LTO vs. Tenotomy During TSA for Primary Osteoarthritis

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The shoulder anterior approach is commonly used by surgeons in total shoulder arthroplasty (TSA). This approach aided in the mobilization of the subscapularis tendon. Subscapularis tenotomy (ST) was the standard method for mobilizing the subscapularis during (TSA). While this method yielded excellent results, there were high rates of subscapularis dysfunction, which lead to less functionality and loss of internal rotation. Many of the high rates are attributed to surgical history, poor healing, aggressive therapy, poor tendon quality and complications related to surgical techniques.

Lesser tuberosity osteotomy (LTO) was thought to combat the concerns related to performing a TSA using ST, including poor tendon and tendon healing. Initial analyses of LTO showed an increased fixation strength and a higher load to failure with bone to bone repair, which originally was hypothesized to increase repair strength and decrease subscapularis dysfunction. However, recent studies have not yielded superior results for LTO. No differences were found in repair strength between ST and LTO. Columbia Orthopedic providers William N. Levine, MD, Christopher S. Ahmad, MD, and emeritus professor Louis U. Bigliani, MD set out to determine if ST or LTO provided better clinical results by creating the first randomized controlled trial comparing the two techniques. The study titled “Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial,” hypothesized that LTO would decrease subscapularis dysfunction and increase healing rates while maintaining similar clinical outcomes and operative time when compared with ST.

“While exceptional clinical results are achieved with TSA, complications associated with post-operative subscapularis dysfunction remain a concern. These failures can lead to painful shoulder instability and decreased strength,” stated Dr. Levine. “Our study sought to determine the best technique for subscapularis management in TSA by creating the first randomized controlled trial comparing ST and LTO.”

The study, published in the Journal of Shoulder and Elbow Surgery, enrolled 60 shoulders in 59 patients who had primary osteoarthritis. Thirty shoulders were randomized to either ST or LTO before surgery. Data, such as ultrasounds, ST/LTO repair time and osteotomy thickness, was collected before surgery as well as at 6-week, 3-month, 6-month, and 1-year after surgery. Results from the study showed no significant differences in range of motion or clinical outcomes for ST and LTO with LTO healing being more reliable than ST.

“Our research concluded that both techniques produced successful subjective and objective results; while LTO provides a greater consistency in subscapularis healing than ST this did not lead to differing clinical outcomes,” said Dr. Levine.

Read the full article here.