Anatomic Total Shoulder Arthroplasty Using Lesser Tuberosity Osteotomy: Technical Considerations

Glenohumeral osteoarthritis (GHO) is a common cause of shoulder pain and dysfunction in middle-aged and older adults. Anatomic total shoulder arthroplasty (aTSA) is the preferred surgical treatment for patients with an intact rotator cuff. This video focuses on technical considerations in aTSA using a lesser tuberosity osteotomy (LTO).

aTSA is indicated in patients with advanced GHO who experience persistent pain, mechanical symptoms, and functional limitations despite prolonged conservative treatment. The rotator cuff should be intact.

The patient is positioned in the beach-chair position. A standard deltopectoral approach is used. The clavipectoral fascia is incised lateral to the biceps tendon. The anterior circumflex vessels are cauterized, and the superior pectoralis tendon is released for exposure. The biceps tendon is tenodesed after sheath release. An oscillating saw and curved osteotome are used to osteotomize the lesser tuberosity with a ~4 mm thick bone block. The lesser tuberosity and subscapularis are tagged. A "double hammock" inferior capsular release is performed to protect the axillary nerve. The humeral head is osteotomized. Glenoid exposure is achieved with retractors and labrum and biceps stump excision. Preoperative planning software is used to correct glenoid version and inclination. A glenoid component is cemented after concentric/eccentric reaming. The humerus is broached sequentially. A press-fit stem is implanted and secured with locking screws if needed. A trial head confirms soft tissue balance before final implantation. The lesser tuberosity is repaired with cerclage sutures. The rotator interval is closed in external rotation.

Postoperative anteroposterior and axillary radiographs confirm proper implant positioning and soft tissue balance. Patients are placed in a sling for 3 weeks for comfort, with immediate full passive range of motion except limiting external rotation to 30° for the first 3 weeks to protect the osteotomy. Active and active-assisted range of motion begins at 4 weeks. Initial resistance strengthening begins at 5 weeks, with advanced resistance at 8 weeks.

We present a reproducible technique using a deltopectoral approach, LTO, capsular releases, and meticulous implant positioning. This implant system accommodates native anatomy with variable offset, inclination, and version. Rigid fixation of the lesser tuberosity allows for reliable healing, which can be assessed on routine postoperative radiographs. Pain-free and improved function can be achieved in patients with an appropriate indication for the procedure.

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