Clinical outcomes of peel versus lesser tuberosity osteotomy subscapularis approach in stemless anatomic total shoulder arthroplasty

Background Subscapularis healing is a critical determinant of successful anatomic total shoulder arthroplasty (aTSA) outcomes. Common subscapularis management techniques include tenotomy, peel, and lesser tuberosity osteotomy (LTO). However, data on subscapularis management in stemless aTSA remain limited. The purpose of this study was to evaluate clinical and functional outcomes at two-year follow-up in patients undergoing stemless aTSA with either subscapularis peel or LTO. Methods A retrospective review was performed of a prospectively maintained, multi-center database of primary RSAs performed by multiple surgeons between 2019 and 2023 with minimum two-year follow-up. A total of 122 patients met the study criteria, 88 in the LTO approach group versus 34 in the peel group. Patient-reported outcome measures (PROMs), range of motion (ROM), and strength were evaluated at baseline and at two-year follow-up, with comparisons made between groups. Results There were no significant differences between BMI, history of tobacco use, and diabetes between LTO and peel groups. There were no significant differences in PROMs, ROM, and strength testing at preoperative evaluation. Significant differences were observed in age (66.8 years old in LTO versus 62.7 in peel, p = 0.021), sex (52% of the LTO group was female versus 6% in peel, p = <0.0001), and Walch classification (p = 0.0004). At two-year follow-up, outcomes were similar between groups, with the exception of greater active external rotation at 90 degrees in the peel group, (84° vs 71°, p = <0.0001). No significant differences were observed in the magnitude of change from preoperative to two-year postoperative outcomes between the LTO and peel groups. Conclusions Both subscapularis peel and lesser tuberosity osteotomy (LTO) techniques in stemless anatomic TSA resulted in favorable outcomes at two-year follow-up. Postoperative outcomes were largely similar between groups, although a difference was observed in active external rotation at 90°. Despite baseline demographic differences, both techniques demonstrated favorable clinical and functional results.