661
LETTERS TO THE EDITOR
Table 2. Thickness, Width, and Cross-Sectional Area of ACL and PCL (at Plane Perpendicular to ACL or PCL Axis) Mean (SD) Specimen ACL Thickness (mm) Width (mm) Cross-sectional area (mm2) PCL Thickness (mm) Width (mm) Cross-sectional area (mm2)
Fig 6F.
important message of our study was that the ACL midsubstance is band-like, with a thickness of about 5 mm in a very narrow space between the lateral femoral condyle and the PCL in extension. We have to take into consideration that an oversized graft can cause impingement to the PCL. We agree with the authors of the letter that, as Harner published, the ACL fans out in the tibial attachment and is 3 times thicker (Fig 6, D and F in our article). Figure 8 is based on our measurements shown in Table 2 in our article. For the measurements, we used a stereo microscope (Leica MZ75; Leica Microsystems, Heerbrugg, Switzerland). The image information was
Femoral MidMidInsertion substance 1 substance 2
Tibial Insertion
3.54 (0.78) 4.78 (0.59) 4.96 (0.57) 11.71 (1.24) 8.22 (1.04) 7.41 (0.82) 7.94 (0.78) 10.85 (1.12) 29.1 (3.2) 35.4 (2.5) 39.4 (2.2) 127.1 (7.3)
9.12 (0.83) 8.03 (1.02) 19.47 (3.22) 20.69 (0.99) 9.58 (0.94) 6.63 (0.86) 3.85 (0.7) 5.35 (1.06)
digitized (with a resolution of 12 bits) by a digital microscope camera (Leica DFC425/DFC425C LED illumination, Trinocular Tube, SmartTouch, and PC System with Leica LAS Software; Leica Microsystems). We also agree that if we create a tunnel that is not perpendicular to a surface, we create an oval opening, but the grafts we use through this tunnel remain the same size. If this oval opening has an implication on the graft’s healing and affects its biomechanical properties later, this was beyond the aim of our study but it is a good idea for future projects. In this article, we studied the shape and width of the midsubstance of the ACL in relation to the narrow space between the PCL and lateral femoral condyle. In our next study, we plan to give our main attention to the tibial attachment of the ACL in the “time of remnant-preserving ACL reconstruction.” We thank the authors very much for their interest in our article and their productive letter with ideas for future projects. Anastasios D. Georgoulis, M.D., Ph.D. Eleni Triantafyllidi, M.D. Nikolaos K. Paschos, M.D., Ph.D. Ioannina, Greece Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.04.001
Arthroscopic Subscapularis Repair: A Look at Primacy From a Historical Perspective
Fig 8.
To the Editor: Recently the Journal of the American Academy of Orthopaedic Surgeons published a review article on arthroscopic subscapularis repair by Kuntz et al.1 This topic has been an area of interest to me for more than 18 years. Writing a complete and comprehensive
662
LETTERS TO THE EDITOR
review and opinion article is no easy task, and the authors provided a good compilation summarizing the many tenets of arthroscopic subscapularis repair concisely. Under the cover of this journal, Arthroscopy: The Journal of Arthroscopic and Related Research, and starting with my first publication in 1998, a chronicle of my progressive insights can be found in the 7 articles I reference here. This began with arthroscopic data compilations from my Sarasota office beginning in October 1995. The references in this letter are chronicled by year. In the review article by Kuntz et al.,1 statements regarding primacy2 were opined. Rarely should these types of statements be made. Not only can they be challenged, but unless one has comprehensive knowledge of all abstracts, articles published in journals not referenced in Index Medicus, poster and scientific exhibits, oral presentations, or publications written in other languages, it is easy to err. Comments relating to the “first to report” possibly should be stated as first to publish, citing the language of origin. The first time I reported on arthroscopic subscapularis repair was a 2-year follow-up in 1998 at the annual AAOS meetingdby way of a poster presentation of the abstract of the study manuscript. After this, I reported with podium presentations at the Eighth ESSKA Congress in 1998 in Nice, France, the Florida Orthopedic Society meeting in 1998, and the AANA annual meeting in 1999. As the author of many articles on this topic, I hope by way of this letter to offer clarifications, help source the subject material, and uncover omissions (thereby making them additions). In the end, I hope that readers will feel that I have contributed additional information to enhance understanding on this subject matter. Many of my comments will be related to the previously cited review article and hopefully will come across more as additions rather than corrections. During the 1990s, I simultaneously compiled arthroscopic data as I arthroscopically repaired subscapularis tendons that were isolated, associated with an anterosuperior tear, or associated with massive tears. Interestingly, there were no arthroscopic citations that discussed the repair of the subscapularis tendon in 1995. In my opinion, there were 2 cadaveric articles in 19923,4 and 1 in 19945 that set out to illustrate the anatomy in and around the subscapularis insertion and 1 clinical article in 19946 that set the groundwork for my later expanded classification of lesions in and around this insertional area, originally referred to as “hidden” lesions of the rotator interval. In fact, the literature on repair of this tendon, even with open surgery, was sparse6-9; it was like it was the forgotten tendon. Back to the review article: regarding the authors’ comment noting that a systematic evaluation of the shoulder should be performed and the intra-articular
portion of the biceps tendon should be included, I will help clarify what I believe the authors were trying to say and point out that because my 1998 study “Specificity of the Speed’s Test: Arthroscopic Technique for Evaluating the Biceps Tendon at the Level of the Bicipital Groove”10 is the source of this information, please reference Fig 7 on page 795 of that article. The non-intra-articular biceps tendon can be made intra-articular by using a neuroprobe to pull more tendon into the joint for visualization, a detail the authors did not address. Merely evaluating the tendon that is in the joint is not enough; with shoulder elevation and elbow flexion, the probe can pull most of the tendon that is hidden by the pulley and in the bicipital groove into the joint (Fig 3 in the referenced article). Fraying of the biceps tendon can be found on both sides of the tendon based on the pathologic condition present, and when looking into the sheath spurs can at times be identified. Kuntz et al.1 also noted that a 70 arthroscope can aid in the visualization of the subscapularis tear. In my article “Visualization of the Anatomy of the Rotator Interval and Bicipital Sheath,”11 Fig 2 compares the view between a 30 and 70 arthroscope and shows how shoulder elevation and internal rotation can further identify upper subscapularis lesions. I would add that the tendon should be viewed from the anterior portal as well. I have found that the dynamic positioning of the shoulder and elbow while viewing with the arthroscope helps the most. Early in 1994, after an upper extremity fellowship sponsored by the AO-ASIF (Association for Osteosynthesis/Association for the Study of Internal Fixation) in Fribourg, Switzerland, I had begun looking at “hidden” rotator interval lesions6 and subscapularis tears with the arthroscope during rotator cuff repairs. Although I agree with the authors that a generally accepted classification system for subscapularis tears has not been widely accepted and that most classify by partial thickness versus full thickness, upper versus complete length, retraction versus no retraction, and additional tendons involved, I would like the readers to refer to both Tables 2 and 3 in “Subscapularis, Medial, and Lateral Head Coracohumeral Ligament Anatomy: Arthroscopic Appearance and Incidence of ’Hidden’ Rotator Interval Lesions,”12 which explicitly lays this out from data compiled from more than 165 arthroscopic shoulder procedures between 1995 and 1998. I could not agree more that associated tendon tears are important (Table 3 of referenced article). However, I would suggest that the subscapularis tear type be documented with any associated pulley lesions. In this article, I coined the term confluence of the superior glenohumeral and coracohumeral ligaments (biceps pulley), describing the heads of the coracohumeral ligament as medial and lateral in relation to the biceps tendon and noting that the origin of this ligament is the medial
LETTERS TO THE EDITOR
coracoid and the lateral humeral head, the course of the ligament’s path. In this article, Fig 2 outlines these lesions. To be complete, other terms for the pulley are medial or internal reflection pulley and anteromedial and posterolateral head of the coracohumeral ligament. I documented the lesions surrounding the bicipital sheath, which include the subscapularis tendon (with or without the medial reflection pulley), the medial reflection pulley without the subscapularis tendon, and the lateral coracohumeral ligament insertion (see Fig 3 of referenced article for arthroscopic examples). The diagrams in Fig 2 were painstakingly created after meeting with a medical artist and using numerous arthroscopic photographs. We reconstructed the arthroscopically viewed anatomy around these areas. Later, I asked the artist to create drawings that were easier to understand; see Fig 9 in “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability.”13 I called this a classification for biceps tendon subluxation. Here I added 2 types of lesions that were not included in the 2001 article. In addition to type 1 subscapularis tear without pulley involvement, type 2 medial pulley tear without subscapularis tear, type 3 medial pulley and subscapularis tear, and type 4 lateral head coracohumeral ligament tear with partial or complete tears of the supraspinatus, I added a type 5 tear, one that included the subscapularis, medial pulley, and lateral pulley with a partial or complete tear of the supraspinatus. Finally, and more pointedly than my earlier publications, I noted that with an upper subscapularis tear and an intact pulley, the biceps tendon can undergo subluxation within the sheath because of plastic deformation of the pulley. Type 2 lesions can occur with delamination of the subscapularis as well. Kuntz et al.1 correctly identify 2 of my 4 published articles on arthroscopic subscapularis repair. In the first, “Arthroscopic Repair of Isolated Subscapularis Tears: A Prospective Cohort with 2- to 4-Year Follow-Up,”13 with the help of the medical artist, I illustrated the technique that I developed for repairing the upper subscapularis tendon and pulley lesion. In the second article cited by the authors, “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability,” 14 the biceps classification system is offered. Interestingly, there are 2 other articles15,16 that have significant numbers of patients who underwent arthroscopic repair included. These 2 articles of mine are often overlooked. I suspect that because they focus on other topics primarily, keywords for arthroscopic subscapularis repair are not being found when the search is conducted.
663
In “Arthroscopic Repair of Massive Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year FollowUp,”15 I broke down these massive repairs into anterosuperior and posterosuperior tears, and 29 of the 37 patients had arthroscopic subscapularis repairs included. In essence, only 9 of the 37 patients, the posterosuperior group, were void of subscapularis tear repairs! These results implicated that good and excellent results could be obtained in both groups. Literature from the early 1990s indicated that massive anterosuperior tear repairs did not do as well as massive posterosuperior repairs. This was because the subscapularis was not being repaired routinely. In another report, “Arthroscopic Bicipital Sheath Repair: Two-Year Follow-Up with Pulley Lesions,”16 all 18 patients had arthroscopic subscapularis repair. This study was on my patients who had type 5 lesions only; see Fig 9 in “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability.”14 In closing, the subscapularis tear, whether an upper subscapularis lesion or more extensive, is still underrecognized. In the article I consider the most important, “Subscapularis, Medial, and Lateral Head Coracohumeral Ligament Anatomy: Arthroscopic Appearance and Incidence of “Hidden” Rotator Interval Lesions,”12 there was a 35% incidence of subscapularis tears found when other rotator cuff tears were present. With 18 years of performing arthroscopic subscapularis repairs, I would now say that percentage is too small; it is actually substantially higher. There are 2 reasons why the subscapularis tear is missed; first, non-complete length tears are often held in a relatively anatomical position by the outer fibers of the subscapularis tendon, confluent with the coracohumeral ligament. The lateral head is rarely disrupted with subscapularis tears, the comma sign2 (however, it can be with supraspinatus tears and type 5 lesions), so the subscapularis is held in a relatively anatomical position by this structure most of the time because supraspinatus and lateral head coracohumeral ligament lesions occur less than 4% of the time with rotator cuff tears. For both the lateral decubitus position, with the arm in traction and the patient in the beach chair position, surgeons should make an effort to release tension, elevate the shoulder, and internally rotate the shoulder because the dynamic evaluation of the anatomy is the most effective for identifying subscapularis tears; many might be surprised to see the medial insertion of the subscapularis lift off the bone with this maneuver. Tears surrounding the upper subscapularis and leading edge of the supraspinatus tendon are implicated in biceps pathologic processes. The biceps, even with a completely intact upper subscapularis and medial pulley, and when a lateral coracohumeral ligament/
664
LETTERS TO THE EDITOR
supraspinatus tendon tear is present, can allow for subluxation laterally out of the groove, causing fraying on the lateral aspect of the biceps tendon. Addressing these anatomical lesions become less important when biceps tenodesis is performed, because the biceps is thus stabilized from movement in either direction. However, reconstruction of the pulley in patients who may benefitde.g., gymnasts, trapeze artists, and throwing athletes (as proprioceptive nerve fibers have been found coursing the length of the bicipital sheath)d may help these athletes subconsciously better position their arms in space (personal communication, G. Di Giacomo, 2005, Rome, Italy). Therefore, for the elite arthroscopic shoulder surgeon, and for these athletes, reconstruction of the biceps pulley should be considered as an option. However, this technique cannot be performed anatomically until these types of lesions and their variations are recognized and understood. William F. Bennett, M.D. Sarasota, Florida Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.04.003
References 1. Kuntz AF, Raphael I, Dougherty MP, Abboud J. Arthroscopic subscapularis repair. J Am Acad Orthop Surg 2014;22:80-89. 2. Burkhart S, Tehrany A. Arthroscopic subscapularis tendon repair: Technique and Preliminary results. Arthroscopy 2002;18:454-464. 3. Clark JM, Harryman DT. Tendons, ligaments and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am 1992;74:713-725. 4. Klapper RC, Jobe FW, Matsura P. The subscapularis muscle and its glenohumeral like bands. A histomorphologic study. Am J Sportsmed 1992;20:307-310.
5. Gohkle F, Essigkrug B, Schmitz F. The pattern of collagen fiber bundles of the capsule of the glenohumeral joint. J Shoulder Elbow Surg 1994;3:111-128. 6. Walch G, Nove-Josserand L, Levigne C, et al. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elbow Surg 1994;3:353-360. 7. Deutsch A, Altchek DW, Veltri DM, et al. Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings and operative treatment. Am J Sportsmed 1997;25:13-22. 8. Ticker JB, Warner JJP. Single tendon tears of the rotator cuff: Evaluation and treatment of subscapularis tears and principles of treatment for supraspinatus tears. Orthop Clin North Am 1997;28:99-116. 9. Sakurai G, Ozaki J, Tomita Y, Kondo T. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 1998;7:510-515. 10. Bennett WF. Specificity of the Speed’s test: Arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy 1998;14:789-796. 11. Bennett WF. Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy 2001;17:107-111. 12. Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament anatomy. Arthroscopic appearancedIncidence of “hidden” rotator interval lesions. Arthroscopy 2001;17:173-180. 13. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143. 14. Bennett WF. 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 2003;19:21-33. 15. Bennett WF. Arthroscopic repair of massive rotator cuff tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:380-390. 16. Bennett WF. Arthroscopic bicipital sheath repair: Twoyear follow-up with pulley lesions. Arthroscopy 2004;20: 964-973.
LETTERS TO THE EDITOR
Table 2. Thickness, Width, and Cross-Sectional Area of ACL and PCL (at Plane Perpendicular to ACL or PCL Axis) Mean (SD) Specimen ACL Thickness (mm) Width (mm) Cross-sectional area (mm2) PCL Thickness (mm) Width (mm) Cross-sectional area (mm2)
Fig 6F.
important message of our study was that the ACL midsubstance is band-like, with a thickness of about 5 mm in a very narrow space between the lateral femoral condyle and the PCL in extension. We have to take into consideration that an oversized graft can cause impingement to the PCL. We agree with the authors of the letter that, as Harner published, the ACL fans out in the tibial attachment and is 3 times thicker (Fig 6, D and F in our article). Figure 8 is based on our measurements shown in Table 2 in our article. For the measurements, we used a stereo microscope (Leica MZ75; Leica Microsystems, Heerbrugg, Switzerland). The image information was
Femoral MidMidInsertion substance 1 substance 2
Tibial Insertion
3.54 (0.78) 4.78 (0.59) 4.96 (0.57) 11.71 (1.24) 8.22 (1.04) 7.41 (0.82) 7.94 (0.78) 10.85 (1.12) 29.1 (3.2) 35.4 (2.5) 39.4 (2.2) 127.1 (7.3)
9.12 (0.83) 8.03 (1.02) 19.47 (3.22) 20.69 (0.99) 9.58 (0.94) 6.63 (0.86) 3.85 (0.7) 5.35 (1.06)
digitized (with a resolution of 12 bits) by a digital microscope camera (Leica DFC425/DFC425C LED illumination, Trinocular Tube, SmartTouch, and PC System with Leica LAS Software; Leica Microsystems). We also agree that if we create a tunnel that is not perpendicular to a surface, we create an oval opening, but the grafts we use through this tunnel remain the same size. If this oval opening has an implication on the graft’s healing and affects its biomechanical properties later, this was beyond the aim of our study but it is a good idea for future projects. In this article, we studied the shape and width of the midsubstance of the ACL in relation to the narrow space between the PCL and lateral femoral condyle. In our next study, we plan to give our main attention to the tibial attachment of the ACL in the “time of remnant-preserving ACL reconstruction.” We thank the authors very much for their interest in our article and their productive letter with ideas for future projects. Anastasios D. Georgoulis, M.D., Ph.D. Eleni Triantafyllidi, M.D. Nikolaos K. Paschos, M.D., Ph.D. Ioannina, Greece Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.04.001
Arthroscopic Subscapularis Repair: A Look at Primacy From a Historical Perspective
Fig 8.
To the Editor: Recently the Journal of the American Academy of Orthopaedic Surgeons published a review article on arthroscopic subscapularis repair by Kuntz et al.1 This topic has been an area of interest to me for more than 18 years. Writing a complete and comprehensive
662
LETTERS TO THE EDITOR
review and opinion article is no easy task, and the authors provided a good compilation summarizing the many tenets of arthroscopic subscapularis repair concisely. Under the cover of this journal, Arthroscopy: The Journal of Arthroscopic and Related Research, and starting with my first publication in 1998, a chronicle of my progressive insights can be found in the 7 articles I reference here. This began with arthroscopic data compilations from my Sarasota office beginning in October 1995. The references in this letter are chronicled by year. In the review article by Kuntz et al.,1 statements regarding primacy2 were opined. Rarely should these types of statements be made. Not only can they be challenged, but unless one has comprehensive knowledge of all abstracts, articles published in journals not referenced in Index Medicus, poster and scientific exhibits, oral presentations, or publications written in other languages, it is easy to err. Comments relating to the “first to report” possibly should be stated as first to publish, citing the language of origin. The first time I reported on arthroscopic subscapularis repair was a 2-year follow-up in 1998 at the annual AAOS meetingdby way of a poster presentation of the abstract of the study manuscript. After this, I reported with podium presentations at the Eighth ESSKA Congress in 1998 in Nice, France, the Florida Orthopedic Society meeting in 1998, and the AANA annual meeting in 1999. As the author of many articles on this topic, I hope by way of this letter to offer clarifications, help source the subject material, and uncover omissions (thereby making them additions). In the end, I hope that readers will feel that I have contributed additional information to enhance understanding on this subject matter. Many of my comments will be related to the previously cited review article and hopefully will come across more as additions rather than corrections. During the 1990s, I simultaneously compiled arthroscopic data as I arthroscopically repaired subscapularis tendons that were isolated, associated with an anterosuperior tear, or associated with massive tears. Interestingly, there were no arthroscopic citations that discussed the repair of the subscapularis tendon in 1995. In my opinion, there were 2 cadaveric articles in 19923,4 and 1 in 19945 that set out to illustrate the anatomy in and around the subscapularis insertion and 1 clinical article in 19946 that set the groundwork for my later expanded classification of lesions in and around this insertional area, originally referred to as “hidden” lesions of the rotator interval. In fact, the literature on repair of this tendon, even with open surgery, was sparse6-9; it was like it was the forgotten tendon. Back to the review article: regarding the authors’ comment noting that a systematic evaluation of the shoulder should be performed and the intra-articular
portion of the biceps tendon should be included, I will help clarify what I believe the authors were trying to say and point out that because my 1998 study “Specificity of the Speed’s Test: Arthroscopic Technique for Evaluating the Biceps Tendon at the Level of the Bicipital Groove”10 is the source of this information, please reference Fig 7 on page 795 of that article. The non-intra-articular biceps tendon can be made intra-articular by using a neuroprobe to pull more tendon into the joint for visualization, a detail the authors did not address. Merely evaluating the tendon that is in the joint is not enough; with shoulder elevation and elbow flexion, the probe can pull most of the tendon that is hidden by the pulley and in the bicipital groove into the joint (Fig 3 in the referenced article). Fraying of the biceps tendon can be found on both sides of the tendon based on the pathologic condition present, and when looking into the sheath spurs can at times be identified. Kuntz et al.1 also noted that a 70 arthroscope can aid in the visualization of the subscapularis tear. In my article “Visualization of the Anatomy of the Rotator Interval and Bicipital Sheath,”11 Fig 2 compares the view between a 30 and 70 arthroscope and shows how shoulder elevation and internal rotation can further identify upper subscapularis lesions. I would add that the tendon should be viewed from the anterior portal as well. I have found that the dynamic positioning of the shoulder and elbow while viewing with the arthroscope helps the most. Early in 1994, after an upper extremity fellowship sponsored by the AO-ASIF (Association for Osteosynthesis/Association for the Study of Internal Fixation) in Fribourg, Switzerland, I had begun looking at “hidden” rotator interval lesions6 and subscapularis tears with the arthroscope during rotator cuff repairs. Although I agree with the authors that a generally accepted classification system for subscapularis tears has not been widely accepted and that most classify by partial thickness versus full thickness, upper versus complete length, retraction versus no retraction, and additional tendons involved, I would like the readers to refer to both Tables 2 and 3 in “Subscapularis, Medial, and Lateral Head Coracohumeral Ligament Anatomy: Arthroscopic Appearance and Incidence of ’Hidden’ Rotator Interval Lesions,”12 which explicitly lays this out from data compiled from more than 165 arthroscopic shoulder procedures between 1995 and 1998. I could not agree more that associated tendon tears are important (Table 3 of referenced article). However, I would suggest that the subscapularis tear type be documented with any associated pulley lesions. In this article, I coined the term confluence of the superior glenohumeral and coracohumeral ligaments (biceps pulley), describing the heads of the coracohumeral ligament as medial and lateral in relation to the biceps tendon and noting that the origin of this ligament is the medial
LETTERS TO THE EDITOR
coracoid and the lateral humeral head, the course of the ligament’s path. In this article, Fig 2 outlines these lesions. To be complete, other terms for the pulley are medial or internal reflection pulley and anteromedial and posterolateral head of the coracohumeral ligament. I documented the lesions surrounding the bicipital sheath, which include the subscapularis tendon (with or without the medial reflection pulley), the medial reflection pulley without the subscapularis tendon, and the lateral coracohumeral ligament insertion (see Fig 3 of referenced article for arthroscopic examples). The diagrams in Fig 2 were painstakingly created after meeting with a medical artist and using numerous arthroscopic photographs. We reconstructed the arthroscopically viewed anatomy around these areas. Later, I asked the artist to create drawings that were easier to understand; see Fig 9 in “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability.”13 I called this a classification for biceps tendon subluxation. Here I added 2 types of lesions that were not included in the 2001 article. In addition to type 1 subscapularis tear without pulley involvement, type 2 medial pulley tear without subscapularis tear, type 3 medial pulley and subscapularis tear, and type 4 lateral head coracohumeral ligament tear with partial or complete tears of the supraspinatus, I added a type 5 tear, one that included the subscapularis, medial pulley, and lateral pulley with a partial or complete tear of the supraspinatus. Finally, and more pointedly than my earlier publications, I noted that with an upper subscapularis tear and an intact pulley, the biceps tendon can undergo subluxation within the sheath because of plastic deformation of the pulley. Type 2 lesions can occur with delamination of the subscapularis as well. Kuntz et al.1 correctly identify 2 of my 4 published articles on arthroscopic subscapularis repair. In the first, “Arthroscopic Repair of Isolated Subscapularis Tears: A Prospective Cohort with 2- to 4-Year Follow-Up,”13 with the help of the medical artist, I illustrated the technique that I developed for repairing the upper subscapularis tendon and pulley lesion. In the second article cited by the authors, “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability,” 14 the biceps classification system is offered. Interestingly, there are 2 other articles15,16 that have significant numbers of patients who underwent arthroscopic repair included. These 2 articles of mine are often overlooked. I suspect that because they focus on other topics primarily, keywords for arthroscopic subscapularis repair are not being found when the search is conducted.
663
In “Arthroscopic Repair of Massive Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year FollowUp,”15 I broke down these massive repairs into anterosuperior and posterosuperior tears, and 29 of the 37 patients had arthroscopic subscapularis repairs included. In essence, only 9 of the 37 patients, the posterosuperior group, were void of subscapularis tear repairs! These results implicated that good and excellent results could be obtained in both groups. Literature from the early 1990s indicated that massive anterosuperior tear repairs did not do as well as massive posterosuperior repairs. This was because the subscapularis was not being repaired routinely. In another report, “Arthroscopic Bicipital Sheath Repair: Two-Year Follow-Up with Pulley Lesions,”16 all 18 patients had arthroscopic subscapularis repair. This study was on my patients who had type 5 lesions only; see Fig 9 in “Arthroscopic Repair of Anterosuperior (Supraspinatus/Subscapularis) Rotator Cuff Tears: A Prospective Cohort with 2- to 4-Year Follow-Up. Classification of Biceps Subluxation/Instability.”14 In closing, the subscapularis tear, whether an upper subscapularis lesion or more extensive, is still underrecognized. In the article I consider the most important, “Subscapularis, Medial, and Lateral Head Coracohumeral Ligament Anatomy: Arthroscopic Appearance and Incidence of “Hidden” Rotator Interval Lesions,”12 there was a 35% incidence of subscapularis tears found when other rotator cuff tears were present. With 18 years of performing arthroscopic subscapularis repairs, I would now say that percentage is too small; it is actually substantially higher. There are 2 reasons why the subscapularis tear is missed; first, non-complete length tears are often held in a relatively anatomical position by the outer fibers of the subscapularis tendon, confluent with the coracohumeral ligament. The lateral head is rarely disrupted with subscapularis tears, the comma sign2 (however, it can be with supraspinatus tears and type 5 lesions), so the subscapularis is held in a relatively anatomical position by this structure most of the time because supraspinatus and lateral head coracohumeral ligament lesions occur less than 4% of the time with rotator cuff tears. For both the lateral decubitus position, with the arm in traction and the patient in the beach chair position, surgeons should make an effort to release tension, elevate the shoulder, and internally rotate the shoulder because the dynamic evaluation of the anatomy is the most effective for identifying subscapularis tears; many might be surprised to see the medial insertion of the subscapularis lift off the bone with this maneuver. Tears surrounding the upper subscapularis and leading edge of the supraspinatus tendon are implicated in biceps pathologic processes. The biceps, even with a completely intact upper subscapularis and medial pulley, and when a lateral coracohumeral ligament/
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LETTERS TO THE EDITOR
supraspinatus tendon tear is present, can allow for subluxation laterally out of the groove, causing fraying on the lateral aspect of the biceps tendon. Addressing these anatomical lesions become less important when biceps tenodesis is performed, because the biceps is thus stabilized from movement in either direction. However, reconstruction of the pulley in patients who may benefitde.g., gymnasts, trapeze artists, and throwing athletes (as proprioceptive nerve fibers have been found coursing the length of the bicipital sheath)d may help these athletes subconsciously better position their arms in space (personal communication, G. Di Giacomo, 2005, Rome, Italy). Therefore, for the elite arthroscopic shoulder surgeon, and for these athletes, reconstruction of the biceps pulley should be considered as an option. However, this technique cannot be performed anatomically until these types of lesions and their variations are recognized and understood. William F. Bennett, M.D. Sarasota, Florida Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.04.003
References 1. Kuntz AF, Raphael I, Dougherty MP, Abboud J. Arthroscopic subscapularis repair. J Am Acad Orthop Surg 2014;22:80-89. 2. Burkhart S, Tehrany A. Arthroscopic subscapularis tendon repair: Technique and Preliminary results. Arthroscopy 2002;18:454-464. 3. Clark JM, Harryman DT. Tendons, ligaments and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am 1992;74:713-725. 4. Klapper RC, Jobe FW, Matsura P. The subscapularis muscle and its glenohumeral like bands. A histomorphologic study. Am J Sportsmed 1992;20:307-310.
5. Gohkle F, Essigkrug B, Schmitz F. The pattern of collagen fiber bundles of the capsule of the glenohumeral joint. J Shoulder Elbow Surg 1994;3:111-128. 6. Walch G, Nove-Josserand L, Levigne C, et al. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elbow Surg 1994;3:353-360. 7. Deutsch A, Altchek DW, Veltri DM, et al. Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings and operative treatment. Am J Sportsmed 1997;25:13-22. 8. Ticker JB, Warner JJP. Single tendon tears of the rotator cuff: Evaluation and treatment of subscapularis tears and principles of treatment for supraspinatus tears. Orthop Clin North Am 1997;28:99-116. 9. Sakurai G, Ozaki J, Tomita Y, Kondo T. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg 1998;7:510-515. 10. Bennett WF. Specificity of the Speed’s test: Arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy 1998;14:789-796. 11. Bennett WF. Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy 2001;17:107-111. 12. Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament anatomy. Arthroscopic appearancedIncidence of “hidden” rotator interval lesions. Arthroscopy 2001;17:173-180. 13. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:131-143. 14. Bennett WF. 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 2003;19:21-33. 15. Bennett WF. Arthroscopic repair of massive rotator cuff tears: A prospective cohort with 2- to 4-year follow-up. Arthroscopy 2003;19:380-390. 16. Bennett WF. Arthroscopic bicipital sheath repair: Twoyear follow-up with pulley lesions. Arthroscopy 2004;20: 964-973.
