Saturday, June 20, 2015

Shoulder joint replacement arthroplasty - lesser tuberosity osteomy, are there data in support of it?

Lesser Tuberosity Osteotomy Versus Soft-Tissue Subscapularis Release in Shoulder Arthroplasty: A Systematic Review

These authors conducted a systematic review  the available literature clinically comparing subscapularis approaches, using MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials. All clinical trials were identified, and trials comparing at least 2 different subscapularis approaches were examined. Six clinical trials were identified comparing lesser tuberosity osteotomy, subscapularis tenotomy, and peel. Two were randomized-controlled trials comparing osteotomy and peel. Both trials demonstrated improvements in both the groups without demonstrating a significant advantage to either approach. Four trials retrospective analyzed subscapularis osteotomy compared with tenotomy. These trials demonstrate a tendency for improved clinical function with subscapularis osteotomy when patients perform a belly-press test or shirt tuck. Level I and II studies have not shown a significant difference between soft-tissue and bony subscapularis approach with shoulder arthroplasty, but retrospective studies have suggested improved clinical outcomes with osteotomy.

Comment: The keys to subscapularis integrity after shoulder joint replacement arthroplasty are (1) a careful detachment leaving strongly reparable tissues, (2) a secure repair and (3) care of the repair until it has healed. We prefer to detach the subscapularis directly from the lesser tuberosity, maintaining the capsule on the deep surface to optimize later repair. The repair uses six sutures of #2 teflon coated braided polyester suture (Tevdek) passed through secure bone at the lesser tuberosity and through the lateral edge of the detached tendon. External rotation stretching and internal rotational loading are avoided for 6 weeks after surgery. The method is detailed in this post.

We avoid the lesser tuberosity osteotomy for several reasons. First, it requires sacrifice of the long head tendon of the biceps, which we retain in the great majority of cases. Secondly, it compromises the ability to achieve secure fixation with metaphyseal impaction grafting because it disrupts the integrity of the metaphyseal ring (see figure 2 in this article). Thirdly, the osteotomy can fail to heal, possibly resulting in the need to convert to a reverse total shoulder arthroplasty to regain stability. See also here. While, some contend that a lesser tuberosity osteotomy enables glenoid exposure, we have not found the osteotomy to be necessary for this purpose.

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