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(1)

The rotator cuff in The rotator cuff in

arthroplasty arthroplasty

Introduction and the Introduction and the

role of subscapularis role of subscapularis

Christian Dumontier, MD, PhD Christian Dumontier, MD, PhD Institut de la Main (groupe de l

Institut de la Main (groupe de l ’épaule) & hôpital ’é paule) & hôpital saint Antoine, Paris

saint Antoine, Paris

(2)

Shoulder replacement Shoulder replacement

7000 TSR / year in the USA 7000 TSR / year in the USA

from 1996-2002 (Bohsali) from 1996-2002 (Bohsali)

17000 SR (Norris) 17000 SR (Norris)

75% are performed by 75% are performed by

surgeons who do less than surgeons who do less than

2/yr on average 2/yr on average

(3)

SR complication rate SR complication rate

Complication rate: 10-16%

Complication rate: 10-16%

!! 414/2810 = 14,7% (Literature review)414/2810 = 14,7% (Literature review)

!! 204/1459 = 14% (Wirth)204/1459 = 14% (Wirth)

!! 53/431 = 12% (Chin)53/431 = 12% (Chin)

!! 123 / 1183 = 10% TSR (Cofield)123 / 1183 = 10% TSR (Cofield)

(4)

Complications Complications

Component loosening Component loosening Prosthetic instability Prosthetic instability Cuff rupture

Cuff rupture Stiffness

Stiffness

Peri-prosthetic Fx Peri-prosthetic Fx Infection

Infection

Implant breakage Implant breakage Deltoid weakness Deltoid weakness Neural lesions

Neural lesions

1997 1997 2006 2006

+ +

- -

Component loosening Component loosening

Instability Instability

Periprosthetic Fx Periprosthetic Fx Rotator cuff tears Rotator cuff tears

Neural injury Neural injury

Infection Infection

Deltoid muscle Deltoid muscle

dysfonction

dysfonction

(5)

Causes for revision of Causes for revision of

shoulder arthroplasty shoulder arthroplasty

Dines, JBJS Dines, JBJS

20062006 Bayley, 2005Bayley, 2005 Swedish RSwedish R Glenoid revision

Glenoid revision 2222 2525 66

Conversion hemi to total

Conversion hemi to total 1616 1919 6565 Humeral stem revision

Humeral stem revision 88 33 1212

Periprosthetic Fx

Periprosthetic Fx 44 33 55

Rotator cuff repair

Rotator cuff repair 1010 2424 Tuberosity

Tuberosity reconstruction

reconstruction 44 Cuff tear

Cuff tear 44 1111

Instability

Instability 55 5959

Infection

Infection 44 11 1919

(6)

Take home message Take home message

Rotator cuff problems are among the most frequent Rotator cuff problems are among the most frequent

problems after TSR problems after TSR

They also interfere with glenoid fixation and prosthetic They also interfere with glenoid fixation and prosthetic

stability stability

They must be checked before - during and after They must be checked before - during and after

surgery surgery

(7)

Subscapularis Subscapularis

Is violated during the surgical Is violated during the surgical approach in almost all cases approach in almost all cases

Can be damaged after surgery due to:

Can be damaged after surgery due to:

Implant designs/size Implant designs/size Implant instability

Implant instability

(8)

Surgical approach Surgical approach

1st: There is no

1st: There is no ““retractionretraction”” of the of the subscapularis muscle

subscapularis muscle

2nd: Solid subscapularis repair is 2nd: Solid subscapularis repair is

mandatory mandatory

Be able to do a

Be able to do a ““360° release360° release”” to to mobilize the tendon

mobilize the tendon (axillary nerve)(axillary nerve)

Anticipate the difficulty Anticipate the difficulty ““toto lenghten

lenghten”” the tendon (bone the tendon (bone resorption, loss of ER

resorption, loss of ER (1 cm = 20°)(1 cm = 20°), ...), ...)

(9)

Subscapularis Subscapularis

Section of the tendon (1,5 cm from Section of the tendon (1,5 cm from

insertion) with suture at the end (ER >

insertion) with suture at the end (ER >

35°)35°)

Length is gained by releasing the CH Length is gained by releasing the CH

ligament +/- the intra-articular ligament +/- the intra-articular

subscapularis tendon subscapularis tendon

(10)

Subscapularis Subscapularis

Disinsertion from the lesser tuberosity Disinsertion from the lesser tuberosity Length is gained by releasing the CH Length is gained by releasing the CH ligament +/- the intra-articular

ligament +/- the intra-articular

subscapularis tendon +/- reinsertion of subscapularis tendon +/- reinsertion of the tendon into the humeral edges

the tendon into the humeral edges

(11)

Subscapularis Subscapularis

Abnormal results in 2/3 of patients for lift-off and Abnormal results in 2/3 of patients for lift-off and

press-belly tests (Miller, JSE 2003).

press-belly tests (Miller, JSE 2003).

Patients reported difficulty in tucking up their shirt in the Patients reported difficulty in tucking up their shirt in the backback

Does subscapularis release / section lead to muscle Does subscapularis release / section lead to muscle denervation ?

denervation ?

(12)

Subscapularis Subscapularis

Osteotomy of the lesser Osteotomy of the lesser

tuberosity tuberosity

(13)

Subscapularis Subscapularis

Osteotomy of the lesser Osteotomy of the lesser

tuberosity tuberosity

(14)

Subscapularis osteotomy Subscapularis osteotomy

39 patients 39 patients

All osteotomy healed All osteotomy healed

2/3 to 3/4 of patients had normal lift-off or press-belly 2/3 to 3/4 of patients had normal lift-off or press-belly testtest

"

"

Fatty infiltration F had progressed by one stage (24%),had progressed by one stage (24%), by two stages (15%), and by three stages (6%) and by two stages (15%), and by three stages (6%) and

was correlated with poorer results was correlated with poorer results

(15)

Subscapularis experimental repair Subscapularis experimental repair

After repair, length of the subscapularis tendon was reduced by 15% in the tendon-to-tendon group and by 12% in the bone-to- bone group and was increased by 7% in the tendon-to-bone group.

Complete failure occurred in four tendon-to-bone specimens, one tendon-to-tendon specimen, and no bone-to-bone specimen

during the 150-N cyclic test (Hoeneke)

On the basis of the ultimate strength, the osteotomized specimens with single and double-row repair had a significantly higher load to failure than the tenotomy specimens did (430, 466, and 252 N, respectively).

(16)

Implant positioning Implant positioning

Oversized heads Oversized heads Lateralization

Lateralization

will increase loadings on the will increase loadings on the tendon repair

tendon repair

(17)

Implant positioning Implant positioning

Increased retroversion increases Increased retroversion increases loads on the subscapularis during loads on the subscapularis during

external rotation +++

external rotation +++

Per-op testing (40-50-60 rules) Per-op testing (40-50-60 rules)

(18)

Implant design Implant design

Almost 100% of glenoid component Almost 100% of glenoid component

did not fit glenoid anatomy did not fit glenoid anatomy

Larger implant may act as a buttress Larger implant may act as a buttress

on the subscapularis on the subscapularis

(19)

Implant design Implant design

The humeral head is almost a sphere The humeral head is almost a sphere

Radius in the frontal plane > sagittal Radius in the frontal plane > sagittal

plane plane

If the prosthesis is fitted in the frontal If the prosthesis is fitted in the frontal plane

plane # # oversized in the sagittaloversized in the sagittal plane (

plane (!! 3 mm) 3 mm)

(20)

Conclusion Conclusion

Subscapularis is a major stabilizer of SR arthroplasty Subscapularis is a major stabilizer of SR arthroplasty

Outcomes of SR is linked to integrity of the Outcomes of SR is linked to integrity of the

subscapularis tendon subscapularis tendon

Surgical approaches violate the integrity of the Surgical approaches violate the integrity of the

subscapularis subscapularis

Implant design and positioning may also interfere with Implant design and positioning may also interfere with

the subscapularis the subscapularis

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