Illustrated Tips & Tricks CH16

Chapter 16 Arthroscopic Subscapularis Repair

ROBERT U. HARTZLER STEPHEN S. BURKHART

Instruments and Equipment

ll 30- and 70-degree arthroscopes ll Antegrade and retrograde suture passers ll Suture anchors ll Arthroscopic pump ll Arthroscopic shaver and burr (5 mm) and electrocautery device ll Arthroscopic ring curettes and elevators (15 and 30 degrees) ll Arthroscopic cannulas ll 18-gauge spinal needles

Positioning and Operating Room Setup

ll 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). ll 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 ll 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. ll LHB tenodesis high in the groove 1 (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 subscapu- laris tendon tears (Fig. 16-4B). ll 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

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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.

Monitor

Pump

Tower: Shaver/Burr Electrocautery Camera

Second Surgical Tech

Traction Device

Mayo #2

Drape

Anesthesia

Surgeon

Assistant

Primary surgical Tech

Monitor

Mayo #1

A

Instrument table

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.

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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.

groove (for a high tenodesis) (Fig. 16-4A) with a shallow (10 to 15 degrees) angle to the lesser tuberosity (Fig. 16-4B). nn The ASL portal is made anterior to the supraspinatus through the rotator interval (Fig. 16-4C). nn 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) nn Spinal needle placement often appears to be “very medial” on the skin (Fig. 16-3A). nn Anterior portals can be used for retrograde suture passage or for suture management and typically are percutaneous (noncannulated). ll 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 nn The medial side wall of the bicipital groove is examined for tearing (Fig. 16-12A and B), because this can reveal an occult tear. nn 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.

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nn The pump is run at an adequate pressure (minimum 60 mm Hg). nn 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 nn The comma tissue is the lateral part of the rotator interval capsule and contains the coracohumeral and superior glenohumeral ligaments. nn 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. ll 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 foot- print (Fig. 16-7F). • The comma tissue is preserved (Figs. 16-6 and 16-7) because this tissue: nn Acts as a “rip stop” for sutures of the upper tendon nn Aids in reduction of the supraspinatus when a retracted anterosuperior tear exists • As needed, instruments are used either anterior (Fig. 16-6A and B) or posterior (Fig. 16-6C) to the comma to expose the coracoid, conjoint tendon, subscapularis tendon, and lesser tuberosity by removing pathologic fibrofatty and bursal tissue. ll All subscapularis tendon tears where there has been fiber failure from the footprint (Fig. 16-7F) are repaired. Abrasive wear of the tendon (Fig. 16-7E) or linear, longitudinal tearing without failure at the tendon insertion can occasionally be treated by subcoracoid decompression (Fig. 16-7) alone. • Subcoracoid stenosis (coracohumeral distance <6 mm) (Fig. 16-7B) is treated by removing any coracoid tip osteophyte with a burr (Fig. 16-7C). • The end point of this step occurs when the posterior coracoid is coplanar with the conjoint tendon and there exists 7-10 mm of space between the coracoid and the subscapularis tendon (Fig. 16-7D). ll Lesser tuberosity bone bed preparation is critical when repairing the subscapularis. • All soft tissue remnants are removed with electrocautery (Fig. 16-8A). • The “charcoal” bone is removed with a burr on reverse or a ring curette (Fig. 16-8B) to expose healthy bone to maximize the chances of healing of the repair. Repair Techniques

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Figure 16-7 || Coracoplasty technique (right shoulder, 30 degree (A) and 70 degree (B-F) views). A. The rotator interval has been opened while preserving the comma tissue ( black comma symbol ) to show a coracoid (C) tip osteophyte. B. Before coracoplasty, less than a 3-mm coracohumeral interval is present with upper subscapularis (SSc) fraying (E) from impingement on the osteophyte. C. A high-speed burr is used to perform the coracoplasty from an ASL working portal with the instrument anterior to the comma. D. The end point of coracoplasty is a 7- to 10-mm coracohumeral interval and the conjoint tendon (CT) coplanar with the coracoid. F. Internal rotation and the posterior lever push bring the lesser tuberosity (LT) bone into the working space. H, humeral head.

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Figure 16-8 || Lesser tuberosity bone bed preparation (right shoulder) viewing with a 70-degree arthroscope and working from an ASL portal. The typical, “sharp angled” appearance of the superomedial border of the lesser tuberosity articular margin is outlined in dotted yellow . A. Electrocautery is used to remove soft tissue remnants. B. Ring curette (shown) or burr on reverse is used to remove the “charcoal” bone leaving a healthy bone bed with a sharp articular margin. H, humeral head; SSc, subscapularis.

Retracted Subscapularis Tears

ll Most retracted subscapularis tendon tears can be repaired primarily or to a slightly (~5 mm) medialized bone bed 5 ; however, a three-sided release may be necessary (Fig. 16-9). • The comma tissue is identified and protected. • A traction suture is placed at the junction of the comma and upper tendon border (Fig. 16-13A and B) through the ASL portal but maintained outside of the cannula. • Anterior (Fig. 16-9A) and superior (Fig. 16-9B) releases involve skeletonizing the coracoid from lateral (tip) along the neck to the base to release adhesions between the subscapularis tendon and the bone. nn A combination of electrocautery and shaver is used (Fig. 16-9A). nn The subscapularis is freed from the deep fascia and conjoint tendon, if necessary, respecting the proximity of the musculocutaneous nerve. nn A 30-degree elevator is used bluntly under the neck of the coracoid (Fig. 16-9B) to lyse adhesions in this area (it is unnecessary and risky to dissect medial to the neck). • Posterior release (Fig. 16-9C) involves freeing adhesions between the subscapularis and the scapula. nn Blunt dissection with a 15-degree elevator is used typically, as this is a relatively avascular plane.

Figure 16-9 || Left shoulder 70-degree arthroscopic views showing three-sided subscapularis releases. A. The anterior release involves lysis of adhesions between the coracoid ( C ) and the subscapularis tendon (SSc). A shaver from anterosuperior is used to resect adhesions in this area ( white arrow ). B. A 30-degree arthroscopic elevator bluntly releases adhesions between the tendon and the coracoid neck (CN). C. A 15-degree elevator is used to free the posterior subscapularis from the anterior scapula. H, humeral head; L, anterior labrum.

Chapter 16 Arthroscopic Subscapularis Repair  119 Partial-Thickness and Full-Thickness Upper Subscapularis Tears ll Tears of the upper 50% of the subscapularis tendon (Fig. 16-10A) fixed with a single anchor (Fig. 16-10B) represent the majority of repairs in our practice. • A tape suture secured with a knotless, threaded suture anchor (eg, FiberTape and SwiveLock, Arthrex, Inc., Naples, FL) is a very efficient construct (SpeedFix, Arthrex, Inc., Naples, FL). 6 nn Usually the tape suture is passed antegrade (Fig. 16-10C and D) (eg, Scorpion suture passer, Arthrex, Inc., Naples, FL) through the ASL portal. nn The anchor (Fig. 16-11) is placed through the ASL portal or through an accessory anterior portal, depending on the best angle of approach (Fig. 16-11). • Sutures (no. 2 FiberWire, Arthrex, Inc., Naples, FL) from a high biceps tenodesis construct can be used to suture the upper subscapularis tendon (Fig. 16-12). nn The tenodesis socket is placed slightly medial at the top of the groove (Fig. 16-12D) so that the tendon is compressed against the lesser tuberosity (Fig. 16-12F). nn One FiberWire limb from each suture pair is passed antegrade using a Scorpion through the ASL portal. nn The sutures are tied with a six-throw surgeon’s knot 7 with a double-diameter knot pusher (6th Finger, Arthrex, Inc., Naples, FL). nn This is most commonly done as a single-portal technique.

Figure 16-10 || SpeedFix upper subscapularis repair (right shoulder). A. 70-degree view demonstrates the subscapularis (SSc) tear and (B) final anatomic repair (30-degree view) with preserved comma tissue ( black comma symbol ). (C) A FiberTape suture is passed through the ASL working portal with a Scorpion suture passer (D) . Care must be taken to not fire the Scorpion needle against the coracoid (C) or into the conjoint tendon (CT). The suture tails are retrieved out of the anterior portal, threaded through the eyelet of the anchor, and secured using a SwiveLock anchor (E) . After the FiberTape has been cut (F) , the final construct is very low profile (70 degrees view). C, coracoid; CT, conjoint tendon; H, humeral head; LT, lesser tuberosity.

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Figure 16-10 || ( Continued )

Figure 16-11 || Right shoulder external (A and C) and 70-degree arthroscopic (B and D) views demonstrate how an accessory anterior portal often is required to gain the appropriate angle to the lesser tuberosity ( green arrows ). This angle often results in instruments being used very close to the patient’s face (C) because of the retroversion of the proximal humerus. Depending on the patient’s anatomy, an ASL portal ( red arrow ) also can provide a good angle of approach for upper subscapularis anchor placement with rotation of the humerus. C, coracoid; CT, conjoint tendon; H, humeral head; SSc, subscapularis.

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Figure 16-12 || Left shoulder upper subscapularis tear repaired using biceps tenodesis construct sutures. A. 70-degree view down the bicipital groove shows medial side wall high-grade tearing ( blue arrows ) and (B) abrasive wear ( black arrow ) of the medial biceps tendon (BT). Additionally, this patient had a type 2 SLAP tear with a displaceable biceps root (C) . An arthroscopic biceps tenodesis (D) was performed, with the tenodesis socket placed slightly medially at the top of the groove ( white arrow shows guide pin for a cannulated reamer). After the tenodesis screw has been placed, no. 2 FiberWire sutures (typically 2 pairs of sutures) are then available to be passed (E) and tied for subscapularis (SSc) repair (F) . G, glenoid; H, humeral head.

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Multiple Anchor and Double-Row Repairs Larger subscapularis tears may require additional anchors and/or linked, double-row fixation. ll Two medial suture anchors are used for tears larger than 50% of the superoinferior length of the lesser tuberosity (rule of thumb: one double-loaded suture anchor [5.5 or 4.5 mm BioComposite FT CorkScrew (Arthrex, Inc., Naples, FL)] is used for each linear centimeter of tear). • The inferior medial anchor can be placed transtendon for nonretracted tears (Fig. 16-13A and B), from lateral to the retracted edge (ensure a good angle of approach using spinal needle), or by coming “over the top” of the superior border of the subscapularis (Fig. 16-14C). • In the case of two medial anchors, sutures can be passed and tied using a double-pulley construct (Fig. 16-14F and J), in a horizontal mattress fashion (Fig. 16-13C and D) or as simple sutures. ll Linked, double-row repairs of the subscapularis may require novel constructs, as the “real estate” for lateral row anchors can be limited. • Double-row repair should be attempted for large (50%-100% bare lesser tuberosity) tears (Fig. 16-14B), particularly those that are full thickness from medial to lateral and retracted.

Figure 16-13 || Left shoulder single-row subscapularis (SSc) repair with two medial anchors. A. 70-degree view showing a bone socket being punched transtendon with the lower medial anchor (B) also being inserted in this fashion. The sutures from both medial anchors have been passed (C) in mattress fashion and then tied using a double-diameter knot pusher. The final construct (D) shows an anatomic repair. H, humeral head; LT, lesser tuberosity.

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Figure 16-14 || Left shoulder showing a linked, double-row subscapularis repair (SpeedBridge). A. In this case, even with a posterior lever push, there was limited working space ( red double arrow ) anteriorly. A traction suture placed at the junction of the comma tissue ( black comma symbol  ) and the upper subscapularis (SSc) is being retrieved out of an accessory anterior portal. B. The working space ( green double arrow ) has been dramatically improved with anteriorly directed traction ( black arrow ) from the traction suture. Nearly the entire lesser tuberosity (LT) has bare bone. C. The punch for the lower medial anchor is being brought in superior to the subscapularis tendon. This anchor also can be placed transtendon. D. The superomedial anchor is inserted at the superomedial aspect of the LT. E. Antegrade lower medial anchor suture passage using a Scorpion from the ASL portal. F. The final six-throw surgeon’s knot is tied in the subcoracoid space completing a medial double-pulley construct ( white sutures from each anchor tied together as a double mattress). G. The blue sutures from each anchor passed and tied as standard horizontal mattresses. Half of the suture limbs were retrieved and fixed laterally to SwiveLock anchors (H) . The final 70-degree intra-articular (I) and subacromial (J) views of the repair show anatomic restoration of the footprint. In this case, because the biceps tendon had been chronically torn, the bicipital groove was unobstructed for placement of inferior ( orange arrow ) and superior ( blue arrow ) lateral row anchors. H, humeral head.

• If a SpeedFix upper tendon repair has not fully restored the footprint, the FiberTape suture can be left long and secured laterally into a biceps tenodesis construct or another SwiveLock anchor as a linked, double-row construct. 8 • If the LHB tendon has been chronically torn and retracted (or with tenotomy), there may be ade- quate room for a true SutureBridge or SpeedBridge (Arthrex, Inc., Naples, FL) repair with two lateral row knotless anchors (Fig. 16-14).

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• In the case of planned LHB tenodesis, most of the subscapularis repair can be completed up to placement of an inferolateral row anchor. Then the biceps tenodesis can be completed with the tenodesis anchor (BioComposite SwiveLock Tenodesis or Bio-Tenodesis, Arthrex, Inc., Naples, FL) serving as the superolateral row anchor. Postoperative Care Arthroscopic rotator cuff repair allows postoperative rehabilitation that prioritizes tendon-to-bone healing over early, aggressive shoulder range of motion, as the risk of stiffness is low. 9,10 ll 0-6 weeks: Sling immobilization • Three times daily passive external rotation of shoulder with the arm at the side (PVC cane) to 0 degrees (larger, full-thickness subscapularis tears) or 30 degrees (small, partial-thickness subscapularis tears). • Isolated subscapularis tears or other at-risk patients (calcific tendonitis, adhesive capsulitis, concomitant labral repair) perform early, closed chain, passive overhead motion (table slide) ll 6-12 weeks: Sling is discontinued and full passive range of motion (ROM) is added. • Full passive external rotation (ER) stretching is begun. • Rope and pulley overhead and behind back internal rotation stretches are begun. • Arm can be used for light activities of daily living below shoulder level. ll 3-6 months: Full active overhead ROM and strengthening • Rubber band strengthening is initiated. • No heavy overhead lifting and no acceleration of arm in sport is allowed. References 1. Brady PC, Narbona P, Adams CR, et al. Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of out- comes, complications, and revision rate. Arthroscopy . 2015;31(3):470-476. 2. Sheean AJ, Hartzler RU, Denard PJ, Lädermann A, Hanypsiak BT, Burkhart SS. A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position. Arthroscopy . 2016;32(9):1745-1749. 3. Hartzler RU, Burkhart SS. Medial biceps sling takedown may be necessary to expose an occult subscapularis tendon tear. Arthrosc Tech . 2014;3(6):e719-e722. 4. Lo IK, Burkhart SS.The comma sign: an arthroscopic guide to the torn subscapularis tendon. Arthroscopy . 2003;19(3):334-337. 5. Denard PJ, Burkhart SS. Medialization of the subscapularis footprint does not affect functional outcome of arthroscopic repair. Arthroscopy . 2012;28(11):1608-1614. 6. Denard PJ, Burkhart SS. A new method for knotless fixation of an upper subscapularis tear. Arthroscopy . 2011;27(6):861-866. 7. Burkhart SS, Lo IK, Brady PC. Burkhart’s View of the Shoulder: A Cowboy’s Guide to Advanced Shoulder Arthroscopy . Philadelphia, PA: Lippincott Williams & Wilkins; 2006:48-52. 8. Denard PJ, Lädermann A, Burkhart SS. Double-row fixation of upper subscapularis tears with a single suture anchor. Arthroscopy . 2011;27(8):1142-1149. 9. Koo SS, Parsley BK, Burkhart SS, Schoolfield JD. Reduction of postoperative stiffness after arthroscopic rotator cuff repair: results of a customized physical therapy regimen based on risk factors for stiffness. Arthroscopy . 2011;27(2):155-160. 10. Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy . 2009;25(8):880-890.