Shoulder joint replacement - management of the subscapularis: LTO and peel

Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes

These authors conducted a retrospective review of the minimum 2 year outcomes for 189 primary total shoulder arthroplasty patients having a lesser tuberosity osteotomy (LTO) to take down the subscapularis.

The LTO was repaired using a series of 4 transosseous FiberWire sutures placed through the biceps groove with an additional FiberTape suture placed as a cerclage suture through the greater tuberosity, wrapped around the humeral stem, and passed through the bone tendon junction of the subscapularis.

Postoperatively, patients wore a shoulder immobilizer with pendulum exercises only for the first 6 weeks, followed by an active-assisted stretching program. Strengthening and lifting were delayed for 3 months.

Postoperative radiographs were used to classify LTO healing as “bony union,” “nondisplaced nonunion,” “displaced nonunion,” and “not seen.” 

24% of patients did not have radiographic union:  16 had nondisplaced nonunion, 14 had displaced nonunion, and in 16 the lesser tuberosity was not seen. 

An example of a displaced non union is shown below.

Patients with displaced nonunions had 

(1) no improvement in Single Assessment Numeric Evaluation  or internal rotation, 

(2) lower postoperative Simple Shoulder Test scores

(3) higher pain scores and 

(4) a higher rate of glenoid gross loosening. 

Three patients were treated with revision. One patient with a displaced LTO nonunion did not improve clinically and was converted to a reverse shoulder arthroplasty. One patient developed a late postoperative infection at 5 years and was treated with a 2-stage revision to a reverse shoulder arthroplasty. The other developed a massive rotator cuff tear of the supraspinatus and infraspinatus 5 years after surgery and was revised to a reverse shoulder arthroplasty.

Comment: This is an interesting study that shows the importance of secure subscapularis reattachment after shoulder arthroplasty and the results of LTO in expert hands. The article points to the need for care during the first 3 months after repair, avoiding active internal rotation and passive stretching in external rotation.

Instead of an LTO, we prefer a careful subscapularis peel and reattachment for several reasons:

(1) it does not require sacrifice of the biceps tendon

(2) it does not compromise the strength of the proximal humerus

(3) it does not require the complex suture / tape technique described above

(4) by leaving the capsule on the deep surface of the tendon, repair sutures can be securely passed through tissue of good quality on both the tendon side and the bone side

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Is lesser tuberosity an advantage in total shoulder arthroplasty?

Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes

These authors examined differences in the minimum two year total shoulder outcomes in 189 shoulders having a lesser tuberosity osteotomy (LTO) related to the healing of the osteotomy.

There were 143 patients with union, 16 with nondisplaced nonunion, 14 with displaced nonunion, and 16 not seen.

Patients with displaced nonunion had lower postoperative functional scores (Simple Shoulder Test and American Shoulder and Elbow Surgeons scores; P < .01), and higher pain scores (visual analog scale for pain.

A higher rate of gross glenoid loosening was present in the displaced nonunion cohort (3 patients [21.4%]; P < .01).

Comment: In the hands of a highly experienced total shoulder arthroplasty surgery, at least one out of five patients had non-union of the lesser tuberosity osteotomy. One in ten had a displaced non-union. Those with displaced non-unions had poorer outcomes and increased rates of glenoid component failure.

This article can be viewed alongside another recent publication:
Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.

LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Further comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.

That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.

The repair allows immediate postoperative assisted elevation

 with external rotation to neutral

Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Lesser tuberosity osteotomy - does it provide an advantage in shoulder joint replacement?

Comparison of Lesser Tuberosity Osteotomy to Subscapularis Peel in Shoulder Arthroplasty A Randomized Controlled Trial

Lesser tuberosity osteotomy (LTO) has been proposed as a superior method for managing the subscapularis during shoulder arthroplasty. These authors conducted a randomized double-blind study to compare lesser tuberosity osteotomy and the standard subscapularis peel from the lesser tuberosity.

Forty-three patients were allocated to subscapularis osteotomy, and forty-four patients were allocated to subscapularis peel. Eighty-three percent of the study cohort returned for the twenty-four-month follow-up. The primary outcome of subscapularis muscle strength at twenty-four months revealed no significant difference (p = 0.131) between the lesser tuberosity osteotomy group (mean [and standard deviation], 4.4 ± 2.9 kg) and the subscapularis peel group (mean, 5.5 ± 2.6 kg). Comparison of secondary outcomes, including theWestern Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons scores, demonstrated no significant differences between groups at any time point.

Two patients had a nonunion at the osteotomy site as seen on postoperative radiographs. Neither of these patients reported a feeling of instability, and both were satisfied with the results of surgery.We did not observe any evidence of loosening or instability of the implants in either group. Two patients in the subscapularis peel group underwent further surgery. The first patient underwent two-stage revision because of implantrelated infection. The second patient underwent revision surgery to a reverse total shoulder arthroplasty after sustaining a massive posterosuperior rotator cuff tear. There were no reoperations for the treatment of subscapularis failure in either group.

This trial does not demonstrate any clear advantage of one subscapularis treatment technique over the other.

Comment: This is a carefully done study that does not show that "LTO" offers an advantage over the technically simpler peel. While these authors had a low non-union rate after LTO, this has not been the case in the experience of other surgeons as shown in the article below.

Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.

LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.

That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.

The repair allows immediate postoperative assisted elevation

 with external rotation to neutral

Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.

=

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Lesser tuberosity osteotomy nonunion - why not avoid this problem?

Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.

LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.

That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.

The repair allows immediate postoperative assisted elevation

 with external rotation to neutral

Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.

=

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Is there an advantage to mini humeral stems and lesser tuberosity osteotomy in shoulder arthroplasty?

Shoulder arthroplasty using mini‑stem humeral components and a lesser tuberosity osteotomy

These authors conducted a retrospective review of 75 patients who underwent anatomic shoulder arthroplasty utilizing a short stemmed humeral component inserted using a lesser tuberosity osteotomy with mean follow-up of 27.8 months (24–50 months).

Sixty-seven (89.3%) shoulders had uneventful LTO healing. There were five (6.67%) LTO failures, one (1.33%) fibrous union, and two (2.67%) osteotomies that had displaced > 4 mm at 6 weeks; four of the five failures required open repair, including one converted to reverse TSA. The other failure, the fibrous union, and the two displaced osteotomies were without clinical deficits and elected for non-operative management. One patient required intraoperative conversion to a long stem due to concern that metaphyseal bone integrity was compromised, in part, by the LTO. Four (5.33%) stems subsided, with one of them also being frankly loose and requiring revision, while the other three were asymptomatic, not requiring treatment.

Comment: This article points to the risks of poor healing after lesser tuberosity osteotomy and the risks of humeral component loosening and subsidence when lesser tuberosity osteotomy and a short stemmed humeral component are combined.

As illustrated in the figure below from this article,  the amount of bone removed with a standard stem (left) is not greater than that removed for a short stemmed implant (right).  It is also the case that a tightly fit short stem can give rise to proximal stress shielding as suggested in the x-ray below right (arrow).

Our practice is to use an impaction grafted standard humeral stem inserted without a lesser tuberosity osteotomy as shown in this post (see link).

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Total shoulder: lesser tuberosity osteotomy or subscapularis tenotomy

Subscapularis Tenotomy Versus Lesser Tuberosity Osteotomy for Total Shoulder Arthroplasty: A Systematic Review 

Subscapularis tenotomy (ST) has been the standard method of mobilizing the subscapularis during the approach to a total shoulder arthroplasty (TSA). Recently, lesser tuberosity osteotomy (LTO) has gained in popularity. These authors performed a systematic review to elucidate any differences in clinical or radiographic outcomes between ST and LTO. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we identified clinical and/or radiographic TSA studies with minimum mean 2-year follow-up and level I to IV evidence. Twenty studies (1420 shoulders, 1392 patients) were included in the study. The ST group had significantly more patients with osteoarthritis (P = .03) and fewer patients with posttraumatic arthritis (P = .04). At final follow-up, mean (SD) forward elevation improvements were significantly (P < .01) larger for the ST group, +50.9° (17.5°) than for the LTO group, +31.3° (0.9°). Complication rates were almost identical, but the ST group showed a trend (P = .31) toward fewer revisions (10.0% vs 16.2%). There were no differences in Constant scores, pain scores, or radiolucencies.

Comment: We avoid lesser tuberosity osteotomy because (1)  it can weaken the metaphysics, compromising press fit fixation of the humeral component in the metaphysis, (2) it obligates sacrifice of the long head tendon of the biceps, which is an important contributor to shoulder stability, and (3) it can lead to troublesome non union of the osteotomized fragment.

Our surgical approach involves a careful peel of the subscapularis tendon from the lesser tuberosity with attention to preserving the integrity of the biceps tendon and a 360 degree release of the capsule from the glenoid to resolve limitation of external rotation. By retaining the capsule on the deep surface of the tendon, the strength of the repair is enhanced.

At the conclusion of the case, drill holes are placed through good bone at the margin of the neck cut and six sutures of #2 non-absorbable suture are passed through these holes.

 These sutures are then passed through the tendon edge and tied securely.

A principal cause of post operative subscapularis failure is the overzealous and premature stretching of external rotation or premature initiation of internal rotation strengthening as explained in this post:
Rehabilitation after shoulder arthroplasty - cautions!

Our approach is to limit external rotation stretching to zero degrees (the hand shake position) and avoid internal rotation strengthening exercises for at least 3 months after surgery. We also caution patients about the risk of events that may suddenly externally rotate the shoulder such as a fall or a sudden pull on the arm from a leashed dog.

The interested reader will want to read the related posts below:

Subscapularis failure after arthroplasty - evaluation and management

The biomechanics of subscapularis repair - all sutures are not equal!

Subscapularis in shoulder arthroplasty

Subscapularis and shoulder arthroplasty

The subscapularis - does it ever recover after shoulder arthropllasty - peel vs LTO?

Shoulder joint replacement arthroplasty - spare the subscapularis, spoil the arthroplasty?

How well does the subscapularis work after total shoulder arthroplasty? ?Hazards of inter scalene block?

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

Is lesser tuberosity osteotomy a benign approach to shoulder arthroplasty?
Shoulder joint replacement arthroplasty - lesser tuberosity osteotomy, are there data in support of it?

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Healing through joint replacement

Supporting progress in shoulder surgery

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How should the subscapularis be managed in total shoulder arthroplasty?

Lift-off Test Results After Lesser Tuberosity Osteotomy Versus Subscapularis Peel in Primary Total Shoulder Arthroplasty

These authors conducted a retrospective cohort study of 90 primary anatomic total shoulder (TSA) procedures performed with either a subscapularis peel (SP) or a lesser tuberosity osteotomy (LTO) from 2002 to 2010. Procedures performed after 2007 had a LTO (44) whereas those before 2007 had a SP (46).

The authors used the 'lift off test' as their primary outcome measure, recognizing that while this assessment can be a highly specific and sensitive test of subscapularis function, "it is difficult to perform correctly."

Their lift-off test results plotted against the ordinal sequence of patients. Abnormal results are noted with a vertical line. Procedures 1 to 46 were performed with subscapularis peel. Procedures 47 to 90 were performed with lesser tuberosity osteotomy.

The results of their multivariate analysis is shown below, showing that in their patients, workers' compensation insurance, subscapularis peel, and smoking had the highest odds ratios of an abnormal lift off test.

The authors point out the limitations of this study:  different surgical techniques were employed between the two groups, different implants were used in the two groups, the two groups of procedures were not performed during the same time period, and the followup interval was twice as long for the SP group (5.6 vs 2.7 years).

They include a summary of some of the prior articles on the subject:

Comment: We avoid lesser tuberosity osteotomy because it can compromise the fixation of the humeral component in the metaphysis and obligates sacrifice of the long head tendon of the biceps (we are not routine 'biceps killers').

Our surgical approach involves a careful peel of the subscapularis tendon from the lesser tuberosity with attention to preserving the integrity of the biceps tendon and a 360 degree release of the capsule from the glenoid to resolve limitation of external rotation. By retaining the capsule on the deep surface of the tendon, the strength of the repair is enhanced.

At the conclusion of the case, drill holes are placed through good bone at the margin of the neck cut and six sutures of #2 non-absorbable suture are passed through these holes.

 These sutures are then passed through the tendon edge and tied securely.

A principal cause of post operative subscapularis failure is the overzealous and premature stretching of external rotation or premature initiation of internal rotation strengthening as explained in this post:
Rehabilitation after shoulder arthroplasty - cautions!

Our approach is to limit external rotation stretching to zero degrees (the hand shake position) and avoid internal rotation strengthening exercises for at least 3 months after surgery. We also caution patients about the risk of events that may suddenly externally rotate the shoulder such as a fall or a sudden pull on the arm from a leashed dog.

Other related posts are listed below:

Subscapularis failure after arthroplasty - evaluation and management

The biomechanics of subscapularis repair - all sutures are not equal!

Subscapularis in shoulder arthroplasty

Subscapularis and shoulder arthroplasty

The subscapularis - does it ever recover after shoulder arthropllasty - peel vs LTO?

Shoulder joint replacement arthroplasty - spare the subscapularis, spoil the arthroplasty?

How well does the subscapularis work after total shoulder arthroplasty? ?Hazards of inter scalene block?

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

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Shoulder joint replacement arthroplasty - lesser tuberosity osteotomy, 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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You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty

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, here, here, 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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The subscapularis - does it ever recover after shoulder arthropllasty - peel vs LTO?

The return of subscapularis strength after shoulder arthroplasty.

These authors compared the strength of the subscapularis at baseline (preoperatively) and at follow-up after unilateral shoulder arthroplasty to that of the contralateral normal side in sixty-four patients.

Two different means of managing the subscapularis were used, subscapularis peel (34 patients; 53%) and osteotomy of the lesser tuberosity (30 patients; 47%). After arthroplasty and subscapularis repair, a shoulder sling was worn for the first 6 weeks. On the first postoperative day, patients were instructed to initiate self-assisted, passive forward elevation to 90 in the supine position and to limit external rotation to neutral for 6 weeks. Active elevation was allowed at 6 weeks, and gentle strengthening was begun 12 weeks postoperatively.

The primary outcome measure was subscapularis strength in both the operative and contralateral (normal) arms as measured by a hand-held dynamometer in the belly-press position preoperatively

and at 3, 6, 12, and 24 months after surgery. The dynamometer was strapped to the patient’s hand; the hand was placed on the lower sternum with the elbow in line with but not posterior to the hand. The patient was asked to press the dynamometer into his or her sternum with a maximum force for a 5-second duration. The mean strength was calculated on the basis of 2 separate trials.

At 24 months the mean subscapularis strength on the operative side was 19% greater than preoperatively. On average, the operative side improved from 54% of the normal side at before surgery to 70% of the normal side at two years. 

Subscapularis strength recovery was significantly less than supraspinatus recovery, suggesting that the surgical release and repair of the subscapularis may account in part for the poorer recovery.

Multivariable regression analysis did not demonstrate any correlation between the independent variables studied and final subscapularis strength - including whether a lesser tuberosity osteotomy or  subscapularis peel was performed.  Specifically, no associations were identified among factors including sex, age, surgery on the dominant arm, baseline strength, baseline external rotation, subscapularis management technique, and fatty infiltration.

Comment: This is a well done and interesting study in that it indicates that the subscapularis function is compromised before surgery and never fully recovers.

Readers may wish to review a prior article on this topic by these authors. Our preferred method for caring for the subscapularis in shoulder arthroplasty is shown here.

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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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