Systematic Review and Network Meta-Analysis of Subscapularis Management Techniques in Anatomic Total Shoulder Arthroplasty

Introduction: Controversy exists regarding the optimal subscapularis management technique in patients undergoing anatomic total shoulder arthroplasty (TSA). The purpose of this study was to compare clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (P) techniques.

Methods: We performed a level III systematic review and network meta-analysis comparing subscapularis tenotomy, lesser tuberosity osteotomy, and subscapularis peel in patients undergoing anatomic total shoulder arthroplasty. Our primary collection end points included range of motion (ROM), subscapularis function, subscapularis healing, functional patient reported outcomes, complications, and revisions surgeries. Data was pooled and network meta-analysis was performed due to comparison of 3 groups.

Results: 8 studies meet our inclusion criteria for meta-analysis. There was no difference in gender or primary diagnosis between the three cohorts. No significant difference was found in postoperative external rotation (ER) or forward flexion (FF) between the groups. Meta-analysis found the P cohort to have a significantly greater internal rotation (IR) strength when compared to the ST cohort. Belly press was negative most commonly with the LTO group and there was a significant difference as compared to the tenotomy or peel groups (p<0.0001). The weighted mean healing of the LTO osteotomy site was 98.9% on radiographic imaging. There was a significantly higher US healing rate in the LTO compared to the ST and P cohorts. All groups had good postoperative patient reported outcomes scores (average ASES score range 78.6-87) and a relatively low rate of complications (3%).

Conclusion: This network meta-analysis demonstrates that LTO has superior healing and postoperative subscapularis specific physical exam tests compared with ST and P groups. However, no difference in postoperative ROM was found between the groups and all techniques demonstrated good functional patient reported outcomes, with a low rate of postoperative complications. These findings provide evidence-based support that subscapularis tenotomy, peel, and lesser tuberosity osteotomy all demonstrate similar outcomes therefore, selection should be based on surgeon experience and comfort.

Level of evidence: Level III; Meta-Analysis; Treatment Study.

Keywords: anatomic total shoulder arthroplasty; lesser tuberosity osteotomy; meta-analysis; subscapularis peel; subscapularis tenotomy.