Illustrated Tips & Tricks CH16

Chapter 16 Arthroscopic Subscapularis Repair  115

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.