Is lesser tuberosity an advantage in total shoulder arthroplasty?

Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes

These authors examined differences in the minimum two year total shoulder outcomes in 189 shoulders having a lesser tuberosity osteotomy (LTO) related to the healing of the osteotomy.

There were 143 patients with union, 16 with nondisplaced nonunion, 14 with displaced nonunion, and 16 not seen.

Patients with displaced nonunion had lower postoperative functional scores (Simple Shoulder Test and American Shoulder and Elbow Surgeons scores; P < .01), and higher pain scores (visual analog scale for pain.


A higher rate of gross glenoid loosening was present in the displaced nonunion cohort (3 patients [21.4%]; P < .01).

Comment: In the hands of a highly experienced total shoulder arthroplasty surgery, at least one out of five patients had non-union of the lesser tuberosity osteotomy. One in ten had a displaced non-union. Those with displaced non-unions had poorer outcomes and increased rates of glenoid component failure.

This article can be viewed alongside another recent publication:
Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty
(Journal of Shoulder and Elbow Arthroplasty Volume 2: 1–8, 2018)

These authors observe that lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate.

They present 9 patients with LTO nonunion after primary anatomic shoulder arthroplasty.



LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group.

Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128 forward elevation (FE) and 33 external rotation (ER) compared to 148 FE and 62 ER. One patient with LTO nonunion required conversion to reverse replacement.

They concluded that surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.

Further comment: We have not found a place for LTO in our arthroplasty practice because it is not necessary, it creates a new possible complication, it requires sacrifice of the long head biceps tendon, and it compromises the integrity of the proximal humerus.

We prefer the bone and biceps preserving subscapularis peel.





That is carefully repaired with six #2 non-absorbable sutures 

 and well-tied knots.



The repair allows immediate postoperative assisted elevation


 with external rotation to neutral






Stretching beyond neutral rotation and internal rotation strengthening are not started until 8 weeks after surgery.



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Is lesser tuberosity an advantage in total shoulder arthroplasty?