Subscapularis Management in Total Shoulder Arthroplasty: Current Evidence Comparing Peel, Osteotomy, and Tenotomy

The optimal approach to management of the subscapularis in total shoulder arthroplasty (TSA) is controversial. Options include the subscapularis tenotomy, lesser tuberosity osteotomy (LTO), and peel. This review provides a summary of subscapularis anatomy and function, outcomes associated with subscapularis management options in TSA, and postoperative subscapularis deficiency. Based on the available literature, LTO appears to result in improved function and subscapularis integrity relative to tenotomy, while peel and LTO have generally led to equivalent outcomes. The highest level of evidence to date is derived from a randomized controlled trial that demonstrated that outcomes following peel and LTO were not significantly different. There is currently a paucity of high-quality evidence as most studies have consisted of small retrospective series with varying outcome measures. Furthermore, the optimal approach to establishing the diagnosis of subscapularis deficiency following TSA is unclear.

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Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial

Journal of Shoulder and Elbow Surgery ◽

10.1016/j.jse.2018.11.057 ◽

2019 ◽

Vol 28 (3) ◽

pp. 407-414 ◽

Cited By ~ 14

Author(s):

William N. Levine ◽

Julianne Munoz ◽

Stephanie Hsu ◽

Ian R. Byram ◽

Louis U. Bigliani ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Shoulder Arthroplasty ◽

Controlled Trial ◽

Total Shoulder Arthroplasty ◽

Lesser Tuberosity ◽

Randomized Controlled ◽

Primary Osteoarthritis ◽

Prospective Randomized Controlled Trial ◽

Subscapularis Tenotomy

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

Journal of Shoulder and Elbow Surgery ◽

10.1016/j.jse.2013.12.009 ◽

2014 ◽

Vol 23 (9) ◽

pp. 1309-1317 ◽

Cited By ~ 57

Author(s):

Taylor Buckley ◽

Richard Miller ◽

Gregg Nicandri ◽

Richard Lewis ◽

Ilya Voloshin

Keyword(s):

Clinical Outcome ◽

Outcome Measures ◽

Shoulder Arthroplasty ◽

Total Shoulder Arthroplasty ◽

Lesser Tuberosity ◽

And Function ◽

Subscapularis Tenotomy

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Stress shielding following stemless anatomic total shoulder arthroplasty

Shoulder & Elbow ◽

10.1177/17585732211058804 ◽

2021 ◽

pp. 175857322110588

Author(s):

William R Aibinder ◽

Fares Uddin ◽

Ryan T Bicknell ◽

Ryan Krupp ◽

Markus Scheibel ◽

...

Keyword(s):

Shoulder Arthroplasty ◽

Functional Outcomes ◽

Total Shoulder Arthroplasty ◽

Case Series ◽

Stress Shielding ◽

Implant Design ◽

Level Of Evidence ◽

Lesser Tuberosity ◽

Significant Difference

Background Finite element analysis has suggested that stemless implants may theoretically decrease stress shielding. The purpose of this study was to assess the radiographic proximal humeral bone adaptations seen following stemless anatomic total shoulder arthroplasty. Methods A retrospective review of 152 prospectively followed stemless total shoulder arthroplasty utilizing a single implant design was performed. Anteroposterior and lateral radiographs were reviewed at standard time points. Stress shielding was graded as mild, moderate, and severe. The effect of stress shielding on clinical and functional outcomes was assessed. Also, the influence of subscapularis management on the occurrence of stress shielding was determined. Results At 2 years postoperatively, stress shielding was noted in 61 (41%) shoulders. A total of 11 (7%) shoulders demonstrated severe stress shielding with 6 occurring along the medial calcar. There was one instance of greater tuberosity resorption. At the final follow-up, no humeral implants were radiographically loose or migrated. There was no statistically significant difference in clinical and functional outcomes between shoulders with and without stress shielding. Patients undergoing a lesser tuberosity osteotomy had lower rates of stress shielding, which was statistically significant ( p = 0.021) Discussion Stress shielding does occur at higher rates than anticipated following stemless total shoulder arthroplasty, but was not associated with implant migration or failure at 2 years follow-up. Level of evidence IV, Case series.

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Analysis of Subscapularis Integrity and Function After Lesser Tuberosity Osteotomy Vs. Subscapularis Tenotomy in Total Shoulder Arthroplasty Using Ultrasound and Validated Clinical Outcome Measures

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2013.07.203 ◽

2013 ◽

Vol 29 (10) ◽

pp. e153-e154

Author(s):

Taylor Joseph Buckley ◽

Richard Miller ◽

Richard Lewis ◽

Ilya Voloshin

Keyword(s):

Clinical Outcome ◽

Outcome Measures ◽

Shoulder Arthroplasty ◽

Total Shoulder Arthroplasty ◽

Lesser Tuberosity ◽

And Function ◽

Subscapularis Tenotomy

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Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty

Journal of Shoulder and Elbow Arthroplasty ◽

10.1177/2471549218807777 ◽

2018 ◽

Vol 2 ◽

pp. 247154921880777

Author(s):

Zachary J Bloom ◽

Cesar D Lopez, BA ◽

Stephen P Maier ◽

Brian B Shiu ◽

Djuro Petkovic ◽

...

Keyword(s):

Treatment Outcomes ◽

Shoulder Arthroplasty ◽

Surgical Repair ◽

Total Shoulder Arthroplasty ◽

Case Series ◽

Radiographic Evaluation ◽

Lesser Tuberosity ◽

Conservative Care ◽

Conservative Group

Introduction Lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate. Treatment for LTO nonunion is controversial and poorly described in the literature. The purpose of this study was to compare the surgical and nonsurgical treatment outcomes of LTO nonunion. Methods A retrospective case series of 9 consecutive patients with LTO nonunion after primary anatomic shoulder arthroplasty at 1 institution from 2010 to 2016 were studied. Outcomes measured were radiographic evaluation of LTO on axillary X-ray, clinical range of motion (ROM), subscapularis strength, and pain at the time of LTO nonunion diagnosis and after either conservative care or surgical repair of the LTO nonunion. Results LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. There were no significant differences in age, sex, or smoking status between groups. Treatment decision was a shared model of surgeon and patient. 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. Only 1 patient with LTO nonunion required conversion to reverse replacement. Conclusion LTO nonunion after shoulder arthroplasty is rare. Surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

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Anatomic Total Shoulder Arthroplasty With a Stemless Humeral Component

Video Journal of Sports Medicine ◽

10.1177/2635025421997126 ◽

2021 ◽

Vol 1 (3) ◽

pp. 263502542199712

Author(s):

Jordan D. Walters ◽

Stephen F. Brockmeier

Keyword(s):

Bone Quality ◽

Shoulder Arthroplasty ◽

Total Shoulder Arthroplasty ◽

Complication Rates ◽

Lesser Tuberosity ◽

Critical Elements ◽

Implant Placement ◽

Humeral Component ◽

Component Loosening ◽

Deltopectoral Approach

Background: This technique video reviews anatomic total shoulder arthroplasty (TSA) with a stemless humeral component using a representative case example. Indications: Stemless TSA is indicated for patients with symptomatic glenohumeral arthritis typically younger than 65 years of age. Stemless TSA may be used for other glenohumeral degenerative conditions such as avascular necrosis or posttraumatic arthropathy, provided acceptable humeral bone quality is confirmed intraoperatively using a thumb-press test. Poor bone quality is the primary contraindication. Technique Description: Preoperatively, computed tomography is typically used for planning, and intraoperative navigation through magnetic resonance imaging is also useful. The procedure’s critical elements include beach chair positioning, standard deltopectoral approach with lesser tuberosity osteotomy (LTO), freehand proximal humeral osteotomy, perpendicular proximal humeral exposure and subsequent preparation over a central guidewire, stemless implant and humeral head sizing, perpendicular glenoid exposure and implant placement, and final humeral implantation with LTO repair/fixation. A phased rehabilitation protocol includes 6-week sling immobilization to protect the subscapularis/LTO repair and return to normal activities between 3 and 6 months postoperatively. Discussion/Conclusion: Stemless TSA shows promising early and mid-term outcomes with complication rates, including humeral loosening rates, similar to standard stemmed components. Potential complications include neurovascular injury, infection, glenoid or humeral component loosening, and rotator cuff failure.

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Combined Hip Abductor and External Rotator Strengthening and Hip Internal Rotator Stretching Improves Pain and Function in Patients With Patellofemoral Pain Syndrome: A Randomized Controlled Trial With Crossover Design

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967121989729 ◽

2021 ◽

Vol 9 (4) ◽

pp. 232596712198972

Author(s):

Anis Jellad ◽

Amine Kalai ◽

Mohamed Guedria ◽

Mahbouba Jguirim ◽

Sana Elmhamdi ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Pain Syndrome ◽

Patellofemoral Pain Syndrome ◽

Patellofemoral Pain ◽

Level Of Evidence ◽

Randomized Controlled ◽

Group Standard ◽

Hip Muscle ◽

And Function

Background: Active rehabilitation has an important role in the management of patellofemoral pain syndrome (PFPS). Although some studies have shown the benefit of hip-muscle strengthening, the effect of combining hip-muscle stretching with strengthening has not yet been defined. Purpose: To evaluate the effect of combined strengthening of the hip external rotators and abductors and stretching of the hip internal rotators on pain and function in patients with PFPS. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 109 patients with PFPS (75 female and 34 male; mean age, 31.6 ± 10.8 years) were first randomly assigned to protocol A (n = 67) of the A-B arm (AB group; standard rehabilitation) or protocol B (n = 42) of the B-A arm (BA group; standard rehabilitation with strengthening of the hip external rotators and abductors and stretching of the hip internal rotators). Each protocol consisted of 3 sessions a week for 4 weeks. After a washout period, corresponding to a symptom-free period, rehabilitation programs were crossed over. A visual analog scale (VAS) evaluating perceived pain, the Functional Index Questionnaire (FIQ), and the Kujala score were administered at baseline, the end of each rehabilitation protocol, and 12 weeks after the completion of the second protocol for each group. Results: Until the final follow-up, VAS, FIQ, and Kujala scores were significantly improved in both the A-B and B-A arms ( P < .05 for all). Compared with protocol A, protocol B provided significant improvement in terms of pain and function in both the BA (VAS and Kujala; P < .001) and AB (VAS and Kujala; P < .001) groups. Conclusion: Combined strengthening of the hip abductors and external rotators with stretching of the hip internal rotators provided better outcomes, which were maintained for at least 12 weeks, in terms of pain and function in patients with PFPS.

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No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis

Shoulder & Elbow ◽

10.1177/17585732211060754 ◽

2021 ◽

pp. 175857322110607

Author(s):

Michelle Xiao ◽

Daniel M Curtis ◽

Emilie V Cheung ◽

Michael T Freehill ◽

Geoffrey D Abrams

Keyword(s):

Shoulder Arthroplasty ◽

Nearest Neighbor ◽

Total Shoulder Arthroplasty ◽

Opioid Use ◽

Therapeutic Level ◽

Level Of Evidence ◽

Opioid Prescription ◽

Significant Difference ◽

Outpatient Settings ◽

Baseline Demographic

Background The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naïve patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings. Methods A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naïve TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts. Results A total of 11,703 opioid naïve patients (mean age 72.5 ± 8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n = 1447 inpatients; n = 1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p < 0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p = 0.25). Conclusions Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts. Level of evidence Therapeutic Level III.

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Higher preoperative sensitivity to pain and pain at rest are associated with worse functional outcome after stemless total shoulder arthroplasty

The Bone & Joint Journal ◽

10.1302/0301-620x.100b4.bjj-2017-1000.r1 ◽

2018 ◽

Vol 100-B (4) ◽

pp. 480-484 ◽

Cited By ~ 4

Author(s):

B. Kadum ◽

C. Inngul ◽

R. Ihrman ◽

G. O. Sjödén ◽

A. S. Sayed-Noor

Keyword(s):

Shoulder Arthroplasty ◽

Pearson Correlation ◽

Total Shoulder Arthroplasty ◽

Linear Regression Analysis ◽

Short Version ◽

Preoperative Pain ◽

Postoperative Function ◽

Pain At Rest ◽

And Function ◽

Sensitivity To Pain

Aims The aims of this study were to investigate any possible relationship between a preoperative sensitivity to pain and the degree of pain at rest and on exertion with postoperative function in patients who underwent stemless total shoulder arthroplasty (TSA). Patients and Methods In this prospective study, we included 63 patients who underwent stemless TSA and were available for evaluation one year postoperatively. There were 31 women and 32 men; their mean age was 71 years (53 to 89). The pain threshold, which was measured using a Pain Matcher (PM) unit, the degree of pain (visual analogue scale at rest and on exertion, and function using the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), were recorded preoperatively, as well as three and 12 months postoperatively. Results We found an inverse relationship between both the preoperative PM threshold and pain (VAS) at rest and the 12-month postoperative QuickDASH score (Pearson correlation coefficient (r) ≥ 0.4, p < 0.05). A linear regression analysis showed that the preoperative PM threshold on the affected side and preoperative pain (VAS) at rest were the only factors associated with the QuickDASH score at 12 months. Conclusion These findings indicate the importance of central sensitization in the restoration of function after TSA. Further studies are required to investigate whether extra analgesia and rehabilitation could influence the outcome in at risk patients. Cite this article: Bone Joint J 2018;100-B:480–4.

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