Review Question - QID 214540

The patient underwent a deltopectoral approach for an anatomic total shoulder arthroplasty, which requires a subscapularis tenotomy, peel, or lesser tuberosity osteotomy. Regardless of how the subscapularis is managed, in the postoperative period the subscapularis repair needs to be protected. As such, passive shoulder external rotation beyond 30° should be avoided in order to protect the subscapularis tendon repair.

Total shoulder arthroplasty is an effective treatment for the degenerative joint disease of the glenohumeral joint but is dependent on a competent rotator cuff for successful outcomes. During the standard deltopectoral approach, the subscapularis tendon is incised near the insertion to the lesser tuberosity in order to gain access to the glenohumeral joint. In the immediate postoperative period, shoulder external rotation should be limited to protect the subscapularis tendon repair.

Boardman et al. performed a study of 77 patients and 81 shoulders treated with an anatomic total shoulder arthroplasty and underwent a graduated rehabilitation program. They reported that 70% of patients maintained their intraoperative elevation and 90% maintained their intraoperative external rotation with the prescribed rehabilitation program detailed in illustration A. The authors concluded that their rehabilitation program is effective at maintaining shoulder motion after shoulder arthroplasty with better motion and tendon healing expected for patients with primary osteoarthritis.

Armstrong et al. performed a retrospective EMG study of 30 patients that underwent an anatomic total shoulder arthroplasty. They reported normal EMG findings in 15 patients and chronic denervation and reinnervation in the remaining 15 patients which affected the subscapularis in 30%, the infraspinatus in 27%, the supraspinatus in 20%, the teres minor 20%, and the rhomboids in 13% of patients. The authors theorized surgical exposure, traction, and interscalene nerve block may contribute to these EMG findings.

Illustration A is the graduated rehabilitation program that was prescribed by Boardman et al. to patients undergoing anatomic total shoulder arthroplasty.

Incorrect answers:
Answer 1: Passive internal rotation to the chest would not affect the integrity of the subscapularis repair.
Answer 2: Passive forward shoulder elevation to 90° would not affect the integrity of the subscapularis repair and helps prevent excessive shoulder stiffness from occurring.
Answer 3: Shoulder pendulum exercises place no added stress to the subscapularis repair and allow for a safe early range of motion.
Answer 4: Active elbow flexion to 100° would have no bearing on the subscapularis repair.