Open Subscapularis Repair

Indications

• Retracted tear (Fig. 15-1)

• Difficult to mobilize arthroscopically

• Isolated tear

• Open approach can be combined with mini-open supraspinatus and/or infraspinatus repairs.

Sterile Instruments/Equipment

• Surgical assistant

• For deltopectoral approach

▪ Difficult to retract deltoid laterally

• No. 2 synthetic, nonabsorbable braided suture on a no. 2 curved Mayo needle

• Traction sutures

• 4.5-mm suture anchors (2-4) with no. 2 synthetic, nonabsorbable braided suture

• No. 5 curved Mayo needles

• Right-angled retractors

• Richardson or Army/Navy

• Self-retaining retractors

• Weitlaner retractor

Positioning and Preparation

• Beach chair

• Difficult to do in lateral position

• Bony landmarks are marked (Fig. 15-2)

• Coracoid process

• Acromion: anterior and lateral borders

• Anterior clavicle

• Acromioclavicular joint

Surgical Approach/Technique

• Classic open deltopectoral approach

• A 4- to 6-cm-long incision is made.

• The incision begins slightly lateral and inferior to coracoid.

• The deltopectoral interval is identified.

• The cephalic vein is identified in the interval and retracted laterally.

• Richardson retractors are placed under the deltoid and vein, and both are retracted laterally.

• The clavipectoral fascia is incised, and conjoined tendon is identified medially.

• The bicipital groove is identified (between the greater and lesser tuberosities) (Fig. 15-3).

• The long head of the biceps tendon (LHBT) is an excellent landmark for the bicipital groove.

Figure 15-1 | A. Coronal T2-weighted MRI indicating an acute, massive, retracted tear of the supraspinatus tendon. The lateral edge (blue arrow) is retracted past the apex of the humeral head. B. Axial T2 weighted image demonstrating subscapularis tear retracted nearly to the level of the glenoid (red arrow). The bicipital groove is empty, indicating a retracted LHBT tear (green arrow).

Figure 15-2 | Surgical landmarks and incision. Right shoulder with patient in the beach chair position. The scissors point to the coracoid. The clavicle, acromion, and acromioclavicular joint are marked. The vertical line indicates the planned incision.