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.

Comparison of the clinical outcomes and temporal changes between superior capsular reconstruction and reverse total shoulder arthroplasty in patients with irreparable rotator cuff tear without osteoarthritic change.

BACKGROUND: Superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (RTSA) are widely performed in patients with irreparable rotator cuff tears, including pseudoparalytic shoulder (PPS), and have shown positive clinical outcomes. However, limited studies have compared these two in terms of functional recovery in patients with PPS without osteoarthritic change. Thus, this study aimed to compare the clinical outcomes and to clarify the characteristics and differences in temporal changes among patients who underwent either RTSA or SCR using tensor fascia lata for PPS due to irreparable rotator cuff tear without osteoarthritic change (Hamada grade ≤ 3). METHODS: We enrolled a total of 39 patients who underwent SCR (n = 20) or RTSA (n = 19 cases) with a follow-up period of 2 years. All patients were follow-up at 2, 3, 4, 5, 6, 8, 10, 12, and 24 months postoperatively. Preoperative and postoperative range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) scores, and temporal changes in ROMs were compared between the two groups. RESULTS: The SCR group had significantly better ROM than the RTSA group in flexion (146° ± 34° vs. 132° ± 23°, P = 0.022), abduction (147° ± 36° vs. 130° ± 23°, P = 0.0092), internal rotation (11 ± 3 Th10 vs. 6 ± 3 L3, P < 0.001), and ASES score (84.1 ± 13.8 vs. 80.1 ± 6.1, P = 0.0096). While the RTSA group achieved 100° in flexion and abduction after 3 months postoperatively, the SCR group took approximately 5 months. However, the SCR group exceeded the RTSA group in flexion and abduction at six months postoperatively. In the SCR group, some patients with irreparable subscapularis tendon tears could not achieve 90° shoulder elevation. Both groups showed significant improvements in shoulder flexion and abduction compared to the preoperative state (P < 0.001). CONCLUSION: Although SCR requires a longer rehabilitation period, it provides similar outcomes to RTSA after two years for non-osteoarthritic, irreparable cuff tears with pseudoparalysis.

Trans-axillary sonography in the ABER (ABduction and External Rotation) position: a window to the subscapularis, teres major and latissimus dorsi.

Shoulder ultrasound is a key tool used by musculoskeletal practitioners to diagnose and treat a variety of upper girdle diseases. While magnetic resonance imaging is the cornerstone of shoulder imaging, sonography is readily available, practical and superior in its ability for dynamic assessment of musculoskeletal pathologies. The subscapularis, teres major and latissimus dorsi muscles are commonly involved in a myriad of pathology including myofascial pain and spasticity. There is scarce literature on the assessment of these muscles for diagnostic and therapeutic purposes. Conventional approaches to shoulder ultrasound have not included a dedicated assessment of the subscapularis muscle due to its inherent anatomical location deep to the scapular blade which blocks sound wave penetration. We describe an approach to visualizing the subscapularis muscle as a short addition to the established shoulder sonography format, which also permits assessment of both the latissimus dorsi and teres major muscles, which are important muscles for shoulder spasticity. The patient is imaged in a semi-recumbent position with the arms elevated above and behind the head in the ABduction and External Rotation (ABER) position. The relative ease of positioning and sonographic access to the musculature coupled with the potential for assessment and intervention makes this approach extremely desirable to the musculoskeletal practitioner looking to diagnose or treat muscle belly pathologies of the subscapularis, teres major or latissimus dorsi.

Tensionable lesser tuberosity osteotomy repair for anatomic total shoulder arthroplasty.

A lesser tuberosity osteotomy (LTO) is commonly performed during total shoulder arthroplasty to access the glenohumeral joint. Healing of the LTO is critical to optimizing the outcome of the procedure and is enhanced by a repair that provides stability and compression across the osteotomy site. The purpose of this article is to describe a technique that uses a tensionable suture construct to repair the LTO during anatomic total shoulder arthroplasty using a stemless humeral component. The technique involves passing a row of high-tensile sutures through bone tunnels lateral to the osteotomy site (transosseous sutures) and another row of sutures through the humeral implant (implant sutures). One limb of each bone tunnel suture is then tied to its corresponding limb of implant suture and the remaining free strands of the tied sutures are manually tensioned and tied to each other. This technique is an efficient and reproducible method for creating compression and stability across the osteotomy site that facilitates bony healing.

Chronic Adaptation of the Coracohumeral Space and Subscapularis Tendon in Professional Baseball Pitchers.

BACKGROUND: Pitchers frequently experience anterior shoulder pain, possibly associated with coracohumeral impingement; however, whether the coracohumeral distance (CHD) and/or subscapularis tendon adapt chronically (bilateral difference) due to pitching, and whether clinical measures are associated with CHD and subscapularis tendon organization have not been evaluated in professional pitchers. HYPOTHESIS: The authors hypothesized that dominant arm CHD would be smaller than the nondominant arm, dominant subscapularis tendon would have increased spatial frequency (ie, be more disorganized), and humeral retroversion (HR) would predict CHD and subscapularis tendon organization. LEVEL OF EVIDENCE: Level 4. METHODS: Healthy professional baseball pitchers were recruited during their preseason physical examination. Bilateral diagnostic ultrasound measured CHD, HR, and posterior capsule thickness (PCT), and quantified subscapularis tendon organization. External rotation, neutral, and crossbody CHD was measured. RESULTS: Overall, 52 healthy professional baseball pitchers participated. The dominant arm of pitchers demonstrated a significantly narrower CHD in all 3 positions (P < 0.01), increased scapular protraction (163 vs 156 mm; P < 0.01), and increased spatial frequency of the subscapularis tendon (1.8 vs 1.6 peaks/mm; P < 0.01). HR was associated with CHD in 30° of external rotation (R2 = 0.12; P < 0.01), neutral rotation (R2 = 0.11; P < 0.01), and the crossbody position (R2 = 0.28; P < 0.01). PCT was associated with CHD in 30° of external rotation (R2 = 0.16; P = 0.05). HR and CHD in 30° of external rotation was associated most strongly with subscapularis tendon organization (R2 = 0.11; P = 0.03). CONCLUSION: The dominant shoulder of professional pitchers presents with a smaller CHD, more scapular protraction, and more subscapularis tendon disorganization than the nondominant shoulder. CLINICAL RELEVANCE: Professional pitchers demonstrate chronic CHD and subscapularis tendon adaptations, which may increase their risk for anterior shoulder pain and subscapularis tendon injury.

Anatomical and surgical considerations of the pectoralis muscle.

Introduction: The pectoralis major (PM) muscle is the largest and most superior muscle of the anterior chest wall. The PM plays an important role in flexion, adduction, and internal rotation of the arm. The pectoralis major's size, strength, and anatomical location make it an excellent candidate in transfer surgeries due to its ability to restore balancing forces that may be lost in scapular winging and subscapularis tears. Each of these injuries and pathologies involves the PM muscle in some way, and careful consideration of its anatomy and physiology is necessary. This review article aims to provide a comprehensive overview of the anatomy, physiology, and surgical considerations of the pectoralis muscle with a specific focus on the surgical techniques involving the muscle. Methods: A comprehensive literature search using a combination of the following terms: pectoralis major, rupture, transfer, chronic subscapularis tear, pectoralis surgery, anatomy, scapular winging, and long thoracic nerve anatomy. There were no limitations with regards to article type or publishing date, but article language was limited to only English. Conclusion: The pectoralis muscle is an important muscle when it comes to function of the upper extremity primarily or through transfer procedure. Injuries and impairments of the pectoralis major or other muscles of the upper extremity can significantly impact an individual's quality of life, limiting their ability to perform activities of daily living. A thorough understanding of anatomical, functional, and surgical purposes of the pectoralis muscle is crucial for achieving optimal outcomes and avoiding complications.

Clinical outcomes of over-the-top subscapularis repair in reverse shoulder arthroplasty.

Background: Biomechanical research demonstrates increased subscapularis abduction range of motion (ROM) when the tendon's upper two-thirds is repaired over-the-top of the center of rotation during reverse shoulder arthroplasty (RSA). This study compares the clinical outcomes of patients undergoing RSA with over-the-top subscapularis repair (OTTR) to patients without repair. Methods: We retrospectively reviewed 97 consecutive RSAs with either OTTR of the subscapularis (N = 75) or no repair (N = 22). Repair was attempted in all patients but not performed if the subscapularis could not be brought to the over-the-top position in 20° of external rotation (ER) and 30° of abduction. Improvements in ROM were compared to the minimal clinically important difference for RSA. Results: The mean follow-up was 3.8 ± 1.6 years. Demographics were similar between groups. Preoperatively, patients undergoing repair had greater ER when compared to those without repair (15 ± 16° vs. 5 ± 12°, P = .003). Postoperatively, patients undergoing repair had greater forward elevation (132 ± 21° vs. 126 ± 22°, P = .268) and abduction (114 ± 26° vs. 106 ± 23°, P = .193) with both exceeding the minimal clinically important difference (-2.9° and -1.9°, respectively); however, not statistically significant. Patients with repair were more frequently able to reach the small of their back postoperatively (65% vs. 21%, P = .006) but had less improvement in ER (13 ± 20° vs. 24 ± 20°, P = .028). Postoperative outcome scores, complications, and reoperations were similar between groups. Discussion: OTTR of the subscapularis in RSA had similar ROM and outcome scores compared to no repair, but a significantly larger proportion of patients with repair achieved functional internal rotation to the small of the back. ER limitations seen after conventional repair may also apply to this novel technique, but without a corresponding detrimental effect on forward elevation or abduction.

Quantitative evaluation of adhesion severity around subscapularis and its relationship with shoulder range of motion in frozen shoulder and rotator cuff disorder: an observational study using dynamic ultrasonography.

Background: This study aimed to evaluate the severity of adhesion between muscles in the shoulder joint using dynamic ultrasonography and to confirm whether adhesions cause range of motion (ROM) restrictions. Methods: Twenty-four shoulders from 15 frozen shoulder patients and 24 shoulders from 18 rotator cuff disorder patients were enrolled. We obtained ultrasound video sequences of the subscapularis (SSC) and deltoid muscles during shoulder external rotation. The mean stretching velocities of the deltoid and SSC were subsequently analyzed using a personal computer. If adhesions occurred between both muscles, the deltoid was stretched more vigorously, and we calculated mean stretching velocity of the deltoid / SSC as adhesion severity. The coracohumeral ligament thickness was measured using the same images. Shoulder ROM was measured by using a universal goniometer. Results: The intraclass correlation coefficients (1.1) and (2.1) of the adhesion severity measurements were 0.85 and 0.91, respectively. Multiple linear regression analysis revealed that the adhesion severity is a significant predictor for external rotation ROM in the rotator cuff disorder group (R2 = 0.44, F = 10.1, P < .01, t = -2.9), while coracohumeral ligament thickness predicts ROM in the frozen shoulder group (R2 = 0.28, F = 5.5, P = .01, t = -3.0). Conclusion: The proposed method is reliable. Muscle adhesion causes ROM restriction of the shoulder joint. The primary cause of shoulder ROM restriction differed between the diagnostic groups.

Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability.

BACKGROUND: Open Bankart repair and Latarjet stabilization are two of surgical procedures used in the treatment of shoulder instability in contact athletes. The aim of this study is to evaluate the outcomes of bone block arthroscopic procedure, performed with xenograft, in combination with Bankart repair and selective subscapularis augmentation (ASA) for contact athletes with recurrent anterior shoulder instability. METHODS: We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, WOSI score, ASES score) were assessed. A CT scan at 2-year follow-up was performed to assess the status of Bone block integration, its displacement and restoration of glenoid surface. RESULTS: 16 patients were included in the study with a mean age of 24. None of the patients treated with arthroscopic bone block and ASA presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up, in particular the ASES, Rowe, and WOSI scores increased from 69±7, 31±9 , 1235±46 respectively to 96.1±3.2, 94±6, 119±51. All athletes returned to sporting activity at or near the same level as pre-surgery. The glenoid bone surface increase from 83% to 116% at last follow-up. CONCLUSION: Bone block treatment with Xenograft combined with Bankart repair and ASA procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the pre-intervention period.

Arthroscopic lasso-loop technique for subscapularis repair with anterolateral viewing portal yields better clinical outcomes for Lafosse grade 3 and 4 tears: a prospective study with minimum 2 years of follow-up.

Background: Contracted subscapularis tears, especially Lafosse grade 3 and 4, pose a significant challenge in surgical repair due to the need for extensive release of retracted tendon and the risk of cut-through due to poor tissue quality. The posterior viewing portal may hinder adequate visualization and extensive release of retracted tendons, particularly in addressing the bursal surface of the tears. Tension-free robust repair is critical to prevent retears and for achieving successful outcomes for these massive and complex retracted tears. This study investigates the clinical outcomes of the Lasso-Loop technique with an anterolateral viewing portal, aiming to enhance tendon release, improve footprint fixation, and optimize tissue grip, particularly in cases of chronic retracted Lafosse 3 and 4 tears. This innovation also eliminates the need for arthroscope switching and serves as a crucial measure for averting axillary nerve injuries during the procedure. Methods: The study included 40 patients with isolated subscapularis or combined anterosuperior rotator cuff tears (Lafosse grade 3 and 4) that underwent arthroscopic subscapularis repair using a Lasso-Loop technique through an anterolateral viewing portal. Evaluations were conducted both preoperatively and at predefined postoperative intervals: 6 weeks, 3 months, 6 months, 1 year, and 2 years. The evaluations in this study encompassed a comprehensive range of clinical assessments, which included a complete range of movements, specialized tests for subscapularis muscle functionality (specifically the lift-off test and belly press test), the utilization of the University of California at Los Angeles and Oxford shoulder scoring systems, and a postoperative ultrasonography conducted at the 6-month mark to assess the presence of any retear. Clinical outcomes were compared with that of the opposite normal shoulder. Results: There was considerable improvement in the active painless range of motion postoperatively. During the 2-year follow-up, the positive belly press test decreased from 50% (n = 20) to 2.5% (n = 1), while the positive lift-off test decreased from 100% (n = 40) to 5% (n = 2). The modified University of California at Los Angeles score increased significantly from 10.15 preoperatively to 30.17 at 2 years postoperatively (P value = .001). Oxford's Shoulder Score increased significantly from 15.6 preoperatively to 40.64 at 2 years postoperatively (P value = .001). Conclusion: This technique has produced positive functional outcomes, in cases categorized as massive subscapularis tears and chronic tears indicating the superiority over other conventional techniques of subscapularis repair described in the literature.

Subscapularis atrophy and function after arthroscopic Trillat procedure.

INTRODUCTION: Several studies have reported a strength deficit in internal rotation (IR) following a Latarjet procedure, which can persist for months or even years. The arthroscopic Trillat procedure does not require splitting the subscapularis muscle, potentially making it less damaging. HYPOTHESIS: The arthroscopic Trillat procedure does not cause any atrophy or strength deficit in the subscapularis muscle. METHODS: This was a single center, retrospective study of patients treated between 2013 and 2021. Included were patients who had chronic anterior shoulder instability with an indication for surgical stabilization using an arthroscopic Trillat procedure and who underwent a CT scan before surgery and a second one at 6 months postoperative. The following morphological parameters were measured on all the rotator cuff muscles: cross-sectional area (CSA), thickness and fatty infiltration using the mean muscle attenuation (MMA) measurement. Isokinetic tests were done 1 year post-surgery. RESULTS: One hundred seventeen patients underwent arthroscopic Trillat surgery between 2013 and 2021; 58 were included, 30 were analyzed and 17 patients underwent isokinetic testing. The CSA of the subscapularis was significantly smaller by 5.3% (17.0 vs. 16.1; p = 0.03). None of the other rotator cuff muscles had a smaller CSA. The MMA of the subscapularis increased significantly while the MMA of the external rotators decreased postoperatively. No strength deficit was found at 1 year postoperative in the internal and external rotators. DISCUSSION: The arthroscopic Trillat procedure produces minor atrophy of the subscapularis muscle at 6 months, with no strength deficit at 1 year postoperative. Several studies have reported a deficit in internal rotation strength after a Latarjet procedure, ranging from 6% to 19% depending on the study. LEVEL OF EVIDENCE: IV.

Rate of graft retear is higher in over-the-top superior capsular reconstruction for massive posterosuperior rotator cuff tears with subscapularis tear.

PURPOSE: To compare side-to-side superior capsular reconstruction (SCR) with over-the-top SCR in terms of functional outcomes, pain relief and allograft survival rates. METHODS: Patients who had undergone arthroscopic dermal allograft SCR for massive irreparable rotator cuff tears and clinical follow-up for ≥2 years were recruited. All patients underwent postoperative assessment with routine radiographic analysis for acromiohumeral distances, ultrasound imaging 1 and 3 months after SCR and magnetic resonance imaging (MRI) at least 12 months after SCR. The outcome measures were visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant and Single Assessment Numeric Evaluation (SANE) scores. RESULTS: SCR was performed in 56 patients including side-to-side SCR in 32 and over-the-top SCR in 24. Postoperative MRI showed that the grafts were intact in 46 patients (82.1%; 26 who underwent side-to-side SCR and 20 who underwent over-the-top SCR). The proportion of nonhealing grafts in the over-the-top group was significantly higher with concomitant subscapularis tears (60% vs. 5.3%; p = 0.02). VAS scores and functional outcomes improved postoperatively in both groups and postoperative VAS (1.4 vs. 1.7; n.s.), Constant (74.8 vs. 76.0; n.s.), mean ASES (87.4 vs. 89.1; n.s.) and mean SANE (81.7 vs. 84.3; n.s.) scores did not differ significantly. CONCLUSION: For massive rotator cuff tears, over-the-top and side-to-side SCR achieve similar pain relief and functional improvement, and the rate of healing allografts is high. However, over-the-top SCR is not recommended for massive posterosuperior rotator cuff tears with repairable subscapularis tendon tears due to a higher nonhealing rate. LEVEL OF EVIDENCE: Level III.

Partial subscapularis tear: State-of-the-art.

The subscapularis (SSC) muscle is a crucial anterior glenohumeral stabilizer and internal rotator of the shoulder joint. The partial tears of the SSC might result from traumatic injury or intrinsic degeneration. Partial SSC tears can range in severity and be classified into different categories based on the location of the tear, size of the lesion, and associated pathology. The tear usually begins from the superolateral margin in the first facet and propagates downwards. It is frequently associated with biceps pathology or anterosuperior lesions. These tears are now increasingly recognized as distinct pathology that requires specific diagnostic and management approaches. The current management approaches are shifting towards operative, as partial SSC tears are increasingly recognized as a distinct pathology. At present, there is no consensus regarding the timing of repair, but the relative tendency of the SSC to retract much faster than other rotator cuff muscles, and difficulty in mobilization, advocates an early repair for SSC irrespective of the lesion size. An associated biceps pathology can be treated with either tenotomy (biceps delamination/erosion) or tenodesis. The techniques of partial SSC repair are constantly improving. There is no reported difference in use of 2-anchor-based conventional single-row (SR), a 3-anchor-based interconnected double-row technique, or a 2-anchor-based interconnected hybrid double-row construct in the repair construct. However, the 2-anchor-based interconnected double-row provides an advantage of better superolateral coverage with leading-edge protection, as it helps in placing the superolateral anchor superior and lateral to the original footprint. A timely intervention and restoration of the footprint will help restore and rehabilitate the shoulder. Future directions should prioritise injury prevention, early diagnosis with clinic-radiological cues and targeted interventions to mitigate risk.

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.

Splitting the subscapularis at the upper two-third and lower one-third junction or in the middle during the Latarjet-Walch procedure does not affect the external rotation range of motion.

BACKGROUND: Our purpose was to investigate (1) the difference in external rotation range of motion (ROM) limitation between the two recommended subscapularis-splitting techniques (mid-split vs. upper 2/3rd -lower 1/3rd split) and (2) the differences in elevation ROM, internal rotation (IR) ROM, the functional outcomes and the IR strength between the two techniques in the Latarjet-Walch procedure. MATERIAL AND METHODS: We conducted a prospective cohort study of patients with recurrent shoulder instability treated by the Latarjet-Walch procedure between January 2021 and January 2022. After a priori calculation of sample size, 32 patients were divided into two groups according to the type of intraoperative subscapularis split [upper 2/3rd -lower 1/3rd level split (LS group, n = 19) vs. mid-LS (MS group, n = 13)] performed in the Latarjet-Walch procedure. RESULTS: The final external rotation with the arm adducted deficit (as compared to opposite normal shoulder) was not significantly different between the LS (9° ± 8°) and the MS (10° ± 8°, P = .8) groups. The final ER with the elbow abducted @ 90° (ER2) deficit was not significantly different between that of the LS (14° ± 12°) and the MS groups (12° ± 9°, P = .5). Only in the MS group were the final ER with the arm adducted deficit (P = .03) and the final ER with the elbow abducted @ 90° deficits (P = .05) significantly better (smaller) than the corresponding baseline values. The Rowe scores (P = .2) and the Shoulder Subjective Value (P = .7) were not significantly different between the two groups. There were no postoperative subluxations in either group. However, 3 patients tested positive in apprehension testing in the LS group compared to none in the MS group, the difference being statistically insignificant. The IR strength was 95% of the normal, unaffected shoulder in the LS group and 93% of the normal in the MS group (P = .6). Computed tomography scan evaluation showed that the transverse diameter index of subscapularis (upper subscapularis diameter/lower subscapularis diameter) was not different in the MS (0.9 ± 0.1) and the LS (0.9 ± 0.1, P = .3) groups. CONCLUSION: We found no difference in final external rotation limitation between the upper 2/3rd - lower 1/3rd vs. mid-level subscapularis split techniques. The functional outcomes, the IR strength, subscapularis transverse diameter index, and fatty infiltration in the computed tomography scan were similar in both groups.

Retrospective analysis of the subscapularis-sparing approach for reverse total shoulder arthroplasty.

PURPOSE: The influence of the subscapularis tendon on reverse total shoulder arthroplasty (RTSA) has been discussed controversially. The aim of the study was to investigate the subscapularis-sparing approach for RTSA and the effect of the intact subscapularis tendon. METHODS: This retrospective comparative study included 93 patients. Among these, 55 underwent the deltopectoral subscapularis-sparing approach, and in 38 cases, the standard deltopectoral approach with subscapularis tenotomy was applied. At the final follow-up, representative shoulder scores were measured, radiographs were taken in two planes, and shoulder sonography was performed. RESULTS: The subscapularis-sparing group showed a significantly higher Constant score (71.8 vs. 65.9 points) and adapted Constant score if the subscapularis tendon was shown to be intact in the postoperative sonography (85.2% vs. 78.6%) (p = 0.005; p = 0.041). Furthermore, these patients had improved abduction (128.2 vs. 116.8, p = 0.009) and external rotation (34.6 vs. 27.1, p = 0.047). However, no significant differences were found for the degree of internal rotation and internal rotation strength. No dislocation or infection was observed. The degree of scapular notching was not significantly different between the two groups (p = 0.082). However, independently from the integrity of the subscapularis the subscapularis-sparing approach showed no difference in clinical and radiographic outcome (Constant score scapularis-sparing 70.0 points vs. tenotomy 66.8 points; p = 0.27). CONCLUSION: The subscapularis-sparing approach RTSA showed improved clinical outcome, abduction, and external rotation, if the subscapularis was shown to be intact at time of follow-up. Both groups showed no difference in internal rotation.

Surgical anatomical landmarks for arthroscopic repair of subscapularis tendon tears.

Background: Subscapularis repair has recently garnered significant interest. A thorough understanding of the tendon's anatomy is essential for precise and safe repair. Our objectives were to describe the anatomy of the subscapularis insertion, define its landmarks, and analyze nearby structures to guide arthroscopic repair. Methods: We conducted an anatomical study, dissecting 12 shoulders. We evaluated the distance from the footprint to the axillary nerve, the dimensions, and shape of the footprint, and its relationship with the humeral cartilage. Results: The distance to the axillary nerve was 32 mm (standard deviation [SD], 3.7 mm). The craniocaudal length of the footprint was 37.3 mm (SD, 4.6 mm). Its largest mediolateral thickness was 16 mm (SD, 2.2 mm), wider at the top and narrower distally. The distance between the footprint and the cartilage varied, being 3.2 mm (SD, 1.2 mm) in the upper part, 5.4 mm (SD, 1.8 mm) in the medium, and 15.9 mm (SD, 2.9 mm) in the lower part. Conclusions: When performing a repair of the subscapularis tendon, the distance to the cartilage should be carefully evaluated as it varies proximally to distally, and the shape of the footprint (wider proximally, tapered distally) should be considered for implant positioning. The distance to the axillary nerve is approximately 30 mm. Anterior visualization guarantees direct control of all landmarks and allows accurate implant positioning with safe tendon release.

Does the subscapularis repair affect the clinical outcome after primary reverse shoulder arthroplasty?

BACKGROUND: Reverse shoulder arthroplasty is an established procedure for patients with rotator cuff tear arthropathy. However, the repair of the subscapularis tendon remains a controversial and frequently discussed topic. This prospective randomized study was conducted to evaluate the clinical benefit of the subscapularis repair after reverse shoulder arthroplasty. METHODS: Fifty patients (36 female and 14 male) were randomized and assigned to either the "repaired" (rep) or the "not repaired" (nrep) cohort. Intraoperatively, the subscapularis tendon was reattached in the rep cohort with 4 tendon-to-tendon sutures, whereas no repair was performed in the nrep cohort. The Constant-Murley Score (CS) and the range of motion were evaluated preoperatively as well as 12 and 36 months postoperatively. The Subjective Shoulder Value and the Lift-off test were performed 36 months postoperatively. The postoperative subscapularis integrity was assessed sonographically. RESULTS: Twelve months postoperatively the rep cohort presented better results in the CS (rep: 71 vs. nrep: 66, P = .037). The normalized CS was 80% in the rep cohort and 75% in the nrep cohort (P = .114). At our last follow-up after 36 months, we did not find significant differences between the rep cohort and the nrep cohort in the CS (rep: 76 vs. nrep: 75, P = .285) and normalized CS (rep: 91% vs. nrep: 91%, P = .388). Concerning internal rotation (in points), the rep cohort achieved better results than the nrep cohort (rep: 7.3 vs. nrep: 6.6, P = .040). Flexion (rep: 145° vs. nrep: 151°, P = .826), abduction (rep: 135° vs. nrep: 137°, P = .816), external rotation (rep: 34° vs. nrep: 37°, P = .817), and the Subjective Shoulder Value (rep: 81% vs. nrep: 77%, P = .398) presented no significant differences between the cohorts. The ultrasound examination after 36 months displayed an intact tendon in 70%. CONCLUSIONS: Although the subscapularis repair affects the postoperative internal rotation positively, there were no differences in midterm follow-up concerning the overall results after reverse total shoulder arthroplasty. Further, the external rotation is not affected by the repair of the subscapularis tendon.