Management of Subscapularis Insufficiency After Total Shoulder Arthroplasty

Abstract

The functional success of anatomic total shoulder arthroplasty (TSA) relies heavily on the healing integrity of the subscapularis tendon. Access to the glenohumeral joint is performed through a deltopectoral approach, and takedown of the subscapularis tendon is necessary in most surgeons' hands. Although initially described as a tenotomy, lesser tuberosity osteotomy and subscapularis peel are two techniques more commonly used today. Both of these options offer good results as long as proper repair is done. A subscapularis-sparing approach has more recently been advocated but is technically demanding. Failure of tendon repair can lead to early failure of anatomic total shoulder arthroplasty with accelerated glenoid loosening, decreased function, and anterior instability. Treatment options for subscapularis insufficiency include nonsurgical management, revision tendon repair, tendon reconstruction or transfer, or conversion to reverse shoulder arthroplasty. As shoulder arthroplasty continues to become increasingly prevalent, subscapularis insufficiency, too, will become more common. Accordingly, a surgeon's knowledge of subscapularis management in an arthroplasty setting must encompass treatment options for postoperative subscapularis insufficiency. P roper assessment, handling, and repair of the rotator cuff tendons are vital to a successful clinical outcome after total shoulder arthroplasty (TSA). Although tendon-sparing surgical approaches have been proposed, most TSA surgeries conducted still use a subscapularis tendon takedown to gain access to the glenohumeral joint. Failure to adequately repair the subscapularis tendon or rupture of the tendon postoperatively can lead to poor outcomes including pain, loss of motion, instability, and even accelerated implant loosening (Figure 1). In cases of failure where repair is not an option, various tendon transfers or augmentation procedures can be considered. In some cases, conversion to a reverse shoulder arthroplasty (RSA) may be necessary.

Subscapularis Repair Augmentation With the Long Head Biceps Tendon During Anatomic Total Shoulder Arthroplasty: The “Biceps-Subscap Sling” Technique

“… 8 , 14 , 15 , 16 Subscapularis re-repair with or without augmentation, pectoralis major transfer, and latissimus dorsi transfer have been described, although none reliably lead to satisfactory outcome. 17 In many cases, conversion to a reverse shoulder arthroplasty may be warranted. 8 , 14 , 15 , 16 Therefore, it is important to maximize stability of the initial subscapularis repair to avoid this potential complication.…”

“…Numerous studies have reported on the biomechanical strength of different subscapularis repair techniques following TSA, primarily LTO, tenotomy, or peel. 3 , 17 , 26 The LTO, in particular, has demonstrated greater strength and load to failure when compared to peel or tenotomy. 27 , 28 , 29 , 30 Studies exploring the ultimate load to failure for LTO report values ranging from 301.3 to 632.3 N. 27 , 28 , 29 , 30 In the biomechanical study by Hawthorne et al., the V-shaped biceps augmented repair had a mean load to failure of 563.3N.…”

Lesser Tuberosity Osteotomy for the Management of the Subscapularis During Total Shoulder Arthroplasty

“…42 The current options for revision surgery include conservative treatment, soft-tissue repair, tendon or graft augmentation, and reverse shoulder arthroplasty (RSA). 43,44…”