Arthroscopic subscap repair surgical techniques. These are my disclosures, none of it is really wrong with this talk. If we look at the epidemiology of subscap tears, it can be partial or full thickness tears. It was first described by Dr. Smith in 1835, described as a rare tear, but the problem is I think a lot of these are missed, either partial or small full thickness tears, and a forgotten tendon in the literature. And if you look at the real incidence in the literature of cadaver studies, subscap tear range between 10 to 30 percent. Looking at subscap tear prevalence in ultrasound evaluation, 236 patients clinically found that prevalence is up to 31 percent. In comparison to clinical structural outcomes of subscap tears, whether you repair or not, in massive cuff tears, 122 consecutive patients, this is a study out of Korea, and they found that 63 percent of these patients with degenerative tears had subscap tear, either partial or full thickness. If you don't repair the subscap, the retail rate is 50 percent versus 20 percent if you were to repair it. In terms of anatomy, subscap is the largest, most powerful rotator cuff muscle. It's on the anterior surface of the scapula, four to six tendon slips, and 50 percent of rotator cuff strain comes from subscap. There's a two-part attachment, the superior two-thirds tendinous, and the inferior one-third is muscular. Intraarticulately, when you put the scope in, you can see about superior one-third of the tendon subscap, and the inferior two-third, it's very difficult to see, is covered by capsule, and usually that's the muscle belly. The location of the lesser tuberosity and footprint is very long and wide, three by two centimeters in size. Anterior borders is a bicep groove. If you have a subscap tear, sometimes you can see the bicep's dislocated joint immediately. The maximum injury is subscap. Majority of these are degenerative. They're associated with large rotator cuff tears. Traumatic is very less common. They're younger patients. Hyperextension, external rotation, associated with anterior dislocation events. You need something traumatic, high energy to dislocate the shoulder to cause a subscap rupture. You can also get impingement, anterior superior impingement, subcortical impingement. Over time, these impingement may result in degenerative subscap. In terms of evaluation, the history, pain is most common. What I find in my patients, anterior location-based pain, weakness, and belly press or bear hug. The exams I use is that you look at first on external rotation. Passive external rotation, you have more increase in passive external rotation on one side. Anterior-based pain, you want to think about subscap in an older patient or traumatic injuries. Patient has a positive liftoff sign or belly press. This is basically putting an arm either on the back or the front, and have weakness in the front in terms of belly press, where they can't lift the arm in the back. You want to think about subscap. The bear hug test is you put the arm on the contralateral shoulder like a bear hug, and then if they have weakness, compare to the other side as a positive test. The overall accuracy is about 54% to 77%. In terms of radiographic evaluation, I start with the x-ray. If you have a chronic subscap tear, you can see anterior subluxation of the shoulder. We call it anterior superior escape. You can get neural in the chromohumeral space as well. The more specific test is MRI. T2 images give you high signal, and you can see tendon discontinuity. If you have fatty infiltration on an image, then what happens, these patients that are chronic tears, they're not repairable. It's very difficult to repair this. Even if you repair them, they're not going to work, especially if you have grade 4 fatty infiltration. These are the patients that, depending on the age, either you can do a muscle transfer, which is a pec major transfer. More recently, people are starting to do a latissimus dorsi transfer, which the vector is much better than pec major. For the patients older, the more predictable option will be a reverse shoulder arthroplasty. Ultrasound, 75% sensitive, 90% specific. If you have it, use it. If you don't, MRI is probably the best option for most people here to get to evaluate for subscap tears. In terms of management, atraumatic older patients, they're associated with large ulcerative colitis. These are patients that can get concerned management, activity modification, anti-inflammations, physical therapy. If they don't do well after three, six months of the treatment, then surgery is indicated. Small partial, debris, full things repair, but I favor repair on mostly patients. Even if you have a small partial, you can put one anchor down and repair it. It's very easy to do, and I think patients do better. Traumatic or younger patients, you want to get them to the OR ASAP to repair it. It's a much better outcome with surgery. The FOSS classification and management subscap tears is just for academic practice. The FOSS type one in the top, upper one-third. Type two is the upper one-third is complete. These are the typical 90, 80, 90% of the patients you see is going to be these because this is what you see with the scope. If you have somebody who has type four or type five, complete anterior subluxation, phallofiltration, these are the patients that need reverse shoulder arthroplasty. In terms of how do you fix it, arthroscopic repair, I prefer the B-chur position. You can do lateral decubitus, but I feel that if you do lateral decubitus, it can be very difficult because the shoulder is internally rotated. You have to rotate the shoulder externally to see the lesser tuberosity to be able to put the anchor in and to be able to fix the subscap. Like the B-chur setup for me, you do a diagnostic scope, evaluate the subscap. The way you can do that is you flex the shoulder 45 degrees, internally rotate it, hold back in the humeral head, turn the scope, either 30 or 70 degree scope, you can see the less tuberosity very well. In terms of arthroscopic portals, the posture portals for the viewing. Anteriorly, the first one, this is where you put the anchor, you want to go a little bit more medial. Then you have a second working portal right here, which is where you shuttle the sutures. When you put the anchor in, you can see the bottom right picture is that you want the arm in forward flexion, 90 degrees, maximum rotation to get the anchor to be able to reach the lesser tuberosity, and that's really important. In terms of what type of anchors I use, I like a metal anchor. The reason being is that you do not have to try to find the hole that you punched. Double or triple load of number two sutures is what I typically like. You put the arm in neutral position for repair. Posture viewing, 30 or 70. I usually use a 30 degree scope for all my repairs. I think you could be able to see what you need to see for that. The biceps tendon, tenotomy, or tenodesis arthroscopically first, and that's dealer's choice. I typically like a tenodesis in younger patients and tenotomy in older patients or lower demand patients. I use a 90 degree pass through or metal shuttling device, expresso, you can also use. If the subscap is retracted, you want to put a traction suture first, release the scar tissue to make sure you get tension for your repair, and then you repair it down. The suture configuration, vertical mattress below, lasso loop above, single double loaded base and repair. You want to tie the repair with arm in neutral position. Arthroscopic repair of the cuff after that, go on top of the subclone space to complete your cuff repair. Sling abstention and pedal for six weeks, and here's a video that we published in Arthroscopic Technique on how to do a subscap repair using clever hook, lasso loop technique, and I'll just run the video for the next five minutes for you guys. Arthroscopic subscap delirious repair using clever hook and lasso loop technique in the beach chair position. Here are the author's disclosures. This is a patient with a full thickness subscap rupture from the back with a 30 degree scope. Also, he had a mass rotator cuff tear and biceps frame. So, I do the biceps tendendesis arthroscopically, and then I like to release the rotator airfoam, which is our device, as well as the shaver, down to the coracoid base. I think it's really important. I put the arm in a forward flexion exhalation to expose the lesser tuberosity so they have a better trajectory for the anchor insertion. Here we're using anterior superior lateral portal. We're using a shaver to debride the lesser tuberosity. With the anterior portal, a metal anchor is inserted. This is a 4.5 millimeter anchor, triple loaded with number two sutures. You want to make sure you're right on the lesser tuberosity. Here's a patient with a retracted subscap tear. I like to place a lasso loop on the top for traction to help release the scar tissue. And the way you do this is you place a number two suture at the midpoint expresso. You put the suture on the top of the subscap tendon, create a loop, and then using a ring grasper, you go through the loop and grab the residual two sutures from the anterior lateral portal. Then I make an accessory portal just between two cannulas anteriorly, a little small nick incision. Using a ring grasper, I take the sutures out from here so you can get it out of the two portals. This way you can tie without getting caught up within the portals with the sutures. With the traction on the subscap, you release the scar tissue anteriorly, posteriorly, and superiorly. Now you can get a tension-free repair. So now coming back to our patient, here's a patient did not need a traction stitch. With the arm in neutral position and no rotation, I take the suture on the anterior lateral portal. And then first I like to put a vertical mattress beneath for the repair. And this is done with a 90-degree passer. Use your system to grab the top of the tendon. You're able to reduce it. And then you take the 90-degree passer you go underneath. You pass this loop across, which is a metal tip loop, which can get through the soft tissue very easily. After you do that, you shuttle this to the anterior lateral portal. And then you shuttle the suture that you docked out there into the tendon. And you do repeat this step with the other suture. And then lastly, with the top suture that you're going to use for the last loop as well. This will create a post and then take the suture, which is the blue one on the anterior lateral portal. And then you dock this into the subscap recess. Using a clever hook, or you can do a penetrator. Your system helps you reduce the top of the tendon with the clasper. You go through with a clever hook. And then once you're through, you want to take one of the limbs that you docked into the recess here. Shuttle across the subscap. And then you create this loop. Now what you do is you take your clever hook and go through the loop. And sometimes it's difficult because the loop moves and you can always have your assistant grab it. You can go through with either a clever hook or a penetrator. Then you grab the residual number two suture from the anterior lateral portal. And here you create the last loop. So this loop will lock on top of the tendon. And then the post, when you pull on it, will take the tendon and reduce it. And then you can tie over the top for the last loop repair. It is very important that you take all the sutures out of the anterior portal. And I always like to tie the last loop first. And the way you do this is you pull on the post, which is the first suture you pass through across the top of the subscap tendon. And when you do that, it sucks down the tendon to reduce it to the lesser tuberosity you can see here. And you do alternating half-stitches. Four to six of them will be enough. And this will finish the tie in the top of the last loop. Now I shut the last loop out of the anterior lateral portal. And then the two sutures from the vertical mattress to the anterior portal. This is tied out using alternating half-stitches times four to six total. Here's the final repair. You can see it's very stable with less tuberosity. Alternatively, if you're concerned about the repair, you can always do a double row. What you do is take out the four sutures that you just tied out, load it into a silver lock into the anterior portal. And then the double row is put just lateral to the original anchor. Here's the final repair and double row. Then I go on top and address the rotator cuff here, the supra-infrared spinous tendon. And then here's the final repair of the cuff up top. Viewing from the anterior lateral portal, you can see the subscap is completely repaired down with the double row technique here. It's very stable and solid onto the lesser tuberosity. Thank you. In terms of post-op rehab, sling abduction bone for six weeks. You want to avoid any kind of internal rotation or excessive external rotation for the first few weeks. Pendulum is okay. Passive range of motion, I start four weeks, act about eight weeks. And if you have a large tear, usually about six weeks when I start passive range of motion. Strengthening at two to three months and return for activity is going to take you up to nine months to 12 months to recover. So with that, thank you so much and good luck of course.

arthroscopic subscapularis repair

surgical techniques

subscapularis tears

post-operative rehabilitation

traumatic injuries

evaluation and management

surgical technique

post-operative care