Technical note: subscapularis-sparing approach to perform anatomic total shoulder arthroplasty using a multiplanar humeral osteotomy and angled glenoid instruments

Abstract

Background Anatomic total shoulder arthroplasty is typically performed through the deltopectoral approach followed by either a subscapularis tenotomy, tendon peel, or lesser tuberosity osteotomy to provide adequate exposure. These subscapularis-takedown methods have been associated with incomplete subscapularis healing, however, and as a result often lead to functional deficits and complications. Subscapularis-sparing approaches have been introduced to mitigate these complications, but thus far have either been limited to hemiarthroplasty or resulted in residual inferior humeral head osteophytes and humeral component size mismatch. The present technique demonstrates the possibility for surgeons to capitalize on the improved patient outcomes that are afforded by subscapularis-sparing approaches, while still utilizing the deltopectoral interval to perform a total glenohumeral joint arthroplasty. Methods This article describes in detail the placement of a stemless anatomic TSA with the use of angled glenoid instruments through a subscapularis-sparing deltopectoral approach. Postoperatively, patients are placed in a sling but are instructed to remove as tolerated, as early as the 1st postoperative week. Physical therapy is started at week 1 with a 4-phase progression. Conclusions This technique using a TSA system with a polyaxial glenoid reamer and angled pegs on the backside of the glenoid allows the potential for maintenance of the strong postoperative radiographic and patient-reported outcomes that are achieved using traditional TSA approaches, with the advantage of accelerated rehabilitation protocols and decreased risk of subscapularis insufficiency that result from the use of subscapularis-sparing approaches.

Custom, 3-Dimensional Patient-Specific Instrumentation in Anatomic Total Shoulder Arthroplasty: Part 2, Dissection and Soft Tissue Management

“…In all techniques, care must be taken when releasing the subscapularis muscle belly medially and manipulating the tendon, as the muscle innervation can be at risk in the DP approach. 30 , 31 Subscapularis sparing approaches (SSA) 32 are described as an option to preserve the subscapularis tendon integrity and reduce subscapularis-related complications. 33 The SSA most commonly used techniques involving a partial subscapularis tenotomy, 34 a subscapularis muscle belly window, 35 or a rotator interval opening approach 36 to access the glenohumeral joint without detaching the subscapularis tendon completely.…”