Anterosuperior Tears (Reparable): Arthroscopic Repair—Suture Tunnels

Sumant “Butch” Krishnan

Eddie Y. Lo

INDICATIONS

Anterosuperior rotator cuff tears are defined as combined rotator cuff tears involving the subscapularis tendon, supraspinatus tendon, and/or biceps tendon.¹^, ² ^and ³ This is a unique subset of rotator cuff tears that occur 12% to 18% of the time.⁴^,⁵ These tears involve the anterior rotator cable and rotator interval, with associated biceps pulley lesions and biceps tendon tears. Arthroscopic anchorless transosseous repairs are appropriate treatments for anterosuperior cuff tears that fit the following:

High-grade partial thickness or full-thickness tears
Supraspinatus, infraspinatus, and/or subscapularis tendon involvement
Fatty Infiltration (Goutallier Stage) ≤2
No dynamic anterosuperior escape

PREOPERATIVE PREPARATION

Most patients with anterosuperior cuff tears can present with clinical history of pain, weakness, and decreased range of motion. Although patients can have a history of traumatic injury,⁵ the tear can arise from degenerative tearing following chronic overuse. Some patients may describe a popping sensation and associated bruising in the arm. Biceps pathology has been reported in as high as 100% of the anterosuperior cuff tear cases.²^,⁵ Lafosse et al described a subscapularis tear classification system, which includes articular partial tendon tears (type I), full-thickness tears in only the superior part of the tendon (types II and III), full-thickness tears without humeral head subluxation (type IV), and full-thickness tears with humeral head subluxation (type V) (Table 23-1).⁴ Collin et al described five common types of massive rotator cuff tears and identified anterosuperior cuff tear as a unique tear type with more than 80% risk of pseudoparalysis, especially if it involved most of the subscapularis.³

TABLE 23-1 Lafosse Classification for Subscapularis Tear

Lafosse Classification	Tear Type
Type 1	Partial tear of superior 1/3
Type 2	Full-thickness tear of superior 1/3
Type 3	Full tear of superior 2/3
Type 4	Full-thickness tear with centered head and fatty infiltration <3
Type 5	Full-thickness tear with decentered head and fatty infiltration ≥3
From Lafosse L, Jost B, Reiland Y, et al. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Jt Surg. 2007;89(6):1184-1193.

On clinical examination, there can be decreased active shoulder elevation and internal rotation. Patients with full-thickness subscapularis tears can have increased passive external rotation with the arm at the side. On strength examination, patients may demonstrate supraspinatus weakness with full can, empty can, and drop arm tests. Subscapularis-specific exams such as lift-off, belly press, and bear hug test have variable specificity.⁶ Biceps directed tests including O’Brien test and speed test may be positive due to associated biceps injury.

On radiographic imaging, Grashey AP, scapular Y, and axillary lateral views can be grossly normal. With large retracted full-thickness tears, anterior subluxation of humeral head relative to glenoid on axillary lateral views can be seen. If dynamic anterosuperior escape is visualized on Grashey AP or axillary lateral views, one should be concerned about chronic massive cuff tear versus cuff tear arthropathy.⁷ Magnetic Resonance Imaging with arthrogram (MRA) is the preferred imaging modality of choice (Figure 23-1). Although MRA is comparable to MRI in sensitivity and specificity in evaluation of full-thickness retracted cuff tears, MRA is superior in identifying partial-thickness cuff tears.⁸^,⁹ In retracted subscapularis tendon tears, biceps pulley disruption and medialization of the biceps tendon can be noted with disruption of the transverse humeral ligament.⁴^,⁵

FIGURE 23-1 MR arthrogram of a right shoulder is demonstrated.

A, The axillary plane is shown with a retracted full-thickness subscapularis tear (arrow) and a dislocated biceps tendon (circle). B, The sagittal plane is ideal for assessing the muscle quality medially (arrows, subscapularis) with degree of fatty infiltration.

TECHNIQUE: PRINCIPLE OF ANTEROSUPERIOR ANCHORLESS TRANSOSSEOUS CUFF REPAIR

Patient Positioning

Most anterosuperior rotator cuff tears can be managed arthroscopically. Surgical techniques can be performed in either beach-chair or lateral decubitus position, with respective pros and cons.

Lateral decubitus arthroscopic repair has the patient positioned on a flat bed with the arm suspended in 10 to 15 lb of traction. The arm is mostly stationary, but can be rotated or angulated if needed. Most surgeons orient their arthroscopic portals to target the specific tear of interest (Figure 23-2). When attempting to visualize an anterosuperior cuff tear on the bursal side with the patient in lateral decubitus position, the arm is internally rotated with the subscapularis and biceps rotated away from the arthroscope—potentially complicating the bursal repair (Figure 26-3A). Hence, many surgeons opt for an intra-articular repair (Figure 23-3B), use a 70° scope for improved visualization, and/or have an assistant physically hold the arm in external rotation while performing the repair with a posterior-directed force (“posterior lever push”; Figure 23-3C).

FIGURE 23-2 Shoulder arthroscopy is demonstrated in the standard lateral decubitus position.

The arm is suspended in balance traction of 10 to 15 lb.

FIGURE 23-3 Surgery is performed in lateral decubitus position here.

A, Bursal arthroscopic view is shown. The arm is internally rotated and subscapularis tendon and biceps groove (dashed lines) are shown. Subscapularis tendon can be far from surgeons view. B, The intra-articular view is shown with the subscapularis insertion demonstrated. Intra-articular repair can be performed with the aid of the 70° scope. C, Bursal visualization can be improved with external rotation of the arm with subscapularis tendon and biceps groove brought closer to the field of view.

Beach chair arthroscopic repair has the arm prepped into the field and may have the arm supported by an arm holder, allowing for easier intraoperative mobilization of the involved extremity. Intraoperative flexion and external rotation brings the lesser tuberosity and subscapularis tendon into an optimal view for repair (Figure 23-4A and B). The bursal arthroscopic view is optimized by the arm adjustment and the repair is done technically akin to posterosuperior cuff repairs (Figure 23-5).

FIGURE 23-4 Surgery is performed in a beach-chair position here.

The arm is prepped into the field. It can be adjusted to help with arthroscopic visualization from neutral (A) to external rotation (B).

FIGURE 23-5 Bursal arthroscopy of a right shoulder is demonstrated.

The arm is in slight flexion and external rotation to aid with visualization. The anterosuperior rotator cuff tear is visualized here akin to posterosuperior cuff tear. Supraspinatus tendon, subscapularis tendon, and lesser tuberosities are visualized and labeled.

Arthroscopic Anchorless Transosseous Repair With a 4-Portal Technique

The ideal rotator cuff repair must satisfy the following: (1) strong biomechanical time-zero fixation, (2) anatomic footprint restoration, and (3) optimal biologic healing environment. The preferred surgical technique outlined here is an arthroscopic anchorless cuff repair via transosseous tunnels, performed in the beach-chair position using a 4-portal arthroscopic technique. This technique is similar to the arthroscopic posterosuperior cuff repair already reported in the literature.¹⁰^,¹¹ However, to address the unique anatomy of anterosuperior tears, the three working arthroscopic portals are shifted slightly anteriorly (

Video 23-1, time: 0-0:24) (Figure 23-6). The posterolateral portal is the ultimate viewing portal with a 30° scope, whereas the anterolateral portal is the main instrumentation portal for suture passage. The camera is rotated anteriorly to keep the humerus as the “floor” of the camera view and the arm is rotated toward the camera for optimal visualization of the entire subscapularis tendon and bicipital groove.

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