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.
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
The repair allows immediate postoperative assisted elevation
Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.
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