Lesser Tuberosity Osteotomy Failure After TSA with Shoulder Resurfacing Implant
A 58-year-old male patient underwent a right total shoulder arthroplasty with a resurfacing implant for glenohumeral arthritis. Three weeks postoperatively, he was found to have failure of his lesser tuberosity osteotomy repair. What is the best treatment option and what are the differences in techniques for subscapularis management in total shoulder arthroplasty?
Ryan M. Cox, MD, and Daniel E. Davis, MD, MS
Total shoulder arthroplasty (TSA) is a reliable treatment option for degenerative conditions of the glenohumeral joint. Published reports of good long-term results have contributed to an increase in the number of shoulder arthroplasty procedures performed each year. [1-6]
The deltopectoral approach is typically used for TSA, which requires the subscapularis tendon to be taken down to provide access to the glenohumeral joint. A variety of techniques can be utilized to take down and manage the subscapularis tendon, including subscapularis tenotomy, subscapularis peel, and a lesser tuberosity osteotomy.  Newer subscapularis-sparing approaches are reported to prevent the complications that may be associated with subscapularis repair failure. 
Subscapularis failure or dysfunction can occur following TSA regardless of which technique is used. This can lead to increased pain, decreased range of motion, worse outcomes, and the need for revision surgery.  Treatment options for subscapularis failure include non-operative management, soft-tissue repair, tendon transfer, and reverse shoulder arthroplasty. 
In this case report, we describe the management of a patient who underwent TSA with a resurfacing humeral component and then experienced failure of his lesser tuberosity osteotomy repair in the acute postoperative period. The case highlights the various methods for subscapularis management during TSA and the repair technique with a resurfacing implant versus a traditional stemmed humeral component.
A 58-year-old man presented to the office after several years of right shoulder pain due to glenohumeral osteoarthritis (OA). He had undergone extensive non-operative management, including activity modification, use of non-steroidal anti-inflammatory drugs, and corticosteroid injections, with minimal symptomatic relief.
He was indicated for TSA of the right shoulder and underwent the procedure with a shoulder resurfacing implant. Approximately 3 weeks postoperatively, the patient developed severe pain in his anterior shoulder after reaching behind his back with his right upper extremity.
- Well-healed surgical incision with no erythema or drainage
- Passive forward elevation of 140°
- Passive external rotation of 40° with pain at the end range of motion (ROM)
- Positive abdominal compression test
Initial preoperative views of the right shoulder demonstrated glenohumeral joint OA with joint space narrowing and osteophyte formation (Figure 1).
Figure 1. Anteroposterior (AP; left) and axillary (right) radiographs of the right shoulder demonstrate glenohumeral joint OA.
The initial postoperative radiographs following TSA with a resurfacing humeral component did not show evidence of lesser tuberosity osteotomy failure (Figure 2).
Figure 2. Initial postoperative radiographs: AP (left) and axillary (right) views.
After developing acute anterior shoulder pain approximately 3 weeks postoperatively, the patient presented to the office for an urgent evaluation. Radiographs obtained in the office demonstrated displacement of the lesser tuberosity indicative of lesser tuberosity osteotomy repair failure (Figure 3).
Figure 3. Displacement of the lesser tuberosity osteotomy in the postoperative AP (left) and axillary (right) radiographs indicate lesser tuberosity osteotomy repair failure.
- Failure of the lesser tuberosity osteotomy repair after TSA with a shoulder resurfacing implant
The subscapularis tendon is essential for good function following anatomic TSA. Using a traditional deltopectoral approach requires the subscapularis tendon to be taken down to allow access to the glenohumeral joint. The tendon can be managed with several different techniques:
With the subscapularis peel technique, the entire subscapularis insertion is removed from the lesser tuberosity with electrocautery or a scalpel. This technique is useful if the tendon needs to be medialized or lengthened for a preoperative internal rotation contracture. A disadvantage is that it relies on tendon-to-bone healing.
Subscapularis tenotomy can be performed as a partial or complete tenotomy. It is typically done 1 cm medial to the lesser tuberosity insertion to maintain enough tissue for adequate repair. An advantage is that it is less technically challenging than other techniques, but like the subscapularis peel, it relies on tendon-to-tendon healing.
Lesser tuberosity osteotomy can be performed with an osteotome or oscillating saw. The osteotomy fragment should be approximately 0.5 cm to 1.0 cm thick to allow for adequate repair. It should be done just medial to the bicipital groove and remain parallel to the subscapularis tendon. This technique allows for more reliable bone-to-bone healing, but it is also more technically demanding.
Unfortunately, subscapularis tendon repair occasionally fails to heal or ruptures postoperatively. It is essential for the surgeon to recognize this complication early so that the tendon can be repaired in a timely fashion to preserve function, decrease tendon degeneration and fatty infiltration, and avoid further surgical procedures such as tendon transfers or reverse shoulder arthroplasty.
Repair of the subscapularis failure should be undertaken for acute injuries with good tendon quality and in younger patients. When a stemmed humeral shoulder arthroplasty component is utilized, the suture repair can be incorporated into a flange or peg in the humeral component.
Tendon transfer involves transfer or the pectoralis major or latissimus dorsi muscles and it is primarily utilized to augment subscapularis repair or in younger patients who are not candidates for reverse shoulder arthroplasty.
Revision to reverse shoulder arthroplasty should be reserved for more chronic tears with poorer quality tissue and for older patients.
All repair options were discussed in detail with the patient. It was recommended that he undergo revision repair of his lesser tuberosity osteotomy, given the findings of displacement of the lesser tuberosity osteotomy on radiographs and subscapularis muscle disruption on physical exam. The patient agreed and he subsequently underwent the procedure, during which a suture anchor technique was used to repair the lesser tuberosity osteotomy.
Initial Procedure: TSA with Humeral Resurfacing Component
- The patient was taken to the operating room and positioned in a well-padded beach chair positioner. General anesthesia was induced.
- A deltopectoral approach was utilized for the procedure, with the incision made beginning at the coracoid process and extended distal laterally. The deltopectoral interval was identified and the cephalic vein was taken laterally.
- The conjoint tendon was identified and incised laterally over the clavipectoral fascia and retracted medially.
- The biceps tendon was subsequently tenotomized and a tenodesis was performed using an Ethibond suture (Ethicon; Bridgewater, New Jersey) at the upper border of the pectoralis major.
- A tag suture was placed in the subscapularis and an osteotome was used to perform a lesser tuberosity osteotomy. Electrocautery was then used to release the remaining portion of the subscapularis and capsule from the humerus extending around beyond the 6 o’clock position.
- The humerus was dislocated. The centering point of the humeral head was identified and a pin was placed. The starting reamer was then used to ream the proximal portion of the humerus. The chamfer cuts were performed using the cutting guides and a trial implant was placed per the technique of the resurfacing system (Catalyst OrthoScience; Naples, Florida).
- The glenoid was subsequently exposed and prepared and a cemented glenoid component was placed.
- The humerus was again dislocated and a FiberWire suture (Arthrex; Naples, Florida) was placed through the osteotomy site of the lesser tuberosity osteotomy and out the anterior osteotomy site of the humerus so that the suture was secured below a bony bridge.
- The final Catalyst TSA component was impacted into position with excellent fit.
- Three #2 FiberWire sutures were then passed around the bone tendon junction of the subscapularis in a simple fashion. The suture that was passed through the osteotomy sites was taken through the subscapularis in a horizontal mattress fashion from deep to superficial.
- The horizontal sutures were then brought over the lesser tuberosity, through the bed of the lesser tuberosity osteotomy, deep to the bicipital groove, and out laterally. The deep portion of the simple sutures were then brought through the bed of the lesser tuberosity osteotomy in a similar fashion.
- The tension band (horizontal) sutures were tied to reduce the lesser tuberosity into place. The tuberosity was then compressed by tightly securing the 3 FiberWire sutures. There was excellent stability of the tuberosity and stability of the joint.
- The wound was copiously irrigated and closed in a layered fashion. The patient was placed in a sling postoperatively.
Revision Procedure: Revision Subscapularis Repair
- The patient was again taken to the operating room and positioned in a well-padded beach chair positioner. General anesthesia was induced.
- The previous surgical incision and deltopectoral approach were utilized.
- The osteotomy site of the lesser tuberosity was bare and visible and all sutures were intact. However, the bone of the inferior portion of the lesser tuberosity had broken and sheared off the tendon, causing failure of the repair.
- The remaining portions of the lesser tuberosity and subscapularis were retrieved with a Kocher forceps.
- Sutures were passed around the remaining portion of the lesser tuberosity at the bone-tendon interface in a modified Mason-Allen configuration for a better grasp of the tendon. A total of 5 sutures were placed through the tendon, providing good stability.
- A 4.75 SwiveLock anchor (Arthrex; Naples, Florida) loaded with a fiber tape was placed in the medial aspect of the tuberosity bed. The tape suture was then passed through the subscapularis in a horizontal mattress fashion.
- Similar to the primary repair, the horizontal mattress sutures were brought over the remaining portion of the tuberosity, passed through the tuberosity bed, deep to the bicipital groove, and out laterally. The Mason-Allen sutures were brought through the osteotomy bed and out laterally.
- The horizontal mattress suture was tied first and then the repair was compressed with the simple sutures, achieving solid fixation of the lesser tuberosity.
- The wound was copiously irrigated and closed in a layered fashion. The patient was placed in a sling postoperatively.
- Immediate postoperative radiographs are shown in Figure 4.
Figure 4. Immediate postoperative AP (left) and axillary (right) radiographs demonstrate a well-reduced lesser tuberosity after repair with a suture anchor.
After the initial surgery, the patient was taught passive ROM exercises with external rotation to 40° and forward elevation to 140°. He was instructed to limit any weight-bearing to less than 1 pound, to avoid active motion, and to perform only passive ROM exercises.
2-Week Postoperative Visit
The patient was seen in the office for evaluation of his wound. His surgical incision was healing well with normal postoperative ecchymosis and swelling. On physical exam, passive forward elevation was 100° and passive external rotation was 30°. The patient was neurovascularly intact and had a negative abdominal compression test. He was instructed to continue his passive ROM exercises and to avoid any active motion.
3 Weeks Postoperatively
The patient called the office after developing severe pain in his anterior right shoulder after reaching behind his back and internally rotating his right shoulder. On physical exam, passive forward elevation was 150° and passive external rotation was 40°. The patient was still neurovascularly intact, however, his abdominal compression test was now positive. Radiographs of the right shoulder demonstrated that the lesser tuberosity osteotomy was displaced and retracted medially (Figure 3, above). After discussion of the risks and benefits, it was recommended that he undergo revision subscapularis repair.
Revision Subscapularis Repair
One week later – approximately 1 month from his initial surgery – the patient underwent revision subscapularis repair. Postoperatively, he was placed in a sling. He was instructed to remain in the sling for 4 to 6 weeks, with no active shoulder ROM, to allow the lesser tuberosity to heal appropriately.
2 Weeks Postoperatively from Revision Subscapularis Repair
The patient’s surgical wound was evaluated in the office and was healing appropriately. On physical exam, passive external rotation was to neutral and his abdominal compression test was negative. Radiographs of the right shoulder demonstrated that the lesser tuberosity remained in an adequate position. The patient was instructed to continue using the sling at all times and to avoid any active shoulder ROM.
4 Weeks Postoperatively from Revision Subscapularis Repair
The patient had been compliant with his postoperative restrictions and his pain was well controlled. On physical exam, passive forward elevation was 90°, passive external rotation was 10°, and his abdominal compression test was negative. Radiographs of the right shoulder again demonstrated that the lesser tuberosity was in an adequate position, without signs of implant failure. Given the risk for recurrent subscapularis failure, the decision was made to continue the sling at all times, with no active ROM of the shoulder, for an additional 2 weeks.
6 Weeks Postoperatively from Revision Subscapularis Repair
The patient remained compliant with his restrictions and his pain remained well controlled. There had been no acute interval events. On physical exam, passive forward elevation was 100°, passive external rotation was 30°, and passive internal rotation was to his side. His abdominal compression test was negative. Radiographs of the right shoulder showed that the lesser tuberosity was in a good position, with evidence of bony healing. It was recommended that the patient start physical therapy to improving his ROM and follow up in 6 weeks for repeat clinical and radiographic evaluation.
Ryan M. Cox, MD, is an orthopaedic surgery resident at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Daniel E. Davis, MD, MS, is an orthopaedic surgeon with The Rothman Institute, Philadelphia, Pennsylvania, specializing in the treatment of shoulder and elbow conditions. He is also the Shoulder Section Editor for Rothman Institute Grand Rounds on ICJR.net.
Disclosures: Dr. Cox has no disclosures relevant to this article. Dr. Davis has disclosed that he owns stock/stock options in Catalyst OrthoScience.
- Cil A, Veillette CJH, Sanchez-Sotelo J, Sperling JW, Schleck CD, Cofield RH. Survivorship of the humeral component in shoulder arthroplasty. J Shoulder Elbow Surg. 2010 Jan;19(1):143–150. doi:10.1016/j.jse.2009.04.011
- Harjula JNE, Paloneva J, Haapakoski J, Kukkonen J, Äärimaa V, Finnish Shoulder Arthroplasty Registry Group. Increasing incidence of primary shoulder arthroplasty in Finland – a nationwide registry study. BMC Musculoskelet Disord. 2018 Jul 21;19(1):245. doi:10.1186/s12891-018-2150-3
- Khan A, Bunker TD, Kitson JB. Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement: a minimum ten-year study. J Bone Joint Surg Br. 2009 Dec;91(12):1594–1600. doi:10.1302/0301-620X.91B12.22139
- Raiss P, Schmitt M, Bruckner T, Kasten P, Pape G, Loew M, et al. Results of cemented total shoulder replacement with a minimum follow-up of ten years. J Bone Joint Surg Am. 2012 Dec 5;94(23):e1711-1710. doi:10.2106/JBJS.K.00580
- Schoch B, Schleck C, Cofield RH, Sperling JW. Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up. J Shoulder Elbow Surg. 2015 May;24(5):705–710. doi:10.1016/j.jse.2014.07.016
- Zmistowski B, Austin L, Ciccotti M, Ricchetti E, Williams G. Fatal venous air embolism during shoulder arthroscopy: a case report. J Bone Joint Surg Am. 2010 Sep 1;92(11):2125–2127. doi:10.2106/JBJS.I.01704
- Shields E, Ho A, Wiater JM. Management of the subscapularis tendon during total shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2017 Apr;26(4):723–731. doi:10.1016/j.jse.2016.11.006
- Defranco MJ, Higgins LD, Warner JJP. Subscapularis management in open shoulder surgery. J Am Acad Orthop Surg. 2010 Dec;18(12):707–717. doi:10.5435/00124635-201012000-00001
- Entezari V, Henry T, Zmistowski B, Sheth M, Nicholson T, Namdari S. Clinically significant subscapularis failure after anatomic shoulder arthroplasty: is it worth repairing? Journal of Shoulder and Elbow Surgery. 2020 Sep;29(9):1831–1835. doi:10.1016/j.jse.2020.01.070