Review Question - QID 220011

The patient had an anatomic total shoulder arthroplasty (TSA) complicated by late rupture of her subscapularis (Answer 5).

Total shoulder arthroplasty (TSA) allows for relief of pain and restoration of function while helping to preserve a greater range of motion for patients with painful shoulder osteoarthritis. Given that the glenoid component is essentially a resurfacing and does not allow for an increased level of constraint, the procedure requires a competent rotator cuff. During the procedure, the subscapularis must be mobilized through either a tenotomy, a "peel," or a lesser tuberosity osteotomy (LTO) and must be successfully repaired back to its origin to allow for restoration of the concavity compression forces that stabilize the head within the glenoid. If the repair fails acutely in the post-operative period, especially in young active patients, a revision surgery to repair the subscapularis may be attempted; however, in older patients or in more chronic injuries, revision to a reverse total shoulder arthroplasty is likely more appropriate.

Piper et al. reviewed the management of subscapularis insufficiency after total shoulder arthroplasty. The authors note that the functional success of anatomic total shoulder arthroplasty (TSA) relies heavily on the healing integrity of the subscapularis tendon, with failure of tendon repair leading to early failure of the arthroplasty with accelerated glenoid loosening, decreased function, and anterior instability. They conclude by describing the armamentarium of treatment options the surgeon must be familiar with, which includes non-surgical management for the low-demand patient, revision tendon repair, tendon reconstruction or transfer, or more commonly conversion to reverse shoulder arthroplasty.

Shields et al. published on the management of the subscapularis tendon during total shoulder arthroplasty. The authors note that for anatomic total shoulder arthroplasty, controversy exists regarding the best technique for detachment and repair of the subscapularis tendon, with options including tendon tenotomy, peel, lesser tuberosity osteotomy, and even subscapularis-sparing techniques. They conclude that the biomechanical and clinical data regarding tenotomy, peel, and LTO techniques have failed to distinguish a superior method because of inconsistencies, largely equivalent findings, and limited Level 1 evidence in the current literature, with all appearing to result in a similar rate of satisfactory outcomes.

Figure A is the initial post-operative AP radiograph of a stemless anatomic total shoulder replacement with an appropriately positioned, cemented glenoid component and an appropriately positioned and sized stemless humeral head component.

Incorrect Answers:
Answer 1: There is no evidence on the initial post-operative radiograph shown in Figure A of a technical error that would have led to a late rupture of the subscapularis.
Answer 2: There is no evidence in the clinical vignette to suggest catastrophic failure of the glenoid component.
Answer 3: The description of the axillary radiograph suggests asymmetry in the anteroposterior direction, which would not reflect a failure of the supraspinatus. In addition, an isolated non-retracted supraspinatus tear would not likely present in this fashion and is not considered a contraindication to performing a TSA.
Answer 4: A biceps tenodesis is most often performed during the initial anatomic total shoulder arthroplasty, so a spontaneous rupture is unlikely and would not present in this fashion.