JBJS - 2026-08-04 - Journal Article
The Impact of Lesser Tuberosity Osteotomy Repair After Reverse Total Shoulder Arthroplasty: A Randomized Controlled Trial.
Aleem AW, Zmistowski BM, Sefko J, Chen L, Keener JD
Topics
Key Takeaway
LTO repair after rTSA produced significantly higher ASES scores (90.4 vs 82.3, p=0.01) and 7-fold better odds of improved internal rotation at 2 years compared to no repair.
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Summary
This single-institution, patient-blinded RCT asked whether LTO repair during rTSA improves functional outcomes versus no subscapularis reattachment. Patients with an intact subscapularis were randomized to LTO repair (n=43) or no repair, with ASES score as the primary outcome. At 2 years, the repair group achieved superior ASES scores (90.4 vs 82.3, p=0.01) and 7 times greater odds of improved internal rotation without differences in other planes of motion.
Key Limitation
The 2-year follow-up is insufficient to determine whether LTO healing is durable or whether the functional advantage persists or diminishes as repair integrity evolves over time.
Original Abstract
BACKGROUND
Although reverse total shoulder arthroplasty (rTSA) is widely used to treat a variety of complex shoulder pathologies, the management of the subscapularis tendon during rTSA remains controversial. The aim of this study was to prospectively compare outcomes following rTSA with and without lesser tuberosity repair for subscapularis management.
METHODS
This patient-blinded randomized controlled trial, conducted at a single institution, enrolled patients with a sufficiently intact subscapularis suitable for reattachment. Patients were randomized to either repair or no repair of the lesser tuberosity osteotomy (LTO) fragment to which the subscapularis was attached. Pre- and postoperative assessments involved radiographs, clinical examinations, and patient-reported outcomes, including a validated internal rotation functional score. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) score.
RESULTS
Eighty-five shoulders in 81 patients met the inclusion criteria and had at least 2 years of follow-up. Forty-three of these shoulders had been randomized to LTO repair. At 2 years of follow-up, the repair group demonstrated significantly better ASES scores compared with the no-repair group (90.4 versus 82.3, p = 0.01). Repair provided 7 times better odds of achieving improved internal rotation range of motion. There were no significant differences in other active shoulder motions or outcome scores.
CONCLUSIONS
In primary rTSA, subscapularis reattachment (by repair of the LTO) yielded better functional outcomes and internal rotation range of motion, as well as a trend toward a better internal rotation functional score. These benefits were seen without sacrificing shoulder motion in other planes.
LEVEL OF EVIDENCE
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.