Clinics in Shoulder and Elbow

Korean Shoulder and Elbow Society (대한견·주관절의학회)
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Surgical anatomical landmarks for arthroscopic repair of subscapularis tendon tears

  • Santiago Gabardo (Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundacion Jimenez Diaz, Universidad Autonoma de Madrid) ;
  • Maria Valencia-Mora (Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundacion Jimenez Diaz, Universidad Autonoma de Madrid) ;
  • Ismael Coifman (Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundacion Jimenez Diaz, Universidad Autonoma de Madrid) ;
  • Emilio Calvo (Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Hospital Universitario Fundacion Jimenez Diaz, Universidad Autonoma de Madrid)
  • Received : 2023.12.30
  • Accepted : 2024.03.02
  • Published : 2024.09.01
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Abstract

Background: Subscapularis repair has recently garnered significant interest. A thorough understanding of the tendon's anatomy is essential for precise and safe repair. Our objectives were to describe the anatomy of the subscapularis insertion, define its landmarks, and analyze nearby structures to guide arthroscopic repair. Methods: We conducted an anatomical study, dissecting 12 shoulders. We evaluated the distance from the footprint to the axillary nerve, the dimensions, and shape of the footprint, and its relationship with the humeral cartilage. Results: The distance to the axillary nerve was 32 mm (standard deviation [SD], 3.7 mm). The craniocaudal length of the footprint was 37.3 mm (SD, 4.6 mm). Its largest mediolateral thickness was 16 mm (SD, 2.2 mm), wider at the top and narrower distally. The distance between the footprint and the cartilage varied, being 3.2 mm (SD, 1.2 mm) in the upper part, 5.4 mm (SD, 1.8 mm) in the medium, and 15.9 mm (SD, 2.9 mm) in the lower part. Conclusions: When performing a repair of the subscapularis tendon, the distance to the cartilage should be carefully evaluated as it varies proximally to distally, and the shape of the footprint (wider proximally, tapered distally) should be considered for implant positioning. The distance to the axillary nerve is approximately 30 mm. Anterior visualization guarantees direct control of all landmarks and allows accurate implant positioning with safe tendon release. Level of evidence: IV.

Keywords

Acknowledgement

We would like to express our gratitude to Dr. Ariza for her assistance in conducting this study; Dr. Clasca for his invaluable guidance and dedication not only in this research, but in many other areas; and the entire Anatomy Department at the Autonoma de Madrid University for their support and resources, which were key in the successful completion of this project.

References

  1. Lee J, Shukla DR, Sanchez-Sotelo J. Subscapularis tears: hidden and forgotten no more. JSES Open Access 2018;2:74-83. 
  2. Edwards TB, Walch G, Sirveaux F, et al. Repair of tears of the subscapularis. J Bone Joint Surg Am 2005;87:725-30. 
  3. Lafosse L, Lanz U, Saintmard B, Campens C. Arthroscopic repair of subscapularis tear: surgical technique and results. Orthop Traumatol Surg Res 2010;96(8 Suppl):S99-108. 
  4. Burkhart SS, Brady PC. Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy 2006;22:1014-27. 
  5. Richards DP, Burkhart SS, Lo IK. Subscapularis tears: arthroscopic repair techniques. Orthop Clin North Am 2003;34:485-98. 
  6. Bell JP, Field LD. Combined intra-articular and extra-articular visualization for repair of a complete subscapularis tear: the "blended view" technique. Arthrosc Tech 2021;10:e1879-82. 
  7. Fox O, Lorentzos P, Farhat M, Kanawati A. The change in position of the axillary nerve with rotation of the arm. Clin Anat 2019;32:268-71. 
  8. Cho TH, Kwon HJ, Choi YJ, O J, Won SY, Yang HM. Intramuscular innervation of the subscapularis muscle and its clinical implication for the BoNT injection: an anatomical study using the modified Sihler's staining. Clin Anat 2019;32:110-6. 
  9. Burkhead WZ Jr, Scheinberg RR, Box G. Surgical anatomy of the axillary nerve. J Shoulder Elbow Surg 1992;1:31-6. 
  10. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff: gross and microscopic anatomy. J Bone Joint Surg Am 1992;74:713-25. 
  11. Arai R, Mochizuki T, Yamaguchi K, et al. Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon. J Shoulder Elbow Surg 2010;19:58-64. 
  12. Taylor SA, Fabricant PD, Bansal M, et al. The anatomy and histology of the bicipital tunnel of the shoulder. J Shoulder Elbow Surg 2015;24:511-9. 
  13. Lin L, Zhang L, Cui G, Yan H. The prevalence, classification, radiological and arthroscopic findings of intratendinous subscapularis tears. Knee Surg Sports Traumatol Arthrosc 2023;31:1970-7. 
  14. D'Addesi LL, Anbari A, Reish MW, Brahmabhatt S, Kelly JD. The subscapularis footprint: an anatomic study of the subscapularis tendon insertion. Arthroscopy 2006;22:937-40. 
  15. Richards DP, Burkhart SS, Tehrany AM, Wirth MA. The subscapularis footprint: an anatomic description of its insertion site. Arthroscopy 2007;23:251-4. 
  16. Ide J, Tokiyoshi A, Hirose J, Mizuta H. An anatomic study of the subscapularis insertion to the humerus: the subscapularis footprint. Arthroscopy 2008;24:749-53. 
  17. Collin P, Matsumura N, Ladermann A, Denard PJ, Walch G. Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion. J Shoulder Elbow Surg 2014;23:1195-202. 
  18. Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy 2006;22:609. 
  19. Saltzman BM, Collins MJ, Leroux T, et al. Arthroscopic repair of isolated subscapularis tears: a systematic review of technique-specific outcomes. Arthroscopy 2017;33:849-60. 
  20. Kim SJ, Jung M, Lee JH, Kim C, Chun YM. Arthroscopic repair of anterosuperior rotator cuff tears: in-continuity technique vs. disruption of subscapularis-supraspinatus tear margin: comparison of clinical outcomes and structural integrity between the two techniques. J Bone Joint Surg Am 2014;96:2056-61. 
  21. Kordasiewicz B, Kicinski M, Pronicki M, Malachowski K, Brzozowska M, Pomianowski S. A new look at the shoulder anterior capsuloligamentous complex complementing the insertion of the subscapularis tendon: anatomical, histological and ultrasound studies of the lesser tuberosity enthesis. Ann Anat 2016;205:45-52. 
  22. Gelber PE, Reina F, Caceres E, Monllau JC. A comparison of risk between the lateral decubitus and the beach-chair position when establishing an anteroinferior shoulder portal: a cadaveric study. Arthroscopy 2007;23:522-8.