UW Shoulder and Elbow Academy: Total shoulder arthroplasty

Systematic Review and Network Meta-Analysis of Subscapularis Management Techniques in Anatomic Total Shoulder Arthroplasty

Subscapularis failure can be a devastating complication of shoulder arthroplasty, leading to weakness and instability (see this link).

In a systematic review and meta analysis of 8 qualifying articles, these authors compared the clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (P) for managing the subscapularis during shoulder arthroplasty.

No significant difference was found in postoperative external rotation (ER) or forward flexion (FF) between the groups.

Meta-analysis found the P cohort to have a significantly greater internal rotation (IR) strength when compared to the ST cohort.

Belly press was negative most commonly with the LTO group and there was a significant difference as compared to the tenotomy or peel groups (p<0.0001).

The preoperative to postoperative improvement for the peel group was somewhat higher than for the other methods.

All groups had good postoperative patient reported outcomes scores (average ASES score range 78.6-87), with the peel group scores being somewhat higher.

Comment: It is apparent that surgeons can successful use any of these methods for managing the subscapularis at the time of shoulder arthroplasty. Perhaps more important than the method is how well the takedown is done, how well it repaired, and how well the repair is protected during healing.

Our surgical approach to subscapularis management can be used with any prosthesis. It involves a careful peel of the subscapularis tendon from the lesser tuberosity with attention to preserving the integrity of the biceps tendon and a 360 degree release of the capsule from the glenoid to resolve limitation of external rotation. By retaining the capsule on the deep surface of the tendon, the strength of the repair is enhanced.

At the conclusion of the case, drill holes are placed through good bone at the margin of the neck cut and six sutures of #2 non-absorbable suture are passed through these holes. The security each suture is verified to make sure it does not pull through the bone.

These sutures are then passed through the tendon edge, including the capsule retained on its deep surface, and tied securely.

Of these the most important stitch is the superior one (the "mother stitch") in that this suture takes the most load when the arm is externally rotated. See The biomechanics of subscapularis repair - all sutures are not equal!

A principal cause of post operative subscapularis failure is the overzealous and premature stretching of external rotation or premature initiation of internal rotation strengthening. We limit external rotation stretching to zero degrees (the hand shake position) and avoid internal rotation strengthening exercises for at least 3 months after surgery.

We also caution patients about the risk of events that may suddenly externally rotate the shoulder such as a fall or a sudden pull on the arm from a leashed dog.

Signs of subscapularis failure in include excessive passive external rotation

and weakness of the belly press

and sometimes anterior instability.

When a subscapularis repair fails, the tendon is in worse condition than it was at the index arthroplasty.

Thus attempting a "repair" by trying to sew the tendon back again is likely to fail.

When we see a patient with chronic subscapularis failure, we place the patient on an exercise program to strengthen the other internal rotators or the shoulder (pectorals and teres major).

For patients with traumatic failure or those who have symptomatic refractory chronic failure, we discuss a reconstruction using a hamstring allograft to reinforce the reattachment.

The subscapularis - does it ever recover after shoulder arthropllasty - peel vs LTO?

Shoulder joint replacement arthroplasty - spare the subscapularis, spoil the arthroplasty?

How well does the subscapularis work after total shoulder arthroplasty? ?Hazards of inter scalene block?

Failure of lesser tuberosity osteotomy in total shoulder joint replacement - a cautionary tale

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