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. 2016 Feb 22;5(1):e177–e183. doi: 10.1016/j.eats.2015.10.018

The Combined “Double-Pulley” Simple Knot Technique for Arthroscopic Transtendon Fixation of Partial Articular-Sided Tear of the Subscapularis Tendon

Nata Parnes a, Paul Carey b,∗, Mario Ciani c, Monica Morman d
PMCID: PMC4886038  PMID: 27274450

Abstract

Subscapularis tendon tears occur more frequently than previously suspected. Most subscapularis tendon tears are partial tears that have the potential to progress to complete tears. Repairs of partial tears of the tendon are performed to preserve normal shoulder function. This report describes a combined transtendon double-pulley and simple knot technique for repair of partial articular tears of the subscapularis tendon. This technique incorporates the advantages of transtendon repair, the double-pulley technique, and simple knot fixation.

The subscapularis, as the only anterior muscle of the rotator cuff, has great biomechanical importance in the shoulder.1, 2, 3, 4, 5 It contributes to anterior stability and balance of the transverse force couples, internally rotates the shoulder, and helps to elevate the arm.1, 2, 3, 4, 5 Anatomically, the upper portion of the subscapularis serves as the insertion point for the anterior aspect of the rotator cable.6 Subscapularis tendon tears are more common than initially realized. In the clinical part of a study by Arai et al.,7 the incidence of subscapularis tendon tears found at arthroscopy was 27.4%. Sakurai et al.8 have shown that most subscapularis tendon tears are partial tears, often associated with supraspinatus tendon tears, and typically involving the broader, superior portion. Partial tears have the potential to progress to complete tears. Given the biomechanical and anatomic importance of the subscapularis, repairs of partial tears of the subscapularis are most often indicated.9, 10, 11, 12, 13, 14 A recent study that compared arthroscopic repair of significant (>50%) partial-thickness articular-sided subscapularis tendon tears, by either transtendon repair or tear completion, found no significant differences between the groups, including the retear rate.15

We present a combined transtendon double-pulley and simple knot technique16 for repair of partial articular tears of the subscapularis tendon. This technique incorporates the advantages of transtendon repair and retention of the lateral insertion with the increased bone-tendon contact area and equalization of contact pressure across the repair afforded by the double-pulley component of this technique. The simple knot repair of the upper border of the tear gives extra strength to the repair.

Surgical Technique

This technique was developed by the first author (N.P.). It combines simple knot and double-pulley suture configuration techniques for partial articular-sided subscapularis tendon tear repair (Table 1). The patient is placed in the beach-chair position with a Spider hydraulic arm holder (Tenet Medical, Calgary, Alberta, Canada) to hold the arm in the desired position (Video 1). A 30° arthroscope is introduced into the glenohumeral joint through a standard posterior portal. An anterior portal is established, in the rotator interval region, by an outside-in technique, with a spinal needle used to verify position. The needle is replaced with an 8.25-mm Clear-Trac threaded arthroscopic shoulder cannula (Smith & Nephew, Andover, MA).

Table 1.

Step-by-Step Surgical Technique

1. Position the patient in the beach-chair position.
2. Perform diagnostic arthroscopy through the posterior portal and the anterior portal (place an 8.5-mm cannula in the anterior portal).
3. Perform tenotomy of the biceps tendon.
4. Use a spinal needle and a No. 11 blade knife to place an anterolateral portal while viewing from the posterior portal (place a 5.5-mm smooth cannula over a switching stick into the joint).
5. Perform a three-sided exposure of the subscapularis tendon from the subscapularis fossa to the lesser tuberosity. (Avoid dissecting medial or distal to the coracoid base.)
6. Use a 4.5-mm shaver through the anterior portal while the arm is in internal rotation to prepare the bone bed and the edge of the torn tendon.
7. Through the anterior portal, place a single-loaded anchor at the distal aspect of the exposed lesser tuberosity footprint.
8. Retrieve both limbs of the suture through the anterolateral portal.
9. Place the arm in neutral rotation. Then, use a shuttling device to retrieve both limbs of the suture through the inferomedial aspect of the subscapularis tendon.
10. Through the anterior portal, place a double-loaded anchor at the proximal aspect of the exposed lesser tuberosity footprint.
11. Retrieve all limbs of both sutures from the second anchor through the anterolateral portal.
12. Use a shuttling device through the anterior portal to retrieve three limbs of the sutures from the upper anchor through the superior aspect of the tendon.
13. With the use of a suture manipulator through the anterolateral portal, retrieve the matching limb of the suture that was previously retained there.
14. Through the anterior cannula, tie sutures from the two anchors together using the double-pulley technique.
15. Through the anterior portal, retrieve the two remaining suture limbs and tie them using a simple vertical knot technique, completing the repair.
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A complete diagnostic arthroscopy of the glenohumeral joint is performed. Associated intra-articular pathology is documented and addressed as indicated. Then, by use of a probe and spinal needle through the anterior portal, the partial articular-sided subscapularis tendon tear is confirmed according to the existence of a partial detachment of the subscapularis tendon from the lesser tuberosity, and the quality of the remnant tendon is assessed (Fig 1). Once the partial tear is verified and the remnant tendon quality is deemed sufficient for repair, arthroscopic biceps tenotomy is performed with a radiofrequency device and motorized shaver through the anterior portal. Then, an anterolateral portal is created at the lateral aspect of the rotator interval, again by use of an outside-in technique. A 5.5-mm Clear-Trac smooth cannula (Smith & Nephew) is placed in this portal.

Fig 1.

Fig 1

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By use of a probe through the anterior portal, the partial articular-sided subscapularis tendon tear is confirmed according to the existence of a partial detachment of the subscapularis tendon (SST) from the lesser tuberosity (left shoulder, viewing from posterior). (HH, humeral head.)

With the arthroscope in the posterior portal, a 4.5-mm shaver and radiofrequency device are used in an alternating fashion, through the anterior and anterolateral portals, to resect the rotator interval, exposing the posterolateral aspect of the coracoid and the upper border of the subscapularis tendon from the subscapularis fossa to the attachment of the tendon to the lesser tuberosity. Debridement of tissue along the anterior aspect of the tendon is performed under direct visualization, with avoidance of dissection medial or distal to the coracoid base to avoid injury to the neurovascular structures (Fig 2).

Fig 2.

Fig 2

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Debridement of tissue along the anterior aspect of the tendon is performed under direct visualization, with avoidance of dissection medial or distal to the coracoid base to avoid injury to the neurovascular structures (same left shoulder shown in Fig 1, viewing from posterior).

Then, by use of a motorized shaver through the anterior portal while the arm is in internal rotation, the exposed bone of the lesser tuberosity is debrided, and all the remnant soft tissue is removed from the bone (Fig 3). An arthroscopic burr or shaver is used to abrade but not decorticate the bone of the lesser tuberosity, creating a roughened bone surface effective for tendon healing. The edge of the subscapularis partial tendon tear is similarly debrided back to healthy tissue.

Fig 3.

Fig 3

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By use of a motorized shaver through the anterior portal while the arm is in internal rotation, the exposed bone of the lesser tuberosity is debrided and all the remnant soft tissue is removed from the bone (same left shoulder shown in Fig 1, viewing from posterior).

Next, through the anterior portal, a Healicoil Regenesorb 4.75-mm single-loaded anchor (Smith & Nephew) is placed at the distal-most aspect of the exposed lesser tuberosity footprint. Both suture strands are retrieved through the anterolateral portal. A straight Acupass device (Smith & Nephew) is used through the anterior portal to shuttle both strands of the suture through the inferomedial aspect of good-quality tendon (Fig 4).

Fig 4.

Fig 4

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The straight Acupass device (Smith & Nephew) is used through the anterior portal to shuttle both limbs of the suture through the inferomedial aspect of good-quality tendon (same left shoulder shown in Fig 1, viewing from posterior).

A Healicoil Regenesorb 4.75-mm double-loaded anchor (Smith & Nephew) is placed at the proximal portion of the exposed lesser tuberosity footprint (Fig 5). All suture limbs from this anchor are retrieved through the anterolateral portal. The straight Acupass device (Smith & Nephew) is used again through the anterior portal to shuttle three suture limbs from the second anchor through the upper portion of the tendon in line with the sutures from the first anchor (Fig 6).

Fig 5.

Fig 5

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The Healicoil Regenesorb 4.75-mm double-loaded anchor (Smith & Nephew) is placed at the proximal portion of the exposed lesser tuberosity footprint (same left shoulder shown in Fig 1, viewing from posterior).

Fig 6.

Fig 6

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The straight Acupass device (Smith & Nephew) is used through the anterior portal to shuttle three suture limbs through the upper portion of the tendon in line with the sutures from the first anchor (same left shoulder shown in Fig 1, viewing from posterior).

By use of a suture manipulator (DePuy, Raynham, MA) through the anterolateral portal, the matching limb of the suture that was previously retained in the cannula is retrieved (Fig 7). At this point, one suture pair from each of the inferior and superior anchors is retrieved through the anterior cannula. One suture limb from each anchor is chosen to be coupled in a double-pulley configuration. These limbs are tied in an extracorporeal manner by use of multiple half-hitches on alternating posts. Traction on the other two limbs of these sutures advances the knot into the joint onto the anterior surface of the subscapularis tendon. These limbs are then tied by a nonsliding arthroscopic knot-tying technique (Fig 8). The extra length of the suture is removed by use of arthroscopic scissors. The two limbs of the second suture from the upper anchor are retrieved through the anterior portal and used for fixation of the upper border of the subscapularis tendon by a simple vertical knot-tying technique.

Fig 7.

Fig 7

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The matching limb of the suture that was previously retained in the cannula is retrieved through the anterolateral portal (same left shoulder shown in Fig 1, viewing from posterior).

Fig 8.

Fig 8

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Through the anterior cannula, the sutures from the two anchors are tied by a double-pulley technique (same left shoulder shown in Fig 1, viewing from posterior).

At the end of the procedure, the adequacy of the repair is confirmed with a probe. The shoulder is taken through a full range of motion to ensure that there is no excess tension on the repair and that the repair is stable (Fig 9, Fig 10, Table 2).

Fig 9.

Fig 9

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At the end of the procedure, the adequacy of the repair is confirmed with a probe (same left shoulder shown in Fig 1, viewing from posterior).

Fig 10.

Fig 10

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Final view through anterolateral portal after combined double-pulley simple knot repair technique (same left shoulder shown in Fig 1, viewing from posterior).

Table 2.

Pearls, Pitfalls, Key Points, and Indications

Pearls
 The procedure can easily be performed with the patient in the beach-chair or lateral decubitus positions.
 The surgeon should perform tenotomy of the biceps.
 It is important to perform preliminary anterior subscapularis tendon bursectomy under direct visualization with special attention not to harm the neurovascular structures.
 While the surgeon is preparing the bony bed of the lesser tuberosity and placing the distal anchor, it is helpful to position the arm in internal rotation.
 The arm should be in neutral rotation while the surgeon is shuttling the sutures through the tendon.
 The surgeon should verify that the sutures on both anchors slide easily.
 While tying the sutures from the two anchors using the double-pulley technique, the surgeon should verify that the knot is stable and not sliding before pulling it into the subcoracoid space.
 The surgeon should move both limbs of the second suture from the upper anchor to the anterolateral portal before performing the double-pulley repair through the anterior portal.
 The final tendon fixation to the lesser tuberosity should be performed by tying an arthroscopic nonsliding knot in the subcoracoid space and should be confirmed by intra-articular and subcoracoid views.
 At the endpoint of the procedure, the arm should easily rotate into full external rotation and the repair should be stable.
Pitfalls
 Debridement medial or inferior to the coracoid base can endanger the anterior neurovascular structures of the shoulder.
 Failure of one of the two anchors will lead to failure of the double-pulley fixation.
Key points
 The technique combines the double-pulley technique with a simple vertical knot repair technique.
 The double-pulley technique provides a large footprint of fixation.
 The technique is simple and can easily be converted at any stage to the traditional repair technique.
Indications
 Intraoperative evidence of partial articular tear of subscapularis tendon with good-quality remnant tendon
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The postoperative protocol consists of sling immobilization for 6 weeks. Patients are limited to early pendulum shoulder exercises. Passive range of motion only is performed under the supervision of a physical therapist for the first 6 weeks, with no external rotation past 45°. At 6 weeks postoperatively, active and active-assisted range of motion is initiated with a gradual progression to full range of motion. Strengthening exercises begin 12 weeks after surgery in a progressive strengthening program. Return to unrestricted activities, including vigorous sports, is permitted at 6 months postoperatively.

Discussion

Of the four rotator cuff muscles, the subscapularis has been proved in cadaveric studies to be the most powerful, responsible for 53% of the cuff moment.1, 2 The subscapularis provides internal rotation of the shoulder but is also noted to be possibly the most important elevator in the scapular plane.5 Burkhart et al.3, 4 have illustrated the biomechanical importance of the subscapularis as the anterior component of the transverse force couple, most relevant in massive rotator cuff tears.

The subscapularis footprint has also been described in various anatomic studies.17, 18, 19, 20 D'Addesi et al.17 found the average height of the subscapularis footprint to be 25.8 mm and the average width to be 18.1 mm. Richards et al.18 described the subscapularis as trapezoidal in shape, similar to the state of Nevada, emphasizing the broad medial-to-lateral superior subscapularis insertion with a more narrow inferior insertion. The structural properties of the subscapularis were detailed by Halder et al.,21 noting higher stiffness and ultimate load in the superior portion of the tendon.

Further cadaveric evaluation of the subscapularis anatomy was performed by Boon et al.,22 describing a tissue connection between the subscapularis and the supraspinatus. Possibly related findings were reported by Sakurai et al.,8 who showed the high prevalence of partial subscapularis tendon tears that occurred in conjunction with tears of the supraspinatus tendon, noting that these tears occurred in the wider, superior insertion of the subscapularis. Burkhart et al.6 have also described this, relative to the superior subscapularis insertion, as the anatomic insertion of the anterior portion of the rotator cable.

Various treatment algorithms and surgical techniques for symptomatic partial-thickness rotator cuff tears are found in the literature.9, 10, 11, 12 The systematic review by Strauss et al.9 concluded that debridement of tendon tears involving less than 50% of the thickness, with or without acromioplasty, is associated with good results, though recognizing the risk of tear progression. Similarly, it is generally recommended that tears greater than 50% of the thickness be surgically repaired.9, 13, 23 However, Denard and Burkhart,14 recognizing the unique importance of the superior insertion of the subscapularis, advised against debridement alone of subscapularis tears.

Repair of partial rotator cuff tears has evolved from completion of the tear to transtendon or PASTA (partial articular supraspinatus tendon avulsion) repairs.10, 11 It is logically concluded that completion of a partial rotator cuff tear requires excision of normal tendon and that repair can alter the position of the tendon on the tuberosity, thus leading to length-tension mismatch.10 With the transtendon approaches, the lateral row is maintained whereas the medial row is repaired, restoring the normal tendon footprint and essentially increasing the surface area for healing while avoiding the potential disadvantages of completion of the tear with subsequent repair.10, 11

Burkhart and colleagues16 described a novel double-row “double-pulley” rotator cuff repair technique in which the contact area between the tendon and bone is increased at the medial row of the repair. The double-pulley technique provides a broad area of tissue compression while equally distributing the pressure between the suture strands overlying the tendon.16 Similar techniques have also been described emphasizing how the technique maximizes compression along the medial-row fixation and improves the pressurized contact area.24, 25

Although standard rotator cuff tendon repair techniques can be applied to any part of the rotator cuff, specific methods for subscapularis tendon repair have also been reported in the literature.14, 26 Denard et al.26 describe use of a single knotless suture anchor for upper border and partial-thickness subscapularis tendon tears. We are not aware of any previous description of a double-pulley construct for partial-thickness articular-sided tendon tears of the subscapularis.

With an understanding of the biomechanical and anatomic importance of the subscapularis tendon insertion, especially along its superior insertion,1, 2, 3, 4, 5, 6, 22 it is concluded that durable and reproducible repair of subscapularis tendon tears is critical for optimal shoulder function. Furthermore, in keeping with the proven biomechanical superiority of footprint coverage and avoidance of normal tendon excision with footprint alteration,10, 11, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36 transtendon subscapularis tendon repairs have multiple potential advantages. By incorporating the double-pulley technique of Burkhart and colleagues16 into repair of partial articular-sided tendon repairs, excellent footprint coverage with even distribution of stress over the tendon repair may afford improvement in biomechanical and clinical outcomes.

The described technique for double-pulley repair of partial articular-sided subscapularis tendon tears is simple to perform arthroscopically and can be accomplished without having to take down the intact lateral tendon insertion, thus avoiding excision of healthy tendon or alteration of the footprint.10, 11 As elucidated by Burkhart and colleagues16 in their description of the double-pulley technique for rotator cuff repair, a greater surface area of tendon-bone contact is achieved with even distribution of stress over the repair site because the pressure is balanced between the anchors. Furthermore, if one is unable to perform this technique, it is easy to convert to standard methods of subscapularis tendon repair. If only one suture pair from each anchor is used, a disadvantage is that failure of one anchor or one suture strand can result in failure of the entire construct. For this reason, we recommend that a reinforcing simple suture be placed with the second suture pair from the superior anchor. One may also elect to use the second suture pair from both anchors for additional fixation as described in the original technical note of Burkhart and colleagues.16 A potential disadvantage is that of additional cost from additional suture anchors and lengthened operating time. Outcome studies could provide additional information regarding the cost relative to the benefit.

Footnotes

The authors report that they have no conflicts of interest in the authorship and publication of this article.

Supplementary Data

Video 1

Repair of a partial articular-sided tear of the subscapularis tendon in a left shoulder by the double-pulley transtendon technique. The primary viewing portal is posterior. With the double-pulley technique, a broad section of material is compressed between two anchor points.

Download video file (35.9MB, mp4)

References

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Supplementary Materials

Video 1

Repair of a partial articular-sided tear of the subscapularis tendon in a left shoulder by the double-pulley transtendon technique. The primary viewing portal is posterior. With the double-pulley technique, a broad section of material is compressed between two anchor points.

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Articles from Arthroscopy Techniques are provided here courtesy of John Wiley & Sons on behalf of the Arthroscopy Association of North America

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