Original Research

Radiographic Study of Humeral Stem in Shoulder Arthroplasty After Lesser Tuberosity Osteotomy or Subscapularis Tenotomy

Publish date: May 23, 2018

Robert Mason, MD

Taylor Buckley, MD

Richard Southgate, MD

Gregg Nicandri, MD

Richard Miller, MD

Ilya Voloshin, MD

TAKE-HOME POINTS

LTO and ST remain viable options for takedown of the subscapularis.
No difference exists in subsidence, lucent lines, and posterior subluxation on radiographic evaluation between LTO and ST.
No clinically significant difference exists between outcome scores of patients with either technique.
HAD was statistically significant but not clinically relevant between the 2 techniques.
Results from the study do not apply to metaphyseal fitting stems, only diaphyseal fitting stems.

References

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12. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasy. 1999;14(6):756-760.

13. Saupe N, Pfirmann CW, Schmid MR, et al. Association between rotator cuff abnormalities and reduced acromiohumeral distance. AJR Am J Roentgenol. 2006;187(2):376-382. doi:10.2214/AJR.05.0435.

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22. Lapner PLC, Sabri E, Rakhra K, Bell K, Athwal GS. Comparison of LTO to subscapularis peel in shoulder arthroplasty. J Bone Joint Surg Am. 2012;94(24):2239-2246. doi:10.2106/JBJS.K.01365.

ABSTRACT

Lesser tuberosity osteotomy (LTO) and subscapularis tenotomy (ST) are used for takedown of the subscapularis during shoulder arthroplasty. LTO offers the theoretical but unproven benefit of improved healing and function of the subscapularis. However, humeral stem subsidence and loosening may be greater when osteotomy is performed, which may compromise functional outcomes. Our hypothesis is that no difference in proximal collar press-fit humeral stem subsidence or loosening exists, with no impairment of functional outcomes using the LTO technique.

During the surgical approach for total shoulder arthroplasty (TSA), the subscapularis is taken down for adequate exposure to the glenohumeral joint. Various methods are available for taking down the subscapularis, including lesser tuberosity osteotomy (LTO) and a subscapularis tenotomy (ST). LTO offers the theoretical but unproven benefit of improved healing and function of the subscapularis secondary to bone-to-bone healing. One concern, however, is that humeral stem subsidence may be greater when an osteotomy is performed owing to compromise of metaphyseal cortical bone, which may compromise functional outcomes. The humeral stem design may also influence subsidence when metaphyseal bone proximally is compromised. This is a concern in both metaphyseal and diaphyseal fitting stems. Metaphyseal collars on diaphyseal fitting stems rely on adequate bone stock in the metaphysis to provide the additional support needed. Also, posterior subluxation remains a challenge in shoulder arthroplasty. The integrity of the subscapularis is important in prevention of posterior subluxation.¹ To our knowledge, no study to date has directly compared differences in humeral stem subsidence, loosening, or posterior subluxation between LTO and ST techniques with any humeral stem design. Our hypothesis is that no difference in proximal collar press-fit humeral stem subsidence or loosening exists, with no impairment of functional outcomes using the LTO technique. We also hypothesize that no difference in posterior subluxation exists between LTO and ST techniques.

MATERIALS AND METHODS

INCLUSION CRITERIA

Consecutive patients with a minimum of 12 months of radiographic follow-up were selected from 2007 to 2010 after TSA was performed by 1 of the senior authors (Dr. Miller and Dr. Voloshin). Study patients underwent primary TSA for primary osteoarthritis or rheumatoid arthritis.

EXCLUSION CRITERIA

Patients were excluded if they underwent TSA for posttraumatic glenohumeral arthritis, hemiarthroplasty, or osteonecrosis. Patients were also excluded if a rotator cuff tear was discovered intraoperatively or if they had a history of a rotator cuff repair. Additional exclusion criteria included postoperative trauma to the operative shoulder, postoperative infection, extensive documentation of chronic pain, and underlying neurologic disorder (eg, Parkinson disease, dystonia). Patients with a history of diabetes mellitus were not excluded.

SURGICAL TECHNIQUE

All patients underwent TSA via a deltopectoral approach in a modified beach chair position. Biceps tendons were tenodesed at the level of the pectoralis major. All patients received the same proximal collar press-fit implant (Bigliani-Flatow; Zimmer Biomet). These stems provide rotational stability in the metaphyseal segment via fins, vertical stability with the proximal collar, and distal fixation via an interference fit. All parts of the procedure were performed in similar fashion with the exception of ST vs LTO (Figures 1A-1D).

All patients followed the same postoperative rehabilitation protocol.

Continue to: LTO was performed as the primary...

References

1. Blasier R, Soslowsky L, Malicky D, Palmer M. Posterior glenohumeral subluxation: Active and passive stabilization in a biomechanical model. J Bone Joint Surg Am. 1997;79-A(3):433-440.

4. Sanchez-Sotelo J, Wright TW, O'Driscoll SW, Cofield RH, Rowland CM. Radiographic assessment of uncemented humeral components in total shoulder arthroplasty. J Arthroplasty. 2001;16(2):180-187.

10. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-164.

12. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasy. 1999;14(6):756-760.

13. Saupe N, Pfirmann CW, Schmid MR, et al. Association between rotator cuff abnormalities and reduced acromiohumeral distance. AJR Am J Roentgenol. 2006;187(2):376-382. doi:10.2214/AJR.05.0435.

22. Lapner PLC, Sabri E, Rakhra K, Bell K, Athwal GS. Comparison of LTO to subscapularis peel in shoulder arthroplasty. J Bone Joint Surg Am. 2012;94(24):2239-2246. doi:10.2106/JBJS.K.01365.

Radiographic Study of Humeral Stem in Shoulder Arthroplasty After Lesser Tuberosity Osteotomy or Subscapularis Tenotomy

TAKE-HOME POINTS

References

ABSTRACT

MATERIALS AND METHODS

INCLUSION CRITERIA

EXCLUSION CRITERIA

SURGICAL TECHNIQUE

Pages

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