Head splitting fracture, ORIF, post traumatic arthritis, ream and run, subscapularis failure, graft reconstruction

 A 51 year old active man sustained a head splitting fracture in a high velocity ski injury.

This was treated at an outside hospital with open reduction and plate fixation. Radiographs showed an incomplete reduction with posterior displacement of the proximal humerus and posterior decentering of the head on the glenoid,

By six months after surgery, the shoulder was stiff, painful, and arthritic.

He presented to us requesting a ream and run procedure with a chrome cobalt humeral head. At the time of this surgery his plate was preserved to minimize the risk of postoperative fracture. The head was centered using soft tissue balancing.

He did well for the the first 2 months after surgery, when he started himself on a vigorous external rotation stretching program. This led to abrupt failure of his subscapularis.

After discussion of the alternatives of non-operative management, reverse total shoulder or attempted subscapularis reconstruction with allograft, he elected the latter.

While his procedure was on the right shoulder, our technique of hamstring reconstruction is shown below for a left shoulder.

In this procedure the retracted subscapularis muscle is carefully freed from the coracoid muscles, neuromuscular structures, and glenoid.

Two holes are made in the lesser tuberosity using a pinecone bur. These holes are connected using curved curettes.

A high quality, long hamstring tendon graft is prepared and threaded through these holes.

Two vertical slits are made in quality subscapularis tissue

The ends of the hamstring graft are passed through these slits.

The graft strands are pulled laterally, approximating the subscapularis to the lesser tuberosity.

And secured to the bone lateral to the lesser tuberosity.

This technique provides four strong strands of allograft that can reinforce a tendon repair or span a gap if the mobilized tendon cannot reach the lesser tuberosity without undue tension.

The mobility and the security of the repair is verified.

Two years after his repair, the patient reported he was doing well, being active in Tai Chi, swimming, weight lifting and throwing with his son, having only minimal discomfort. On examination he had 160 degrees of active flexion with good strength, external rotation to 45 degrees and 4/5 strength of belly press.

His x-rays show a stable, centered humeral head and a remodeling, reamed glenoid. 

This procedure is a valuable procedure for those young, active patients with a failed subscapularis after shoulder arthroplasty who wish to avoid a reverse total shoulder.

Considering the big picture

Mt. Rainier

July 4, 2025

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).