Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

In diagnosis and repair of partial subscapularis tendon tears, we used a simplified arthroscopic direct technique. We used the anterosuperior arthroscopic portal to visualise the subscapularis tendon insertion, while probing and repairing from the adjacent anterior portal. Three anatomical dissections were done to define the insertion of the subscapularis tendon at the lesser tuberosity. While viewing from the anterosuperior portal, we repaired the subscapularis tendon with one or two suture anchors, inserted into the lesser tuberosity from the anterior portal. Suture management was via the standard posterior portal. From the anterior portal, a tendon-penetrating grasping device passed the sutures through the displaced subscapularis tendon. The arthroscopic knots were tied from the anterior portal. Associated with the first 10 subscapularis repairs were six complete and four partial thickness supraspinatus/infraspinatus tears. There were no isolated subscapularis tears. Three patients had associated biceps lesions. Subscapularis tears are often associated with supraspinatus and infraspinatus tendon tears. Direct anterosuperior viewing and anterior probing enables the surgeon to see and repair ‘hidden’ tears

Purpose of the study: Injury of the long head of the biceps (LHB) can cause pain in rotator cuff tears (RCT). Our objectives were to:. establish an epidemiological database on LHB injuries in RCT;. study the dynamic behaviour of LHB in RCT;. search for a correlation between injected imaging findings and arthroscopic findings. Materials and Methods: Prospective, consecutive, multi-centric study (April 2005-June 2006). Inclusion criteria:. partial or full-thickness RCT demonstrated arthroscopically,. arthorscopic description of LHB,. imaging with injection (arthroscan or arthro-MR),. data collected on the internet site of the Socité Française d’Arthroscopie (SFA). Other reasons for arthroscopy, past surgery and MRI were excluded. The dynamic examination consisted in a search for the incapacity to glide the LHB in its gutter during passive abduction of the arm leading to intra-articular fold (hourglass test) and instability of the LHB in its groove during external rotation (medial instability) or internal rotation (lateral instability) with the arm at 90° abduction (RE2 and RI2 tests). Extension of the RCT in the frontal and sagittal plane were determined using the classification of the French Arthroscopic Society. Results: 378 patients (378 shoulders, 211 women, 167 men, mean age 57.9 years, age range 28–93 years). Arthroscan for 312 shoulders and arthroMR for 66 shoulders revealed 61 partial deep RCT and 317 full-thickness RCT. Among the full-thickness tears, 15 involved the subscapularis (SSc) alone, one the infraspinatus (ISp) alone and 301 the supraspinatus (SSp) alone (with 52 posterior extensions to the ISp, 90 anterior to the SSc and 31 mixted). Epidemiological data (static test): LHB intact 21%, tenosynovitis 51%, hypertrophy 21%, delamination 12%, pre-tears 7%, subluxation 18%, dislocation 9%, tear 2%. No influence of age, gender or side operated. Conversely, the rate of lesions increased significantly with extention of the RCT in the frontal and sagittal plane. Dynmaic study: positive hourglass test 29%, instability in RE2 26%, instability in RI2 8%. Hourglass test correlated with intra-articular hypertrophy of the LHB (76% versus 2%). Subscapularis tears lead to medial instability in 82% of cases. Among the 81 shoulders with an intact LBH statically, 17% presented a dynamic anomaly. In all the static and dynamic tests only left 18% of the LHB intact. Imaging-dynamic arthroscopy correlation: 25% of LHB lesions were not diagnosed by injected imaging. Inversely, there was a good correlation to determine the position of the LHB in its groove

The October 2024 Shoulder & Elbow Roundup360 looks at: Proximal humeral fractures with vascular compromise; Outcomes and challenges of revision arthroscopic rotator cuff repair: a systematic review; Evaluating treatment effectiveness for lateral elbow tendinopathy: a systematic review and network meta-analysis; Tendon transfer techniques for irreparable subscapularis tears: a comparative review; Impact of subscapularis repair in reverse shoulder arthroplasty; Isolated subscapularis tears strongly linked to shoulder pseudoparesis; Nexel and Coonrad-Morrey total elbow arthroplasties show comparable revision rates in New Zealand study; 3D MRI matches 3D CT in assessing bone loss and shoulder morphology in dislocation cases.

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears.

In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001).

It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign.

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (sd) as endpoints. The Constant score was found to improve from a mean of 26.8 (sd 10.3) pre-operatively to 57.6 (sd 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (sd 27.4) pre-operatively to 125° (sd 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (sd 6.5) pre-operatively to 30.3° (sd 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years.

Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.