Arthroscopic Subscapularis Repair

Robert U. Hartzler

Stephen S. Burkhart

Instruments and Equipment

• 30- and 70-degree arthroscopes

• Antegrade and retrograde suture passers

• Suture anchors

• Arthroscopic pump

• Arthroscopic shaver and burr (5 mm) and electrocautery device

• Arthroscopic ring curettes and elevators (15 and 30 degrees)

• Arthroscopic cannulas

• 18-gauge spinal needles

Positioning and Operating Room Setup

• We recommend the lateral position (Fig. 16-1A) with the patient leaning backward 20-30 degrees so that the glenohumeral joint lies horizontal and the working space in front of the shoulder remains open.

• Goggles should be placed on the patient to protect the eyes, because the angle of approach to the lesser tuberosity often is very close to the face (Fig. 16-1B).

• A skilled surgical tech stands across from the surgeon (Fig. 16-2A) and manipulates the arm to improve visualization and access to critical working spaces.

• The posterior lever push (Fig. 16-2B) is performed by applying a posteriorly directed force and an anteriorly directed counter force to the proximal and distal humerus, respectively.

Surgical Approach and Intraoperative Diagnostic Techniques

• Subscapularis repair and arthroscopic long head of biceps (LHB) tenodesis should be done first if there is an associated posterosuperior rotator cuff tear, because anterior swelling can compromise the ability to carry out these procedures arthroscopically.

• LHB tenodesis high in the groove¹ (Chapter 17) is almost always indicated with arthroscopic subscapularis tendon repair:

• Tenodesis protects the subscapularis repair from abrasion by the LHB when the medial sling is incompetent.

• LHB tendon pathology (medial subluxation, partial tearing) commonly occurs with subscapularis tendon tears (Fig. 16-4B).

• Working anterosuperior-lateral (ASL) and anterior portals are created with an outside-in technique aided by spinal needles:

• The ASL skin incision usually is located just off the anterolateral corner of the acromion (Fig. 16-3A) and should result in a perpendicular angle of approach to the proximal bicipital

groove (for a high tenodesis) (Fig. 16-4A) with a shallow (10 to 15 degrees) angle to the lesser tuberosity (Fig. 16-4B).

Figure 16-1 | Lateral positioning (right shoulder) shown from the head of the table (A) and superior (B) with the patient leaning back 20-30 degrees ensures that there is adequate working space anteriorly. Goggles should be placed before draping, because the instruments for placing anchors in the lesser tuberosity will pass very close to the patient’s face. G, glenoid; H, humeral head.

Figure 16-2 | Schematic (A) and photo (B) of our standard operating room setup (right shoulder) demonstrates how the second surgical technician can apply the posterior lever push to improve the arthroscopic view (inset) of the subscapularis (SSc) and lesser tuberosity. A posterior force is applied to the upper arm (white arrow), and an anterior counter force is applied to the lower arm (green arrow), H, humeral head.

Figure 16-3 | Left shoulder external view (A) and 70-degree arthroscopic view (B). The anterosuperior-lateral (ASL) portal (cannulated) is typically located just off the anterolateral corner of the acromion (blue line) on the skin. A spinal needle (white arrow) shows the location of an accessory anterior portal, which often seems “very medial” but is necessary to gain the correct angle of approach (white arrow, B) to the lesser tuberosity (LT). H, humeral head; SSc, subscapularis.

Figure 16-4 | Creation of an ASL portal (left shoulder) using an outside-in technique with a spinal needle to ensure the correct working angles from the chosen skin location. A. 70-degree view of the top of the bicipital groove shows a good angle for biceps tenodesis. B. 70-degree view of the tear shows a good working angle (shallow) to the lesser tuberosity. C. 30-degree view shows the portal created through the rotator interval anterior to the supraspinatus tendon (SS). Note the high-grade partial tearing of the medially subluxated BT (B). BT; biceps tendon; H, humeral head; SSc, subscapularis.

▪ The ASL portal is made anterior to the supraspinatus through the rotator interval (Fig. 16-4C).

▪ A cannula usually is used through the ASL portal.

• Anterior portal(s) usually are required for anchor placement to improve the angle of approach to the lesser tuberosity (Figs. 16-3B and 16-11)

▪ Spinal needle placement often appears to be “very medial” on the skin (Fig. 16-3A).

▪ Anterior portals can be used for retrograde suture passage or for suture management and typically are percutaneous (noncannulated).

• Diagnostic techniques

• Subscapularis tears remain generally underrecognized and undertreated. A high index of suspicion and a systematic examination of the bicipital groove, subcoracoid space, and tendon insertion should be used to avoid a missed diagnosis.

• Use of a 70-degree arthroscope is critical when assessing these areas, because it greatly expands the surgeon’s field of view (Fig. 16-5) and can aid in diagnosing occult tears.²

▪ The medial side wall of the bicipital groove is examined for tearing (Fig. 16-12A and B), because this can reveal an occult tear.

▪ Rarely, takedown of the medial sling is required to demonstrate an occult tear.3

• The posterior lever push with internal rotation often reveals nonretracted (Fig. 16-5C) or occult subscapularis tears.

• Viewing can be optimized by controlling bleeding through fluid management.

Figure 16-5 | The subscapularis (SSc) tendon often looks normal on casual inspection with a 30-degree scope (right shoulder) (A). A 70-degree scope dramatically improves the view of the subscapularis (B); however, the bare lesser tuberosity (LT) is not seen until internal rotation with the posterior lever push is applied (C). H, humeral head.

▪ The pump is run at an adequate pressure (minimum 60 mm Hg).

▪ Fluid extravasation from portals is stopped with cannulas or the Dutch boy technique (manual pressure by assistant) to minimize fluctuations in pressure and turbulence.

• Recognition of the “comma sign” is critical when a retracted subscapularis tear is present.⁴

▪ The comma tissue is the lateral part of the rotator interval capsule and contains the coracohumeral and superior glenohumeral ligaments.

▪ The comma tissue connects the superolateral subscapularis tendon with the supraspinatus tendon.

• In primary, retracted subscapularis tears, the upper tendon border usually lies at the middle of the glenoid.

• Working in the subcoracoid space is essential in treating subscapularis tears.

• Work in this area is always started by opening the rotator interval medial to the comma with a shaver or cautery from an ASL portal while viewing with a 30-degree arthroscope from a posterior portal (Fig. 16-6A).

Figure 16-6 | Working in the subcoracoid space (left shoulder) requires repositioning of instruments posterior (A and B) and anterior (C) to the comma tissue (black comma symbol). Work with a 30-degree scope (A and B) until the interval has been opened and landmarks defined. A 70-degree scope improves the view (C) for working anterior to the tendon. C, coracoid; CT, conjoint tendon; H, humeral head; SS, supraspinatus tendon; SSc, subscapularis tendon.

• Once the anatomic landmarks have been identified, switching to a 70-degree scope allows an excellent view of the entire subcoracoid space (Figs. 16-6C and 16-7B) and lesser tuberosity footprint (Fig. 16-7F).

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