Subscapularis Tenotomy or Osteotomy? Opening the Door

The surgical approach to conventional total shoulder replacement requires a trans subscapularis approach. Some investigators have found that subscapularis dysfunction accompanies a significant percentage of patients who undergo this reconstructive surgery. Consequently, considerable controversy and discussion have erupted regarding the optimal method of managing the subscapularis during the surgical approach. Historically a subscapularis tenotomy was the preferred method of entering the glenohumeral joint. This then necessitated a tendon-to-tendon repair during the cuff repair and joint closure. Some authors feel that bone-to bone healing is more predictable than the soft tissue repair alone and hence recommend a lesser tuberosity osteotomy as the more optimal way to access the joint. In this way, as the argument is put forth, the subscapularis tendon is not violated because the entire construct of the lesser tuberosity and subscapularis muscle and tendon are retracted medially. Closure is then performed using bone-to-bone osteosynthesis techniques. But is this newer technique another classic “solution looking for a problem” or does it merely create even more opportunities for newer and different complications? This presentation will discuss these issues and summarize contemporary recommendations.

Keywords: lesser tuberosity osteotomy, subscapularis tenotomy, surgical approach TSR