Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?

doi:10.1016/j.jse.2005.07.013

Journal of Shoulder and Elbow Surgery

Volume 15, Issue 6, November–December 2006, Pages 659-664

https://doi.org/10.1016/j.jse.2005.07.013 Get rights and content

Ruptures of the subscapularis tendon, isolated or combined, are rare, and the treatment modalities are controversial. Of 1345 patients who underwent rotator cuff repair in a 7-year period, 73 had either an isolated rupture of the subscapularis or a subscapularis rupture combined with rupture of the supraspinatus. All reconstructions were performed through a deltopectoral approach. Reinsertion of the subscapularis was combined with reconstruction of the supraspinatus in 32 patients. Of the patients, 63 (86%) were re-examined at a mean follow-up of 35 months. The modified Constant score improved from 62% preoperatively to 91% at follow-up. Isolated or combined reconstructions did not result in significant differences with respect to the Constant score. Of the patients, 62 (98%) were satisfied with the operation. Rerupture was found by ultrasound in 8 subscapularis tendons (13%) and 4 supraspinatus tendons (13%). The rerupture rate showed a significant correlation with the Goutallier stage of fatty degeneration and the interval between injury and operation.

Section snippets

Materials and methods

In the period from 1995 to 2001, 1345 reconstructions of ruptures of the rotator cuff were performed at the Schulthess Clinic, Zurich, Switzerland. Of these, 73 involved either an isolated rupture of the subscapularis (at least two thirds of the insertion) or combined ruptures of the subscapularis and supraspinatus, which correspond to 5.5% of the patients. For this retrospective study, 63 (86%) patients were available for follow-up. Of the 10 patients who were not available, 3 had died, 5

Results

Repair of the subscapularis was carried out in all 63 shoulders in the follow-up group. All subscapularis tendons could be reinserted via the mobilization technique described, and transfer surgery because of excessive tendon retraction was not necessary.

In 32 patients (51%), reinsertion of the subscapularis was combined with reconstruction of the supraspinatus. In 36 cases (57%), the long head of the biceps tendon was tenodesed. In addition, 17 patients (27%) also underwent an acromioplasty,

Discussion

Injury to the subscapularis tendon, particularly as a result of a complete rupture, may lead to considerable changes to the shoulder mechanism.5, 29 In the long term, this can result in severe secondary damage with lasting loss of function.³ Because patients with a rupture of the subscapularis tend to be young, usually men of working age, long-term consequences of this kind are also relevant in economic terms.¹³ This is why surgical reinsertion of ruptures of this kind represents the treatment

References (33)

W.F. Bennett
Arthroscopic repair of isolated subscapularis tears: a prospective cohort with 2- to 4-year follow-up
Arthroscopy
(2003)
J.J. Brems
Arthritis of dislocation
Orthop Clin North Am
(1998)
L. Bryant et al.
A comparison of clinical estimation, ultrasonography, magnetic resonance imaging, and arthroscopy in determining the size of rotator cuff tears
J Shoulder Elbow Surg
(2002)
S.S. Burkhart et al.
Arthroscopic subscapularis tendon repair: technique and preliminary results
Arthroscopy
(2002)
B. Fuchs et al.
Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging
J Shoulder Elbow Surg
(1999)
D. Goutallier et al.
Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears
J Shoulder Elbow Surg
(2003)
C. Martin-Hervas et al.
Ultrasonographic and magnetic resonance images of rotator cuff lesions compared with arthroscopy or open surgery findings
J Shoulder Elbow Surg
(2001)
J.J. Warner et al.
Diagnosis and treatment of anterosuperior rotator cuff tears
J Shoulder Elbow Surg
(2001)
J. Biondi et al.
Isolated rupture of the subscapularis tendon in an arm wrestler
Orthopedics
(1988)
S.S. Burkhart
Fluoroscopic comparison of kinematic patterns in massive rotator cuff tearsA suspension bridge model
Clin Orthop Relat Res
(1992)

E.A. Codman

Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

C.R. Constant et al.

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

(1987)

A. Deutsch et al.

Traumatic tears of the subscapularis tendonClinical diagnosis, magnetic resonance imaging findings, and operative treatment

Am J Sports Med

(1997)

P.U. Farin et al.

Site and size of rotator-cuff tearFindings at ultrasound, double-contrast arthrography, and computed tomography arthrography with surgical correlation

Invest Radiol

(1996)

D.F. Gazielly et al.

Functional and anatomical results after rotator cuff repair

Clin Orthop Relat Res

(1994)

C. Gerber et al.

Isolated rupture of the subscapularis tendon

J Bone Joint Surg Am

(1996)

Cited by (96)

Patient-reported outcomes of arthroscopic repair for partial or full-thickness upper third subscapularis tendon tears with open sub-pectoral biceps tenodesis: minimum 10-year outcomes
2024, Journal of Shoulder and Elbow Surgery
Although short-term results are promising, there are limited data for long-term results of arthroscopic subscapularis (SSC) repair. The purpose of this study is to report minimum 10-year outcomes of primary arthroscopic repair of isolated partial or full-thickness tears of the upper third of the SSC tendon.
Patients who underwent arthroscopic repair of isolated upper third SSC tears, Lafosse type I (>50% of tendon thickness) or type II were included. Surgeries were performed by a single surgeon between November 2005 and August 2011. Patient-reported outcome measures were prospectively collected and retrospectively reviewed at minimum follow-up of 10 years. Patient-reported outcomes utilized included the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (SANE), Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH), the Short Form 12 physical component summary, return to activity, and patient satisfaction. A subanalysis of patient age and outcomes was performed. Retears, revision surgeries, and surgical complications were recorded.
In total, 29 patients with isolated upper third SSC repairs were identified. After application of exclusion criteria, 14 patients were included in the final analysis. Follow-up could be obtained from 11 patients. The mean age at surgery was 52.7 years (range: 36-72) and the mean follow-up was 12 years (range 10-15 years). The American Shoulder and Elbow Surgeons score improved from 52.9 ± 21.8 preoperatively to 92.2 ± 13.7 postoperatively (P < .001). Regarding the SANE and QuickDASH scores, only postoperative data were available. Mean postoperative SANE, QuickDASH, and Short Form 12 physical component summary scores were 90.27 ± 10.5, 14.6 ± 15.5, and 49.2 ± 6.6, respectively. Median patient satisfaction was 10 (range 6-10). Patients reported improvements in sleep, activities of daily living, and sports. There was no correlation between patient age and clinical outcome (P > .05). No patients underwent revision surgery for a SSC retear.
Arthroscopic repair of upper third SSC tendon tears leads to improved clinical scores and high patient satisfaction at minimum 10-year follow-up. The procedure is durable, with no failures in the presented cohort.
Management of irreparable subscapularis tears: Current concepts
2024, Journal of ISAKOS
Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC.
When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.
Arthroscopic Subscapularis Repair With Preserved Biceps Anatomy
2023, Arthroscopy Techniques
Arthroscopic subscapularis repair continues to improve with the advancement of surgical technique and critical focus on careful intraoperative evaluation. As identification of these tears increases, there is an expected increase in repair rates as well. Anatomically, the upper border of the subscapularis and the long head of the biceps (LHB) tendon are in close relation. Many surgeons have advocated concomitant LHB tenotomy versus tenodesis in conjunction with operative subscapularis tears. We hypothesized that in the setting of a preserved anatomic biceps pulley and no LHB pathology, isolated subscapularis repair would result in excellent clinical outcomes when compared with subscapularis repair and biceps tenotomy or tenodesis.
Subscapularis tear classification implications regarding treatment and outcomes: consensus decision-making
2023, JSES Reviews, Reports, and Techniques
Several classifications have been proposed for subscapularis tendon tearing (SCTs); however, there remains a poor agreement between orthopedic surgeons regarding the diagnosis and management of these lesions. Distinguishing the various tear patterns and classifying them with some prognostic significance may aid the operating surgeon in planning appropriate treatment.
The purpose of this study was to outline the current literature regarding SCT classification and treatment and conduct a survey among shoulder and elbow surgeons to identify the approaches regarding surgical decision-making for these injuries.
In this systematic review, we analyzed 12 articles regarding the subscapularis tendon tear classification and implications regarding treatment plans and outcomes. In addition, 4 international experts in subscapularis repair surgery participated in the development of a questionnaire form that was distributed to 1161 ASES members. One hundred sixty five surgeons participated and chose whether they agree, disagree, or abstain for each of the 32 statements in 4 parts including indications/contraindications, treatment plan, and the factors affecting outcomes in the survey.
Classification criteria were extremely variable with differing recommendations and descriptions of tear morphology; most were based on tear size, associated shoulder pathology, or lesser tuberosity footprint exposure. Considering the multiple classification systems and the overall poor agreement regarding SCT management, our study found that the most widely agreed upon (more than 80%) statements included early surgery is advised for traumatic SCT, chronic degenerative SCT (without fatty infiltration) associated with acute supraspinatus tear is a candidate for repair, and rotator cuff arthropathy is a contraindication for SCT repair.
Our study was able to identify both patient and tear characteristics that are well agreed upon among surgeons in the treatment of these injuries. Lafosse classification is generally widely accepted; however, it needs to be improved by some additions. Continued collaboration among surgeons is needed to establish an acceptable and broadly applicable classification system for the management of these injuries.
Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.
Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
To systematically review the literature to (1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and (2) compare outcomes after single- and double-row subscapularis repair in both of these settings.
A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis retears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis.
The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 ± 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs used single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in 5 studies comparing isolated to combined tears. Subscapularis retear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and retear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (P > .05 for all).
Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless of whether tears were isolated or combined or if repairs were single or double row.
Level IV, systematic review of Level II-IV studies.

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Original articleRupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?

Section snippets

Materials and methods

Results

Discussion

Arthroscopy

Orthop Clin North Am

J Shoulder Elbow Surg

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Isolated rupture of the subscapularis tendon in an arm wrestler

Orthopedics

Fluoroscopic comparison of kinematic patterns in massive rotator cuff tearsA suspension bridge model

Clin Orthop Relat Res

Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa

A clinical method of functional assessment of the shoulder

Clin Orthop Relat Res

Traumatic tears of the subscapularis tendonClinical diagnosis, magnetic resonance imaging findings, and operative treatment

Am J Sports Med

Site and size of rotator-cuff tearFindings at ultrasound, double-contrast arthrography, and computed tomography arthrography with surgical correlation

Invest Radiol

Functional and anatomical results after rotator cuff repair

Clin Orthop Relat Res

Isolated rupture of the subscapularis tendon

J Bone Joint Surg Am

Original article
Rupture of the subscapularis tendon (isolated or in combination with supraspinatus tear): When is a repair indicated?