Minimally Invasive Rotator Cuff Sparing Total Shoulder Replacement
Worldwide, the number one reason that shoulder replacements fail is that the front rotator cuff tendon, the subscapularis, fails to heal well after it has been detached during the traditional exposure of the shoulder joint. In fact, improper healing of the subscapularis has been noted by ultrasound in up to 50% of total shoulder replacement patients in multiple studies. In 2014, it came to me (in a dream) that an approach to the shoulder might be made between two of the rotator cuff tendons, the subscapularis and the supraspinatus, through the rotator interval where the biceps long head tendon exits the joint. So, I went to the lab and developed the approach, which does not detach any cuff tendons and gives an outstanding view of the glenoid socket. Since October 2014, every one of my hundreds of ‘anatomic’ shoulder replacements has been done using this approach.
Because the rotator cuff is not detached, we can allow people to remove the sling the day after surgery and begin to move the shoulder to the limits of comfort. Physical therapy duration is greatly shortened and many (but not all) people have a normally functioning shoulder with normal range of motion by 6 weeks. Furthermore, the surgical pain is greatly decreased because the muscles are not as traumatized during this approach and a large percentage of people choose to have the replacement done as out-patients. I have designed tools that allow this technique to be performed safely and precisely; patents are pending on the tools and the technique and we have established a program to bring experienced shoulder surgeons to Birmingham to learn the approach and how to properly use the tools.
The incision is a small 3 inches long and is placed in the skin line that gives the nicest scar; we close the incision in such a way that allows people to shower the next day. Since I use the same incision to perform reverse total shoulder replacement, which is done for people who have a large rotator cuff tear with coexisting shoulder arthritis, we can often decide during surgery which prosthesis design will be better for any individual whose preoperative evaluation is not conclusive.
Hover over the photo to see before and after.