Subscapularis Tendon Repair Using Suture Bridge Technique Yong Bok Park, M.D., Young Eun Park, M.D., Kyoung Hwan Koh, M.D., Tae Kang Lim, M.D., Min Soo Shon, M.D., and Jae Chul Yoo, M.D., Ph.D.
Abstract: The subscapularis tendon plays an essential role in shoulder function. Although subscapularis tendon tears are less common than other rotator cuff tears, tears of the subscapularis tendon have increasingly been recognized with the advent of magnetic resonance imaging and arthroscopy. A suture bridge technique for the treatment of posterosuperior rotator cuff tears has provided the opportunity to improve the pressurized contact area and mean footprint pressure. However, suture bridge fixation of subscapularis tendon tears appears to be technically challenging. We describe an arthroscopic surgical technique for suture bridge repair of subscapularis tendon tears that obtains ideal cuff integrity and footprint restoration. Surgery using such a suture bridge technique is indicated for large tears, such as tears involving the entire first facet or more, tears with a disrupted lateral sling, and combined medium to large supraspinatus/infraspinatus tears.
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ears of the subscapularis tendon are much less common than tears of the supraspinatus. However, advancements in shoulder arthroscopy have provided us the chance to evaluate the articular side of the rotator cuff in more detail. We are detecting more and more subscapularis tendon tears, especially partial tears. Recently, the incidence of subscapularis tears has been reported to range between 27% and 43% during arthroscopic evaluation.1,2 Tears of the subscapularis tendon occur more commonly in combination with other rotator cuff tears rather than in isolation. Partial tears are more common than complete tears. In addition, most subscapularis tendon tears are partial tears involving the articular side of the subscapularis tendon.3
From the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University (Y.B.P., Y.E.P., J.C.Y.), Seoul; Department of Orthopaedic Surgery, Seoul Medical Center (K.H.K.), Seoul; Department of Orthopaedic Surgery, Eulji General Hospital (T.K.L.), Seoul; and Department of Orthopaedic Surgery, National Medical Center (M.S.S.), Seoul, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 18, 2013; accepted November 26, 2014. Address correspondence to Jae Chul Yoo, M.D., Ph.D., Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University, 50 Ilwondong, Kangnamgu, Seoul, 135-710, Republic of Korea. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/13802/$36.00 http://dx.doi.org/10.1016/j.eats.2014.11.013
Although several reports have addressed repair of subscapularis tears,2,4,5 arthroscopic repair of subscapularis tears appears to be a challenging task because of the constricted subcoracoid working space.6 Arthroscopic techniques for repairing subscapularis tears have involved single- or double-row repair using a “suture bridge” technique. Treatment of subscapularis tears using arthroscopic repair techniques has been reported with adequate clinical outcomes.1,6 However, another study reported a retear rate of 35% after arthroscopic single-row repair of subscapularis and supraspinatus tears.7 A recent biomechanical study found that the double-row technique was more effective in restoring the characteristics of the intact tendon when compared with conventional single-row repair, with a higher ultimate load, higher stiffness, and smaller elongation.8 On the basis of these results, double-row repair might be suitable to repair subscapularis tendon tears to attain ideal cuff integrity and complete restoration of the insertion area, especially in larger tears. This article describes an arthroscopic repair method for subscapularis tears involving double-row repair with the suture bridge technique.
Arthroscopic Repair Technique The suture bridge technique for subscapularis repair could be performed through the extra-articular (bursal) side in cases with large rotator cuff tears. Surgery using the suture bridge technique was indicated for large tears, such as tears involving the entire first facet or
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Fig 1. The size of the subscapularis tendon tear is evaluated with a calibrated ruler.
more, tears with a disrupted lateral sling, and combined medium to large supraspinatus/infraspinatus tears. With the patient positioned in the lateral decubitus position, the operative arm was placed in a position of 20 to 30 of abduction and 20 of forward flexion (Star Sleeve Traction System; Arthrex, Naples, FL). A diagnostic arthroscopy was performed with a 30 arthroscope viewing through a standard posterior portal. A subscapularis tendon tear was usually combined with a lesion of the long head of the biceps tendon. The biceps was frequently dislocated from the bicipital groove affecting the subscapularis tendon tear. This sometimes could be visualized by noting the snapping movement of the biceps as it dislocated in and out of the groove with humeral rotational movements. Either tenotomy or tenodesis of the biceps could be performed depending on the age, gender, and functional requirements of the patient. The subscapularis tendon tear visualized during arthroscopy frequently had lost its tautness. A firm tendinous appearance could be seen in normal tendons. The torn portion was medially or downwardly (lateral decubitus) migrated, showing some amount of sagging. This finding was typical in a subscapularis tendon tear with detachment of more than half of the first facet. We used a 70 arthroscope to obtain a better view of the subscapularis footprint (so-called aerial view of the footprint). To improve visualization, the arm was placed in 30 of abduction and 30 of internal rotation to view the subscapularis insertion. The size of the subscapularis tendon tear was more thoroughly evaluated using a probe and calibrated ruler with a 1-mm
scale (Fig 1). Then, we moved to the bursal side of the rotator cuff, changing back to the 30 arthroscope. The usual subacromial portals were made: posterior, anterior, anterolateral, and posterolateral portals. With the arthroscope in the lateral portal, a calibrated probe was introduced from the anterior portal to measure the dimensions of the subscapularis tear laterally to medially. After that, the probe was introduced from the anterior or anterolateral portal with the arthroscope in the lateral or posterolateral portal to measure the dimension of the tear in the superior-to-inferior direction. The extent of the tear was estimated by comparing the first facet dimension, known to be approximately 13 mm anteriorly to posteriorly and 13 mm superiorly to inferiorly. Once we decided to perform a repair, the footprint was prepared with a shaver, burr, and microfracture (Fig 2). The torn tendon edge was lightly shaved to remove poor-quality tissue and enhance bleeding tendency after repair. The coracohumeral ligament and adhesions to the anterosuperior margins of the subscapularis tendon were released to allow better mobilization of the torn, retracted tendon to its footprint without tension (Fig 3). Soft-tissue release was performed to the coracoid base, with caution taken not to completely sever the rotator interval tissue and coracohumeral/superior glenohumeral ligaments. Afterward, a medial anchor and double-loaded suture anchor (Healix; DePuy Mitek, Raynham, MA) were placed as inferiorly and medially as possible to the first facet (Fig 4). For this medial and inferior anchor placement, we had to make an additional anchor portal medial to the anterior portal. It is usually located just lateral to the common tendon. This can be identified
Fig 2. The bone bed is prepared using a burr.
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Fig 3. The coracohumeral ligament is released to allow better mobilization of the torn, retracted tendon to its footprint without tension.
Fig 5. A suture hook penetrates the full thickness of the subscapularis tendon from the bursal side toward the articular side.
using a spinal needle, making the needle perpendicular to the subscapularis footprint (first facet). The doubleloaded suture anchor was inserted in the same direction of the spinal needle left for guidance. After proper anchor insertion, a suture hook (Linvatec, Largo, FL) was preloaded with No. 0 PDS (Ethicon, Somerville, NJ) introduced through the anterior or anterolateral portal for suturing. The suture hook penetrated the full thickness of the subscapularis tendon from the bursal
side toward the articular side 1 or 2 mm below the superior margin of the tear and 12 to 13 mm medial to the lateral margin of the tear (Fig 5). PDS was used to relay both limbs of the sutures simultaneously. The same step was repeated for shuttling of the remaining 2 suture limbs of the anchor approximately 5 to 10 mm inferior to the first stitch. Both limbs were tied with non-sliding knots (one post at the superior position and the other at the inferior position) (Fig 6).
Fig 4. A medial anchor is placed as inferiorly and medially as possible to the first facet.
Fig 6. Both limbs are tied with non-sliding knots (one post at the superior position and the other at the inferior position).
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Fig 7. The same limbs from each tied knot are gathered to place one superiorly and the other inferiorly.
Fig 8. Subscapularis tendon completely repaired on bursal side.
The lateral-row anchors were placed on the bicipital groove. One was on the superior-most side. The other was 1 to 2 cm below the first anchor on the groove. As in the supraspinatus suture bridge, the same limbs from each tied knot were gathered to place one superiorly and the other inferiorly (Fig 7). Then, the torn subscapularis tendon was repaired with full coverage of the footprint on the bursal side (Fig 8). The entire surgical technique is shown in Video 1, including audio narration. Postoperatively, patients were immobilized with a sling for 4 to 6 weeks depending on the combined supraspinatus/infraspinatus tendon tear. Afterward, passive shoulder range-of-motion exercise was started postoperatively. At 12 weeks postoperatively, strengthening exercises were started.
might not be easily detected with a single-row repair, at final repair, the compression of the subscapularis tendon can be readily detected with this technique. There is still no consensus on how to repair subscapularis tendon tears. For larger tears, it is technically challenging to perform repair using an arthroscope. For large, retracted, and atrophied subscapularis tendon tears, it might be impossible to perform repair using arthroscopy. Our technique is for tears that mainly involve the first facet (approximately superior one-third tears). Beyond these tears, it might be impossible to perform repair in a doublerow fashion because of retraction. Some surgeons would argue that single-row repair is sufficient for tears of such a size. We agree that it might be sufficient. However, as in the supraspinatus, a suture bridgeetype repair might have a better chance of healing. Of course, this might require more anchors and a longer surgical time and thus might cost more. We have introduced a relatively simple way to perform a suture bridgeetype double-row subscapularis tendon tear repair. This repair technique might be 1 option for surgeons to choose for the treatment of appropriate tears.
Discussion We have introduced a surgical technique that we have been performing for most subscapularis tendon tears involving the entire first facet or the superior one-third of the entire subscapularis tendon. Our technique has 2 distinct features that might be notable. First, it uses mattress suture for the tear. Although mattress suture might bunch up the tendon superiorly and inferiorly, it provides benefits because many subscapularis tendon tears have a longitudinalsplit component. In such instances, we can prevent ripping (or cutting through) the tendon fibers by performing simple stitches. Second, the suture bridge configuration provides a compression effect of the repaired tendon, which is known to give good contact in the supraspinatus. Although the difference
References 1. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143. 2. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy 2008;24:1381-1389.
SUBSCAPULARIS TENDON REPAIR 3. Sakurai G, Ozaki J, Tomita Y, Kondo T, Tamai S. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 1998;7:510-515. 4. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193. 5. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002;18:454-463.
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6. Burkhart SS, Brady PC. Arthroscopic subscapularis repair: Surgical tips and pearls A to Z. Arthroscopy 2006;22: 1014-1027. 7. Ide J, Tokiyoshi A, Hirose J, Mizuta H. Arthroscopic repair of traumatic combined rotator cuff tears involving the subscapularis tendon. J Bone Joint Surg Am 2007;89: 2378-2388. 8. Wellmann M, Wiebringhaus P, Lodde I, et al. Biomechanical evaluation of a single-row versus double-row repair for complete subscapularis tears. Knee Surg Sports Traumatol Arthrosc 2009;17:1477-1484.
Abstract: The subscapularis tendon plays an essential role in shoulder function. Although subscapularis tendon tears are less common than other rotator cuff tears, tears of the subscapularis tendon have increasingly been recognized with the advent of magnetic resonance imaging and arthroscopy. A suture bridge technique for the treatment of posterosuperior rotator cuff tears has provided the opportunity to improve the pressurized contact area and mean footprint pressure. However, suture bridge fixation of subscapularis tendon tears appears to be technically challenging. We describe an arthroscopic surgical technique for suture bridge repair of subscapularis tendon tears that obtains ideal cuff integrity and footprint restoration. Surgery using such a suture bridge technique is indicated for large tears, such as tears involving the entire first facet or more, tears with a disrupted lateral sling, and combined medium to large supraspinatus/infraspinatus tears.
T
ears of the subscapularis tendon are much less common than tears of the supraspinatus. However, advancements in shoulder arthroscopy have provided us the chance to evaluate the articular side of the rotator cuff in more detail. We are detecting more and more subscapularis tendon tears, especially partial tears. Recently, the incidence of subscapularis tears has been reported to range between 27% and 43% during arthroscopic evaluation.1,2 Tears of the subscapularis tendon occur more commonly in combination with other rotator cuff tears rather than in isolation. Partial tears are more common than complete tears. In addition, most subscapularis tendon tears are partial tears involving the articular side of the subscapularis tendon.3
From the Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University (Y.B.P., Y.E.P., J.C.Y.), Seoul; Department of Orthopaedic Surgery, Seoul Medical Center (K.H.K.), Seoul; Department of Orthopaedic Surgery, Eulji General Hospital (T.K.L.), Seoul; and Department of Orthopaedic Surgery, National Medical Center (M.S.S.), Seoul, Republic of Korea. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 18, 2013; accepted November 26, 2014. Address correspondence to Jae Chul Yoo, M.D., Ph.D., Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University, 50 Ilwondong, Kangnamgu, Seoul, 135-710, Republic of Korea. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/13802/$36.00 http://dx.doi.org/10.1016/j.eats.2014.11.013
Although several reports have addressed repair of subscapularis tears,2,4,5 arthroscopic repair of subscapularis tears appears to be a challenging task because of the constricted subcoracoid working space.6 Arthroscopic techniques for repairing subscapularis tears have involved single- or double-row repair using a “suture bridge” technique. Treatment of subscapularis tears using arthroscopic repair techniques has been reported with adequate clinical outcomes.1,6 However, another study reported a retear rate of 35% after arthroscopic single-row repair of subscapularis and supraspinatus tears.7 A recent biomechanical study found that the double-row technique was more effective in restoring the characteristics of the intact tendon when compared with conventional single-row repair, with a higher ultimate load, higher stiffness, and smaller elongation.8 On the basis of these results, double-row repair might be suitable to repair subscapularis tendon tears to attain ideal cuff integrity and complete restoration of the insertion area, especially in larger tears. This article describes an arthroscopic repair method for subscapularis tears involving double-row repair with the suture bridge technique.
Arthroscopic Repair Technique The suture bridge technique for subscapularis repair could be performed through the extra-articular (bursal) side in cases with large rotator cuff tears. Surgery using the suture bridge technique was indicated for large tears, such as tears involving the entire first facet or
Arthroscopy Techniques, Vol 4, No 2 (April), 2015: pp e133-e137
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Fig 1. The size of the subscapularis tendon tear is evaluated with a calibrated ruler.
more, tears with a disrupted lateral sling, and combined medium to large supraspinatus/infraspinatus tears. With the patient positioned in the lateral decubitus position, the operative arm was placed in a position of 20 to 30 of abduction and 20 of forward flexion (Star Sleeve Traction System; Arthrex, Naples, FL). A diagnostic arthroscopy was performed with a 30 arthroscope viewing through a standard posterior portal. A subscapularis tendon tear was usually combined with a lesion of the long head of the biceps tendon. The biceps was frequently dislocated from the bicipital groove affecting the subscapularis tendon tear. This sometimes could be visualized by noting the snapping movement of the biceps as it dislocated in and out of the groove with humeral rotational movements. Either tenotomy or tenodesis of the biceps could be performed depending on the age, gender, and functional requirements of the patient. The subscapularis tendon tear visualized during arthroscopy frequently had lost its tautness. A firm tendinous appearance could be seen in normal tendons. The torn portion was medially or downwardly (lateral decubitus) migrated, showing some amount of sagging. This finding was typical in a subscapularis tendon tear with detachment of more than half of the first facet. We used a 70 arthroscope to obtain a better view of the subscapularis footprint (so-called aerial view of the footprint). To improve visualization, the arm was placed in 30 of abduction and 30 of internal rotation to view the subscapularis insertion. The size of the subscapularis tendon tear was more thoroughly evaluated using a probe and calibrated ruler with a 1-mm
scale (Fig 1). Then, we moved to the bursal side of the rotator cuff, changing back to the 30 arthroscope. The usual subacromial portals were made: posterior, anterior, anterolateral, and posterolateral portals. With the arthroscope in the lateral portal, a calibrated probe was introduced from the anterior portal to measure the dimensions of the subscapularis tear laterally to medially. After that, the probe was introduced from the anterior or anterolateral portal with the arthroscope in the lateral or posterolateral portal to measure the dimension of the tear in the superior-to-inferior direction. The extent of the tear was estimated by comparing the first facet dimension, known to be approximately 13 mm anteriorly to posteriorly and 13 mm superiorly to inferiorly. Once we decided to perform a repair, the footprint was prepared with a shaver, burr, and microfracture (Fig 2). The torn tendon edge was lightly shaved to remove poor-quality tissue and enhance bleeding tendency after repair. The coracohumeral ligament and adhesions to the anterosuperior margins of the subscapularis tendon were released to allow better mobilization of the torn, retracted tendon to its footprint without tension (Fig 3). Soft-tissue release was performed to the coracoid base, with caution taken not to completely sever the rotator interval tissue and coracohumeral/superior glenohumeral ligaments. Afterward, a medial anchor and double-loaded suture anchor (Healix; DePuy Mitek, Raynham, MA) were placed as inferiorly and medially as possible to the first facet (Fig 4). For this medial and inferior anchor placement, we had to make an additional anchor portal medial to the anterior portal. It is usually located just lateral to the common tendon. This can be identified
Fig 2. The bone bed is prepared using a burr.
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Fig 3. The coracohumeral ligament is released to allow better mobilization of the torn, retracted tendon to its footprint without tension.
Fig 5. A suture hook penetrates the full thickness of the subscapularis tendon from the bursal side toward the articular side.
using a spinal needle, making the needle perpendicular to the subscapularis footprint (first facet). The doubleloaded suture anchor was inserted in the same direction of the spinal needle left for guidance. After proper anchor insertion, a suture hook (Linvatec, Largo, FL) was preloaded with No. 0 PDS (Ethicon, Somerville, NJ) introduced through the anterior or anterolateral portal for suturing. The suture hook penetrated the full thickness of the subscapularis tendon from the bursal
side toward the articular side 1 or 2 mm below the superior margin of the tear and 12 to 13 mm medial to the lateral margin of the tear (Fig 5). PDS was used to relay both limbs of the sutures simultaneously. The same step was repeated for shuttling of the remaining 2 suture limbs of the anchor approximately 5 to 10 mm inferior to the first stitch. Both limbs were tied with non-sliding knots (one post at the superior position and the other at the inferior position) (Fig 6).
Fig 4. A medial anchor is placed as inferiorly and medially as possible to the first facet.
Fig 6. Both limbs are tied with non-sliding knots (one post at the superior position and the other at the inferior position).
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Fig 7. The same limbs from each tied knot are gathered to place one superiorly and the other inferiorly.
Fig 8. Subscapularis tendon completely repaired on bursal side.
The lateral-row anchors were placed on the bicipital groove. One was on the superior-most side. The other was 1 to 2 cm below the first anchor on the groove. As in the supraspinatus suture bridge, the same limbs from each tied knot were gathered to place one superiorly and the other inferiorly (Fig 7). Then, the torn subscapularis tendon was repaired with full coverage of the footprint on the bursal side (Fig 8). The entire surgical technique is shown in Video 1, including audio narration. Postoperatively, patients were immobilized with a sling for 4 to 6 weeks depending on the combined supraspinatus/infraspinatus tendon tear. Afterward, passive shoulder range-of-motion exercise was started postoperatively. At 12 weeks postoperatively, strengthening exercises were started.
might not be easily detected with a single-row repair, at final repair, the compression of the subscapularis tendon can be readily detected with this technique. There is still no consensus on how to repair subscapularis tendon tears. For larger tears, it is technically challenging to perform repair using an arthroscope. For large, retracted, and atrophied subscapularis tendon tears, it might be impossible to perform repair using arthroscopy. Our technique is for tears that mainly involve the first facet (approximately superior one-third tears). Beyond these tears, it might be impossible to perform repair in a doublerow fashion because of retraction. Some surgeons would argue that single-row repair is sufficient for tears of such a size. We agree that it might be sufficient. However, as in the supraspinatus, a suture bridgeetype repair might have a better chance of healing. Of course, this might require more anchors and a longer surgical time and thus might cost more. We have introduced a relatively simple way to perform a suture bridgeetype double-row subscapularis tendon tear repair. This repair technique might be 1 option for surgeons to choose for the treatment of appropriate tears.
Discussion We have introduced a surgical technique that we have been performing for most subscapularis tendon tears involving the entire first facet or the superior one-third of the entire subscapularis tendon. Our technique has 2 distinct features that might be notable. First, it uses mattress suture for the tear. Although mattress suture might bunch up the tendon superiorly and inferiorly, it provides benefits because many subscapularis tendon tears have a longitudinalsplit component. In such instances, we can prevent ripping (or cutting through) the tendon fibers by performing simple stitches. Second, the suture bridge configuration provides a compression effect of the repaired tendon, which is known to give good contact in the supraspinatus. Although the difference
References 1. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143. 2. Adams CR, Schoolfield JD, Burkhart SS. The results of arthroscopic subscapularis tendon repairs. Arthroscopy 2008;24:1381-1389.
SUBSCAPULARIS TENDON REPAIR 3. Sakurai G, Ozaki J, Tomita Y, Kondo T, Tamai S. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 1998;7:510-515. 4. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 2007;89:1184-1193. 5. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002;18:454-463.
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6. Burkhart SS, Brady PC. Arthroscopic subscapularis repair: Surgical tips and pearls A to Z. Arthroscopy 2006;22: 1014-1027. 7. Ide J, Tokiyoshi A, Hirose J, Mizuta H. Arthroscopic repair of traumatic combined rotator cuff tears involving the subscapularis tendon. J Bone Joint Surg Am 2007;89: 2378-2388. 8. Wellmann M, Wiebringhaus P, Lodde I, et al. Biomechanical evaluation of a single-row versus double-row repair for complete subscapularis tears. Knee Surg Sports Traumatol Arthrosc 2009;17:1477-1484.
