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LIFESTYLE

Shoulder Surgery with:
Using superior and inferior windows, correct version and

size of the prosthesis is confirmed prior to final impaction.
After complete excision, two modified small Hohmann Occasionally a single stitch is used to close the interval tissue
retractors are placed through the interval at the anterior and
over the bicipital groove.
posterior aspect of the humeral head. An excellent view of
the superior aspect of the glenohumeral joint is obtained with 2.2. V shape subscapularis tenotomy
minimal retraction.
Despite that some clinical studies have shown that osteotomy
A full soft tissue release is performed, further elevating the have improved functional outcomes and healing rate,

anterior joint capsule from the glenoid and mobilising the subscapularis tenotomy in TSA has been shown to be
subscapularis tendon underneath the coracoid process. Blind biomechanically and clinically safe in order to restore the

dissection of the anterior aspect of the subscapularis muscle, anatomy after TSA. Nevertheless there is inherent risk of
behind the coracoid and conjoint tendon, is avoided as the re-rupture or non healing associated to subscapularis repair.
Below we describe a new V-shaped subscapularis tenotomy
nerves to subscapularis can enter the muscle quite laterally;
however, careful dissection above and behind the muscle is in order to provide accurate location for anatomic restoration,
better mechanical forces for reattachement and more surface
continued until the shoulder can be freely externally rotated
and elevated. The range of motion is checked prior to bony area for tendon healing while performing the tenotomy.

resection to maximise postoperative range of motion.
After standard deltopectoral approach, the first step in
subscapularis tenotomy is to identify the borders of the tendon
Instrumentation, Trialling and Insertion of Prosthesis
as well as its musculotendinous junction. About 1 cm medial
In order to manage the osteotomy of the head through the to the subscapularis insertion, we first mark the superior and
superior window, as the posterior side of the resection is
inferior aspect of the tenotomy using two stitches at the upper
not easy to expose, the resection is managed in 2 steps: part and the lower part of the subscapularis respectively.
the anterior part of the head is resected first followed by the
posterior part. The osteotome is splitting the head in a vertical The subscapularis tendon incisions, superior and inferior are
directed towards the medial aspect of the tendon in a 45o
fashion followed by the antero-posterior osteotomy according angle converging in the center and forming a triangle of tissue
the anatomy of the humeral neck. Once the anterior part
with base over the lesser tuberosity. The subscapularis and
is removed, the posterior part becomes easier to expose underlying anterior capsule are usually incised together. At the
and remove. The humeral head resection is then performed
end of the procedure, the pre-located stitches when aligned
with an oscillating tip saw or flat osteotome. This allows will facilitate the repair.
the saw blade or the osteotome to slide though the rotator
The advantage of the triangle shaped cuff of subscapularis
interval without damaging the supraspinatus or subscapularis
tendons. Most of the resection is performed with the saw; tendon left on the lesser tuberosity is that it offers a broad
surface to perform adequate anatomic soft-tissue repair
however, the final resection is completed with an osteotome
to avoid damage to underlying structures. The resected head (Figure 4). Traction is done from our most medial previously
is reconstructed on the back table and used to determine placed stitches marking the tenotomy site and repair of the

the appropriate size of the prosthetic head. Residual humeral subscapularis tendon is usually performed in figure-of-8
head osteophytes are removed.
fashion using four to five heavy nonabsorbable sutures. The
type of suture and suture configuration is dependent on
Once the head has been removed, the humerus is subluxed
surgeon preference. All repairs should be anatomic, and
inferiorly with the use of the inferior glenoid retractor and the shortening of the musculotendinous unit should be avoided.
modified Hohmann retractors are used on the anterior and
After the subscapularis repair is complete, the lateral aspect
posterior aspect of the glenoid. Once again, the force on the of the rotator interval is closed, often with the arm in slight
retractors is minimal. The technique avoids the need to fully
external rotation to prevent loss of external rotation caused
dislocate the humeral head anteriorly or posteriorly minimizing by rotator interval tightening.
any potential stretch injury to the axillary and brachial plexus

nerves. An excellent view of the glenoid is obtained and the Bibliography
posterior soft tissue releases of the capsule from the glenoid 1. Lafosse L, Shah AA, Butler RB, Fowler RL. Arthroscopic Biceps
and removal of glenoid osteophytes can be completed to Tenodesis to Supraspinatus Tendon: Technical Note. Am J Orthop

prepare the glenoid in a standard manner. Once the glenoid (Belle Mead NJ). 2011 Jul;40(7):345–7
component is implanted, then the humeral canal preparation 2. Lafosse L, Schnaser E, Haag M, Gobezie R. Primary total shoulder
arthroplasty performed entirely through the rotator interval:
is completed with no specific instrumentation needed. The technique and minimum two-year outcomes. J Shoulder Elbow
definitive prosthesis is inserted via the rotator interval initially
Surg. 2009 Nov-Dec;18(6):864 – 73
in an anteverted position. As the prosthesis is pushed into the
shaft, the humeral head is rotated under the supraspinatus

tendon with the aid of a customised spanner attached to
the metaphyseal component. Correct version of the humeral
component is facilitated by the intact infraspinatus and 01 Drawing portals for biceps tendon repair
02 Biceps is tenodesed to the supraspinatus and humeral head
subscapularis tendons as the intact footprint of the tendon 03 Subscapularis sparing technique through anterolateral approach
prevents over rotation in either direction.
04 V shape tenotomy of the subscapularis tendon

14 ISAKOS NEWSLETTER 2014: Volume II