Subscapularis failure after anatomic total shoulder replacement

Tear of the repaired subscapularis tendon after anatomic total shoulder replacement, or hemiarthroplasty remains the main concern that slows down the rehab process. In cases of rupture or stretching of the repaired subscapularis there is external rotational lag or excessive passive external rotation during clinical exam. Radiographically there can be anterior subluxation of the humeral head on axillary view of the shoulder. 

I prefer to use 6 sutures for repair of the subscapularis when I re-attach it back to the humerus. The benefit of this approach is that if stretching or rupture occurs occasionally the lower 1/3 of the repaired subscapularis remains attached and thus the tendon does not retract. This is demonstrated in the picture below (C). If the rupture is complete then there is shortening and revision repair back to the lesser tuberosity may required. In such cases soft tissue releases or even augmentation with tendon allograft may be required (D)

Below there is an example of failure of the repaired subscapularis which was was found during surgery to be only stretching of the upper 2/3 of the row border of the tendon. For that reason it was easy to repair it back to the bone. Axillary xray indicates the rupture below.

This axillary view indicates that the humeral head in centered on the glenoid after the revision repair of the subscapularis tendon

This axillary view indicates anterior subluxation, failure of subscapularis

Six sutures passed through the cortical bone of the lesser tuberosity for repair of the subscapularis. Usually the upper 2/3 of the tendon fails at the repair site, or gets stretched and the lower 1/3 remains attached which helps to avoid complete retraction and shortening of the subscapularis tendon after rupture.

15 years after anatomic total shoulder replacement

The long term outcomes of total shoulder replacement are known. The industry is currently developing hybrid glenoid components, however the all polyethylene glenoid component remains the gold standard in terms of longevity. Metal backed glenoid components have failed to solve the problem of radiolucent lines seen more frequently 5 years after total shoulder replacement. The majority of patients with such a radiographic finding have no clinical adverse event. The following radiographs are 15 years after cemented anatomic total shoulder replacement. The rotator cuff has not failed and the outcome was excellent with active forward elevation to 160 degrees and no pain. There is some polyethylene wear which is expected.

Conservative treatment of the uncomplicated Holstein Lewis humeral shaft fracture

Conservative treatment of the Holstein Lewis humeral shaft fractures remains a very attractive option because there is no risk of iatrogenic radial nerve injury or infection. In addition, the multi-fragmented subgroup of those rare fractures run the risk of non union after operative treatment as there is soft tissue dissection during surgery which disrupts the blood flow to the fracture fragments.

If after application of a Sarmiento brace the fracture shortening is less than 1 cm and the angulation on the AP and lateral plane less than 30 degrees then conservative treatment should be considered.

A case example is shown below that ended up in satisfactory outcome and healing in acceptable position.

Injury film

After application of the Sarmiento brace, AP view

After application of the Sarmiento brace, LAT view

3 months after the fracture is healed

3 months after the fracture is healed

A similar case is illustrated below.

Injury film

Sarmiento application

70 days after the injury the fracture is healed with no angulation of the lateral view

70 days after the injury the fracture is healed with 17 degrees of angulation on the AP view which is within the acceptable limits of malunion

The patient has no function deficits in the ROM of the elbow and is pain free.