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Open repair of subscapularis and biceps tenodesis, using Arthrex Bio-Swivelock anchors and TightRope button

    Overview

    Learn the Open repair of subscapularis and biceps tenodesis, using Arthrex Bio-Swivelock anchors and TightRope button surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Open repair of subscapularis and biceps tenodesis, using Arthrex Bio-Swivelock anchors and TightRope button surgical procedure.
    Rotator cuff tears are a relatively common cause of shoulder pain from the subacromial space. Supraspinatus, the elevator, is the most commonly effected tendon which then extends posteriorly into the adjoining infraspinatus, the external rotator. Subscapularis, the internal rotator anteriorly, is the least affected rotator cuff tendon. Rotator cuff disease that results in tears can be thought of as resulting from either intrinsic or extrinsic factors, or a combination of the two.
    Intrinsic disease occurs due to a patient’s biological and genetic makeup, resulting in disorganisation of the collagen within the tendon, which degenerates and detaches from its bony footprint on the proximal humerus. Extrinsic causes are thought to be attritional wear from repetitive rotation and movement against a thickened coracoacromial ligament or subacromial bony spur. In the case of subscapularis anteriorly it may abrade against the underside of the coracoid process, resulting in rupture of the rotator cuff tendon attachment to the proximal humerus. Rotator cuff tears can also come about as a result of direct injury, with a fall or wrenching force to the joint or even a direct blow to the shoulder. This is the most common cause of a subscapularis avulsion tear when the shoulder is forced into external rotation whilst contracting to internally rotate.
    Rotator cuff tears can be further categorised as either partial thickness or full thickness tears. The latter is a complete deficit of the tendon with detachment from the bone whereas the former describes fraying and scuffing of the upper (bursal) aspect or under (articular surface) aspect of the tendon. There may also be an element of intrinsic intra-substance change within the tendon structure which may only be apparent on cross-sectional imaging such as MRI scan.
    Much has been published in the orthopaedic literature concerning the management of rotator cuff disease, and despite this its management is controversial with fervent supporters of both conservative and surgical treatment. Many shoulder surgeons though will advocate surgical repair of a torn or detached tendon once conservative measures have been proven to be unsuccessful. Exact surgical technique varies with surgeons’ preference, experience and ability and there is little evidence to suggest that the different described surgical techniques have widely different surgical outcomes.
    The technique described here is the one I use for an isolated full thickness tear of subscapularis with dislocation of the long head of biceps tendon out of the bicipital groove and ‘cheese-wiring’ over the top and front of the subscapularis tendon.
    I use the Arthrex shoulder repair instruments and implants during these cases. As with much of the Arthrex inventory the system has been designed to make operations easier, by engineers and surgeons collaborating to optimise the solution. The set of instruments “covers all bases” in terms of having something that helps in every situation and the range of implants allows flexibility between types and sizes of anchors and suture material. In this case I use the 4.75 and 5.5 BioSwivelock C anchors with FiberTape suture material and the Arthrex TightRope implant for the biceps tenodesis.
    Readers will also find of interest the following related OrthOracle techniques:
    Arthroscopic subacromial decompression
    Arthroscopic rotator cuff repair using modified Arthrex suture-bridge technique
    Arthroscopic subscapularis tendon repair utilising Smith and Nephew Healicoils
    Arthroscopic rotator cuff repair with Arthrex Speedbridge

    Indications

    INDICATIONS
    Indication for this surgical procedure is an acute full thickness avulsion tear of the subscapularis insertion from the lesser tuberosity of the proximal humerus and dislocation of the long head of biceps tendon from the bicipital groove. Such acute tears are traumatic in nature as the result of a shoulder injury.
    SYMPTOMS & EXAMINATION
    Patients present with pain, dysfunction and weakness in their affected shoulder. There is likely to be a history of an injury such as a fall or wrenching to the shoulder resulting in pain and subsequent weakness. Patients usually describe pain at the front of the shoulder radiating to the mid upper arm region. They may feel pain lying on that side and exacerbations of the pain are typically felt during activities particularly lifting and using the arm above shoulder height, especially with repetition.
    The shoulder should be closely inspected and compared to the opposite side looking for any signs of asymmetry in the belly of the biceps muscle but there is unlikely to be any discernible muscle wasting.
    Examination should ascertain whether the patient has maintained a full range of motion and also strength with formal testing of rotator cuff. With a dislocated long head of biceps tendon all shoulder movements are irritable. Suspicion of a subscapularis tear should be raised by increased passive external rotation of the affected shoulder with the elbow by the side in neutral compared to the opposite side. Additional examination information is then sought by formal assessment of the subscapularis by testing power of internal rotation as the palm of the hand is pulled into the abdomen and chest the so called hug or bear-hug tests. Also the well described belly push test should be performed. This is positive for a subscapularis deficiency if with the palms of the hands flat against the abdomen the patient is unable to push the elbow of the affected side forwards. The final classic test of subscapularis function is the lift-off test described by Gerber. The affected shoulder is internally rotated so that the dorsum of hand rests against the small of the back at the level of the lumbar spine. The lift-off test is positive for a subscapularis injury if the patient is unable to lift the hand backwards away from the small of the back. In the acutely injured shoulder this test is difficult to perform accurately as pain often prohibits getting the hand around to the back.
    Formal assessment of the long head of biceps is also notoriously difficult and even more so in the acute setting. Palpation over the front of the shoulder in the region of the bicipital groove may reveal tenderness. Resistance of pronation and supination of the forearm with the elbow flexed at 90 degrees may reproduce pain over the front of the shoulder as may resistance of elevation of the arm with the elbow fully extended. As always in examining the shoulder careful assessment of any neurological deficit should be ascertained.
    IMAGING
    In patients with a painful and weak shoulder it is mandatory to obtain plain x-ray films. I always request 3 views with an anteroposterior (AP) view of the glenohumeral joint, a lateral outlet view to show the morphology of the acromion and an axillary view with shoot through of the axilla. X-rays will give an idea as to whether there is a bony injury such as a fracture, subacromial spur, on the axillary view ascertain whether there is an os acromiale and give an indication from all 3 views as to whether there is any arthritis of the glenohumeral or acromioclavicular joints.
    If there is clinical suspicion of a rotator cuff tear then further imaging is indicated. This can be performed either in the form of an ultrasound scan performed by the surgeon themselves or by a sonographer or radiologist. Ultrasound scanning is user dependent and relies on interpretation of the dynamic images. The alternative is to consider an MRI scan which is the gold standard and will give excellent images of the shoulder anatomy and confirm whether or not there is a rotator cuff tear and the position of the long head of biceps tendon.
    ALTERNATIVE OPERATIVE TREATMENT
    There are many described techniques for repairing rotator cuff tears, either as an open operation or mini open surgery as well as numerous arthroscopic techniques which have developed over the last 20-30 years. Most of the techniques involve direct repair of the tendon to the bone, either using interosseous or transosseous suture techniques or more recently using bone anchors which are widely available on the market. Knots can be tied in the suture materials attached to the anchors or knotless techniques, such as described in this case, can be used.
    Likewise there are numerous ways of tenodesing the long head of biceps tendon. This can be a soft tissue suturing, use of bone anchors, interference fixation of the tendon into a drill hole or intramedullary passage of the tendon with an extra-medullary fixation technique.
    The principle is that in a normal shoulder the long head of biceps tendon runs smoothly in the bicipital groove between the lesser and greater tuberosities of the proximal humerus covered by the intertubercular ligament up into the glenohumeral joint to insert with the superior glenoid labrum at the supraglenoid tubercle. If the tendon is damaged or indeed dislocates from the groove due to disruption of the intertubercular ligament, the options are to simply cut the tendon, biceps tenotomy, at it’s insertion in the glenohumeral joint and leave it to retract down the arm or to reattach it into the humerus.
    Reattachment or tenodesis can be performed at any level, within the bicipital groove or distal to it above or below the level of the pectoralis major tendon insertion on the lateral ridge of the bicipital groove of the humerus. The aim of tenodesis is to maintain the working length and hence function of the tendon and the redundant section of proximal tendon is excised. It also aims to maintain the cosmetic appearance of the biceps muscle as tenotomy results in sagging of the biceps muscle belly which bunches up with contraction producing the well described ‘Popeye’ sign.
    Inability to repair the subscapularis may require a tendon transfer which classically requires a section of the pectoralis major.
    NON-OPERATIVE MANAGEMENT
    There is never an absolute indication for surgical intervention in a patient with a rotator cuff tear but a subscapularis deficient shoulder does not function well and predisposes instability and degenerate changes. Non-operative management involves rest with suitable tablet analgesia or anti-inflammatory medication. Injection of steroid and local anaesthetic could be considered in combination with a course of physiotherapy to guide rehabilitation exercises to regain range of motion and then strengthening of shoulder function. In the presence of a small rotator cuff tear such management can be successful. In some patients symptoms improve or disappear with suitable rest, time and rehabilitation such that they can regain function acceptable to their demands and requirements for daily activities. A dislocated long head of biceps tendon will not be rectified with non-operative treatment.
    CONTRAINDICATIONS
    The patient’s general medical health and comorbidities must be taken into consideration. Medical comorbidities are a relative contraindication and a multi-disciplinary approach to pre-operative workup and management with medical and anaesthetic colleagues is essential. The patient must be able to co-operate with the immediate and prolonged perioperative management and rehabilitation to optimise their outcome.

    Setup

    The procedure is performed with the patient supine on the operating table under general anaesthetic supplemented by an interscalene brachial plexus nerve block (performed by the anaesthetist under ultrasound guidance). The head of the table is elevated slightly by approximately 30 degrees.
    Flowtron intermittent calf compression is used as mechanical thromboembolic prophylaxis, chemical prophylaxis is not used for shoulder procedures lasting less than 90 minutes. For open shoulder surgery we administer a single dose of intravenous Ceftriaxone as prophylactic antibiotics.
    Starting with the hand the whole upper limb to the shoulder to the base of the neck and across the axilla and chest wall is prepared with Chlorhexidine. The hand and forearm is covered with a cloth stockinette then wrapped with a crepe bandage. The shoulder girdle in then squared off with adhesive drapes.

    Operation – 1

    AP (anteroposterior) plain x-ray left shoulder.
    The patient in this case is a man in his early 60s who is medically well and working in a manual occupation in a warehouse. He has had a fall injuring his affected shoulder. This shows well aligned glenohumeral joint with no evidence of arthritis in the ball and socket. There is minor sclerosis at the greater tuberosity and significant sclerosis at the lateral edge of the acromion indicating a subacromial spur. There is some age related degenerate change within the acromioclavicular joint which is asymptomatic and an incidental finding.

    Plain lateral x-ray left shoulder. This shows a slight curve to the acromion process of the scapular and previously noted aged related degenerate change in the acromioclavicular joint but little else of significance.

    Plain xray axillary view showing that both the glenohumeral and acromioclavicular joints are well aligned with no arthritic change. It does show an os acromiale (O) – the unfused physis of the acromion – an incidental finding.

    A diagram of the relevant local anatomy, the deltoid and Pec major muscles having been sectioned and reflected laterally, and a section removed from the short head of biceps.
    C: Coracoid process
    CoAc: Coracoacromial ligament
    Sp: Supraspinatous
    Sc: Subscapularis
    Gt: Greater tuberosity
    LH: Long head of biceps
    SH: Short head of biceps
    NV: Neurovascular structures (Anterior humeral circumflex artery and musculocutaneous nerve)

    This is an ultrasound image.
    Such still images are notoriously difficult to interpret as ultrasound is a dynamic imaging modality dependant on the operator’s opinion of the images with respect to the position of their ultrasound probe. Here I believe there is effusion fluid (E) and disruption of the normal anatomy from the lesser tuberosity (LT) of the proximal humerus and an empty bicipital groove (BG) where the tendon of the long head of biceps should normally be found.
    An MRI scan was recommended to confirm suspicions of a subscapularis avulsion tear and dislocation of the long head of biceps tendon.

    Transverse image from MRI scan showing tendon of long head of biceps (LHB) dislocated medially out of the bicipital groove (BG).

    Further transverse image from MRI scan showing subscapularis tendon (SSc) detached from the lesser tuberosity (LT) of the humeral head (HH) and tendon of long head of biceps (LHB) dislocated medially out of the bicipital groove (BG).

    Coronal image from MRI scan showing the tendon of long head of biceps (LHB) – the thin dark structure running from inferior to superior – dislocated medial to the humeral head (HH) and adjacent to the tendon of subscapularis (SSc).

    Further coronal image from MRI scan showing glenoid (G) and humeral head (HH) with lateral clavicle (LC) and acromion (A) making up normal well aligned glenohumeral and acromioclavicular joints. The key feature here is that the supraspinatus (SSp) tendon (the superior of the rotator cuff tendons) is intact with normal insertion to the great tuberosity (GT) of the proximal humerus.

    Prepare the skin and drape the shoulder girdleOnce the patient is positioned with slight head up in supine position in the operating theatre preparation of the upper limb is started. First clear chlorhexidine solution is used to prepare the hand which is then covered in a cloth stockinette. Then chlorhexidine solution is used to prepare the shoulder and the rest of the upper limb.
    Once the whole limb and shoulder girdle is covered in skin preparation the stockinette can be rolled down over the patient’s elbow and wrapped with a crepe bandage (CB).
    Blue adhesive drapes (BD) are applied to ‘square off’ the shoulder ready for surgery.
    The quiver (Q) houses the diathermy forceps and suction tubing.

    Infiltrate the incision site with vasoconstrictive local anaesthetic with adrenalineThe proposed incision site is marked running distally from just lateral to palpable coracoid process at the front of the shoulder.
    To help with initial haemostasis the site is instilled with 20ml 0.5% bupivacaine with adrenaline.

    Incise the skinA skin knife scalpel blade is used to incise the skin from just lateral to palpable coracoid process at the front of the shoulder running distally 7-10 cm.

    The incision is extended down the arm

    Superficial tissues and fat layer are incised with the inside knife scalpel blade. There are often large veins traversing which need diathermy or tying off.

    Identify the deltopectoral intervalOnce the muscle fibres of deltoid and pectoralis major are found, a self-retaining retractor is placed to identify the fat streak that runs approximately from the coracoid process distally in line with the skin incision. This indicates the position of the cephalic vein which marks the deltopectoral interval.

    Use scissors to open the deltopectoral interval taking care to protect the cephalic vein which lies with in the interval between the two muscles.

    The cephalic vein (CV) can be seen lying between the pectoralis major (PM) and deltoid (D) muscles. It has large tributaries draining mainly deltoid and if damaged these cause brisk venous bleeding. The tributaries can be diathermied or tied off without concern. If the large cephalic vein itself is damaged it too can be tied off as it is thought to recannulate in time.

    One may use an index finger to palpate the top of the coracoid process which is the only bony prominence proximally at the top of the skin incision. It is the anterior bony structure easily palpable from the outside which guides the position of the skin incision. This is to allow placement of a superior retractor.

    Place a straight retractor on top of the coracoid process as shown to facilitate access.

    Here the superior retractor is on top of the coracoid (C) process and the self-retaining retractor is taking the conjoint tendon (CT) of the short head of biceps and coracobrachialis which inserts on the point of the coracoid, medially. This exposes the clavi-pectoral fascia (CPF) as a sheet across the front of the shoulder.

    Open the clavi-pectoral fasciaIncising the clavi-pectoral fascia gets straight into the glenohumeral joint with the exposed articular cartilage of the humeral head. As predicted from the preoperative imaging the tendon of the long head of biceps is dislocated medially, ‘cheese-wiring’ over the top of the subscapularis tendon – here only the deepest, most distal fibres remain intact (X) with the more superior fibres seen frayed and torn from the lesser tuberosity.

    Identify dislocated long head of biceps tendonThe forceps are lifting the long head of biceps tendon (LHB) laterally and returning it to the bicipital groove.

    The forceps are replacing the dislocated tendon into the bicipital groove laterally. The bicipital groove is easily palpated as a trough between the lesser tuberosity as its medial border and the lip of the lateral edge.

    With the long head of biceps tendon now back where it belongs relocated in the bicipital groove the damage to subscapularis can be further appreciated.
    The articular cartilage (AC) of the humeral head is seen medially and the bare lesser tuberosity from which the majority of the subscapularis has avulsed is annotated LT. Only a few intact fibres (IF) are seen distally with the torn fibres (TF) seen more proximally & laterally.

    Identify edge of avulsed subscapularis tendonFurther dissection is required to identify and mobilise the torn end of the subscapularis tendon (SSc) here held with forceps. This will be found medially and may have retracted under the coracoid process.
    Care must be taken to avoid damage to the axillary vessels and the branches of the brachial plexus particularly the axillary nerve which runs posteriorly under the medial subscapularis muscle into the quadrangular space. This can be digitally palpated with care medial to the inferior border of the subscapularis muscle (X).

    Operation – 2

    Using dissecting scissors the subscapularis is mobilised releasing the adherent capsular tissue of the rotator interval from the upper border.

    Once the subscapularis tendon is mobilised it can be shown to reduce anatomically back to the bare lesser tuberosity of the proximal humerus.

    Here the forceps are indicating the chosen site for the biceps tenodesis within the bicipital groove (BG). Subscapularis (SSc) is being held medially by the Kocher’s and the long head of biceps (LHB) has been displaced medially from the bicipital groove.

    From the Arthrex shoulder repair set the instruments required for this case are the red handled rasps, the blue handled ring curette and the metallic grey awl for the anchors.

    From the Arthrex shoulder repair instruments choose one of the rasps.

    Prepare the base of the bicipital grooveUsing the Arthrex rasp clear any soft tissue from the floor of the bicipital groove to expose the bone. This may bleed a little but produces an environment onto which the biceps tendon will adhere.

    Once the floor of the bicipital groove has been prepared the long head of biceps tendon is replaced and a site for the tenotomy is chosen to maintain the normal working length of the tendon once it is fixed into the humerus.

    Perform the biceps tenotomyUsing a size 15 scalpel blade divide the long head of biceps tendon at the level that the proximal of the two holes will be drilled, against which the cortical button will be tied down.

    The biceps tenotomy (T) is completed

    I use the Arthrex TightRope implant shown here. Disassemble the implant to use the heavy No5 FiberWire and the choice of two buttons – either the circular one with four holes or the rectangular one with two holes. I almost always use the rectangular one as it sits neatly in the bicipital groove.

    Whip stitch the cut distal end of the biceps tendonLoad a threadable ‘Mayo’ needle with one end of the heavy No5 FiberWire suture material from the TightRope and whip stitch the cut distal end of the biceps tendon (as described in the next step).

    Enter the tendon through the cut surface and run the stitch down one side, across the tendon and up the other to exit on the cut surface again.

    This shows the cut biceps tendon securely held by the heavy FiberWire with both suture limbs exiting the tendon at the cut end.

    Drill holes in the bicipital grooveTake a 4.5mm drill to create the distal of two holes on the prepared bicipital groove.

    Once the medullary canal has been entered by drilling the anterior cortex of the humerus in the bicipital groove, back the drill bit out and rock it whilst continuing to drill to create a smooth trough at the distal edge of the hole into which the tendon will enter.

    Change the drill bit to a smaller 3.2mm to create the second hole approximately 1.5cm proximally in the bicipital groove. Again only drill the anterior cortex of the humerus to enter the medullary canal.

    With the long head of biceps (LHB) pulled out of the way on its heavy whip stitch, this shows the larger distal hole (DH) and 1.5cm up the bicipital groove the smaller proximal hole (PH).

    Re-load the threadable ‘Mayo’ needle with a length of suture material

    Pass the shuttle suture between the two drilled holesPass the Mayo needle from the proximal drill hole into the distal drill hole. Any method to pass a shuttle suture loop can be used here or even using the Arthrex Suture Lasso which a is a curved cannulated suture passing device through which a wire loop can be passed.

    Pull the shuttle suture through the distal drill hole.

    Either cut the shuttle suture to remove the Mayo needle and tie it to recreate a loop or simply break the needle eyelet to leave the shuttle loop. Pass both ends of the heavy whip stitch from the biceps tendon through the shuttle loop.

    Shuttle the heavy whip stitches from the biceps tendon into the drill holesPull on the shuttle suture to advance the heavy whip stitches into the distal drill hole.

    Pull sutures through proximal hole and remove the shuttle suture loop

    Pull the tendon into the distal drill hole and medullary canal of the humerusPull on the heavy sutures to bring the cut end of the biceps tendon into the distal hole. Here the forceps are guiding and facilitating the tendon into the hole.

    Further traction on the heavy FiberWire pulls the biceps into the humerus medullary canal.

    Operation – 3

    Load the FiberWire sutures onto the rectangular buttonTake the rectangular metal button which has two holes and pass a limb of heavy FiberWire from the tendon through one of the button’s holes.

    Push the length of FiberWire through the first button hole.

    Pass the second limb of FiberWire from the tendon into the second hole of the button.

    Tie the FiberWIre sutures down with the button flush to the proximal drill hole on the humerusOnce both limbs of FiberWire are loaded on the button push the button down to sit on the proximal drill hole on the bicipital groove of the humerus and tie down the sutures.
    Make at least three throws on the FiberWire down to the button to fix the biceps tendon into the distal drill hole completing the tenodesis with this extramedullary fixation over the button at the proximal drill hole.

    Once the tenodesis has been completed cut the heavy No5 FiberWire with a scalpel blade.

    Biceps tenodesis completed.Final position of the button lying along the bicipital groove once the biceps tenodesis is completed.

    For the subscapularis repair take the anchor awl (AA) and ring curette (RC) from the Arthrex shoulder repair instruments.

    To start the subscapularis repair prepare the lesser tuberosityHold the subscapularis (SSc) out of the way and identify the bony lesser tuberosity (LT) medial to the bicpital groove in which the button (B) used for the biceps tenodesis is lying. Use the ring curette (RC) to scrape soft tissue off the bone surface of the lesser tuberosity.

    To further prepare the surface of the lesser tuberosity (LT) use the rasp (R) to create a bleeding bony surface onto which the subscapularis tendon (SSc) will be repaired.

    Excise the redundant residual proximal intra-articular biceps tendonNow that the biceps tenodesis has been completed and before the subscapularis (SSc) tendon is repaired, identify the residual redundant stump of the long head of biceps tendon (LHB) here gasped by the Kocher’s (K).

    Pull the biceps tendon stump on the Kocher’s (K) and using a No15 scalpel blade (S) divide the tendon deep in the glenohumeral joint at its insertion at the superior glenoid labrum under direct vision and discard the redundant section of tendon. This can be difficult to see but is facilitated by the surgical assistant elevating the operated arm and translating the humeral head posteriorly on the glenoid with direct pressure on the proximal arm and use of the sucker deep in the glenohumeral joint to clear any pooled blood. A small residual stump of biceps tendon at the superior labrum is not of concern.

    Choose bone anchors for subscapularis repairTake four Arthrex Swivelock C anchors – 2 each of the blue handled 5.5 diameter and green handled 4.75 and two FiberTapes. Note the body of the anchors are perforated with holes (H) to encourage bony ingrowth once inserted to the cancellous bone of the proximal humerus.

    Take the thin tapered end of one of the FiberTapes and pass it into the wire loop of the anchor threader at the eyelet on the end of the first Arthrex 4.75 Swivelock C anchor

    Unclip the orange anchor threader and pull the end of the FiberTape through the eyelet of the anchor

    Load the medial anchors with FiberTapePull the FiberTape through the anchor eyelet so that the ends are together and the eyelet at the distal end of the anchor is loaded with the broad flat FiberTape at its mid-section as shown here.
    Repeat this process with the second green handled anchor.

    Keeping the subscapularis (SSc) tendon retracted out of the way, take the anchor awl (AA) and choose the position for the inferior medial anchor on the medial edge of the prepared lesser tuberosity (LT) footprint just lateral to the humeral head articular surface (AS)

    Make the medial anchor hole using the awlUse a small mallet to impact and insert the anchor awl creating a hole in the desired position.

    Note the line markings on the anchor awl – FT for the ‘fully threaded’ anchors not being used here and SL for ‘Swivelock’.

    Continue inserting the awl until the SL line is buried into the bone of the lesser tuberosity

    Insert the first medial anchorRemove the awl and take the first green handled anchor. Insert the eyelet tip of the anchor into the hole created by the awl.

    Keeping tension on the FiberTapes push the eyelet into the hole until the body of the anchor sits against the bone.

    Holding the flat plate of the green handle steady, screw in the pear-shaped end of the anchor handle so that the screw-in anchor advances into the bone gripping the FiberTapes with an interference fit.

    Ensure the anchor is fully seated into the bone.

    Release the stay sutures (SS) from the top of the anchor handle and remove the green anchor handle completely leaving the anchor fixed in the bone with the FibreTapes (FT) attached. Once the handle has been removed pull the stay suture (SS) out and discard.

    Take the anchor awl again and choose the position for the superior of the two medial anchors. Use the mallet to impact the awl and create the second medial anchor hole.

    Operation – 4

    When the SL line on the awl is embedded in bone remove the awl.

    Insert the second medial anchorInsert the second 4.75 anchor loaded with FiberTape in an identical way as the first.

    When the anchor is fully seated in the bone, release the stay sutures and remove the handle and stay sutures from the anchor.

    With 4 limbs of FiberTape emanating from the two anchors positioned on the medial aspect of the lesser tuberosity, mobilise the avulsed end of the subscapularis tendon. Check there are no residual adhesions to the tendon and at this stage the undersurface of the tendon which we want to heal to the lesser tuberosity can be scraped clear of any fibrous scar tissue using the ring curette or a scalpel blade.

    Pass all four of the FiberTapes through the subscapularis tendon using a needleTake the threadable ‘Mayo’ needle and thread it with the first inferior most of the four FiberTapes. Use the needle to pass the FiberTape through the subscapularis tendon at the same distance as the width of the prepared lesser tuberosity footprint.

    Once the needle has passed the tendon pull the FiberTape through the tissue.

    Repeat the process using the threadable needle to pass each of the remaining three FiberTapes sequentially through the subscapularis tendon in order from inferior to superior.

    This shows all four FiberTapes (1 inferiorly to 4 superiorly) from the medial anchors passed through the subscapularis tendon.

    Crossover FiberTapes for final pairs Cross over the middle pair of FiberTapes as shown so limbs 1 & 3, the inferior limb from each medial anchor, and limbs 2 & 4, the superior limb from each medial anchor, are paired as an inferior and superior pair to be fixed down to the lateral anchors.

    Take a blue handled Arthrex 5.5 Swivelock C anchor and load the eyelet with one of the final pairs of FiberTapes passing the tapered ends through the wire loop of the anchor threader.

    Load the lateral anchors with the FiberTapesUnclip the orange handle and pull the wire threader wire through the eyelet loading it with the pair of FiberTapes.

    Advance the anchor eyelet down the tapes and apply a clip (C) to the ends to secure and prevent the anchor sliding off the tapes.

    Repeat the process to load a second 5.5 Swivelock anchor with the second pair of FiberTapes.

    Take the anchor awl and choose the position of the inferior of the two lateral anchors. This should be on the lateral edge of the prepared lesser tuberosity or on the medial ridge of the bicipital groove. The prepared lesser tuberosity is approximately 2cm wide and the medial and lateral anchors should be placed as far apart as possible to avoid a narrow bone bridge which might predispose to fracture or anchor pull-out. Remember the body of the anchors are perforated to encourage bony ingrowth once inserted to the cancellous bone of the proximal humerus.

    Impact the awl with the mallet to create the first lateral anchor hole.

    Advance the awl until the SL line is embedded in the bone just as with the medial anchors.

    Insert lateral anchors to complete subscapularis footprint repairRemove the awl from the bone. Take the inferior lateral anchor and insert it into the prepared bone hole.

    Pull the FiberTapes to tension them over the lateral aspect of the subscapularis tendon seating it down against the lesser tuberosity and screw in the anchor.

    When the anchor is fully seated remove the stay sutures and introducer handle then use a scalpel blade to cut the FiberTapes flush with the bone as shown.

    Repeat the process with the awl to make the hole for the superior lateral anchor.

    Insert the superior lateral Swivelock C anchor loaded with the FiberTapes.

    When the final anchor is embedded in the bone remove the handle introducer and the core stay suture (SS).

    Cut the final FiberTapes flush with the bone using the scalpel blade.

    Inspect the final subscapularis repair and biceps tenodesis.Final repair showing the cross-over (X) pattern of the FiberTapes compressing the subscapularis tendon onto the lesser tuberosity footprint with a double row knotless technique. The button (B) of the biceps tenodesis can also be seen over the bicipital groove. External rotation of the shoulder confirms a sound repair and estimates the degree to which the postoperative physiotherapy protocol can be limited with minimal tension on the repair.

    Close the surgical wound in layersFollowing thorough washout of the wound and ensuring haemostasis with diathermy, close the surgical wound fascia and fat with continuous running Vicryl sutures.

    Operation – 5

    Close the surgical wound in layers with absorbable Vicryl sutures.

    Close the skin with a continuous running subcuticular absorbable Monocryl suture.

    Pull both ends of the Monocryl suture to secure skin closure.

    Apply paper steristrips across the closed skin wound and to secure the free ends of the absorbable suture. The dressing and steristrips can be removed and the ends of the absorbable suture trimmed at skin level approximately 2 weeks following surgery.

    Apply a simple dressing over the wound and a broad arm sling in which to rest the arm.

    Post Operative

    It is essential that the post op notes are checked to ensure appropriate rehabilitation particularly noting degree of external rotation possible to avoid excessive tension on the subscapularis repair.
    General Points
    Do not push through pain – remember pain inhibits rotator cuff control
    Do not sacrifice quality of movement for ROM
    Remember the pathophysiology of the repaired tendon is probably degenerative and needs to be considered when progressing rehabilitation
    Immobilisation – Patient to wear sling for 4-6 weeks, it can be removed to perform exercises as instructed by physiotherapist
    0-6 weeks: Pendular exercises, elbow, wrist and hand. Encourage optimal scapula-thoracic position
    6-12 weeks: Gradually wean out of sling – light activities only (weight of a cup of tea within the field of vision, short lever); Active assisted exercises gradually increasing ROM – consider short lever, supine and closed kinetic chain; (Anterior deltoid rehab principles); No long lever open chain exercises until 12 weeks
    12 + weeks: Isometric Exercises through available range
    16 + weeks: Resisted through range strengthening

    Recommended Reading

    Repair of Tears of the Subscapularis.
    Edwards BT, Walch G, Sirveaux F, Mole D, Nove-Josserand L, Boulahia A, Neyton L, Szabo I, Lindgren B
    JBJS Am April 2005 Volume 87 Issue 4 pp 725-730
    84 shoulders that had undergone open subscapularis repair are reviewed, 57 traumatic 27 degenerative cases. 54 had dislocation or subluxation of the long head of biceps tendon and 10 had rupture of LHB. 48 underwent concomitant biceps tenodesis, 13 tenotomy. Constant scores increased from 55 preop to 80 postop with 75 patients satisfied or very satisfied with the result. Tenodesis or tenotomy of biceps at the time of subscapularis repair was associated with improved subjective and objective results independant of the preoperative condition of the biceps tendon. Conclusions: Repair of isolated subscapularis tears yields acceptable improvement in shoulder function in selected patients. Additionally, the results of the study support routine tenodesis or tenotomy of the long head of the biceps tendon at the time of subscapularis repair.

    The Biomechanical Evaluation of Four Fixation Techniques for Proximal Biceps Tenodesis.
    Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA
    Arthroscopy Nov 2005 Volume 21 Issue 11 pp 1296-1306
    Fresh frozen cadaveric assessment of cyclic displacement and ultimate failure strength of 4 tenodesis fixation methods: the open subpectoral bone tunnel (SBT), arthroscopic suture anchor (SA), open subpectoral interference screw (SIS) and arthroscopic interference screw (AIS). SBT group showed statistically significant greater displacement than other tenodesis methods. There were no statistically significant differences in ultimate failure strength between any of the methods.

    Open Repair of Isolated Traumatic Subscapularis Tendon Tears.
    Bartl C, Scheibel M, Magosch P, Lichtenberg S, Habermeyer P
    Am J Sports Med Dec 2010 Volume 39 Issue 3 pp 490-496
    Thirty consecutive patients with a traumatic isolated subscapularis tear. All patients underwent open tendon reconstruction with a suture anchor technique via a deltopectoral approach. Clinical assessment was done using the Constant score and specific subscapularis tests. Postoperative tendon integrity was assessed with ultrasound and magnetic resonance imaging. Sports activity, including competition level, sports discipline, and postoperative return to sports was evaluated. Average follow-up 46 months. Seven patients had a full-thickness tear of the upper third of the tendon, 11 patients a full-thickness tear of the upper two-thirds of the tendon, and 12 patients had a complete subscapularis tendon tear. The Constant score increased from 50 preoperatively to 80 postoperatively . Twenty-seven patients rated their postoperative result as excellent or good. Most positive preoperative lift-off and belly-press tests were reversed by surgery, with 20% persistent positive tests after surgery. Ultrasound and magnetic resonance imaging revealed a structural intact repair at follow-up in 28 shoulders (93%). Seventy-five percent of athletes returned to their previous competition level. Conclusions: Early repair of isolated traumatic subscapularis tendon tears and associated biceps tendon lesions or HAGL lesions achieves good functional outcomes with a low rerupture rate and allows return to sports activity. Delay of surgery and higher degrees of preoperative fatty infiltration of the subscapularis muscle impair postoperative subscapularis function.

    Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanics results.
    Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR
    JSES March 2011 Volume 20 Issue 2 pp 326-332
    This review demonstrated a higher incidence of cosmetic deformity in patients treated with biceps tenotomy compared with tenodesis, with an associated lower load to tendon failure. However, there was no consensus in the literature regarding the use of tenotomy vs. tenodesis for LHB tendon lesions due to variable results and methodology of published studies. Individual patient factors and needs should guide surgeons on whether to use tenotomy or tenodesis. There is a great need for future studies with high levels of evidence, control, randomization, and power, with well-defined study variables, to compare biceps tenotomy and tenodesis for the treatment of LHB tendon lesions.

    Outcomes of Arthroscopic and Open Surgical Repair of Isolated Subscapularis Tendon Tears.
    Mall NA, Chahal J, Heard WM, Bach BR, Bush-Joseph CA, Romeo AA, Verma NN
    Arthroscopy Sept 2012 Volume 28 Issue 9 pp 1306-1314
    Three arthroscopic repair studies and six open repair studies met the inclusion criteria and are reviewed. The mean patient age was 49years, and the mean time from injury to surgical repair was 11 months. Constant scores were consistent between groups, with a mean postoperative score of almost 90. Pain scores improved significantly after repair, with a mean of 13 (on a scale ranging from 0 to 15, with 15 being no pain) in the arthroscopic repair group and 11 in the open repair group. Concomitant procedures were common, with biceps tenodesis being the most common performed in 55% of shoulders, followed by biceps tenotomy and biceps recentering. Healing was reported in 90% to 95% of shoulders.
    Pain is reduced and function restored with repair with excellent healing rates. The characteristic injury pattern suggested by a review of the literature is where such tears are full thickness yet involve a portion of the tendon in the craniocaudal dimension. Concomitant procedures are common and can affect the results, because biceps tenotomy and tenodesis have been shown to significantly improve pain as well.

    Subpectoral biceps tenodesis using a novel anterior cortical button technique.
    Javed S, Gheorghiu D, Walton M
    Shoulder & Elbow October 2018 Volume 10 Issue 4 pp 292-295
    Description of a novel technique, which provides an opportunity to obtain a robust cortical and intramedullary tenodesis, performed under direct vision without the risk of drilling the far cortex and therefore avoiding any potential for neurological injury. There is no cortical implant, which may lead to a diaphyseal stress riser and subsequent fracture risk.
    This paper describes the technique used in this Orthoracle case albeit at a different anatomical site.

    Reference

    • orthoracle.com

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