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

The American Journal of Orthopedics. 2017 March;46(2):E131-E138
March 30, 2017 | The American Journal of Orthopedics
Philip K. Louie, MD ; David M. Levy, MD ; Bernard R. Bach Jr, MD ; Gregory P. Nicholson, MD ; Anthony A. Romeo, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Bach reports that he has received research support from Arthrex, Conmed Linvatec, DJ Orthopaedics, Ossur, Slack, Smith & Nephew, and Tornier. Dr. Nicholson reports that he has received publishing royalties and financial or material support from Slack, intellectual property royalties from Innomed, research support and consultant fees from Tornier, and stock or stock options from Zimmer Biomet. Dr. Romeo reports that he
has received research support from Arthrex, DJO Surgical, Ossur, and Smith & Nephew; consultant, presenter, or speaker fees from Arthrex; and royalties or other financial or material support from Arthrex and Slack. The other authors report no actual or potential conflict of interest in relation to this article.

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), which avoids subscapularis complications, has gained in popularity. We 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. Both approaches (ST, LTO) produced excellent outcomes. ST may result in wider range of motion and fewer revisions, but more studies are needed to further evaluate these results.

Conclusion

Our systematic review found similar Constant scores, pain scores, radiographic outcomes, and complication rates for the ST and LTO approaches. Compared with the LTO approach, the ST approach produced significantly more forward elevation improvement and trended toward more external rotation and abduction and fewer revisions. Although not definitive, these data suggest the ST approach may provide more stability over the long term, but additional comprehensive studies are needed to increase the sample size and the power of the trends elucidated in this review. According to the orthopedic literature, both techniques produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.

Am J Orthop. 2017;46(2):E131-E138. Copyright Frontline Medical Communications Inc. 2017. All rights reserved.

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