Lesser Tuberosity Osteotomy Versus Subscapularis Tenotomy: Technique and Rationale

Subscapularis dysfunction after tenotomy for the deltopectoral approach to the shoulder has recently been identified in the orthopedic literature as an under-recognized complication of total shoulder arthroplasty. Attempts to improve the postoperative function of the subscapularis and mitigate rupture of the muscle-tendon unit have focused on alternative methods for subscapularis takedown and repair. Lesser tuberosity osteotomy for release of the subscapularis has been described by multiple authors as an effective way to decrease subscapularis dysfunction and maintain tendon integrity after total shoulder arthroplasty. Proponents of this technique cite maintenance of the integrity of the tendon, direct bone-to-bone healing of the osteotomy, improved strength of repair, and the ability to monitor the integrity of the subscapulairs repair radiographically in the postoperative period as distinct advantages. Short-term clinical studies have documented improved subscapularis function after the osteotomy technique and biomechanical studies have also shown improved strength of repair when compared with tenotomy. However, there are several concerns about the osteotomy technique that have not yet been resolved, including significantly increased operative complexity, inability to medialize the tendon to adjust subscapularis tension, risk of intraoperative humeral fracture, and lack of long-term clinical outcomes. Although lesser tuberosity osteotomy shows promising improvements in short-term clinical results, subscapularis tenotomy has a long proven track record of excellent clinical outcomes and the choice between the 2 methods of subscapularis takedown remains one of surgeon comfort and experience.