Tuesday, June 25, 2013

Reverse total shoulder - should a latissimus dorsi transfer be added?

Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder

Rotator cuff deficiency can lead to pseudoparalysis of elevation as well as weakness of external rotation. When cuff deficiency is treated with a reverse total shoulder, any remaining rotator cuff attachment is ususally moved medially towards the scapula resulting in slackening of the tendon-muscle complex and loss of whatever external rotator strength was there prior to surgery.

One of the procedures that has been used to help improve external rotation is a latissimus dorsi transfer. These authors report a series of cases in which this procedure was combined with a reverse total shoulder arthroplasty. Preoperatively, eleven patients could not actively externally rotate their adducted arm to neutral. In 31 patients a substantial external rotation lag was present. We are not provided with the specific indications for adding the latissimus dorsi transfer nor are we provided with a comparison group of patients having similar preoperative findings who had the reverse total shoulder without latissimus transfer.

At 2 and 5 years after surgery, the patients available for followup who had not had major complications had improved their external rotation from 4 to 27 degrees.

The authors provided detailed information regarding the complications in this series. Out of 40 patients, 3 had perioperative cardiopulmonary complications. 9 orthopedic complications were recorded in 7 patients.  Partial brachial plexus paresis occurred in 2 patients - one a partial elbow flexion paresis with neuropathic pain and the other a partial paresis of the deep finger flexors with neuropathic pain. Early infection occurred in 2 obese patients. One of these also sustained an intraoperative diaphyseal fracture of the humerus at the distal end of the prosthetic shaft; the other had treatment with an antibiotic-loaded cement spacer. One patient had glenoid component loosening. Two patients had traumatic dislocations. Overall these complications do not seem different than that from other series of reverse total shoulders without latissimus dorsi transfers, but one needs to keep in mind that the senior author has decades of experience with this procedure. 

Because the shoulders and the patients having reverse total shoulders are each unique, it is difficult to know whether these patients would have had different clinical outcomes and different complication rates if the reverse total shoulder had been performed without the lat transfer. It is not known how much of a functional advantage it is to increase external rotation from 4 to 28 degrees, in that most activities of daily living are performed with the arm in internal rotation.

In our practice, we have not performed lat transfers in association with reverse total shoulder. While some of our patients have weak external rotation, this does not seem to detract from their enjoyment of the benefits of the reverse total shoulder. 

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