Monday, August 11, 2014

Is lesser tuberosity osteotomy a benign approach to shoulder arthroplasty?

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty

These authors  report a case series of 5 patients who sustained failure of lesser tuberosity osteotomy (LTO) repair after primary total shoulder arthroplasty (TSA). The typical patient was a 52 year old male.  The mean time from initial TSA to diagnosis of LTO failure was 9 weeks. Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall.

All patients required revision surgery. Only 1 patient required no additional procedures beyond the revision LTO repair. Another patient required a second revision LTO repair. The remaining 3 patients either underwent or were recommended to undergo reverse arthroplasty.

The authors conclude that lesser tuberosity osteotomy failure may be an under-reported complication  associated with poor clinical outcomes and limited options for revision surgery. In patients with a high risk of LTO failure, considerations should be made to augment the LTO repair during the index TSA procedure.

Comment: While advocates of LTO claim that this approach offers better glenoid exposure and improved healing of the subscapularis takedown, this article demonstrates the substantial problems that can occur when the repair fails. The loss of the lesser tuberosity makes salvage of a failed repair very difficult. One can only recall the 'old days' of greater trochanteric osteotomy as the recommended approach to total hip arthroplasty - a practice now rarely employed because of complications. We continue to expose the shoulder by incision of the subscapularis from the lesser tuberosity, leaving the lesser tuberosity intact for support of the humeral component and for reattachment of the subscapularis as shown here and here. It is possible that prior reports of failure of tendon to lesser tuberosity repair (i.e. without lesser tuberosity osteotomy) may be related to (a) failure to use at least six strong sutures, (b) failure to achieve secure suture fixation in bone, (c ) failure to achieve secure fixation in the tendon, (d) failure to preserve the capsule on the deep side of the tendon to optimize the quality of the tissue for repair, and (e) failure to avoid subscapularis stretching and strength use for six weeks after surgery. 

Of course yet another issue is that lesser tuberosity osteotomy obligates the surgeon to perform a biceps tenotomy or tenodesis - something we avoid unless the biceps is frayed or unstable.


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