A Level II RCT comparing two ways to take down the subscapularis for exposure during shoulder arthroplasty: lesser tuberosity osteotomy (LTO) versus subscapularis peel. 87 patients were randomized and imaged with CT preoperatively and at 12 months. The question: does bone-to-bone healing with LTO beat tendon-to-bone healing with a peel?
When deciding how to take down the subscapularis during shoulder arthroplasty, this trial says you can pick either LTO or a well-executed peel and expect the same healing.
The critical caveat is the peel technique. This was not a simple tenotomy. The tendon was released at the medial border of the bicipital groove and fixed with bone tunnels reinforced by a mini-plate. That construct likely explains the 100% healing, unlike older tenotomy series with high failure rates.
For boards, know the Goutallier scale (grade 0 no fat through grade 4 fat exceeding muscle) and remember that fatty infiltration progressed in both groups regardless of technique. One surgical pearl: the subscapular nerves enter the muscle on its superficial surface, so overly aggressive deep releases risk denervation.
A Level II RCT comparing two ways to take down the subscapularis for exposure during shoulder arthroplasty: lesser tuberosity osteotomy (LTO) versus subscapularis peel. 87 patients were randomized and imaged with CT preoperatively and at 12 months. The question: does bone-to-bone healing with LTO beat tendon-to-bone healing with a peel?
When deciding how to take down the subscapularis during shoulder arthroplasty, this trial says you can pick either LTO or a well-executed peel and expect the same healing.
The critical caveat is the peel technique. This was not a simple tenotomy. The tendon was released at the medial border of the bicipital groove and fixed with bone tunnels reinforced by a mini-plate. That construct likely explains the 100% healing, unlike older tenotomy series with high failure rates.
For boards, know the Goutallier scale (grade 0 no fat through grade 4 fat exceeding muscle) and remember that fatty infiltration progressed in both groups regardless of technique. One surgical pearl: the subscapular nerves enter the muscle on its superficial surface, so overly aggressive deep releases risk denervation.