Thursday, August 18, 2022

The subscapularis - the limerick

A patient recently sent this limerick - surely worth sharing:


 LIMERICK FOR SUBSCAPULARIS 

 

This muscle is hidden from sight 

It's working for you day and night 

When you stumble and fall 

And it won't work at all 

Who knows if it can be put right?



Failure of the subscapularis after shoulder arthroplasty is a clinically important complication that can substantially compromise the comfort and function of the shoulder. 

Take down and repair

Like most complications, subscapularis failure is better prevented than treated. Our approach includes takedown using a careful subscapularis peel, keeping the subjacent capsule intact to the tendon.

After the arthroplasty, the subscapularis tendon and subjacent capsule are repaired to the humerus using at least 6 sutures passed through secure drill holes at the margin of the humeral head cut.





The superior band of the subscapularis, also known as the upper rolled border, is the major strength of the subscapularis. The suture laced through it at the time of repair carries a disproportionately high percent of the total tendon load when the arm is externally rotated (see this link). We refer to this most important suture as the Mother Stitch.



This repair can be reinforced with a rotator interval plication.

                         

During the first two months after shoulder arthroplasty, we are careful to have the patient stretch in flexion



but NOT in external rotation to avoid stressing the repair.






Diagnosing failure

Because post operative MRIs and sonograms after shoulder arthroplasty can be difficult to interpret, the diagnosis of subscapularis failure is often best made from 

(1) history - force on the repaired tendon within the first two months after surgery resulting from

    a fall on the arm, 

    a sudden or unexpected stretch in external rotation beyond the handshake position 

    a forceful internal rotation (e.g. while restraining a dog chasing a squirrel)

(2) physical exam

    increased external rotation from what was recorded in the operating room at the close of the case


    weakness of belly press with the arm out to the side



(3) radiographs
    
    anterior subluxation of the humeral head on the glenoid seen on the axillary "truth" view of the left shoulder



Reconstruction


    When diagnosed early after injury, the subscapularis can often be reconstructed with a hamstring allograft passed through drill holes in the lesser tuberosity laterally.



and through the residual tendon medially




Securing the graft back to the tuberosity reinforces the subscapularis attachment to the humerus







and restores stability to the joint.

Here's a variation of the method used in a case last week, this time on the right shoulder.  The graft was first passed through the lower hole in the tuberosity, then up through the subscapularis tendon, then back down through the subscapularis tendon and then out the upper hole in the lesser tuberosity. In this case the graft was used to back up a standard repair of the subscapularis tendon to the humeral neck cut.


The two limbs of the graft passed through the lesser tuberosity were then tied to each other and secured with locking sutures.

An alternative to attempting reconstruction of a torn subscapularis is to consider a reverse total shoulder.
This option is discussed in this link.


An article on subscapularis failure was recently published:

Failure rates and outcomes after anatomic total shoulder arthroplasty are equivalent irrespective of subscapularis repair technique

They conducted a retrospective study of patients who underwent primary anatomic TSA with subscapularis tenotomy using either transosseous repair (TOR #=192) or direct primary tendon repair (PTR #=114) of a subscapularis tenotomy. 


The "primary outcome studied was clinical subscapularis failure, defined as anterior subluxation of the glenohumeral joint as seen on axillary lateral radiographs with accompanying clinical decompensation, including pain and loss of active forward elevation and internal rotation.""Patients were not routinely screened by ultrasound or MRI to evaluate subscapularis integrity. Additionally, internal rotation strength testing was based on manual muscle testing. Clinical assessment of internal rotation strength is fairly subjective and limited because nearly all of the patients had 4/5 or 5/5 internal rotation strength." Substantial emphasis was placed on the patient's response to a question from the ASES score which asks about the ability to perform functional internal rotation activities such as putting on a bra or washing the back. Of note only 41.4% of the TOR group and 33.3% of the PTR group responded with “not difficult.”


Subscapularis failure was recognized in 13 patients (4.2% among the TOR group and 4.4% among the PTR group). Reoperation was performed in 18 patients. Subscapularis failures, complications not requiring surgery, and reoperations were not significantly different between the two groups. 


Comment: In this retrospective study of an institutional database it appears that the patients in this series may not have been routinely and systematically examined for subscapularis failure, but rather the diagnosis was inferred from radiographs and from ASES scores. It is therefore possible that the rate of subscapularis failure was underestimated.


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Glenoid component failure after total shoulder arthroplasty


Glenoid component failure remains a most important cause of failure after total shoulder arthroplasty (see Glenoid component failure in total shoulder arthroplasty).  Glenoid component failure may be related to 

(1) poor surgical technique, such as inadequate seating of the component (see The radiographic evaluation of keeled and pegged glenoid component insertion), the use of back-side cement to compensate for inadequate glenoid bone preparation 


or poor cement technique




(2) inferior polyethylene leading to wear and particulate debris (see this link), 





(3) metal backed components (see Metal-Backed Glenoid Components Have a Higher Rate of Failure and Fail by Different Modes in Comparison with All-Polyethylene Components: A Systematic Review

(4) poor humeral component placement



(5) instability or cuff failure giving rise to rocking horse loosening from eccentric loading of the glenoid component (see Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency)


and (6) infection (see Loose glenoid components in revision shoulder arthroplasty: is there an association with positive cultures?)


Glenoid component failure may become clinically evident years after the index procedure as in this case that came to revision 24 years after the index procedure.




 
An interesting question is "how should we monitor our patients for the possibility of glenoid component loosening?" which, as the example above shows, may become manifest years or decades after the arthroplasty.  Obviously having patients come back annually or periodically for x-rays is impractical for them and for us. Since clinical failure is more relevant than radiographic lucent lines, one approach is to send short questionnaires such as the Simple Shoulder Test annually to each patient and to be on the watch for deterioration in comfort and function as discussed here, Patient Functional Self-assessment in Late Glenoid Component Failure at three to eleven years after Total Shoulder Arthroplasty.

The surgical management of a loose glenoid component requires a thorough evaluation of the shoulder pathoanatomy, shoulder function, possibility of infection, and wishes of the patient.

In some cases, arthroscopic glenoid component removal with concurrent culturing of five tissue specimens for Cutibacterium and other organisms can be considered as described here Arthroscopic Glenoid Removal for Symptomatic Component Loosening in Anatomic

Total Shoulder Arthroplasty: Can it Work?


However, this approach does not allow for revision of the humeral head component to compensate for the loss of the glenoid component, which can be accomplished at open revision as shown below.




Finally, consideration can be given to conversion to a reverse total shoulder recognizing the technical difficulty and complication rate as described here, 


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).


Monday, August 15, 2022

Bilateral ream and runs in a weight lifter - one year after second side.

This email came in recently from a patient in Ohio, one year after his second sided ream and run.




"I am now 14 month post-op.  I took these videos at a little more than 12 months post-op.  The only setback that I had was not shoulder related but heart related.  6 months after my second surgery  I had a M.I. caused by my "widow maker" being a 100% blocked.  
As for the shoulder, on a rare occasion during some of my exercise I may feel some pain, but nothing that affects my lifting or causes me to stop.  I have to say 90% of the time, I am completely pain free during and after I lift.  If I do feel any pain, it is more of annoyance than anything else."

Here are some screen shots from the videos he sent.









This man is very strongly motivated and desired to have his shoulder arthritis managed in a manner that avoided the risks and limitations associated with a polyethylene glenoid socket replacement.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).




Wednesday, August 10, 2022

30% Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis

The SANE score is the response to a single question: "How would you rate your affected shoulder as a percentage of normal (0% to 100% scale with 100% being normal)?” By contrast the Simple Shoulder Test (SST) and American Shoulder and Elbow (ASES) scores are based on the answers to multiple questions about shoulder pain and comfort.

The authors of Preoperative Single Assessment Numeric Evaluation Score Predicts Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis conducted a retrospective case-control study of factors predictive of poor outcomes after reverse shoulder arthroplasty performed by fellowship trained surgeons for 60 patients (mean age, 71.4±7.4 years) with massive rotator cuff tears without glenohumeral arthritis (Hamada score ≤3) having a minimum of 2 years of follow-up. Of these, 18 (30%) patients had poor outcomes as defined by one of more of the following:

ASES score of less than 50 

change in ASES score of less than 12

change in SST score of 1 or less

change in SANE score of less than 29

postoperative active forward elevation of less than 90°

revision surgery.


There was no obvious reason (eg, infection, dislocation, nerve injury) for poor outcomes.


The characteristic and outcomes for the controls (good outcomes) and cases (poor outcomes) are shown below 



This study found that higher preoperative SANE scores - but not the preoperative ASES and SST scores - were associated with a greater likelihood of poor outcome after RSA for massive rotator cuff tears.


As seen in the chart below, the preperative ASES and SST scores were the same for the control and case groups, whereas the preoperative SANE scores were higher for the case group than the control group. Thus the preoperative SANE scores did not correlate with the preoperative SST and ASES scores. This finding is unexplained in that the authors of Can the Single Assessment Numeric Evaluation (SANE) be used as a stand-alone outcome instrument in patients undergoing total shoulder arthroplasty? found that the correlation was excellent for the SANE score and the ASES score (n = 1447, r = 0.82, P < .0001), and the SST score (n = 1095, r = 0.81, P < .0001).





















Comment: It is of interest that by the standards used in this study, almost 1/3 of patients with massive cuff tears without arthritis experienced a poor outcome after reverse total shoulder. Further clinical research is needed to establish the patients likely to experience poor outcomes so that alternate methods of management can be considered.


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Muscle Tendon Transfers Around the Shoulder

The function of the shoulder can be seriously impaired by conditions such as serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, and deltoid deficiency. The authors of Muscle Tendon Transfers Around the Shoulder Diagnosis, Treatment, Surgical Techniques, and Outcomes share their expertise, experience and outcomes in managing these disorders with muscle tendon transfers.

Their principles of muscle tendon transfers include 

1. the transferred muscle must be expendable, 

2. the muscle tendon unit needs to have similar excursion, 

3. the line of pull of the transferred tendon and of the recipient muscle should be similar in terms of biomechanical force

4. the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle.

5. candidate patients must have exhausted all nonoperative management, have preserved

passive range of motion, and have an understanding of the postoperative expectations and potential complications.


For patients with scapulothoracic abnormal motion due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer can reduce pain and improve active forward elevation.


For patients with scapulothoracic abnormal motion due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures can reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes.


For patients with isolated irreparable subscapularis deficiency without anterosuperior humeral head escape both pectoralis major and latissimus dorsi transfer procedures can improve pain, forward elevation, and patient-reported outcomes.


For irreparable posterosuperior rotator cuff tears, forward elevation, abduction, and external rotation range of motion latissimus dorsi or lower trapezius tendon transfer procedures can improve patient-reported outcomes


For deficits in active external rotation, latissimus dorsi transfer with or without teres major transfer can restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty.


Complications of muscle tendon transfers. include infection, hematoma, and failure of tendon transfer healing.


The authors recommend that these complex procedures be performed by shoulder surgeons with appropriate training.


Comment: This article provides the most comprehensive information on indications, techniques and outcomes of muscle tendon transfers. It should be studied in detail by surgeons considering these approaches.


You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.


Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).