forming a subscapularis repair, and we will try to interject some comments and questions along the way. So feel free to get to a mic. If I see you at a mic, I'll call on you. Tony, if you're getting this reception, can you tell us a little bit about your shoulder and its orientation? Well, we only have 15 minutes, so we'll go through this briefly with everyone, but thank you for the opportunity. We have a great team. I have Brandon Erickson helping me out. We have a team from Arthrex. We have a team from the Orthopedic Learning Center and our audio-visual people to show you how to do a double row subscapularis repair. And so just to make sure that we're all on the same page, we're gonna be doing a left shoulder, and we'll put the first slide up so that we can think about this. And the first slide shows the anatomy related to the footprint of the subscapularis. So remember, this is a very broad footprint, much larger than the supraspinatus, and getting a nice, solid repair across that one and a half to two centimeters is great, but just keep that picture in mind. We'll go to the next slide, and just keep in mind also that we've learned that there's a very important connection between the supraspinatus and subscapularis. In our cadaver, our supraspinatus was torn, so we can't show you as well as we'd like to the true comma sign. And our next slide will then demonstrate to you. One of the other important things I wanna say before we get started is that you really should read your own MRIs. The radiologists have done much better with subscapularis, but use Chris Adams' paper as a nice little way to do this. So start out with your axial view, and then we'll go to the next one. You wanna look for the dislocated biceps. You look at your sagittal oblique for the muscles, and the sagittal oblique for the attachment of the tendon. And you won't show up in the middle of the OR and say, oh, darn it, there's a subscap tear, now what do I do? So we do this in the beach chair position, so let's go back to our cadaver. We've got this set up so we have a posterior portal as we go through the glenohumeral joint, a lateral portal, an anterolateral portal, and we created an accessory anterior inferior portal just to help ourselves out. And so we'll go ahead and get started with that. I'm doing this in the beach chair position. You can certainly do this in the lateral position without a problem. And we like to start out within the glenohumeral joint so we can see exactly what's going on, have a good identification of our pathology. We've obviously had to do some prosection to get this all ready to go and be prepared for the case. And so hopefully we'll be able to show you the whole process here quickly and efficiently here. So as we back up to our glenohumeral joint, we look at the articular cartilage. We always want to look for that biceps tendon to kind of guide us. We've cut the biceps tendon because then the majority of our subscapularis tears, the biceps is unstable, dislocated, or pathologic, and we're gonna want to take that and move that out of place. We look at our anterior structures and we look at our subscapularis tendon there. We'll take our probe and as we look from our anterior lateral portal we can see, actually we'll go right to our lateral portal here just so we can come around this. Here's our subscapularis and a lot of times it's difficult to know exactly where the end is. This tissue moves over here medially and it's not very clear. We tried to keep the comma sign intact but the supraspinatus is torn. So if we go to our next video and let's show that to the audience. Here's an example of where there's a subscapularis tear and you look here as you're looking from, again, a left shoulder, you're looking from behind and you're thinking, well, maybe that's the comma sign right here and you start to clean up the shoulder a little bit and as you keep working over you realize, no, that's the end of the tear actually. So now I have to find the upper edge of the subscapularis. Well, how do I do that? I work over medially on a left shoulder at about the nine o'clock position and I see a little gap being created here and that is the comma sign as described by Burkhart. The coracohumeral ligament comes down to the upper edge of the subscapularis which clearly defines that upper edge so you know where it has to go on the lesser tuberosities. That's really critical. Let's go back to our cadaver and so what we'll see here on our cadaver view, again, the rest of the shoulder has been, pretty much we're prepared for that. So I'm gonna go ahead at this point and move and put this in the lateral portal which we established a soft cannula so we can see this pretty easily and we'll look here. Now, in preparation for this procedure, we went ahead and placed our anchors but let's just talk about that for a minute and so what we do is we'd like to clean off that lesser tuberosity tissue and make sure that we have a nice view down here. This is the tissue that's been torn off here and get a little bit of that exposure so our cannula's backed out just a little bit here. So Tony, while you're doing that, you have a lateral portal which is adaptable if your cuff tear includes your supraspinatus. Correct. It's a bursal portal. Do you have to adjust that portal if you have an intact supraspinatus? So what will happen is you'll have a little bit less of a view so I'm direct lateral and if we have an intact supraspinatus, you may have to use an anterior lateral and anterior inferior portal to work over that front edge. So very good point, Jeff, but our supraspinatus you see was torn here. This is the view again from that lateral portal and what we did is we prepared our lesser tuberosity down to where the tear occurs. These tears can go even further and be displaced more immediately and what we'd like to do if we're gonna do a double row repair is we'd like to separate our anchors by about two centimeters and we'd like to catch that bottom part of the capsule as well as the actual tissue itself and then bring that into the right position and if I can have the grabbing, yeah, that'll be a little bit helpful. We also wanna make sure when we do these just like when we do them open, if it's been a few months or so since it's actually been torn, they can get pretty stiff and you wanna make sure that you get inside here and do a capsule release. So here's just an example where we release the capsule off that front edge and make sure this is nice and mobile. Now, once we decide where we're gonna put our anchors in, the ideal place to come in for the anchor placement, so we'll take a punch just to show that to you, is to come from our anterior portal and usually we can come over the top and oftentimes to the rotator interval and we can come down to our actual footprint and we pull this down and we can drive our anchors into the position that we see down here through the front. So this will sometimes get a little bit, there we go, we're over the top and we can put the anchor exactly where we need to place that and come over the front edge in this position here and then we have an option how we're gonna pass that through the actual tissue and there's really two methods. One is sort of going through the tendon tissue itself and so what we can do in this situation, if you grab that suture there, Brandon, thank you, and it will slide in and you can actually go through here and with a forward passing device through that is you can come through this tissue and punch through our tendon and then grab the suture and pass that through into a suture sliding technique and the other technique, which a lot of people that do this in the lateral position prefer is using a device that's like a punch device. This one is called the Scorpion. There's others on the available but this device is nice because you can actually get a nice grab on the tendon and squeeze that through and pass your suture through and then we did that for our first two and to get this all set up and ready to go. So far, we did our capsule release, released our biceps, we cleared off the lesser tuberosity, we passed our anchors and now we passed our suture through the tendon and how are we gonna fix this is the next step. So we really need to be able to see this well and we'll start to rearrange a visualization of this and sometimes with this tissue, you have to work on this a few times because it obviously gets a little fuzzy after a while. The biceps tendon is a bit, it can get in your way so we put a suture in this and we've used a technique that holds onto that tendon very well and we're gonna incorporate that into our repair. So we have our two tapes which has a swedged end to it so they are passed as one. We're gonna go ahead and Brandon's gonna cut those and then we're gonna bring those limbs together in a way. So what I'll do is I'll take the lower blue one and I'm gonna pull that up approximately to move it out of our way so we'll just come over the top here and if you can just pull on the white suture for me, keep some tension on that and then we'll come over the top here and grab our other blue one and this will allow us to separate out these two sutures. This device has both the ability to wrap around these tapes but also it has as a grabbing mechanism too which helps us manage this just a little bit easier and while someone's holding onto our actual sutures to help keep that tension in there a little bit, there we go and then I can grab one of them and then we'll pull this out here and keep that with the other one and so now I'm set up for the lower anchor so I'm gonna come back through here and I'm gonna grab the white suture that we separate out so we have our two sutures together and so this will come in this position here and we'll bring this down over the top here. Now, did we cut that stitch? Okay, let's just make sure. Got one, two, okay, good and then let me come back up here and see if we can get this to slide a little bit easier. Okay, there we go and then I preferentially would prefer to actually have my anchor on my two sutures before so just to make sure, hold this right here for me and just to make sure that we don't have any problems with it being with our bicep suture, we can slide down in and make sure that there's no tangles or anything so we're good all the way through with our white stitch and we should be outside of our stitch with our biceps. Again, one more time here, we're not doing that so you gotta hold these here, thank you and then this is actually this one here and this one here, okay, great. So that's why it's important to do that step even when you practice it ahead of time, things can get a little bit out of place and you wanna make sure so I'm gonna slide back down again just to make sure that we have everything separated, there's nothing else in there and that looks like we're pretty good but let's confirm and it looks like just the two tapes and we should be good and this one should be out of our way. All right, good and hold that there for our biceps, we're gonna go ahead and load our anchor so we're ready to go, we're gonna get our orientation back into place and if we have any problems with the bottom, one of the advantages of the beach chair is it's a little bit easier although surgeons with lateral position do an excellent job too, it's a little bit easier just to rotate the arm a little bit and get that full exposure. We wanna have a sense of where that lesser tuberosity, remember we said it's about two centimeters down there so we're just gonna take a punch to make sure that we're coming in at a good angle and I like to, if you look at, here's the actual articular surface, I like to look at the ridge of the biceps as really hard bone or biceps are below us and if we can get right into this corner here, that's usually an excellent position to fix that so we'll go ahead and tap gently just to get started. While you're tapping that in, Tony, talk to us a little bit about external and internal rotation when someone's in lateral decubitus, they're often kind of compelled to be an internal rotation. When you're doing a beach chair, you could kind of set your rotation, what is your favorite position to have the forearm relative to bring that lesser tuberosity so it's perpendicular to your instruments? Yeah, so I really honestly, I would try to do it about 15 degrees but I don't have a set number, hold on the sutures, put some, just hold on the sutures, thank you. I try to have a set, I don't have a set number, I'm really gonna examine that as we go in to make sure that we have the right angle here so let's see what's going on here, we're just getting a little bit of a, let's hold this here for me. So that's helpful for some individuals who do lateral decubitus, you may have to have your assistant rotate the arm a little bit to make the instruments angle perpendicular to the bone so you don't skive and you can go in as a straight up on Foss to put your anchors in. So our biceps just came up into play, so we. Yeah, we're just getting a little, yeah, I appreciate the comment, we're just getting our biceps involved in our repair which was not part of the plan so we have to work around that a little bit and really at this point, yeah, that kind of just pushed me out so let's just see if I can get around that. There we go. And then we'll find our hole which we just made which is right here. So it looks like your parents', your biceps becomes part of your inferior construct, does that sound? Actually, no, we're gonna put it superiorly and I did that because I really wanna make sure this lower one is fixed well and before you hit that in, just hold this for a second but I just wanna put some tension on this so we make sure we're coming up to the proper position superiorly and make sure that's lined up well and that looks fine, so I'm good with that. Okay, so then let's come back to that and let's get our alignment correct again, okay. So to answer your question, Jeff, I'm gonna put the biceps actually higher and we'll show that in just a minute but you could tie it into the lower part especially if you had a problem with the quality of the biceps. In other words, if it came down and was not in good shape, that would definitely be something to do. We're using an anchor here that helps to basically intuitively tension the tissues. People worry about whether you have to put a lesser external rotation to prevent stiffness but what we're trying to do is an anatomic repair and we generally don't worry too much about putting it all the way to where it belongs as long as we've done a nice capsule release and then because we should get our motion back. I can tell you that getting your motion back on the subscapularis, let me just have that for a second. Yep, and let's come forward so we don't cut our other stitch and pull on the biceps tissues please, thank you. Okay, and the biceps is just torturing us a little bit here but we should be okay. All right. Tony, while you guys are working on gathering your next set of stitches, can you comment on when you do a double row subscap repair or when you do a single row? Yeah, so thanks Brian. I was also gonna mention that if this kind of technique with the biceps, hold the tension here please, and it is a bit of a, hang on a second, let's hang on a second, let's get ourselves regrouped. I'll answer your questions in a second Brian, we just need to, just let that go please. Let's bring our other stitches out. Okay, let me, we're almost done so I just want to finish this for all of you but we're gonna grab those other two stitches here and we'll take both of those tapes, those tapes should be out and so now all I have to do is grab the biceps stitch, so let's hold this down here and then we're gonna take our next anchor and of course it's defeating me a little bit here, let's bring this arm up so we can do a little bit more forward elevation so we can see that nicer and please keep tension on the suture or that will defeat us again and then this is not our stitch. Yeah, that's one of the repair stitches, I'm not sure how that got there and we'll take our bicep stitch which is here. Tony, we're gonna just help you with timing and we have a clock here, we're gonna give you two minutes before we have to move on. Okay, thank you. Yeah, we'll be done in two minutes. I just need to find this, okay, let's load that anchor please and I'll fix this for you. Now, if the biceps looks pretty ratty, you can easily just convert and do a sub-scap, a sub-pactral bicep stenodesis. Let's go ahead and load our anchor please and then we'll take the punch. Okay, and let's go ahead and hang on to that, we'll get the punch ready and we'll put this in so we're all set and ready to go here and again, we wanna just identify the proper position for our anchor which is, here's the top edge, we're gonna come over a little bit where we put ours and we'll go right about here so let's go ahead and we'll insert our anchor, you ready? Follow me right in, this angle, thank you. All right, follow me right back in there, see if we can get that right away, hold on the sutures. Using cannula is certainly helpful to get in and out without capturing any coracochromia ligament or anything along those lines. Okay, so here we go. Now, put some tension one at a time so we're gonna tension these, we gotta just make sure we get enough that we get that out of the way and we'll be almost done with this which will be great. Okay, lifted me out but that's okay, it's got better tension and I think we should be okay to go ahead and let me just see what this looks like here one last minute. So while Tony's working on that a little bit, you could see that we're doing some releases as we get some of the loose tissue that helps you along the way and if you're already in a little external rotation, you shouldn't be too concerned about range of motion post-operatively other than protecting it but be aware that you can make shoulders a little tight and you might have to make some adjustments with releases. Yeah, so I'll just show you this real quickly here, we're gonna go ahead and cut these sutures in just a second. I think you should be in far enough by now and we'll take that off and let's just kind of take this out so we can go ahead and free that up. Just, it doesn't matter, just pull it. Yeah, all right and then we're gonna go ahead and cut our stitches and just show you that front edge of our, here's our subscap repair, our double row repair and so we're just pulling back and we're gonna go ahead and cut that real quick if you can and then what we can do is bring the arm up here and this, Brandon, we have the biceps, we're gonna cut that and Brandon, if you can just slowly rotate back and forth just so we can show that, go externally rotate please and then go back and forth again. So you can see, we didn't tension our blue stitch, we really kind of didn't do that as well as we'd like to but you get the concept here that we did that so this can come all the way out, nice secure repair, all the way in for a double row repair and if we can go back to our slides for the last 15 seconds and we'll be all set so let's advance to the next one. We sometimes do a corcoid plasty but often not. Next slide, here, let me have it and we'll prepare the tuberosity. We can do a simple single row repair. We showed you this double row repair. Many people may think that this is a little bit much but this is actually the best way that the person that gets an isolated subscap tear is typically male between the ages of 40 and 60. The whole tendon comes off, it's very valuable. You can also use this technique. If you watch the video here, you can see this is a 13-year-old boy who had a complete avulsion of his subscapularis tendon when he fell on a playground with the periosteum and using the same technique, you were able to get a double row repair on the outside in an anatomic position and within three months, he's back to all of his activities without any restrictions. We've published how to do this in arthroscopy techniques in August of 2018 and so in summary, make sure you understand the subscap and the tear pattern and what it takes to repair that. It can be repaired arthroscopically very well. It can be a little challenging. We could have cleaned it up a little bit more if we had more time. The suture bridge is very, very strong. The clinical outcomes may be similar to something less than that and please don't hesitate to convert to an open if that's in the best interest of your patient if you struggle with this technique. So thank you very much for the opportunity. Tony and Brian, thank you very much for this opportunity. Nice job. Thank you.

double row subscapularis repair

anatomy of subscapularis tendon

shoulder orientation

supraspinatus and subscapularis connection

MRI identification of subscapularis tear

surgical procedure demonstration