This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor. Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid. All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001). Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery. A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy. Cite this article: 2015;97-B:1090–5

Currently, the consensus regarding subscapularis tendon repair during a reverse total shoulder arthroplasty (rTSA) is to do so if it is possible. Repair is thought to decrease the risk of dislocation and improve internal rotation but may also increase stiffness and improvement in internal rotation may be of subclinical benefit. Aim is to retrospectively evaluate the outcomes of rTSA, with or without a subscapularis tendon repair. We completed a retrospective review of 51 participants (25 without and 26 with subscapularis repair) who received rTSR by a single-surgeon using a single-implant. Three patient reported outcome measures (PROM) were assessed pre-operatively and post-operative at twelve months, as well as range of movement (ROM) and plain radiographs. Statistical analysis utilized unpaired t tests for parametric variables and Mann-Whitney U test for nonparametric variables. External Rotation ROM pre-operatively was the only variable with a significance difference (p=0.02) with the subscapularis tendon repaired group having a greater range. Pre- and post-operative abduction (p=0.72 & 0.58), forward flexion (p=0.67 & 0.34), ASES (p=0.0.06 & 0.78), Oxford (p=0.0.27 & 0.73) and post-operative external rotation (p=0.17). Greater external rotation ROM pre-operatively may be indicative of the ability to repair the subscapularis tendon intra-operatively. However, repair does not seem to improve clinical outcome at 12 months. There was no difference of the PROMs and AROMs between the subscapularis repaired and not repaired groups for any of the variables at the pre-operative or 12 month post operative with the exception of the external rotation ROM pre-operatively. We can conclude that from PROM or AROM perspective there is no difference if the tendon is repaired or not in a rTSR and indeed the patients without the repair may have improved outcomes at 12 months

The Latarjet procedure is a well described method to stabilize anterior shoulder instability. There are concerns of high complication rates, one of these being a painful shoulder without instability due to screw irritation. The arthroscopic changes in the shoulder at time of screw removal compared to those pre-Latarjet have not been described in the literature. We conducted a retrospective review of arthroscopic videos between 2015 and 2022 of 17 patients at the time of their Latarjet screw removal and where available (n=13) compared them to arthroscopic findings at time of index Latarjet. Instability was an exclusion criterion. X-rays prior to screw removal were assessed independently by two observers blinded to patient details for lysis of the graft. Arthroscopic assessment of the anatomy and pathological changes were made by two shoulder surgeons via mutual consensus. An intraclass correlation coefficient (ICC) was analyzed as a measure for the inter-observer reliability for the radiographs. Our cohort had an average age of 21.5±7.7 years and an average period of 16.2±13.1 months between pre- and post-arthroscopy. At screw removal all patients had an inflamed subscapularis muscle with 88% associated musculotendinous tears and 59% had a pathological posterior labrum. Worsening in the condition of subscapularis muscle (93%), humeral (31%) and glenoid (31%) cartilage was found when compared to pre-Latarjet arthroscopes. Three failures of capsular repair were seen, two of these when only one anchor was used. X-ray review demonstrated 79% of patients had graft lysis. Excellent inter-rater reliability was observed with an ICC value of 0.82. Our results show a high rate of pathological change in the subscapularis muscle, glenoid labrum and articular cartilage in the stable but painful Latarjet. 79% of patients had graft lysis with prominent screws on X-ray

Shoulder arthroplasty procedures continue to increase in prevalence and controversy still remains about the optimal method to manage the subscapularis. Scalise et al. performed an analysis of 20 osteotomies and 15 tenotomy procedures, and found the tenotomy group had a higher rate of abnormal subscapularis tendons on ultrasound examination. There was one tendon rupture in the subscapularis tenotomy group and no ruptures in the osteotomy group. Jandhyala et al. retrospectively examined 26 lesser tuberosity osteotomies and 10 subscapularis tenotomies for arthroplasty, and their study demonstrated a significant improvement in the belly press test for the osteotomy group. Lapner et al. performed a randomised controlled trial assigning patients to either a lesser tuberosity osteotomy or a subscapularis peel procedure. They evaluated 36 osteotomies and 37 subscapularis peels. The outcomes evaluated were Dynamometer internal rotation strength, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score and American Shoulder and Elbow Surgeons (ASES) score, and in a subsequent paper they evaluated the healing rates and Goutallier grade. Their studies illustrated no difference in the internal rotation strength between groups. Both groups significantly improved WOOS and ASES scores postoperatively, but the difference was not significant between groups. Goutallier grade increased significantly in both groups, but there was no significant difference between the groups. Overall, the different approaches have not demonstrated a meaningful clinical difference. Further studies are needed to help understand issues leading to subscapularis complications after arthroplasty

Introduction & Background. Clinical outcome after reverse total shoulder arthroplasty (RTSA) can be influenced by technical and implant-related factors, so the purpose of this study was to investigate whether individualizing humeral retroversion and subscapularis repair affect the clinical outcomes after RTSA. Material & Method. Authors retrospectively analyzed the prospectively collected data from 80 patients who underwent RTSA from January 2007 to January 2015 using same implant (Biomet Comprehensive. ®. Reverse Shoulder System, Warsaw, Indiana). The mean follow up was 23.3 ± 1.7 (range, 12 ∼ 70) months. The retroversion of humeral component was decided according to native version estimated using shoulder CT in Group I (n=52), and fixed in 20° retroversion in Group II (n=28). Group I was subdivided into Group Ia (n=21, mean 19.3°), less than 20° of retroversion, and Group Ib (n=31, mean 31.9°), more than 20°. Intraoperative tenotomized subscapularis was repaired in 40 patients in Group I, and could not be repaired due to massive tear including subscapularis in remaining 12 patients. Clinical outcomes were evaluated with range of motion (ROM) and several clinical outcome scores. Results. Group I showed significantly better ROM and clinical scores compared to Group II at the final follow up (all p < 0.05). There were no significant differences in ROM and clinical scores between Group Ia and Ib. Group Ia showed better ROM and pain VAS than Group II (all p < 0.05), and Group Ib also demonstrated significantly better ROM and clinical outcome scores than Group II (all p < 0.05). With respect to subscapularis repair, there were no differences in ROM and clinical scores between two groups. No complications such as infection or dislocation were detected according to subscapularis repair. Conclusion. Individualizing humeral retroversion can obtain superior clinical outcomes than fixed 20° retroversion. Subscapularis repair would not be essential for the better clinical outcome in patients with the lateralized RTSA

Background. Long term success of any shoulder joint reconstruction procedure involving subscapularis attachment take down is dictated by the way one chooses to release and repair/reconstruct the subscapularis insertion. There are several methods that were reported in the literature without any preset guidelines which are easily reproducible. Methods. 5 specimens of fresh cadaver shoulder joints dissected and the subscapularis footprint insertion involving the tendon and muscle exposed. We intend to preserve subscapularis tendon footprint along with the lesser tuberosity by performing the footprint osteotomy fashioned step wise in the following manner. Results. It has two vertical components (sagittal and coronal plane osteotomies) and one horizontal component (distal osteotomy at musculo tendinous junction level). Figure 1: demonstrating the three step cuts in the dry bone of proximal humerus with three different ostetomes to mark the plain of osteotomies in the lesser tuberosity. Step-1: Medial wall ridge of the inter-tubercular sulcus serves as landmark for sagittal component. The depth of sagittal component is just 5 – 10mm and its length extending from articular margin proximally and distally up to musculo tendinous junction, measuring approximately 15–20mm. Step-2: Coronal plane osteotomy is in line with and parallel to undersurface of subscapularis tendon adjacent to the articular margin and connecting sagittal component and measured 10–15mm approximately. Figure 2: demonstrating the two cuts / osteotomies to mark the sagittal and coronal components of the subscapularis foot print osteotomy in the lesser tuberosity of a fresh cadaver. Step-3: The horizontal component (distal osteotomy at musculo tendinous junction level is 5–10 mm in width, connects the two vertical components, thus completing the footprint osteotomy. Discussion. Subscapularis reattachment plays a pivotal role in the shoulder joint reconstruction procedures especially total joint arthroplasty. Subscapularis take down either by tenotomy or by periosteal elevation from lesser tuberosity followed by repair carries a risk of retraction and poor healing and early failure. Footprint osteotomy as a thin sliver of cortical bone instead of these above described three steps with the attached tendon carries a risk of fragmentation of the bone sliver along with lack of rotation control on the repair. The necessity for doing such a three step osteotomy procedure which results in a wedge shaped bone tendon foot print construct, we believe is of paramount importance for a successful reconstruction. Figure 3: demonstrating the marking sutures passed into the bone tendon construct comprising of lesser tuberosity and subscapularis for effective foot print reconstruction in a fresh cadaver. Conclusions. This three step footprint osteotomy of the Subscapularis tendon offers a stable construct which is easy to reproduce with better healing potential. For figures, please contact authors directly

There is a large and growing population of patients with shoulder arthritis that are over 70 years old. Many of these patients live alone and sling immobilization after shoulder arthroplasty is problematic. Other than improved internal rotation, there are limited benefits of anatomic shoulder arthroplasty compared to reverse arthroplasty. Anatomic arthroplasty is associated with longer OR time, longer recovery with need for assistance to allow the subscapularis to heal, and more challenging glenoid exposure. The reverse arthroplasty is a faster operation without the need for subscapularis healing and the sphere provides a more forgiving implant position. Additional benefits of reverse arthroplasty include better ability to manage glenoid bone loss and joint subluxation. Data from the Australian Orthopaedic Association National Joint Replacement Registry shows that within the first year of surgery the rate of revision of anatomic shoulder arthroplasty is less than reverse arthroplasty. However, after one year, the overall revision rate of reverse arthroplasty is less than anatomic shoulder arthroplasty. Therefore, increased technical difficulty of anatomic shoulder arthroplasty together with concerns of subscapularis insufficiency, glenoid loosening, and lack of strong evidence of superiority do not warrant changing from reverse for patients over 70 years old

It is undetermined which factors predict return to work following arthroscopic rotator cuff repair. We aimed to identify which factors predicted return to work at any level, and return to pre-injury levels of work 6 months post-arthroscopic rotator cuff repair. Multiple logistic regression analysis of prospectively collected demographic, pre-injury, preoperative, and intraoperative data from 1502 consecutive primary arthroscopic rotator cuff repairs, performed by a single surgeon, was performed to identify independent predictors of return to work, and return to pre-injury levels of work respectively, 6 months post-surgery. Six months post-rotator cuff repair, 76% of patients returned to work (RTW), and 40% returned to pre-injury levels of work (Full-RTW). RTW at 6 months was likely if patients were still working after their injuries, but prior to surgery (Wald statistic [W]=55, p<0.0001), were stronger in internal rotation preoperatively (W=8, p=0.004), had full-thickness tears (W=9, p=0.002), and were female (W=5, p=0.030). Patients who achieved Full-RTW were likely to have worked less strenuously pre-injury (W=173, p<0.0001), worked more strenuously post-injury but pre-surgery (W=22, p<0.0001), had greater behind-the-back lift-off strength preoperatively (W=8, p=0.004), and had less passive external rotation range of motion preoperatively (W=5, p=0.034). Patients who were still working post-injury, but pre-surgery were 1.6-times more likely to RTW than patients who were not (p<0.0001). Patients who nominated their pre-injury level of work as “light” were 11-times more likely to achieve Full-RTW than those who nominated “strenuous” (p<0.0001). Six months post-rotator cuff repair, a higher patient-rated post-injury, but pre-surgery level of work was the strongest predictor of RTW. A lower patient-rated pre-injury level of work was the strongest predictor of Full-RTW. Greater preoperative subscapularis strength independently predicted both RTW, and Full-RTW

Introduction:. The subscapularis muscle experiences significant strain as it accommodates common movements of the shoulder. Little is known about what happens with this obligatory strain once the subscapularis insertion is disrupted and repaired in the course of shoulder arthroplasty. Subscapularis failure is a serious known complication after shoulder arthroplasty. It is not known what the effect of increasing the thickness of the shoulder head will have on subscapularis strain. It is our hypothesis that the use of large or expanded humeral heads during shoulder replacement will cause increased tension in the repaired subscapularis. The primary purpose of this study was to identify the optimal manner to perform a passive range of motion (PROM) program without invoking a significant increase in strain in the repaired subscapularis. The secondary purpose was to determine the impact of varying the thickness of the humeral head on subscapularis strain using the same PROM protocol. Methods:. Eight fresh-frozen, forequarter cadaver (four female, four male) specimens were obtained following IRB approval. An extended deltopectoral incision was performed so that the subscapularis insertion site could be well visualized. PROM exercises with the following motions were evaluated: external rotation, abduction, flexion and scaption. An optical motion analysis system was used to measure strain in the subscapularis. The same measurement protocol was repeated after performing a subscapularis osteotomy and after placement of an anatomic hemiarthroplasty of three different thicknesses (short, tall, expanded). Results:. A decrease in joint laxity (less strain but more tension on the subscapularis) was observed in abduction, external rotation, and forward flexion, following implantation of the shoulder arthroplasty components. For abduction and forward flexion, we observed a trend of decreasing laxity with increasing humeral head component thickness. For external rotation, all components displayed a similar reduction in joint laxity. With the short humeral head, strain was similar to native joint with passive scaption and flexion but not with external rotation or abduction. Discussion:. The PROM that tends to minimize tension on the subscapularis is forward flexion and scaption whereas external rotation and abduction will stress the subscapularis repair. Therefore passive forward flexion or scaption do not need to be limited but clearly external rotation should have passive limits and abduction should probably be avoided. The subscapularis muscle is under greater preload tension after shoulder joint arthroplasty. Even the short head size humeral component demonstrated decreased laxity compared to the intact joint. This suggests that even the shortest head size available may not be anatomical and perhaps a thinner humeral head size would be more representative of the normal anatomy

Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

PURPOSE. We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy. MATERIAL AND METHODS. 20 fresh cadaveric shoulders were dissected by wide delto-pectoral approach. After removal the deltoid and posterior rotator cuff, we removed humeral head on anatomical neck. So we obtained an articular view comparable to arthroscopical posterior portal view. We looked for a structure inserted on subscapularis tendon behind SGHL. By intra-articular view we removed SGHL and CHL from the medial edge of the bicipital groove, then subscapularis tendon from lesser tuberosity. We splitted the rotators interval above the superior edge of subscapularis tendon and observed the connections between subscapularis tendon, CHL and SGHL. RESULTS. 6 shoulders had massive cuff tears and were excluded. No ligamentous structure was visible between rotators interval and subscapularis tendon by simple intra and extra-articular examination. After removal of LGHS humeral insertion, no structure showed vertical attach on tendon yet. But after removal of subscapularis tendon from lesser tuberosity and medial traction we saw constantly a fibers bundle directly inserted onto supero-lateral edge of subscapularis tendon. DISCUSSION/CONCLUSION. Most authors agree about existence of CHL and SGHL and their bone insertions, whereas relations between themselves and subscapularis tendon aren't so well defined. We constantly found an effective link between subscapularis tendon and a fibers bundle mainly coming from LCH. It layed into supero-lateral edge of subscapularis tendon and could be seen only by medial traction of it. This ligamentous structure yields the « Comma Sign » in subscapularis tendon tears. This study confirms our clinical datas

Shoulder arthroplasty procedures continue to increase in prevalence, and controversy still remains about the optimal method to manage the subscapularis. Scalise et al. performed an analysis of 20 osteotomies and 15 tenotomy procedures, and found the tenotomy group had a higher rate of abnormal subscapularis tendons on ultrasound examination. There was one tendon rupture in the subscapularis tenotomy group and no ruptures in the osteotomy group. Jandhyala et al. retrospectively examined 26 lesser tuberosity osteotomies and 10 subscapularis tenotomies for arthroplasty, and their study demonstrated a significant improvement in the belly press test for the osteotomy group. Lapner et al. performed a randomised controlled trial assigning patient to either a lesser tuberosity osteotomy or a subscapularis peel procedure. They evaluated 36 osteotomies and 37 subscapularis peels. The outcomes evaluated were Dynamometer internal rotation strength, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) score and American Shoulder and Elbow Surgeons (ASES) score, and in a subsequent paper they evaluated the healing rates and Goutallier grade. Their studies illustrated no difference in the internal rotation strength between groups. Both groups significantly improved WOOS and ASES scores post-operatively, but the difference was not significant between groups. Goutallier grade increased significantly in both groups, but there was no significant difference between the groups. Overall, the different approaches have not demonstrated a meaningful clinical difference. Further studies are needed to help understand issues leading to subscapularis complications after arthroplasty

Healing of the subscapularis, documented by ultrasound, following total shoulder arthroplasty was examined in thirty shoulders. All had marked improvement in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test, 7/26 patients had a positive compression test despite an intact cuff, and 4/7 patients had a significant internal rotation contracture. The abdominal compression test was not accurate in detecting sub-scapularis tears. There was a significant false positive rate, which may be related to a lack of internal rotation. Overall, the outcome was excellent and not related to the status of the subscapularis. Very little information is available on healing of the subscapularis after shoulder arthroplasty. The purpose of this study was to document the subscapularis healing rate and relate it to post-operative function and the abdominal compression test. Thirty consecutive shoulders (twenty-three patients) s/p total shoulder replacement had standardized pre- and post-operative examinations including quantitative strength assessment and specific subscapularis testing. Ultrasound (validated for postop accuracy) was performed to document tendon healing. All thirty shoulders had marked improvements in pain, SST, and ASES scores. Four subscapularis tears were identified but only one patient had a positive abdominal compression test. Seven out of twenty-six patients had a positive compression test despite an intact cuff. Four of seven patients had a significant internal rotation contracture. Neither the status of the subscapularis nor a positive compression test appeared to affect outcome. Although specific subscapularis tests are often positive, only a small percentage of subscapularis tendons appear to retear after shoulder arthroplasty. The abdominal compression test is not accurate in detecting subscapularis tears post arthroplasty. There is a significant false positive rate, which may be related to a lack of internal rotation. However, overall outcome of shoulder arthroplasty was excellent and did not appear to be dependant on the status of the subscapularis

Subscapularis function following Total shoulder joint replacement has been a concern in recent literature. It has been postulated that lesser tuberosity osteotomy approach may have better Subscapularis function than transtendonous approach. To assess whether lesser tuberosity osteotomy vs. subscapularis tenotomy is better for post-operative function of subscapularis in total shoulder replacements done by a single surgeon in a District general hospital. 117 shoulder replacements performed by the senior author (TH) at Waikato district general hospital between years January 2002 to January 2010 were reviewed retrospectively. Revision replacement, inverse shoulder replacement & acute traumatic hemiarthroplasty were excluded. Patients with previous rotator cuff problems, previous surgery to subscapularis, rheumatoid arthritis and post-trauma sequelae were also excluded from the study. Inclusion criteria were normal subscapularis function and intact subscapularis on MRI pre-operatively. 41 shoulders were eligible to participate in study of which 1 pt died (bilateral TSR), 1 pt unfit to participate due to cervical disc problems. Of remaining 38 shoulders 11 shoulders had transtendonous and 27 shoulders had lesser tuberosity osteotomy approach. 37 shoulders were reviewed clinically for range of motion of the shoulder and subscapularis strength. Range of motion and subscapularis strength was significantly higher in the osteotomy group. All osteotomies were united on axillary radiograph. Lesser tuberosity osteotomy approach result in better subscapularis function than transtendonous approach

Hemi shoulder arthroplasty is a rather successful procedure although revision surgery due to secondary glenoid erosion is reported in more than 25%. The downside of common shoulder arthroplasty is that in a deltopectoral approach the subscapularis tendon needs to be detached for exposure of the humeral head. Refixation of subscapularis tendon is associated with a retear rate of 4%, furthermore with progressing fatty muscle infiltration and loss of function. In case of revision surgery a second subscapularis tendon detachment is even more associated with worse function. Thus, arthroscopic humeral head resurfacing is an expedient alternative for minimal invasive humeral head arthroplasty without compromising subscapularis function. The purpose of this study was to report first clinical and subjective results after arthroscopic-assisted resurfacing of the humeral head. For this prospective case series, 24 patients (7 females, 17 males; mean age 59 years, range 42–73 years) undergoing arthroscopic-assisted partial shoulder resurfacing with the partial eclipse prosthesis were included in the study. Clinical conditions and subjective assessments were evaluated before surgery and annually thereafter using the Constant score (CS), active range of motion (ROM), visual analog scale (VAS) for pain, and the American Shoulder and Elbow Surgeons scale (ASES). Radiological outcomes and major complications were monitored. The mean CS for all patients improved significantly from 51 points preoperatively to 83 points 12 months after surgery (p=0.005). Trends towards increasing ROMs were detected. Subjective scores significantly improved from baseline to the 1-year follow-up (VAS: from 6.4 to 2.5, p=0.010; ASES: from 47 to 76, p=0.026). The majority of patients (88%) stated that they would undergo the procedure again. Revisions were indicated in 17% due to progression of osteoarthritis. Arthroscopic-assisted partial humeral head resurfacing as a minimal invasive procedure with the advantages of bone stock preservation and intact subscapularis tendon allowed immediate postoperative active mobilization and provided significant improvements in subjective outcome. In case of revision surgery a primary situation was encountered with postoperative results comparable to primary arthroplasty

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach. We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon. Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport. With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport

Introduction: A secure repair of the subscapularis represents an integral part of any surgery involving the anterior approach to the shoulder. Dysfunction of the subscapularis leads not only to poor functional results but also to anterior joint instability which is potentially untreatable. We have devised a new technique of double row fixation of the subscapularis using two suture anchors. Aim: To evaluate the biomechanical strength of this double row technique against the established methods of simple suturing and transosseous repair techniques. Method: Twenty matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of 10 shoulders repaired with the double row technique. This involved incising the subscapularis along the bicipital groove and a lesser tuberosity osteotomy carried out leaving the subscapularis attached to a thin island of bone. A suture anchor (Twinfix) was then inserted just medial to the osteotomy site and the tendon repaired to bone using two horizontal mattress sutures. A second anchor was inserted laterally to supplement the repair with two simple suture knots. The remaining 10 contralateral shoulders were allocated equally between groups 2 and 3. In group 2, the subscapularis was divided longitudinally 1cm medial to the bicipital groove and repaired with simple interrupted suture knots. In group 3, the subscapularis was incised at its insertion to lesser tuberosity and the tendon repaired to the osteotomy site by multiple transosseous sutures through drill holes in the anterior humeral cortex. The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded. Results: The load to failure was found to be significantly higher in the double row repair technique compared to simple suturing and transosseous methods. Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This new double row technique is simple to perform and preliminary biomechanical testing has shown this to be superior in terms of fixational strength compared to established methods. Additional advantages of this technique which have not been taken into account in this in vitro study include non violation of the subscapularis tendon with bone to bone healing

Introduction: We have devised a new technique of lesser tuberosity osteotomy with double row fixation of the subscapularis using suture anchors. Aim: To evaluate the biomechanical properties of this novel technique against two established methods of subscapularis repair including tendon to tendon and transosseous repairs. Method: Matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of the double row technique with incision of the subscapularis along the bicipital groove with a lesser tuberosity osteotomy. A double loaded suture anchor was placed along the medial border of the osteotomy site and sutures were passed through subscapularis medial to the bone island in a horizontal mattress manner. A second anchor was inserted along the lateral border of the osteotomy site and the two sutures were tied onto the subscapularis holding sutures. In group 2, the subscapularis was divided 1cm medial to the bicipital groove and repaired with tendon to tendon suturing. In group 3, the subscapularis was repaired to the cut humeral neck through transosseous tunnels. The cyclic elongation, load to failure, displacement and mode of failure were analysed. Results: All specimens in Group 1 and 40% of Group 2 and 3 passed the cyclic loading test. The ultimate tensile strength in Group 1 was found to be 2.8 times that of Group 2 and 2.4 times that of Group 3 (p< 0.05). Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This novel technique is simple to perform and biomechanically stronger than established methods of repair. A stronger fixation may allow early mobilization without the risk of tendon rupture and is much less likely to loosen with gap formation and subsequent fibrous tissue interposition. Additional advantages include bone to bone healing without violation of the subscapularis tendon

Purpose: Short-term results of surgical repair of subscapularis tears are well known. The purpose of this study was to assess long-term outcome after surgical repair of 21 full-thickness tears of the subscapularis. Material and methods: Inclusion criteria were subscapularis tear (n=21) which were isolated (n=9) or associated with a supraspinatus tear (n=11) without intraspinatus tears. The subscapularis was reinserted by transosseous fixation in fifteen cases and with a trapezeal flap in six. The supraspinatus was repaired by transosseous suture. Function (Constant score) was assessed preoperatively, at one and three years, and at last follow-up (nine years, range six to fifteen years). We also noted radiographic changes (subacromial height, osteoarthritis using the Samilson classification, anterior dislocation of the humeral head). Fatty degeneration (FD) of the cuff was assessed on pre-operative scans and at last follow-up. Arthroscan, performed at one year and ultrasonography performed at last follow-up were used to assess cuff continuity. Results: The rough Constant score was 45.2 (12–93.5) preoperatively, 67.5 (20–95) at one and three years and 59.45 (20–95) at last follow-up. At last follow-up, the Constant score was significantly better than preoperatively (improved pain score). There was only one case of repeated tear (repaired supraspinatus). At last follow-up we noted six anterior dislocations. The subacromial space remained unchanged (9.5 mm). Glenohumeral osteoarthritis developed in fourteen cases (2 Samilson class 3) including eight de novo degenerations. FD of repaired subscapularis tendons was 0.8 (0–4) preoperatively and 1.64 (1–4) at last follow-up. FD of unrepaired subscapularis tendons treated with a trapezeal flap worsened (2.2 to 2.7). FD of the supraspinatus and infraspinatus (0.5 preoperatively) worsened one stage. At last follow-up, the Constant score was lower in the presence of anterior dislocation of the humeral head (p=0.013). Development of anterior dislocation of the humeral head was correlated with major preoperative FD of the subscapularis (cut-off between 1.5 and 2, p=0.01). There was a correlation between more FD of the infraspinatus and the presence of anterior dislocation of the humeral head. Among the trapezeal flaps, there were only two good results (Constant scores 74 and 75) in patients with FD of the subscapularis scored 1.5 preoperatively. Conclusion: Functional and radiographic outcome after cuff repair or palliation with a trapezeal flap for subscapularis tears associated or not with supraspinatus tears is not satisfactory unless the fatty degeneration of the subscapularis is low preoperatively (δ 1.5)