Wednesday, January 3, 2018

Subscapularis management in shoulder arthroplasty

Subscapularis Tenotomy in Anatomic Total Shoulder Arthroplasty

This author describes in detail his method for tenotomy of the subscapularis for exposure at the time of anatomic total shoulder arthroplasty, pointing out its simplicity, shorter operative time, and utility in stemless shoulder arthroplasty.

While he achieves excellent results with this method, he points out that consistent performance of a good subscapularis tenotomy is difficult. The most common mistakes include wrong placement of the vertical incision on the subscapularis (either too lateral or too medial), failure to release the anterior capsule to restore subscapularis excursion, and suboptimal repair of the subscapularis, perhaps due to inadequate tissue left on the lateral side of the tenotomy. Failure of the tenotomy to heal leading to anterior instability may be salvaged surgically, but oftentimes requires revision to a reverse arthroplasty. 

Comment: In our practice we use what has been described as the subscapularis 'peel', that allows us to maximize the length of the tendon. The long head tendon of the biceps is carefully preserved.

The capsule is released from the glenoid but retained on the deep surface of the subscapularis tendon to strengthen the tissue available for repair.
 Six secure drill holes are placed at the margin of the humeral head cut. #2 non-absorbable sutures are passed through these holes.
 The sutures are passed through the lateral edge of the tendon and subjacent capsule.
 And tied securely.
 The quality of the repair enables immediate assisted elevation
External rotation is limited to zero degrees for the first 6 weeks.

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