Thursday, December 11, 2014

Failure of lesser tuberosity osteotomy in total shoulder joint replacement - a cautionary tale

These authors report 5 male patients who sustained failure of the lesser tuberosity osteotomy (LTO) repair after primary total shoulder (TSA). These cases represent 3% of the TSAs done by the surgeon during this period.  The mean patient age was 52 years.

In the initial TSA, the long head of the biceps tendon was elevated out of its groove and was tenodesed to the top of the pectoralis major tendon. The lesser tuberosity was osteotomized  by placing an osteotome in the biceps groove and exiting it between the medial edge of the subscapularis insertion and the humeral head cartilage surface, yielding an osteotomy approximately 5 to 6 mm thick. After the arthroplasty, the osteotomy was repaired with 5 No. 5 sutures. The postoperative
rehabilitation protocol consisted of immediate passive range-of-motion exercises with external rotation limited to 30 degrees. Strengthening exercises were permitted 8 weeks after surgery.

In these five cases the mean time from initial TSA to diagnosis of LTO failure was 9 weeks.  At the time of diagnosis of failure of the LTO, clinic examination showed persistent or worsening pain, particularly with the belly-press sign or bear-hug sign Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall. All LTO failures were confirmed by CT scan

One patient had a revision repair.
One had two attempts to revise the repair.
Three patients either underwent or were recommended to have reverse total shoulder arthroplasty.

The authors suggest that failure of the LTO repair after TSA may possibly be an under-reported complication that is associated with poor clinical outcomes and limited options for revision surgery. 

Comment: This is indeed a cautionary note. The initial TSAs in this report were performed by a highly experienced surgeon. Some of these patients had severe complications associated with the LTO failure.

There have been several recent posts regarding various methods of managing the subscapularis at shoulder arthroplasty (here, herehere, and here). They make interesting reading.

At this point we do not find the evidence supporting LTO to be compelling and continue to incise the subscapularis from the lesser tuberosity and to repair it back using six solid sutures as shown here.


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