Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use

BACKGROUND

This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing.

METHODS

An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively.

RESULTS

A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037).

CONCLUSION

A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Systematic review and network meta-analysis of subscapularis management techniques in anatomic total shoulder arthroplasty

BACKGROUND

Controversy exists regarding the optimal subscapularis management technique in patients undergoing anatomic total shoulder arthroplasty. The purpose of this study was to compare clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (SP) techniques.

METHODS

We performed a level III systematic review and network meta-analysis comparing ST, LTO, and SP in patients undergoing anatomic total shoulder arthroplasty. Our primary collection endpoints included range of motion, subscapularis function, subscapularis healing, functional patient-reported outcomes, complications, and revision surgery. Data were pooled and network meta-analysis was performed owing to the comparison of 3 groups.

RESULTS

Eight studies met our inclusion criteria for meta-analysis. There was no difference in sex or primary diagnosis between the 3 cohorts. No significant difference was found in postoperative external rotation or forward flexion between the groups. Meta-analysis found the SP cohort to have significantly greater internal rotation strength than the ST cohort. The belly-press test results were negative most commonly in the LTO group, and there was a significant difference compared with the ST or SP group (P < .0001). The weighted-mean healing rate for the LTO site was 98.9% on radiographic imaging. There was a significantly higher ultrasound healing rate in the LTO cohort than in the ST and SP cohorts. All groups had good postoperative patient-reported outcome scores (average American Shoulder and Elbow Surgeons score range, 78.6-87) and a relatively low rate of complications (3%).

CONCLUSION

This network meta-analysis demonstrates that the LTO group has superior healing and postoperative subscapularis-specific physical examination test results compared with the ST and SP groups. However, no difference in postoperative range of motion was found between the groups, and all techniques demonstrated good functional patient-reported outcomes, with a low rate of postoperative complications. These findings provide evidence-based support that ST, SP, and LTO all demonstrate similar outcomes; therefore, selection should be based on surgeon experience and comfort.

Distal tibia allograft glenoid reconstruction for shoulder instability: outcomes after lesser tuberosity osteotomy

BACKGROUND

Distal tibia allograft reconstruction of the glenoid in shoulder instability has garnered significant attention over the last decade. Prior studies demonstrate significant improvement in all reported patient outcomes albeit the approach is through a subscapularis split. There have not been prior studies evaluating outcomes after lesser tuberosity osteotomy which provides excellent exposure to the anterior glenoid.We hypothesize there is significant improvement in functional outcomes and no deleterious effects after lesser tuberosity osteotomy for distal tibia allograft reconstruction of the glenoid for shoulder instability.

METHODS

A retrospective review was performed from 2016 of 2019 of patients undergoing distal tibia allograft reconstruction of the glenoid through a lesser tuberosity osteotomy. Patients were indicated if they had recurrent anterior shoulder instability with >20% glenoid bone loss and evidence of an off-track lesion. Clinical, imaging, and operative data were evaluated. Objective follow-up data evaluated at minimum 2 years included radiographs, range of motion, DASH, SANE, VAS, SST, ASES, and Constant scores.

RESULTS

A total of 12 patients were available with average follow-up 28 months, average age 26 years old, and average glenoid bone loss of 33%. The patients demonstrated significant improvement in their clinical outcomes at final follow-up: DASH 42.9-8.9 (P = .004), SANE 32.2-85 (P = .00005), VAS 4.6-1.1 (P = .003), SST 7-11.4 (P = .01), ASES 50.2-90.5 (P = .001), and Constant 37.6-86.2 (P = .01). Range of motion at final follow-up was forward flexion to 161.4° (135-170°), external rotation 49.5° (40-65°), and internal rotation to T12-L1 (T7-L2) vertebral body.

CONCLUSION

The present study demonstrates the effectiveness of a lesser tuberosity osteotomy in exposure of the glenoid for reconstruction with a distal tibia allograft. The functional integrity of the subscapularis is maintained and the patient-reported outcomes are comparable with current literature.

Missed Bilateral Anterior Shoulder Dislocation With Bilateral Coracoid Fracture and Unilateral Long Head of Biceps Rupture

Missed or chronic bilateral anterior shoulder dislocation is a rare presentation, usually secondary to epileptic attack. We present herein an exceptional case of this injury pattern, associated with bilateral displaced fracture of the coracoid process, and unilateral rupture of the long head of biceps. Treatment consisted of open reduction through osteotomy of the lesser tuberosity, with additional stabilization of the glenohumeral joint, using the Latarjet procedure by transposition of the coracoid fragment with its attached conjoint tendon to the antero-inferior glenoid rim. Rupture of the long head of the biceps required tenodesis. Temporary glenohumeral pin transfixation was performed for residual instability at the end of the procedure. Patients with postictal shoulder pain, discomfort, or disability should be investigated with adequate radiographs, in addition to CT scan or MRI when needed. Early diagnosis allows for safe closed reduction, and helps avoid late and more complex surgical treatment required for missed or chronic dislocations.

Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy

BACKGROUND

It is unknown whether subscapularis management technique has an influence on the outcomes and complications of stemless total shoulder arthroplasty. The purpose of this study, therefore, was to compare outcomes and complications between subscapularis tenotomy, peel, and lesser tuberosity osteotomy used during stemless shoulder arthroplasty.

METHODS

We reviewed 188 stemless anatomic total shoulder arthroplasties and compared clinical and functional outcomes between those performed through a subscapularis tenotomy (n = 68), subscapularis peel (n = 65), or lesser tuberosity osteotomy (n = 55). Patients were followed up clinically and radiographically at 6 months, 1 year, and 2 years postoperatively.

RESULTS

At 2 years postoperatively, no statistically significant differences in visual analog scale pain scores, American Shoulder and Elbow Surgeons scores, or patient-reported instability (P ≥ .19) were found between groups. Active external rotation was greater in the peel group (P = .006) than in the tenotomy group but was not different compared with the lesser tuberosity osteotomy group (P = .07). No statistically significant difference in clinical subscapularis failures was noted between groups (P = .11); however, 2 patients in the peel group sustained a subscapularis failure requiring reoperation.

DISCUSSION

The results of this multicenter comparative analysis show that all 3 subscapularis management techniques are effective and safe in the short term when used with stemless anatomic total shoulder arthroplasty.

Comparison of Subscapularis Management and Repair Techniques

Management of the subscapularis tendon is a crucial step during the approach for total shoulder arthroplasty. The method of mobilizing the tendon and the technique used to repair it determine the initial integrity of the subscapularis and impact its capacity to heal. Currently, there exist 3 well-described and well-studied approaches to managing and repairing the subscapularis: subscapularis tenotomy, subscapularis peel, and lesser tuberosity osteotomy. More recently, a subscapularis-sparing approach has been proposed as an option. There is debate in the literature regarding which technique provides optimal strength and stability for subscapularis repair following shoulder arthroplasty. In this symposium, we provide an overview of each of the techniques and review the biomechanical studies comparing them.

A Tensionable Method for Subscapularis Repair after Shoulder Arthroplasty

Background

This study compared the biomechanical properties of a new lesser tuberosity (LTO) repair with a tensionable construct with suture tape and preplaced racking hitches vs. a traditional LTO repair using 4 high-strength sutures. The hypothesis was that there would be no difference between the 2 constructs.

Methods

LTO repairs were performed on 6 matched, paired cadaveric shoulders after placement of an uncemented humeral stem. The LTO in group 1 was repaired with 4 high-strength #2 sutures, each passed individually through the subscapularis tendon. The LTO in group 2 was repaired with 2 suture tape loops with a preplaced racking hitch knot and 2 passes through the subscapularis tendon. All sutures were passed around the humeral stem before passing through the subscapularis tendon. The specimens then underwent cyclic displacement and load-to-failure testing.

Results

Load to failure was 209.6 ± 71.2 N in group 1 compared with 502.8 ± 168.6 N in group 2 (P = .018). There was no difference in displacement between the 2 groups. All failures in group 1 occurred by knot slippage. The mode of failure in group 2 was tendon tearing in 5 of 6 cases.

Conclusion

A simplified LTO repair with suture tape and compression bridge and a preplaced half racking knot achieves favorable biomechanical properties in a technically efficient manner that may be useful clinically.

Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review

BACKGROUND

This systematic review aims to synthesize published data for the most common subscapularis takedown and repair to compare outcomes in the setting of shoulder arthroplasty.

METHODS

Searches of MEDLINE and Cochrane Library databases identified studies that reported clinical or radiologic outcomes for subscapularis management in the setting of shoulder arthroplasty. Comparisons included musculotendinous integrity, subscapularis testing and strength, shoulder range of motion, and functional outcome scores.

RESULTS

The 14 included studies reported considerable variability in techniques, outcomes, and musculotendinous integrity. Lesser tuberosity osteotomy (LTO) demonstrated better healing rates (93.1%) than subscapularis peel (SP; 84.1%) and midsubstance tenotomy (ST; 75.7%), although not significantly different. A statistically significant increase in fatty infiltration was found after surgery across techniques, and range of motion and strength were similar. Mean rates of normal results for belly-press and lift-off tests were uniformly better for LTO (79.1% and 80.7%) over ST (66.7% and 65.6%), although multiple studies showed poor correlation between subscapularis functional testing and musculotendinous integrity. Mean total Constant and Western Ontario Osteoarthritis of the Shoulder Index outcome scores were slightly better for LTO (77.6, 84.2) than for SP (71.8 and 82.7). Mean American Shoulder and Elbow Surgeons scores favored the ST group (80.8) over the SP (79.1) and LTO (73) groups.

CONCLUSIONS

The data suggest no significant differences exist for postoperative musculotendinous integrity or clinical outcomes among the subscapularis management techniques in shoulder arthroplasty. Subscapularis healing and integrity appear to favor the lesser tuberosity takedown method. Additional randomized controlled comparisons with long-term follow-up are needed to more effectively compare these surgical approaches.

How should I fixate the subscapularis in total shoulder arthroplasty? A systematic review of pertinent subscapularis repair biomechanics

BACKGROUND

The present study aimed to review the biomechanical outcomes of subscapularis repair techniques during total shoulder arthroplasty (TSA) to assist in clinical decision making.

METHODS

A systematic review of multiple databases was performed by searching PubMed, Scopus, Cochrane Library, Google Scholar, and all databases within EBSCOhost to find biomechanical studies of subscapularis repair techniques in cadaveric models of TSA.

RESULTS

Nine studies met the inclusion criteria. In the majority of studies, lesser tuberosity osteotomy (LTO) techniques had greater load to failure and less cyclic displacement compared to subscapularis tenotomy or peel methods. LTO repairs with sutures wrapped around the humeral stem demonstrated superior biomechanical outcomes compared to techniques using only a tension band. In terms of load to failure, the strongest repair of any study was a dual-row fleck LTO using four sutures wrapped around the stem.

CONCLUSIONS

Several cadaveric studies have shown superior biomechanical outcomes with LTO techniques compared to tenotomy. In the majority of studies, the strongest subscapularis repair technique in terms of biomechanical outcomes is a compression LTO. Using three or more sutures wrapped around the implant and the addition of a tension suture may increase the biomechanical strength of the LTO repair.

Management of the subscapularis tendon during total shoulder arthroplasty

Use of total shoulder arthroplasty has significantly increased during the past decade. For anatomic total shoulder arthroplasty, controversy exists regarding the best technique for detachment and repair of the subscapularis tendon. Options include tendon tenotomy, peel, lesser tuberosity osteotomy, and even subscapularis-sparing techniques. Inadequate healing of the subscapularis tendon can lead to postoperative pain, weakness, and instability. This review discusses the subscapularis pathoanatomy, different techniques for releasing and repairing the tendon, and reports biomechanical and clinical outcomes for each technique after total shoulder arthroplasty.

Immediate versus delayed passive range of motion following total shoulder arthroplasty

BACKGROUND

The goal of this study was to compare immediate with delayed range of motion (ROM) following total shoulder arthroplasty (TSA). The hypothesis was that ROM gains would occur earlier with immediate motion but that there would be no difference in ultimate ROM or functional outcome.

METHODS

Sixty patients were randomized to immediate motion (IM) or delayed motion (DM) following TSA. A lesser tuberosity osteotomy was performed in all cases. ROM and functional outcome were compared at 4 weeks, 8 weeks, 3 months, 6 months, and 1 year postoperatively.

RESULTS

Compared with preoperative values, in the IM group, forward flexion improved from 106° to 141° at 1 year postoperatively, external rotation improved from 21° to 65°, and internal rotation improved by 2 spinal levels (P < .05). In the DM group, forward flexion improved from 104° to 144°, external rotation improved from 20° to 53°, and internal rotation improved by 4 spinal levels (P < .05). The 2 groups regained motion differently, but there were no significant differences in final ROM or functional outcome scores between the 2 groups. The IM group had higher functional outcome scores initially, but by 3 months postoperatively, there was no difference. The rate of osteotomy healing was 81% in the IM group compared with 96% in the DM group (P = .101).

CONCLUSION

Immediate ROM provides a more rapid return of function compared with a delayed ROM protocol following TSA. However, there are no differences in ultimate ROM or functional outcome between the 2 groups. Moreover, immediate ROM may lower the healing rate of a lesser tuberosity osteotomy.

Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty

BACKGROUND

Lesser tuberosity osteotomy (LTO) as an approach during total shoulder arthroplasty (TSA) is a reliable technique with strong biomechanical fixation and a low failure rate. Complications have been infrequently reported in the literature.

METHODS

We report a case series of 5 patients who sustained failure of the LTO repair after primary TSA. The data on the patient demographic characteristics, surgical technique, postoperative care, revision surgery, and clinical outcomes are reported.

RESULTS

The mean age of the 5 patients was 52 years, all patients were men, and the mean body mass index was 28 kg/m(2). They were followed up for a mean of 29 months (range, 24-38 months). The mean time from initial TSA to diagnosis of LTO failure was 9 weeks (range, 5-12 weeks). Two patients reported no trauma, 2 had minor trauma (using a pulley, rolling over in bed), and 1 sustained a fall. At the latest follow-up, the mean visual analog scale; Single Assessment Numeric Evaluation; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 4 (range, 0-6), 48 (range, 20-70), 19 (range, 11-22), and 63 (range, 48-83), respectively. 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.

CONCLUSION

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. In patients with a high risk of LTO failure, considerations should be made to augment the LTO repair during the index TSA procedure.

Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures

BACKGROUND

The optimal method-subscapularis peel (SP) or lesser tuberosity osteotomy (LTO)-for takedown of the subscapularis during total shoulder arthroplasty (TSA) is controversial. This study compares the functional outcomes in a 2-surgeon cohort using the 2 techniques.

METHODS

Patients who underwent TSA with a minimum 1 year of follow-up were evaluated. Physical and ultrasound examinations of the operative shoulder were performed. Radiographs were evaluated for osteotomy healing. Patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, Disability of the Arm, Shoulder, and Hand (DASH), and Constant Scores.

RESULTS

Subscapularis tenotomy (n = 32) and LTO (n = 28) patients were similar in age, hand dominance, and sex. Follow-up duration for subscapularis tenotomy and LTO patients differed (31.7 vs 22.1 months, P = .003). SP patients demonstrated increased external rotation (69° ± 12° vs 60° ± 11°). Belly press and bear hug resistance were not significantly different. WOOS (P = .13), DASH (P = .71), and Constant Scores (P = .80) were not significantly different. After controlling for follow-up imbalance, the WOOS score difference was statistically significant (91.5 ± 10.2 for LTO vs 82.1 ± 18.9 for SP, P = .05) but not clinically significant. By ultrasonography assessment, 4 subscapularis tendons were abnormal in the SP group (3 attenuated, 1 ruptured), and all tendons were normal in the LTO group. Patients with an abnormal ultrasound result had significantly inferior WOOS (88 ± 15 vs 65 ± 18) and DASH (11.5 ± 11.4 vs 25.9 ± 11.2) scores. Belly press resistance was significantly decreased, bear hug resistance trended lower, and external rotation was increased in the abnormal ultrasound group.

CONCLUSIONS

Abnormal subscapularis tendons identified by ultrasonography only in the SP group correlate with clinically significant inferior functional outcome scores.

Biomechanical testing of small versus large lesser tuberosity osteotomies: effect on gap formation and ultimate failure load

BACKGROUND

Subscapularis muscle dysfunction after total shoulder arthroplasty (TSA) can be a devastating complication. Recent biomechanical and clinical results suggest the superiority of lesser tuberosity osteotomy (LTO) over subscapularis tenotomy; however, disagreement over the best repair technique remains. This study aimed to characterize the strength of 2 novel repair techniques for LTO fixation compared with standard tenotomy and dual-row tuberosity osteotomies during TSA.

METHODS

Twenty fresh frozen cadaveric shoulders were dissected of all soft tissues except the humeri and attached subscapularis myotendinous unit. Humeri and subscapularis muscle belly were secured to a materials testing frame and subjected to cyclic loading, followed by load to failure for characterization of gap formation, ultimate failure load, and mechanism of failure. Repair techniques investigated were traditional subscapularis tenotomy and dual-row fleck LTO compared with novel techniques of single-cable and 2-suture large LTO repairs.

RESULTS

No significant difference in ultimate failure load was noted among the repair techniques (P = .565). The tenotomy repair (6.0 ± 3.9 mm) displayed significantly greater gapping in response to increasing load than LTO repair techniques (P < .05). No significant difference was noted between any LTO repairs at specific loads during cyclic testing (P > .05).

CONCLUSION

Our study displayed superior repair integrity of LTO vs tenotomy repairs. The advantages of the 2-suture large LTO technique over other LTO techniques include its simple technique, with a minimum amount of suture, avoidance of metallic hardware, and greater access to the glenoid, while providing comparable repair stability. Further research is warranted to fully evaluate these new techniques.