The Lesser Tuberosity Osteotomy Exposure for Total Shoulder Arthroplasty

Area of Science:

• Orthopedic Surgery
• Shoulder Arthroplasty
• Surgical Techniques

Background:

• The lesser tuberosity osteotomy (LTO) is a surgical technique used in anatomic total shoulder arthroplasty to mobilize the subscapularis tendon.
• This method involves osteotomizing the lesser tuberosity while preserving the subscapularis tendon attachment, facilitating bone-to-bone healing upon reattachment.

Purpose of the Study:

• To describe the technique of lesser tuberosity osteotomy (LTO) for subscapularis tendon mobilization during total shoulder arthroplasty.
• To highlight the rationale behind LTO, emphasizing its bone-to-bone healing advantages over tendon-based repair techniques.

Main Methods:

• The procedure involves a deltopectoral approach, tenotomy of the long head of the biceps tendon, and osteotomy of the lesser tuberosity.
• Following arthroplasty, the osteotomized fragment is secured with sutures, utilizing drill holes for enhanced fixation.
• The arm is positioned in 30° external rotation for suture tensioning and wound closure.

Main Results:

• While numerous studies demonstrate excellent clinical results with anatomic total shoulder arthroplasty, Level-I RCTs show no significant differences in clinical outcomes, range of motion, or strength between LTO and alternative subscapularis management techniques.
• Key technical considerations include achieving adequate osteotomy thickness (goal 10 mm), careful management of the axillary nerve, and proper suture placement for robust repair.

Conclusions:

• The LTO technique offers a method for subscapularis tendon mobilization that capitalizes on bone-to-bone healing principles.
• Despite theoretical advantages, clinical evidence does not demonstrate significant superiority in outcomes compared to other established surgical approaches for subscapularis management in total shoulder arthroplasty.