Rotator Cuff Sparing Approach for Shoulder Arthroplasty
Subscapularis-sparing TSA, deltopectoral approach yield reliable radiographic results
Traditional total shoulder arthroplasty via a deltopectoral approach has demonstrated reliable and durable clinical outcomes. However, a rate-limiting step in return to function is the time to healing of the subscapularis.
The rate of dysfunction or failure of the subscapularis tendon requiring revision surgery has been shown to be 5.8%. Up to 67% of patients have abnormal exam findings related to the subscapularis after total shoulder arthroplasty (TSA). Jeffrey D. Jackson, MD, and colleagues evaluated 15 patients with ultrasound after traditional TSA using tenotomy and repair. They showed that 46% of patients had a complete tear of their subscapularis repair at 6-month follow-up.
Given the relatively high rate of subscapularis complications in traditional shoulder arthroplasty, surgeons have developed alternative techniques to address this problem. Many of these techniques center on approaches to maintain the integrity of the subscapularis. Laurent LaFosse, MD, and colleagues developed a technique utilizing a superolateral approach and it accesses the glenohumeral joint through the rotator interval without disruption of the subscapularis. This technique demonstrated promising results, however, the approach requires elevation of the deltoid origin and open acromioplasty. It was also found to have left many residual humeral osteophytes. David P. Adkison, MD, and colleagues continued to adapt this technique to improve the difficulty with making an anatomic neck cut, removing inferior osteophytes and sizing the humeral head. They recently published on 70 patients treated with subscapularis-sparing TSA in which they found similar radiographic results compared with traditional TSA. Felix H. Savioe, MD, and colleagues performed an alternative method of the subscapularis-sparing approach through the deltopectoral interval. This technique requires tenotomy of the inferior half of the subscapularis with later repair to assist in removal of inferior osteophytes and humeral head exposure. They showed encouraging results with no complications regarding the subscapularis, however, the published results were only in cases of hemiarthroplasty. This approach does not lend itself to being able to access the glenoid.
The goal of the current technique is to combine the benefits of the deltopectoral approach in assisting with inferior osteophyte resection and humeral head sizing with the benefit of maintaining the integrity of the subscapularis tendon. This pilot study introduces a technique to expose the glenohumeral joint through a deltopectoral approach and the rotator interval, and does not require takedown of the subscapularis tendon. When necessary, an inferior access window is created to allow for removal of inferior osteophytes without tenotomy of the inferior half of the subscapularis.