Abstract
Background:
The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear.
Indications:
Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct.
Technique Description:
Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months).
Results:
Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%).
Conclusion:
Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.
This is a visual representation of the abstract.
Video Transcript
The comma sign is seen in combined supraspinatus and subscapularis tears. It was first described by Lo and Burkhart as a “composite ligamentous structure” of the superior glenohumeral ligament and coracohumeral ligament attached to the retracted subscapularis. Dilisio and Neyton suggested that the comma is the verticalization of the superior part of subscapularis pulled upward by retraction of supraspinatus. We present a 58-year-old man after a skiing accident with forceful external rotation of his right arm with impaired shoulder function. Physical examination showed positive Lift off and Jobe tests with unrestricted external rotation to 110° with the arm at side. [The Constant score and Subjective Shoulder Value (SSV) were noted with 35% and 30%, respectively.] An arthro–magnetic resonance imaging confirmed a combined subscapularis and supraspinatus tear with a Patte 2-3 retraction. Key equipment is listed for your reference. A standard beach chair position was used with an armholder. Previously described circumferential portals were used.
Viewing from posterior, the bare lesser tubercle is visible. The comma sign is assessed with a probe showing limited mobility. The long head of biceps is absent due to a previous attritional tear. A tenotomy or tenodesis would have been performed in case of an unstable long head of biceps.
Subscapularis is released from the conjoint tendon and fascia with a radiofrequency ablator.
Releases anterior to subscapularis medial to the coracoid must only be attempted under good direct vision. Prior to a limited coracoplasty, the bone is debrided and the coracoacromial ligament released. The footprint of the supraspinatus is debrided. The excursion of the anterosuperior tear is still not optimal. A Vicryl (J&J Medical Devices) 2 traction suture is passed lateral to the comma and pulled out anterolaterally.
A meticulous release in the subscapularis fossa between subscapularis and the scapula is undertaken with a blunt liberator and radiofrequency ablator. A second Vicryl 2 traction suture is passed medial to the comma and pulled out through the anterior portal after introduction of a PassPort cannula (Arthrex) for fluid control.
Traction on this suture improves viewing and access to the lesser tubercle and the view on the inside of subscapularis for suture passing and management. The release is completed with the ablator being inserted through the anterolateral portal. The scope should always be changed over to the lateral portal to assess the medial part of the release. The first anchor is placed at the lower part of the lesser tubercule through the anterior portal. As a guide for anchor direction, the anchor handle should point to the patients face.
Sutures are first placed between the scapula and the subscapularis and then grabbed through the lowest part of the subscapularis tendon with a retrograde suture passer. After passing a single suture, each subsequent passage can shuttle 2 sutures at once with 2 advantages: efficiency and speed as well as a gapless suture repair.
The sutures are pulled out through the lateral portal. The second anchor is placed at mid-height of the lesser tubercule through the anterior portal. Retrograde suture passing is continued through the superior part of the subscapularis.
The third anchor is placed at the interval junction of subscapularis and supraspinatus through the anterior portal. [The danger of inadvertent suture passing through the obliquely orientated conjoint tendon is caused by its close proximity.] The first blue strand is used to create a lasso loop in the comma tissue and the superior part of the subscapularis. After passage of the second blue strand in the adjacent superior subscapularis tendon, pulling on it will perfectly reduce the comma tissue. Six classic half-hitches (Lafosse easy knots) are tied for each of the 5 pairs of sutures. The footprint is further freshened up with careful microfracture perforations. Further debridement improves the view and opens up the working space.
From now on, the scope remains in the lateral viewing portal. Supraspinatus mobility is assessed. The footprint is further freshened up with a bone resecting shaver. Two white strands of the third anchor are placed in the articular space and passed through the anterior part of the supraspinatus. An anterior acromion portal is created for insertion of the fourth anchor. With internal rotation of the armholder, the anchor is placed central and medial on the supraspinatus footprint.
The footprint is again prepared with careful microperforations. It is important not to destabilize the cortex and anchor. The first blue strand is passed through the full thickness of the tendon. The cleavage between the bursal and capsular layer can clearly be seen. The second blue strand is used to create a lasso loop on the capsular layer for its reduction not further than the medial footprint. Using an opposite retrograde passer, the 2 last white strands are passed through the full thickness of the posterior part of the tendon using a posterolateral portal.
After inserting a PassPort cannula in the anterolateral portal for fluid management, 3 easy knots are tied with half-hitches, including the comma suture. A first 4.75-mm hole is prepared for the posterior knotless anchor of the second row. The anchor is loaded with 3 sutures from supraspinatus. The knotless anchor allows precise tightening of each strand after anchor seating before sutures are manually locked inside the anchor with an audible pop.
The sutures in the anterior supraspinatus, comma tissue, and subscapularis are organized. A second hole is prepared for the anterior anchor of the second row. A second hole is prepared for the anterior anchor of the second row. The second knotless anchor is loaded with 5 sutures including 2 comma tissue sutures and 2 subscapularis traction sutures. A strong repair of this complex anterosuperior tear with solid comma fixation has now been achieved. Insertion of the scope from the anterior portal shows the final assessment of the comma reduction and subscapularis repair.
At the end of the intervention, the acromioplasty is conducted through the anterior portal, using the posterior acromion as a reference.
This sketch summarizes suture and anchor positioning for your reference. Followed by the final double row repair construct.
Prevention strategies and potential complications are listed on this slide.
Postoperative rehabilitation is protective with use of a sling, passive motion and limitation to 90° flexion and 20° external rotation for 6 weeks before active assisted stretching is allowed. Full active mobilization is allowed between weeks 7 and 9. Resistance strengthening is only commenced with care after 3 to 6 months. Return to sport is allowed at 6 to 9 months dependent on a return to play assessment. In our series of 32 patients, good results were noted after 1 year with a clear improvement of functional scores. Denard and Burkhart reported a series of 79 patients, with 83% of good-to-excellent results at 7 years.
Footnotes
Submitted February 5, 2021; accepted March 29, 2021.
Bracketed and italicized text indicates information not included in the video narration.
One or more of the authors has declared the following potential conflict of interest or source of funding: J.C. reports grants from Swiss Orthopaedics, outside the submitted work. G.A. reports personal fees from Conmed Linvatec and personal fees from Wright Medical, outside the submitted work. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.