Combined procedure may benefit subscapularis tear patients less suited for rigorous rehab

Surgery resulted in high levels of patient satisfaction, even though they may not have regained preinjury strength.

Certain patients with subscapularis tears and biceps tendon disease may benefit from combined arthroscopic debridement and biceps tenotomy, a small study suggests.

T. Bradley Edwards, MD, and colleagues in Houston and Lyon, France, retrospectively reviewed their results performing the combined procedures in 11 patients. In all cases, patients had irreparable subscapularis tendon tears and had failed nonoperative treatment, according to the study.

Patients were a mean age of 64.1 years and were followed for a mean 33.5 months postop. The researchers focused on evaluating the efficacy of surgery in patients with poor tendon quality or who had less potential for completing postop rehabilitation programs. All patients "were unwilling or unable to comply with the prescribed postoperative rehabilitation regimen for subscapularis repair," the study authors said.

Preoperatively, tears were limited to the superior third of the subscapularis tendon in four shoulders and, in two shoulders, tears involved the superior two-thirds of the tendon. The remaining five shoulders had complete subscapularis tendon tears, according to the study.

All cases involved full-thickness tears that occurred in the anteroposterior dimension, the authors noted.

After diagnostic arthroscopy, surgeons resected any apparent synovitis and debrided any frayed areas of the subscapularis tendon. For all cases with a subluxated or dislocated biceps tendon, surgeons also tenotomized that tendon by releasing it from the superior glenoid labrum insertion, allowing it to retract from the glenohumeral joint, according to the study.

Postoperative rehabilitation mainly involved passive mobilization, with active mobility as tolerated. "No strengthening exercises were performed. Full activity was allowed as soon as postoperative pain had subsided," the authors said.

At final follow-up, the mean Constant score had significantly improved to 79.7 points from 48.6 points preoperatively (P<.0001), with significant improvements in all score subscales. Six patients (55%) subjectively rated their results as "excellent" and three rated them as "good." One patient who had a ruptured biceps tendon preoperatively rated his result as "fair." The remaining one patient had a normal-appearing biceps tendon preoperatively that was not treated. This patient rated the result as "poor," according to the study.

Although the findings were not statistically significant, the researchers noted some improvements in strength. At final follow-up, three patients had positive lift-off tests, down from four patients preoperatively. Eight patients also had a positive belly-press test at final follow-up, while all patients had positive test results preoperatively.

"The inability of these patients to comply with rigorous postoperative physical therapy, which was the primary reason they were selected for isolated debridement, suggests a decreased functional demand on their shoulders during daily activities. Therefore, it is not surprising that postoperative improvement in pain, activity and mobility scores resulted in high levels of overall patient satisfaction, even though preinjury strength may not have been restored," the authors said.

For more information:
Edwards TB, Walch G, Nové-Josserand L, et al. Arthroscopic debridement in the treatment of patients with isolated tears of the subscapularis. Arthroscopy. 2006;22:91-946.