Reverse shoulder arthroplasty may be best for subscapularis failure
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KOLOA, Hawaii — A speaker at Orthopedics Today Hawaii discussed his approaches to reverse shoulder arthroplasty to treat subscapularis failure after total shoulder arthroplasty.
“Subscapularis failures are common causes for both early and late [total shoulder arthroplasty] TSA,” Mark A. Mighell, MD, said during his presentation. “Repair of the pectoralis major hasn’t really worked for me, so I think RSA has offered us an option or solution to this problem. If you don’t take out the subscapularis in the first place, it’s probably a better option.”
He said when he removes the glenoid, he uses a “tic-tac-toe” approach.
“You can actually draw a tic-tac-toe board and you can actually break [the glenoid] up,” Mighell said. “It’s easier to take a micro sagittal saw and cut the glenoid component, and then you can piecemeal it out.”
With this approach, dead bone develops behind the glenoid due to the thermal effect, so surgeons need to get back to healthy bleeding bone, according to Mighell.
“I like to make things easier for myself,” he said. “I look for windows.”
He uses a medial coracoid window, where the pectoralis minor is removed and an osteotome is placed directly across the glenoid faceplate. A wire is sent back posteriorly and comes in parallel to the glenoid with the posterior percutaneous window.
“These additional windows have allowed me to manage revision cases very well,” Mighell said.
With the coracoacromial ligament window, surgeons can use the coracoid as a graft and go down to the top of the glenoid. This approach allows surgeons to work circumferentially around the glenoid and remove it, according to Mighell.
“But this has really changed my ability to do revision surgery,” he said. “I will tell you going on the medial side of the coracoid is the best thing I ever realized. I did that about 3 years ago, and I’ve never looked back. So, these windows help you get out the components when they are difficult to remove.” – by Monica Jaramillo
Reference:
Mighell MA. Subscapularis failure after TSA: What you need to know. Presented at: Orthopedics Today Hawaii; Jan. 12-16, 2020; Koloa, Hawaii.
Disclosures: Mighell reports he is a paid presenter or speaker for DePuy, a Johnson & Johnson Company, and Wright Medical Technology Inc.; is a paid consultant and paid presenter or speaker and receives research support from for DJ Orthopaedics; is a paid consultant for and a paid presenter or speaker for Stryker; receives intellectual property royalties from NewClip Technics and is aboard or committee member for the Foundation for Orthopaedic Research and Education.