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    Arthroscopic Repair of the Rotator Cuff and Subscapularis

    A 65-year-old woman presents with a 2-month history of increased anterior/lateral right shoulder pain without trauma. She had previously been treated non-operatively for a small rotator cuff tear – which appears to have have progressed.

    Authors

    Justin C. Wong, MD, and Joseph A. Abboud, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Case Presentation

    A 65-year-old, right hand-dominant female presents with a 2-month history of increased anterior/lateral right shoulder pain without trauma. Several years prior, she had been treated non-operatively for a small rotator cuff tear in her right shoulder.

    She now has difficulty with lifting weights overhead and folding laundry; she also reports night pain. Ibuprofen provides mild relief of the pain.

    She has no significant past medical history.

    Physical Examination

    • Range of motion (right/left): Forward elevation – 120°/170°; abduction – 80°/170°; external rotation at side – 20°/40°; internal rotation at side – L3/T10 (Note: Although not seen in this patient, patients with complete subscapularis deficiency often demonstrate increased external rotation on the affected side.)
    • Strength testing: Weakness with resisted external rotation, internal rotation, and Jobe’s test
    • Impingement signs: Positive Neer test and positive Hawkins test
    • Positive belly press test

    Differential Diagnosis

    • Rotator cuff tear (superior-posterior alone or in conjunction with the subscapularis)
    • Adhesive capsulitis
    • Glenohumeral arthritis

    Imaging

    • Shoulder radiographs demonstrate mild superior migration of the humeral head, without fracture or dislocation (Figure 1). Note that the axillary view may reveal anterior subluxation of the humeral head in association with subscapularis deficiency, although that was not seen in this patient’s radiographs.
    • MRI of the shoulder shows a tear of the supraspinatus and infraspinatus muscles, plus an upper subscapularis tear with biceps subluxation (Figure 2)

    Figure 1. Preoperative radiographs.

    Figure 2. Preoperative MRI. The axillary cut on the left demonstrates long head of biceps subluxation out of the bicipital groove, while axillary cut on the right demonstrates a subscapularis tear off of the lesser tuberosity (BG – bicipital groove, LHB – long head of biceps, SS – subscapularis).

    Diagnosis

    • Complete rotator cuff tear involving the subscapularis, supraspinatus, infraspinatus muscles

    Treatment

    The patient is scheduled for arthroscopic rotator cuff and subscapularis repair with biceps tenotomy. This procedure is indicated for patients with full-thickness rotator cuff tears, dysfunction, and pain.

    Advantages

    • Arthroscopic approach avoids crossing neurovascular bundle during mobilization of the subscapularis
    • Can be performed in the beach-chair or lateral decubitus positions
    • Tenotomy of the long head of biceps decreases stress at the subscapularis repair site

    Disadvantages

    • May require a 70° scope for visualization
    • Requires surgeon familiarity with technique

    The type of implant to be used in this procedure is a suture anchor.

    Advantages

    • Suture anchors are widely available
    • Suture anchors allow for accurate re-approximation of tendon edge to native footprint

    Disadvantage

    • Cost of the implant

    Procedure

      • The patient is placed in the beach-chair position with an arm holder. The lateral decubitus position can be used at the discretion of the surgeon.
      • Using a standard shoulder arthroscopy setup, the portals for the arthroscope are placed as follows (Figure 3): A – Anterior portal, placed lateral to the coracoid; B – anterosuperolateral portal, placed 2 cm lateral to the anterolateral corner of the acromion, parallel to the lesser tuberosity; and C – posterior portal, placed 1 cm medial and 2 cm distal to the posterolateral corner of the acromion.

    Figure 3. Portal placement.

      • Perform a diagnostic arthroscopy to confirm pathologic lesions, as well as to identify coexisting pathology.
      • Perform a biceps tenotomy to improve visualization and release potential stressor of the subscapularis repair.
      • For concomitant superior/posterior rotator cuff tears, perform the subscapularis repair first, when anterior glenohumeral joint visualization is best.
      • The anterior exposure is then done. Open the rotator interval to identify the coracoid, using a combination of shaver and electrocautery (Figure 4). Expose the coracoid after opening the rotator interval.
      • In patients with suspected coracoid impingement, a coracoplasty is performed, as demonstrated in Figure 4B. A coracoplasty opens the interval between the anterior subscapularis and posterior border of the coracoid to prevent impingement. The normal interval is 7 to 11 mm.

    Figure 4. Anterior exposure. In this example of coracoid exposure from a different patient, note the subscapularis (SS), coracoid (C), and humeral head (HH).

      • The subscapularis is mobilized as follows: Stage 1: Anterior release of subscapularis from posterior aspect of coracoid; use a combination of electrocautery/shaver. Stage 2: Posterior release from anterior glenoid neck; traction suture in subscapularis; use liberator, rasps, biters. Stage 3: Superior release from the lateral arch of the coracoid neck; avoid dissection medial to the base of the coracoid to prevent injury to neurovascular structures
      • The lesser tuberosity is prepared by skeletonizing the subscapularis footprint with electrocautery; decorticate the footprint with a burr.
      • Anchor placement is done next. Use the anterosuperolateral portal to place the anchor pilot hole (Figure 5). The upper border of subscapularis tears may need only 1 suture anchor, while complete subscapularis tears may need up to 3 anchors. If more than 1 anchor is utilized, all sutures should be passed prior to knot tying. The upper border of the tear can be fixed in a knotless manner. Knotless suture fixation is described in Figure 6 and Video 1.

    Figure 5. Anchor placement (SS – subscapularis , LT – lesser tuberosity).

    Figure 6. Knotless suture fixation (SS – subscapularis, HH – humeral head, LT – lesser tuberosity).

    Video 1. Upper border subscapularis tear repair – knotless luggage tag technique.

      • Complete the subscapularis repair with a knotless technique (Figure 7)

    Figure 7. Final subscapularis construct (SS – subscapularis, HH – humeral head).

    Postoperative Care

    Following arthroscopic rotator cuff and subscapularis repair with biceps tenotomy, the authors’ general protocol is:

    • Sling for 6 weeks
    • No external rotation greater than neutral position and no overhead reaching for 6 weeks
    • Stretching during weeks 6 through 12
    • Strengthening begins at week 12
    • Unrestricted activities at 6 to 12 months

    This patient returned 2 weeks after surgery to have her sutures removed. Immobilization maintained until 6 weeks following surgery. She then started physical therapy for passive range of motion.

    At 2 months after surgery, the patient’s range of motion had improved and she progress to phase 2 of her rehabilitation, which included stretching active range-of-motion exercises. A month later, her forward elevation was at 110°, abduction was at 80°, and external rotation was at 30°. She had 4+/5 strength to resisted external rotation, internal rotation, and Jobe’s test.

    By 5 months after surgery, her range of motion continued to improve. She had 5/5 strength to resisted external rotation, internal rotation, and Jobe’s test.

    At 8 months after surgery, her forward elevation had improved to 150°, her abduction was 150°, and her external rotation was to 40°. She scored a 9 on the QuickDASH test.

    Author Information

    Justin C. Wong, MD, and Joseph A. Abboud, MD, are from The Rothman Institute, Philadelphia, Pennsylvania.

    Shoulder Section Editor, The Rothman Institute Grand Rounds

    Luke S. Austin, MD