AANA Lab Course 906- Técnicas Avanzadas de Cirugía de Hombro-Manejo del subscapular en artroplastia antomica e invertida-Philipp N. Streubel, MD

Manejo del subscapular en artroplastia antomica e invertida-Philipp N. Streubel, MD

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This presentation by Dr. Philipp N Streubel discusses the management of the subscapularis tendon in anatomical and reverse shoulder arthroplasty, emphasizing its critical role in shoulder function and implant success.<br /><br />The subscapularis originates from the subscapular fossa and inserts on the proximal humerus, with tendinous and muscular portions. It acts as an internal rotator and stabilizer of the glenohumeral joint, both statically and dynamically. Historically, failure of the subscapularis is a common cause of shoulder arthroplasty failure.<br /><br />In anatomical shoulder arthroplasty, techniques for subscapular management include tenotomy (tendon-to-tendon repair), peel (tendon-to-bone), osteotomy (bone-to-bone), and preservation approaches. Key initial surgical steps involve identifying the long head of the biceps tendon, axillary nerve, and humeral circumflex vessels. Biomechanical studies indicate osteotomy offers stronger fixation and less gap formation, suggesting better outcomes. Clinical studies reveal osteotomy (less commonly called lesser tuberosity osteotomy - LTO) shows higher consolidation rates and possibly superior clinical scores compared to tenotomy or peel techniques.<br /><br />Preservation approaches involve posterior or rotator interval approaches, partial tenotomy (30-50% fibers), and require special instruments. These may reduce damage but are more technically challenging, with limited data showing comparable results.<br /><br />In reverse shoulder arthroplasty, subscapularis integrity reduces instability and improves internal rotation but may limit external rotation. Repair of the subscapularis decreases dislocation rates significantly (0.7% vs 4%) in meta-analyses. Different surgical approaches (deltopectoral, trans-subscapular, anterosuperior) affect subscapularis preservation. A balance exists between stability and range of motion depending on repair.<br /><br />In summary, subscapularis management is critical in shoulder arthroplasty. Osteotomy tends to provide better healing in anatomical replacements, while in reverse arthroplasty, maintaining subscapularis reduces instability though may limit motion. Preservation techniques are emerging but require expertise. Proper repair techniques and exposure are vital for optimal clinical outcomes.

Keywords

subscapularis tendon

shoulder arthroplasty

anatomical shoulder arthroplasty

reverse shoulder arthroplasty

lesser tuberosity osteotomy

tenotomy

peel technique

subscapularis preservation

shoulder stability

internal rotation