Review Question - QID 218981

An irreparable subscapularis tear is a contraindication to a superior capsular reconstruction (SCR). The subscapularis receives innervation from both the upper (D) and lower subscapular nerves.

The management of irreparable rotator cuff tears represents a challenging-to-navigate clinical scenario. While older and/or lower-demand patients can often be treated with a reverse total shoulder arthroplasty (rTSA), high failure rates preclude this treatment option in younger patients. In younger patients, treatment options for irreparable posterosuperior rotator cuff tears include SCR, tendon transfers, partial repair and subacromial balloon spacer (SAB) placement, with no one option demonstrating clinical superiority. When evaluating patients in anticipation of performing an SCR, evaluation of the subscapularis is critical, as an irreparable tear of this tendon represents a contraindication to SCR.

Mihata et al. provide one of the earliest reports of outcomes following SCR. Their study included 24 SCRs performed in 23 patients with a mean age of 65.1 years. The authors note that overall SCR was able to provide patients with excellent improvement in range of motion at a mean follow-up of 34.1 months. The authors note, however, that either an intact or reparable subscapularis tendon must be present in order to maximize outcomes.

Hartzler and Burkart provide an overview of the SCR. The authors note that posterosuperior cuff irreparability shoulder only be diagnosed after a thorough diagnostic arthroscopy, and other joint-preserving procedures can be performed during SCR to maximize patient outcomes. Similar to Mihata et al. the authors highlight the importance of ensuring that the subscapularis is intact or, if torn, reparable, prior to performing an SCR.

Figure A is an illustration of the brachial plexus. A is the dorsal scapular nerve, which innervates the rhomboid and levator scapulae, B is the long thoracic nerve, which innervates the serratus anterior, C is the suprascapular nerve which innervates the supraspinatus and infraspinatus, D is the upper subscapular nerve, which innervates the subscapularis, and E is the axillary nerve, which innervates the deltoid and teres minor. Illustration A is a labeled diagram of the brachial plexus.

Incorrect Answers:
Answer 1: the dorsal scapular nerve innervates the rhomboid and levator scapulae.
Answer 2: the long thoracic nerve innervates the serratus anterior.
Answer 3: the suprascapular nerve innervates the supraspinatus and infraspinatus.
Answer 4: the axillary nerve innervates the teres minor and deltoid. A functional deltoid is required for SCR to be effective, but the deltoid is not a rotator cuff muscle.