The subscapularis is an important component of the rotator cuff and contributes to internal rotation of the shoulder and dynamic stabilization of the glenohumeral joint. Tears of the subscapularis tendon may occur following trauma, degenerative changes, or a combination of both.
When a tendon tear requires surgical treatment, the objective is to restore the tendon toward its anatomical attachment on the lesser tuberosity of the humerus. Suture anchor fixation is one technique used to secure soft tissue to bone and support tendon-to-bone healing.
Arthroscopic subscapularis repair involves careful assessment of the tear, preparation of the tendon and its bony footprint, appropriate anchor placement, and secure suture fixation. The choice of repair configuration depends on tear size, tendon retraction, tissue quality, bone quality, and the surgeon's assessment.
A suture anchor system generally consists of an anchor, one or more sutures, and an insertion instrument. When appropriately selected and implanted, the system provides a means of attaching soft tissue to bone during orthopedic procedures.
This article reviews the principles of subscapularis tendon tear classification, arthroscopic repair, suture anchor placement, and the role of PEEK suture anchors in tendon-to-bone fixation.
Pathology and Classification of Subscapularis Tendon Tears
2.1 Common Causes of Subscapularis Tendon Tears
Subscapularis tendon tears may develop through several mechanisms.
Degenerative changes
Age-related tendon degeneration and repetitive mechanical loading may contribute to reduced tendon quality and progressive tearing.
Traumatic injury
A sudden force applied to the shoulder, including forced external rotation or other injury mechanisms, may damage the subscapularis tendon.
Associated shoulder pathology
Subscapularis tears may coexist with other rotator cuff injuries, biceps tendon pathology, or additional abnormalities of the shoulder joint. These associated conditions should be evaluated during clinical assessment.
2.2 Clinical and Imaging Assessment
Clinical examination and imaging are used together to assess the suspected tear.
Evaluation may include:
Shoulder pain and functional limitations
Weakness during internal rotation
Physical examination findings
MRI assessment of tendon integrity and retraction
Ultrasound when appropriate
Arthroscopic assessment of the tear pattern and tissue quality
Imaging findings should be interpreted alongside the clinical examination rather than used in isolation to determine treatment.
2.3 Lafosse Classification
The Lafosse classification is commonly used to describe the extent of subscapularis tendon tears. The classification considers the extent of tendon involvement and, in more advanced patterns, the degree of retraction and associated changes.
| Type | General description |
|---|
| Type I | Partial tear involving the upper portion of the tendon |
| Type II | Complete tear of the upper third |
| Type III | Complete tear involving approximately the upper two-thirds |
| Type IV | Extensive tear involving the entire tendon, with the humeral head remaining centered in the glenoid |
| Type V | Extensive tear associated with anterior subluxation or displacement of the humeral head |
The precise assessment should be based on the classification criteria and the findings documented during imaging or arthroscopy. The classification is a descriptive tool and does not independently determine the surgical technique.
Preoperative Preparation and Arthroscopic Portals
Appropriate preoperative planning helps establish the repair strategy and identify potential technical challenges.
The surgeon should evaluate:
Tear location and extent
Tendon mobility and retraction
Tendon quality
Condition of the lesser tuberosity
Associated rotator cuff pathology
Biceps tendon involvement
Bone quality and the intended anchor fixation site
Arthroscopic access is established according to the patient's anatomy and the planned procedure.
3.1 Posterior Viewing Portal
A posterior portal is commonly used for visualization of the glenohumeral joint. It provides a perspective for assessing intra-articular structures and identifying the subscapularis tear.
3.2 Anterior Working Portal
An anterior working portal provides access for instruments used in tissue mobilization, footprint preparation, anchor insertion, and suture management.
3.3 Additional Portal When Required
An additional portal may be established when required for visualization, instrument access, or suture management. Portal placement should be tailored to the tear pattern and the chosen repair technique.
The exact portal configuration varies according to surgical requirements and should not be regarded as a universal fixed sequence.
Arthroscopic Suture Anchor Repair: Key Surgical Steps
The following sequence describes general principles of arthroscopic tendon repair. The actual procedure should follow the selected implant system's instructions for use and the surgeon's established technique.
Step 1: Diagnostic Arthroscopy
The glenohumeral joint is examined to assess the subscapularis tendon and identify associated pathology.
The surgeon evaluates:
The findings help determine whether the tendon can be mobilized and repaired without excessive tension.
Step 2: Tendon Mobilization and Footprint Preparation
The torn tendon is mobilized as necessary to facilitate anatomical reduction.
The intended tendon attachment site on the lesser tuberosity is prepared according to the repair technique. Preparation should provide an appropriate surface for tendon-to-bone healing while avoiding unnecessary removal of healthy bone.
Important considerations include:
Adequate tendon mobilization
Preservation of viable tendon tissue
Identification of the anatomical footprint
Appropriate preparation of the bone surface
Avoidance of excessive repair tension
The goal is to position the tendon as close as appropriate to its anatomical attachment while maintaining a repair configuration that the tissue can tolerate.
Step 3: Suture Anchor Insertion
A suture anchor is inserted into the selected bone location according to the implant system's surgical technique.
Anchor selection and placement should account for:
Available bone stock
Anchor dimensions
Intended insertion trajectory
Required fixation points
Tendon tear configuration
The planned suture repair pattern
The anchor should be seated according to the manufacturer's instructions. The insertion angle and depth should be appropriate for the specific anchor design and anatomical location.
There is no single insertion angle or depth that is suitable for every suture anchor and every repair configuration.
Step 4: Suture Passage and Tendon Fixation
After anchor placement, the sutures are passed through the tendon according to the selected repair configuration.
The suture arrangement should distribute fixation forces appropriately while allowing the tendon to be reduced toward its anatomical footprint.
The surgeon assesses:
The number of anchors and sutures depends on the tear size, tissue quality, repair configuration, and implant specifications.
A single-row or multiple-row repair may be selected according to the specific clinical and technical requirements. A more complex construct is not automatically superior in every case; excessive tension or poor tissue quality may compromise the repair.
Step 5: Final Arthroscopic Assessment
The completed repair is inspected arthroscopically.
The assessment may include:
The surgeon should confirm that the construct is consistent with the intended repair and the instructions for the selected implant system.
The final appearance alone does not establish tendon healing. Healing and functional recovery require postoperative follow-up and depend on patient factors, tissue quality, repair integrity, and rehabilitation.
Key Considerations for Suture Anchor Fixation
5.1 Appropriate Anchor Selection
Suture anchors are available in different materials, sizes, and configurations. The choice should be based on the intended application, anatomical location, bone quality, suture requirements, and the implant's approved indications.
5.2 Bone Quality and Anchor Purchase
Anchor fixation depends partly on the quality of the surrounding bone. Poor bone quality may compromise fixation, while inappropriate anchor placement can increase the risk of loosening or pullout.
The insertion method should be tailored to the specific anchor design and surgical site.
5.3 Suture and Tendon Integrity
The anchor is only one part of the repair construct. Suture strength, suture passage, tendon quality, and the distribution of forces across the repair also influence mechanical performance.
5.4 Repair Tension
Excessive tension may compromise the tendon or place additional stress on the repair construct. The tendon should be reduced according to the tear pattern and tissue mobility, without assuming that maximal tension is always desirable.
5.5 Potential Complications
Potential complications of anchor-based tendon repair include:
Anchor loosening or pullout
Suture breakage
Tendon retear
Inadequate tendon-to-bone healing
Articular cartilage injury associated with malpositioned hardware
Stiffness or persistent shoulder symptoms
These risks depend on the patient, anatomy, implant design, surgical technique, and rehabilitation. No suture anchor can guarantee that complications will not occur.
PEEK Suture Anchor: Material and Design Considerations
Polyetheretherketone (PEEK) is a high-performance polymer used in selected orthopedic implant applications.
The ATOM Suture Anchor is specified as a PEEK anchor supplied with sutures and an inserter. The product page describes the system as intended to secure tendons, ligaments, and grafts to bone in orthopedic procedures.
6.1 PEEK Anchor Material
The product page identifies PEEK as the anchor material. PEEK is radiolucent compared with conventional metallic implant materials, although imaging visibility depends on the complete construct, imaging modality, and surrounding anatomy.
It is more accurate to describe PEEK as potentially reducing implant-related imaging interference than to claim that it guarantees artifact-free imaging under all circumstances.
6.2 Preloaded Sutures
The ATOM product page describes the anchor as preloaded with one to three sutures, depending on configuration.
Preloaded sutures may simplify instrument preparation and suture management. The exact suture count and configuration should be confirmed for the selected model.
6.3 Dual-Color Suture
The product page describes a combination of white and blue-white sutures.
Color contrast can assist visual identification and suture handling during a procedure. It should not be presented as independently improving clinical outcomes.
6.4 Depth-Marked Inserter
The inserter handle and rod incorporate depth markings intended to support controlled insertion.
The markings are an aid to placement, not a substitute for appropriate technique, anatomical assessment, or verification of implant position.
6.5 Available Sizes
The ATOM product page lists the following size configurations:
4.5 mm × 14 mm
4.75 mm × 14 mm
5.5 mm × 15 mm
6.5 mm × 15 mm
Confirm the exact model-to-size mapping and availability with the current product specification before publication or ordering.
ATOM Suture Anchor for Tendon-to-Bone Fixation
The ATOM Suture Anchor is designed for orthopedic procedures in which tendons, ligaments, or grafts need to be secured to bone.
According to the product page, the system consists of an anchor, suture, and inserter. It is listed for use in knee, hip, shoulder, elbow, and ankle procedures.
| Specification | ATOM Suture Anchor |
|---|
| Product name | Suture Anchor |
| Anchor material | PEEK |
| Components | Anchor, suture, and inserter |
| Suture configuration | Preloaded; one to three sutures depending on configuration |
| Listed applications | Selected knee, hip, shoulder, elbow, and ankle procedures |
| Listed sizes | 4.5/4.75 mm × 14 mm; 5.5/6.5 mm × 15 mm |
The product's indications and specifications should always be checked against the current product documentation and applicable instructions for use.
For subscapularis tendon repair specifically, the selected anchor must be appropriate for the intended anatomical site, repair configuration, and applicable device indications. The product page's general shoulder application does not, by itself, establish that every size or configuration is indicated for every subscapularis repair.
Postoperative Assessment and Rehabilitation Considerations
Postoperative management should be individualized according to the tear pattern, repair configuration, tendon quality, associated procedures, and surgeon's protocol.
Rehabilitation commonly involves a protected phase followed by progressive restoration of movement and strength.
The timing and progression of rehabilitation should account for:
Early unrestricted loading should not be assumed to be appropriate for every repair. Conversely, prolonged immobilization without a clinical reason may also affect shoulder mobility.
Follow-up assessment may include clinical examination and imaging when indicated. Postoperative imaging should be interpreted together with symptoms and functional findings rather than treated as a stand-alone measure of success.
Key Principles of Suture Anchor Repair
Successful anchor-based tendon repair depends on the complete fixation strategy rather than the anchor alone.
The principal considerations are:
Accurate identification and classification of the tear.
Adequate tendon mobilization and appropriate footprint preparation.
Selection of an anchor suitable for the anatomical site and intended repair.
Correct anchor placement according to the device-specific technique.
Appropriate suture passage and management of repair tension.
Assessment of tendon-to-bone contact and construct stability.
Individualized postoperative protection and rehabilitation.
Suture anchor design, material, and configuration should be selected according to the specific surgical application. Available evidence does not support a claim that one anchor material or configuration is universally superior for every tendon repair.
Conclusion
Suture anchor fixation is an established method of securing soft tissue to bone in orthopedic surgery. In arthroscopic subscapularis tendon repair, the repair strategy should be based on the tear pattern, tendon mobility, tissue quality, bone quality, and the intended fixation construct.
Appropriate anchor placement, careful suture management, suitable repair tension, and individualized postoperative rehabilitation are all important considerations. The anchor is one component of the repair and cannot independently guarantee tendon healing or prevent complications.
The ATOM Suture Anchor is a PEEK anchor system supplied with preloaded sutures and an inserter. Its listed applications include selected orthopedic procedures involving soft-tissue-to-bone fixation. Product selection for a specific repair should be based on the current specifications, approved indications, and applicable instructions for use.
