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Single Portal Subscapular Repair by a Cross Shuttle Loop Technique
Single Portal Subscapular Repair by a Cross Shuttle Loop Technique Bancha Chernchujit, M.D., and Nalla Sandeep, M.S. Ortho
Abstract: With the rise in subscapular tendon tears, most of them being partial that eventually end up in complete tears, we present our experience in the management of such tears using a cross shuttle loop technique. This technique incorporates the advantages of a single portal for anchor placement and repair, easy to use cross loops in limited working space, and familiar viewing.
T
he subscapularis is more important for arm elevation and internal rotation than the other rotator cuff muscles.1,2 It must be repaired to balance the posterior forces of the rotator cuff for maintenance of good shoulder function.2 Most of these tears progress to complete tears; hence, addressing these injuries at the earliest and with the simplest surgical procedures becomes essential.3-7 Various techniques are described for partial subscapularis repair, many use more than one working portal for repair, and few are technically demanding.3,5,7,8 Especially in patients with other tendon injuries in the shoulder, one needs a less technically demanding procedure and surgical time. Our technique describes the use of cross shuttle loops for arthroscopic management of partial subscapular tendon tears that involves advantages of a single portal for anchor placement and repair and less surgical time.
Surgical Technique This technique uses cross shuttle loop sutures for the repair of subscapular tendon tears. From the Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Klong-Luang, Pathumthani, Thailand. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 19, 2016; accepted November 30, 2016. Address correspondence to Nalla Sandeep, M.S. Ortho, Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Klong 1, Klong-Luang, Pathumthani 12121, Thailand. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16903/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.012
The patient is operated in the beach-chair position with an assistant to hold the arm in the desired position (Fig 1, Table 1). As a general protocol we mark all the bony landmarks and portals for ease of surgery (Video 1). A 30 arthroscope is introduced into the glenohumeral joint through a standard posterior portal and diagnostic arthroscopy is performed. Subscapular tendon tear is confirmed and then assessed about its configuration, especially the quality (Fig 2). The status of biceps is evaluated; if it is healthy, only the subscapular tendon is repaired, and in case of any pathology, we perform arthroscopic biceps tenotomy using a radiofrequency device. The accessory-anterior portal is established in the rotator interval region after localization with a spinal needle by an inside-out technique. The needle is then replaced with a 7-mm threaded arthroscopic shoulder cannula (Conmed Linvatec, Bangkok, Thailand). With the arthroscope in the posterior portal, a 4.5-mm shaver and the radiofrequency device are introduced to be used in an alternating fashion through the accessory-anterior portal to open the rotator interval. The edge of the subscapular partial tendon tear is debrided until the healthy tissue is visible (Fig 3). Now through the accessory-anterior portal, a doubleloaded (2 threads) Y-Knot is hammered through the uppermost part of the subscapularis fossa (Fig 4). For creating a vertical loop, with the help of spectrum 1 (Conmed), a bite is taken superiorly through the tendon and the entire polydioxanone suture (PDS) is introduced into the joint. The outer end is clamped to avoid slippage and confusion. The inner end of the PDS is brought out of the joint along with one limb of the first suture thread and both are tied to each other. Now the outer end (clamped) of the PDS is pulled such that
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Fig 1. Left shoulder in the frontal view with the subscapularis tendon insertion at the lesser tuberosity of the humerus. The long head of the biceps runs in the interval between the supraspinatus tendon inserted at the greater tuberosity and subscapularis showing the technique: (A) torn partial articular side tear of the subscapular tendon and (B) the cross shuttle loop placed at the upper border of the subscapular tendon. A cross loop is formed by the vertical loop (red) and horizontal loop (green).
the limb of the suture shuttles through the tendon and is retrieved out. Another bite is taken inferiorly parallel to the previous one and a limb of the first thread is shuttled as the previous one. Now for creating a horizontal loop, another bite is taken few millimeters
medial to the previous 2 bites and a limb of the second suture thread is shuttled through the tendon and retrieved out (Fig 5), and the same is performed on the lateral aspect to create “þ” configuration as shown in Video 1.
Table 1. Step-by-Step Surgical Technique 1. After general anesthesia, place the patient in the beach-chair position with an assistant to hold the arm in the desired position. 2. Mark all landmarks and portals. 3. Perform diagnostic arthroscopy through the standard posterior portal, assess subscapularis tear, mainly, configuration and quality of tendon, status of biceps, and other rotator cuff muscles. In case of partial subscapularis tears, the cross shuttle loop technique is performed, and if biceps pathology is identified, biceps tenotomy is performed. 4. In this technique, establishment of an accessory-anterior portal and creation of a vertical loop and horizontal loop are needed. 5. Use a spinal needle and a No. 11 blade knife to place an accessory-anterior portal while viewing from the posterior portal. Open the rotator interval. 6. Use a 4.5-mm shaver through the accessory-anterior portal while the arm is in internal rotation to prepare the bony bed and the edge of the torn tendon. 7. Through the accessory-anterior portal (place a 7.0-mm threaded cannula over a switching stick into the joint), place a Y-Knot at the uppermost part of the subscapularis insertion and hammer it. 8. Place the arm in neutral rotation. The spectrum is used to take a bite superiorly from the subscapularis tendon and throw all the PDS inside the joint. The inner end of the PDS is taken out of the joint and tied to one limb of the first suture thread and then shuttled through the tendon. Another bite is taken inferiorly to create a vertical loop and another limb of the first suture thread shuttled like previously. 9. Now in a similar fashion, a horizontal loop is created by taking a bite few millimeters medial to the previous 2 bites and a limb of the second suture thread is shuttled. Similarly, few millimeters lateral to inferior and superior bites, take another bite and another limb of the second suture thread is shuttled. 10. Now the matching limbs of the suture thread, that is, superior and inferior limbs, are tied by a sliding knot; similarly, the medial and lateral limbs are tied thereby completing the procedure. PDS, polydioxanone suture.
SINGLE PORTAL SUBSCAPULAR REPAIR
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Fig 2. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the rotator interval superiorly, in middle, partial tear of the subscapular tendon at insertion, and inferiorly, the humeral head is seen.
Fig 4. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing passing of a Y-Knot through a 7-mm cannula on the left side and anchoring at the superior aspect of insertion of the subscapular tendon over the humerus and subscapularis tendon on the right side.
Now the superior and inferior limbs are tied by sliding arthroscopic knots on the anterior surface of the tendon; any excess length of the suture is cut using arthroscopic scissors. The 2 limbs of the second suture
thread tied in a similar fashion, thereby creating cross loops over the torn subscapularis tendon (Fig 6). At the end of the procedure, the adequacy of the repair is confirmed with a probe. The shoulder is tested
Fig 3. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing, superiorly, a 7-mm blue cannula in the rotator interval, through which a shaver is passed to the debride torn part of the subscapularis and the humeral head is seen inferiorly.
Fig 5. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the articular side of the subscapular tendon and shuttling of the suture (green) through the subscapularis tendon with the help of a polydioxanone suture (violet).
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B. CHERNCHUJIT AND N. SANDEEP Table 3. Advantages and Disadvantages Advantages Can be easily reproduced by an inexperienced surgeon No additional portals required Less surgical time Disadvantages Cannot be used in complete subscapularis tears, poor tendon quality, and advanced glenohumeral degenerative disease
exercises. Passive range of motion is performed only under the supervision of a physical therapist for the first 6 weeks, with no external rotation past 45 . At 6 weeks postoperatively, active assisted range of motion is initiated with a gradual progression to full range of motion. Strengthening exercises begin 12 weeks after the surgery. Return to unrestricted activities, including vigorous sports, is permitted at 6 months postoperatively. Fig 6. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the long head of the biceps superolaterally, the humeral head inferiorly, and the repaired subscapular tendon medially with cross shuttle loop stiches.
for a full range of motion to ensure that there is no excess tension on the repair (Table 2). The postoperative protocol consists of abduction sling immobilization with slight internal rotation for 6 weeks. Patients are limited to early pendulum shoulder
Table 2. Pearls, Pitfalls, and Indications Pearls The procedure can easily be performed with the patient in the beach-chair position. The surgeon should perform tenotomy of the biceps if unhealthy. While the surgeon is preparing the bony bed of the lesser tuberosity and placing the anchor, it is helpful to position the arm in internal rotation. After anchoring the suture to bone, check the strength by pulling out. The arm should be in neutral rotation while the surgeon is shuttling the sutures through the tendon. After taking a bite with the spectrum throw all PDS inside the joint and clamp the outer edge of the PDS to avoid confusion and slippage. Creating a vertical loop and horizontal loop is the key. Apply a sliding arthroscopic knot. At the endpoint of the procedure, the arm should easily rotate into full external rotation and the repair should be stable. Pitfalls Debridement medial or inferior to the coracoid base can endanger the anterior neurovascular structures of the shoulder. Failure of the anchor will lead to failure of the cross shuttle loop fixation. Indications Intraoperative evidence of partial articular tear of the subscapularis tendon with the good-quality remnant tendon. PDS, polydioxanone suture.
Discussion Numerous techniques of arthroscopic subscapularis tendon repair have been described in the literature.3,5-9 Subscapularis repair is technically demanding because of its intricate anatomy, difficult visualization, and instrumentation making surgery very tricky, whereas successful repair provides a satisfactory experience.5,8,10 The limitations and risks associated with this technique are very few in the authors’ experience; they being irreparable subscapularis tears, poor tendon quality, and advanced glenohumeral degenerative disease (Table 3). The cross shuttle loop technique is a simple method to perform arthroscopic subscapularis tendon repair. This technique allows for single portal placement for anchor and repair while one is visualizing through the posterior portal. No additional portal is required and can be easily reproduced by inexperienced surgeons also.
References 1. Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Jt Surg Br 1993;75:137-140. 2. Kuechle DK, Newman SR, Itoi E, Morrey BF, An KN. Shoulder muscle moment arms during horizontal flexion and elevation. J Shoulder Elb Surg 1997;6:429-439. 3. Strauss EJ, Salata MJ, Kercher J, et al. The arthroscopic management of partial-thickness rotator cuff tears: A systematic review of the literature. Arthroscopy 2011;27: 568-580. 4. Ticker JB, Burkhart SS. Why repair the subscapularis? A logical rationale. Arthroscopy 2011;27:1123-1128. 5. Richards DP, Burkhart SS, Lo IKY. Subscapularis tears: Arthroscopic repair techniques. Orthop Clin North Am 2003;34:485-498. 6. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143.
SINGLE PORTAL SUBSCAPULAR REPAIR 7. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002;18:454-463. 8. Denard PJ, Ldermann A, Burkhart SS. Double-row fixation of upper subscapularis tears with a single suture anchor. Arthroscopy 2011;27:1142-1149.
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9. Denard PJ, Burkhart SS. Arthroscopic recognition and repair of the torn subscapularis tendon. Arthrosc Tech 2013;2:e373-e379. 10. Denard PJ, Jiwani AZ, Ladermann A, Burkhart SS. Long-term outcome of arthroscopic subscapularis tendon repairs. Arthroscopy 2012;28:e7-e8 (suppl 1).
Abstract: With the rise in subscapular tendon tears, most of them being partial that eventually end up in complete tears, we present our experience in the management of such tears using a cross shuttle loop technique. This technique incorporates the advantages of a single portal for anchor placement and repair, easy to use cross loops in limited working space, and familiar viewing.
T
he subscapularis is more important for arm elevation and internal rotation than the other rotator cuff muscles.1,2 It must be repaired to balance the posterior forces of the rotator cuff for maintenance of good shoulder function.2 Most of these tears progress to complete tears; hence, addressing these injuries at the earliest and with the simplest surgical procedures becomes essential.3-7 Various techniques are described for partial subscapularis repair, many use more than one working portal for repair, and few are technically demanding.3,5,7,8 Especially in patients with other tendon injuries in the shoulder, one needs a less technically demanding procedure and surgical time. Our technique describes the use of cross shuttle loops for arthroscopic management of partial subscapular tendon tears that involves advantages of a single portal for anchor placement and repair and less surgical time.
Surgical Technique This technique uses cross shuttle loop sutures for the repair of subscapular tendon tears. From the Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Klong-Luang, Pathumthani, Thailand. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received September 19, 2016; accepted November 30, 2016. Address correspondence to Nalla Sandeep, M.S. Ortho, Department of Orthopaedic Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Klong 1, Klong-Luang, Pathumthani 12121, Thailand. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/16903/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.012
The patient is operated in the beach-chair position with an assistant to hold the arm in the desired position (Fig 1, Table 1). As a general protocol we mark all the bony landmarks and portals for ease of surgery (Video 1). A 30 arthroscope is introduced into the glenohumeral joint through a standard posterior portal and diagnostic arthroscopy is performed. Subscapular tendon tear is confirmed and then assessed about its configuration, especially the quality (Fig 2). The status of biceps is evaluated; if it is healthy, only the subscapular tendon is repaired, and in case of any pathology, we perform arthroscopic biceps tenotomy using a radiofrequency device. The accessory-anterior portal is established in the rotator interval region after localization with a spinal needle by an inside-out technique. The needle is then replaced with a 7-mm threaded arthroscopic shoulder cannula (Conmed Linvatec, Bangkok, Thailand). With the arthroscope in the posterior portal, a 4.5-mm shaver and the radiofrequency device are introduced to be used in an alternating fashion through the accessory-anterior portal to open the rotator interval. The edge of the subscapular partial tendon tear is debrided until the healthy tissue is visible (Fig 3). Now through the accessory-anterior portal, a doubleloaded (2 threads) Y-Knot is hammered through the uppermost part of the subscapularis fossa (Fig 4). For creating a vertical loop, with the help of spectrum 1 (Conmed), a bite is taken superiorly through the tendon and the entire polydioxanone suture (PDS) is introduced into the joint. The outer end is clamped to avoid slippage and confusion. The inner end of the PDS is brought out of the joint along with one limb of the first suture thread and both are tied to each other. Now the outer end (clamped) of the PDS is pulled such that
Arthroscopy Techniques, Vol 6, No 3 (June), 2017: pp e537-e541
e537
e538
B. CHERNCHUJIT AND N. SANDEEP
Fig 1. Left shoulder in the frontal view with the subscapularis tendon insertion at the lesser tuberosity of the humerus. The long head of the biceps runs in the interval between the supraspinatus tendon inserted at the greater tuberosity and subscapularis showing the technique: (A) torn partial articular side tear of the subscapular tendon and (B) the cross shuttle loop placed at the upper border of the subscapular tendon. A cross loop is formed by the vertical loop (red) and horizontal loop (green).
the limb of the suture shuttles through the tendon and is retrieved out. Another bite is taken inferiorly parallel to the previous one and a limb of the first thread is shuttled as the previous one. Now for creating a horizontal loop, another bite is taken few millimeters
medial to the previous 2 bites and a limb of the second suture thread is shuttled through the tendon and retrieved out (Fig 5), and the same is performed on the lateral aspect to create “þ” configuration as shown in Video 1.
Table 1. Step-by-Step Surgical Technique 1. After general anesthesia, place the patient in the beach-chair position with an assistant to hold the arm in the desired position. 2. Mark all landmarks and portals. 3. Perform diagnostic arthroscopy through the standard posterior portal, assess subscapularis tear, mainly, configuration and quality of tendon, status of biceps, and other rotator cuff muscles. In case of partial subscapularis tears, the cross shuttle loop technique is performed, and if biceps pathology is identified, biceps tenotomy is performed. 4. In this technique, establishment of an accessory-anterior portal and creation of a vertical loop and horizontal loop are needed. 5. Use a spinal needle and a No. 11 blade knife to place an accessory-anterior portal while viewing from the posterior portal. Open the rotator interval. 6. Use a 4.5-mm shaver through the accessory-anterior portal while the arm is in internal rotation to prepare the bony bed and the edge of the torn tendon. 7. Through the accessory-anterior portal (place a 7.0-mm threaded cannula over a switching stick into the joint), place a Y-Knot at the uppermost part of the subscapularis insertion and hammer it. 8. Place the arm in neutral rotation. The spectrum is used to take a bite superiorly from the subscapularis tendon and throw all the PDS inside the joint. The inner end of the PDS is taken out of the joint and tied to one limb of the first suture thread and then shuttled through the tendon. Another bite is taken inferiorly to create a vertical loop and another limb of the first suture thread shuttled like previously. 9. Now in a similar fashion, a horizontal loop is created by taking a bite few millimeters medial to the previous 2 bites and a limb of the second suture thread is shuttled. Similarly, few millimeters lateral to inferior and superior bites, take another bite and another limb of the second suture thread is shuttled. 10. Now the matching limbs of the suture thread, that is, superior and inferior limbs, are tied by a sliding knot; similarly, the medial and lateral limbs are tied thereby completing the procedure. PDS, polydioxanone suture.
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Fig 2. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the rotator interval superiorly, in middle, partial tear of the subscapular tendon at insertion, and inferiorly, the humeral head is seen.
Fig 4. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing passing of a Y-Knot through a 7-mm cannula on the left side and anchoring at the superior aspect of insertion of the subscapular tendon over the humerus and subscapularis tendon on the right side.
Now the superior and inferior limbs are tied by sliding arthroscopic knots on the anterior surface of the tendon; any excess length of the suture is cut using arthroscopic scissors. The 2 limbs of the second suture
thread tied in a similar fashion, thereby creating cross loops over the torn subscapularis tendon (Fig 6). At the end of the procedure, the adequacy of the repair is confirmed with a probe. The shoulder is tested
Fig 3. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing, superiorly, a 7-mm blue cannula in the rotator interval, through which a shaver is passed to the debride torn part of the subscapularis and the humeral head is seen inferiorly.
Fig 5. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the articular side of the subscapular tendon and shuttling of the suture (green) through the subscapularis tendon with the help of a polydioxanone suture (violet).
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B. CHERNCHUJIT AND N. SANDEEP Table 3. Advantages and Disadvantages Advantages Can be easily reproduced by an inexperienced surgeon No additional portals required Less surgical time Disadvantages Cannot be used in complete subscapularis tears, poor tendon quality, and advanced glenohumeral degenerative disease
exercises. Passive range of motion is performed only under the supervision of a physical therapist for the first 6 weeks, with no external rotation past 45 . At 6 weeks postoperatively, active assisted range of motion is initiated with a gradual progression to full range of motion. Strengthening exercises begin 12 weeks after the surgery. Return to unrestricted activities, including vigorous sports, is permitted at 6 months postoperatively. Fig 6. Arthroscopic view from the posterior portal in a left shoulder with a 30 arthroscope, patient in the beach-chair position showing the long head of the biceps superolaterally, the humeral head inferiorly, and the repaired subscapular tendon medially with cross shuttle loop stiches.
for a full range of motion to ensure that there is no excess tension on the repair (Table 2). The postoperative protocol consists of abduction sling immobilization with slight internal rotation for 6 weeks. Patients are limited to early pendulum shoulder
Table 2. Pearls, Pitfalls, and Indications Pearls The procedure can easily be performed with the patient in the beach-chair position. The surgeon should perform tenotomy of the biceps if unhealthy. While the surgeon is preparing the bony bed of the lesser tuberosity and placing the anchor, it is helpful to position the arm in internal rotation. After anchoring the suture to bone, check the strength by pulling out. The arm should be in neutral rotation while the surgeon is shuttling the sutures through the tendon. After taking a bite with the spectrum throw all PDS inside the joint and clamp the outer edge of the PDS to avoid confusion and slippage. Creating a vertical loop and horizontal loop is the key. Apply a sliding arthroscopic knot. At the endpoint of the procedure, the arm should easily rotate into full external rotation and the repair should be stable. Pitfalls Debridement medial or inferior to the coracoid base can endanger the anterior neurovascular structures of the shoulder. Failure of the anchor will lead to failure of the cross shuttle loop fixation. Indications Intraoperative evidence of partial articular tear of the subscapularis tendon with the good-quality remnant tendon. PDS, polydioxanone suture.
Discussion Numerous techniques of arthroscopic subscapularis tendon repair have been described in the literature.3,5-9 Subscapularis repair is technically demanding because of its intricate anatomy, difficult visualization, and instrumentation making surgery very tricky, whereas successful repair provides a satisfactory experience.5,8,10 The limitations and risks associated with this technique are very few in the authors’ experience; they being irreparable subscapularis tears, poor tendon quality, and advanced glenohumeral degenerative disease (Table 3). The cross shuttle loop technique is a simple method to perform arthroscopic subscapularis tendon repair. This technique allows for single portal placement for anchor and repair while one is visualizing through the posterior portal. No additional portal is required and can be easily reproduced by inexperienced surgeons also.
References 1. Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Jt Surg Br 1993;75:137-140. 2. Kuechle DK, Newman SR, Itoi E, Morrey BF, An KN. Shoulder muscle moment arms during horizontal flexion and elevation. J Shoulder Elb Surg 1997;6:429-439. 3. Strauss EJ, Salata MJ, Kercher J, et al. The arthroscopic management of partial-thickness rotator cuff tears: A systematic review of the literature. Arthroscopy 2011;27: 568-580. 4. Ticker JB, Burkhart SS. Why repair the subscapularis? A logical rationale. Arthroscopy 2011;27:1123-1128. 5. Richards DP, Burkhart SS, Lo IKY. Subscapularis tears: Arthroscopic repair techniques. Orthop Clin North Am 2003;34:485-498. 6. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143.
SINGLE PORTAL SUBSCAPULAR REPAIR 7. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: Technique and preliminary results. Arthroscopy 2002;18:454-463. 8. Denard PJ, Ldermann A, Burkhart SS. Double-row fixation of upper subscapularis tears with a single suture anchor. Arthroscopy 2011;27:1142-1149.
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9. Denard PJ, Burkhart SS. Arthroscopic recognition and repair of the torn subscapularis tendon. Arthrosc Tech 2013;2:e373-e379. 10. Denard PJ, Jiwani AZ, Ladermann A, Burkhart SS. Long-term outcome of arthroscopic subscapularis tendon repairs. Arthroscopy 2012;28:e7-e8 (suppl 1).