///

Arthroscopic subscapularis tendon repair utilising Smith and Nephew Healicoils

    Overview

    Learn the Arthroscopic subscapularis tendon repair utilising Smith and Nephew Healicoils surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic subscapularis tendon repair utilising Smith and Nephew Healicoils surgical procedure.
    The subscapularis is the largest of the rotator cuff tendons, lying anterior to the shoulder and playing a vital role in both humeral head depression and stabilising against anterior shoulder dislocation.
    With improved imaging and arthroscopic techniques, as well as a growing cohort of “sport-active” older patients, Surgeons are increasingly recognising and treating ever more subscapularis tears in this demanding patient group. Rotator cuff tears involving the subscapularis are less common than those involving the more superior parts of the rotator cuff.
    Subscapularis tears usually originate in the superior bands of the tendon and propagate distally. They can result from acute external rotation injuries or occur more chronically due to subcoracoid impingement. Burkhart described the “roller wringer” effect where the upper subscapularis tendon is pinched between the lesser tuberosity and the tip of the coracoid process causing tendon attrition. A coraco-humeral interval of less than 6mm can be considered to be stenotic and is probably associated with the development of such tears.
    In many instances the tear may be associated with a biceps tendon which has slipped out of it’s groove and cut through the subscapularis tendon, and this should be looked for and treated also. Combined tears of subscapularis, supraspinatous and infraspinatous if large can result in defunctioning of overhead ability and proximal migration of the humeral head and can also be repaired arthroscopically.
    Readers will also find of use Mark Crowthers comprehensive techniques Arthroscopic rotator cuff repair using modified Arthrex suture-bridge techniqueas well as Arthroscopic subacromial decompression
    These both cover extensively with the detail required to perform shoulder arthroscopy.

    Indications

    INDICATIONS
    Partial and full thickness tears of subscapularis tendons are common and are under diagnosed. They should be looked for in patients with anterior shoulder pain and with long head of biceps symptoms. The torn tendon should be repaired in active individuals and an arthroscopic approach offers superior visualisation and ease of mobilisation with potentially earlier recovery.
    A “roller-wringer” effect has been described in association with degeneration of the subscapularis tendon, and the concept should be understood when deciding upon the nature of surgical treatment. Here the upper subscapularis tendon is pinched between the lesser tuberosity and the tip of the coracoid process causing tendon attrition, and probably contributing to the development of tears. A coraco-humeral interval of less than 6mm can be considered to be stenotic and is likely associated with the development of such tears. A coracoid-plasty should be considered to accompany the repair to prevent this mechanism causing recurrence.
    SYMPTOMS & EXAMINATION
    Although subscapularis tears can occur alone, they are often associated with supraspinatus tears or a subluxing biceps tendon. Patients present with pain at the front of the shoulder and weakness on shoulder internal rotation and extension. Younger patients can present following a fall onto an outstretched hand or when the shoulder has been forced into extension. A subluxing biceps tendon can present with symptoms of instability with instances where the tendon slips out of place or clicking at the front of the shoulder.
    Examination findings include an increase in passive external rotation or weakness in active internal rotation.
    The lift-off test is often difficult to perform due to restricted internal rotation so new tests are used to try and identify weakness in the subscapularis muscle.
    The Belly-press test is performed with the arm internally rotated and hand resting on the abdomen while the examiner tries to resist the motion.
    The Bear-hug test is useful for detecting upper fibre tears in subscapularis. The patients hand is placed on the contra lateral shoulder and the elbow is lifted to point forwards. The examiner tries to pull the hand off the shoulder whilst the patient resists.
    IMAGING
    Radiological examination is essential for accurate diagnosis. Plane X-rays AP and axillary views identify superior humeral head migration with massive cuff tears or anterior subluxation with large suscapularis tears.
    Ultrasound scans have become established in identifying cuff tears but the identification of subscapularis tears can be difficult especially with partial tears or individuals with limited rotation using ultrasound.
    MRI is the current test of choice when evaluating the soft tissues of the shoulder. T1 weighted images revealing increased signal in the tendon combined with a focal defect on T2 weighted imaging being a common finding.
    ALTERNATIVE OPERATIVE TREATMENT
    Arthoscopic subscapularis tendon repairs have largely replaced open procedures. Arthroscopy has improved visualisation and ease of tendon release with quicker recovery.
    NON-OPERATIVE MANAGEMENT
    Conservative nonoperative treatment is usually reserved for patients who don’t want surgery or are medically unfit or of low functional demand.
    Physiotherapy involves trying to maintain movement and strengthening of anterior deltoid muscle to compensate for weakness in internal rotation.
    CONTRAINDICATIONS
    One contraindication to surgery, as with most operations, is those patients unfit for surgical intervention.
    Repairing the tendon in the presence of severe osteoarthritis in the glenohumeral joint though is a relative specific contraindication, where the management of the arthritic joint should take priority.
    One overarching consideration to be borne in mind is there is limited expected functional improvement following surgery in the presence of chronic and massive cuff tears with significant muscle fatty infiltration.

    Setup

    The procedure is performed in the beach chair position using an appropriate operating table attachment and under general anaesthetic (aiming to keep the systolic blood pressure at approximately 100mmHg) supplemented by suprascapular nerve block (performed by the anaesthetist under ultrasound guidance). An alternative, depending on the patient’s medical and pain relief requirements, is to use an interscalene brachial plexus nerve block. Flowtron intermittent calf compression is used as mechanical thromboembolic prophylaxis. No prophylactic antibiotics are required for such arthroscopy.
    I use the T-Max (marketed in the UK by Smith & Nephew) table attachment as shown. The patient is slid onto the table and both side supports are fixed into position. The wedge is then placed under the patient’s legs and the power assisted table attachment can then be elevated to a suitable beach chair position. The patient’s head is positioned safely on the table head piece, adjusting the position with the anaesthetist’s approval and secured using the foam face mask clipped into position as shown.
    The Trimano (Arthrex) arm positioned is attached to the edge of the operating table in a position that will reach the operated hand and arm. The Trimano is then covered with the sterile plastic cover, attaching the black fitment to its end. Starting with the hand, the whole upper limb to the base of the neck and across the axilla and chest wall is prepared with chlorhexidine and then covered with specifically designed beach chair shoulder arthroscopy drape. The blue foam arm-holder is clicked into place on the black Trimano fitment and then folded over and secured with the Velcro edges to wrap the forearm. The blue foam arm-holder is then wrapped in self-adhesive stretch tape, to hold the arm in position during surgery. The Trimano can be single-handedly manoeuvred to hold the shoulder in different positions during the operation with traction as required. A 30⁰ shoulder arthroscope is used and the arthroscopic pump instils saline at approximately 50mmHg.

    Operation – 1

    The patient is placed in a deckchair position on a shoulder table. Straight arm traction is applied of around 2Kg.

    The shoulder is prepped and draped allowing exposure of the back of the shoulder and anteriorly up to the medial border of the coracoid process.

    The bony anatomy is marked out including the coracoid process.
    Marking helps with portal placement especially as the shoulder becomes more swollen with fluid insulation and the bony landmarks become difficult to palpate

    A standard posterior portal is made 2cm inferior and lateral to the posterolateral corner of the acromion.

    The camera is inserted through the posterior portal, aiming towards the acromion, to enter the glenohumeral joint. A routine diagnostic arthroscopy is first performed.Feel for the soft spot between the humeral head, glenoid and rotator cuff.

    A routine diagnostic arthroscopy is performed viewing through the posterior portal.Assess the glenohumeral joint looking for signs of instability and labral damage.

    Evaluate the relationship of the biceps tendon to the subscapularis tendon. The biceps(B) should not normally be located posterior to the plane of the subscapularis.Check to see if the biceps tendon subluxes medially and posteriorly, which can occur with pulley injuries. The tendon instead should run smoothly and elevating the arm will demonstrate it’s tracking.
    If the biceps tendon is unstable it may require a tenotomy or tenodesis within the groove. A persistent subluxed biceps will stress the subscapularis repair and cause it to fail.
    Look also for tears to the leading edge of supraspinatus (S)

    The supraspinatus(S) should be viewed by looking laterally.
    Be careful to identify articular sided partial thickness tears or PASTA lesions effecting the supraspinatus tendon.
    Unstable biceps tendons with damaged pulleys may also be associated with anterior leading edge tears to the supraspinatus tendon.

    Rotating the shoulder will help to identify partial tears of subscapularis by seeing the tendon “peel off” the lesser tuberosity during this movement.Visualising the subscapularis tendon and it’s footprint can be difficult and a 70 degree scope may be useful. This image shows a partial thickness tear of the superior edge of the subscapularis tendon(PT).
    Tears usually propagate from the superior edge extending inferiorly and full thickness tears may result in the tendon retracted out of view. The “comma sign” (not shown) can help identify the subscapularis tendon and differentiate it from the coracoacromial ligament. The coma is made up of the remnant of the medial sling of biceps which is adherent to the superior border of subscapularis.

    An anterior and superolateral portal is sited using a needle anteriorly to help guide a straight line approach to the lesser tuberosity and subscapularis tendon footprint.A small incision is required, being careful not to damage the subscapularis tendon.

    The subscapularis tendon is lifted with a blunt hook, inserted through the anterior portal. This assists in demonstration of the extent of the tear (ST) and exposing its footprint.

    A shaver( a full radius and “non-aggressive” resector) is used through the anterior working portal to freshen up the subscapularis tendon surface.This creates a bleeding bed to aid tendon healing.

    The Arthocare wand is next used to open a widow in the anterior (rotator) interval, above the subscapularis tendon.If the tendon is retracted the releases are performed anteriorly, superiorly and posteriorly.
    The rotator interval is a triangular space located in the anterosuperior aspect of the shoulder. its superior border is formed by the anterior border of the supraspinatus, its inferior border is the superior border of the subscapularis and its medial border is the base of the coracoid process.
    The Rotator Interval of the Shoulder: Implications in the Treatment of Shoulder Instability. Orthop J Sports Med. 2015 Dec; 3(12).

    The subscapularis footprint is prepared using a burr to produce a bleeding bed.
    The burr should be pointed away from the tendon using the shield to protect it from inadvertent damage.

    The anterior portal is then dilated with the use of a switching stick whilst maintaining the view through the posterior portal.

    The switching stick and dilator aid accurate placement of the anterior cannula.

    The cannula should be directed down for a straight line approach to the tendon footprint.

    The Smith and Nephew Healicoil awl dilator is inserted through the anterior cannula and tapped into the bone down to its laser mark.This provides a blind ended tunnel for the anchor.

    A Healicoil PK Suture Anchor (Smith and Nephew) with two Ultrabraid sutures is tapped into the tunnel just created in the greater tuberosity.The sutures are aligned superior to inferior to produce an even spread of tension once tied off subsequently.

    The sutures rest against the superior edge of the tendon, and the anchor itself sits beneath the articular surface.
    The sutures should have tension applied to them externally and sound attachment of the anchor observed directly.

    For more detail on the use of the Smith and Nephew Healicoil anchors refer to the official techniques in the Implants section of this operation technique.

    A suture retriever is now used to accurately position each suture individually through the subscapularis tendon. This aids optimal reattachment of the tendon.

    The 45 degree curved “bird beak” is passed through the tendon and each suture is retrieved through the subscapularis tendon.
    Care should be taken to avoid the sutures becoming tangled at this point.

    The process is repeated for all four suture limbs, which are individually retrieved.

    The sutures are tied over the tendon firmly, again using the posteriorly placed arthroscope to ensure appropriate knot position and tension is achieved.

    A “past pointing” arthroscopic knot tying technique is used to tighten each knot so the tendon lies flat on the prepared bone bed.

    Operation – 2

    The tendon should now lie flat and well opposed against the bone.

    Following the repair the biceps tendon should be assessed to check it runs smoothly through the sling and that it hasn’t been inadvertently over tightened.

    Attention is now moved to the coracoid process which is identified as a bulge in the anterior interval and the gap between the coracoid process and the lesser tuberosity is estimated.A space of less than 6mm is associated with coracoid impingement of subscapularis.
    Check the gap with the shoulder positioned into internal rotation and also forward flexion. Linear longitudinal tears near the tendon insertion are a sign of indentation.

    An arthrocare wand(A) is used to make a window in the anterior interval and identify the coracoid tip.

    The tip of the coracoid(A) is removed using a burr, working through the anterior portal, being careful to avoid damage to the conjoint tendon.The space between the coracoid and lesser tuberosity is checked once again to ensure adequate clearance has been achieved.

    The wound are closed with interrupted sutures.

    Mepore dressing are used and a pressure dressing is applied.

    Post Operative

    General Points
     Do not push through pain – remember pain inhibits rotator cuff control
     Do not sacrifice quality of movement for Range of Motion (ROM)
     Remember the pathophysiology of the rotator cuff may be degenerative and needs to be
    considered when progressing rehabilitation
    Immobilisation
     No formal period of immobilisation, sling maybe provided for comfort only
     Wean out of sling as soon as able and comfortable
    There are no specific time scales, progression occurs as symptoms and ROM allows- but
    NO SIGNIFICANT UPPER LIMB RESISTANCE WORK FOR 6 WEEKS
    The emphasis of rehabilitation should be based on:
     Scapula stability/ control and progressive strengthening
     Regaining range of movement of all affected joints
     Rotator cuff control, strength and stamina – remember all components of a functional cuff – Internal Rotation/External Rotation/Abduction
     Functional, general strengthening and core stability
     Postural re-education – work and leisure
     Assessing other associated areas as necessary, such as cervical and thoracic spine.
    Exercises should be pain free, but should challenge stamina
    Post Operative Day 1: Pendular exercises; Active assisted exercises– consider use of table slides or walk backs as well as supine elevation
    Driving, Light work, sedentary activity: 10 – 14 days but may return sooner if pain and function allow.
    Heavy work or sustained over head postures: minimum 6 weeks but dependent on symptoms – this is typically between 6-12 weeks
    Non contact sports: minimum 6 weeks as comfort and ROM allows
    Contact sports: minimum 6 weeks as comfort and ROM allows

    Recommended Reading

    The results of arthroscopic subscapularis tendon repairs.
    Adams CR ,Burkhart SS, Schoolfield JD. Arthroscopy. 2008 Dec; 24(12):1381-9.
    At a median follow-up of 5 years, 80% of 40 patients reviewed had a minimum of at least a good result after an arthroscopic subscapularis tendon repair

    Outcomes of arthroscopic and open surgical repair of isolated subscapularis tendon tears. Arthroscopy. 2012 Sep;28(9):1306-14.
    Mall NA, Chahal J, Heard WM, Bach BR Jr, Bush-Joseph CA, Romeo AA, Verma NN.
    This group reviewed 3 papers reporting an arthroscopic technique and 6 an open technique. Pain scores were improved significantly post-operatively in both groups, though more in the arthroscopic cases. A biceps tenodesis was required in over 50% of cases.

    Repair of tears of the subscapularis. J Bone Joint Surg Am. 2005 Apr;87(4):725-30.
    Edwards TB, Walch G, Sirveaux F, Molé D, Nové-Josserand L, Boulahia A, Neyton L, Szabo I, Lindgren B.
    Eighty-four shoulders following open repair of the subscapularis tendon were reviewed, twenty-three tears involved the superior one-third of the subscapularis tendon, forty-one tears involved the superior two-thirds, twenty tears being complete
    Forty-eight shoulders required biceps tenodesis, thirteen biceps tenotomy, and four recentering of the biceps. At a mean of forty-five months the Constant score had increased from 55.0 points preoperatively to 79.5 points postoperatively. Seventy-five patients were satisfied or very satisfied and biceps interventions, irrespective of the state of the biceps were associated with improved outcomes.

    The Rotator Interval of the Shoulder: Implications in the Treatment of Shoulder Instability. Orthop J Sports Med. 2015 Dec; 3(12):
    Rachel M. Frank MD, Dean Taylor, MD, Nikhil N. Verma, MD, Anthony A. Romeo, MD, Timothy S. Mologne, MD, and Matthew T. Provencher, MD
    A useful and well illustrated open access paper on the surgical and pathological anatomy.


    Reference

    • orthoracle.com

    Tags:

    You might be interested in

    Dark mode powered by Night Eye