Fig. 1
Traumatic injury to right shoulder with inability to forward flex
The examination is used to distinguish active and passive ranges of motion. Some shoulders develop stiffness after a traumatic anterosuperior tear [17]. Most will have a near to normal passive range of motion. Weakness during attempts at elevation, external rotation, and belly-press signs are common in shoulders with multitendon tears. The examiner should evaluate internal rotation weakness with liftoff, belly-press, and bear-hug signs [4]. External rotation weakness can be assessed and compared to the uninjured side (Fig. 2). Reduction of elevation can be the result of pain, and can be altered with an injection. True anterosuperior glenohumeral escape, when chronic, may require a different approach, and a soft tissue repair may be inadequate to improve the functional loss.
Fig. 2
External rotation lag sign. (a) Passive assist external rotation. (b) After releasing, the arm returns to internal rotated position
Imaging studies should include radiographs in an upright patient. Maintenance of the acromiohumeral interval and a normal-appearing acromion are important features of a shoulder that has maintained the humeral head concentric position. Advanced glenohumeral arthritis may require an arthroplasty to reduce the articular symptoms of incongruity of the surfaces to improve pain and function.
Additional imaging studies include magnetic resonance imaging or computerized technology with or without articular contrast. Changes in the muscle trophicity may indicate the chronicity of muscle changes and influence the ability to improve the shoulder following a repair.
The ideal candidate for surgical repair is one that has been functioning well with little or no shoulder pain, and is injured acutely, changing their shoulder function. Their exam would demonstrate a multitendon deficit, in an otherwise stable shoulder. Imaging studies would demonstrate minimal or no glenohumeral arthritis and minimal superior humeral head migration. The MRI would demonstrate a multitendon tear with supraspinatus retraction, an intact biceps tendon, and grade I or II muscle changes as presented by Goutallier [18, 19].
Technique
The shoulder is examined under anesthesia. A full range of motion can be demonstrated and if not, gentle manipulation will reverse any adhesions that may restrict motion. The patient is then positioned for arthroscopic repair in either the beach chair or lateral decubitus position.
A posterior portal is created 2 cm inferior to the junction of the spine of the scapula and posterior extension of the acromion. After irrigation of the articulation, an anterior portal is created inferior to the acromioclavicular joint, entering into the rotator interval. After achieving satisfactory flow, a systematic examination of the glenohumeral joint is performed.
The superior border of the subscapularis is visualized and its relationship to the long head of the biceps. The medial pulley is often detached and can retract toward the glenoid edge, creating a “comma sign” (Fig. 3). The middle capsular ligaments may remain intact, hiding a retracted subscapularis tendon. The supraspinatus tear is confirmed, and the footprint and articular margin are identified.
Fig. 3
Retracted subscapularis tear with connected pulley capsular ligaments creating a comma sign
The scope is then switched to the anterior portal and the posterior extension of the tear is revealed. A posterior capsulotomy can be performed, which extends inferiorly, allowing improved internal rotation. Further inspection of the subscapularis can visualize the lesser tuberosity footprint and amount of retraction.
The arthroscope is placed within the subacromial bursa and a brief debridement is performed to understand the tear pattern and muscle and tendon quality. A lateral portal, 3 cm lateral to the anterior margin of the acromion, is created.
Once the diagnostic arthroscopy is completed, the arthroscope is placed in the posterior articular portal. A suture is placed in the long head of the biceps and a tenotomy at this junction of the superior labrum is performed (Fig. 4).
Fig. 4
A suture is placed through the long head of the biceps prior to tenotomy
An arthroscopic subscapularis repair is completed using both the articular and bursal viewing portals. Any medialization or tendon retraction should be reduced without complete division to the pulley and the coracohumeral ligaments. This additional tissue can provide additional length to reduce the tension of the repair. At the completion of the repair, the surgeon should confirm a safe interval between the repair and the coracoid process and short head of the biceps and brachioradialis. Gentle rotation will confirm this interval.
The arthroscope is now placed in the posterior portal, entering within the subacromial space. There is often a partial reduction of the supraspinatus tear following the subscapularis repair. Posterior medial retraction is common, and the multiple delaminations within the infraspinatus can often be seen from a lateral viewing portal. Anteriorly, additional bursal releases can be performed adjacent to the coracoid’s lateral border. A modified acromial decompression is performed without complete detachment or resection of the coracoacromial ligament. Any significant osteophytes from the anterior margin of the acromion or clavicle are resected with a burr. Preservation of the coracoacromial ligament insertion may be important in providing stability to the anterior aspect of the humeral head. Following debridement and decompression, additional viewing space allows instrumentation and tissue mobilization. Preparation of the greater tuberosity includes a gentle debridement of devitalized tissue.
A percutaneous placed posterior anchor is used to reduce multiple layers and reattach the infraspinatus and posterior margin of the supraspinatus with multiple mattress sutures (Fig. 5). When multistitch anchors are used, a stitch is retracted for biceps reattachment. A second anchor is placed anteriorly on medial margin of the greater tuberosity. Sutures are passed through the supraspinatus as simple, mattress, or combination for optimal security. The posterior sutures are tied first to confirm proper tension, followed by the anterior sutures.
