A Superolaterally Placed Anchor for Subscapularis “Leading-Edge” Refixation: A Biomechanical Study

Purpose To compare a conventional single-row (SR) repair technique and 2 double-row (DR) repair techniques to restore and protect the superolateral aspect of the subscapularis (SSC) tendon and ensure SSC leading-edge reconstruction in a cadaveric model. Methods The native footprint was measured in 15 pairs of human cadaveric shoulders (N = 30) with a mean age of 67.2 years. According to the Fox-Romeo classification, a 25% defect or 50% defect in a superior-inferior direction was created. Specimens were mounted onto a servohydraulic test system to analyze contact variables at 0° and 20° of abduction with a force-controlled ramped program up to 50 N. In addition, each specimen was cyclically loaded (10-100 N, 300 cycles). The tears were repaired with 1 of 3 constructs: a 2-anchor medially based conventional SR construct, a 2-anchor-based hybrid DR construct, or a 3-anchor-based DR construct. The outcome variables were ultimate tensile load, displacement, and pressurized footprint coverage. Results All reconstructions resulted in stable constructs with peak loads exceeding 450 N ( P  = .68). The overall displacement during cyclic loading was between 1.2 and 3.0 mm ( P  = .70). A significant difference was seen when the 2 arm positions of 0° and 20° of abduction were compared, showing a constant reduction of pressurized footprint coverage with the arm abducted ( P  = .01). Analyzing footprint coverage with respect to the region of interest—the leading edge of the SSC—we observed a significant difference between the SR construct and a construct using a superolaterally placed anchor (25% defect, P  = .01; 50% defect, P  = .01), whereas no statistical differences were detectable between the hybrid DR construct and the DR construct. Conclusions The leading edge of the SSC tendon can best be restored by using a superolateral anchor, whereas no statistical difference in load to failure in comparison with an SR construct or with the addition of a third anchor was detectable. Clinical Relevance The SSC is critical for proper shoulder function. Without an increase in the number of implants, a significantly better footprint reconstruction can be achieved by placing an anchor superior and lateral to the native footprint area close to the entrance of the bicipital groove.