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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 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.
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.
1
Tears of the supraspinatus and even isolated upper fiber
subscapularis tears have been shown to alter the
biomechanics of the glenohumeral joint, increasing
both anterior and superior humeral translation.
2
Sub-
coracoid stenosis and impingement causing tensile
undersurface fiber failure have been proposed as a
mechanism for the etiology of subscapularis tears.
3
Although the advent of arthroscopy has allowed for
significant 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 fixation and, therefore, provides an envi-
ronment that maximizes the potential for improved
functional outcomes and decreased rates of rerup-
ture.
4,5
This procedure has been shown to demonstrate
a significant biomechanical advantage compared with a
single-row repair.
6
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 authors’preferred
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 difficult 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 conflicts of interest or sources of
funding: A.R. receives financial 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 financial and material support, research support, and
consultant and presenter or speaker payments from Arthrex; and personal
fees, publishing royalties, and financial 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: bcabarcas44@gmail.com
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://
creativecommons.org/licenses/by-nc-nd/4.0/).
2212-6287/18289
https://doi.org/10.1016/j.eats.2018.03.020
Arthroscopy Techniques, Vol 7, No 8 (August), 2018: pp e805-e809 e805
identified 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 confirmed 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 final ante-
rosuperior lateral portal is then placed 2 fingerbreadths
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
Joint
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
first 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
significant 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
Approximation
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 difficult 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
structures.
Ensure proper suture management. Overdebridement of the rotator interval can cause increased
swelling, necessitating prompt fixation.
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.
e806 B. C. CABARCAS ET AL.
-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 identified and sepa-
rated from the tendon with an electrothermal device.
The anterosuperior lateral portal is then established,
and an arthroscopic grasper (Kingfisher; Arthrex) is
used to identify maximal tendon excursion (Fig 2). This
“excursion test”serves to define 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 first anchor is
placed at the tear’s 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 sufficient, 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 final lateral-row repair.
Fig 2. Right subscapularis (SS) tendon approximation and
excursion test performed with an arthroscopic grasper
(Kingfisher; Arthrex) in the anterosuperior lateral portal. This
excursion test serves to help define the previously distorted
anatomy of the tendon and characterize the repair footprint.
Viewed from posterior portal. (LT, lesser tuberosity of
humerus.)
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
portal.)
DOUBLE-ROW SUBSCAPULARIS REPAIR e807
Achieving Adequate Fixation
Final lateral-row fixation 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.
Discussion
The technical difficulties 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.
7
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.
8
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.
9
Additionally, forward
flexion significantly 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
performed.
e808 B. C. CABARCAS ET AL.
A systematic review by Saltzman et al.
5
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 difficult cases. Positive
clinical outcomes were also reported by Lanz et al.
10
in
a case series of 52 patients who underwent arthroscopic
repair of Lafosse type III and IV subscapularis tears with
primarily double-row configuration 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) significantly 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 difficulty associated with the procedure, the
available evidence demonstrates excellent clinical out-
comes after double-row repair.
5,7,8,10,11
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 circumflex humeral artery courses
along with the axillary nerve to eventually enter the
quadrangular space.
12
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 difficult to
observe, as the prevalence of subscapularis tears in
patients undergoing arthroscopic rotator cuff repair has
been reported to be higher than 31%.
13
Increased
swelling may significantly 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 specific patient group.
References
1. Garofalo R, Flanagin BF, Castagna A, Krishnan SG.
Subscapularis tear: Intraoperative evaluation and treat-
ment. In: Gumina S, ed. Rotator cuff tear: Pathogenesis,
evaluation and treatment. Cham, Switzerland: Springer,
2017;345-351.
2. Su W-R, Budoff JE, Luo Z-P. The effect of anterosuperior
rotator cuff tears on glenohumeral translation. Arthroscopy
2009;25:282-289.
3. 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;19:1142-1150.
4. Denard PJ, Burkhart SS. Arthroscopic recognition and
repair of the torn subscapularis tendon. Arthrosc Tech
2013;2:e373-e379.
5. Saltzman BM, Collins MJ, Leroux T, et al. Arthroscopic
repair of isolated subscapularis tears: A systematic re-
view of technique-specificoutcomes.Arthroscopy
2017;33:849-860.
6. Wellmann M, Wiebringhaus P, Lodde I, et al. Biome-
chanical evaluation of a single-row versus double-row
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
imagingecontrolled case series with 1 year of follow-up.
Arthroscopy 2014;30:665-672.
8. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B,
Gobezie R. Structural integrity and clinical outcomes after
arthroscopic repair of isolated subscapularis tears. J Bone
Joint Surg Am 2007;89:1184-1193.
9. Lin EC, Mall NA, Dhawan A, et al. Arthroscopic primary
rotator cuff repairs in patients aged younger than 45
years. Arthroscopy 2013;29:811-817.
10. Lanz U, Fullick R, Bongiorno V, Saintmard B, Campens C,
Lafosse L. Arthroscopic repair of large subscapularis
tendon tears: 2- to 4-year clinical and radiographic out-
comes. Arthroscopy 2013;29:1471-1478.
11. Barth J, Fotiadis E, Barthelemy R, Genna S, Saffarini M.
Ultrasonic evaluation of the repair integrity can predict
functional outcomes after arthroscopic double-row rota-
tor cuff repair. Knee Surg Sports Traumatol Arthrosc 2015;23:
376-385.
12. Kuntz AF, Raphael I, Dougherty MP, Abboud JA.
Arthroscopic subscapularis repair. J Am Acad Orthop Surg
2014;22:80-89.
13. Narasimhan R, Shamse K, Nash C, Dhingra D, Kennedy S.
Prevalence of subscapularis tears and accuracy of shoulder
ultrasound in pre-operative diagnosis. Int Orthop 2016;40:
975-979.
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