SUBSCAPULARIS TEARS Indications? Open or arthroscopic?
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1 SUBSCAPULARIS TEARS Indications? Open or arthroscopic? PETER HABERMEYER FRANK MARTETSCHLÄGER ATOS-KLINIK Munich SCHULTER-& ELLBOGENCHIRURGIE Habermeyer P, Martetschläger F, Tauber M Anatomy Musular and tendinous insertions: Cranial 60%: tendinous insertion Caudal 40%: muskular insertion Courtesy F. Martetschläger Hinton et al. (1994) J Shoulder Elbow Surg Morag et al (2011) Skeletal Radiol Footprint HIGHL Ide et al. (2008) Arthroscopy comma shape a: anatomic neck b: Bare area A: 39,5 mm B: 16 mm 1
2 Function Internal rotation Adduktion and abduction Depressor for humeral head Anterior part of force couples Centering humeral head Static and dynamic stabiliser Stabilizes LHB Courtesy F. Martetschläger Burkhart SS (1991) Clin Orthop Relat Res Halder et al. (2000) J Orthop Res Kato (1989) Anat Anz Ward et al (2006) Clin Orthop Relat Res Prävalenz Incidence von SSC Läsionen Isolated SSC-tears 5% 5,7% (Bennett et al. 2003) 4,9% (Lafosse et al. 2007) 5,3% (Nové- Josserand et al. 2012) Combined SSC/ SSP-tears 30% (Bennett et al. 2001) 29,4% (Barth et al. 2006) 30% (Bartsch et al. 2010) 30% Etiologie Etiology Traumatic: isolated SSC # - Forced ERO and abduction - Fall on hyperextended arm - Ant-inf. Shoulder dislocation Degenerative: ant.-sup RC# - Medial lesion of pulley sling - ASI - Anterosuperior RC-Läsion 2
3 MECHANISM OF INJURY Mechanism of Injury Number 33 Hyperextension of the abducted arm 8 Forced external rotation of the abducted arm 10 Fall on the backward outstretched arm 6 Traumatic anterior dislocation 1 Direct blow to anterior shoulder 2 Motorcycle accident 1 Not reproducible 2 Bartl, Habermeyer,2010, AJSM, Prävalenz Classifications von SSC Läsionen Martetschläger et al. (2012) Techn Shoulder Elbow Surg Diagnosis: MRI Localisation and extension of tear retraction Atrophy and fatty infiltration LHB and pulley Goutallier et al. (1994) Clin Orthop Relat Res Morag et al (2011) Skeleta Radiol Pfirrmann et al. (1999) Radiology 3
4 Indication Indications Contraindications Pain, loss of function Cuff tear arthropathy Positive tests high-grade atrophy of SSC Mild SSC atrophy fatty infiltration > grade III Fatty infiltration < grade III Bartl et al.(2007) Arthroskopie Portals for SC reconstruction Posterior portal (A) Anterosuperior portal (E) Anterolateral portal (D) Arthroscopy SSC in neutral position and in Abd + IRO Identification of superolateral edge of the tear Static and dynamic evaluation of LHB + pulley Martetschläger et al., Tech Shoulder Surg,
5 Comma sign Medial retraction of complete tears Torn medial pulley forms scar tissue at the superolateral edge of the tendon = comma sign Lo et al.(2003) Arthroscopy Classification I partial rupture II complete, 25% III complete, 50% IV complete, > 50% Fox et al. (2003) Techn Shoulder Elbow Surg Arthroscopic repair 5
6 Coracoplasty when and how? Normal coraco-humeral distance approx. 11mm Correlation: reduced CHD <> ant-sup pathologies CP when ant.-sup. pathology and narrowed interval But: Personally i have never performed CP Martetschläger, KSSTA, 2013 Additional Pulley lesions Fraying Tear anteromedial (AM) posterolateral (PL) LHB instability LHB subluxation/ dislocation Habermeyer et al., JSES, 2008 Arthroscopic tenotomy 6
7 Tenotomy or Tenodesis? Tenotomy: good functional results but: Often Popeye Biceps Elbow: Pro-/Supination little weaker Gill et al., JSES, 2001 Wolf et al., Arthroscopy, 2005 Arthroscopic Tenodesis Subpectoral tenodesis Mazzocca et al et al. (2005) Arthroscopy 7
8 Results When do I open it? Open surgery: Complete SSC tears(4&5) Chronic & complete SSC tears with high-grade retraction Massive combined SSC + SSP tears in the younger P. Advantages: * time sparing, * refixation of HAGL Lesion * pec. major transfer can easily be added Habermeyer et al., Schulterchirurgie, Elsevier, 2010 Rare: Isolated inferior SSC lesion Traumatic isolated tear of caudal SSC Easily overlooked Thorough clinical, radilogical and arthroscopic evaluation necessary Open repair! Achtnich, Martetschläger, KSSTA,
9 Literatur: Results Ergebnisse isolated SSC - arthroscopic Good short- and midterm results following arthroscopic repair of isolated SSC tears Small case series Constant: ~ ~ Small re-tear rate (< 10%) Remaining positive SSC tests in 13-25% Bartl, AJSM, 2011 Mall, Arthroscopy, 2012 Kuntz, JAAOS, 2014 Lanz, Arthroscopy, 2013 Adams et al, Arthroscopy, 2008 Burkhard & Tehrany, Arthroscopy, 2002 Heikenfeld et al, Arthroscopy, 2012 Lafosse et al, JBJS Am, 2007 Nové-Josserand et al, JBJS Am, 2012 Literatur: Results Ergebnisse isolated SSC - open N=30; age 43y; Fup: 90% 7 grade II ; 11 III ; 12 IV (Fox & Romeo) FU 46 months (25-72) Constant: 51p ~ 82p Small re-tear rate (7%) Remaining positive SSC tests in 20% AJSM 2011 Conclusion SUBSCAPULARIS TEARS Indications? Pain, loss of function especially in the young Open or arthroscopic? Partial tears arthroscopic Complete and chronic, retracted tears u pick! 9
10 Thank you! PETER HABERMEYER ATOS-KLINIK SCHULTER-& ELLBOGENCHIRURGIE Habermeyer P, Martetschläger F, Tauber M 10
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