Original Research

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

Publish date: May 23, 2018

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.

2. 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. doi:10.1016/j.jse.2013.12.009.

3. 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. doi:10.1016/j.jse.2009.03.003.

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.

5. Litchfield RB, McKee MD, Balyk R, et al. Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthrtitis of the shoulder: A prospective, randomized, double-blind clinical trial-A JOINTs Canada Project. J Shoulder Elbow Surg. 2013;20(4):529-536. doi:10.1016/j.jse.2011.01.041.

6. Lo IK, Griffin S, Kirkley A. The development of a disease specific quality of life measurement tool for osteoarthritis of the shoulder: The Western Ontario Osteoarthritis of the Shoulder (WOOS) index. Osteoarthritis Cartilage. 2001;9(8):771-778. doi:10.1053/joca.2001.0474

7. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality of life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87(10):2178-2185. doi:10.2106/JBJS.D.02198

8. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602-608. doi:10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L.

9. Constant CR, Gerber C, Emery RJ, Sojbjerg JO, Gohlke F, Boileau P. A review of the constant score: Modifications and guidelines for its use. J Shoulder Elbow Surg. 2008;17(2):355-361. doi:10.1016/j.jse.2007.06.022.

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

11. Mayerhoefer ME, Breitenseher MJ, Wurnig C, Roposch A. Shoulder impingement: Relationship of clinical symptoms and imaging criteria. Clin J Sport Med. 2009;19(2):83-89. doi:10.1097/JSM.0b013e318198e2e3.

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.

14. Jackson J, 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. doi:10.1016/j.jse.2010.04.001.

15. 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. doi:10.1067/mse.2003.128195.

16. Gerber C, Yian EH, Pfirrmann AW, 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. doi:10.2106/JBJS.D.02788.

17. Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL. Subscapularis function after total shoulder replacement: results with lesser tuberosity osteotomy. J Shoulder Elbow Surg. 2008;17(1): 68-72. doi:10.1016/j.jse.2007.04.018.

18. 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. doi:10.2106/JBJS.G.01461.

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

20. 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. doi:10.1016/j.jse.2011.07.008.

21. Caplan JL, Whitfield W, Nevasier 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. doi:10.1016/j.jse.2008.10.019.

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 DATA

There was no significant difference in preoperative HAD between the LTO and ST groups (9.5 ± 2.4 mm vs 10.9 ± 2.7 mm, P = .11). The immediate postoperative HAD was statistically significant between the LTO and ST groups (11.9 ± 3.7 mm vs 15.9 ± 4.5 mm, P = .005). There was as statistically significant difference noted in the final follow-up films between the LTO and ST groups (11.8 ± 3.2 mm vs 14.5 ± 3.9 mm, P = .025) (Table 2).

Table 2. Radiographic Data
Humeral Acromial Distance
	LTO		ST		P-Value
Preoperative, mm	9.5	[2.4]	10.9	[2.7]	0.11
Postoperative, mm	11.9	[3.7]	15.9	[4.5]	0.005
Final follow-up, mm	11.8	[3.2]	14.5	[3.9]	0.025
Subsidence
	LTO		ST		P-Value
Subsidence, mm	2.8	[3.1]	2.5	[3.1]	0.72
Subluxation Index
	LTO		ST		P-Value
Preoperative, %	0.55	[0.06]	0.54	[0.07]	0.45
Postoperative, %	0.55	[0.09]	0.48	[0.05]	0.015
Lucent Lines
	LTO		ST		P-Value
Lines >2 mm, %	0.00		0.08		0.51

Abbreviations: LTO, lesser tuberosity osteotomy; ST, subscapularis tenotomy.

There were no statistically significant differences found in subsidence between LTO and ST groups at final follow-up (2.8 mm ± 3.1 mm vs 2.5 mm ± 3.1 mm, P = .72) (Table 2). No statistically significant difference was noted in the subluxation index between the LTO and ST groups (0.55% ± .06% vs 0.54% ± 0.07%, P = .45), but there was a statistically significant difference noted postoperatively between the LTO and ST groups (0.55% ± 0.09% vs .48% ± 0.05%, P = .015) (Table 2).

Two stems were noted to have lucent lines >2 mm, both within the ST cohort. Each had 1 stem zone >2 mm, 1 in zone 7, and 1 in zone 4. No statistically significant difference was identified between the LTO and ST groups (0/15 vs 2/24, P = .51) (Table 2).

FUNCTIONAL OUTCOMES

Study patients were evaluated using functional outcome scores, including the Constant, WOOS, and DASH scores (Table 3).

Table 3. Functional Data
	LTO		ST		P-Value
WOOS index	93.3	[5.3]	81.5	[20.8]	0.013
DASH score	8.4	[6.6]	13.8	[4.9]	0.13
Constant score	83.3	[9.1]	81.8	[10.1]	0.64

Abbreviations: DASH, disabilities of the arm, shoulder and hand; WOOS, Western Ontario Osteoarthritis of the Shoulder.

No statistically significant differences were noted in the DASH scores (8.4 ± 6.6 vs 13.8 ± 4.9, P = .13) or Constant scores (83.3 ± 9.1 vs 81.8 ± 10.1, P = .64) between the LTO and ST cohorts. There was a statistically significant difference between the WOOS scores (93.3 ± 5.3 vs 81.5 ± 20.8, P = .013). Because separate radiographic reviews were done by 3 independent personnel at 3 different times, it was important to ensure agreement among the reviewers. This was compared using the intraclass correlation coefficients. In the statistical analysis completed, the intraclass coefficients showed the 3 reviewers agreed with each other throughout the radiographic analysis (Table 4).

Table 4. Testing Agreement: ICC
		ICC	CI, 2.5%	CI, 97.5%
HAD	Preoperative	0.4451	0.2202	0.6443
	Postoperative	0.6997	0.4836	0.834
	Final follow-up	0.5575	0.3592	0.7218
Subsidence		0.6863	0.5349	0.807
SI	Preoperative	0.3087	0.1061	0.5213
SI	Final follow-up	0.5364	0.299	0.7186

Abbreviations: CI, confidence interval; HAD, humeral acromial distance; ICC, intraclass correlation coefficient; SI, subluxation index.

DISCUSSION

At final follow-up, we identified no statistically significant difference between the LTO and ST patients in subsidence, lucent lines >2 mm, or functional outcomes (Constant and DASH scores) in patients who underwent TSA with the same proximal collar press-fit humeral stem. In regard to the functional outcome scores, although the WOOS score was statistically significant (P = .013) between the LTO and ST cohorts, we do not feel that this is clinically relevant because it does not reach the minimal clinically important difference threshold of 15 points.⁸

A statistically significant difference was noted in postoperative subluxation index but was not clinically relevant, because the values between the LTO and ST groups (0.55 vs 0.48) still showed a centered humeral head. Gerber and colleagues³ discussed using a value of 0.65 as a measure of posterior humeral head subluxation, whereas Walch and colleagues¹² defined posterior humeral head subluxation as a value >0.55. On the basis of these numbers, the values obtained in this study demonstrated that the postoperative values were still centered on the glenoid, and therefore were not clinically significant.^3,12

Continue to: In regard to HAD, there...

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

References

RADIOGRAPHIC DATA

FUNCTIONAL OUTCOMES

DISCUSSION

Pages

Recommended Reading