AANA Middle East Arthroscopy Master Course (International)-Subscapularis Repair

Subscapularis Repair

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Dr. Robert Hunter presented on subscapularis repair at the AANA Middle East Arthroscopy Master Course in Dubai, September 2019. He discussed clinical and arthroscopic diagnosis, repair techniques, and outcomes.<br /><br />The subscapularis tear symptoms include anterior shoulder pain, internal rotation weakness, biceps pain or instability, radiating pain, clunk with rotation, and possible rotator cuff tear (RCT) signs. Physical exam may reveal weakness and pain with internal rotation and positive special tests such as Lift-Off, Belly Press, and Bear-Hug tests. MRI assists in diagnosis.<br /><br />The Lafosse classification categorizes subscapularis tears from partial superior third involvement (Type I) to complete tears with fatty degeneration and head translation (Types IV-V).<br /><br />Arthroscopic diagnosis involves identifying the superior margin of the subscapularis tendon, the “comma sign,” and biceps tendon stability. Biceps instability is often associated with subscapularis tears.<br /><br />Surgical repair indications include preoperative complaints of internal rotation weakness, anterior pain, positive biceps clunk, and Lafosse II-IV tears with unstable biceps tendon seen arthroscopically. The repair "from below" approach utilizes anterior portals and scopes at 30° and 70°, with careful release of adhesions including the middle glenohumeral ligament to mobilize the tendon for reduction.<br /><br />Anchors are placed at the lesser tuberosity, typically one for smaller tears, two for complete tears. Suturing uses a pierce-and-grab method, often employing a traction stitch on retracted tendons. Sutures are placed medial to lateral in a mattress configuration working inferior to superior to restore footprint.<br /><br />Systematic reviews show consistent improvement in pain, strength, range of motion, and functional tests after repair, with retear rates between 5-12%. Double-row repairs might yield better outcomes. Addressing biceps pathology leads to improved results. In massive anterosuperior RCTs, intact subscapularis correlates with better outcomes, though retear rates remain high (~53%). Isolated subscapularis repair for irreparable posterosuperior RCTs improves outcomes and strength with a 27% retear rate.<br /><br />Overall, Dr. Hunter emphasized accurate diagnosis, comprehensive arthroscopic release and repair, and the importance of addressing biceps pathology to optimize shoulder function after subscapularis tears.

Keywords

Subscapularis repair

Arthroscopic diagnosis

Lafosse classification

Anterior shoulder pain

Internal rotation weakness

Biceps tendon instability

Shoulder arthroscopy techniques

Rotator cuff tear

Subscapularis tear symptoms

Surgical repair outcomes