This talk is on subscapularis tears, from small to big. I'll try to show some different elements during this talk. These are my disclosures, and they're available on the Academy site. I'll go through these steps. And if you'll note from these pictures, the biceps is dislocated. The biceps treatment is integral, but I won't have time to address it here. You need to plan for it early in your procedure. As far as coracoplasty, I haven't found a need for it in quite some time. Why do we repair the subscapularis? This is viewing from the left lateral portal. You can see the subscapularis coming over the left tuberosity. And you can see the posterior superior component of the tear being brought laterally. Here it is not repaired. Here it is repaired. If you repair the subscapularis, the posterior superior component of the repair is much easier, and you can make it more secure. And the essential feature is the comet tissue. By keeping that intact, you can translate the subscapularis and the anterior aspect of the supraspinatus laterally. If you don't repair the subscapularis in this setting, it's like zippering only halfway. But if you do repair the subscapularis, you bring the posterior superior cuff laterally, and you can get a nice, secure repair. Again, this is because of the comet tissue. It's something Steve Burkart and I published some years ago. The probe is showing you the comet tissue, but I also want to show you one other thing. By retracting the tendon laterally, you now see the middle glenohumeral ligament in the position which you normally see it if there's no tear. That tells me how much I've got to translate the subscapularis laterally in my repair. There are MRI features I want to point out. If you look at a normal subscapularis, it abuts the medial aspect of the coracoid. So this is something that I look for in cases. On this coronal view, you can see the posterior superior tear but a few more cuts anteriorly, you can now see a space where the muscle is not against the coracoid. I call that the medial coracoid sign, and I do look for that on the coronal view because it should be closer, if not abutting the medial coracoid. You can also note in this case, the biceps is vertical. It's dislocated medially, and that also tells me what's going on to the subscapularis. Furthermore, you want to look for cysts in the bone. If this is where you're going to plan to place anchors, you need to know this in advance. Also in this case, you can see the subscapularis is torn. It allows the biceps, in this case, to sublux medially. And then I'll show you the arthroscopic view in this case. But first, some other findings. The os subscapularis, I call it, it's an ossicle of bone. When I see this, I'm very suspicious for a subscapularis tear. Can also note it on MRI. So keep a lookout for that. Here it is arthroscopically and after repair. So we're going to look at some small lesions. I like to point out the hidden lesion. It looks pretty normal here, but if you don't go down the biceps groove and look medially, you're going to miss some pathology. Here's another case, seemingly a split. But if you look down into that split and laterally, you can see the biceps tendon at about the three o'clock position. This needs to be addressed during your care for this patient. One last example, subscapularis looks decent. But if you go down the groove, you'll see the less tuberosity exposed right here. So I'll go through a partial tear repair, one of the smaller lesions. Here's the arm in neutral. In internal rotation, it's more significant. Internal rotation is something I do often to look better at the subscapularis. Here you can see the tear and how I approach it. And I like this angle of approach because of how the tear tends to pull off the bone. So I'll use a retrograde technique with a crescent shaped hook to pass sutures in this angle. I don't prefer this angle, however, to get a nice secure repair in neutral and now internal rotation again. This is a complete tear of the upper portion of the subscapularis. So after you prepare the less tuberosity and denude the soft tissue to expose the bone, you can now place an anchor and plan for your repair. This is a retrograde shuttling technique with a zero proline, and it pulls the sutures through. Then you tie, get a near anatomic repair. As get larger in size, this is 50% full thickness tear. You can see on MRI, the subscapularis findings I've pointed out as well as the biceps findings. And here it is. Before you start the video, you can see the biceps is perched on the medial edge of the biceps groove because the subscapularis is torn. When you look live, you can now see the tear and the exposed less tuberosity of the upper portion of the subscapularis. Anchors are placed, and then sutures are passed. The medial sutures are already through the tendon. The lateral sutures will need to go through the tendon so that you don't come over the rolled superior edge. When all the sutures are in the cannula, and I use one cannula for this particular case, you need to remove them. You can use a number one PDS loop and retrieve it all up into the cannula and then pull it out through the needle hole. Once they're out, then you can pull them back into the single anterior cannula and tie to get this type of a repair. Here it is viewed from the anterior portal. And this is the seven month post-op outcome. So there are some technique steps that I want to point out and won't be able to point out all of them given the time I have. I do like a traction suture for tears that are retracted medially. I use a number one PDS for that as well. I use a spinal node to locate a puncture wound inter laterally, retrieve both limbs and then pull on it. This helps with the releases as well as controlling when you're tying. And this is what it looks like on the outside. You also want to develop a plain anterior. This is a left shoulder viewing from lateral portal so that you can work in this space and manage sutures as well as secure them. Releases are critical to this operation. Here's a case that also had a supraspinatus repair, I'm sorry, tear. And I'm able to see down through that portal laterally to release to the base of the coracoid. The middle glenohumeral ligament has already been released as it is in all of these cases. And of course, the inferior glenohumeral ligament and then you have good tendon releases and you can mobilize it as much as you are able. Anchor insertion. You can do it percutaneously. Here's a spinal needle looking for the location that I'll want as well as externally rotating. I've already prepared the lesser tuberosity here. And you can insert the anchor as you can see here. I do a lateral single row technique and the anchor is placed at about the location where I can bring the tendon laterally with my traction suture with the arm in neutral position. But you can place anchors through the portal as well. Suture passage. As you can tell, I like a retrograde technique and I like it because I can mirror how the tendon pulls off. Here you can see the Oz subscapular. There's another case where it's pulled off in this position and I can get a good passage through the tendon with a crescent shaped hook. So here I'm passing the crescent hook and I can go down two centimeters from the rolled edge and shuttle my first suture through. I'm using a lateral portal through the posterior superior cuff tear and then bring one suture at a time into the cannula and then tie it down nicely. This is that same case, the repair complete, test to external rotation so that you know where the limits are for rehab. If you recall, this is the same case where I showed the middle glenohumeral ligament and this is the outcome at six months. I also had to repair his other side with a similar type tear pattern. Adverse events can happen. You just need to be prepared for those. Re-tears are very rare. This is a patient four years later who reached for a softball to catch it and the anchor pulled out or removed it. I've not had neurologic injury. If you know where the nerves are including the musculocutaneous, you can be careful and avoid problems. As with any procedure, infection stiffness can present extremely rare. Weakness though is one thing that I warn patients. The more chronic the tear, the less likely they're gonna get their strength back. So here's some principles I like to follow. There are diagnostic findings on MRI and arthroscopy to look at. Here you have a comet tissue which guides you to find the rolled edge of the subscapularis and you bring it laterally till you see the middle glenohumeral ligament. I prefer a single row repair and I'm showing two cases with metal anchors so you can see where they're located. But non-metal anchors are perfectly good for this operation and I use them regularly. I like retrograde suture passage and a shuttling technique as I've described because of the angle I can approach through the tendon and get a good one and a half centimeter bite in many cases. But you can't forget about the controlled rehab. It takes time and patients understand this beforehand if you let them know. You can find my protocols on my website. Thank you very much.

subscapularis tears

repair techniques

MRI features

arthroscopic views

rehabilitation protocols