Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study.

BACKGROUND: Most anatomic total shoulder arthroplasty (ATSA) techniques release and reattach the subscapularis tendon. The risk of failed healing is a widely recognized complication. The purpose of this study was to radiographically compare a traditional deltopectoral (DP) approach and a superolateral subscapularis sparing (SSS) technique through the rotator interval. METHODS: A single, independent, blinded, reviewer analyzed preoperative and postoperative radiographs of patients undergoing ATSA performed by a single surgeon. The reviewer assessed humeral head height, humeral head medial offset, humeral head diameter, head-neck angle, humeral head centering, and coracohumeral offset, and used the anatomic reconstruction index (ARI) to evaluate overall reconstruction quality. RESULTS: There were 70 SSS and 20 DP patients included. When comparing preoperative with postoperative differences, we found that there was no difference between groups in humeral head height (P = .19), humeral head medial offset (P = .38), and coracohumeral offset (P = .07). The DP group had a mean humeral head diameter oversizing of 1.4 mm, whereas the superolateral group had an undersizing of 2.8 mm (P < .001). The head-neck angle difference of the SSS approach was 2° greater than that found with the DP group (P < .001). The humeral head centering in the DP group was 7% displaced vs. 12% with the SSS group (P = .001) relative to the glenoid size. The ARI was 7.35 for the DP group and 6.93 for the SSS group (P = .50). DISCUSSION AND CONCLUSIONS: Radiographic comparison of these 2 ATSA techniques identified no statistical significant difference in 4 of 7 radiographic measurements and ARI. The SSS ATSA is a reasonable approach that yields similar radiographic measurements as a traditional DP total shoulder arthroplasty approach.

Subscapularis-Sparing Rotator Interval Approach for Anatomic Total Shoulder Arthroplasty.

BACKGROUND: A subscapularis-sparing approach to anatomic total shoulder arthroplasty (TSA) is used for patients with glenohumeral osteoarthritis who have an intact rotator cuff and sufficient bone volume. DESCRIPTION: A 7 to 10-cm anterosuperior incision is made with the patient in the beach chair position. The anterolateral deltoid muscle raphe is split, and the shoulder is externally rotated to bring the rotator interval to the field. A flap of interval tissue is incised, tenodesis of the biceps tendon is performed, and the interval tissue is incised straight back to the glenoid from the upper edge of the subscapularis, creating a triangular piece of tissue referred to as a "trapdoor." Two Darrach retractors are placed to expose the humeral head. An intramedullary guide is placed, and a humeral head osteotomy is performed. The glenoid is exposed, and the glenoid component is placed after sizing, preparation, drilling, and insertion of trial components per the surgical technique. The humeral head size is estimated by measuring, and the humeral stem size is decided by sequentially inserting the trial components. The permanent humeral stem is inserted, and the permanent humeral head is implanted after insertion of trial components. The trapdoor is sutured, the deltoid is reattached, and subcutaneous tissue and skin are sutured. ALTERNATIVES: The traditional surgical approach for anatomic TSA involves release and reattachment of the subscapularis tendon. RATIONALE: Nearly all anatomic TSA techniques require the subscapularis to be released, with a peel, tenotomy, or osteotomy, and then repaired on completion of the arthroplasty. Failure of the subscapularis to heal is an unfortunate and potentially devastating complication following anatomic TSA that has been linked to decreased function, instability, and pain1-4. Subscapularis dysfunction following anatomic TSA is seen in one-third to two-thirds of patients, with evidence of complete tears in up to 50% of asymptomatic patients using ultrasound examinations1-5.Sling immobilization with avoidance of excessive passive external rotation and active internal rotation is recommended to help prevent postoperative rupture of the subscapularis repair6-8. However, postoperative motion restrictions to protect the subscapularis may lead to stiffness and may negatively impact function and satisfaction.We describe a subscapularis-sparing TSA, in which we address and improve on 3 technical difficulties identified by Lafosse et al.9: (1) difficulty ensuring an anatomic humeral neck cut because of the difficulty visualizing the anterior aspect of the shoulder, (2) inadequate resection of inferior humeral neck osteophytes, and (3) undersizing of the humeral head.