Concomitant coracoplasty during arthroscopic subscapularis repair does not yield better clinical outcomes and structural integrity

Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up

Background

Few studies have reported clinical outcomes and tendon healing rates after arthroscopic isolated subscapularis (SSC) repair (AISR).

Purpose/Hypothesis

The primary purpose of this study was to evaluate clinical outcomes and tendon healing after AISR. It was hypothesized that AISR would result in satisfactory clinical outcomes along with a high rate of tendon healing at the midterm follow-up. The secondary purpose was to assess the influence of tear size and muscle atrophy on SSC tendon healing and patient-reported outcomes. It was hypothesized that both would be negatively correlated with healing but would have no effect on clinical outcomes .

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective analysis was conducted on prospectively collected data for 77 patients who underwent primary AISR between 2011 and 2021 at a single institution, with a minimum 2-year postoperative follow-up for all patients. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Shoulder Value (SSV), and the visual analog scale for pain. Repair techniques and concomitant procedures were also collected. SSC tendon healing was evaluated via ultrasound at the final follow-up. Linear regression analysis was performed to determine factors affecting SSC healing.

Results

The mean follow-up was 58.1 ± 3.3 months. ASES scores significantly improved from 41.5 to 81.6, and the SSV improved from 38.2 to 80.5 (P < .01 for both). Among the 40 patients (51.9%) who underwent postoperative ultrasound, 87.5% showed complete tendon healing. There were no significant differences in outcome scores between healed and unhealed tendons. Increased muscle atrophy and larger tears were correlated with failure of SSC healing (β = -0.285 [P = .015] and β = -0.157 [P = .045], respectively).

Conclusion

Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. Smaller tear sizes with less muscle atrophy were correlated with improved tendon healing. However, even when the tendon incompletely healed, the procedure improved functional outcomes.

The effect of arthroscopic coracoplasty on subscapularis strength in cases of subcoracoid impingement in the absence of subscapularis tear

Subcoracoid impingement leads to anterior shoulder pain, and arthroscopic subcoracoid decompression (coracoplasty) is the preferred treatment in recalcitrant cases. The purpose of the present study was to evaluate the effect of coracoplasty on the severity of anterior shoulder pain and the strength of the subscapularis muscle and to correlate it with the preoperative and postoperative coracohumeral distance (CHD) (t:transverse, s:sagittal). Sixteen patients without any subscapularis tendon tears who underwent arthroscopic subcoracoid decompression and rotator cuff repair with 2 years follow-up were included. Preoperative and postoperative 2-year assessments of function and pain were performed using the modified Kennedy-Hawkins test, power grading of various subscapularis muscle tests, and ASES scores. Preoperative and postoperative coracohumeral distance (tCHD, sCHD) and coracoid overlap (CO) were measured using MRIs before and after surgery. The Mean Hawkins pain score and coracoid overlap were decreased. The strength scores for subscapularis strength testing, ASES score, maximum degree of internal rotation, and coracohumeral distance increased (P < .05). Changes in belly press strength were negatively correlated with postoperative tCHD (r = -0.6, P = .04) and postoperative sCHD (r = -0.7, P = .008). A significant increase in the internal rotation range of the shoulder, subscapularis strength, and relief of anterior shoulder pain was observed. However, this increase was inversely proportional to the postoperative CHD, indicating the mechanical effect of the coracoid on subscapularis strength.

Anterior capsular reconstruction in irreparable subscapularis tear: human dermal allograft

BACKGROUND

The irreparable subscapularis (SSc) tears pose an extremely difficult situation to manage, especially in the younger population. The anterior capsular reconstruction (ACR) with human dermal allograft (HDA) is an alternative to tendon transfer with sound biomechanical advantages and clinical outcomes. The purpose of this study was to evaluate the early clinical and radiologic outcomes of open ACR with HDA in patients with irreparable SSc tears.

METHODS

Eighteen patients who had an open ACR with HDA for irreparable SSc tears between August 2020 and January 2022 were enrolled. There were 11 male and 7 female patients with a mean age of 63.7 years and a mean follow-up of 17 months (range, 12-28 months). The dominant side was affected in 10 patients. One of the 18 patients had reconstruction with single-layer HDA, 14 had double-layer HDA, and 3 had SSc augmentation over double-layer HDA. Clinical and radiologic outcomes were assessed and compared pre- and postoperatively.

RESULTS

There was significant improvement in visual analog scale score from 6.6 ± 1.6 to 1.6 ± 1.5 (P < .001) and in the total University of California-Los Angeles shoulder score from 12.4 ± 4.3 to 29.0 ± 4.5 (P < .001). Forward flexion, abduction, and internal rotation (IR) increased by 28.6°, 32.5°, and 11.8°, respectively (P < .001). External rotation decreased by 6.4° (P = .020). There was notable improvement in IR strength (percentage of that of the opposite, normal side) from 66.0% ± 19.4% to 84.4% ± 22.3% (P = .008). The mean postoperative coracohumeral distance improved from 3.0 to 6.0 mm (P < .001), the anterior translation of the humeral head reduced from 1.5 to 0.5 mm (P = .210), and the acromiohumeral interval from 8.1 to 8.8 mm (P = .070). The patients' satisfaction at final follow-up was rated 4.1 of 5.0 (P < .001). Sixteen of 18 patients (88.9%) had the HDA healed at the glenoid and humeral side, and 2 (11.1%) had retear at the final follow-up. Among the 17 who had double-layer HDA, none showed any healing between the layers.

CONCLUSION

This study showed that early significant and comprehensive improvement inclusive of pain relief, improvement in range of motion, IR strength, and reduction of anterosuperior translation was achievable by open ACR with HDA for irreparable SSc tear.

Age, Tear Size, Extent of Retraction, and Fatty Infiltration Associated With a High Chance of a Similar Rotator Cuff Tear in the Contralateral Shoulder Regardless of Symptoms in Patients Undergoing Cuff Repair in the Index Shoulder

PURPOSE

To investigate the prevalence of a contralateral rotator cuff tear (RCT) in patients with a symptomatic RCT requiring repair and to determine whether findings from magnetic resonance imaging (MRI) of the affected shoulder can predict the presence of a contralateral tear.

METHODS

Patients with atraumatic RCTs who had undergone arthroscopic repair between March 2019 and February 2021 were reviewed in this study. MRI of both shoulder joints was performed to evaluate the bilaterality of RCT. Demographic factors and MRI findings of index shoulders were assessed using logistic regression analysis to reveal any correlations with the presence of RCT in the contralateral shoulder.

RESULTS

A total of 428 patients were enrolled in this study. When the affected shoulders had a posterosuperior rotator cuff (PSRC) or subscapularis tear including either an isolated or combined tear, 63.6% and 67.8% had the same tears on the contralateral side, respectively. A contralateral-side tear was found in 74.6% (185/248) of symptomatic cases and 44.8% (65/145) of asymptomatic cases, which represents a significant difference (P < .001). Logistic regression analysis revealed that age ≥67.5 years, tear size ≥17 mm, Goutallier grade ≥1.5, and Patte grade ≥1.5 were found to be indicative of potential contralateral PSRC tears. By contrast, the presence of a subscapularis tear in the affected shoulder was the only significant risk factor in predicting a potential subscapularis tear in the contralateral shoulder.

CONCLUSIONS

Among patients with a symptomatic RCT requiring arthroscopic repair, 63.6% with a PSRC tear and 67.8% with a subscapularis tear in the affected shoulder were found to have a similar tear in the contralateral shoulder regardless of symptoms. Age, tear size, extent of retraction, fatty infiltration of PSRC tears, and the presence of subscapularis tears were identified as factors predictive of tears on the contralateral side.

LEVEL OF EVIDENCE

IV, case series.

Is it the subcoracoid impingement or the subacromial impingement that tears the subscapularis tendon? A comparison of the MRI findings of the operated and healthy shoulders of the patients

BACKGROUND

: The purpose of this study is to investigate whether the etiological factors accepted as causes of idiopathic subscapularis tears are true or not when the comparison is made with the opposite side healthy shoulder of the patients who underwent arthroscopic repair for an isolated subscapularis tear.

METHODS

Sixteen patients who underwent shoulder arthroscopy between February 2016 and January 2018 and were diagnosed with isolated subscapularis tear were evaluated. The coracohumeral distance (CHDax), coracoid overlap (CO), and tuberculum minus cysts (TMC) were evaluated on the axial images of the MRI studies while the acromiohumeral distance (AHDsag), CHDsag, and subscapularis tendon slip number (STSN) on the sagittal oblique images and the AHDcor and SLAP lesion on the coronal oblique images. Degeneration of the coracoacromial ligament was evaluated during arthroscopy.

RESULTS

The mean CHDsag (11.26-10.08), CHDax (10.63-9.98), CO (14.2-15.43), AHDsag (8-7.66), and AHDcor (7.65-7.68) measurements (operated side-healthy side, respectively) were statistically similar (p > 0.05). No statistically significant difference was found between TMC and STSN in healthy and operated shoulders (p > 0.05). There was mild coracoacromial ligament fraying in 4 (25%) and obvious coracoacromial ligament fraying in 8 (50%) which indicated subacromial impingement in 75% of the patients.

DISCUSSION

The parameters of the coracoid process did not reveal any significant difference between the operated (for an isolated subscapularis tear) and opposite-side healthy shoulders of the patients. However, coracoacromial ligament degeneration was present in 75% of the patients.

Subscapularis tendon tears hidden by the medial biceps sling can be missed on arthroscopic examination

INTRODUCTION

To investigate (1) the prevalence of "hidden lesions" and "non-hidden lesions" of subscapularis tendon tears requiring repair during arthroscopic examination that would be missed by a 30° arthroscope, but could be identified by a 70° arthroscope, from the standard posterior portal and (2) the correlation of preoperative internal rotation weakness and findings of magnetic resonance imaging (MRI) indicating hidden lesions.

MATERIALS AND METHODS

We retrospectively examined 430 patients who underwent arthroscopic subscapularis repair between was initially nonvisible with a 30° arthroscope but became visible only with a 70° arthroscope from the standard posterior portal. The preoperative and intraoperative findings of the hidden lesion group (n = 82) were compared with those of the non-hidden lesion group (n = 348). 2016 and 2020. A hidden lesion was defined as a subscapularis tendon tear requiring repair that preoperative internal rotation weakness was assessed using the modified belly-press test. Preoperative MR images were reviewed using a systemic approach.

RESULTS

The prevalence of hidden lesions was 19.1% (82/430). No significant difference was found in preoperative internal rotation weakness between the groups. Preoperative MRI showed a significantly lower detection rate in the hidden lesion group than in the non-hidden group (69.5% vs. 84.8%; P = 0.001). The hidden lesions were at a significantly earlier stage of subscapularis tendon tears than the non-hidden lesions, as revealed by the arthroscopic findings (Lafosse classification, degree of retraction; P = 0.003 for both) and MR findings (muscle atrophy, fatty infiltration; P = 0.001, P = 0.005, respectively).

CONCLUSIONS

Among the subscapularis tears requiring repair, 19.1% could be identified by a 70° arthroscope, but not by a 30° arthroscope, through the posterior portal. The hidden lesions showed a significantly lower detection rate on preoperative MRI than the non-hidden lesions. Thus, for subscapularis tears suspected on preoperative physical examination, the 70° arthroscope would be helpful to avoid a misdiagnosis.

Arthroscopic single portal - single row knotless repair of subscapularis tendon tear: Technical note

The subscapularis (SSc) is the most powerful muscle of the rotator cuff. His role in shoulder stability and shoulder motion is well studied and due to functional and frequent association with concomitant other lesions, the repair of the SSc tendon is always desirable to restore force and stability to the shoulder.

Morphology of the coracoid process as a predictor of articular-side tear at the upper border of the subscapularis

BACKGROUND

Articular-side tear at the upper border of the subscapularis (SSC-AST) is often detected during shoulder arthroscopic surgery, although its exact pathology remains unknown. The purpose of this study was to investigate the correlation between various characteristics of the coracoid process, including classification of the morphology of the coracoid process tip, and the presence of SSC-AST.

METHODS

This retrospective, case-controlled study included patients who underwent arthroscopic subacromial decompression with or without rotator cuff repair between January 2018 and September 2021. A total of 130 shoulders in 124 patients, including 77 male and 53 female shoulders (mean age at surgery, 64 years [range, 39-88 years]), were included in this study. Three-dimensional (3D) computed tomography examination was performed preoperatively, and the following indices were measured: coracoid proximal length, coracoid distal length, coracoid angle, coracoglenoid angle, offset of the coracoid process and glenoid (anterior, lateral, and superior offset), and coracoid base angle. The morphology of the tip of the coracoid process was classified into 3 types according to 3D reconstructed views: flat type, round type, and beak type. The presence of SSC-AST was intraoperatively evaluated arthroscopically via a posterior glenohumeral portal. Morphologic risk factors for SSC-AST were evaluated between SSC-AST cases (group T) and non-SSC-AST cases (group N) by multivariable logistic analysis. In addition, the correlation between the incidence of SSC-AST and classification of the tip of the coracoid process was analyzed.

RESULTS

SSC-AST was present in 53 shoulders (40.8%). Group T patients were significantly older than group N patients (68.4 ± 10.0 years vs. 61.5 ± 11.8 years, P < .001). No sex difference was detected between the 2 groups (28 male and 25 female shoulders in group T vs. 49 male and 28 female shoulders in group N, P = .28). Multivariate analysis of morphologic parameters between the 2 groups detected a smaller superior offset as a risk factor for SSC-AST (odds ratio, 0.91; 95% confidence interval, 0.84-0.98; P = .01). No significant differences were found in the other parameters. Regarding classification of the tip of the coracoid process, round- and beak-type coracoid tips had a significantly higher rate of SSC-AST than flat-type tips (flat type, 21.8%; round type, 64.7%; and beak type, 46.3%) (P < .001).

CONCLUSIONS

Evaluation of the correlation between the morphology of the coracoid process on 3D computed tomography and the presence of SSC-AST visualized during arthroscopy indicated a significant association between SSC-AST and the morphology of the coracoid process.

Current concepts review in the management of subscapularis tears

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.

Literature Review of Subscapularis Tear, Associated injuries, and the Available Treatment Options

The population of Hawai'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

Biomechanical Analysis of Coracoid Stability After Coracoplasty: How Low Can You Go?

Background:

Arthroscopic coracoplasty is a procedure for patients affected by subcoracoid impingement. To date, there is no consensus on how much of the coracoid can be resected with an arthroscopic burr without compromising its stability.

Purpose:

To determine the maximum amount of the coracoid that can be resected during arthroscopic coracoplasty without leading to coracoid fracture or avulsion of the conjoint tendon during simulated activities of daily living (ADLs).

Study Design:

Controlled laboratory study.

Methods:

A biomechanical cadaveric study was performed with 24 shoulders (15 male, 9 female; mean age, 81 ± 7.9 years). Specimens were randomized into 3 treatment groups: group A (native coracoid), group B (3-mm coracoplasty), and group C (5-mm coracoplasty). Coracoid anatomic measurements were documented before and after coracoplasty. The scapula was potted, and a traction force was applied through the conjoint tendon. The stiffness and load to failure (LTF) were determined for each specimen.

Results:

The mean coracoid thicknesses in groups A through C were 7.2, 7.7, and 7.8 mm, respectively, and the mean LTFs were 428 ± 127, 284 ± 77, and 159 ± 87 N, respectively. Compared with specimens in group A, a significantly lower LTF was seen in specimens in group B (P = .022) and group C (P < .001). Postoperatively, coracoids with a thickness ≥4 mm were able to withstand ADLs.

Conclusion:

While even a 3-mm coracoplasty caused significant weakening of the coracoid, the individual failure loads were higher than those of the predicted ADLs. A critical value of 4 mm of coracoid thickness should be preserved to ensure the stability of the coracoid process.

Clinical Relevance:

In correspondence with the findings of this study, careful preoperative planning should be used to measure the maximum reasonable amount of coracoplasty to be performed. A postoperative coracoid thickness of 4 mm should remain.

Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review

PURPOSE

To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings.

METHODS

A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis.

RESULTS

The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all).

CONCLUSION

Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Bilateral coracohumeral distance discrepancy is associated with subscapularis tear in rotator cuff rupture patients

PURPOSE

To describe the bilateral coracohumeral morphological discrepancy in rotator cuff rupture patients with and without subscapularis (SSC) involvement and to investigate its association with SSC tears.

METHODS

Two hundred and thirteen consecutive patients who were scheduled to have arthroscopic rotator cuff repair were prospectively enrolled in the current study. Patients with acute traumatic rotator cuff rupture, glenohumeral osteoarthritis, bilateral rotator cuff rupture, recurrent shoulder instability, systemic inflammatory disease, and previous shoulder surgery history were excluded. Coracohumeral distance (CHD), coracoid overlap (CO), lesser tuberosity index (LTI) and acromiohumeral interval (AHI) were measured bilaterally using CT scans. Based on arthroscopic findings, patients were included in either the SSC tear group (n = 72) or the control group (n = 141).

RESULTS

In the SSC tear group, the affected shoulder possessed a significantly smaller CHD [95% confidence interval (CI) 6.1-7.2 vs. 7.2-8.0 mm, p < 0.0001], larger LTI (95% CI 9.4-9.9 vs. 9.0-9.6 mm, p < 0.0001), and smaller AHI (95% CI 5.0-5.5 vs. 7.1-7.5 mm, p < 0.0001) than the contralateral normal shoulder. In the control group, there was no significant difference between bilateral CHD and CO, and the AHI bilateral discrepancy was less distinct. CO did not differ significantly in the bilateral comparison in either group. Among all evaluated parameters, bilateral CHD discrepancy was the best predictor of SSC tears, with an area under the curve (AUC) of 0.882. A cutoff value of 0.5 mm had a sensitivity of 76.4% and specificity of 99.3% for SSC tears.

CONCLUSION

The CHD values are significantly different between affected and contralateral shoulders in SSC tear patients. Bilateral CHD discrepancy is closely associated with subcoracoid impingement and SSC tears, and its presence warrants specific intraoperative SSC inspection.

LEVEL OF EVIDENCE

Level II.

Arthroscopic Revision Rotator Cuff Repair: The Role of Previously Neglected Subscapularis Tears

BACKGROUND

Concomitant full-thickness tear of the subscapularis tendon is often neglected during primary posterosuperior rotator cuff repair, and its significance has not been investigated by any previous clinical study.

PURPOSE

To investigate (1) the clinical and radiological outcomes of revision arthroscopic rotator cuff repair and (2) the number of neglected concomitant subscapularis full-thickness tears in the revision of posterosuperior rotator cuff retears and their structural integrity after repair.

STUDY DESIGN

Case series, Level of evidence, 4.

METHODS

This study retrospectively examined 58 patients who underwent arthroscopic rotator cuff revision for a retear of a previously repaired posterosuperior rotator cuff. Preoperative and postoperative functional scores and active range of motion (ROM) were assessed. The initial and most recent follow-up magnetic resonance imaging scans before revision and arthroscopic findings at the time of primary repair were reviewed to determine whether the concomitant subscapularis tear was newly developed or preexisting. Final confirmation of the tendon's full-thickness tear was made during the revision procedure.

RESULTS

At final follow-up, mean functional shoulder scores and ROM improved significantly compared with the preoperative values (P < .001). Among the 58 revision cases, 25 (43.1%) had a neglected full-thickness tear of the subscapularis tendon. The fatty infiltration grade of the neglected subscapularis tear progressed from a mean of 1.1 before primary repair to a mean of 1.6 before revision, and the change indicated statistically significant deterioration (P < .001). Despite clinical improvement after revision surgery, the retear rate was considerable in the re-repaired cuff tendons (37.9%) as well as for the repaired concomitant subscapularis tears (24%).

CONCLUSION

Among revision rotator cuff repairs, 43.1% had neglected subscapularis tears, and fatty infiltration of these initially neglected subscapularis tendons showed further progression at the time of revision. The retear rate after the repair of neglected subscapularis tears was higher than expected. Thus, detecting and treating subscapularis tear via meticulous preoperative evaluation and thorough inspection during primary arthroscopy are essential.

Clinical Outcomes for Isolated Subscapularis Tears With Advanced Fatty Infiltration: Nonoperative Treatment Versus Arthroscopic Single-Row Repair

Background:

No study has investigated the treatment outcomes of isolated subscapularis tears with advanced fatty infiltration and tear progression to the supraspinatus tendon.

Purpose:

To assess the natural progression of isolated subscapularis tears with advanced fatty infiltration and compare clinical outcomes between nonoperative and operative treatment.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This study included 52 patients who received either operative (group A) or nonoperative (group B) treatment at our institution for isolated subscapularis full-thickness tears with grade 3 or 4 advanced fatty infiltration. All study patients had a minimum 2-year follow-up. The following 4 functional measures were used: visual analog scale for pain, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and University of California Los Angeles score. The modified belly-press test was used to assess subscapularis muscle strength. In group A, structural integrity was evaluated using magnetic resonance imaging at 6 months after surgery. In addition, ultrasonographic evaluation was performed on both groups during the follow-up period to assess tear progression into the supraspinatus tendon.

Results:

At initial presentation, all functional assessment scores were significantly worse in group A versus group B (P ≤ .05 for all 4 scores). When we compared the mean change in scores before treatment versus after treatment, the group A patients were found to have significantly greater improvement than group B patients (P < .001 for all 4 scores); however, no significant difference was seen in final outcome scores between the groups. Although a high retear rate of 78.6% (22/28) was identified in group A, both groups showed no further tear progression to the supraspinatus tendon at the final ultrasonographic evaluation.

Conclusion:

For isolated subscapularis tears with advanced fatty infiltration, clinical improvement was seen with both nonoperative and operative treatment. Although the operatively treated group started with lower baseline scores, there were no significant differences in outcomes at final follow-up. Considering the high retear rate even after repair, surgical treatment of these lesions may not be warranted. Early detection and prompt repair of subscapularis tears, before the lesion becomes advanced with grade 3 or 4 fatty infiltration, are important for better outcomes.

Diagnosis and Management of Subcoracoid Impingement

Impingement of the subcoracoid space is a poorly understood pathologic cause of anterior shoulder pain. Because of its relative rarity in isolation and nonspecific presentation, diagnosis and management are often challenging for orthopaedic surgeons and their patients. Stenosis of the subcoracoid space between the lesser tuberosity and the coracoid process <6 mm can lead to anterior shoulder pain and associated rotator cuff and biceps pathology. Multiple imaging modalities are available to assess narrowing of the coracohumeral interval, each with its strengths and limitations. If the patient can be accurately diagnosed with subcoracoid impingement, both conservative and surgical management options are available. Despite earlier case series demonstrating promising results with arthroscopic treatment, comparative studies have yet to support these initial claims.

Anterior rotator cable disruption does not affect outcomes in rotator cuff tear with subscapularis involvement

PURPOSE

The purpose of this study was to compare clinical and radiological outcomes after arthroscopic repair of two different rotator cuff tear configurations: anterosuperior rotator cuff tear and rotator cuff tears with subscapularis involvement. It was hypothesized that, although both tear configurations would show significant improvement in clinical outcomes after arthroscopic repair, the rotator cuff tears with subscapularis involvement where the anterior rotator cable maintains its integrity would have better clinical outcomes and structural integrity.

METHODS

This study included 226 patients who underwent arthroscopic repair of anterosuperior rotator cuff tears (n = 107, group A) and rotator cuff tears with subscapularis involvement (n = 119, group B). The visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and active range of motion (ROM) were assessed. Modified belly press test was performed to assess the strength of the subscapularis muscle. Cuff integrity was evaluated using magnetic resonance arthrography or computed tomographic arthrography at 6 months after operation.

RESULTS

At 3-year follow-up, the VAS score, SSVs, ASES scores, UCLA shoulder scores, active ROM, and modified belly press test showed significant improvement in both groups (p < 0.001). However, these improvements showed no statistical significance between the two groups. On follow-up radiologic evaluations, no significant difference in re-tear rates between group A (25 of 107, 23.4%) and group B (23 of 119, 19.3%) was observed.

CONCLUSIONS

The presence of anterior cable involvement of the anterosuperior rotator cuff tear did not affect postoperative clinical outcomes and re-tear rate compared to rotator cuff tears with subscapularis involvement where the anterior cable integrity was maintained, although the anterosuperior rotator cuff tear was associated with more significant preoperative supraspinatus fatty infiltration. Therefore, the present study determined that it would not be necessary to differentiate treatment protocols between these patterns.

LEVEL OF EVIDENCE

Level III.

The anterior translation of the humeral head leads to a decrease in the coracohumeral distance in subscapularis tear

A total of 297 patients who classified as subscapularis (SC) tears through arthroscopic evaluation were retrospectively enrolled, and Fifty-seven patients with impingement syndrome were also enrolled as the control group for normal-population comparison. The coracohumeral distance (CHD) and humeral head anterior translation (HHAT) were measured on magnetic resonance imaging. Our study demonstrated that the anterior translation of the humeral head is related with a decrease in the coracohumeral distance in subscapularis tear. Although, correlation between radiologic parameters (coracohumeral distance and anterior translation of the humeral head) and severity of subscapularis tear was note detected.

Level of evidence

Level IV, retrospective study.

Do coracohumeral interval and glenoid version play a role in subscapularis tears?

Purpose

To study the effect of the coracohumeral interval and orientation of the glenoid for causation of subscapularis tears and literature review for the need of coracoplasty.

Methods

This is a retrospective cohort study of patients who underwent arthroscopic shoulder surgery from January 2013 to December 2017. The coracohumeral interval and orientation of the glenoid in patients with arthroscopically diagnosed subscapularis tears (group A, n = 40) were compared with 2 control groups (group B, n = 38 [intact subscapularis with supraspinatus and infraspinatus cuff tears] and group C, n = 39 [intact rotator cuff]). Group A1 (n = 23) consisted of the isolated subscapularis and combined subscapularis + supraspinatus tears, and group A2 (n = 17) all the 3 rotator cuff tears. The measurements were made on preoperative axial magnetic resonance imaging. Statistical analysis was performed to compare the groups.

Results

The mean coracohumeral interval was 8.81 ± 2.69 mm in group A and 10.62 ± 2.21 and 10.39 ± 2.59 mm in control groups B and C, respectively; this difference was statistically significant (P = .002 and .01, respectively). The mean glenoid version in patients with subscapularis tears was -3.7°, whereas the mean version in patients with intact cuff was -3.4°, and this difference was not statistically significant (P = .74). The mean glenoid version was -4.69° ± 4.22° in group A1 and -3.28° ± 4.04° in group B, with no statistically significant difference (P = .07).

Conclusion

The coracohumeral interval was significantly decreased in patients with subscapularis tears. The glenoid was retroverted in the subscapularis group but was not statistically significant.

Coracoid morphology is not associated with subscapularis tears

BACKGROUND

The observation of the roller-wringer effect fueled the idea that coracoid morphology is related to subscapularis pathology. We aimed to examine this relationship, specifically focusing on how the coracohumeral distance (CHD) and 2 new metrics of coracoid morphology relate to subscapularis tears.

METHODS

In this retrospective study, we identified consecutive patients 45 years or older who underwent shoulder arthroscopy for any indication. We blindly reviewed preoperative magnetic resonance imaging studies of each patient, measuring the CHD, lateral extent (LE), and caudal extent (CE) of the coracoid process. Patients' subscapularis condition was assessed via operative reports; stratified according to Lafosse grade criteria; and compared for differences in the CHD, LE, and CE by 1-way analysis of variance and 2-tailed t tests.

RESULTS

The study included 201 patients. Of these, 112 had no evidence of subscapularis injury, whereas Lafosse grade I injuries were identified in 52 patients; grade II, in 19; and grades III-V, in 18. The CHD, LE, and CE were not correlated with subscapularis injury (CHD, P = .36; LE, P = .36; and CE, P = .13).

CONCLUSIONS

We found no correlation between subscapularis injury and the CHD, LE, and CE. These findings support the idea that coracoid morphology may not be a cause of subscapularis pathology and suggest that coracoplasty may not be necessary prophylactically or as part of subscapularis repair.

New predictors for subscapularis tear: Coraco-lesser tuberosity angle, lesser tuberosity angle, and lesser tuberosity height

BACKGROUND

The pathogenesis of degenerative subscapularis (SC) tear is not clear, several mechanisms are involved: intrinsic tendon degeneration or subcoracoid impingement. The aim of this study was to propose new radiographic markers, the coraco-lesser tuberosity angle (CLA), lesser tuberosity angle (LTA) and lesser tuberosity height (LTH). The hypothesis was that higher values of CLA, LTA, and LTH would be associated with a higher likelihood in detecting a SC tear.

METHOD

A total of 114 patients who classified as SC tears through arthroscopic evaluation were retrospectively enrolled in the study from 2016 to 2018. Fifty-seven patients with impingement syndrome were also enrolled as the control group for normal-population comparison. The CLA was measured on an anteroposterior shoulder x-ray image with the arm in neutral rotation, the LTA and LTH were measured on magnetic resonance imaging. Multivariable analyses were used to clarify the potential risks for SC tears. All measurements were calculated by two shoulder surgeons independently measured at 2 different times, 1 month apart.

RESULTS

The intra- and inter-observer reliabilities for radiologic measurements and the interobserver reliability of SC tear classification were almost perfect. The mean CLA value of SC tear group (41.4±4.2°) was significantly larger than that of the control group (38.7±4.0°, p<0.001). The mean LTA value of SC tear group (33.4±4.3°) was significantly larger than that of the control group (31.0±3.9°, p=0.001). Mean LTH value was 9.5±1.9mm in patients and 8.9±1.5mm for controls, there was no statistically significant difference (p=0.054). Multivariable analysis showed that larger CLAs significantly increased the risk of SC tears, with odds ratios of 1.17 per degree. Moreover, larger LTAs also significantly increased the risk of SC tears, with odds ratios of 1.14 per degree.

CONCLUSION

Our findings confirmed associations between new predictors (CLA and LTA) and SC tears. CLA and LTA values were greater in patients with SC tears than in controls, suggesting that they may be independent risk factors for SC tear onset.

LEVEL OF EVIDENCE

IV, retrospective study.

Arthroscopic Repair of the Isolated Subscapularis Full-Thickness Tear: Single- Versus Double-Row Suture-Bridge Technique

BACKGROUND

No clinical comparative study has addressed isolated subscapularis tears after arthroscopic repair with either single-row or double-row suture-bridge technique.

PURPOSE/HYPOTHESIS

The purpose of this study is to compare clinical outcomes and structural integrity after arthroscopic repair of an isolated subscapularis full-thickness tear with either the single-row technique or the double-row suture-bridge technique. The authors hypothesized that there would be no significant differences in clinical outcomes and structural integrity between approaches.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study included 56 patients who underwent arthroscopic repair of an isolated subscapularis full-thickness tear with grade II or less fatty infiltration in the subscapularis muscle with either a single-row technique (n = 31) or a double-row suture-bridge technique (n = 25). Functional outcomes were assessed with the visual analog scale (VAS) for pain, Subjective Shoulder Value (SSV), American Shoulder and Elbow Surgeons (ASES) score, the University of California, Los Angeles (UCLA) shoulder score, and active range of motion. Magnetic resonance arthrography (MRA) or computed tomographic arthrography (CTA) was performed 6 months after surgery to assess the structural integrity of the repaired tendon.

RESULTS

At the 2-year follow-up, all scoring parameters applied (VAS, SSV, ASES, and UCLA), subscapularis strength, and active range of motion improved significantly in both groups as compared with preoperative values ( P < .001). However, there were no significant differences between groups in any of these clinical outcome measurements (VAS, 1.2 vs 1.1; SSV, 91.3 vs 91.8; ASES, 91.0 vs 91.4; UCLA, 31.9 vs 32.1). On follow-up MRA or CTA, the overall retear rate did not differ significantly between the single-row group (13%, 4 of 31) and the double-row group (12%, 3 of 25).

CONCLUSION

Arthroscopic single-row repair and double-row suture-bridge repair of isolated full-thickness subscapularis tears both yielded satisfactory clinical outcomes and structural integrity with no significant differences among patients with good muscle quality.

Medial Subluxation or Dislocation of the Biceps on Magnetic Resonance Arthrography Is Reliably Correlated with Concurrent Subscapularis Full-Thickness Tears Confirmed Arthroscopically

Background

The purpose of this study was to investigate the relationship between biceps medial subluxation/dislocation on the magnetic resonance arthrography (MRA) imaging and subscapularis full-thickness tear confirmed arthroscopically. We hypothesized that presence of a biceps medial subluxation or dislocation would strongly indicate a subscapularis full-thickness tear.

Methods

A total of 432 consecutive patients who underwent arthroscopic repair for rotator cuff tears with/without subscapularis tears at our institute were retrospectively reviewed. The inclusion criterion of this study was preoperative MRA images taken within 6 months of arthroscopic repair. The presence of medial subluxation/dislocation was evaluated on the preoperative MRA images, and subscapularis tear was confirmed on arthroscopic examination.

Results

Biceps subluxation/dislocation was identified in 46 of the 432 patients on MRA. Forty-five of these 46 patients also had a subscapularis full-thickness tear identified in arthroscopic examination. Among the 386 patients who did not have biceps subluxation or dislocation, 54 patients had a subscapularis full-thickness tear diagnosed arthroscopically. The presence of a biceps subluxation/dislocation could predict a subscapularis full-thickness tear with sensitivity of 45% (45/99), specificity of 99% (332/333), positive predictive value of 98% (45/46), negative predictive value of 86% (332/386), and accuracy of 87% (377(45 +332)/432).

Conclusion

Medial subluxation/dislocation of the biceps on MRA images was highly associated with a concurrent subscapularis full-thickness tear which was confirmed arthroscopically. This association had 99% specificity and 98% positive predictive value. Therefore, if a biceps subluxation/dislocation is identified on MRA images, there is a high chance that a concurrent subscapularis full-thickness tear exists.