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Repair of tears of the subscapularis tendon
REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON T. BRADLEY EDWARDS, MD, and GILLES WALCH, MD
Tears of the subscapularis are much less common than tears of the supraspinatus and infraspinatus. Subscapularis lesions are usually traumatic in etiology and occur in younger patients. These lesions can be complete or limited to the superior insertion of the subscapularis, and they may be isolated or occur with other rotator cuff lesions. In most instances, treatment of subscapularis tears is surgical. In this article, we present the clinical and radiographic findings, discuss operative indications, and illustrate our preferred surgical technique for tears of the subscapularis tendon. KEY WORDS: Subscapularis tears, surgical technique, repair
Copyright 2002, Elsevier Science (USA). All rights reserved.
Tears of the subscapularis tendon are much less common than those of the supraspinatus and infraspinatus. Additionally, lesions of the rotator cuff isolated to the subscapularis are exceedingly rare, with 21 cases the largest series reported in the literature. 1 Traumatic anterior glenohumeral dislocation has been implicated as a cause of subscapularis tendon tear, particularly in patients older than 40 years. 2-7 Excluding these older patients with a prior shoulder dislocation, isolated subscapularis disruption tends to occur in a population younger than that sustaining tears of the supraspinatus and infraspinatus, and tends to be traumatic in etiology.8-1° Lesions of the subscapularis tendon have also been described to occur concomitantly with supraspinatus tears, biceps tendon pathology, and rotator interval lesions. 11-14 These associated subscapularis lesions can be complete or partial and are most often limited to the superior portion of the tendon. Additionally, particularly in the case of partial lesions, these tears may not be recognized during arthroscopy. 14 The purpose of this article is to review the clinical and radiographic findings of subscapularis tears, to describe our preferred operative technique, and give results of treatment for tears of the subscapularis tendon.
CLINICAL AND RADIOLOGICAL FINDINGS Patients with isolated lesions of the subscapularis often give a clinical history of trauma. Older patients have frequently had an associated glenohumeral dislocation. In
From the Minneapolis Sports Medicine Center, Minneapolis, MN, and Department of Orthopaedic Surgery, Clinique Ste. Anne Lumi6re, Lyon, France. The authors have not received any benefits for personal or professional use from a commercial party related to the subject of this manuscript. Address reprint requests to T. Bradley Edwards, MD, Minneapolis Sports Medicine Center, 9957 Valley View Rd, Eden Prairie, MN 55344 Copyright 2002, Elsevier Science (USA). All rights reserved. 1060-1872/02/1002-0002535.00/0 doi: 10.1053/ots m.2002.30173 86
younger patients, traumatic injury frequently includes a history of forced external rotation or forced extension of a partially abducted arm. 8 This mechanism may be the result of violent trauma, ie, a motor vehicle crash, or may be sustained during athletic participation. A subset of patients with isolated subscapularis tears exists with no recallable traumatic episode, suggesting that a degenerative etiology may play a role in certain isolated lesions. 1 Patients with a subscapularis tear associated with supraspinatus/infraspinatus lesions are less likely to give a history of trauma, because most of these lesions are degenerative in nature. 3 On clinical examination, different investigators have reported a variety of findings. 1,7-9 A complete examination of the shoulder is undertaken, specifically evaluating the status of the rotator cuff tendons. In the case of a complete subscapularis disruption, passive external rotation of the arm is classically increased, but may be normal or even decreased. 8 Active internal rotation may be decreased or normal. 8 The Jobe test for supraspinatus integrity will frequently show marked weakness with a subscapularis tear, even in the absence of supraspinatus pathology. 1,8 Internal rotation strength is typically compromised by 1 muscle gradation. 1,8 We use 2 tests especially for evaluation of subscapularis integrity: the "lift-off" test and the "belly-press" test. 7,9 The lift-off test, as described and validated by Gerber, is frequently positive in patients with a complete subscapularis disruption; however, pain and limited internal rotation can limit the usefulness of this test (Fig 1). 1,8,9 Additionally, the examiner must be vigilant to ensure that the patient does not recruit other means (use of elbow motion) to perform the objective of the test. In the belly-press test, the patient is asked to forcefully pull the examiner's hand toward his or her abdomen; if the wrist is flexed and the arm is extended in the accomplishment of this test, the test is considered representative of subscapularis insufficiency (Fig 2). Findings are more variable in patients with partial subscapularis lesions. 14,15These are frequently combined with lesions of the supraspinatus; hence, testing of the su-
Operative Techniques in Sports Medicine, Vol 10, No 2 (April), 2002: pp 86-92
Fig 1. (A) Negative lift-off test. The patient is able to keep his hand from resting on his back during shoulder internal rotation. (B) Positive lift-off test. The patient cannot lift his hand off of his back.
praspinatus often yields positive findings. The presence of a positive lift-off test and positive belly-press test are less reliable with these incomplete tears. Frequently, minimally decreased strength in internal rotation is all that is noted on examination of the subscapularis. Plain radiography typically does not yield positive findings in subscapularis tears. Avulsions of the lesser
tuberosity have been reported, but these cases are exceedingly rare. 16,17 In the patient with a suspected prior glenohumeral dislocation or subluxation, radiographs m a y show instability lesions (humeral head impaction fracture or bony glenoid rim lesion), but these do not necessarily correlate with subscapularis injury.
Fig 2. (A) Negative belly-press test. The patient is able to press on his abdomen while maintaining his wrist in neutral position and his elbow in front of his body. (B) Positive belly-press test. As the patient presses his abdomen, the wrist is flexed and the arm is extended. REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
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Fig 3. Computed tomographic arthrogram showing contrast medial to the biceps sheath at the level of the lesser tuberosity (arrow) indicating detachment of the upper portion of the subscapularis tendon.
Arthrography can be used in the diagnosis of subscapularis tears if the biceps tendon is dislocated medially from the bicipital groove. 9,18 This bicipital dislocation generally only occurs with a large lesion of the subscapularis and also requires that the ligamentous pulley be disrupted. In the case of small tears without biceps dislocation, an arthrogram may be normal. Computed tomographic arthrography and magnetic resonance imaging have both been used as secondary imaging techniques for subscapularis disruption. 1,5,810,12,14,18,19 Complete subscapularis disruptions are readily diagnosed using either of these modalities; however, partial disruptions present a more difficult diagnostic scenario. By using computed tomographic arthrography, partial tears of the superior part of the subscapularis can be identified by the presence of contrast medial to the biceps tendon sheath at the level of the lesser tuberosity (Fig 3). These superior partial lesions may not be apparent on magnetic resonance imaging; however, magnetic resonance arthrography seems to be reliable in identifying these lesions. 2° In addition to evaluating the subscapularis tendon, computed tomography is used to evaluate the status of the subscapularis musculature. Fatty degeneration of the musculature is graded according to the method of Goutallier to assist in preoperative decision-making and in establishment of a prognosis. 21,22Alternatively, magnetic resonance imaging can be used to grade rotator cuff fatty degeneration and atrophy although it has not been found to correlate with computed tomographic grading. 23,24
INDICATIONS AND CONTRAINDICATIONS FOR TREATMENT The indications for repair of the ruptured subscapularis are based on multifactorial criteria. Patient history is taken into account. The patient's clinical examination, specifically the function of the injured shoulder, also plays a crucial role. Additionally, the imaging studies obtained 88
before operative intervention play a critical role in selecting the appropriate patient for subscapularis repair. Patient history, including the patient's age, motivation, activity level, and expectations after surgery, must be evaluated before undertaking subscapularis repair. Subscapularis repair is recommended in younger (less than 50 years), active patients with a tear of traumatic etiology. Older patients with a functional affected extremity and who complain only of pain may be more effectively treated by an arthroscopic debridement. 11 Additionally, a patient must be of sufficient motivation, including willingness to undergo 6 months of rehabilitation and convalescence, before repair should be undertaken. Physical examination divulges information regarding concomitant involvement of other rotator cuff tendons. Concomitant massive tears of the superior and posterior rotator cuff may contraindicate repair. Additionally, if stiffness is detected on clinical examination, a course of physiotherapy to regain passive mobility should be undertaken before subscapularis repair is considered. Secondary imaging studies are important in patient selection for operative treatment. The size of any associated supraspinatus and infraspinatus tears can be evaluated. Significant fatty degeneration of the subscapularis musculature represents a relative contraindication to repair. 21,22,24 Finally, static anterior subluxation of the humeral head is a poor prognostic indicator and a relative contraindication to repair. 3 In summary, the ideal candidate for subscapularis repair is the young, motivated patient with a traumatic tear without clinical or radiographic signs of muscular damage who is willing to undergo surgical intervention followed by 6 months of rehabilitation. Contraindications to this technique are patients unwilling to undergo the procedure and associated rehabilitation and patients with evidence of fatty degenerated subscapularis musculature, an associated massive superior/posterior rotator cuff tear, a n d / o r static anterior subluxation of the humeral head.
AUTHORS'PREFERRED TREATMENT Surgical Approach
One of three surgical approaches can be used when addressing tears of the subscapularis tendon: arthroscopic, deltopectoral, or anterior deltoid-splitting. Although arthroscopic repair of the subscapularis is technically possible, we believe that arthroscopy gives inadequate visualization of partial tears involving the superior portion of the tendon. In these "hidden" lesions of the subscapularis, the overlying bicipital pulley may not be disrupted, making arthroscopic diagnosis difficult, hence, we rarely address repair of subscapularis lesions arthroscopically. Classically, the deltopectoral approach is used in the repair of subscapularis tears, providing the best visualization of the entire subscapularis tendon. This is our approach of choice when repairing isolated, complete, or retracted tears of the subscapularis. For partial tears or in the event that an associated supraspinatus/infraspinatus lesion exists, we prefer use of an anterior deltoid-splitting approach that better addresses these lesions. EDWARDS AND WALCH
Fig 5. Completed surgical exposure with the anterior deltoid-splitting approach. Fig 4. Skin incision used for anterior deltoid-splitting approach.
For the anterior deltoid-splitting approach, a 7-cm skin incision is made, starting just posterior to the acromioclavicular joint and extending anteriorly parallel to Langer's lines (Fig 4). The anterior deltoid is split in line with its fibers, and a small flap of the deltoid origin is elevated from the anterior acromion starting just lateral to the acromioclavicular joint, which is not violated. A selfretaining retractor is placed to retract the medial and lateral deltoid. An osteotome is used to perform a small anterior acromioplasty, enhancing exposure of the subacromial bursa. The subacromial bursa is excised to reveal the underlying rotator cuff, completing the surgical exposure (Fig 5).
lesser tuberosity attachment using the closed tips of blunt Metzenbaum scissors (Fig 6). No "bare bone" should be palpable between the articular surface of the humeral head and the lesser tuberosity; if a bare area is palpated, this is diagnostic of a subscapularis lesion.
fO
Opening of the Rotator Interval and Bicipital Groove and Identification of the Subscapularis Tendon When using the anterior deltoid-splitting approach, manual traction is placed on the arm, revealing the rotator interval with the overlying coracohumeral ligament. The rotator interval is opened longitudinally from the glenoid, extending laterally to the bicipital groove. The bicipital groove is opened on its medial aspect to avoid the laterally based vasculature. At this time, the biceps tendon, the bicipital pulley, and the upper part of the subscapularis can be inspected. Inspection of the biceps and bicipital pulley is through direct visualization, observing for biceps subluxation or dislocation and tearing or distension of the ligamentous pulley. A biceps tenodesis is systematically performed in all patients with a subscapularis tear using the technique developed by the senior author (G.W.) (see the related article by us in this issue). Inspection of the subscapularis tendon requires palpation of the tendon's REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
Fig 6. Palpation of the attachment of the subscapularis insertion with Metzenbaum scissors. 89
Fig 7. Identification of the superior aspect of the subscapularis tendon as seen from the anterior deltoid-splitting approach. The middle glenohumeral ligament is easily visualized as well.
With either the anterior or the deltopectoral approach, the superior margin of the subscapularis tendon must then be identified. When using the anterior approach, this identification is aided by pushing the humeral head in a posterior direction, using direct force with an instrument such as a bone tamp, and looking for the tendon from inside the glenohumeral joint. Once the tendon is visualized, a traction suture is placed in the tendon to aid in later reinsertion (Fig 7). In complete tears, a second traction suture is placed inferior to the first.
Fig 8. Safe division of the inferior glenohumeral ligament performed through a deltopectoral approach. The subscapularis muscle belly protects the axillary nerve during ligament transection.
Subscapularis Tendon Release and Reinsertion
the surface with a curette. In the past, we have used transosseous sutures and suture anchors for tendon reinsertion; however, we began using metallic staples because of the optimized contact area provided by this device. After witnessing migration of a few of these staples late in the postoperative period after tendon healing, we have begun using a cannulated bioabsorbable screw (Biocorkscrew; Arthrex Inc, Naples, FL) to avoid this complication. This has clinically performed well, providing excellent contact area and purchase. Additionally, the bioabsorb-
Traction is applied to the previously placed sutures to test the mobility of the subscapularis tendon. In the event that the tendon is retracted and not sufficiently mobile to permit reinsertion, a systematic release of the glenohumeral ligameIits and overlying subscapularis bursa is performed to attain the required tendon mobilization. The superior aspect of the tendon is freed from surrounding structures (coracohumeral ligament) by passing Metzenbaum scissors along the superior aspect of the tendon to the level of the gle~oid. The middle glenohumeral ligament can then be released again using the scissors. If the tendon is still not sufficiently mobile, the inferior glenohumeral ligament can be divided along with any adhesions within the subscapularis bursa. In the case of these retracted tears in which release of the glenohumeral ligaments is anticipated, a deltopectoral approach is generally used, allowing identification of the axillary nerve and safe release of the inferior glenohumeral ligament in a plane deep to the subscapularis musculature protecting the nerve (Fig 8). The release of the glenohumeral ligaments carries the theoretical risk of postoperative instability, although we have not observed this. Because of the relatively thin nature of the subscapularis tendon, we avoid z-plasty lengthening. After the tendon is sufficiently mobilized, the bare bone area on the lesser tuberosity is prepared for tendon reinsertion by removing remaining soft tissue and roughening
Fig 9. Placement of the guide wire for the cannulated bioabsorbable screw.
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EDWARDSAND WALCH
The Biocorkscrew is then advanced over the guide wire, securing the tendon to the bone (Fig 10). The number of Biocorkscrews used depends on the size of the tear, with three or four being used for complete detachments. When placing multiple Biocorkscrews, the inferior ones should be placed first, facilitating placement of those located more superior. The stability of the repair and the range of motion are then tested and recorded for later use in postoperative rehabilitation. A no. 1 braided nonabsorbable suture is then used to close the rotator interval.
Deltoid Reattachment Meticulous repair of the deltoid to the acromion using transosseous sutures is imperative. Our technique for deltoid reinsertion is shown in Fig 11. Using this technique, we have seen only two complications involving the deltoid in more than 1,200 cases. The w o u n d is then closed in layers over a drain. The patient is placed in a simple sling or 30 ° abduction sling, depending on whether supraspinatus/infraspinatus repair was also performed.
Fig 10. Final construct with the use of three bioabsorbable screws for subscapularis reinsertion.
able nature of this device minimizes concerns of late-term migration. After preparation of the lesser tuberosity, the previously placed traction sutures are used to reapproximate the subscapularis tendon to the lesser tuberosity. A guide pin for the Biocorkscrew is placed using the cannulated instrumentation (Fig 9). In most cases, the "tapping" step can be bypassed, although it may be necessary in very hard bone.
COMPLICATIONS Complications of subscapularis reattachment are those shared by other rotator cuff procedures. 25 Postoperative stiffness is the major risk after subscapularis repair. To avoid this complication, only patients without preoperative stiffness are selected for repair. Early, aggressive physiotherapy is instituted, consisting of a passive mobility protocol based on hydrotherapy. Details of this rehabilitation protocol are outlined in the following section. Another concern with any rotator cuff repair is that of repair failure. Although actual repair failure is tough to
Fig 11. (A) and (B) Technique of deltoid reattachment. A no. 2 nonabsorbable braided suture is placed through the deltoid at the aponeurosis from lateral to medial, through the acromion from superior to inferior, back through the acromion from inferior to superior, and finally back through the deltoid from medial to lateral. The repair is then further secured with additional intermuscular sutures using a simple, interrupted technique. REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
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d e f i n e w i t h o u t s u r g i c a l e x p l o r a t i o n , c l i n i c a l l y e v i d e n t rep a i r f a i l u r e h a s b e e n u n c o m m o n . I n 72 c a s e s of i s o l a t e d subscapularis tears with a minimum 1-year follow-up and r e p a i r e d w i t h a v a r i e t y of t e c h n i q u e s , w e h a v e o n l y o b s e r v e d 2 c a s e s of r e - r u p t u r e 5 5 W e h a v e m o r e f r e q u e n t l y w i t n e s s e d l a t e s t a p l e m i g r a t i o n a n d , b e c a u s e of this, n o w f a v o r b i o a b s o r b a b l e s c r e w fixation.
REHABILITATION P a s s i v e m o b i l i t y is i n i t i a t e d o n p o s t o p e r a t i v e d a y 1 w i t h t h e a i d of a p h y s i o t h e r a p i s t . P a s s i v e e x t e r n a l r o t a t i o n is l i m i t e d b a s e d o n i n t r a o p e r a t i v e r a n g e of m o t i o n a n d sec u r i t y o f t h e r e p a i r . O n p o s t o p e r a t i v e d a y 3, t h e h y d r o t h e r a p y is i n i t i a t e d a f t e r c o v e r i n g t h e s u r g i c a l w o u n d w i t h a n i m p e r m e a b l e d r e s s i n g . H y d r o t h e r a p y c o n s i s t s of s u b m e r g i n g t h e p a t i e n t i n a 34°C p o o l a n d c o m m e n c i n g p a s s i v e r a n g e of m o t i o n e x e r c i s e s like t h o s e u s e d b y N e e r et al. 26 H y d r o t h e r a p y s e s s i o n s a r e d o n e t w i c e p e r d a y w i t h a n i n t e r m i t t e n t s e s s i o n of l a n d - b a s e d r e h a b i l i t a t i o n . A f t e r 3 weeks, provided good mobility has been obtained, hyd r o t h e r a p y s e s s i o n s a r e d e c r e a s e d to t w i c e w e e k l y . Reh a b i l i t a t i o n c o n s i s t s o n l y of p a s s i v e m o b i l i z a t i o n ; n o s t r e n g t h e n i n g e x e r c i s e s a r e p e r f o r m e d . F u l l a c t i v i t y is all o w e d at 6 m o n t h s . F o r m o r e d e t a i l s of this p r o t o c o l , t h e r e a d e r is r e f e r r e d to t h e w o r k of L i o t a r d et al. 27,28
RESULTS R e s u l t s a f t e r r e p a i r of t h e s u b s c a p u l a r i s c a n g e n e r a l l y b e e x p e c t e d to b e g o o d . 1,3,8,1°,15,29 I n o u r y e t - t o - b e p u b l i s h e d s e r i e s of 72 c a s e s of i s o l a t e d s u b s c a p u l a r i s r u p t u r e w i t h a n a v e r a g e f o l l o w - u p o f 32 m o n t h s ( m i n i m u m f o l l o w - u p , 12 m o n t h s ) , w e h a v e o b s e r v e d 96% g o o d a n d e x c e l l e n t s u b j e c t i v e r e s u l t s u s i n g r e p a i r (62 cases) o r a r t h r o s c o p i c d e b r i d e m e n t (10 cases) b a s e d o n t h e p r e v i o u s l y m e n t i o n e d criteria. T h e C o n s t a n t s c o r e i m p r o v e d a m e a n of 23 p o i n t s f r o m t h e p r e o p e r a t i v e v a l u e at t h e l a t e s t p o s t o p e r a t i v e follow-up. Nineteen patients were involved in competitive s p o r t s b e f o r e t h e i r s h o u l d e r i n j u r y . A t l a t e s t f o l l o w - u p , 18 of t h e s e p a t i e n t s w e r e p a r t i c i p a t i n g at t h e i r p r e v i o u s l e v e l of c o m p e t i t i o n a n d 1 w a s p a r t i c i p a t i n g at a l o w e r level.
REFERENCES 1. Nove-Josserand L, Levigne C, Noel E, et al: Les lesions isol6es du sous scapulaire: Apropos de 21 cas. Rev Chir Orthop Reparatrice Appar Mot 80:595-601, 1994 2. Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 70:1308-1311, 1988 3. Pisan M, Gerber C: Repair of the subscapularis. Techniques Shoulder Elbow Surg 1:146-153, 2000 4. Symeonides PP: The significance of the subscapularis muscle in the pathogenesis of recurrent anterior shoulder instability. J Bone Joint Surg Br 54:476-483, 1972 5. Tucker WF Jr, Silliman JF: Disruption of the subscapularis, in Burkhead WZ (ed): Rotator Cuff Disorders. Baltimore, MD, Williams and Wilkins, pp 199-209, 1996
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6. Wirth MA, Rockwood CA Jr: Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am 79:722-731, 1997 7. Resch H, Povacz P, Ritter E, et al: Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am 82:372-382, 2000 8. Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 25:13-22, 1997 9. Gerber C, Krushell RJ: Isolated rupture of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 73:389-394, 1991 10. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 78:1015-1023, 1996 11. Kempf JF, Gleyze P, Bonnomet F, et al: A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthroscopy 15:56-66, 1999 12. Sakurai G, Ozaki J, Tomita Y, et al: Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 7:510-515, 1998 13. Walch G, Marechal E, Maupas J, et al: The surgical treatment of ruptures of the rotator cuff of the shoulder: Prognostic factors. Rev Chir Orthop Reparatrice Appar Mot 78:379-388, 1992 14. Walch G, Noveqosserand L, Levigne C, et al: Tears of the supraspinatus tendon associated with "hidden" lesions of the rotator interval. J Shoulder Elbow Surg 3:353-360, 1994 15. Walch G, Boulahia A, Edwards TB: Unpublished data 16. Nove-Josserand L, Levigne C, Noel E, et al: Les fractures chez I'adulte: Diagnostic, traitement. J Traumatol Sport 12:213-217, 1995 17. McAuliffe TB, Dowd GS: Avulsion of the subscapularis tendon: A case report. J Bone Joint Surg Am 69:1454-1455, 1987 18. Bernageau J, Goutallier D: Isolated lesions of the subscapularis tendon and internal malpositions of the biceps tendon: Apropos of 45 cases. J Radiol 78:1255-1263, 1997 19. Patten RM: Tears of the anterior portion of the rotator cuff (the subscapularis tendon): MR imaging findings. AJR Am J Roentgenol 162:351-354, 1994 20. Pfirrmann CW, Zanetti M, Weishaupt D, et al: Subscapularis tendon tears: Detection and grading at MR arthrography. Radiology 213:709714, 1999 21. Goutallier D, Postel JM, Bernageau J, et al: Fatty muscle degeneration in cuff ruptures: Pre- and postoperative evaluation by CT scan. Clin Orthop 304:78-83, 1994 22. Goutallier D, Postel JM, Lavau L, et al: Influence de la d6g6n6rescence graisseuse des muscles supra4pineux et infra6pineux sur le pronostic des reparations chirurgicales de la coiffe des rotateurs. Rev Chir Orthop Reparatrice Appar Mot 85:668-676, 1999 23. Fuchs B, Weishaupt D, Zanetfi M, et al: Fatty degeneration of the muscles of the rotator cuff: Assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 8:599605, 1999 24. Thomazeau H, Boukobza, E, Morcet N, et al: Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop 344:275283, 1997 25. Naranja RJ, Iannotti JP: Complications related to rotator cuff surgery, in Iannotti JP (ed): The Rotator Cuff: Current Concepts and Complex Problems. Rosemont, IL; American Academy of Orthopaedic Surgeons, 1998, pp 95-109 26. Neer CS II, McCann PD, McFarlane EA, et al: Earlier passive motion following shoulder arthroplasty and rotator cuff repair: A prospective study. Orthop Trans 11:231, 1987 27. Liotard JP: Rehabilitation following shoulder arthroplasty: Experience at a rehabilitation center, in Walch G, Boileau P (eds): Shoulder Arthroplasty. Berlin, Germany, Springer-Verlag, 1999, pp 383-389 28. Liotard JP, Expert JM, Mercanton G, et al: R66ducation de l'6paule. Encycl M6d Chir (Editions Techniques, Elsevier SAS, Paris), Kin6sith6rapie-R66ducation fonctionnelle, 210:1-23, 1995 29. Ticker JB, Warner JJ: Single-tendon tears of the rotator cuff: Evaluation and treatment of subscapularis tears and principles of treatment for supraspinatus tears. Orthop Clin North Am 28:99-116, 1997
EDWARDS AND WALCH
Tears of the subscapularis are much less common than tears of the supraspinatus and infraspinatus. Subscapularis lesions are usually traumatic in etiology and occur in younger patients. These lesions can be complete or limited to the superior insertion of the subscapularis, and they may be isolated or occur with other rotator cuff lesions. In most instances, treatment of subscapularis tears is surgical. In this article, we present the clinical and radiographic findings, discuss operative indications, and illustrate our preferred surgical technique for tears of the subscapularis tendon. KEY WORDS: Subscapularis tears, surgical technique, repair
Copyright 2002, Elsevier Science (USA). All rights reserved.
Tears of the subscapularis tendon are much less common than those of the supraspinatus and infraspinatus. Additionally, lesions of the rotator cuff isolated to the subscapularis are exceedingly rare, with 21 cases the largest series reported in the literature. 1 Traumatic anterior glenohumeral dislocation has been implicated as a cause of subscapularis tendon tear, particularly in patients older than 40 years. 2-7 Excluding these older patients with a prior shoulder dislocation, isolated subscapularis disruption tends to occur in a population younger than that sustaining tears of the supraspinatus and infraspinatus, and tends to be traumatic in etiology.8-1° Lesions of the subscapularis tendon have also been described to occur concomitantly with supraspinatus tears, biceps tendon pathology, and rotator interval lesions. 11-14 These associated subscapularis lesions can be complete or partial and are most often limited to the superior portion of the tendon. Additionally, particularly in the case of partial lesions, these tears may not be recognized during arthroscopy. 14 The purpose of this article is to review the clinical and radiographic findings of subscapularis tears, to describe our preferred operative technique, and give results of treatment for tears of the subscapularis tendon.
CLINICAL AND RADIOLOGICAL FINDINGS Patients with isolated lesions of the subscapularis often give a clinical history of trauma. Older patients have frequently had an associated glenohumeral dislocation. In
From the Minneapolis Sports Medicine Center, Minneapolis, MN, and Department of Orthopaedic Surgery, Clinique Ste. Anne Lumi6re, Lyon, France. The authors have not received any benefits for personal or professional use from a commercial party related to the subject of this manuscript. Address reprint requests to T. Bradley Edwards, MD, Minneapolis Sports Medicine Center, 9957 Valley View Rd, Eden Prairie, MN 55344 Copyright 2002, Elsevier Science (USA). All rights reserved. 1060-1872/02/1002-0002535.00/0 doi: 10.1053/ots m.2002.30173 86
younger patients, traumatic injury frequently includes a history of forced external rotation or forced extension of a partially abducted arm. 8 This mechanism may be the result of violent trauma, ie, a motor vehicle crash, or may be sustained during athletic participation. A subset of patients with isolated subscapularis tears exists with no recallable traumatic episode, suggesting that a degenerative etiology may play a role in certain isolated lesions. 1 Patients with a subscapularis tear associated with supraspinatus/infraspinatus lesions are less likely to give a history of trauma, because most of these lesions are degenerative in nature. 3 On clinical examination, different investigators have reported a variety of findings. 1,7-9 A complete examination of the shoulder is undertaken, specifically evaluating the status of the rotator cuff tendons. In the case of a complete subscapularis disruption, passive external rotation of the arm is classically increased, but may be normal or even decreased. 8 Active internal rotation may be decreased or normal. 8 The Jobe test for supraspinatus integrity will frequently show marked weakness with a subscapularis tear, even in the absence of supraspinatus pathology. 1,8 Internal rotation strength is typically compromised by 1 muscle gradation. 1,8 We use 2 tests especially for evaluation of subscapularis integrity: the "lift-off" test and the "belly-press" test. 7,9 The lift-off test, as described and validated by Gerber, is frequently positive in patients with a complete subscapularis disruption; however, pain and limited internal rotation can limit the usefulness of this test (Fig 1). 1,8,9 Additionally, the examiner must be vigilant to ensure that the patient does not recruit other means (use of elbow motion) to perform the objective of the test. In the belly-press test, the patient is asked to forcefully pull the examiner's hand toward his or her abdomen; if the wrist is flexed and the arm is extended in the accomplishment of this test, the test is considered representative of subscapularis insufficiency (Fig 2). Findings are more variable in patients with partial subscapularis lesions. 14,15These are frequently combined with lesions of the supraspinatus; hence, testing of the su-
Operative Techniques in Sports Medicine, Vol 10, No 2 (April), 2002: pp 86-92
Fig 1. (A) Negative lift-off test. The patient is able to keep his hand from resting on his back during shoulder internal rotation. (B) Positive lift-off test. The patient cannot lift his hand off of his back.
praspinatus often yields positive findings. The presence of a positive lift-off test and positive belly-press test are less reliable with these incomplete tears. Frequently, minimally decreased strength in internal rotation is all that is noted on examination of the subscapularis. Plain radiography typically does not yield positive findings in subscapularis tears. Avulsions of the lesser
tuberosity have been reported, but these cases are exceedingly rare. 16,17 In the patient with a suspected prior glenohumeral dislocation or subluxation, radiographs m a y show instability lesions (humeral head impaction fracture or bony glenoid rim lesion), but these do not necessarily correlate with subscapularis injury.
Fig 2. (A) Negative belly-press test. The patient is able to press on his abdomen while maintaining his wrist in neutral position and his elbow in front of his body. (B) Positive belly-press test. As the patient presses his abdomen, the wrist is flexed and the arm is extended. REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
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Fig 3. Computed tomographic arthrogram showing contrast medial to the biceps sheath at the level of the lesser tuberosity (arrow) indicating detachment of the upper portion of the subscapularis tendon.
Arthrography can be used in the diagnosis of subscapularis tears if the biceps tendon is dislocated medially from the bicipital groove. 9,18 This bicipital dislocation generally only occurs with a large lesion of the subscapularis and also requires that the ligamentous pulley be disrupted. In the case of small tears without biceps dislocation, an arthrogram may be normal. Computed tomographic arthrography and magnetic resonance imaging have both been used as secondary imaging techniques for subscapularis disruption. 1,5,810,12,14,18,19 Complete subscapularis disruptions are readily diagnosed using either of these modalities; however, partial disruptions present a more difficult diagnostic scenario. By using computed tomographic arthrography, partial tears of the superior part of the subscapularis can be identified by the presence of contrast medial to the biceps tendon sheath at the level of the lesser tuberosity (Fig 3). These superior partial lesions may not be apparent on magnetic resonance imaging; however, magnetic resonance arthrography seems to be reliable in identifying these lesions. 2° In addition to evaluating the subscapularis tendon, computed tomography is used to evaluate the status of the subscapularis musculature. Fatty degeneration of the musculature is graded according to the method of Goutallier to assist in preoperative decision-making and in establishment of a prognosis. 21,22Alternatively, magnetic resonance imaging can be used to grade rotator cuff fatty degeneration and atrophy although it has not been found to correlate with computed tomographic grading. 23,24
INDICATIONS AND CONTRAINDICATIONS FOR TREATMENT The indications for repair of the ruptured subscapularis are based on multifactorial criteria. Patient history is taken into account. The patient's clinical examination, specifically the function of the injured shoulder, also plays a crucial role. Additionally, the imaging studies obtained 88
before operative intervention play a critical role in selecting the appropriate patient for subscapularis repair. Patient history, including the patient's age, motivation, activity level, and expectations after surgery, must be evaluated before undertaking subscapularis repair. Subscapularis repair is recommended in younger (less than 50 years), active patients with a tear of traumatic etiology. Older patients with a functional affected extremity and who complain only of pain may be more effectively treated by an arthroscopic debridement. 11 Additionally, a patient must be of sufficient motivation, including willingness to undergo 6 months of rehabilitation and convalescence, before repair should be undertaken. Physical examination divulges information regarding concomitant involvement of other rotator cuff tendons. Concomitant massive tears of the superior and posterior rotator cuff may contraindicate repair. Additionally, if stiffness is detected on clinical examination, a course of physiotherapy to regain passive mobility should be undertaken before subscapularis repair is considered. Secondary imaging studies are important in patient selection for operative treatment. The size of any associated supraspinatus and infraspinatus tears can be evaluated. Significant fatty degeneration of the subscapularis musculature represents a relative contraindication to repair. 21,22,24 Finally, static anterior subluxation of the humeral head is a poor prognostic indicator and a relative contraindication to repair. 3 In summary, the ideal candidate for subscapularis repair is the young, motivated patient with a traumatic tear without clinical or radiographic signs of muscular damage who is willing to undergo surgical intervention followed by 6 months of rehabilitation. Contraindications to this technique are patients unwilling to undergo the procedure and associated rehabilitation and patients with evidence of fatty degenerated subscapularis musculature, an associated massive superior/posterior rotator cuff tear, a n d / o r static anterior subluxation of the humeral head.
AUTHORS'PREFERRED TREATMENT Surgical Approach
One of three surgical approaches can be used when addressing tears of the subscapularis tendon: arthroscopic, deltopectoral, or anterior deltoid-splitting. Although arthroscopic repair of the subscapularis is technically possible, we believe that arthroscopy gives inadequate visualization of partial tears involving the superior portion of the tendon. In these "hidden" lesions of the subscapularis, the overlying bicipital pulley may not be disrupted, making arthroscopic diagnosis difficult, hence, we rarely address repair of subscapularis lesions arthroscopically. Classically, the deltopectoral approach is used in the repair of subscapularis tears, providing the best visualization of the entire subscapularis tendon. This is our approach of choice when repairing isolated, complete, or retracted tears of the subscapularis. For partial tears or in the event that an associated supraspinatus/infraspinatus lesion exists, we prefer use of an anterior deltoid-splitting approach that better addresses these lesions. EDWARDS AND WALCH
Fig 5. Completed surgical exposure with the anterior deltoid-splitting approach. Fig 4. Skin incision used for anterior deltoid-splitting approach.
For the anterior deltoid-splitting approach, a 7-cm skin incision is made, starting just posterior to the acromioclavicular joint and extending anteriorly parallel to Langer's lines (Fig 4). The anterior deltoid is split in line with its fibers, and a small flap of the deltoid origin is elevated from the anterior acromion starting just lateral to the acromioclavicular joint, which is not violated. A selfretaining retractor is placed to retract the medial and lateral deltoid. An osteotome is used to perform a small anterior acromioplasty, enhancing exposure of the subacromial bursa. The subacromial bursa is excised to reveal the underlying rotator cuff, completing the surgical exposure (Fig 5).
lesser tuberosity attachment using the closed tips of blunt Metzenbaum scissors (Fig 6). No "bare bone" should be palpable between the articular surface of the humeral head and the lesser tuberosity; if a bare area is palpated, this is diagnostic of a subscapularis lesion.
fO
Opening of the Rotator Interval and Bicipital Groove and Identification of the Subscapularis Tendon When using the anterior deltoid-splitting approach, manual traction is placed on the arm, revealing the rotator interval with the overlying coracohumeral ligament. The rotator interval is opened longitudinally from the glenoid, extending laterally to the bicipital groove. The bicipital groove is opened on its medial aspect to avoid the laterally based vasculature. At this time, the biceps tendon, the bicipital pulley, and the upper part of the subscapularis can be inspected. Inspection of the biceps and bicipital pulley is through direct visualization, observing for biceps subluxation or dislocation and tearing or distension of the ligamentous pulley. A biceps tenodesis is systematically performed in all patients with a subscapularis tear using the technique developed by the senior author (G.W.) (see the related article by us in this issue). Inspection of the subscapularis tendon requires palpation of the tendon's REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
Fig 6. Palpation of the attachment of the subscapularis insertion with Metzenbaum scissors. 89
Fig 7. Identification of the superior aspect of the subscapularis tendon as seen from the anterior deltoid-splitting approach. The middle glenohumeral ligament is easily visualized as well.
With either the anterior or the deltopectoral approach, the superior margin of the subscapularis tendon must then be identified. When using the anterior approach, this identification is aided by pushing the humeral head in a posterior direction, using direct force with an instrument such as a bone tamp, and looking for the tendon from inside the glenohumeral joint. Once the tendon is visualized, a traction suture is placed in the tendon to aid in later reinsertion (Fig 7). In complete tears, a second traction suture is placed inferior to the first.
Fig 8. Safe division of the inferior glenohumeral ligament performed through a deltopectoral approach. The subscapularis muscle belly protects the axillary nerve during ligament transection.
Subscapularis Tendon Release and Reinsertion
the surface with a curette. In the past, we have used transosseous sutures and suture anchors for tendon reinsertion; however, we began using metallic staples because of the optimized contact area provided by this device. After witnessing migration of a few of these staples late in the postoperative period after tendon healing, we have begun using a cannulated bioabsorbable screw (Biocorkscrew; Arthrex Inc, Naples, FL) to avoid this complication. This has clinically performed well, providing excellent contact area and purchase. Additionally, the bioabsorb-
Traction is applied to the previously placed sutures to test the mobility of the subscapularis tendon. In the event that the tendon is retracted and not sufficiently mobile to permit reinsertion, a systematic release of the glenohumeral ligameIits and overlying subscapularis bursa is performed to attain the required tendon mobilization. The superior aspect of the tendon is freed from surrounding structures (coracohumeral ligament) by passing Metzenbaum scissors along the superior aspect of the tendon to the level of the gle~oid. The middle glenohumeral ligament can then be released again using the scissors. If the tendon is still not sufficiently mobile, the inferior glenohumeral ligament can be divided along with any adhesions within the subscapularis bursa. In the case of these retracted tears in which release of the glenohumeral ligaments is anticipated, a deltopectoral approach is generally used, allowing identification of the axillary nerve and safe release of the inferior glenohumeral ligament in a plane deep to the subscapularis musculature protecting the nerve (Fig 8). The release of the glenohumeral ligaments carries the theoretical risk of postoperative instability, although we have not observed this. Because of the relatively thin nature of the subscapularis tendon, we avoid z-plasty lengthening. After the tendon is sufficiently mobilized, the bare bone area on the lesser tuberosity is prepared for tendon reinsertion by removing remaining soft tissue and roughening
Fig 9. Placement of the guide wire for the cannulated bioabsorbable screw.
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EDWARDSAND WALCH
The Biocorkscrew is then advanced over the guide wire, securing the tendon to the bone (Fig 10). The number of Biocorkscrews used depends on the size of the tear, with three or four being used for complete detachments. When placing multiple Biocorkscrews, the inferior ones should be placed first, facilitating placement of those located more superior. The stability of the repair and the range of motion are then tested and recorded for later use in postoperative rehabilitation. A no. 1 braided nonabsorbable suture is then used to close the rotator interval.
Deltoid Reattachment Meticulous repair of the deltoid to the acromion using transosseous sutures is imperative. Our technique for deltoid reinsertion is shown in Fig 11. Using this technique, we have seen only two complications involving the deltoid in more than 1,200 cases. The w o u n d is then closed in layers over a drain. The patient is placed in a simple sling or 30 ° abduction sling, depending on whether supraspinatus/infraspinatus repair was also performed.
Fig 10. Final construct with the use of three bioabsorbable screws for subscapularis reinsertion.
able nature of this device minimizes concerns of late-term migration. After preparation of the lesser tuberosity, the previously placed traction sutures are used to reapproximate the subscapularis tendon to the lesser tuberosity. A guide pin for the Biocorkscrew is placed using the cannulated instrumentation (Fig 9). In most cases, the "tapping" step can be bypassed, although it may be necessary in very hard bone.
COMPLICATIONS Complications of subscapularis reattachment are those shared by other rotator cuff procedures. 25 Postoperative stiffness is the major risk after subscapularis repair. To avoid this complication, only patients without preoperative stiffness are selected for repair. Early, aggressive physiotherapy is instituted, consisting of a passive mobility protocol based on hydrotherapy. Details of this rehabilitation protocol are outlined in the following section. Another concern with any rotator cuff repair is that of repair failure. Although actual repair failure is tough to
Fig 11. (A) and (B) Technique of deltoid reattachment. A no. 2 nonabsorbable braided suture is placed through the deltoid at the aponeurosis from lateral to medial, through the acromion from superior to inferior, back through the acromion from inferior to superior, and finally back through the deltoid from medial to lateral. The repair is then further secured with additional intermuscular sutures using a simple, interrupted technique. REPAIR OF TEARS OF THE SUBSCAPULARIS TENDON
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d e f i n e w i t h o u t s u r g i c a l e x p l o r a t i o n , c l i n i c a l l y e v i d e n t rep a i r f a i l u r e h a s b e e n u n c o m m o n . I n 72 c a s e s of i s o l a t e d subscapularis tears with a minimum 1-year follow-up and r e p a i r e d w i t h a v a r i e t y of t e c h n i q u e s , w e h a v e o n l y o b s e r v e d 2 c a s e s of r e - r u p t u r e 5 5 W e h a v e m o r e f r e q u e n t l y w i t n e s s e d l a t e s t a p l e m i g r a t i o n a n d , b e c a u s e of this, n o w f a v o r b i o a b s o r b a b l e s c r e w fixation.
REHABILITATION P a s s i v e m o b i l i t y is i n i t i a t e d o n p o s t o p e r a t i v e d a y 1 w i t h t h e a i d of a p h y s i o t h e r a p i s t . P a s s i v e e x t e r n a l r o t a t i o n is l i m i t e d b a s e d o n i n t r a o p e r a t i v e r a n g e of m o t i o n a n d sec u r i t y o f t h e r e p a i r . O n p o s t o p e r a t i v e d a y 3, t h e h y d r o t h e r a p y is i n i t i a t e d a f t e r c o v e r i n g t h e s u r g i c a l w o u n d w i t h a n i m p e r m e a b l e d r e s s i n g . H y d r o t h e r a p y c o n s i s t s of s u b m e r g i n g t h e p a t i e n t i n a 34°C p o o l a n d c o m m e n c i n g p a s s i v e r a n g e of m o t i o n e x e r c i s e s like t h o s e u s e d b y N e e r et al. 26 H y d r o t h e r a p y s e s s i o n s a r e d o n e t w i c e p e r d a y w i t h a n i n t e r m i t t e n t s e s s i o n of l a n d - b a s e d r e h a b i l i t a t i o n . A f t e r 3 weeks, provided good mobility has been obtained, hyd r o t h e r a p y s e s s i o n s a r e d e c r e a s e d to t w i c e w e e k l y . Reh a b i l i t a t i o n c o n s i s t s o n l y of p a s s i v e m o b i l i z a t i o n ; n o s t r e n g t h e n i n g e x e r c i s e s a r e p e r f o r m e d . F u l l a c t i v i t y is all o w e d at 6 m o n t h s . F o r m o r e d e t a i l s of this p r o t o c o l , t h e r e a d e r is r e f e r r e d to t h e w o r k of L i o t a r d et al. 27,28
RESULTS R e s u l t s a f t e r r e p a i r of t h e s u b s c a p u l a r i s c a n g e n e r a l l y b e e x p e c t e d to b e g o o d . 1,3,8,1°,15,29 I n o u r y e t - t o - b e p u b l i s h e d s e r i e s of 72 c a s e s of i s o l a t e d s u b s c a p u l a r i s r u p t u r e w i t h a n a v e r a g e f o l l o w - u p o f 32 m o n t h s ( m i n i m u m f o l l o w - u p , 12 m o n t h s ) , w e h a v e o b s e r v e d 96% g o o d a n d e x c e l l e n t s u b j e c t i v e r e s u l t s u s i n g r e p a i r (62 cases) o r a r t h r o s c o p i c d e b r i d e m e n t (10 cases) b a s e d o n t h e p r e v i o u s l y m e n t i o n e d criteria. T h e C o n s t a n t s c o r e i m p r o v e d a m e a n of 23 p o i n t s f r o m t h e p r e o p e r a t i v e v a l u e at t h e l a t e s t p o s t o p e r a t i v e follow-up. Nineteen patients were involved in competitive s p o r t s b e f o r e t h e i r s h o u l d e r i n j u r y . A t l a t e s t f o l l o w - u p , 18 of t h e s e p a t i e n t s w e r e p a r t i c i p a t i n g at t h e i r p r e v i o u s l e v e l of c o m p e t i t i o n a n d 1 w a s p a r t i c i p a t i n g at a l o w e r level.
REFERENCES 1. Nove-Josserand L, Levigne C, Noel E, et al: Les lesions isol6es du sous scapulaire: Apropos de 21 cas. Rev Chir Orthop Reparatrice Appar Mot 80:595-601, 1994 2. Neviaser RJ, Neviaser TJ, Neviaser JS: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am 70:1308-1311, 1988 3. Pisan M, Gerber C: Repair of the subscapularis. Techniques Shoulder Elbow Surg 1:146-153, 2000 4. Symeonides PP: The significance of the subscapularis muscle in the pathogenesis of recurrent anterior shoulder instability. J Bone Joint Surg Br 54:476-483, 1972 5. Tucker WF Jr, Silliman JF: Disruption of the subscapularis, in Burkhead WZ (ed): Rotator Cuff Disorders. Baltimore, MD, Williams and Wilkins, pp 199-209, 1996
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6. Wirth MA, Rockwood CA Jr: Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am 79:722-731, 1997 7. Resch H, Povacz P, Ritter E, et al: Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am 82:372-382, 2000 8. Deutsch A, Altchek DW, Veltri DM, et al: Traumatic tears of the subscapularis tendon: Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med 25:13-22, 1997 9. Gerber C, Krushell RJ: Isolated rupture of the subscapularis muscle: Clinical features in 16 cases. J Bone Joint Surg Br 73:389-394, 1991 10. Gerber C, Hersche O, Farron A: Isolated rupture of the subscapularis tendon. J Bone Joint Surg Am 78:1015-1023, 1996 11. Kempf JF, Gleyze P, Bonnomet F, et al: A multicenter study of 210 rotator cuff tears treated by arthroscopic acromioplasty. Arthroscopy 15:56-66, 1999 12. Sakurai G, Ozaki J, Tomita Y, et al: Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 7:510-515, 1998 13. Walch G, Marechal E, Maupas J, et al: The surgical treatment of ruptures of the rotator cuff of the shoulder: Prognostic factors. Rev Chir Orthop Reparatrice Appar Mot 78:379-388, 1992 14. Walch G, Noveqosserand L, Levigne C, et al: Tears of the supraspinatus tendon associated with "hidden" lesions of the rotator interval. J Shoulder Elbow Surg 3:353-360, 1994 15. Walch G, Boulahia A, Edwards TB: Unpublished data 16. Nove-Josserand L, Levigne C, Noel E, et al: Les fractures chez I'adulte: Diagnostic, traitement. J Traumatol Sport 12:213-217, 1995 17. McAuliffe TB, Dowd GS: Avulsion of the subscapularis tendon: A case report. J Bone Joint Surg Am 69:1454-1455, 1987 18. Bernageau J, Goutallier D: Isolated lesions of the subscapularis tendon and internal malpositions of the biceps tendon: Apropos of 45 cases. J Radiol 78:1255-1263, 1997 19. Patten RM: Tears of the anterior portion of the rotator cuff (the subscapularis tendon): MR imaging findings. AJR Am J Roentgenol 162:351-354, 1994 20. Pfirrmann CW, Zanetti M, Weishaupt D, et al: Subscapularis tendon tears: Detection and grading at MR arthrography. Radiology 213:709714, 1999 21. Goutallier D, Postel JM, Bernageau J, et al: Fatty muscle degeneration in cuff ruptures: Pre- and postoperative evaluation by CT scan. Clin Orthop 304:78-83, 1994 22. Goutallier D, Postel JM, Lavau L, et al: Influence de la d6g6n6rescence graisseuse des muscles supra4pineux et infra6pineux sur le pronostic des reparations chirurgicales de la coiffe des rotateurs. Rev Chir Orthop Reparatrice Appar Mot 85:668-676, 1999 23. Fuchs B, Weishaupt D, Zanetfi M, et al: Fatty degeneration of the muscles of the rotator cuff: Assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg 8:599605, 1999 24. Thomazeau H, Boukobza, E, Morcet N, et al: Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop 344:275283, 1997 25. Naranja RJ, Iannotti JP: Complications related to rotator cuff surgery, in Iannotti JP (ed): The Rotator Cuff: Current Concepts and Complex Problems. Rosemont, IL; American Academy of Orthopaedic Surgeons, 1998, pp 95-109 26. Neer CS II, McCann PD, McFarlane EA, et al: Earlier passive motion following shoulder arthroplasty and rotator cuff repair: A prospective study. Orthop Trans 11:231, 1987 27. Liotard JP: Rehabilitation following shoulder arthroplasty: Experience at a rehabilitation center, in Walch G, Boileau P (eds): Shoulder Arthroplasty. Berlin, Germany, Springer-Verlag, 1999, pp 383-389 28. Liotard JP, Expert JM, Mercanton G, et al: R66ducation de l'6paule. Encycl M6d Chir (Editions Techniques, Elsevier SAS, Paris), Kin6sith6rapie-R66ducation fonctionnelle, 210:1-23, 1995 29. Ticker JB, Warner JJ: Single-tendon tears of the rotator cuff: Evaluation and treatment of subscapularis tears and principles of treatment for supraspinatus tears. Orthop Clin North Am 28:99-116, 1997
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