Subscapularis in shoulder arthroplasty

Comparison of Lesser Tuberosity Osteotomy to Subscapularis Peel in Shoulder Arthroplasty: A Randomized Controlled Trial

This is a well-done randomized controlled trial comparing two methods for take-down and repair of the subscapularis for shoulder arthroplasty: lesser tuberosity osteotomy and subscapularis peel. There is a third method used by some, the subscapularis tenotomy, but that was not included in this study (the authors do include it in their discussion, however). The primary outcome was subscapularis muscle strength as measured with an electronic handheld dynamometer at two years after surgery.  83% of the patients completed the study. The subscapularis peel group had strength measured at 5.5 ± 2.6 kg while the lesser tuberosity osteotomy group had 4.4 ± 2.9 kg (p = 0.131). There were no significant differences between the two methods for the Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores.Two patients had a nonunion at the osteotomy site as seen on postoperative radiographs. There were no reoperations for the treatment of subscapularis failure in either group.

Our experience has taught us that postoperative care is important for preserving the integrity of the subscapularis after repair. In this study, a conservative approach to rehabilitation was used. A shoulder sling was worn for the first six weeks. Self-assisted supine forward elevation was initiated on the first postoperative day to a maximum of 90°, and self-assisted supine external rotation was limited to neutral for the first six weeks. Patients were instructed to perform exercises every two hours with the contralateral arm by guiding the involved arm through the exercise while maintaining the involved arm in a completely relaxed state. Active range of motion was not started until six weeks. Strengthening was not started until twelve weeks postoperatively.

Interested readers may wish to look at prior posts on the subscapularis. You can find them by entering "subscapularis" in the 'search' box to the right or by going to the posts dated 4/15/11, 7/19/11, 7/23/11, 10/27/11, 2/23/12, 8/15/12, 10/26/12, 11/22/12, and 11/23/12.

Our method of managing the subscapularis is shown here.

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