The subscapularis-sparing approach in humeral head replacement

• Published in: Journal of shoulder and elbow surgery 2015-04, Vol.24 (4), p.606-612
• Main Authors: Savoie, Felix H., MD, Charles, Ryan, MD, Casselton, Jane, MD, O'Brien, Michael J., MD, Hurt, James A., MD
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Atrophy; deltopectoral approach; Female; Follow-Up Studies; Hemiarthroplasty - methods; Humans; Humeral Head - diagnostic imaging; Humeral Head - surgery; Humeral head replacement; Magnetic Resonance Imaging; Male; Middle Aged; minimally invasive humeral head replacement; Minimally Invasive Surgical Procedures - methods; Organ Sparing Treatments; Orthopedics; Pain Measurement; partial subscapularis takedown; Physical Examination; Prospective Studies; Rotator Cuff - diagnostic imaging; Rotator Cuff - pathology; Rotator Cuff - surgery; Shoulder Joint - diagnostic imaging; Shoulder Joint - surgery; subscapularis; subscapularis-sparing; Ultrasonography
• ISSN: 1058-2746; 1532-6500
• DOI: 10.1016/j.jse.2014.07.020

Background This report represents a prospective case series evaluating an open deltopectoral approach, both radiologically and clinically, without tenotomy or complete takedown of the subscapularis tendon insertion. We hypothesized that this novel technical approach would allow preservation of the upper tendon border, thus decreasing subscapularis repair failures and fatty infiltration while simultaneously allowing accelerated rehabilitation. Methods Fifty patients underwent humeral head replacement surgery through a subscapularis-sparing approach. In this approach, we take down only the inferior 30% to 50% of the subscapularis tendon, leaving the critical superior aspect of the tendon attached to the lesser tuberosity. Forty-three patients were included in the postoperative results (7 were lost to follow-up). Nineteen patients had a postoperative magnetic resonance imaging study, and 24 patients had ultrasound evaluation. Physical examination included belly-press and lift-off tests; follow-up included visual analog scale, American Shoulder and Elbow Surgeons, Constant, modified UCLA, Rowe, and Short Form 12 scores. Results All patients had a minimum 2-year follow-up. All patients had subscapularis strength equal to the opposite side as measured by lift-off, belly-press, and bear hug tests. Average postoperative scores all showed statistically significant improvement except for general health. All had an intact subscapularis tendon attachment as evaluated by either magnetic resonance imaging or ultrasound imaging. None had atrophy in the muscle belly. Conclusions The subscapularis-sparing, minimally invasive approach to the glenohumeral joint provides adequate exposure to allow humeral head replacement. When the upper border of the subscapularis insertion is left intact, there is a decreased risk of postoperative failure (rupture or atrophy) of the subscapularis tendon.