Anatomy
Largest and most powerful rotator cuff
- arises coastal border of scapula
- superior 2/3 tendon inserts into LT
- inferior 1/3 inserts into proximal humerus
Action
- IR (with T major, P major, Lat Dorsi)
- part of force couplet depressing humeral head
Incidence
Can be isolated event
More commonly seen with SS tears (2% in MRI study)
- anterosuperior tears
Associations
- HAGL
- biceps subluxation
- coracoid impingement
MOI
Trauma
- hyperextension and ER
Degenerative
Examination
Pain anterior shoulder
Increased ER
Lift off test
Belly Press
- elbow falls posteriorly to harvest post deltoid
MRI
Arthroscopy
Complete absence of SSC
Comma Sign
Medially Subluxed Biceps
Management
Operative Indications
Degenerative
- failure of 6/12 non operative
Trauma
- fix acutely
Options
1. Debridement
2. Open Repair
3. Arthroscopic Repair
Debridement
Results
Edwards et al Arthroscopy 2006
- 11 patients with SSC tears
- debridement
- tenotomy in 9 with dislocating / unstable biceps
- 9/11 good results
Open Repair
Technique
Deltopectoral approach
- preserve axillary nerve inferiorly
- mobilise SSC
- subscapular nerves on anterior surface medial to glenoid rim
- tenodesis LHB
- suture anchor repair to lesser tuberosity
Results
Barti et al Am J Sports Med 2010
- 30 traumatic tears, patient average age 43
- associated biceps subluxation and HAGL's seen
- repair structurally intact in 93%
- 20% still unable to perform lift off / belly press tests
- these patients had higher degree of fatty infiltration preoperatively
Arthroscopic Repair
Intra-articular technique
- camera in GHJ
- anterosuperior portal
- mobilise tendon front and back
- must remove adhesions
- roughen insertion point on LT / gentle with burr as bone is soft
- insert twinfix anchors x 2 via stab incision
- pass birdsbeak suture passer through portal and through SSC
- retrieve 3 sutures through tendon
- retrieve 4th suture over top of SSC
Extra-articular Technique
- see article
Results
Lafosse et al JBJS Am 2007
- isolated repair in 17 patients
- 15 intact repairs and 2 partial reruptures on CT arthrogram
- good outcomes
https://www.vumedi.com/video/arthroscopic-double-row-subscapularis-repa…
Technique
- extra-articular
Portals
- posterior portal very lateral so can see anterior aspect subacromial space
- port of Wilminton at anterolateral acromion to access SSC
- anterior portal in normal position, slightly more lateral so becomes working portal
GHJ
- identify tendon
- work through portal Wilmington
- grasp, forms comma sign
- perform biceps tenodesis
- tag SSC with fibrewire
Subacromial space
- place standard lateral portal as well
- total bursectomy plus acromioplasty
- use tagging sutures to identify SSC
- release as necessary
- may need long posterior cannula to see anteriorly
- may need to move camera to lateral portal to see around corner anteriorly
- can use 70 degree scope
Prepare footprint
- debride
- insert anchors (retract port of Wilminton into subacromial space)
- pass sutures with suture passer
- tie
Late reconstruction
P. major transfer
Results
Jost et al JBJS Am 2003
- good results in isolated SSC tears
- results poor in shoulder arthroplasty