Subscapularis management in stemmed and stemless total shoulder arthroplasty: a surgeon decision-making analysis study

BACKGROUND: Stemless total shoulder arthroplasty (TSA) continues to grow in popularity as an evolution of stemmed humeral implants. Proposed advantages include bone preservation and ease of potential revision. However, absence of a stem may necessitate a change in subscapularis takedown approach. Specifically, there is theoretical concern about violation of supportive bone with lesser tuberosity osteotomy when using a stemless device. Therefore, the goal of this study was to identify if surgeons change their subscapularis takedown preference when performing stemless vs. stemmed TSA. METHODS AND MATERIALS: Data from a consecutive series of patients who underwent stemmed and stemless TSA at an academic institution were collected. The subscapularis management technique was documented. Subscapularis takedown techniques were divided into 2 groups: soft-tissue approach (subscapularis tenotomy or peel) and bony approach (lesser tuberosity osteotomy). Historical preference for each surgeon was determined by evaluating techniques employed using stemmed TSA. A Cramers V analysis was run to determine the strength of association between this historical preference and subscapularis management technique used for stemless TSA. RESULTS: One hundred and fifty-four patients were included in this analysis. There were 72 and 82 stemmed and stemless arthroplasty cases performed, respectively. Of the 154 patients, 50.6% were women. The average age of patients was 64.2 years. Four surgeons were included in this study. In all, there were 79 and 75 bony and soft-tissue subscapularis techniques, respectively. The historical preference for 3 of the surgeons was a subscapularis bony approach, and the historical preference for one of the surgeons was a soft-tissue approach. A Cramer’s V analysis was used to measure the relative strength of association between patient factors, historical subscapularis management preference, and subscapularis takedown approach in stemless TSA. Our analysis yielded a value of 0.65 (P < .01), indicating a redundant association between subscapularis management approach used between stemmed and stemless implant per surgeon. CONCLUSION: In determining subscapularis tendon management strategy, in surgeons who performed stemmed TSA before stemless TSA, the subscapularis takedown approach used for stemless TSA is strongly associated with surgeon’s historical preference for stemmed TSA. Future research will be needed to determine the clinical ramifications of this finding.