Comparison of Functional and Radiological Outcomes of Tears Involving the Subscapularis: Isolated Subscapularis Versus Combined Anterosuperior Rotator Cuff Tears

The Subscapularis Healing Index: A New Scoring System for Predicting Subscapularis Healing After Arthroscopic Repair

BACKGROUND

Previous research has emphasized the effect of prognostic factors on arthroscopic rotator cuff repair (ARCR) success, but a specific focus on subscapularis (SSC) tendon repair healing is lacking.

PURPOSE

To identify prognostic factors for SSC healing after ARCR and develop the Subscapularis Healing Index (SSC-HI) by incorporating these factors.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This was a retrospective study using prospectively maintained data collected from patients with isolated or combined SSC tears who underwent ARCR between 2011 and 2021 at a single institution with a minimum 2-year follow-up. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and visual analog scale (VAS) pain scale. SSC tendon healing was evaluated via ultrasound at the final follow-up. Multivariate logistic regression analysis was performed to determine the factors affecting SSC healing, and based on these factors, the SSC-HI, which ranges from 0 to 15 points, was developed using odds ratios (ORs).

RESULTS

Among 1018 ARCR patients, 931 met the inclusion criteria; 279 returned voluntarily for postoperative SSC ultrasound assessment. The overall healing failure rate was 10.8% (30/279). Risk factors for healing failure included female sex (P = .008; OR, 3.119), body mass index (BMI) ≥30 (P = .053; OR, 2.323), supraspinatus fatty infiltration ≥3 (P = .033; OR, 3.211), lower SSC fatty infiltration ≥2 (P = .037; OR, 3.608), and Lafosse classification ≥3 (P = .007; OR, 3.224). A 15-point scoring system comprised the following: 3 points for female sex, 2 points for BMI ≥30, 3 points for supraspinatus fatty infiltration ≥3, 4 points for lower SSC fatty infiltration ≥2, and 3 points for Lafosse classification ≥3. Patients with ≤4 points had a 4% healing failure rate, while those with ≥9 points had a 55% rate of healing failure. Patients with a healed SSC reported significantly higher ASES (healed SSC: ΔASES, 44.7; unhealed SSC: ΔASES, 29; P < .01) and SSV (healed SSC: ΔSSV, 52.9; unhealed SSC: ΔSSV, 27.5; P < .01) and lower VAS (healed SSC: ΔVAS, -4.2; unhealed SSC: ΔVAS, -3; P < .01) scores compared with those with an unhealed SSC.

CONCLUSION

The SSC-HI scoring system integrates clinical and radiological factors to predict SSC healing after surgical repair. Successful SSC healing was found to be associated with enhanced functional outcomes, underscoring the clinical relevance of SSC healing prediction in the management of these tears.

Arthroscopic Modified Subacromial Viewing Portal Repair of Upper Third of Subscapularis Tendon Partial-Thickness Tears

At present, the repair pattern of upper third of subscapularis tendon partial-thickness tears (upper-third tendon tears) is performed in the glenohumeral joint and conventional subacromial viewing portal, but the visualization of subscapularis tendon and footprint is poor when using a 30° scope. The modified subacromial viewing portal presented in this Technical Note is a modified surgical technique for the repair of upper-third tendon tears. Since the scope forms an angle of 70° with the subscapularis tendon and footprint of lesser tuberosity, satisfactory visualization can be obtained when using 30° scope; the predesigned surgical portal and working space without bony barrier can offer a smooth surgical procedure. Our surgical technique is described in pearls, pitfalls, advantages, and disadvantages.

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.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Arthroscopic Repair of Large Subscapularis Tear Over the First Facet

BACKGROUND

Long-term studies on arthroscopic repair of large subscapularis (SSC) tears over the first facet with or without supraspinatus (SSP) tear are limited.

PURPOSE

To assess the structural and clinical outcomes of arthroscopic repair of large SSC tears using magnetic resonance imaging (MRI) and identify the factors related to SSC retear and poor outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study involved 109 patients (84.0 ± 36.2 months of follow-up) who underwent arthroscopic repair of large SSC tears (Yoo and Rhee classification type III [n = 81] or IV [n = 28]) between 2011 and 2019. All patients underwent MRI at 6.1 ± 0.4 months after surgery, and 79 of 109 patients (72.5%) were followed up over 7 years. Clinical outcomes (active range of motion, functional scores, and belly press strength) and final poor clinical outcomes (reoperation, osteoarthritic change, and poor clinical outcome) were recorded. SSP tear size, rotator cuff atrophy and fatty infiltration (Goutallier classification), SSC tendon integrity (intact, intermediate, definite tear), and SSP tendon integrity (Sugaya classification) were evaluated by MRI.

RESULTS

The overall SSC retear rate was 8.3% (9/109) (type III, 2/81 [2.5%]; type IV, 7/28 [25.0%]; P < .001). SSC Goutallier grade 4 showed a higher retear rate than grade 3 (7/33 [21.2%] vs 2/33 [6.1%]; P = .149). A large SSP tear (in millimeters) (odds ratio [OR], 1.5; P = .003), SSC Goutallier grade 4 (OR, 10.8; P = .047), and SSP Goutallier grade 3 or 4 (OR, 0.02; P = .013) were independent factors for SSC retear. Clinical outcomes, except for external rotation, were poorer in patients with SSC retear than in those without retear. Final poor clinical outcomes were observed in 27 of 79 patients (34.2%); female sex (OR, 7.7; P = .007), SSC retear (OR, 8.2; P = .025), and SSP retear (OR, 4.7; P = .031) were independent factors.

CONCLUSION

Arthroscopic repair of large SSC tears has shown promising structural outcomes for type III tears but not type IV tears. SSC retear was affected by SSC atrophy, as well as SSP tear size and atrophy. Approximately one-third of the final poor clinical outcomes could be predicted, and SSC retear, SSP retear, and female sex were associated with long-term poor clinical outcomes, underscoring the importance of carefully selecting patients for arthroscopic repair of large SSC tears.

Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: A Systematic Review

Purpose

To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies.

Methods

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale.

Results

Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%).

Conclusion

Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears.

Clinical Relevance

Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.

Arthroscopic Repair of Isolated Subscapularis Tears Show Clinical and Structural Outcome Better for Small Tears Than Larger Tears

Purpose

To retrospectively investigate the mid-term outcomes after arthroscopic repair of isolated subscapularis tears with a relatively large number of patients and to compare them by tear size.

Methods

Medical records were reviewed for patients who underwent arthroscopic rotator cuff repair between 2010 and 2017 at our institute. The inclusion criterion was isolated subscapularis tears that underwent arthroscopic rotator cuff repair. The exclusion criteria were (1) previous rotator cuff surgery, (2) lack of imaging studies or clinical evaluation data, (3) neuromuscular diseases, and (4) <2-year follow-up. Range of motion, American Shoulder and Elbow Society score, and bear-hug or belly-press test were assessed pre- and postoperatively. Repair integrity was evaluated with magnetic resonance imaging at postoperative1 year. The clinical and imaging study outcomes were compared between smaller (Lafosse types 1-3) and larger (types 4 and 5) tears.

Results

The subjects included 38 males and 8 females with a mean age of 59 years (range, 25-77 years). The mean follow-up was 36 months (range, 24-96 months). There were 13 type 1, 10 type 2, 12 type 3, 6 type 4, and 5 type 5 shoulders. Postoperative American Shoulder and Elbow Society scores were significantly better in smaller tears than larger tears: 93 ± 8 and 75 ± 14, respectively (P = .003). Smaller tears showed better postoperative internal rotation than larger tears (P = .004). Significant decrease of positive bear-hug or belly-press test was observed in smaller tears (preoperative, 25; postoperative, 11; P < .001), but there was no significant improvement in larger tears (preoperative, 11; postoperative, 9). The retear rate was significantly greater in larger tears (64%) than smaller tears (6%, P < .001).

Conclusions

The clinical and structural outcomes after arthroscopic repair of isolated subscapularis tears were better in smaller tears than larger tears with a mid-term follow-up. Larger tears showed high retear rates with poorer improvement in active range of internal rotation and subscapularis strength.

Level of Evidence

Level III, retrospective, comparative study.

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.

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.

Revision Rotator Cuff Repair Versus Primary Repair for Large to Massive Tears Involving the Posterosuperior Cuff: Comparison of Clinical and Radiological Outcomes

Background:

The retear rate after revision rotator cuff repair (rRCR) ranges from 50% to 90%. Patients who undergo primary RCR (pRCR) for large to massive rotator cuff tear (mRCT) also have unpredictable outcomes.

Purpose:

To compare the clinical outcomes after rRCR for a posterosuperior rotator cuff tear of any size with those after pRCR for mRCT and to identify the risk factors for poor outcomes and retear after rRCR.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Among patients with posterosuperior cuff tear treated between 2010 and 2017, the clinical outcomes of 46 patients who underwent rRCR were compared with 106 patients who underwent pRCR for mRCT. Between-group differences in patient-reported outcomes (visual analog scale [VAS] for pain, VAS for satisfaction and American Shoulder and Elbow Surgeons [ASES] and Constant scores) at final follow-up were evaluated and compared with previously published minimal clinically important difference (MCID) values. Radiological outcomes were evaluated using magnetic resonance imaging or ultrasonography at a minimum 1-year follow-up. Multivariate linear regression analysis was performed to identify the risk factors for poor ASES score, and multivariate logistic regression analysis was used to assess the risk factors for retear after rRCR.

Results:

The mean follow-up was 26.4 months (range, 24-81 months). Although final VAS for pain, VAS for satisfaction, and ASES scores in the rRCR group were significantly worse than those in the pRCR group, the Constant score was similar between the groups. These differences in outcomes did not exceed the MCID threshold. The retear rate in the rRCR group was 50% compared with 39% for the pRCR group (P = .194). In the rRCR group, risk factors for worse ASES score were retear (P = .043; r = –11.3), lower body mass index (P = .032; r = 1.9), and lower preoperative VAS for pain (P = .038; r = 2.3), and risk factors for retear were preoperative high-grade fatty degeneration (Goutallier grades 3 and 4) of the supraspinatus muscle (P = .026; odds ratio, 5.2) and serum hyperlipidemia (P = .035; odds ratio, 11.8).

Conclusion:

Both study groups had similar clinical and radiological outcomes. Patients with symptomatic failed rotator cuff repairs having high-grade fatty degeneration of the supraspinatus muscle and/or serum hyperlipidemia had a greater likelihood of retear after rRCR.