Joaquin Sanchez-Sotelo, MD, PhD

Levy and colleagues should be congratulated for their publication on the impact of radiographic healing of lesser tuberosity osteotomies on outcomes after anatomic total shoulder arthroplasty. Management of the subscapularis for exposure at the time of shoulder arthroplasty continues to be debated. Advocates of lesser tuberosity osteotomy often enumerate several potential advantages, including a biomechanically stronger repair, the ability to monitor healing on plain radiographs and extremely high healing rates.

The data from Levy’s study demonstrate that healing of the lesser tuberosity osteotomy is not universal (healing was confirmed on radiographs on 76% of the shoulders) and cannot always be monitored radiographically. This study also showed that worse outcomes are to be expected only when displaced nonunion occurs, which was extremely rare (0.5%) in this cohort. Displaced nonunion was associated with no improvement in subjective shoulder values and worse pain, internal rotation and ASES scores. Specially alarming was the more than 20% rate of gross glenoid radiographic loosening at a mean follow-up time of 4 years.

Surgeons selecting osteotomy of the lesser tuberosity as their exposure technique of choice should make every effort to avoid displaced nonunion of the osteotomy, which is likely related to how the osteotomy is performed, how the anterior capsule is released, how the fixation of the osteotomy is achieved, postoperative protection and patient-related individual factors. In the hands of Levy, lesser tuberosity osteotomy had a low displaced nonunion rate; however, as with many other surgical techniques, this exposure is not 100% successful.

Joseph Zuckerman, MD

Jonathan C. Levy, MD, and colleagues should be congratulated on their in-depth analysis of the impact of lesser tuberosity osteotomy healing on the outcomes of anatomic total shoulder arthroplasty. Management of the subscapularis during anatomic total shoulder arthroplasty continues to be an important topic of discussion among shoulder arthroplasty surgeons. Regardless of the technique utilized—lesser tuberosity osteotomy, subscapularis tenotomy or subscapularis peel—there is general agreement that integrity of the subscapularis attachment is an important factor in postoperative outcomes following anatomic total shoulder arthroplasty. Lesser tuberosity osteotomy is commonly used and the authors have performed an in-depth analysis of this technique by classifying outcomes as union, nondisplaced nonunion, displaced nonunion and “not seen”. Their conclusion that displaced nonunion of the lesser tuberosity osteotomy resulted in lower functional scores and higher pain scores is consistent with other studies of subscapularis integrity following anatomic total shoulder arthroplasty as is their observation that these patients still obtain substantial clinical improvement and high satisfaction rating. In my experience, the most significant problems related to subscapularis compromise occurs when it results in anterior subluxation. It is interesting to me that in the authors’ postoperative radiographic analysis, the subluxation index for all four categories was not significantly different. This may indicate, even in the context of a nonunion that there was sufficient soft tissue stabilization to prevent instability. If anterior subluxation/instability had been present, I am certain that the function and outcomes measures would have been even more compromised. Also notable is the higher rate of glenoid component loosening in the displaced nonunion group. One can postulate that this could have resulted from eccentric loading of the glenoid from some degree of dynamic anterior stability. 

As total shoulder surgeons continue to debate the advantages and disadvantages of different methods of managing the subscapularis, this study provides important information that enhances our understanding of lesser tuberosity osteotomy and the impact of compromised healing.