Saturday, August 8, 2015

Reverse total shoulder - can a secondary latissimus dorsi transfer salvage a failure?

Secondary latissimus dorsi transfer after failed reverse total shoulder arthroplasty

In order to treat pseudoparalysis of external rotation after previous reverse total shoulder arthroplasty (RTSA) the authors performed a latissimus dorsi transfer (LDT) in ten patients at a mean of 27 months (range, 4-134 months) after RTSA.

The gains were modest at 49 months after surgery:
The mean relative Constant score changed from 51%  to 58%
The mean subjective shoulder value changed from 44% to 56%.
Mean active flexion increased from 86 to 109 degrees.
Mean active external rotation increased from -18 to 2 degrees.

There were four complications: two infections, one transcient axillary neuropathy and one case of instability.

Comment: The acquired weakness of external rotation after reverse total shoulder with the Grammont design (as used in these cases) have always been interesting. In this series, the average active external rotation before the reverse total shoulder was 0 degrees, dropping to - 18 degrees after the reverse (and then restored to 2 degrees after the tendon transfer).

This acquired weakness of external rotation seems to be due to the medialization of the center of rotation so that the residual external rotators are slackened and their effect weakened as shown in the diagram by Steve Lippitt below.
Reverse prostheses with more lateral centers of rotation (as shown in the bottom figure) may reduce the risk of pseudoparalysis of external rotation and the need for latissimus transfers.


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