Reverse total shoulder - are latissiumus and teres major transfers helpful for patients with combined loss of elevation and external rotation?

Some authors have advocated that latissimus dorsi (LD) and teres major (TM) tendon transfers be performed concurrently with reverse shoulder arthroplasty (RSA) to address Combined Loss of Elevation and External Rotation (CLEER) of the shoulder. 

The authors of Reverse shoulder arthroplasty with and without latissimus and teres major transfer for patients with combined loss of elevation and external rotation: a prospective, randomized investigation sought to compare RSA outcomes in patients with rotator cuff tear arthropathy and CLEER in a randomized controlled study using RSAs without (below left) and with (below right) LD-TM tendon transfer using implants that lateralized the greater tuberosity.

The primary outcome measure was the two year postoperative Activities of Daily Living and External Rotation (ADLER) score as described by the authors of Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty

Secondary outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Simple Shoulder Test (SST) score.

Both the treatment and control groups showed significant improvements in the ability to perform activities of daily living requiring active external rotation measured by the ADLER score postoperatively. No significant differences in the ADLER, DASH, ASES, or SST score were  found between the 2 groups at final follow-up even though resolution of the Hornblower sign occurred postoperatively in 58% of patients in the control group and 73% of those in the treatment group.

These results can be compared with those presented in Reversed shoulder Arthroplasty with modified L’Episcopo for combined loss of active elevation and externalrotation. The authors of this article used a Grammont-type implant (that does not lateralize the greater tuberosity, see below) and reported that in the absence of both the infraspinatus and teres minor, a RSA alone would not restore external rotation.

In their series the ADLER score started lower (7) than the other series above and improved to 25. No control group was included.

Most recently the authors of Concomitant Latissimus Dorsi Tendon Transfer during Reverse Total Shoulder Arthroplasty Does Not Improve Active External Rotation or Clinical Outcomes in Patients with External Rotation Deficit sought to assess the role of latissimus dorsi tendon transfer with reverse total shoulder arthroplasty in patients with external rotation deficit (positive external lag sign and <10⁰ of active external rotation) using an implant system that lateralizes the tuberosity somewhat (see below).

They compared a latissimus dorsi transfer (LDT) group with a historical control group having no transfer (NT) with similar age, sex distributions, and follow-up duration.

Baseline measures were similar, except for the LDT group having slightly less active ER (-8 ⁰ vs 0⁰).

No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and SSV scores. All postoperative ROM measures including aER were similar, except for a slight improvement in active internal rotation in the NT group. 

Comment: From the foregoing it is apparent that a number of factors may determine whether latissimus transfer without or with teres major transfer are likely to benefit the patient enough to offset the risks of nerve injury, increased surgical time, the risk of compromising active internal rotation, and the more demanding post operative rehabilitation requirements,.

These factors might include (1) the severity of the preoperative external rotation deficit, (2) the degree to which the implant changes the line of pull of the deltoid,  (3) whether both the latissimus and the teres major are transferred, and the degree to which the greater tuberosity and center of rotation are medialized or lateralized by the prosthetic implant.

The studies published to this point include a small number of patients. Controlled clinical research with a substantially larger case volume will be required to evaluate these and other factors that determine the outcome for the patient with external rotation deficits having a reverse total shoulder.

It may be that patients with functionally severe preoperative limitation of external rotation having reverse total shoulder with a medialized center of rotation and humeral offset may benefit from these tendon transfers.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Reverse total shoulder - the issue of external rotation

The influence of preoperative external rotation weakness or stiffness on reverse total shoulder arthroplasty
These authors point out that patients having reverse total shoulder arthroplasty (rTSA) may have limited preoperative external rotation (ER) because of either stiffness or weakness.

They considered the outcomes of 608 patients having a primary rTSA using the Eactech Equinoxe prosthesis with a "medial glenoid lateral humerus". None of these patients had tendon transfers.

Patients with limited preoperative external rotation due to weakness or stiffness were compared to patients with normal preoperative range of motion.

The specific preoperative criteria for each cohort was defined as follows: 

(1) Normal cohort: passive ER 30 and a lag <10; 

(2) Stiff cohort: passive ER 20 and a lag 10; 

(3) Weak cohort: passive ER 30 and a lag 20.

They hypothesized that (1) patients with a preoperative ER deficit would have worse clinical outcomes and (2)  that patients with ER deficits due to stiffness will have better clinical outcomes than patients with ER deficits due to weakness and will also have a greater improvement in postoperative ER.

They found that good clinical outcomes can be achieved in patients with preoperative ER deficits with this prosthesis, with improvement in active ER range of motion regardless of the cause of the deficit (stiffness vs. weakness).

They found that stiff patients had greater improvement in their clinical scores than patients with weak or normal preoperative ER.

Comment: 
See related post (click on this link)

A recent article, "A method for documenting the change in center of rotation with reverse total shoulder arthroplasty and its application to a consecutive series of 68 shoulders having reconstruction with one of two different reverse prostheses" (see this link) helps understand the effect of a reverse total shoulder on external rotation and the importance of prosthesis design. The authors showed that a reverse medializes the center of rotation

and that the amount of medialization differs among prosthesis designs as shown below.

This is shown nicely in the figure below from Steve Lippitt. (A) is the normal shoulder, (B) shows the relaxation of the residual rotators including the posterior deltoid and remaining cuff) with a lot of medialization (which can weaken external rotation), while (C) shows tensioning of the posterior residual rotators by an implant with less medialization (which can restore external rotation).

Thus, "East-West" tensioning has the potential for improving active external rotation.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.
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Reverse total shoulder and the external rotation issue

Latissimus dorsi muscle transfer reduces external rotation deficit at the cost of internal rotation in reverse shoulder arthroplasty patients: a cohort study

These authors reviewed 26 patients with cuff tear arthropathy and a positive lag sign with maximum external rotation of zero degrees having a reverse total shoulder (RSA). 

26 RCA patients with a deficit in active external rotation (ERD) (ie, positive lag sign and maximum active ER of 0°) Latissimus dorsi transfer (LDT) was carried out in 13 of these patients. 

In addition, 88 control patients without external rotation deficits who underwent only RSA were identified.

The LDT procedure extended the surgical time by 26 minutes (P = .003). LDT patients had up to 22° better postoperative active ER than control patients (P < .001), although this was accompanied by an internal rotation deficit (77% vs 46% of control patients could not reach the lumbosacral region, P = .010).

They calculated a 23% risk of local procedure–related complications for RSA patients with an active ERD and LDT. 

The clinical outcomes are shown here, with a slight drop off in the quality of the result for the LDT group at longer term followup.

Comment: This article does a nice job of pointing out the challenges involved in using an LDT in an attempt to improve active external rotation.

It is worthwhile pointing out that with reverse total shoulders that medicalize the center of rotation, a reverse may actually slacken / weaken the external rotators, as shown in diagram B below by Steve Lippitt. Diagram C shows that lateralizing the center of rotation may help keep the external rotators under tension.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder - the effect of implant design on external rotation range of motion

The Effect of Humeral Inclination on Range of Motion in Reverse Total Shoulder Arthroplasty: A Systematic Review.


These authors conducted a systematic review of studies evaluating reverse total shoulders (RTSA) that reported the type of prosthesis as well as active postoperative ROM at a minimum of 12 months after surgery. Preoperative range of motion, postoperative range of motion and the difference in range of motion was compared between RTSA humeral components with cup inclination 135° and 155°.

Sixty-five studies with 3302 patients (3434 shoulders; 1211 in the 135° group and 2223 in the 155° group) were included. 

Patients in the 135° group had significantly greater improvement in external rotation (P < .001) and significantly more overall external rotation compared to the 155° group. No significant difference were found between the 135° and 155° groups in range of motion improvements in forward elevation or abduction.

Comment: As the authors point out, the 135° neck shaft angle humeral prosthesis is usually used with a laterally offset glenosphere

whereas the 155° humeral prosthesis is usually used with a medialized glenosphere

So the effects of the humeral neck shaft angle may not be separable from the effects of the glenosphere design.

While the authors do not suggest why the 135° neck shaft angle humeral prosthesis is associated with more rotation, it is possible that the steeper angle and the lateral glenosphere offset reduce the risk of humeral abutment against the glenoid in external rotation as suggested by this axillary view.

Our approach to reverse total shoulder arthroplasty is shown in this link. Our goal, whenever possible, is a cementless impaction grafted humeral stem with a 135 degree angle and a laterally offset glenopshere securely fixed with screws in the high quality bone at the base of the subscapularis fossa with minimal inferior placement to avoid excess tension on the acromion and the brachial plexus. This combination may allow for a greater range of external rotation.

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