Subscapularis tenotomy, peel yielded similar internal rotation strength for shoulder arthroplasty
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Published results showed the subscapularis tenotomy and subscapularis peel approaches for anatomic total shoulder arthroplasty had no differences in internal rotation strength for the belly-press position.
Peter Lapner, MD, FRCSC, and colleagues randomly assigned 100 patients undergoing anatomic shoulder arthroplasty to either the subscapularis tenotomy (n=47) or subscapularis peel approach (n=53). Researchers considered internal rotation strength in the belly-press position measured at 24 months postoperatively as the primary outcome, while Western Ontario Osteoarthritis of the Shoulder (WOOS) index score, American Shoulder and Elbow Surgeons score, range of motion, radiographic lucencies and adverse events were secondary outcomes.
Researchers found 81% of patients returned for the 24-month follow-up. Results showed both groups had improvements in mean internal rotation strength in the belly-press position, WOSS index score and ASES score at final follow-up compared with baseline measures. Patients in the subscapularis tenotomy approach group had no differences in internal rotation strength at 24 months vs. the subscapularis peel approach group, according to results of the intention-to-treat analysis. Researchers also found no significant differences in WOOS and ASES scores between the two groups at any time. However, Lapner noted a significantly lower WOSS score among patients with significant subscapularis weakness “as demonstrated by the inability to hold their elbow in line with their wrist during testing.” Ultrasound showed healing rates of 72% and 71% for the tenotomy and peel approaches, respectively.
“Either technique may be used in anatomic total shoulder arthroplasty — our study did not show a clear advantage to one approach over the other. However, we found that patient-centered outcome scores were lower when significant subscapularis weakness was present,” Lapner told Healio Orthopedics. “Surgeons can rest assured that either technique is equally effective, but to be meticulous about tendon repair given that subscapularis weakness is associated with poorer shoulder function.” – by Casey Tingle
Disclosures: Lapner reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Lawrence V. Gulotta, MD
Subscapularis failure following anatomic shoulder replacement is a rare but devastating complication. There is some debate in terms of the best way to repair it in order to minimize this fate. The three most common techniques are a subscapularis peel, tenotomy and lesser tuberosity osteotomy. While there have been several studies that have compared a combination of these techniques, the study by Peter Lapner, MD, FRCSC, and colleagues is the first to directly compare the two most common soft tissue repair – the peel and tenotomy. They did so in a prospective, randomized, double-blind trial. The main outcomes used were internal rotation strength, functional outcomes scores and radiographic findings of subscapularis repair and implant loosening. They found no differences between the two techniques in any of the outcomes studied. Therefore, this paper supports the use of either technique.
While this paper is interesting in that it uses a rigorous methodology seldom seen in the orthopedic literature, I believe the most important point involves the techniques used to perform the two types of subscapularis repairs. For the tenotomy, the authors repaired the tendon to the stump on the lesser tuberosity with several side-to-side, high-tensile sutures in addition to sutures placed through bone tunnels and then tied over a small plate placed lateral to the bicipital groove. The peel group was repaired in a similar fashion with high-tensile strength sutures passed through bone tunnels and the tied over a lateral plate. My take-home point from this study is that meticulous attention to detail during subscapularis repair at the conclusion of a total shoulder replacement is more important than the actual technique used.
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