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Subscapularis Muscle Function and Structure After Total Shoulder Replacement with Lesser Tuberosity Osteotomy and Repair
Christian Gerber, MD1; Edward H. Yian, MD2; Christian A.W. Pfirrmann, MD1; Matthias A. Zumstein, MD1; Clément M.L. Werner, MD1
1 Department of Orthopedic Surgery, Balgrist Hospital, Forchstrasse 340, 8032 Zurich, Switzerland. E-mail address for C. Gerber: christian.gerber@balgrist.ch
2 Department of Orthopaedic Surgery, Southern California Permanente Medical Group, 3401 South Harbor Boulevard, Room 3326, Santa Ana, CA 92704
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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the ResOrtho Foundation. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Zimmer, Inc., Warsaw, Indiana). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Balgrist Hospital, Zurich, Switzerland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Aug 01;87(8):1739-1745. doi: 10.2106/JBJS.D.02788
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Abstract

Background: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes.

Methods: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis.

Results: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%).

Conclusions: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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