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Quantification of the exposure of the glenohumeral joint
from the minimally invasive to more invasive
subscapularis approach to the anterior shoulder: a
cadaveric study
Jaime L. Bellamy, DO, MS
a,
*, Anthony E. Johnson, MD
a
, Michael J. Beltran, MD
a
,
Joseph R. Hsu, MD
b
, Skeletal Trauma Research Consortium (STReC)
b
a
Department of Orthopaedics & Rehabilitation, San Antonio Military Medical Center, Fort Sam Houston, TX, USA
b
Orthopaedic Trauma Service, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA
Background: There are multiple techniques to approach the glenohumeral joint. Our purpose was to quan-
tify the average area of the glenohumeral joint exposed with 3 subscapularis approaches and determine the
least invasive approach for placement of shoulder resurfacing and total shoulder arthroplasty instruments.
Methods: Ten forequarter cadaveric specimens were used. Subscapularis approaches were performed
sequentially from split, partial tenotomy, and full tenotomy through the deltopectoral approach. Glenohum-
eral joint digital photographs were analyzed in Image J software (National Institutes of Health, Bethesda,
MD, USA). Shoulder resurfacing and total shoulder arthroplasty instruments were placed on the humeral
head, and anatomic landmarks were identified.
Results: The average area of humeral head visible, from the least to the most invasive approach, was 3.2,
8.1, and 11.0 cm
2
, respectively. The average area of humeral head visible differed significantly according
to the approach. Humeral head area increased 157% when the subscapularis split approach was compared
with the partial tenotomy approach and 35% when the partial approach was compared with the full tenot-
omy approach. The average area of glenoid exposed from least to most invasive approach was 2.0, 2.3, and
2.5 cm
2
, respectively. No significant difference was found between the average area of the glenoid and the
type of approach. Posterior structures were difficult to visualize for the subscapularis split approach. Partial
tenotomy of the subscapularis allowed placement of resurfacing in 70% of the specimens and total arthro-
plasty instruments in 90%.
Conclusions: The subscapularis splitting approach allows adequate exposure for glenoid-based proce-
dures, and the subscapularis approaches presented expose the glenohumeral joint in a step-wise manner.
Level of evidence: Anatomy Study, Cadaver Dissection.
Ó2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Glenohumeral joint; cadaver; subscapularis split; partial tenotomy; full tenotomy; shoulder
resurfacing; total shoulder arthroplasty
The Brooke Army Medical Center Institutional Review Board approved
this study (#C.2011.161n).
*Reprint requests: Jaime L. Bellamy, DO, MS, Department of Ortho-
paedics & Rehabilitation, San Antonio Military Medical Center, 3851
Roger Brooke Dr, Fort Sam Houston, TX 78234, USA.
E-mail address: jaime.l.bellamy.mil@mail.mil (J.L. Bellamy).
J Shoulder Elbow Surg (2013) -, 1-7
www.elsevier.com/locate/ymse
1058-2746/$ - see front matter Ó2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2013.09.013
The frequency of total shoulder arthroplasty has
increased significantly within the last decade.
15
The del-
topectoral approach to the shoulder through the sub-
scapularis has proven over time to provide adequate
access to the shoulder joint for treatment of fractures to
the glenoid or proximal humerus, shoulder resurfacing,
total shoulder arthroplasty, and soft tissue repair around
the shoulder, including the labrum, rotator cuff, and
cartilaginous surfaces of the glenohumeral joint.
13,21
A
surgical approach should have the parallel goals of
providing adequate exposure for safe performance of the
desired procedure, allow for minimal disruption of soft
tissue attachments to the region of interest, and avoid
putting adjacent neurovascular structures of interest at
risk of injury.
The partial and full tenotomies of the subscapularis
have both been under scrutiny. Loss of function of the sub-
scapularis has been reported due to failure of the tendon
repair or muscular changes, or both, leading to muscle
insufficiency,
10,11,30,31
which has the potential to negatively
affect clinical outcome.
10,20,23 ,24,27,29
Multiple alternative
approaches have been developed, including the subscapu-
laris split,
14
through the rotator interval,
16
lesser tuberosity
osteotomy,
9
subscapularis peel,
12
dual-window sub-
scapularis-sparing approach combined with the subscapularis
splitting approach,
3
and the anterior-superior approach.
25
Some reports have shown primary tendon-to-tendon re-
pairs have inadequate results; however, others have shown
it is more efficient and avoids nonunion with osteotomy.
6
A
more recent study in which the lesser tuberosity osteotomy
was compared with the subscapularis peel found no sig-
nificant difference in fatty infiltration, strength, and shoul-
der outcome scores at 2 years of follow-up.
17,18
Despite the
alternatives, the subscapularis tenotomy has been the most
widely used approach to the glenohumeral joint.
The subscapularis splitting approach has less theoret-
ical risk, but whether it allows adequate exposure of the
glenohumeral joint compared with the partial and full
tenotomies is unknown. The purpose of the study was to
quantify the average area of the humeral head and glenoid
exposedwitheachtypeofapproach,identify6anatomic
landmarks, and determine the least invasive approach that
can be used for placement of the instruments used for
shoulder resurfacing and total shoulder arthroplasty. To
our knowledge, quantification of the average area of the
humeral head and glenoid through the subscapularis ap-
proaches presented in this study has not been previously
reported.
Materials and methods
The study used 10 fresh frozen cadaveric limb specimens (each
composed of 1 forequarter shoulder). All procedures were per-
formed by the 2 senior authors (A.E.J. and J.R.H.). A standard
deltopectoral approach to the shoulder was performed as described
below.
Dissection
With the specimens supine, a 10-cm line was drawn on the skin of
the anterior shoulder using a metric ruler to develop the delto-
pectoral interval. This line was made 3 cm distal to the coracoid
process, along the lateral border of the biceps, and parallel to the
anterior aspect of the deltoid. An incision was made along this line
to expose the cephalic vein. The clavipectoral fascia was exposed
and divided just lateral to the coracoid and conjoint tendon. The
incision was extended vertically to the coracoacromial ligament
and distally to the level of the anterior circumflex artery to expose
the subscapularis tendon.
The subscapularis approaches were performed sequentially to
further expose the glenohumeral joint. The subscapularis muscle
was split in the mid portion, parallel to the plane of pull and in line
with the tendon fibers of the muscle. For the partial tenotomy
portion of the approach, a vertical incision (perpendicular to the
plane of pull of the muscle) was made through the tendinous
portion of the muscle 1 cm medial to its insertion on the lesser
tuberosity and taken down to where the muscle was split for the
subscapularis split. The partial tenotomy was completed for the
full tenotomy. A capsulotomy was performed after the sub-
scapularis-splitting approach to expose the glenohumeral joint.
The shoulder was externally rotated to relax the nerve and
enhance capsule exposure.
Identification of landmarks
Shoulder resurfacing and total shoulder arthroplasty instruments
were placed on the humeral head with each approach (Fig. 1). Six
anatomic landmarks (Table I) were identified by direct visuali-
zation or palpation, or both. Maximum reach along the anterior
and posterior glenoid was identified for each specimen.
Photographic analysis
After each surgical exposure, the best view, in the opinion of the
operating surgeon, was obtained and maintained for photographs
using standard surgical retractors to expose the glenohumeral joint.
Digital photographs of the exposed glenohumeral joint were taken
perpendicular to the dissection from the surgeon’s perspective and
analyzed using Image J software (National Institutes of Health,
Bethesda, MD, USA), as previously described.
2,4,7
This program
compared a known distance (ie, a metric ruler in each image) with
the actual number of pixels in each image to calculate the square
area of the glenoid and humeral head in each exposure.
Statistical analysis
Statistical analysis consisted of 2-way, repeated measures analysis
of variance with Tukey adjustment for pair-wise comparisons. A P
value of <.05 was considered significant.
Results
Demographic data for all specimens are included in
Table II. One specimen had rheumatoid arthritis of the
hands and feet, 1 specimen had rheumatoid arthritis of the
2 J.L. Bellamy et al.
hands, 1 had arthritis not specified, 1 had osteoarthritis of
the left hip, and 1 had no arthritis reported. Specimens 1, 3,
5, 6, 7, and 8 had obvious osteoarthritis of the humeral
head. The soft tissues were not inspected for rotator cuff,
labral tears, or biceps tendinopathy.
The average area of humeral head exposed from the least
to the most invasive approach was 3.2, 8.1, and 11.0 cm
2
,
respectively (Table III). A significant difference found in
the average area of the humeral head exposed among the
subscapularis split, partial tenotomy, and full tenotomy
approaches (P<.0001). A significant difference was found
in average area of the humeral head exposed between the
partial and full tenotomy approaches (P¼.012; Fig. 2). The
humeral head area exposed increased 157% when the
subscapularis split was compared with the partial tenotomy
approach and increased 35% when the partial tenotomy was
compared with the full tenotomy approach (Fig. 2).
The average area of glenoid exposed, from the least to the
most invasive approach was 2.0, 2.3, and 2.5 cm
2
,respec-
tively (Ta ble III). No significant difference found between
the average area of the glenoid and type of subscapularis
approach (Fig. 2). The glenoid area exposed increased 18.6%
when the subscapularis split was compared with the partial
tenotomy approach and increased 7.2% when the partial
tenotomy was compared with the full tenotomy approach
(Fig. 2).
For the subscapularis split approach, the coracoid,
biceps anchor and groove, axillary pouch, and posterior
capsule were palpated in all specimens. Visualization of the
coracoid, axillary pouch, and posterior capsule was 90%,
70%, and 50%, respectively, through the subscapularis split
approach. The biceps anchor and groove were visible in all
specimens. The humeral start point was visualized in 10%
and palpated in 20% of specimens through the sub-
scapularis split approach. All 6 anatomic landmarks were
identified by direct visualization and palpation in 100% of
Table I Anatomic landmarks that were visualized and
palpated
Anatomic landmarks
Coracoid
Biceps anchor
Biceps groove
Axillary pouch
Posterior capsule
Anterior humeral start point
Figure 1 Shoulder resurfacing and total shoulder instruments were placed on the humeral head: (A) humeral head pin positioning guide
for shoulder resurfacing, (B) corresponding reamer for shoulder resurfacing, and (C) humeral intramedullary canal reamer for total shoulder
arthroplasty.
Glenohumeral joint quantification via subscapularis approach 3
the specimens through the partial and full tenotomy ap-
proaches. Neither the resurfacing nor total arthroplasty in-
struments could be placed on the humeral head through the
subscapularis split approach. Partial tenotomy of the sub-
scapularis allowed placement of resurfacing instruments in
70% of the specimens and total shoulder arthroplasty in-
struments in 90%. Resurfacing and total shoulder arthro-
plasty instruments were easily placed with full tenotomy of
the subscapularis.
The subscapularis split approach allowed maximum
reachtothe6o’clockpositionontheanteriorandpos-
terior aspect of the glenoid in 50% and 60% of the spec-
imens, respectively (Table IV). Partial and full tenotomies
allowed maximum reach in 80% to 100% of the specimens
(Tab l e I V ).
Discussion
The anterior approach to the shoulder through the delto-
pectoral interval through the subscapularis muscle is a
standard approach with many utilities. The 3 approaches to
the subscapularis in this study were the subscapularis split,
partial tenotomy, and full tenotomy. The tenotomies pro-
vide the most exposure, but there are risks to surrounding
neurologic structures and reported negative effects on
rehabilitation after repair.
The least invasive exposure in this study was the sub-
scapularis split approach. The subscapularis split approach
involves splitting the muscle along its fibers to expose
the capsule rather than tenotomy at the lesser tuberosity,
providing a protective barrier to the axillary nerve inferi-
orly.
14
A study of 128 anterior stabilization surgeries using
the subscapularis split approach, without exposing the
axillary nerve in any case, reported only 1 patient who
developed paresthesia in the axillary nerve distribution,
with complete resolution by 6 weeks.
22
Maynou et al
20
compared the partial tenotomy and subscapularis split
approaches and found higher functional scores and less
fatty degeneration with the subscapularis split approach,
with a mean follow-up of 7.5 years. However, preoperative
imaging was done with computed tomography.
20
The sub-
scapularis split approach is an attractive choice because it
may expedite postoperative motion and rehabilitation and
maintain an anatomic guard against iatrogenic axillary
nerve injury, but there is less exposure.
In this study, the subscapularis split had the least amount
of exposure by surface area, identification of landmarks,
and placement of arthroplasty instruments. The average
area of the humeral head exposed was significantly smaller
compared with the partial and full tenotomies. The humeral
head area exposed increased 157% when the subscapularis
split was compared with the partial tenotomy and increased
another 35% when partial tenotomy was compared with the
full tenotomy. If more visualization is required, a tenotomy
may be sequentially performed. The glenoid area exposed
for each approach was not significantly different (Fig. 3).
For the subscapularis split approach, posterior landmarks
were difficult to visualize, not all were palpated, and
resurfacing and total shoulder arthroplasty instruments
could not be placed in any specimen. Anterior soft tissue
based procedures of the glenohumeral joint, such as ante-
rior capsular plication of the capsulolabral ligamentous
complex (eg, Bankart procedure), may be performed with
the subscapularis split with the same amount of exposure as
a tenotomy, with the added benefit of protecting the
Table II Specimen demographics
Variable Average (range) or No. (n ¼10)
Age, y 66.6 (45-77)
Height, cm 166.9 (149.9-175.3)
Weight, kg 63.6 (57.7-80.9)
Body mass index, kg/m
2
22.8 (20-27)
Sex
Male 2
Female 3
Caucasian race 10
Laterality
Right 5
Left 5
Table III Average area of the glenoid and humeral head
exposed for the subscapularis split, partial tenotomy, and full
tenotomy approaches
Structure Approach Average
area (cm
2
)
Standard
deviation
Glenoid Split 2.0 0.59
Partial 2.3 0.91
Full 2.5 1.12
Humeral head Split 3.2 2.16
Partial 8.1 3.84
Full 11.0 3.79
Figure 2 Average area (cm
2
) of the glenoid and humeral head
exposed for the subscapularis split, partial tenotomy, and full
tenotomy approaches, with an incremental increase in exposure
among the approaches.
4 J.L. Bellamy et al.
subscapularis from axillary nerve injury while avoiding the
complications of fatty infiltration and weakness.
20,22,26,28
The partial tenotomy of the subscapularis involves
detachment of a portion of the tendon. Multiple studies
have reported that subscapularis tenotomy leads to degen-
erative changes; however, this is not consistent across all
studies and may already be present preoperatively.
8
The
average area of the humeral head exposed by partial
tenotomy was 8.1 cm
2
. There was a large incremental in-
crease, 157%, in exposure of the humeral head from the
subscapularis split to the partial tenotomy. The partial
tenotomy approach allowed visualization and palpation of
all 6 landmarks and was the least invasive adequate
approach that allowed placement of resurfacing and total
shoulder arthroplasty instruments (Fig. 4). Because the
theoretical risks of tenotomy have not been consistent, a
tenotomy should be used to approach the humeral head
because it will give the most cost-effective exposure
compared with the subscapularis split approach.
Traditionally, the subscapularis approach involves full
tenotomy with complete detachment of the subscapularis
tendon. The axillary nerve courses along the inferolateral
border of the subscapularis 3 to 5 mm medial to its mus-
culotendinous junction and contacts the inferior capsule
as it passes through the quadrilateral space.
1,19
With full
tenotomy and elevation of the subscapularis, an anatomic
barrier to injury of the axillary nerve is removed. A review
of neurologic complications from shoulder surgery found
that the nerve injury rate was 1% to 2% in rotator cuff
repairs, 1% to 8% in anterior stabilization procedures, and
1% to 4% in shoulder arthroplasty.
5
Some authors recom-
mend visualizing the nerve before tenotomy of the sub-
scapularis tendon due to the high risk of injury during
exposure.
19
Postoperatively, the subscapularis repair must
be allowed to heal sufficiently, limiting motion and
rehabilitation.
The largest average surface area exposed of the humeral
head in our study, 11.0 cm
2
, was through the full tenotomy.
If more exposure is needed beyond a partial tenotomy,
this can be completed to a full tenotomy and will give an
additional 35% more exposure of the humeral head. All 6
landmarks were visualized and palpated, and resurfacing
and total shoulder arthroplasty instruments were easily
placed in all specimens with the full tenotomy approach
(Fig. 5).
Table IV Number of specimens in which maximum reach on
the glenoid was obtained to the 6 o’clock position by approach
Approach Specimens, No. (%) (n ¼10)
Subscapularis split
Anterior 5 (50)
Posterior 6 (60)
Partial tenotomy
Anterior 8 (80)
Posterior 9 (90)
Full tenotomy
Anterior 10 (100)
Posterior 9 (90)
Figure 3 Subscapularis split approach shows almost complete
exposure of the glenoid.
Figure 4 Subscapularis partial tenotomy approach represents a
difficult placement of the shoulder resurfacing instrument on the
humeral head.
Figure 5 Subscapularis full tenotomy approach allows almost
an entire view of the humeral head.
Glenohumeral joint quantification via subscapularis approach 5
This study has numerous limitations. Specimens 1, 3, 5,
6, 7, and 8 had obvious osteoarthritis of the humeral head,
and the soft tissues were not inspected for rotator cuff,
labral tears, or biceps tendinopathy. The osteoarthritis and
presence of soft tissue pathology could have affected the
amount of exposure of the glenohumeral joint. In addition,
there was no variability in the race or ethnicity of our
specimens, and a small number of cadavers were used.
The typical dissection of the subscapularis for the partial
tenotomy uses a 2/3 and 1/3 split of the tendon from
proximal to distal. To ease sequential dissection in this
study, the partial tenotomy cut the subscapularis tendon in
half, which may have underestimated the amount of
exposure. No method was used to control for a specific
point on the landmarks visualized. During the dissection,
no method was used to control for the amount of arm
rotation or the amount of torque used by retractors that
were placed, and both could have increased or decreased
amount of exposure.
This study used digital imaging software, which used
a 2-dimensional photograph attempting to represent a 3-
dimensional surface. However, this photograph was quan-
tified and has been deemed appropriate, as previously
described.
2,4,7
The photograph taken in the surgeon’s view
may have underestimated the average area exposed: surgery
in real time is a dynamic process because retractors and
arm placement can change.
This is the first study to quantify the amount of exposure
of the humeral head and glenoid by the anterior approach to
the shoulder through the subscapularis split, partial tenot-
omy, and full tenotomy. Six landmarks were identified in all
3 exposures of the subscapularis. In addition, this is the first
study to compare placement of shoulder resurfacing and
total shoulder arthroplasty instruments through each expo-
sure of the subscapularis.
Conclusions
The type of subscapularis approach does not matter for
procedures focused on the glenoid. However, the type
of subscapularis approach does matter for procedures
focused on the humeral head. The partial tenotomy was
the least invasive adequate approach for resurfacing
and total shoulder arthroplasty instruments. The sub-
scapularis split approach allows adequate exposure for
glenoid-based procedures, and the subscapularis ap-
proaches presented expose the glenohumeral joint in a
step-wise manner.
Disclaimer
The opinions or assertions contained herein are the
private views of the authors and are not to be construed
as official or reflecting the views of the Department of
Defense or United States Government. The authors are
employees of the United States Government. This work
was prepared as part of their official duties and, as such,
there is no copyright to be transferred.
Funding for the project was received from Brooke
Army Medical Center, Department of Clinical Investi-
gation, as an intramural grant fund (#C.2011.161n).
Anthony E. Johnson, MD, has received institutional
support from the Geneva Foundation; served as a board
member, owner, officer, or committee member of the
Society of Military Orthopaedic Surgeons, the Major
Extremity Trauma Research Consortium, the Musculo-
skeletal Tumor Society, and the United States Olympic
and Paralympic Committees. He serves as a paid
consultant for Pfizer Inc, Nexus Medical Consulting, and
the Orthopaedic & Rehabilitation Panel of the Medical
Devices Advisory Committee, Center for Devices and
Radiological Health, Food and Drug Administration,
U.S. Department of Health & Human Services; and holds
stock in Pfizer Inc. Joseph R. Hsu, MD, has received
institutional support from the Geneva Foundation, the
Combat Casualty Care Research Program, and the Major
Extremity Trauma Research Consortium, and serves as a
board member, owner, officer, or committee member of
the Society of Military Orthopaedic Surgeons, the Limb
Lengthening and Reconstruction Society, the Ortho-
paedic Trauma Association, the Major Extremity Trauma
Research Consortium, the Skeletal Trauma Research
Consortium, and the American Academy of Orthopaedic
Surgeons. The other authors, their immediate families,
and any research foundations with which they are affili-
ated have not received any financial payments or other
benefits from any commercial entity related to the subject
of this article.
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Glenohumeral joint quantification via subscapularis approach 7
