Clinical Review

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

Am J Orthop. 2017 March;46(2):E131-E138

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.

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References

1. Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Joint Surg Br. 1993;75(1):137-140.

2. Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am. 2005;87(suppl 2):1-8.

3. Miller SL, Hazrati Y, Klepps S, Chiang A, Flatow EL. Loss of subscapularis function after total shoulder replacement: a seldom recognized problem. J Shoulder Elbow Surg. 2003;12(1):29-34.

4. Gerber A, Ghalambor N, Warner JJ. Instability of shoulder arthroplasty: balancing mobility and stability. Orthop Clin North Am. 2001;32(4):661-670, ix.

5. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM. Instability of the shoulder after arthroplasty. J Bone Joint Surg Am. 1993;75(4):492-497.

6. Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Subscapularis muscle function and structure after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am. 2005;87(8):1739-1745.

7. Van den Berghe GR, Nguyen B, Patil S, et al. A biomechanical evaluation of three surgical techniques for subscapularis repair. J Shoulder Elbow Surg. 2008;17(1):156-161.

8. Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009;18(2):193-196.

9. Armstrong A, Lashgari C, Teefey S, Menendez J, Yamaguchi K, Galatz LM. Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty. J Shoulder Elbow Surg. 2006;15(5):541-548.

10. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.

11. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.

12. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. 2010;92(12):2220-2233.

13. Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation—a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791.

14. Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg. 2014;23(9):1309-1317.

15. Scalise JJ, Ciccone J, Iannotti JP. Clinical, radiographic, and ultrasonographic comparison of subscapularis tenotomy and lesser tuberosity osteotomy for total shoulder arthroplasty. J Bone Joint Surg Am. 2010;92(7):1627-1634.

16. Jandhyala S, Unnithan A, Hughes S, Hong T. Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replacement: a comparison of patient outcomes. J Shoulder Elbow Surg. 2011;20(7):1102-1107.

17. Fucentese SF, Costouros JG, Kühnel SP, Gerber C. Total shoulder arthroplasty with an uncemented soft-metal-backed glenoid component. J Shoulder Elbow Surg. 2010;19(4):624-631.

18. Clement ND, Duckworth AD, Colling RC, Stirrat AN. An uncemented metal-backed glenoid component in total shoulder arthroplasty for osteoarthritis: factors affecting survival and outcome. J Orthop Sci. 2013;18(1):22-28.

19. Rosenberg N, Neumann L, Modi A, Mersich IJ, Wallace AW. Improvements in survival of the uncemented Nottingham Total Shoulder prosthesis: a prospective comparative study. BMC Musculoskelet Disord. 2007;8(1):76.

20. Small KM, Siegel EJ, Miller LR, Higgins LD. Imaging characteristics of lesser tuberosity osteotomy after total shoulder replacement: a study of 220 patients. J Shoulder Elbow Surg. 2014;23(9):1318-1326.

21. Mileti J, Sperling JW, Cofield RH, Harrington JR, Hoskin TL. Monoblock and modular total shoulder arthroplasty for osteoarthritis. J Bone Joint Surg Br. 2005;87(4):496-500.

22. Merolla G, Paladini P, Campi F, Porcellini G. Efficacy of anatomical prostheses in primary glenohumeral osteoarthritis. Chir Organi Mov. 2008;91(2):109-115.

23. Jackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(7):1085-1090.

24. Jost PW, Dines JS, Griffith MH, Angel M, Altchek DW, Dines DM. Total shoulder arthroplasty utilizing mini-stem humeral components: technique and short-term results. HSS J. 2011;7(3):213-217.

25. Razmjou H, Holtby R, Christakis M, Axelrod T, Richards R. Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study. J Shoulder Elbow Surg. 2013;22(2):206-214.

26. Raiss P, Schmitt M, Bruckner T, et al. Results of cemented total shoulder replacement with a minimum follow-up of ten years. J Bone Joint Surg Am. 2012;94(23):e1711-1710.

27. Litchfied RB, McKee MD, Balyk R, et al. Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial—a JOINTs Canada Project. J Shoulder Elbow Surg. 2011;20(4):529-536.

28. Martin SD, Zurakowski D, Thornhill TS. Uncemented glenoid component in total shoulder arthroplasty. Survivorship and outcomes. J Bone Joint Surg Am. 2005;87(6):1284-1292.

29. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008;90(10):2180-2188.

30. Budge MD, Nolan EM, Heisey MH, Baker K, Wiater JM. Results of total shoulder arthroplasty with a monoblock porous tantalum glenoid component: a prospective minimum 2-year follow-up study. J Shoulder Elbow Surg. 2013;22(4):535-541.

31. Gerber C, Costouros JG, Sukthankar A, Fucentese SF. Static posterior humeral head subluxation and total shoulder arthroplasty. J Shoulder Elbow Surg. 2009;18(4):505-510.

32. Giuseffi SA, Wongtriratanachai P, Omae H, et al. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg. 2012;21(8):1087-1095.

33. Van Thiel GS, Wang VM, Wang FC, et al. Biomechanical similarities among subscapularis repairs after shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(5):657-663.

34. Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS. Comparison of lesser tuberosity osteotomy to subscapularis peel in shoulder arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2012;94(24):2239-2246.

35. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am. 1984;66(6):899-906.

36. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg. 1997;6(6):495-505.

Take-Home Points

According to the orthopedic literature, ST and LTO for a TSA produce excellent clinical outcomes, and technique selection should be based on surgeon discretion and expertise.
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.
ST and LTO approaches for a TSA result in similar Constant scores, pain scores, radiographic outcomes, and complication rates.

During total shoulder arthroplasty (TSA) exposure, the subscapularis muscle must be mobilized; its repair is crucial to the stability of the arthroplasty. The subscapularis is the largest rotator cuff muscle and has a contractile force equal to that of the other 3 muscles combined.^1,2 Traditionally it is mobilized with a tenotomy just medial to the tendon’s insertion onto the lesser tuberosity. Over the past 15 years, however, numerous authors have reported dysfunction after subscapularis tenotomy (ST). In 2003, Miller and colleagues³ reported that, at 2-year follow-up, almost 70% of patients had abnormal belly-press and liftoff tests, surrogate markers of subscapularis function. Other authors have found increased rates of anterior instability after subscapularis rupture.^4,5

In 2005, Gerber and colleagues⁶ introduced a technique for circumventing surgical division of the subscapularis. They described a lesser tuberosity osteotomy (LTO), in which the subscapularis tendon is detached with a bone fragment 5 mm to 10 mm in thickness and 3 cm to 4 cm in length. This approach was based on the premise that bone-to-bone healing is more reliable than tendon-to-tendon healing. Initial studies reported successful osteotomy healing, improved clinical outcome scores, and fewer abnormalities with belly-press and liftoff tests.^2,6 More recent literature, however, has questioned the necessity of LTO.^2,4,7-9We performed a systematic review to evaluate the literature, describe ST and LTO, and summarize the radiographic and clinical outcomes of both techniques. We hypothesized there would be no significant clinical differences between these approaches.

Methods

Search Strategy and Study Selection

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically reviewed the literature.¹⁰ Searches were completed in September 2014 using the PubMed Medline database and the Cochrane Central Register of Clinical Trials. Two reviewers (Dr. Louie, Dr. Levy) independently performed the search and assessed eligibility of all relevant studies based on predetermined inclusion criteria. Disagreements between reviewers were resolved by discussion. Key word selection was designed to capture all English-language studies with clinical and/or radiographic outcomes and level I to IV evidence. We used an electronic search algorithm with key words and a series of NOT phrases to match certain exclusion criteria:

(((((((((((((((((((((((((((((((((((((total[Text Word]) AND shoulder[Title]) AND arthroplasty[Title] AND (English[lang]))) NOT reverse[Title/Abstract]) NOT hemiarthroplasty[Title]) NOT nonoperative[Title]) NOT nonsurgical[Title] AND (English[lang]))) NOT rheumatoid[Title/Abstract]) NOT inflammatory[Title/Abstract]) NOT elbow[Title/Abstract]) NOT wrist[Title/Abstract]) NOT hip[Title/Abstract]) NOT knee[Title/Abstract]) NOT ankle[Title/Abstract] AND (English[lang]))) NOT biomechanic[Title/Abstract]) NOT biomechanics[Title/Abstract]) NOT biomechanical [Title/Abstract]) NOT cadaveric[Title/Abstract]) NOT revision[Title]) NOT resurfacing[Title/Abstract]) NOT surface[Title/Abstract]) NOT interphalangeal[Title/Abstract] AND (English[lang]))) NOT radiostereometric[Title/Abstract] AND (English[lang]))) NOT cmc[Title/Abstract]) NOT carpometacarpal[Title/Abstract]) NOT cervical[Title/Abstract]) NOT histology[Title/Abstract]) NOT histological[Title/Abstract]) NOT collagen[Title/Abstract] AND (English[lang]))) NOT kinematic[Title/Abstract]) NOT kinematics[Title/Abstract] AND (English[lang]))) NOT vitro[Title/Abstract] AND (English[lang]))) NOT inverted[Title/Abstract]) NOT grammont[Title/Abstract]) NOT arthrodesis[Title/Abstract]) NOT fusion[Title/Abstract]) NOT reverse[Title/Abstract] AND (English[lang]))

Study exclusion criteria consisted of cadaveric, biomechanical, histologic, and kinematic results as well as analyses of nonoperative management, hemiarthroplasty, or reverse TSA. Studies were excluded if they did not report clinical and/or radiographic data. Minimum mean follow-up was 2 years. To discount the effect of other TSA technical innovations, we evaluated the same period for the 2 surgical approaches. The first study with clinical outcomes after LTO was published in early 2005,⁶ so all studies published before 2005 were excluded.

We reviewed all references within the studies included by the initial search algorithm: randomized control trials, retrospective and prospective cohort designs, case series, and treatment studies. Technical notes, review papers, letters to the editor, and level V evidence reviews were excluded. To avoid counting patients twice, we compared each study’s authors and data collection period with those of the other studies. If there was overlap in authorship, period, and place, only the study with the longer follow-up or more comprehensive data was included. All trials comparing ST and LTO were included. If the authors of a TSA study did not describe the approach used, that study was excluded from our review.

Data Extraction

We collected details of study design, sample size, and patient demographics (sex, age, hand dominance, primary diagnosis). We also abstracted surgical factors about the glenoid component (cemented vs uncemented; pegged vs keeled; all-polyethylene vs metal-backed) and the humeral component (cemented vs press-fit; stemmed vs stemless). Clinical outcomes included pain scores, functional scores, number of revisions, range of motion (ROM), and subscapularis-specific tests (eg, belly-press, liftoff). As pain scales varied between studies, all values were converted to a 10-point scoring scale (0 = no pain; 10 = maximum pain) for comparisons. Numerous functional outcome scores were reported, but the Constant score was the only one consistently used across studies, making it a good choice for comparisons. One study used Penn Shoulder Scores (PSSs) and directly compared ST and LTO groups, so its data were included. In addition, radiographic data were compiled: radiolucencies around the humeral stem and glenoid component, humeral head subluxation/migration, and osteotomy healing. The only consistent radiographic parameter available for comparisons between groups was the presence of radiolucencies.

References

1. Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Joint Surg Br. 1993;75(1):137-140.

2. Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am. 2005;87(suppl 2):1-8.

3. Miller SL, Hazrati Y, Klepps S, Chiang A, Flatow EL. Loss of subscapularis function after total shoulder replacement: a seldom recognized problem. J Shoulder Elbow Surg. 2003;12(1):29-34.

4. Gerber A, Ghalambor N, Warner JJ. Instability of shoulder arthroplasty: balancing mobility and stability. Orthop Clin North Am. 2001;32(4):661-670, ix.

5. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM. Instability of the shoulder after arthroplasty. J Bone Joint Surg Am. 1993;75(4):492-497.

6. Gerber C, Yian EH, Pfirrmann CA, Zumstein MA, Werner CM. Subscapularis muscle function and structure after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am. 2005;87(8):1739-1745.

7. Van den Berghe GR, Nguyen B, Patil S, et al. A biomechanical evaluation of three surgical techniques for subscapularis repair. J Shoulder Elbow Surg. 2008;17(1):156-161.

8. Caplan JL, Whitfield B, Neviaser RJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg. 2009;18(2):193-196.

9. Armstrong A, Lashgari C, Teefey S, Menendez J, Yamaguchi K, Galatz LM. Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty. J Shoulder Elbow Surg. 2006;15(5):541-548.

10. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. Int J Surg. 2010;8(5):336-341.

11. Cowan J, Lozano-Calderón S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.

12. Harris JD, Siston RA, Pan X, Flanigan DC. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. 2010;92(12):2220-2233.

13. Harris JD, Siston RA, Brophy RH, Lattermann C, Carey JL, Flanigan DC. Failures, re-operations, and complications after autologous chondrocyte implantation—a systematic review. Osteoarthritis Cartilage. 2011;19(7):779-791.

14. Buckley T, Miller R, Nicandri G, Lewis R, Voloshin I. Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg. 2014;23(9):1309-1317.

15. Scalise JJ, Ciccone J, Iannotti JP. Clinical, radiographic, and ultrasonographic comparison of subscapularis tenotomy and lesser tuberosity osteotomy for total shoulder arthroplasty. J Bone Joint Surg Am. 2010;92(7):1627-1634.

16. Jandhyala S, Unnithan A, Hughes S, Hong T. Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replacement: a comparison of patient outcomes. J Shoulder Elbow Surg. 2011;20(7):1102-1107.

17. Fucentese SF, Costouros JG, Kühnel SP, Gerber C. Total shoulder arthroplasty with an uncemented soft-metal-backed glenoid component. J Shoulder Elbow Surg. 2010;19(4):624-631.

18. Clement ND, Duckworth AD, Colling RC, Stirrat AN. An uncemented metal-backed glenoid component in total shoulder arthroplasty for osteoarthritis: factors affecting survival and outcome. J Orthop Sci. 2013;18(1):22-28.

19. Rosenberg N, Neumann L, Modi A, Mersich IJ, Wallace AW. Improvements in survival of the uncemented Nottingham Total Shoulder prosthesis: a prospective comparative study. BMC Musculoskelet Disord. 2007;8(1):76.

20. Small KM, Siegel EJ, Miller LR, Higgins LD. Imaging characteristics of lesser tuberosity osteotomy after total shoulder replacement: a study of 220 patients. J Shoulder Elbow Surg. 2014;23(9):1318-1326.

21. Mileti J, Sperling JW, Cofield RH, Harrington JR, Hoskin TL. Monoblock and modular total shoulder arthroplasty for osteoarthritis. J Bone Joint Surg Br. 2005;87(4):496-500.

22. Merolla G, Paladini P, Campi F, Porcellini G. Efficacy of anatomical prostheses in primary glenohumeral osteoarthritis. Chir Organi Mov. 2008;91(2):109-115.

23. Jackson JD, Cil A, Smith J, Steinmann SP. Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(7):1085-1090.

24. Jost PW, Dines JS, Griffith MH, Angel M, Altchek DW, Dines DM. Total shoulder arthroplasty utilizing mini-stem humeral components: technique and short-term results. HSS J. 2011;7(3):213-217.

25. Razmjou H, Holtby R, Christakis M, Axelrod T, Richards R. Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study. J Shoulder Elbow Surg. 2013;22(2):206-214.

26. Raiss P, Schmitt M, Bruckner T, et al. Results of cemented total shoulder replacement with a minimum follow-up of ten years. J Bone Joint Surg Am. 2012;94(23):e1711-1710.

27. Litchfied RB, McKee MD, Balyk R, et al. Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial—a JOINTs Canada Project. J Shoulder Elbow Surg. 2011;20(4):529-536.

28. Martin SD, Zurakowski D, Thornhill TS. Uncemented glenoid component in total shoulder arthroplasty. Survivorship and outcomes. J Bone Joint Surg Am. 2005;87(6):1284-1292.

29. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH. Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component. Medium to long-term results. J Bone Joint Surg Am. 2008;90(10):2180-2188.

30. Budge MD, Nolan EM, Heisey MH, Baker K, Wiater JM. Results of total shoulder arthroplasty with a monoblock porous tantalum glenoid component: a prospective minimum 2-year follow-up study. J Shoulder Elbow Surg. 2013;22(4):535-541.

31. Gerber C, Costouros JG, Sukthankar A, Fucentese SF. Static posterior humeral head subluxation and total shoulder arthroplasty. J Shoulder Elbow Surg. 2009;18(4):505-510.

32. Giuseffi SA, Wongtriratanachai P, Omae H, et al. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg. 2012;21(8):1087-1095.

33. Van Thiel GS, Wang VM, Wang FC, et al. Biomechanical similarities among subscapularis repairs after shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(5):657-663.

34. Lapner PL, Sabri E, Rakhra K, Bell K, Athwal GS. Comparison of lesser tuberosity osteotomy to subscapularis peel in shoulder arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2012;94(24):2239-2246.

35. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am. 1984;66(6):899-906.

36. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg. 1997;6(6):495-505.

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

References

Take-Home Points

Methods

Search Strategy and Study Selection

Data Extraction

Pages

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