Arthroscopic subscapularis repair

OVERVIEW

Chapter synopsis

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 outcomes of arthroscopic subscapularis repairs.

Important points

Patients often are seen after a traumatic event with internal rotation weakness and pain.
Physical examination tests that isolate the subscapularis include the belly press, lift-off, and/or bear hug tests.
The entire shoulder should be carefully examined to evaluate other causes of pathology.
It is paramount to have the repair be tension free and attached securely to the lesser tuberosity.

Clinical/surgical pearls

An interscalene block or catheter can reduce the anesthetic required and help with postoperative pain.
The comma sign can make identification of the tendon tear easier.
A 70-degree scope and switching the arthroscope from posterior and lateral working portals can aid in visualization
Coracoidplasty can increase working space during the procedure and decreases impingement postoperatively.
Place anchors inferiorly to superiorly, and tie knots superiorly to inferiorly.
Use of a limb positioner can aid in anchor placement, allowing appropriate angle tension of repair while sutures are being tied.
Check motion after repair to aid in the initial safe range of motion for postoperative rehabilitation.

Clinical/surgical pitfalls

Straying medial to the coracoid puts neurovascular structures at risk.
Do not fail to address concomitant pathology.
Do not over tension the repair.

Video available

: Identification and demonstration of the comma sign.
: Assessing the mobility of the subscapularis.
: Demonstration of traction stitch.
: Assessing the mobility of the supraspinatus.
: Assessing the final repair of lateral row anchor and subscapularis repair.

Introduction

As arthroscopic techniques in shoulder surgery have improved, recognition of subscapularis tendon injuries has increased. The prevalence of subscapularis tears in patients undergoing arthroscopic rotator cuff repair has been estimated to be greater than 31%. Subscapularis tears are infrequently found to be isolated tears; however, they are more commonly seen in association with supraspinatus or infraspinatus tears with an incidence estimated at 27% to 43%. ^, Because of this, there has been increased interest in arthroscopic subscapularis tendon repairs and a corresponding increase in cases performed. The main advantages of an arthroscopic repair of the subscapularis tendon are smaller incisions, less postoperative pain, and/or the ability to better visualize and address coexisting pathologic processes, including labral tears, long head biceps injury, and superior and/or posterior rotator cuff tears. This chapter addresses the preoperative considerations and the techniques involved in performing an arthroscopic subscapularis repair.

Pre-operative considerations

History

The majority of subscapularis tears are degenerative. Isolated tears are more prevalent in younger patients, typically as a result of a traumatic injury, which may include an abduction and external rotation moment, direct blow, heavy lifting, or traction injury to the shoulder.

Signs and symptoms

The most common symptom experienced by patients with a subscapularis tear is anterior shoulder pain. One should consider a full differential diagnosis for anterior shoulder pain including acromioclavicular joint arthrosis or dislocation, biceps tendon tear or inflammation, anterior capsulolabral damage, and fractures of the lesser tuberosity. Patients may note difficulty or weakness with internal rotation movements, such as when tucking in a shirttail.

Physical examination

A complete shoulder examination should begin with observation, range of motion, and strength testing. The most common physical examination findings associated with a subscapularis tear are weakness and pain with isolation of internal rotation. External rotation, which can be increased in the injured shoulder due to loss of internal rotation, is evaluated with the arm and elbow at the side and then compared with the contralateral extremity.

It is important to isolate the subscapularis muscle from other internal rotators during examination. Owing to the high association with biceps tendon pathology, careful examination with the Speed and O’Brien tests is also important. The belly press test is performed by asking the patient to press the ipsilateral hand on the abdomen while maintaining the elbow anterior to the body. The belly press test result is considered positive if the patient is not able to keep the elbow anterior to the trunk or if the wrist is flexed in attempting to press into the abdomen. The lift-off test requires the patient to be able to place the ipsilateral hand behind the back. The patient is then asked to lift the hand off of the back; if the patient is unable to do so, the test result is considered positive. The most sensitive test is the bear hug test. The patient places his or her ipsilateral hand on the contralateral shoulder with the elbow elevated forward. The test result is positive if the surgeon is able to lift the patient’s hand off the shoulder more easily compared to the contralateral shoulder.

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