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Subscapularis tendon tears hidden by the medial biceps sling can be missed on arthroscopic examination

  • Arthroscopy and Sports Medicine
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Introduction

To investigate (1) the prevalence of “hidden lesions” and “non-hidden lesions” of subscapularis tendon tears requiring repair during arthroscopic examination that would be missed by a 30° arthroscope, but could be identified by a 70° arthroscope, from the standard posterior portal and (2) the correlation of preoperative internal rotation weakness and findings of magnetic resonance imaging (MRI) indicating hidden lesions.

Materials and methods

We retrospectively examined 430 patients who underwent arthroscopic subscapularis repair between was initially nonvisible with a 30° arthroscope but became visible only with a 70° arthroscope from the standard posterior portal. The preoperative and intraoperative findings of the hidden lesion group (n = 82) were compared with those of the non-hidden lesion group (n = 348). 2016 and 2020. A hidden lesion was defined as a subscapularis tendon tear requiring repair that preoperative internal rotation weakness was assessed using the modified belly-press test. Preoperative MR images were reviewed using a systemic approach.

Results

The prevalence of hidden lesions was 19.1% (82/430). No significant difference was found in preoperative internal rotation weakness between the groups. Preoperative MRI showed a significantly lower detection rate in the hidden lesion group than in the non-hidden group (69.5% vs. 84.8%; P = 0.001). The hidden lesions were at a significantly earlier stage of subscapularis tendon tears than the non-hidden lesions, as revealed by the arthroscopic findings (Lafosse classification, degree of retraction; P = 0.003 for both) and MR findings (muscle atrophy, fatty infiltration; P = 0.001, P = 0.005, respectively).

Conclusions

Among the subscapularis tears requiring repair, 19.1% could be identified by a 70° arthroscope, but not by a 30° arthroscope, through the posterior portal. The hidden lesions showed a significantly lower detection rate on preoperative MRI than the non-hidden lesions. Thus, for subscapularis tears suspected on preoperative physical examination, the 70° arthroscope would be helpful to avoid a misdiagnosis.

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References

  1. Adams CR, Brady PC, Koo SS et al (2012) A systematic approach for diagnosing subscapularis tendon tears with preoperative magnetic resonance imaging scans. Arthroscopy 28(11):1592–1600

    PubMed  Google Scholar 

  2. Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K (2008) Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy 24(9):997–1004

    PubMed  Google Scholar 

  3. Bennett WF (2001) Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of "hidden" rotator interval lesions. Arthroscopy 17(2):173–180

  4. Bennett WF (2003) Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Classification of biceps subluxation/instability. Arthroscopy 19(1):21–33

    PubMed  Google Scholar 

  5. Bennett WF (2003) Arthroscopic repair of isolated subscapularis tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy 19(2):131–143

    PubMed  Google Scholar 

  6. Burkhart SS, Brady PC (2006) Arthroscopic subscapularis repair: surgical tips and pearls A to Z. Arthroscopy 22(9):1014–1027

    PubMed  Google Scholar 

  7. Burkhart SS, Esch JC, Jolson RS (1993) The rotator crescent and rotator cable: an anatomic description of the shoulder’s “suspension bridge.” Arthroscopy 9(6):611–616

    CAS  PubMed  Google Scholar 

  8. Burkhart SS, Tehrany AM (2002) Arthroscopic subscapularis tendon repair: technique and preliminary results. Arthroscopy 18(5):454–463

    PubMed  Google Scholar 

  9. David TS, Bravo H, Scobercea R (2009) Arthroscopic visualization of subscapularis tendon lesions. Orthopedics. https://doi.org/10.3928/01477447-20090728-38

    Article  PubMed  Google Scholar 

  10. de Jesus JO, Parker L, Frangos AJ, Nazarian LN (2009) Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol 192(6):1701–1707

    PubMed  Google Scholar 

  11. Denard PJ, Burkhart SS (2013) Arthroscopic recognition and repair of the torn subscapularis tendon. Arthrosc Tech 2(4):e373-379

    PubMed  PubMed Central  Google Scholar 

  12. Deutsch A (2007) Arthroscopic repair of partial-thickness tears of the rotator cuff. J Shoulder Elbow Surg 16(2):193–201

    PubMed  Google Scholar 

  13. Foad A, Wijdicks CA (2012) The accuracy of magnetic resonance imaging and magnetic resonance arthrogram versus arthroscopy in the diagnosis of subscapularis tendon injury. Arthroscopy 28(5):636–641

    PubMed  Google Scholar 

  14. Furukawa R, Morihara T, Arai Y et al (2014) Diagnostic accuracy of magnetic resonance imaging for subscapularis tendon tears using radial-slice magnetic resonance images. J Shoulder Elbow Surg 23(11):e283-290

    PubMed  Google Scholar 

  15. Garavaglia G, Ufenast H, Taverna E (2011) The frequency of subscapularis tears in arthroscopic rotator cuff repairs: a retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int J Shoulder Surg 5(4):90–94

    PubMed  PubMed Central  Google Scholar 

  16. Gleason PD, Beall DP, Sanders TG et al (2006) The transverse humeral ligament: a separate anatomical structure or a continuation of the osseous attachment of the rotator cuff? Am J Sports Med 34(1):72–77

    PubMed  Google Scholar 

  17. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC (1994) Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res (304):78–83

  18. Hartzler RU, Burkhart SS (2014) Medial biceps sling takedown may be necessary to expose an occult subscapularis tendon tear. Arthrosc Tech 3(6):e719-722

    PubMed  PubMed Central  Google Scholar 

  19. Ide J, Maeda S, Takagi K (2005) Arthroscopic transtendon repair of partial-thickness articular-side tears of the rotator cuff: anatomical and clinical study. Am J Sports Med 33(11):1672–1679

    PubMed  Google Scholar 

  20. Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K (2009) Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am 91(5):1055–1062

    PubMed  Google Scholar 

  21. Katthagen JC, Vap AR, Tahal DS, Horan MP, Millett PJ (2017) Arthroscopic repair of isolated partial- and full-thickness upper third subscapularis tendon tears: minimum 2-year outcomes after single-anchor repair and biceps tenodesis. Arthroscopy 33(7):1286–1293

    PubMed  Google Scholar 

  22. Kelly BT, Williams RJ, Cordasco FA et al (2005) Differential patterns of muscle activation in patients with symptomatic and asymptomatic rotator cuff tears. J Shoulder Elbow Surg 14(2):165–171

    PubMed  Google Scholar 

  23. Kim SH, Oh I, Park JS, Shin SK, Jeong WK (2005) Intra-articular repair of an isolated partial articular-surface tear of the subscapularis tendon. Am J Sports Med 33(12):1825–1830

    PubMed  Google Scholar 

  24. Kim SJ, Choi YR, Jung M, Lee W, Chun YM (2017) Arthroscopic repair of anterosuperior massive rotator cuff tears: does repair integrity affect outcomes? Am J Sports Med 45(8):1762–1768

    PubMed  Google Scholar 

  25. Kim SJ, Choi YR, Jung M, Yoon YK, Chun YM (2018) Concomitant coracoplasty during arthroscopic subscapularis repair does not yield better clinical outcomes and structural integrity. Knee Surg Sports Traumatol Arthrosc 26(1):56–62

    PubMed  Google Scholar 

  26. Kim SJ, Jung M, Lee JH, Kim C, Chun YM (2014) 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 96(24):2056–2061

    PubMed  Google Scholar 

  27. Kim SJ, Jung M, Lee JH, Park JH, Chun YM (2015) Arthroscopic repair of a significant (>50%) partial-thickness subscapularis tear concomitant with a full-thickness supraspinatus tear: technical considerations for subscapularis repair (transtendon technique versus tear completion). J Shoulder Elbow Surg 24(6):875–881

    PubMed  Google Scholar 

  28. Kim TK, Rauh PB, McFarland EG (2003) Partial tears of the subscapularis tendon found during arthroscopic procedures on the shoulder: a statistical analysis of sixty cases. Am J Sports Med 31(5):744–750

    PubMed  Google Scholar 

  29. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R (2007) Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am 89(6):1184–1193

    PubMed  Google Scholar 

  30. Lafosse L, Lanz U, Saintmard B, Campens C (2010) Arthroscopic repair of subscapularis tear: surgical technique and results. Orthop Traumatol Surg Res 96(8 Suppl):S99-108

    CAS  PubMed  Google Scholar 

  31. Lee J, Shukla DR, Sanchez-Sotelo J (2018) Subscapularis tears: hidden and forgotten no more. JSES Open Access 2(1):74–83

    PubMed  PubMed Central  Google Scholar 

  32. Malavolta EA, Assunção JH, Gracitelli MEC, Yen TK, Bordalo-Rodrigues M, Neto AAF (2019) Accuracy of magnetic resonance imaging (MRI) for subscapularis tear: a systematic review and meta-analysis of diagnostic studies. Arch Orthop Trauma Surg 139(5):659–667

    PubMed  Google Scholar 

  33. Mazzocca AD, Rincon LM, O’Connor RW et al (2008) Intra-articular partial-thickness rotator cuff tears: analysis of injured and repaired strain behavior. Am J Sports Med 36(1):110–116

    PubMed  Google Scholar 

  34. Miller MD, Wiesel SW (2012) Operative techniques in sports medicine surgery. Lippincott Williams & Wilkins

    Google Scholar 

  35. Neyton L, Daggett M, Kruse K, Walch G (2016) The hidden lesion of the subscapularis: arthroscopically revisited. Arthrosc Tech 5(4):e877–e881

    PubMed  PubMed Central  Google Scholar 

  36. Nove-Josserand L, Hardy MB, Leandro Nunes Ogassawara R, Carrillon Y, Godeneche A (2012) Clinical and structural results of arthroscopic repair of isolated subscapularis tear. J Bone Joint Surg Am 94(17):e125

    PubMed  Google Scholar 

  37. Patte D (1990) Classification of rotator cuff lesions. Clin Orthop Relat Res 254:81–86

    Google Scholar 

  38. Pfirrmann CW, Zanetti M, Weishaupt D, Gerber C, Hodler J (1999) Subscapularis tendon tears: detection and grading at MR arthrography. Radiology 213(3):709–714

    CAS  PubMed  Google Scholar 

  39. Ranalletta M, Rossi LA, Bertona AB et al (2016) Arthroscopic transtendon repair of partial-thickness articular-side rotator cuff tears. Arthroscopy 32(8):1523–1528

    PubMed  Google Scholar 

  40. Richards DP, Burkhart SS, Lo IK (2003) Subscapularis tears: arthroscopic repair techniques. Orthop Clin North Am 34(4):485–498

    PubMed  Google Scholar 

  41. Sahu D, Fullick R, Giannakos A, Lafosse L (2016) Sentinel sign: a sign of biceps tendon which indicates the presence of subscapularis tendon rupture. Knee Surg Sports Traumatol Arthrosc 24(12):3745–3749

    PubMed  Google Scholar 

  42. Sheean AJ, Hartzler RU, Denard PJ, Ladermann A, Hanypsiak BT, Burkhart SS (2016) A 70 degrees arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position. Arthroscopy 32(9):1745–1749

    PubMed  Google Scholar 

  43. Shin SJ (2012) A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy 28(1):25–33

    PubMed  Google Scholar 

  44. Tebaa E, Tantot J, Isaac-Pinet S, Nove-Josserand L (2019) Histologic characteristics of the subscapularis tendon from muscle to bone: reference to subscapularis lesions. J Shoulder Elbow Surg 28(5):959–965

    PubMed  Google Scholar 

  45. Walch G, Nove-Josserand L, Levigne C, Renaud E (1994) Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elbow Surg 3(6):353–360

    CAS  PubMed  Google Scholar 

  46. Ward JRN, Lotfi N, Dias RG, McBride TJ (2018) Diagnostic difficulties in the radiological assessment of subscapularis tears. J Orthop 15(1):99–101

    PubMed  PubMed Central  Google Scholar 

  47. Weber SC (1999) Arthroscopic debridement and acromioplasty versus mini-open repair in the treatment of significant partial-thickness rotator cuff tears. Arthroscopy 15(2):126–131

    CAS  PubMed  Google Scholar 

  48. Wright JM, Heavrin B, Hawkins RJ, Noonan T (2001) Arthroscopic visualization of the subscapularis tendon. Arthroscopy 17(7):677–684

    CAS  PubMed  Google Scholar 

  49. Yoon JS, Kim SJ, Choi YR, Kim SH, Chun YM (2019) Arthroscopic repair of the isolated subscapularis full-thickness tear: single- versus double-row suture-bridge technique. Am J Sports Med 47(6):1427–1433

    PubMed  Google Scholar 

  50. Yoon TH, Kim SJ, Choi YR, Cho JT, Chun YM (2021) Arthroscopic revision rotator cuff repair: the role of previously neglected subscapularis tears. Am J Sports Med 49:3952–3958

    PubMed  Google Scholar 

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Acknowledgements

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Funding

This study was supported by a faculty research grant from the Yonsei University College of Medicine (6-2018-0067).

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, 134, Shinchon-Dong, Seodaemun-Gu, CPO Box 8044, Seoul, 120-752, Republic of Korea

    Joo-Hyung Kim, Woo-Sung Do, Joon-Ryul Lim, Tae-Hwan Yoon & Yong-Min Chun

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Contributions

J-HK, MD, involved in writing—original draft, conceptualization, data curation, formal analysis, investigation, resources, visualization, approval of the submitted and final versions. W-SD, MD, took part in writing—review and editing, conceptualization, data curation, approval of the submitted and final versions. J-RL, MD, PhD, involved in conceptualization, supervision, visualization, approval of the submitted and final versions. T-HY, MD, PhD, involved in data curation, resources, validation, visualization, approval of the submitted and final versions. Y-MC, MD, PhD, took part in conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, resources, visualization, writing—original draft, writing—review and editing, approval of the submitted and final versions. All authors have read approved the final submitted manuscript.

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Correspondence to Yong-Min Chun.

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The authors have no conflicts of interest to declare that are relevant to the content of this article.

Ethical approval

This study was approved by the Institutional Review Board for Severance Hospital at the Yonsei University College of Medicine (IRB No. 4-2021-1074).

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Our institutional review board approved this study after waiving the requirement for the informed consent.

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Kim, JH., Do, WS., Lim, JR. et al. Subscapularis tendon tears hidden by the medial biceps sling can be missed on arthroscopic examination. Arch Orthop Trauma Surg 143, 3251–3258 (2023). https://doi.org/10.1007/s00402-022-04681-1

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