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

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

Reverse shoulder arthroplasty is becoming a frequent treatment of choice for patients with shoulder disorders. Complication rates after reverse shoulder arthroplasty may be three-fold that of conventional total shoulder arthroplasty especially in high risk patient populations and diagnoses like revision arthroplasty, fracture sequelae, and severe glenoid bone loss. Complications include component malposition, stiffness, neurological injury, infection, dislocation or instability, acromial or scapular spine fractures, scapular notching, and loosening of implants. Recognition of preoperative risk factors and appropriate 3D planning are essential in optimizing patient outcome and intraoperative success. Failure of reverse shoulder arthroplasty is a significant challenge requiring appropriate diagnosis of the failure mode. The most common neurological injuries involve the brachial plexus and the axillary nerve due to traction, manipulation of the arm, aberrant retractor placement, or relative lengthening of the arm. Intraoperative fractures are relatively uncommon but include the greater tuberosity, acromion, and glenoid. Tuberosity fracture can be repaired intraoperatively with suture techniques, glenoid fractures may be insignificant rim fractures or jeopardise baseplate fixation and require abandoning RSA until glenoid fracture ORIF heals and then a second stage RSA. Periprosthetic infection after RSA ranges from 1 to 10% and may be higher in revision cases and frequently is Propionibacterium acnes and Staphylococcus epidermidis. Dislocation was one of the most common complications after RSA approximately 5% but with increased surgeon experience and prosthetic design, dislocation rates are approaching 1–2%. An anterosuperior deltoid splitting approach has been associated with increased stability as well as subscapularis repair after RSA. Scapular notching is the most common complication after RSA. Notching may be caused by direct mechanical impingement of the humerosocket polyethylene on the scapular neck and from osteolysis from polyethylene wear. Sirveaux classified scapular notching based on the defect size as it erodes behind the baseplate towards the central post. Acromial fractures are infrequent but more common is severely eroded acromions from CTA, with osteoporosis, with excessive lengthening, and with superior baseplate screws that penetrate the scapular spine and create a stress riser. Nonoperative care is the mainstay of acromial and scapular spine fractures. Recognizing preoperative risk factors and understanding component positioning and design is essential to maximizing successful outcomes

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

The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure. In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively. In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results

In diagnosis and repair of partial subscapularis tendon tears, we used a simplified arthroscopic direct technique. We used the anterosuperior arthroscopic portal to visualise the subscapularis tendon insertion, while probing and repairing from the adjacent anterior portal. Three anatomical dissections were done to define the insertion of the subscapularis tendon at the lesser tuberosity. While viewing from the anterosuperior portal, we repaired the subscapularis tendon with one or two suture anchors, inserted into the lesser tuberosity from the anterior portal. Suture management was via the standard posterior portal. From the anterior portal, a tendon-penetrating grasping device passed the sutures through the displaced subscapularis tendon. The arthroscopic knots were tied from the anterior portal. Associated with the first 10 subscapularis repairs were six complete and four partial thickness supraspinatus/infraspinatus tears. There were no isolated subscapularis tears. Three patients had associated biceps lesions. Subscapularis tears are often associated with supraspinatus and infraspinatus tendon tears. Direct anterosuperior viewing and anterior probing enables the surgeon to see and repair ‘hidden’ tears

Background: Rotator cuff tears involving the subscapularis are less common than those involving the posterior superior rotator cuff. The purpose of this study is to report the results of repair of isolated tears of the subscapularis. Methods: Eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age at surgery was 53.2 years. The mean interval from onset of symptoms to surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative in etiology. Twenty-three of the tears involved the superior third of the subscapularis tendon, forty-one involved the superior two thirds, and twenty were complete tears. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, while ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis; thirteen shoulders underwent concomitant biceps tenotomy; and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean fortyfive month follow-up (range 24 to 132 months). Results: The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively (p< 0.001). Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four patients had mild glenohumeral arthritis. Postoperatively, twenty-five patients had mild glenohumeral arthritis and two patients had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results independent of the preoperative condition of the biceps tendon

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

Over 40 months, 264 arthroscopic rotator cuff repairs were assessed prospectively. Preoperatively all patients were assessed using a modified Constant score and Visual Analogue Pain Scale (VAPS). The mean age at surgery was 59 years (19 to 83). In 151 cases (62%) the shoulders were on the dominant side. All patients underwent postoperative ultrasonography to assess cuff integrity at three weeks. Twenty-two patients were lost to follow-up. Of the rest, 210 were clinically reviewed and Constant scores produced. The remaining 32 were assessed using the VAPS and a subjective satisfaction questionnaire. The Constant score improved by a mean of 29.6, with 166 patients (69%) reporting complete resolution of pain. The subjective outcome was rated excellent by 162 patients, good by 55, moderate by 20 and poor by five. There were 13 retears, 11 of which were identified on the three-week ultrasound. When four of these were revised, two required subscapularis repair. Importantly, five patients with retears had excellent subjective outcome. Complications were five superficial infections, 13 cases of transient neuritis following interscalene nerve blocks, four cases of bursitis, which required debridement and suture removal, and two anchor pull-outs. The overall reoperation rate was 4%. Arthroscopic rotator cuff repair offers excellent objective and subjective outcomes, particularly pain relief. Ultrasonography at three weeks is a good indicator of whether or not a repair has taken

Aims

To report early (two-year) postoperative findings from a randomized controlled trial (RCT) investigating disease-specific quality of life (QOL), clinical, patient-reported, and radiological outcomes in patients undergoing a total shoulder arthroplasty (TSA) with a second-generation uncemented trabecular metal (TM) glenoid versus a cemented polyethylene glenoid (POLY) component.

Aims

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

The deltopectoral approach is a common approach for Shoulder joint replacements where a normal subscapularis tendon is divided. Despite meticulous attention to the subscapular repair, suboptimal return of function was found on clinical examination in 92% of patients (Miller S L: Journal of Shoulder & Elbow Surgery. 12(1): 29–34, February 2003). Therefore the aim was to study the integrity of the Subscapularis tendon in patients with Shoulder joint Replacements both clinical and ultrasound examination. Methods: A cohort of 25 subjects who had undergone Copeland Shoulder replacements through deltopectoral approach were included. All patients had same technique of tendon-to-tendon repair and postoperative rehabilitation. After ethics committee approval subjects were evaluated prospectively with Lift off test, Belly press test and the Constant score. Average follow-up was 29.6 months. An experienced Radiologist performed the Ultrasound examination. Results: Ultrasound examination showed 8 % (2 of 25) had full thickness rupture of subscapularis with 44% (11 of 25) showed mild to moderate atrophy of subscapularis muscle and 12%(3 of 25) severe atrophy. 20%(5 of 25) had Lift off test and Belly press test positive. 40%(10 of 25) had either or both of these tests positive. 60%(15 of 25) had clinical or radiological evidence of reduced function (Fisher exact test, P < 0.01). Constant score are 37.5 with full thickness tears compared to 59.4 with intact subsapularis tendon. Conclusion: Subscapularis tendon function following shoulder replacement had received poor attention. It is deficient in over 60% of patients with joint replacement through Deltopectoral approach with tendon-to-tendon repair. We therefore conclude for this study that alternative techniques of subscapularis tendon repair or alternative approaches to the shoulder joint need to be considered to improve the functional outcome in these patients

The June 2012 Shoulder & Elbow Roundup³⁶⁰ looks at: reverse shoulder replacement; torn rotator cuffs and platelet-rich fibrin; rotator cuff repair; frozen shoulder; whether an arthroscopic rotator cuff repair actually heals; the torn rotator cuff’s effect on activities of daily living; subacromial impingement; how to improve the reliability of the Constant-Murley score; and failure of the Neer modification of an open Bankart procedure.