibers of supraspinatus tendon forming the anterior cable. Subscapularis tears usually originate proximally in the upper band and tend to propagate distally to the lower band. An EMG study showed, however, that the lower subscapularis has significantly higher muscle activity during shoulder elevation and this reflect its greater role as a humeral head depressor and anterior stabilizer [3]. A recent clinical paper confirmed this evidence, and furthermore showed that a dysfunction of the entire subscapularis (upper and lower part) and supraspinatus was associated with the loss of active elevation and was a risk factor to develop a pseudoparalytic shoulder [4].
Purpose: Subscapularis tears can be difficult to diagnose and their treatment requires advanced arthroscopic skills. The objective of this study was to find the prevalence of subscapularis tears on arthroscopic examination of shoulders with rotator cuff pathology and to determine the accuracy of pre-operative ultrasound in diagnosing these tears. Method: Ultrasound and intra-operative reports of 236 patients who underwent shoulder arthroscopy for rotator cuff pathology by the senior author at his institution were compared. Prevalence of subscapularis tear was noted and classified using Lafosse classification system. Ultrasound reports and intra-operative findings were compared to determine the accuracy, sensitivity and specificity of ultrasound in detecting subscapularis tears. Results: The prevalence of subscapularis tears in patients needing rotator cuff repair was found to be 31.4 %. A total of 6.4 % of patients needing a rotator cuff repair had an isolated subscapularis tear. The sensitivity of ultrasound was 39.5 % and specificity 93.1 % in detection of these tears. The overall accuracy of ultrasound was 75.8 %. Sensitivity of ultrasound was low (42.8 %) for smaller (type 1 and 2) tears and higher (79 %) for larger (types 3, 4, 5) tears. The overall positive predictive value of USS was 73.1 % and negative predictive value 76.4 %. Conclusion: The shoulder surgeon should be skilled in diagnosing and repairing subscapularis tendon tears arthroscopically and cannot completely rely on pre-operative ultrasound scans in ruling out smaller tears as its sensitivity in diagnosing smaller tears is quite low. Unsettling anterior shoulder pain with a normal ultrasound may need further arthroscopic evaluation to rule out missed subscapularis tears.
Despite proven accuracy of US for the evaluation of rotator cuff integrity, there is no US-based classification for this purpose. This study aimed to assess US for the evaluation of rotator cuff repair integrity in accordance with a well-established MRI classification. The authors retrospectively reviewed 257 patients who underwent arthroscopic double-row suture anchor repair for rotator cuff tears. Post-operative function was rated using the Constant score, the UCLA rating and the SSV, whereas repair integrity was assessed using US as described in the MRI classification of Sugaya et al. A total of 212 patients aged 55.6 ± 9.8 years had complete functional and radiographic assessments at a mean follow-up of 36.8 ± 11.6 months. Using all three ratings, repairs of Type I had highest scores, repairs of Type II had discernibly lower scores, whereas repairs of Types III, IV and V had similar intermediate scores. Comparison of the UCLA scores with those of Sugaya et al. revealed similar scores for repairs of Type I and of Type V. The scores are less comparable for repairs of Types II, III and IV, because US does not allow identification of partial tears if shielded by bony structures and because partial tears correspond to minimal impairment. The study reveals that US is an adequate imaging modality to classify rotator cuff repair integrity, which could reduce economic and practical burdens of CTA, MRI or MRA. The results also confirm that post-operative repair integrity and functional outcome depend on pre-operative tear size and fatty infiltration, which provides clinicians with reasoning for early surgical repair and warning of the risks of strenuous activity for patients with larger tears. Prognostic study, Level IV.
The purpose of this study was to prospectively assess the efficacy of arthroscopic repair of isolated high-grade subscapularis (SSC) tendon lesions by means of clinical follow-up combined with magnetic resonance imaging investigations. Between January 2008 and September 2010, 11 patients (9 men and 2 women; mean age, 45 ± 10 years) with Lafosse type III or IV traumatic isolated SSC tendon lesions underwent arthroscopic repair including tenodesis of the long head of the biceps tendon. All patients were preoperatively assessed by clinical examination (Constant-Murley score [CMS]) and contrast-enhanced magnetic resonance arthrography. At 1 year of follow-up, specific clinical SSC tests, the CMS, and the loss of external rotation were evaluated. A native magnetic resonance investigation was performed to assess the structural integrity of the repair. The SSC muscle was compared with its preoperative condition regarding fatty infiltration and size (cross-sectional area). Patient satisfaction was graded from 1 (poor) to 4 (excellent). The mean time interval from trauma to surgery was 3.7 months. A concomitant lesion of the biceps tendon was observed in 10 patients (91%). The mean CMS improved from 44 to 89 points (P < .001). The functional tests showed a significant increase in strength (P < .05) (belly-press test, 4.8 v 2.9; lift-off test, 4.8 v 2.9). The mean loss of external rotation at 0° of abduction was 10° compared with the contralateral side (P < .05). Patient satisfaction was high. Magnetic resonance imaging evaluation showed complete structural integrity of the tendon repair in all studies. The SSC showed a significant decrease in fatty infiltration and increase in the cross-sectional area. Arthroscopic repair of higher-grade isolated SSC lesions provides reliable tendon healing accompanied by excellent functional results 1 year after surgery. Level IV, prospective therapeutic case series.
As the largest and most powerful rotator cuff muscle, the subscapularis plays a critical role in proper shoulder function. The diagnosis of subscapularis tears is made based on history and physical examination and confirmed with imaging studies. Historically, subscapularis tears have been addressed in an open fashion. Recent literature has demonstrated successful all-arthroscopic repair of isolated subscapularis tears and anterosuperior rotator cuff tears. Successful arthroscopic treatment follows several critical steps: patient positioning, portal placement, obtaining adequate visualization and working space, identifying and mobilizing the subscapularis tendon, preparation of the tendon edge and lesser tuberosity, appropriate anchor placement, suture passage, and finally, secure knot-tying and fixation. Excellent functional and clinical outcomes following these steps have been demonstrated by various investigators. Additional research is needed, however, because direct comparison between all-arthroscopic and open subscapularis repair is limited, and neither technique has proved to be superior.
The purpose of this study was to evaluate outcome and structural integrity after arthroscopic repair of large subscapularis tendon (SSC) tears at 2 to 4 years' follow-up. Between January 2006 and October 2008, 52 consecutive patients underwent arthroscopic repair of Lafosse type III and IV SSC ruptures. A total of 46 patients (38 men and 8 women) with a mean age of 62 years (range, 45 to 81 years) were available for final follow-up. Clinical findings were assessed for all patients preoperatively and postoperatively, including range of motion, the lift-off test, the belly-press test, the Constant score, and the modified University of California, Los Angeles score. Subscapularis muscle strength by use of the bear-hug test and external rotation were compared in both shoulders postoperatively. Patients were evaluated with plain radiographs and magnetic resonance imaging or computed tomographic arthrography before surgery. Postoperatively, radiographic examination was completed by use of magnetic resonance imaging or computed tomographic arthrography in 39 patients (85%). Patients completed the subjective shoulder value and rated their satisfaction at final follow-up. The mean follow-up period was 35.3 ± 9.6 months (range, 23 to 57 months). An isolated lesion was detected in 13% of patients; a lesion of the SSC and supraspinatus tendon was found in 37%; and a lesion of the SSC, supraspinatus tendon, and infraspinatus tendon was detected in 50%. At latest follow-up, the mean Constant score significantly improved from 46.4 points to 79.9 points and the modified University of California, Los Angeles score improved from 15.1 points to 31.5 points (P < .001). Subscapularis strength was 92% and external rotation was 96% of the nonoperative shoulder. All outcome scores were similar between Lafosse type III and IV SSC ruptures. Radiographic evaluation showed a rerupture rate of 11%. The coracohumeral distance increased from 9.7 mm to 10.1 mm postoperatively (P = .086). The subjective shoulder value improved from 51% to 88% (P < .001), and 98% of patients were satisfied or very satisfied. Arthroscopic treatment of large to massive SSC ruptures results in significant clinical improvements, excellent maintenance of muscle strength, and durable tendon integrity at 2 to 4 years' follow-up. Level IV, therapeutic case series.
Purpose: The purpose of this study was to evaluate the mechanism of injury, patient characteristics, tear size, and clinical outcomes after arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years. Methods: A total of 70 consecutive patients were reviewed in a retrospective, multicenter (2 institutions) study evaluating prospectively collected data. Fifty-three patients, with a mean age of 37.5 years (range, 16.2 to 44.9 years), were available for follow-up at a mean of 35.8 months (range, 13.8 to 59.1 months). Exclusion criteria included patients with revision procedures, repair of partial tears, and follow-up of less than 12 months. Follow-up evaluation included physical examination with dynamometer strength testing and clinical outcome measures including the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, pain score on a visual analog scale, and Simple Shoulder Test score. Results: A total of 60% of the patients (32 of 53) had a traumatic etiology, with 38% (12 of 32) of these related to an athletic event. Of the tears, 36 (68%) were medium tears. Concomitant procedures performed at the time of rotator cuff repair included acromioplasty (51), biceps tenodesis or tenotomy (24), distal clavicle excision (10), anteroinferior stabilization (2), and labral repair (1). The mean postoperative ASES score was 84.6 (range, 21.6 to 100.0), with 2 patients recording ASES scores of less than 50 (21.7 and 41.7) at final follow-up. In the 38 patients available for clinical follow-up examination, forward flexion improved from 158.7° (range, 45° to 180°) to 168.4° (range, 120° to 180°) (P = .014). At the time of follow-up, no patients had undergone revision surgery. On the basis of poor clinical outcome scores, 2 patients (4.0%) were considered failures. Conclusions: Arthroscopic primary rotator cuff repair of full-thickness tears in patients aged younger than 45 years results in improved outcomes with regard to pain, subjective patient satisfaction, and shoulder function. Level of evidence: Level IV, therapeutic case series.