Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study

Ransom, Erin F.; Adkison, David; Woods, David P.; Pinto, Martim; He, Jun Kit; Worthen, James V; Brabston, Eugene W.; Ponce, Brent A.

doi:10.1016/j.jse.2019.08.009

Cited by 8 publications

(11 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Due to these concerns, different types of less cuff-jeopardizing approaches for performing aTSA have been proposed, including an anterior deltopectoral approach with only partial take-down of the inferior subscapularis [ 6 ], a superior approach through the deltoid and the rotator interval [ 7 ], and an anterior deltopectoral approach through the rotator interval [ 8 ]. While the clinical outcome for the complete rotator-cuff sparing interval approaches were comparable to the results obtained with traditional approaches, there was concern regarding non-anatomical neck osteotomies, head sizing, and neck-shaft angle, as well as increased superior decentering and an inability to resect inferior osteophytes in the calcar area, due to limited exposure [ 7 , 8 , 9 , 10 ].…”

Section: Introductionmentioning

confidence: 99%

Implant Sizing and Positioning in Anatomical Total Shoulder Arthroplasty Using a Rotator Cuff-Sparing Postero-Inferior Approach

Moroder

Lacheta

Minkus

et al. 2022

JCM

View full text Add to dashboard Cite

Background: The goal of this study was to compare the effectiveness of a rotator cuff-sparing postero-inferior (PI) approach with subdeltoidal access to the traditional subscapularis-takedown deltopectoral approach, in terms of implant sizing and positioning in anatomical total shoulder arthroplasty (aTSA). Methods: This study involved 18 human cadaveric shoulders with intact rotator cuffs and no evidence of head deforming osteoarthritis. An Eclipse stemless aTSA (Arthrex, Naples, FL, USA) was implanted in nine randomly selected specimens using a standard subscapularis-tenotomy deltopectoral approach, and in the other nine specimens using the cuff-sparing PI approach. Pre- and postoperative antero-posterior (AP) and axillary fluoroscopic radiographs were analyzed by two independent, blinded raters for the following parameters: (1) anatomic and prosthetic neck-shaft angle (NSA); (2) the shift between the anatomic and prosthetic center of rotation (COR); (3) anatomical size matching of the prosthetic humeral head; (4) the calculated Anatomic Reconstruction Score (ARS); (5) glenoid positioning; as well as (6) glenoid inclination and version. Results: While the COR was slightly but significantly positioned (p = 0.031) to be more medial in the PI approach group (3.7 ± 3.4%, range: −2.3% to 8.7%) than in the deltopectoral approach group (−0.2 ± 3.6%, range: −6.9% to 4.1%), on average, none of the remaining measured radiographic parameters significantly differed between both groups (PI approach group vs. deltopectoral group: NSA 130° vs. 127°, p = 0.57; COR supero-inferior, 2.6% vs. 1.0%, p = 0.35; COR antero-posterior, 0.9% vs. 1.7%, p = 0.57; head size supero-inferior, 97.3% vs. 98.5%, p = 0.15; head size antero-posterior, 101.1% vs. 100.6%, p = 0.54; ARS, 8.4 vs. 9.3, p = 0.13; glenoid positioning supero-inferior, 49.1% vs. 51.1%, p = 0.33; glenoid positioning antero-posterior, 49.3% vs. 50.4%, p = 0.23; glenoid inclination, 86° vs. 88°, p = 0.27; and glenoid retroversion, 91° vs. 89°, p = 0.27). Conclusions: A PI approach allows for sufficient exposure and orientation to perform rotator-cuff sparing aTSA with acceptable implant sizing and positioning in cadaveric specimens.

show abstract

Section: Introductionmentioning

confidence: 99%

Implant Sizing and Positioning in Anatomical Total Shoulder Arthroplasty Using a Rotator Cuff-Sparing Postero-Inferior Approach

Moroder

Lacheta

Minkus

et al. 2022

JCM

View full text Add to dashboard Cite

show abstract

“…Therefore, surgeons have sought subscapularis-sparing approaches. These alternative approaches include a rotator interval approach [7,15,16,21,23] and a newer posterior shoulder approach [10,11,12]. The rotator interval approach can be challenging because of limited visualization.…”

Section: Introductionmentioning

confidence: 99%

“…The rotator interval approach also may be associated with increased difficulty visualizing retroverted glenoids, retention of residual inferior humeral osteophytes, humeral head undersizing, and differences in component position [7,15,21,23]. It is also reported to have a 15.2% proportion of intraoperative approach abandonment and may result in deltoid release, anterior supraspinatus release, or muscular subscapularis release [7,15,16,21,23]. Alternatively, the posterior approach may offer a viable subscapularissparing approach to shoulder arthroplasty.…”

Section: Introductionmentioning

confidence: 99%

What Are Practical Surgical Anatomic Landmarks and Distances from Relevant Neurologic Landmarks in Cadavers for the Posterior Approach in Shoulder Arthroplasty?

Bahk

Greiwe

2021

Clin Orthop Relat Res

View full text Add to dashboard Cite

Background Traditional total shoulder arthroplasty is performed through the deltopectoral approach and includes subscapularis release and repair. Subscapularis nonhealing or dysfunction may leave patients with persistent pain, impairment, and instability. Alternative approaches that spare the subscapularis include rotator interval and posterior shoulder approaches; however, to our knowledge, a cadaveric study describing pertinent surgical anatomy for a posterior shoulder approach regarding shoulder arthroplasty has not been performed. Questions/purposes (1) What are the distances from important neurologic structures of the shoulder for arthroplasty through a posterior approach? (2) What surgical landmarks can help identify the internervous interval between the infraspinatus and teres minor? Methods Twelve hemitorso cadaver specimens with intact rotator cuffs were dissected to study posterior shoulder anatomy regarding posterior shoulder arthroplasty. The median (range) age of the specimens was 79 years (55 to 92). Six of the 12 specimens were right-hand dominant, and 10 specimens were male. Cadaver height was a median 171 cm (155 to 191) and weight was a median of 68 kg (59 to 125). A posterior deltoid split and internervous approach between the infraspinatus and teres minor were used. A posterior T capsulotomy was performed. The distances to important neurologic structures were measured with an electronic caliper and provided in median (range) distances in millimeters. Although not as meaningful as distance ratios accounting for a specimen’s body size, neurologic distances in millimeters are surgically practical and provide intraoperative usefulness. Surgical landmarks that can help identify the infraspinatus and teres minor plane were noted. Practical visual and tactile cues between the infraspinatus and teres minor were identified. Posterior rotator cuff tendon morphologies and widths were recorded. Results The closest important neurologic structure was the axillary nerve, measuring a median (range) 17 mm (9 to 19) from the inferior glenoid rim while the infraspinatus branch of the suprascapular nerve measured 21 mm (15 to 36) from the posterior glenoid rim. The axillary nerve measured 84 mm (70 to 97) from the posterior tip of the acromion in the deltoid split. Three surgical landmarks were helpful for identifying the plane between the infraspinatus and teres minor in all 12 specimens: (1) identifying the triangular teres minor tendon insertion, (2) medial palpation identifying the low point between the prominent muscle bellies of the infraspinatus and teres minor, and (3) identifying the distinct and prominent teres minor tubercle, which is well localized and palpable. Conclusion A major benefit of the posterior approach for shoulder arthroplasty is subscapularis preservation. Multiple practical surgical cues are consistently present and can help identify the infraspinatus and teres minor interval. We did not find the presence of fat stripes to be helpful. The suprascapular nerve is in proximity to posterior surgical dissection and differs from the deltopectoral approach. This is an important distinction from an anterior approach and requires care with dissection. Future studies are necessary to assess iatrogenic risk to the posterior rotator cuff and external rotation strength. This may entail intraoperative nerve conduction studies of the posterior rotator cuff and clinical studies assessing external rotation strength. Clinical Relevance Studying posterior shoulder anatomy is an initial first step to assessing the feasibility of the posterior approach for anatomic shoulder arthroplasty. Additional studies assessing the degree of glenohumeral exposure and possible iatrogenic posterior rotator cuff injury are necessary. Because of the proximity of neurologic structures, it is recommended that surgeons not perform this technique until sufficient evidence indicates that it is equivalent or superior to standard anterior approach total shoulder arthroplasty. After such evidence is available, proper training will be necessary to ensure safe use of the posterior shoulder approach.

show abstract

“…Given the relatively high rate of subscapularis complications in traditional shoulder arthroplasty, surgeons have developed alternative techniques to perform TSA while maintaining the integrity of the subscapularis. 1,5,9,[15][16][17][18] Lafosse et al 9 were among the first authors to report on a series of patients who were treated with TSA through a subscapularis-sparing approach. Their technique used a superolateral approach and accessed the glenohumeral joint through the rotator interval without disruption of the subscapularis.…”

mentioning

confidence: 99%

“…They have recently published a study on 70 patients treated with subscapularis-sparing TSA in which similar radiographic results were found in comparison to traditional TSA. 15 Savoie et al 16 have also performed an alternative method of the subscapularissparing approach but have done so through the deltopectoral interval as opposed to the superolateral approach. Their technique includes tenotomy of the inferior half of the subscapularis with later repair to assist in removal of inferior osteophytes and humeral head exposure.…”

mentioning

confidence: 99%

The subscapularis-sparing windowed anterior technique for total shoulder arthroplasty

Ross¹,

Lee²,

Neeley

et al. 2021

Journal of Shoulder and Elbow Surgery

View full text Add to dashboard Cite

Background: Traditionally, total shoulder arthroplasty (TSA) involves detaching the subscapularis tendon through either tenotomy or lesser tuberosity osteotomy. A subscapularis-sparing approach avoids detachment but may make re-creation of the anatomy more difficult because of limited exposure. The primary aim of this study was to evaluate the ability to re-create the proximal humeral geometry and assess for osteophyte removal with this technique. The secondary aim was to assess for complications or an inability to complete the procedure with this technique. Methods: We performed a retrospective review of a consecutive series of 47 patients (100% with osteoarthritis; 59% Walch type A and 41% Walch type B; 50% male and 50% female patients; and average body mass index, 28.21 AE 4.6) who underwent the subscapularissparing windowed anterior technique for TSA. The ability to reconstruct the proximal humeral geometry and remove the inferior osteophytes was assessed by 2 independent observers using the center-of-rotation difference (DCOR) between the native and prosthetic humeral heads. The ability to complete the procedure was recorded, and a chart review was performed to assess for complications. Results: The procedure was successfully completed in 44 of the 47 patients. Radiographic review demonstrated an average DCOR of 2.28 mm (range, 0.2-6.05 mm; intraclass correlation coefficient, 0.971), below the previously reported acceptable DCOR of 3 mm. The DCOR was >3 mm in 31.8% of patients (14 of 44; 8 Walch type A and 6 Walch type B; 9 male and 5 female patients). There was no difference in DCOR based on Walch type (P ¼ .824). Male patients on average showed a higher DCOR (2.62 mm) than female patients (1.94 mm) (P ¼ .099) and more commonly had a DCOR > 3 mm (P ¼ .195). Body mass index was not significantly correlated with DCOR (r ¼ 0.077, P ¼ .619). For all cases in which the DCOR was >3 mm, the prosthetic humeral head was undersized. Osteophytes were successfully removed in 75% of cases (33 of 44) and had no effect on average DCOR (P ¼ .468). No revisions or mechanical failures in the early postoperative period were identified in the treatment group of 44 patients (range, 3-15 months). In the group with unsuccessful treatment, there was 1 case of infection treated with 1-stage revision reverse TSA. Discussion: The subscapularis-sparing windowed anterior technique is an effective approach to TSA that allows for early unrestricted motion. Over 90% of cases can be completed using this technique. Radiographic analysis demonstrated that this approach can be used successfully without compromising anatomic reconstruction of the proximal humerus. Further study is necessary to identify patient factors that would favor a traditional deltopectoral approach and to assess the functional outcomes of this technique.

show abstract

Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study

Cited by 8 publications

References 24 publications

Implant Sizing and Positioning in Anatomical Total Shoulder Arthroplasty Using a Rotator Cuff-Sparing Postero-Inferior Approach

Implant Sizing and Positioning in Anatomical Total Shoulder Arthroplasty Using a Rotator Cuff-Sparing Postero-Inferior Approach

What Are Practical Surgical Anatomic Landmarks and Distances from Relevant Neurologic Landmarks in Cadavers for the Posterior Approach in Shoulder Arthroplasty?

The subscapularis-sparing windowed anterior technique for total shoulder arthroplasty

Contact Info

Product

Resources

About