This systematic review and network meta-analysis compare clinical outcomes of three different subscapularis management techniques in anatomic total shoulder arthroplasty: lesser tuberosity osteotomy, subscapularis peel, and subscapularis tenotomy.
Methods
PubMed, Web of Science, Embase, and Cochrane's trial registry were searched in July 2021. Comparative studies and case series evaluating the outcomes of these three techniques were included. The network meta-analysis was performed only on comparative studies.
Results
Twenty-three studies were included. Both lesser tuberosity osteotomy and subscapularis peel had significantly higher Western Ontario Osteoarthritis Scores compared to subscapularis tenotomy, but no difference in American Shoulder and Elbow Society Scores. Subscapularis peel had superior external rotation compared to lesser tuberosity osteotomy. However, no difference was found in external rotation between subscapularis peel and subscapularis tenotomy or between subscapularis tenotomy and lesser tuberosity osteotomy. The overall weighted average for lesser tuberosity osteotomy bony union was 93.6%, whereas the overall weighted average for subscapularis tendon healing was 79.4% and 87% for subscapularis tenotomy and subscapularis peel, respectively.
Discussion
This network meta-analysis demonstrated that lesser tuberosity osteotomy and subscapularis peel were associated with the high union and subscapularis healing rates and may be associated with improved shoulder function and quality of life, compared to subscapularis tenotomy. Lesser tuberosity osteotomy and subscapularis peel demonstrate a trend of superior outcomes compared to subscapularis tenotomy during anatomic total shoulder arthroplasty.
LiuEYKordDHornerNS, et al.Stemless anatomic total shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg2020; 29: 1928–1937.
2.
SimovitchRWFriedmanRJCheungEV, et al.Rate of improvement in clinical outcomes with anatomic and reverse total shoulder arthroplasty. J Bone Joint Surg Am2017; 99: 1801–1811.
3.
BestMJAzizKTWilckensJH, et al.Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg2021; 30: 1159–1166.
4.
NeerCS2ndWatsonKCStantonFJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am1982; 64: 319–337.
5.
GerberCYianEHPfirrmannCA, et al.Subscapularis muscle function and structure after total shoulder replacement with lesser tuberosity osteotomy and repair. J Bone Joint Surg Am2005; 87: 1739–1745.
6.
KrishnanSGStewartDGReineckJR, et al.Subscapularis repair after shoulder arthroplasty: biomechanical and clinical validation of a novel technique. J Shoulder Elbow Surg2009; 18: 184–192. Discussion 197–198.
7.
PonceBAAhluwaliaRSMazzoccaAD, et al.Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am2005; 87: 1–8.
8.
LapnerPLSabriERakhraK, et al.Comparison of lesser tuberosity osteotomy to subscapularis peel in shoulder arthroplasty: a randomized controlled trial. J Bone Joint Surg Am2012; 94: 2239–2246.
9.
ClydeCTThrockmortonTWDuquinTR. Subscapularis peel in anatomic total shoulder arthroplasty. J Shoulder Elbow Arthroplasty2018; 2: 247154921881340. Review. DOI: 10.1177/2471549218813409.
10.
HeckmanDSHooverSAWeinholdPS, et al.Repair of lesser tuberosity osteotomy for shoulder arthroplasty: biomechanical evaluation of the Backpack and Dual Row techniques. J Shoulder Elbow Surg2011; 20: 491–496.
11.
AngstFSchwyzerHKAeschlimannA, et al.Measures of adult shoulder function: disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) and its short version (QuickDASH), Shoulder Pain and Disability index (SPADI), American Shoulder and Elbow Surgeons (ASES) Society standardized shoulder assessment form, Constant (Murley) Score (CS), Simple Shoulder Test (SST), oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ), and Western Ontario Shoulder Instability Index (WOSI). Arthritis Care Res (Hoboken)2011; 63: S174–S188.
12.
UngerRZBurnhamJMGammonL, et al.The responsiveness of patient-reported outcome tools in shoulder surgery is dependent on the underlying pathological condition. Am J Sports Med2019; 47: 241–247.
13.
LoIKGriffinSKirkleyA. The development of a disease-specific quality of life measurement tool for osteoarthritis of the shoulder: the Western Ontario Osteoarthritis of the Shoulder (WOOS) index. Osteoarthr Cartil2001; 9: 771–778.
14.
IzquierdoRVoloshinIEdwardsS, et al.American Academy of orthopaedic surgeons clinical practice guideline on the treatment of glenohumeral joint osteoarthritis. J Bone Joint Surg Am2011; 93: 203–205.
15.
ChoateWSKwapiszAMomayaAM, et al.Outcomes for subscapularis management techniques in shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg2018; 27: 363–370.
16.
Del CoreMACutlerHSAhnJ, et al.Systematic review and network meta-analysis of subscapularis management techniques in anatomic total shoulder arthroplasty. J Shoulder Elbow Surg2021; 30: 1714–1724.
17.
ShieldsEHoAWiaterJM. Management of the subscapularis tendon during total shoulder arthroplasty. J Shoulder Elbow Surg2017; 26: 723–731.
18.
MoherDLiberatiATetzlaffJ, et al.Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol2009; 62: 1006–1012.
19.
PageMJMcKenzieJEHigginsJPT. Tools for assessing risk of reporting biases in studies and syntheses of studies: a systematic review. BMJ Open2018; 8: e019703.
20.
SlimKNiniEForestierD, et al.Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg2003; 73: 712–716.
21.
LapnerPLSabriERakhraK, et al.Healing rates and subscapularis fatty infiltration after lesser tuberosity osteotomy versus subscapularis peel for exposure during shoulder arthroplasty. J Shoulder Elbow Surg2013; 22: 396–402.
22.
ArmstrongALashgariCTeefeyS, et al.Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty. J Shoulder Elbow Surg2006; 15: 541–548.
23.
ArmstrongADSouthamJDHorneAH, et al.Subscapularis function after total shoulder arthroplasty: electromyography, ultrasound, and clinical correlation. J Shoulder Elbow Surg2016; 25: 1674–1680.
24.
O’BrienPMKazanjianJEKellyJDII, et al. Subscapularis function after total shoulder arthroplasty using lesser tuberosity osteotomy or tenotomy. JAAOS Global Research & Reviews2020; 4: e20.00032.
25.
LapnerPPollockJWZhangT, et al.A randomized controlled trial comparing subscapularis tenotomy with peel in anatomic shoulder arthroplasty. J Shoulder Elbow Surg2019; 29: 225–234.
26.
AibinderWRBicknellRTBartschS, et al.Subscapularis management in stemless total shoulder arthroplasty: tenotomy versus peel versus lesser tuberosity osteotomy. J Shoulder Elbow Surg2019; 28: 1942–1947.
27.
BaumgartenKMOsbornRSchweinleWEJr, et al. The influence of anatomic total shoulder arthroplasty using a subscapularis tenotomy on shoulder strength. J Shoulder Elbow Surg2018; 27: 82–89.
28.
JandhyalaSUnnithanAHughesS, et al.Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder replacement: a comparison of patient outcomes. J Shoulder Elbow Surg2011; 20: 1102–1107.
29.
ScaliseJJCicconeJIannottiJP. Clinical, radiographic, and ultrasonographic comparison of subscapularis tenotomy and lesser tuberosity osteotomy for total shoulder arthroplasty. J Bone Joint Surg Am2010; 92: 1627–1634.
30.
JacksonJDCilASmithJ, et al.Integrity and function of the subscapularis after total shoulder arthroplasty. J Shoulder Elbow Surg2010; 19: 1085–1090.
31.
LiemDKleeschulteKDedyN, et al.Subscapularis function after transosseous repair in shoulder arthroplasty: transosseous subscapularis repair in shoulder arthroplasty. J Shoulder Elbow Surg2012; 21: 1322–1327.
32.
BuckleyTMillerRNicandriG, et al.Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures. J Shoulder Elbow Surg2014; 23: 1309–1317.
33.
CaplanJLWhitfieldBNeviaserRJ. Subscapularis function after primary tendon to tendon repair in patients after replacement arthroplasty of the shoulder. J Shoulder Elbow Surg2009; 18: 193–196. Discussion 197–198.
34.
QureshiSHsiaoAKlugRA, et al.Subscapularis function after total shoulder replacement: results with lesser tuberosity osteotomy. J Shoulder Elbow Surg2008; 17: 68–72.
35.
MillerSLHazratiYKleppsS, et al.Loss of subscapularis function after total shoulder replacement: a seldom recognized problem. J Shoulder Elbow Surg2003; 12: 29–34.
36.
LevineWNMunozJHsuS, et al.Subscapularis tenotomy versus lesser tuberosity osteotomy during total shoulder arthroplasty for primary osteoarthritis: a prospective, randomized controlled trial. J Shoulder Elbow Surg2019; 28: 407–414.
37.
AndrewsJRBaumgartenTE. Arthroscopic anatomy of the elbow. Orthop Clin North Am1995; 26: 671–677.
38.
SmallKMSiegelEJMillerLR, et al.Imaging characteristics of lesser tuberosity osteotomy after total shoulder replacement: a study of 220 patients. J Shoulder Elbow Surg2014; 23: 1318–1326.
39.
De WildeLFDe ConinckTDe NeveF, et al.Subscapularis release in shoulder replacement determines structural muscular changes. Clin Orthop Relat Res2012; 470: 2193–2201.
40.
JohnsonNRTrofaDPSaltzmanBM, et al.Healing rate and clinical outcomes of lesser tuberosity osteotomy for anatomic shoulder arthroplasty. JAAOS Global Res Rev2020; 4: e19.00119.
41.
LevyJCDeVitoPBerglundD, et al.Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes. J Shoulder Elbow Surg2019; 28: 1082–1090.
42.
GobezieRDenardPJShishaniY, et al.Healing and functional outcome of a subscapularis peel repair with a stem-based repair after total shoulder arthroplasty. J Shoulder Elbow Surg2017; 26: 1603–1608.
43.
MasonRBuckleyTSouthgateR, et al.Radiographic study of humeral stem in shoulder arthroplasty after lesser tuberosity osteotomy or subscapularis tenotomy. Am J Orthop (Belle Mead NJ)2018; 47. DOI: 10.12788/ajo.2018.0036.
44.
ShafritzABFitzgeraldMGBeynnonBD, et al.Lift-off test results after lesser tuberosity osteotomy versus subscapularis peel in primary total shoulder arthroplasty. J Am Acad Orthop Surg2017; 25: 304–313.
45.
GerberCPenningtonSDYianEH, et al.Lesser tuberosity osteotomy for total shoulder arthroplasty. Surgical technique. J Bone Joint Surg Am2006; 88: 170–177.
46.
IvesEPNazarianLNParkerL, et al.Subscapularis tendon tears: a common sonographic finding in symptomatic postarthroplasty shoulders. J Clin Ultrasound2013; 41: 129–133.
47.
ScheibelMTsynmanAMagoschP, et al.Postoperative subscapularis muscle insufficiency after primary and revision open shoulder stabilization. Am J Sports Med2006; 34: 1586–1593.
48.
MillerBSJosephTANoonanTJ, et al.Rupture of the subscapularis tendon after shoulder arthroplasty: diagnosis, treatment, and outcome. J Shoulder Elbow Surg2005; 14: 492–496.
49.
MoeiniSRasmussenJVKlausenTW, et al.Rasch analysis of the Western Ontario Osteoarthritis of the Shoulder index – the Danish version. Patient Relat Outcome Meas2016; 7: 173–181.
50.
BornesTDRollinsMDLapnerPLC, et al. Subscapularis management in total shoulder arthroplasty: current evidence comparing peel, osteotomy, and tenotomy. J Shoulder Elbow Arthroplasty2018; 2: 247154921880777. Review.
51.
DunnRJoyceCDBravmanJT. Comparison of subscapularis management and repair techniques. J Shoulder Elbow Arthroplasty2019; 3: 247154921984815. Review.
52.
BryantDLitchfieldRSandowM, et al.A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am2005; 87: 1947–1956.
53.
EdwardsTBKadakiaNRBoulahiaA, et al.A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg2003; 12: 207–213.
