Postoperative clinical outcomes and radiological healing according to deep and superficial layer detachment in first facet involving subscapularis tendon tear

The Destiny of the Subscapularis Tendon after Arthroscopic Supraspinatus Repair

Background

The purpose of this study was to identify the changes in untreated subscapularis in patients who underwent supraspinatus repair and to evaluate the factors related to the changes in the subscapularis.

Methods

A cohort of patients who underwent isolated supraspinatus repair with preservation of the subscapularis was reviewed. Changes in the subscapularis, including any newly formed lesion and aggravation of an existing lesion, were evaluated 12 months postoperatively on magnetic resonance imaging along with an examination to identify causative factors after supraspinatus repair. Clinical scores were compared between patients with and without subscapularis changes.

Results

A total of 528 patients were reviewed. Changes in the subscapularis, including newly formed lesions and aggravation of an existing lesion, were shown in 90 patients (17.0%). Upon regression analysis, changes in the subscapularis were associated with the initial existence of a subscapularis lesion (grade I: p = 0.042, grade II: p = 0.025), an accompanying biceps lesion (p = 0.038), and a retear of the repaired supraspinatus (p = 0.024). No significant differences were shown in clinical scores between patients with and without subscapularis changes after supraspinatus repair.

Conclusions

Untreated asymptomatic subscapularis may undergo morphological changes even after repair of the torn supraspinatus. Preoperative subscapularis lesions, biceps long head pathology, and retears of the repaired supraspinatus were associated with subscapularis pathology in patients who underwent supraspinatus repair.

Subscapularis Tendon Tears: How Best to Approach This Issue

Subscapularis tears, either in combination with more extensive rotator cuff pathology or in isolation, are a relatively common cause of shoulder pain and dysfunction which often requires surgical intervention. Similar to the general treatment of most rotator cuff tears, patients may respond to conservative treatment and not require surgical intervention, especially in the elderly or those with partial tears. However, many subscapularis tears require intervention to address complaints of pain, dysfunction, or both. The spectrum of subscapularis tears ranges from low-grade partial requiring simple debridement to full-thickness tears which have become retracted and irreparable necessitating complex repair. Although open repair had been performed with success, most subscapularis repairs can be accomplished with arthroscopic techniques.

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.

Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear

BACKGROUND

Neglected partial subscapularis tears often cause functional impairment even after repair of the supraspinatus and infraspinatus tear is done. Numerous physical examinations for detecting partial subscapularis tears have been described in previous studies.

PURPOSE

To analyze the relationship between the preoperative clinical features and the severity of a partial subscapularis tear and to provide diagnostic clues for patients requiring subscapularis repair.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

This retrospective study included 286 patients who underwent arthroscopic shoulder surgery between 2020 and 2022. Preoperative clinical features, including range of motion, functional scores, muscle strength ratio, modified belly-press test (measuring belly-press angle), and bear-hug test, were collected. Magnetic resonance imaging (MRI) evaluation was done according to the Yoo and Rhee classification. Types of subscapularis tear, supraspinatus lesion, and biceps lesion were recorded during arthroscopic surgery. A comparison of preoperative clinical features between the no-repair group (type 2A or less) and surgical repair group (type 2B or more) was done. The optimal cutoff value of the belly-press angle was determined and the diagnostic performance of the belly-press angle, bear-hug test, and MRI were evaluated using the receiver operating characteristic curve.

RESULTS

Among 286 patients, 189 (66.1%) had subscapularis tears with type 2A or more. There was a significant difference in muscle strength ratio of the belly-press (P < .001), belly-press angle (P < .001), and bear-hug test (P < .001) between the no-repair group (type 2A or less) and the surgical repair group (type 2B or more). With a belly-press angle of 15° as a new cutoff value, the modified belly-press test showed 67.6% sensitivity, 73.9% specificity, and 69.6% accuracy in detecting type 2B or higher subscapularis tear.

CONCLUSION

Patients with type 2A and 2B subscapularis tears (according to the Yoo and Rhee classification) showed differences in belly-press strength ratio, belly-press angle, and bear-hug test. The cutoff value of the 15° belly-press angle showed an accuracy of 69.6% in detecting subscapularis tears with type 2B or higher.

Bilateral dislocation of the long head of biceps tendon with intact rotator cuff tendon: A case report

BACKGROUND

Dislocation of the long head of biceps tendon (LHBT) usually involves rotator cuff injury, and isolated dislocation with an intact rotator cuff is rare. Some cases of isolated dislocation have been reported. However, to the best of our knowledge, there has been no report of bilateral dislocation of the LHBT without rotator cuff pathology.

CASE SUMMARY

A 23-year-old male presented to our outpatient clinic with left side dominant pain in both shoulders. The patient had no history of trauma or overuse. The patient underwent intra-articular injection and physical therapy, but his symptoms aggravated. Based on preoperative imaging, the diagnosis was bilateral dislocation of the LHBT. Dysplasia of the bicipital groove was detected in both shoulders. Active dislocation of the biceps tendon over an intact subscapularis tendon was identified by diagnostic arthroscopy. Staged biceps tenodesis was performed and continuous passive motion therapy was administered immediately after surgery. The patient's pain was resolved, and full functional recovery was achieved, and he was satisfied with the condition of his shoulders.

CONCLUSION

This study describes a rare case of bilateral dislocations of the LHBT without rotator cuff injury due to dysplasia of the bicipital groove.

Comparison of the Goutallier Classification of Fatty Infiltration for the Subscapularis With a Novel Modified Classification

Background

Fatty infiltration in the subscapularis muscle extends to the upper portion of the muscle first and then to the lower portion only after some degree of fatty change has taken place in the upper region. Although the Goutallier classification is the most widely used method to categorize fatty infiltration, how to accurately and reliably determine the extent of infiltration is controversial.

Purpose

To examine a modified classification that is more reliable in (1) assessing fatty infiltration of the subscapularis muscle and (2) predicting the structural integrity of the repaired tendon by identifying cutoff points for retear.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

This study retrospectively examined the records of 545 patients who underwent arthroscopic repair for a subscapularis tear. Two shoulder surgeons reviewed the preoperative magnetic resonance imaging scans of all enrolled patients and evaluated the fatty infiltration of the subscapularis muscle based on the original Goutallier classification, as well as a novel modified Goutallier classification designed to measure the proportion of fat and muscle in the upper and lower portions of the muscle separately. Intra- and interobserver agreement of the reviewers was calculated using κ statistics. Using receiver operating characteristic curve analysis, we determined the cutoff point for the particular fatty infiltration grade related to the occurrence of retear for each classification scheme.

Results

The κ values for interobserver reliability were 0.743 and 0.856 for the original and modified Goutallier classifications, respectively, with the modified classification having significantly higher reliability (Z = 4.064; P < .001). Cutoff points for the fatty infiltration grade associated with retear were 2.5 for the original Goutallier classification (sensitivity, 65.3%; specificity, 95.6%; accuracy, 87.8%) and 3.5 for the modified classification (sensitivity, 52.5%; specificity, 97.8%; accuracy, 89.7%).

Conclusion

In assessing fatty infiltration of the subscapularis muscle, the modified Goutallier classification showed higher reliability than the original Goutallier classification. The cutoff point for potential retear (grade 3.5) was at a point where the fatty infiltration extended to the lower portion of the subscapularis muscle.