**8. Arthroscopic repair**

**Figure 18.** Open subscap tear.

**7.1. Open repair**

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Open repair surgery is performed by deltopectoral approach or anterior deltoid splitting approach in beach chair position. The anterior deltoid splitting approach is mainly used in subscapularis tear associated with supraspinatus or infraspinatus. The deltopectoral approach is used in isolated subscapularis tear. In deltopectoral approach advantage is deltoid is still intact and we can visualize retracted subscapularis tendon. Careful blunt dissection should be done to protect axillary nerve as it lies inferior border of subscapularis. In both approaches we have to open rotator interval from bicipital groove to glenoid. We should be careful for any bicep tendon or supraspinatus pathologies. "Bare bone" will be present between the lesser tuberosity and articular humeral head when there will be complete tear of subscapularis. To visualize the superior subscapular tendon margin, the humeral head must be pushed posteriorly and the tendon seen inside the glenohumeral joint. Tendon should be isolated and then released from its insertion site. In the bare area on the lesser tuberosity with the help of suture anchors or intraosseous sutures the detached tendon is fixed. To fully mobilize the torn tendon if the tendon is too much retracted then release of glenohumeral ligament on the articular side

**Figure 19.** Open repair.

Arthroscopic subscapularis repair surgery can be done with the patient in lateral or beachchair position. Arthroscopy allows a complete visualization of intraarticular aspects of the joint. In proper position the subscapularis footprint can be visualized that is arm in abduction and internal rotation. For improved visualization of the footprint, a new technique described by Burkhart that is "Posterior lever push." In this technique, the elbow is grasped while a posterior force is applied on the humerus. This results into better visualization of subscapularis insertion site as the intact fibers are pulled away from footprint. This technique may increase the field of view by 5–10 mm. Another method is use of a 70° scope for better visualization of the footprint. The assessment of the tear depends upon the size, direction of the tear and the amount of retraction. It becomes highly impossible to distinguish from conjoint tendon when the tendon is totally retracted. In this situation, finding of "the comma sign," an arc-shaped area of tissue at the superior-most aspect of the subscapularis becomes important. Fibers from the superior glenohumeral ligament as well as the medial head of the coracohumeral ligament comprise the "comma" which serves as a useful lighthouse for the tendon edge.

Biceps tendon pathology like medial subluxation, tears and even SLAP lesions are common with Subscapularis tears, it should be evaluated. The biceps tenotomy or tenodesis is required in order to enhance visualization and protect the repair in case of these pathologies. After a tear of the subscapularis has been identified, subsequent repair should be performed before other shoulder areas are addressed.

Mainly three portals are made to repair the subscapularis.

The posterior portal (P) is the primary viewing portal as commonly used in glenohumeral arthroscopy.

An anterosuperolateral portal (AL) is used to prepare the subscapularis footprint as well as for repair. It lies just anterior to the biceps tendon and anterolateral edge of the acromion.

An anterior portal (AI), is made on just lateral to the coracoid process and it is used for anchor placement.

It becomes very difficult to treat retracted subscapularis tears due to inadequate immobilization. Lo and Burkhart describe the "interval slide in continuity" in which part of the rotator interval and coracohumeral ligament are resected and released in order to increase mobility of the subscapularis tendon. The coracohumeral ligament is "peeled away" from the lateral coracoid, which provides the subscapularis with greater excursion. Preservation of the coracohumeral ligament also allows stable tissue for any associated posterior tears to be approximated via margin convergence.

In this procedure foot print is made by using the same principles that are used for rotator cuff surgery. When the lesions are retracted the bone surface is carefully decorticated, the foot print and subchondral bone exposure is medialised up to 7 mm. Healing process and biological response at the bone tendon interface is improved by micro fractures [12].

Depending upon choices absorbable or non-absorbable anchor sutures can be used in same manner like rotator cuff repair surgery. In almost all cases single anchor suture can be sufficiently used. It is advised that biomechanically one anchor for each square cm. of bare foot print area. It is advised that double row repair has advantages like in rotator cuff surgery in terms of strength and least failure rates. You can use bridging sutures or knotless anchors alternatively. To pass the sutures we can use same techniques that we are using in rotator cuff surgery, paying attention that the sub-coracoid space is far narrower than the sub-acromial space. By using small instruments which pass within the tendon without damaging lesion further, double layer and splitting tears need to be noted. Diagnostic arthroscopy can be used in partial tears thus allowing to undertake transtendineous repair similarly to repair of "PASTA" lesions of the rotator cuff [13] (**Figures 20**–**31**).

**Figure 22.** Anchor inserted.

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**Figure 23.** Sutures management.

**Figure 24.** Sutures passing through tendon.

**Figure 20.** Arthroscopy positions and portals.

**Figure 21.** Arthroscopy glenohumeral view.

**Figure 22.** Anchor inserted.

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Figure 23. Sutures management.
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**Figure 20.** Arthroscopy positions and portals.

54 Advances in Shoulder Surgery

**Figure 21.** Arthroscopy glenohumeral view.

"PASTA" lesions of the rotator cuff [13] (**Figures 20**–**31**).

Depending upon choices absorbable or non-absorbable anchor sutures can be used in same manner like rotator cuff repair surgery. In almost all cases single anchor suture can be sufficiently used. It is advised that biomechanically one anchor for each square cm. of bare foot print area. It is advised that double row repair has advantages like in rotator cuff surgery in terms of strength and least failure rates. You can use bridging sutures or knotless anchors alternatively. To pass the sutures we can use same techniques that we are using in rotator cuff surgery, paying attention that the sub-coracoid space is far narrower than the sub-acromial space. By using small instruments which pass within the tendon without damaging lesion further, double layer and splitting tears need to be noted. Diagnostic arthroscopy can be used in partial tears thus allowing to undertake transtendineous repair similarly to repair of

**Figure 24.** Sutures passing through tendon.

**Figure 25.** Completed repair.

**Figure 28.** Suture passing through tendon.

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**Figure 29.** Special instrument for suture passing.

**Figure 30.** Suture management.

**Figure 26.** Tout tendon after repair.

**Figure 27.** Full thickness tear sub acromial view.

**Figure 28.** Suture passing through tendon.

**Figure 25.** Completed repair.

56 Advances in Shoulder Surgery

**Figure 26.** Tout tendon after repair.

**Figure 27.** Full thickness tear sub acromial view.

**Figure 29.** Special instrument for suture passing.

**Figure 30.** Suture management.

**Figure 31.** Final repair.
