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Pasqualini I, Menendez ME, Ardebol J, Denard PJ. Lesser Tuberosity Osteotomy for the Management of the Subscapularis During Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:1120-1127. [PMID: 37506312 DOI: 10.5435/jaaos-d-22-01093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Subscapularis integrity is critical after anatomic total shoulder arthroplasty, with failure leading to potential instability, loss of function, and revision surgery. The three well-described subscapularis mobilization techniques during total shoulder arthroplasty include tenotomy, peel, and lesser tuberosity osteotomy (LTO). While several comparative studies exist, the optimal approach remains controversial. LTO has been associated with the highest healing rates, but techniques and repair constructs are highly variable. The purpose of this article was to provide an overview of LTO with attention on radiographic assessment, repair options, and clinical outcomes.
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Wellington IJ, Hewitt CR, Hawthorne BC, Mancini MR, Dorsey CG, Quintana JO, Talamo M, Obopilwe E, Cote MP, Mazzocca AD, Sethi PM. Biomechanical Evaluation of the Efficacy of Suture Tape Augmentation for Subscapularis Peel Repair. Orthop J Sports Med 2023; 11:23259671231162361. [PMID: 37056453 PMCID: PMC10087657 DOI: 10.1177/23259671231162361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/19/2023] [Indexed: 04/15/2023] Open
Abstract
Background Failure of a subscapularis repair construct after anatomic total shoulder arthroplasty can result in difficulty with internal rotation and an increased likelihood of dislocation. Although suture tape has been demonstrated to be an efficacious augment for tendonous repairs elsewhere in the body, it has not been investigated as a method for augmenting subscapularis peel repairs. Purpose To determine the biomechanical efficacy of suture tape augmentation for the repair of a subscapularis peel. Study Design Controlled laboratory study. Methods Twelve human cadaveric shoulders underwent a subscapularis peel. Specimens were randomly split into 2 groups: 6 specimens underwent repair using a transosseous bone tunnel technique with 3 high-strength sutures placed with a Mason-Allen configuration (control group), and 6 specimens underwent the control repair using augmentation with 2 suture tapes placed in an inverted mattress fashion and secured to the proximal humerus using a suture anchor (augmentation group). Shoulders underwent biomechanical testing to compare repair displacement with cyclic loading, load at ultimate failure, and construct stiffness. Results There were no significant between-group differences in displacement after cyclic loading at the superior (P = .87), middle (P = .47), or inferior (P = .77) portions of the subscapularis tendon. Load to failure was significantly greater in the augmentation group (585.1 ± 97.4 N) than in the control group (358.5 ± 81.8 N) (P = .001). Stiffness was also greater in the augmentation group (71.8 ± 13.7 N/mm) when compared with the control group (48.7 ± 5.7 N/mm) (P = .003). Conclusion Subscapularis peel repair with augmentation via 2 inverted mattress suture tapes secured with an anchor in the proximal humerus conferred significantly greater load at ultimate failure and construct stiffness when compared with a traditional repair using 3 Mason-Allen sutures. There was no difference in repair displacement with cyclic loading between the repair groups. Clinical Relevance Suture tape augmentation of subscapularis peel repairs after shoulder arthroplasty provides an effective segment to the strength of the repair.
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Affiliation(s)
- Ian J. Wellington
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
- Ian J. Wellington, MD,
Department of Orthopaedic Surgery, University of Connecticut School of Medicine,
120 Dowling Way, Farmington, CT 06032, USA (
)
| | - Cory R. Hewitt
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Benjamin C. Hawthorne
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Michael R. Mancini
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Caitlin G. Dorsey
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Julio O. Quintana
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
| | - Michael Talamo
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mark P. Cote
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Augustus D. Mazzocca
- Massachusetts General Brigham Sports
Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Sethi
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
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Hawthorne BC, Shuman ME, Wellington IJ, Mancini MR, Hewitt CR, Dorsey CG, Quintana JO, Talamo M, Obopilwe E, Cote MP, Mazzocca AD, Sethi PM. Biomechanical evaluation of subscapularis peel repairs augmented with the long head of the biceps tendon for anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:326-332. [PMID: 36108881 DOI: 10.1016/j.jse.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/28/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Subscapularis failure is a troublesome complication following anatomic total shoulder arthroplasty (aTSA). Commonly discarded during aTSA, the long head of the biceps tendon (LHBT) may offer an efficient and cheap autograft for the augmentation of the subscapularis repair during aTSA. The purpose of this study was to biomechanically compare a standard subscapularis peel repair to 2 methods of subscapularis peel repair augmented with LHBT. METHODS 18 human cadaveric shoulders (61 ± 9 years of age) were used in this study. Shoulders were randomly assigned to biomechanically compare subscapularis peel repair with (1) traditional single-row repair, (2) single row with horizontal LHBT augmentation, or (3) single row with V-shaped LHBT augmentation. Shoulders underwent biomechanical testing on a servohydraulic testing system to compare cyclic displacement, load to failure, and stiffness. RESULTS There were no significant differences in the cyclic displacement between the 3 techniques in the superior, middle, or inferior portion of the subscapularis repair (P > .05). The horizontal (436.7 ± 113.3 N; P = .011) and V-shape (563.3 ± 101.0 N; P < .001) repair demonstrated significantly greater load to failure compared with traditional repair (344.4 ± 82.4 N). The V-shape repair had significantly greater load to failure compared to the horizontal repair (P < .001). The horizontal (61.6 ± 8.4 N/mm; P < .001) and the V-shape (62.8 ± 6.1; P < .001) repairs demonstrated significantly greater stiffness compared to the traditional repair (47.6 ± 6.2 N). There was no significant difference in the stiffness of the horizontal and V-shape repairs (P = .770). CONCLUSIONS Subscapularis peel repair augmentation with LHBT autograft following aTSA confers greater time zero load to failure and stiffness when compared to a standard subscapularis peel repair.
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Affiliation(s)
- Benjamin C Hawthorne
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Matthew E Shuman
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ian J Wellington
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Michael R Mancini
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Cory R Hewitt
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Caitlin G Dorsey
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Julio O Quintana
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
| | - Michael Talamo
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
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Romero BA, Horneff JG. Soft Tissue Management in Shoulder Arthroplasty. Orthop Clin North Am 2022; 53:339-347. [PMID: 35725042 DOI: 10.1016/j.ocl.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Total shoulder arthroplasty is a rapidly growing field, with more procedures performed each year. An important aspect of shoulder arthroplasty surgery is the management of soft tissues. Good functional outcomes in shoulder arthroplasty are significantly dependent on the repair of the rotator cuff tendons and proper release of the shoulder capsule. The success of any shoulder arthroplasty is predicated upon the meticulous handling of these tissues. The surgeon's ability to execute appropriate soft tissue techniques will facilitate easier surgery by increasing exposure and lead to better outcomes for the patient.
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Affiliation(s)
| | - John Gabriel Horneff
- University of Pennsylvania, 3737 Market Street 6th Floor, Philadelphia, PA 19104, USA.
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Subscapularis Repair Prior to Subscapularis Takedown in Anatomic Shoulder Arthroplasty: Improving Anatomic Restoration and Mechanics of the Subscapularis. Arthrosc Tech 2022; 11:e321-e326. [PMID: 35256970 PMCID: PMC8897647 DOI: 10.1016/j.eats.2021.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/09/2021] [Indexed: 02/03/2023] Open
Abstract
Traditionally, total shoulder arthroplasty is performed using a deltopectoral approach through which the glenohumeral joint is accessed by mobilization of the subscapularis. Despite several variations on the subscapularis management techniques, postoperative complications, including subscapularis deficiency and lower functional outcomes, remain an area for improvement. The purpose of this Technical Note is to describe in detail our technique for management of the subscapularis in the setting of a stemless humeral implant through which the repair is planned and almost entirely performed at the beginning of the case, prior to the subscapularis peel. This technique aims to improve outcomes after total shoulder arthroplasty by 1) avoiding the anatomic implant with anchor drilling, 2) improving procedure efficiency, and 3) anatomically "repairing" the subscapularis prior to takedown by placing anchors exactly at the repair-tension site.
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Werner BC, Griffin JW, Thompson T, Lendhey M, Higgins LD, Denard PJ. Biomechanical evaluation of 2 techniques of repair after subscapularis peel for stemless shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2240-2246. [PMID: 33675968 DOI: 10.1016/j.jse.2021.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) has been gaining significant popularity but poses unique challenges for subscapularis repair. Tenotomy with side-to-side repair has been the most frequently reported technique for subscapularis repair with stemless TSA but has the poorest biomechanical properties, and clinical failures have been reported. There is limited biomechanical evidence evaluating other subscapularis repair techniques for stemless TSA. Therefore, the goal of this study was to investigate 2 additional techniques using a subscapularis peel for subscapularis repair with a stemless TSA. METHODS We used 18 male cadaveric specimens to investigate the native subscapularis (n = 6) and 2 subscapularis repair techniques (n = 12) after stemless anatomic TSA (Eclipse). A subscapularis peel with double-row, knotless anchor-based repair (n = 6) was compared with a subscapularis peel with a "backpack" repair (n = 6). The specimens then underwent biomechanical testing, including cyclic displacement and load-to-failure testing. The mode of failure was also recorded. RESULTS The native tendon had the highest ultimate load to failure (mean, 1017.1 N). Load to failure was similar between the 2 study groups: 397.9 N for the peel and backpack repair and 593.7 N for the knotless anchor-based repair (P > .05 for all comparisons). Moreover, no significant differences in cyclic displacement or construct stiffness were found between the groups (P > .05 for all comparisons). CONCLUSIONS A double-row, knotless anchor-based repair of a subscapularis peel for stemless anatomic shoulder arthroplasty has similar biomechanical properties to a backpack repair technique; however, both techniques fail to reproduce the native biomechanical properties at time zero.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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Goetti P, Denard PJ, Collin P, Ibrahim M, Mazzolari A, Lädermann A. Biomechanics of anatomic and reverse shoulder arthroplasty. EFORT Open Rev 2021; 6:918-931. [PMID: 34760291 PMCID: PMC8559568 DOI: 10.1302/2058-5241.6.210014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The biomechanics of the shoulder relies on careful balancing between stability and mobility. A thorough understanding of normal and degenerative shoulder anatomy is necessary, as the goal of anatomic total shoulder arthroplasty is to reproduce premorbid shoulder kinematics.With reported joint reaction forces up to 2.4 times bodyweight, failure to restore anatomy and therefore provide a stable fulcrum will result in early implant failure secondary to glenoid loosening.The high variability of proximal humeral anatomy can be addressed with modular stems or stemless humeral components. The development of three-dimensional planning has led to a better understanding of the complex nature of glenoid bone deformity in eccentric osteoarthritis.The treatment of cuff tear arthropathy patients was revolutionized by the arrival of Grammont's reverse shoulder arthroplasty. The initial design medialized the centre of rotation and distalized the humerus, allowing up to a 42% increase in the deltoid moment arm.More modern reverse designs have maintained the element of restored stability but sought a more anatomic postoperative position to minimize complications and maximize rotational range of motion. Cite this article: EFORT Open Rev 2021;6:918-931. DOI: 10.1302/2058-5241.6.210014.
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Affiliation(s)
- Patrick Goetti
- Division of Orthopaedics and Trauma Surgery, Centre Hospitalier |Universitaire Vaudois, Lausanne, Switzerland
| | - Patrick J. Denard
- Denard Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, United States
| | - Philippe Collin
- Collin Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Mohamed Ibrahim
- Mohamed Ibrahim, Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Adrien Mazzolari
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Henderson DJH, Christensen TJ, Vo A, Plath JE, Popescu IA, Lafosse L. The V-shaped subscapularis tenotomy for anatomic total shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2020; 45:199-208. [PMID: 33210169 DOI: 10.1007/s00264-020-04880-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. In our unit, subscapularis tenotomy is the preferred technique; however, the potential for tendon gapping and failure is recognised. The purpose of this study is to describe and provide early clinical results of a novel, laterally based V-shaped tenotomy (VT) technique hypothesised to provide greater initial repair strength and resistance to gapping than a transverse tenotomy (TT), with both clinically and radiologically satisfactory post-operative tendon healing and function. METHODS A retrospective study of patients who underwent primary TSA with VT over a three year period was performed using shoulder and subscapularis-specific outcome scores, radiographs, and ultrasound. A separate cohort of patients who underwent TSA using a subscapularis sparing approach was also reviewed to provide comparative clinical outcomes of a group with TSA and an un-violated subscapularis. RESULTS Eighteen patients were reviewed at mean 30.4 months (± 11.7). Constant (78.2 ± 12.3), UCLA (8.4 ± 1.5), pain VAS (2.3 ± 2.8), and strength in internal rotation were no different from the comparison group. Likewise, neither were the clinical outcomes of range-of-motion, belly-press, lift-off, and shirt-tuck tests. One patient (5.5%) was found to have a failed subscapularis repair on ultrasound. CONCLUSION VT during TSA appears to provide healing rates at least equal to those reported for TT, and not dissimilar from those of lesser tuberosity osteotomy. Clinical outcomes are comparable to reported results in the literature for alternative techniques, and not different from those observed here in a comparison cohort with TSA performed without violating the subscapularis tendon. VT therefore potentially offers a more effective and secure tendon repair than a traditional TT, with at least comparable clinical outcomes.
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Affiliation(s)
- Daniel J H Henderson
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France. .,Department of Trauma & Orthopaedics & Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, LS7 4SA, UK.
| | - Thomas J Christensen
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Reno Orthopaedic Clinic, Reno, NV, USA
| | - Austin Vo
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Austin & Monash Health, Melbourne, Australia
| | - Johannes E Plath
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,Department of Trauma, Orthopaedic, Plastic & Hand Surgery, Zentralklinikum, Augsburg, Augsburg, Germany
| | - Ion-Andrei Popescu
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France.,European Shoulder & Hand Unit, Bucharest, Romania
| | - Laurent Lafosse
- Alps Surgery Institute, Clinique Générale d'Annecy, 4 Chemin de la Tour la Reine, 74000, Annecy, France
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