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    The Bear Hug Test Improves Sensitivity Compared With the Belly Press Test for Identifying Subscapularis Tendon Tears, but Both Tests Miss the Majority of Partial Tears
    (Elsevier Inc., 2024) Kilic A.I.; Ardebol J.; Pak T.; Menendez M.E.; Denard P.J.
    Purpose: To investigate the performance of the bear hug (BH) and belly press (BP) tests in diagnosing tears of the subscapularis (SSC). Methods: A retrospective review was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair (ARCR) of SSC tears between 2011 and 2021. A control group also was obtained of ARCRs with an intact SSC tendon. All examinations and ARCRs were performed by one high-volume shoulder surgeon. The BH test and BP test results were compared with arthroscopic findings as the gold-standard diagnostic modality. Tear type was classified based on the Lafosse classification. Sensitivity, specificity, positive and negative predictive values, false-positive and false-negative rates, and accuracy were calculated for both tests. Results: A total of 1,122 patients were included for analysis, 866 with intraoperatively confirmed SSC tears (77%) and 256 without (23%). The BH test diagnosed SSC tears with a sensitivity of 46.1% and a specificity of 83.2%, whereas the BP test diagnosed tears with a sensitivity of 23.3% and a specificity of 93.4%. Overall, both tests missed SSC tears in 42.3% (n = 475) of cases. The BH test had accuracy rates of 25.9% for SSC type I tear, 48.7% for type II tear, 65% for type III tear, and 81.7% for type IV-V tear. In contrast, the BP test had accuracy rates of 7.6% for type I tear, 14.7% for type II tear, 42% for type III tear, and 68.7% for type IV-V tear. Conclusions: The BH test had greater sensitivity than the BP test in identifying SSC tears. Both tests showed low accuracy in identifying SSC tears as tear size decreased. Combining both tests did not provide any additional benefits over using the BH test alone. Level of Evidence: Level III, diagnostic study. © 2023
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    Both Radiologists and Surgeons Miss a Substantial Number of Subscapularis Tears on Magnetic Resonance Imaging Examination Prior to Shoulder Arthroscopy
    (Elsevier Inc., 2024) Kilic A.I.; Ardebol J.; Ghayyad K.; Pak T.; Menendez M.E.; Denard P.J.
    Purpose: To compare radiologist and surgeon magnetic resonance imaging (MRI) interpretations of subscapularis (SSC) tears against intraoperative arthroscopic examination. Methods: We conducted a retrospective review of prospectively maintained data on patients who underwent arthroscopic rotator cuff repair with and without SSC tears between 2011 and 2022. The radiologists’ assessments of SSC integrity were extracted from the MRI reports. One high-volume fellowship-trained shoulder surgeon assessed all MRI scans for the presence or absence of SSC tears. Radiologist and surgeon MRI-based assessments were compared against the diagnostic gold standard (intraoperative arthroscopic examination) and classified according to the Lafosse classification. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. Results: A total of 1,090 patients were included for analysis, 839 with intraoperatively confirmed SSC tears (77%) and 251 without such tears (23%). Radiologists diagnosed SSC tears with a sensitivity of 56.0% (470 of 839 patients) and specificity of 67.3% (169 of 251 patients) via MRI, whereas the surgeon diagnosed SSC tears with a sensitivity of 71.4% (599 of 839 patients) and specificity of 78.1% (196 of 251 patients). Overall, radiologists only correctly identified 56% of SSC tears whereas the shoulder surgeon correctly identified approximately 71.4% of tears. When considering arthroscopically confirmed tear size, that is, intact, partial, full thickness [upper border], and complete, the radiologists’ diagnosis rates with MRI were 67.3%, 40.4%, 64.6%, and 78.3%, respectively, and the surgeon's diagnosis rates were 78.1%, 52.7%, 81.9%, and 97.5%, respectively. Conclusions: In a community practice, radiologists miss approximately 50% of SSC tears on MRI examination. A shoulder surgeon with the benefit of clinical examination misses 28.6% of tears on MRI. Accuracy increases as tear size increases, with radiologists detecting 40.4% of partial tears and 78.3% of complete tears and a surgeon detecting 52.7% and 97.5%, respectively. Level of Evidence: Level III, diagnostic study (nonconsecutive patients). © 2023
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    Clinical Outcomes and Tendon Healing After Arthroscopic Isolated Subscapularis Tendon Repair: Results at Midterm Follow-up
    (SAGE Publications Ltd, 2024) Kilic A.I.; Zuk N.A.; Ardebol J.; Pak T.; Menendez M.E.; Denard P.J.
    Background: Few studies have reported clinical outcomes and tendon healing rates after arthroscopic isolated subscapularis (SSC) repair (AISR). Purpose/Hypothesis: The primary purpose of this study was to evaluate clinical outcomes and tendon healing after AISR. It was hypothesized that AISR would result in satisfactory clinical outcomes along with a high rate of tendon healing at the midterm follow-up. The secondary purpose was to assess the influence of tear size and muscle atrophy on SSC tendon healing and patient-reported outcomes. It was hypothesized that both would be negatively correlated with healing but would have no effect on clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis was conducted on prospectively collected data for 77 patients who underwent primary AISR between 2011 and 2021 at a single institution, with a minimum 2-year postoperative follow-up for all patients. Functional outcomes were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Subjective Shoulder Value (SSV), and the visual analog scale for pain. Repair techniques and concomitant procedures were also collected. SSC tendon healing was evaluated via ultrasound at the final follow-up. Linear regression analysis was performed to determine factors affecting SSC healing. Results: The mean follow-up was 58.1 ± 3.3 months. ASES scores significantly improved from 41.5 to 81.6, and the SSV improved from 38.2 to 80.5 (P <.01 for both). Among the 40 patients (51.9%) who underwent postoperative ultrasound, 87.5% showed complete tendon healing. There were no significant differences in outcome scores between healed and unhealed tendons. Increased muscle atrophy and larger tears were correlated with failure of SSC healing (? = ?0.285 [P =.015] and ? = ?0.157 [P =.045], respectively). Conclusion: Improved clinical outcomes and an overall high rate of tendon healing were seen at the midterm follow-up after AISR. Smaller tear sizes with less muscle atrophy were correlated with improved tendon healing. However, even when the tendon incompletely healed, the procedure improved functional outcomes. © The Author(s) 2024.
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    Higher Upper Subscapularis Goutallier Grade and Coracohumeral Distance Narrowing Are Predictive of Subscapularis Tears in Patients Undergoing Arthroscopic Rotator Cuff Repair
    (W.B. Saunders, 2023) Kilic A.I.; Ardebol J.; Pak T.; Menendez M.E.; Denard P.J.
    Purpose: To evaluate the relation between subscapularis (SSC) Goutallier grade or coracohumeral distance (CHD) and SSC tears, as well as the relation between these radiographic variables and long head of the biceps tendon lesions. Methods: A retrospective analysis was conducted on prospectively maintained data on patients who underwent arthroscopic rotator cuff repair of SSC tears between 2011 and 2021 with at least 6 months of follow-up. Patients with identified subscapularis tears during arthroscopy were included. A control group was established by randomly selecting patients without SSC tears from the same study period. Goutallier grading and CHD were obtained from preoperative magnetic resonance imaging (MRI) scans. Receiver operating characteristic analysis was conducted to define optimal cutoff values for these diagnostic measures. Results: The study included 735 patients with SSC tears and 249 patients in the control group. Comparing subscapularis tear and intact groups’ Goutallier grades revealed significant differences in infraspinatus, upper and lower SSC, and overall SSC (P < .001). No significant difference was detected in supraspinatus Goutallier grade (P = .364). An SSC tear was observed in 58.3% (n = 265) of patients with Goutallier grade 0 of the upper SSC, 77.1% (n = 195) of patients with grade 1 changes, 98.7% (n = 155) with grade 2 changes, and 100% of grade 3 or 4 changes. Goutallier grade of the upper SSC showed a significant correlation with tear size (rs = 0.533; P < .01). CHD measurements were lower in individuals with SSC tears compared to those without tears (6.6 ± 1.7 vs 9.6 ± 1.8; P < .001). Upper SSC Goutallier grade >1 had an acceptable area under the curve (AUC) of 0.742. CHD of 7.96 mm or less had an excellent predictive AUC of 0.879. Conclusions: Higher Goutallier grade and CHD narrowing are potential associations predictive of SSC tears. Routine MRI assessment of muscle of the upper SSC and the CHD can contribute to the diagnostic accuracy of SSC tears and offer valuable information regarding the severity of such tears. Level of Evidence: Level III, diagnostic study. © 2023 Arthroscopy Association of North America