The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 5

Scientific Articles | May 01, 2007

Reverse Delta-III Total Shoulder Replacement Combined with Latissimus Dorsi Transfer: A Preliminary Report

Christian Gerber, MD, FRCSEd¹; Scott D. Pennington, MD¹; Erich J. Lingenfelter, MD¹; Atul Sukthankar, MD¹

¹ University of Zurich, Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland. E-mail address for C. Gerber: christian.gerber@balgrist.ch

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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from ResOrtho Foundation, Zurich, Switzerland. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

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Investigation performed at the Department of Orthopaedics, University of Zurich, Balgrist, Zurich, Switzerland

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 May 01;89(5):940-947. doi: 10.2106/JBJS.F.00955

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Abstract

Background: Reverse total shoulder arthroplasty allows the restoration of active overhead elevation in patients with a massive rotator cuff tear and pseudoparesis of elevation. However, it does not restore active external rotation, the lack of which can also constitute a substantial functional handicap and compromise the outcome of this arthroplasty. Latissimus dorsi tendon transfer reliably restores control of active external rotation in rotator-cuff-deficient shoulders. In this preliminary study, we assessed the results of the combination of a latissimus dorsi transfer to the greater tuberosity and a reverse total shoulder arthroplasty in the presence of lost active external rotation.

Methods: Twelve shoulders in eleven patients (ten women and one man; average age, seventy-three years) with combined pseudoparesis of anterior elevation and external rotation were enrolled in the study. All demonstrated severe dysfunction of the teres minor with an external rotation lag sign, a hornblower's sign, and fatty degeneration of the teres minor classified as stage 2 or greater according to the system of Goutallier et al. or Fuchs et al. All were treated with a reverse total shoulder arthroplasty and a latissimus dorsi transfer during one operative procedure. One patient had a postoperative infection necessitating removal of the prosthesis. Another patient could not be examined because of an unrelated medical disability, leaving ten shoulders in nine patients available for evaluation on the basis of the history, results of a physical examination, and patient-based outcomes.

Results: On the average, forward flexion improved from 94° preoperatively to 139° at the time of follow-up (p = 0.028), abduction improved from 87° to 145° (p = 0.007), and strength improved from 0.25 to 4.12 kg (p = 0.005). The subjective shoulder value increased from 23% to 64% (p = 0.005), the relative Constant score increased from 47% to 93% (p = 0.005), and the pain score improved from 6.1 to 10.9 points (p = 0.012). While improvement in active external rotation with the arm at the side (from 12° to 19°) was not significant, the score for functional active external rotation improved from 4.6 to 8.2 of 10 points according to the system of Constant and Murley (p = 0.024). The score for activities of daily living improved from 2.3 to 7.9 of 10 points (p = 0.005).

Conclusions: In the presence of severe loss of active elevation and external rotation, combined latissimus dorsi transfer and reverse total shoulder arthroplasty can restore elevation and external rotation, at least in the short term.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Reverse total shoulder arthroplasty is a semiconstrained joint replacement that has proven to be an effective treatment for patients with pseudoparesis of the shoulder, providing pain relief and recovery of forward flexion and abduction^1-10. The normal concave glenoid is replaced with a noncemented convex glenoid component (the so-called glenosphere) and the humeral head is replaced by a conforming concave cup, thereby reversing the ball-and-socket configuration. The resulting biomechanics compensate for the function of the rotator cuff in elevation and abduction⁹. However, active external rotation is critical for some activities of daily living, such as eating, combing hair, and working with the arm overhead. Control of active external rotation is not improved after reverse total shoulder arthroplasty alone^8-10, and additional impairment has been observed (Figs. 1-A, 1-B, 1-C, 1-D). The clinical outcome after a reverse total shoulder arthroplasty is poorer in the absence of residual teres minor function to provide external rotation^8,9,11.

Restoration of active external rotation has been reported following latissimus dorsi transfer in patients with a massive rotator cuff tear^12-15. As reverse total shoulder arthroplasty restores elevation in the presence of a functioning deltoid^2,8 and latissimus dorsi transfer restores functional external rotation^14,15, we hypothesized that the combination of these two procedures would address the problem of combined pseudoparesis of elevation and external rotation. It was the purpose of this study to assess the preliminary outcomes of combined reverse total shoulder arthroplasty and latissimus dorsi tendon transfer in twelve consecutive shoulders.

Materials and Methods

Materials and Methods | Results | Discussion | Acknowledgements | References

Between April 2002 and June 2005, twelve shoulders in eleven patients underwent a reverse total shoulder arthroplasty combined with a latissimus dorsi transfer. There were ten women and one man, and their ages ranged from fifty-nine to eighty-five years (average, seventy-three years). The inclusion criteria were painful pseudoparesis secondary to an irreparable rotator cuff lesion with or without destruction of the glenohumeral joint in the presence of a functional deltoid muscle as well as severe deficiency of active external rotation as documented by a positive external rotation lag sign¹⁶ and a dropping sign¹⁷. Patients with functional pseudoparesis who stated that they could not use the arm above shoulder level because of weakness but could actively elevate the arm above the horizontal if the elbow was flexed were also included. All of these patients also had a lag of at least 10° in forward flexion or abduction if the outstretched arm was brought to 120° of elevation. Concomitant incompetence of the subscapularis was not an exclusion criterion. Six of the twelve shoulders had undergone previous surgery; five had had a failed rotator cuff repair and one, an unsatisfactory result after rotator cuff débridement.

Preoperatively and at the time of final follow-up, all patients were interviewed and underwent a thorough clinical examination. In addition, functional scoring was performed with use of the system of Constant and Murley¹⁸. Computed tomography or magnetic resonance imaging was performed for all patients to assess fatty infiltration of the rotator cuff muscles, which was graded with use of the classification system of Goutallier et al.¹⁹, with modification for the magnetic resonance imaging as defined by Fuchs et al.²⁰. True anteroposterior radiographs with the arm in neutral rotation and the patient standing were used to determine the acromiohumeral distance.

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Fig. 1-A: A sixty-five-year-old woman with a massive rotator cuff tear involving the supraspinatus, infraspinatus, and teres minor associated with pseudoparesis of elevation and of external rotation. Elevation is limited to 60°, and the arm falls into internal rotation at any attempt to elevate it anteriorly.

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Fig. 1-B: Pseudoparesis of external rotation. Active external rotation is <0°, but passive external rotation is free.

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Fig. 1-C: Two years after reverse total shoulder arthroplasty without a latissimus dorsi transfer, overhead elevation is 100° but the arm remains in full internal rotation, preventing more anterior elevation.

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Fig. 1-D: At two years, active external rotation is not improved.

Initially, twelve shoulders in eleven patients were enrolled in this study. In one woman, who had not undergone previous surgery but had diabetes mellitus and was obese, a deep infection developed two months postoperatively, leading to explantation of the prosthesis. Another patient did not return for further evaluation because of unrelated medical problems. Thus, ten shoulders in nine patients were followed for an average of eighteen months (range, twelve to thirty-three months) postoperatively.

Preoperative findings included an average subjective shoulder value (the patient's estimation of the value of the operatively treated shoulder as a percentage of the value for an entirely normal shoulder) of 23% (range, 0% to 70%), an age-adjusted Constant score of 47% (range, 16% to 80%), and a pain score of 6.1 points on a scale of 0 to 15 points with 15 points indicating no pain (Table I). Preoperatively, the average forward flexion was 94° (range, 30° to 160°) and the average abduction was 87° (range, 20° to 170°). The average active external rotation in adduction measured 12° (range, —20° to 40°) with an average external rotation lag of 47° (range, 20° to 80°). Strength of abduction in the scapular plane averaged 0.25 kg (range, 0 to 1.3 kg). Findings on magnetic resonance imaging or computed tomography arthrography included rupture of the supraspinatus and infraspinatus in all shoulders. On plain radiographs made with the arm in neutral rotation, the average acromiohumeral distance measured 4.7 mm (range, 3 to 8 mm). Computed tomography or magnetic resonance imaging showed fatty infiltration of the supraspinatus, infraspinatus, and teres minor of at least grade two according to the system of Goutallier et al.¹⁹ or Fuchs et al.²⁰ in all shoulders. The average Goutallier stage of fatty infiltration of the teres minor was 2.8 (range, 2 to 4).

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TABLE I Preoperative Findings and Results at an Average of Eighteen Months Postoperatively in Eighteen Shoulders

	Mean (Range)
	Preop.	Postop.	Change	Significance of Change
Forward flexion	94° (30°-160°)	139° (115°-175°)	45°	p = 0.028
Abduction	87° (20°-170°)	145° (90°-170°)	58°	p = 0.007
External rotation	12° (-20°-40°)	19° (0°-50°)	7°	p = 0.496 (not significant)
Strength	0.25 kg (0-1.3 kg)	4.12 kg (1.3-8.2 kg)	3.87 kg	p = 0.005
Pain (0-15, 15 = no pain)	6.1 (0-10)	10.9 (4-14)	4.8	p = 0.012
Subjective shoulder value	23% (0%-70%)	64% (30%-85%)	41%	p = 0.005
Absolute Constant score	34 (11-55)	70 (47-89)	36.7	p = 0.005
Relative Constant score	47% (16-80%)	93% (68-100%)	45.20%	p = 0.005
Ability to work (0-4)	0.5 (0-1)	3.2 (2-4)	2.7	p = 0.004
Recreation/sport ability (0-4)	1.4 (0-4)	3.1 (2-4)	1.7	p = 0.014
Ability to sleep (0-2)	0.9 (0-2)	1.6 (1-2)	0.7	p = 0.053 (not significant)
Activities of daily living (0-10)	2.3 (0-4)	7.9 (5-10)	5.6	p = 0.005
Functional internal rotation (0-10)	5.8 (0-10)	4.8 (0-10)	-1	p = 0.473 (not significant)
Functional external rotation (0-10)	4.6 (0-10)	8.2 (6-10)	3.6	p = 0.024
Functional use of arm (0-10)	4.6 (0-10)	8.9 (4-10)	4.3	p = 0.034
External rotation lag sign	47° (20°-80°)	3.8° (0°-10°)	43.2°	p = 0.008

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TABLE I Preoperative Findings and Results at an Average of Eighteen Months Postoperatively in Eighteen Shoulders

	Mean (Range)
	Preop.	Postop.	Change	Significance of Change
Forward flexion	94° (30°-160°)	139° (115°-175°)	45°	p = 0.028
Abduction	87° (20°-170°)	145° (90°-170°)	58°	p = 0.007
External rotation	12° (-20°-40°)	19° (0°-50°)	7°	p = 0.496 (not significant)
Strength	0.25 kg (0-1.3 kg)	4.12 kg (1.3-8.2 kg)	3.87 kg	p = 0.005
Pain (0-15, 15 = no pain)	6.1 (0-10)	10.9 (4-14)	4.8	p = 0.012
Subjective shoulder value	23% (0%-70%)	64% (30%-85%)	41%	p = 0.005
Absolute Constant score	34 (11-55)	70 (47-89)	36.7	p = 0.005
Relative Constant score	47% (16-80%)	93% (68-100%)	45.20%	p = 0.005
Ability to work (0-4)	0.5 (0-1)	3.2 (2-4)	2.7	p = 0.004
Recreation/sport ability (0-4)	1.4 (0-4)	3.1 (2-4)	1.7	p = 0.014
Ability to sleep (0-2)	0.9 (0-2)	1.6 (1-2)	0.7	p = 0.053 (not significant)
Activities of daily living (0-10)	2.3 (0-4)	7.9 (5-10)	5.6	p = 0.005
Functional internal rotation (0-10)	5.8 (0-10)	4.8 (0-10)	-1	p = 0.473 (not significant)
Functional external rotation (0-10)	4.6 (0-10)	8.2 (6-10)	3.6	p = 0.024
Functional use of arm (0-10)	4.6 (0-10)	8.9 (4-10)	4.3	p = 0.034
External rotation lag sign	47° (20°-80°)	3.8° (0°-10°)	43.2°	p = 0.008

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Fig. 2: With the patient in the beach-chair position, the arm draped free, and the arm elevated and internally rotated, a curved incision is made lateral to the axillary crease.

Surgical Technique

The patient was placed in a beach-chair position, and the deltopectoral approach was utilized for exposure. The interval between the humeral head, the remaining parts of the rotator cuff, and the undersurface of the deltoid was identified and was freed from adhesions. A second incision was then made lateral to the posterior axillary crease with the arm held in elevation and internal rotation (Fig. 2). The tendon of the latissimus dorsi was identified and was released from its insertion on the humeral shaft under direct vision. Number-2 FiberWire sutures (Arthrex, Naples, Florida) were used to grasp the latissimus dorsi tendon with use of a running, locking stitch. A large blunt clamp was then passed through the deltopectoral interval into the plane between the teres minor and the deltoid until it exited underneath the posterior part of the deltoid through the posterior axillary incision. The two sutures were grasped with the clamp, and the tendon was passed into the superior incision (Fig. 3). The posterior axillary incision was then closed with interrupted and running skin sutures after a drain was placed, and a sterile dressing was applied. The humeral head was then resected at the anatomical neck, and the metaphysis and shaft were serially reamed and broached. The arm was then brought into adduction, hyperextension of approximately 45°, and external rotation of approximately 60°. The two sutures in the latissimus dorsi tendon were fixed transosseously to the posterolateral aspect of the greater tuberosity, resulting in a transferred musculotendinous unit under good tension and allowing fixation of the tendon to the bone and internal rotation of the adducted arm so that the forearm could be laid down on the abdomen of the patient. Both strands of both sutures were then passed through the cortex and then through holes of a small seven-hole titanium AO plate (Synthes, Paoli, Pennsylvania). This plate came thus to lie in the medullary canal. The respective strands were knotted over this plate to prevent suture cutout through the bone (Fig. 4).

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Fig. 3: No remaining rotator cuff is attached to the humerus. The humerus is in internal rotation, and the deltoid muscle is retracted with a deltoid retractor. The transferred latissimus dorsi is passed between the teres minor and the deltoid and thus in front of the deltoid retractor. The latissimus dorsi tendon is secured with number-2 polyester sutures.

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Fig. 4: The humeral head is resected at the level of the anatomical neck and brought into external rotation. The sutures are passed through the cortex at the posterior-inferior aspect of the greater tuberosity, at the insertion site of the teres minor. The sutures are passed through a seven-hole button plate and are tied inside the medullary canal. This secures fixation of the tendon to the bone and prevents sutures from cutting through the bone.

Reverse total shoulder arthroplasty then proceeded in the usual fashion through the deltopectoral approach: the glenoid component was inserted in between 0° and 10° of retroversion without any superior tilt, and the humeral component was inserted in between 0° and 20° of retroversion. The superior incision was also closed over drains, and the arm was placed in 20° of abduction and in neutral rotation in an adaptable aluminum abduction brace (Abduction Brace "Dr. Berrehail"; Pharmap Medical, Geneva, Switzerland) for between two days (the duration of patient-controlled interscalene anesthesia) and ten days. Passive mobilization of the arm out of the brace, with the goal of regaining full passive anterior elevation and with avoidance of forceful internal rotation, was started after two days postoperatively. The brace was replaced with a sling after two to ten days. Assisted active range-of-motion exercises were started after six weeks; strengthening exercises were not begun until three months postoperatively. The last three patients did not use a postoperative abduction brace; instead the shoulder was immediately placed into a sling.

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Fig. 5-A: A seventy-one-year-old woman with a massive rotator cuff tear involving the supraspinatus, infraspinatus, and teres minor. She still has very weak anterior elevation (to 140°), but the arm falls into full internal rotation during elevation. There is severe pseudoparesis of external rotation with the arm at the side and active external rotation of —25° with free passive external rotation.

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Fig. 5-B: Two years after a reverse total shoulder arthroplasty and a concomitant latissimus dorsi transfer, elevation has been fully restored and automatic external rotation also has been restored. There is excellent active external rotation, and the dropping sign has been corrected.

Statistical Analysis

The Wilcoxon test was used to compare preoperative and postoperative functional values. A p value of <0.05 was considered to be significant.

Results

Materials and Methods | Results | Discussion | Acknowledgements | References

The average duration of the combined procedure was less than 2.5 hours, ranging from 1.7 to three hours. There were two complications. As mentioned, one patient with an infection underwent removal of the implants and was excluded from further evaluation in the study. In another patient, a hematoma developed, was immediately evacuated, and healed without sequelae, and this patient remained in the study group.

The preoperative and postoperative ranges of motion, strength, pain scores, subjective shoulder values, Constant scores with its components, and external rotation lags are shown in Table I. The subjective shoulder value improved almost threefold, from 23% to 64% (p = 0.005), and the age-adjusted Constant score doubled, from 47% to 93% (p = 0.005). The score for activities of daily living more than tripled, from 2.3 to 7.9 points (p = 0.005). Significant gains were observed in average forward flexion (from 94° to 139°, p = 0.028), abduction (from 87° to 145°, p = 0.007), strength (from 0.25 to 4.12 kg, p = 0.005), and the pain score (from 6.1 to 10.9 points, p = 0.012). While the improvement in active external rotation, as measured with the arm fully adducted, was only 7° and not significant (p = 0.5), the decrease in the external rotation lag (from 47° to 3.8° p = 0.008) and the improvement in functional external rotation (from 4.6 to 8.2 of 10 points, p = 0.024) were significant. Additionally, the average ability to work and engage in recreational activities increased significantly (Table I).

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Fig. 5-C: The patient can control external rotation of the abducted arm with the transferred latissimus dorsi, evidence of at least partial restoration of teres minor function. The functionally disturbing hornblower's sign also has been corrected. This patient had an optimal result of the combination of a latissimus dorsi transfer and a reverse total shoulder replacement.

Discussion

Materials and Methods | Results | Discussion | Acknowledgements | References

Before modern reverse total shoulder arthroplasty, treatment options for painful pseudoparesis secondary to rotator cuff insufficiency included rotator cuff débridement^21,22, hemiarthroplasty^23,24, allografts²⁵, glenohumeral fusion²⁶, and constrained^27-29 and semiconstrained^29-31 shoulder arthroplasty. Conventional shoulder arthroplasties failed to restore satisfactory active motion because they did not address the absence of the rotator cuff. Total joint arthroplasties were further complicated by frequent glenoid loosening secondary to the superior-inferior translational "rocking-horse effect,"³² and early reverse prostheses failed because of catastrophic component loosening³³.

The redesign of reverse total shoulder arthroplasties by Grammont et al.^1,2 has opened a new era, allowing freedom from pain and restoring good overhead elevation with use of the deltoid alone^5,9. However, two recent clinical studies confirmed that the excellent restoration of overhead elevation was not associated with an increase in active external rotation and that the absence of teres minor integrity was associated with a substantially poorer outcome and functionally disabling loss of active external rotation^8,9.

Constant introduced the term functional external rotation³⁴, recognizing that deficient external rotation with the arm at the side does not correlate with shoulder disability, as deficient external rotation with the arm in space does. He therefore measured external rotation with the arm in space and scored external rotation in functional positions. This method of scoring external rotation correlates well with the scoring of disability³⁴. Since Constant's report, his proposed method has been used to measure functional external rotation. Latissimus dorsi transfer for restoration of active external rotation in patients with a functional external rotation deficit associated with a massive rotator cuff tear was introduced in 1988¹². The mid-term to long-term results of this procedure have shown that it can improve functional external rotation in patients with a massive posterosuperior tear of the rotator cuff^13-15,35.

In the current investigation, we assessed the results following a combination of a reverse total shoulder arthroplasty and a latissimus dorsi transfer for patients with a combined loss of active anterior elevation and external rotation. The duration of follow-up was short, but there is no evidence to suggest that the functional results at a minimum of two years should be different from those at a minimum of one year. The results of the reverse arthroplasty^8,10 and those of the latissimus dorsi transfer^12,36 at one to two years have not differed substantially from those at two to three years. Also, the current study was not meant to address the longevity of the results of this treatment but rather its functional value. Functionally, combined reverse total shoulder arthroplasty and latissimus dorsi transfer for the treatment of combined pseudoparesis of external rotation and elevation was subjectively and objectively successful (Figs. 5-A, 5-B, and 5-C) and not associated with a measurably increased complication rate. However, the series was small and, as the only relevant complication was the one infection, the complication rate cannot be compared with those in other series or experiences. The potential increase in the risk of infection caused by adding a tendon transfer to the prosthetic replacement is a concern, but we have not observed any additional infections in thirteen shoulders that were operated on after the first twelve shoulders reported on here. Nonetheless, the single infection in this series, which developed in an obese diabetic patient, should serve as a reminder that great care has to be taken in selecting patients and executing the procedure. Currently, there is no proof of either the presence or the absence of an increased risk of infection when a tendon transfer is added to a reverse total shoulder replacement. We think that this potential risk should be taken into consideration in the decision-making process.

The average subjective shoulder value, absolute and relative Constant and Murley scores, scores for activities of daily living and pain, strength, and working capacity were not only significantly improved but also were substantially improved clinically compared with the preoperative state. Compared with the results in a previous study in which patients with the same condition were treated with a reverse total shoulder arthroplasty alone as a primary intervention or as a revision of a nonprosthetic procedure and were assessed in an identical fashion¹⁰, the subjective shoulder value, relative Constant and Murley score, strength, and ranges of active elevation and abduction were better in the current series, in which the reverse total shoulder arthroplasty was done with a latissimus dorsi transfer. Sirveaux et al.⁸ documented results of a reverse total shoulder arthroplasty in shoulders with a deficient teres minor that were inferior to the results reported in this series, and our previous experience with reverse total shoulder arthroplasty in the presence of preoperative fatty infiltration of the teres minor¹¹ confirmed inferior results in the presence of fatty filtration of the teres minor. We therefore think that the excellent functional results of the combination of a reverse total shoulder arthroplasty and a latissimus dorsi transfer suggest that the latissimus dorsi transfer confers a functional benefit, and we demonstrated that latissimus dorsi transfer can restore control of external rotation in selected patients. We believe that the quality of the results in the present study necessitates a randomized trial to quantitatively establish the risks and benefits of adding a latissimus dorsi transfer.

The limitations of the reverse prostheses did not influence the results of the current study. We have not utilized the procedure in deltoid-deficient shoulders, we have not observed any more notching than has been reported in association with other reverse total shoulder arthroplasties, and we have not seen any clinical problems with instability. An external rotation contracture did not develop in any patient. The limitations of latissimus dorsi tendon transfer include weakness of elevation, which is addressed by the reverse total shoulder arthroplasty, and concomitant subscapularis insufficiency¹⁴. Subscapularis incompetence is frequently seen in shoulders requiring a reverse total shoulder arthroplasty, and latissimus dorsi transfer has not been observed to increase internal rotator weakness; thus, this contraindication to the transfer should not be considered a contraindication if the transfer is done with a reverse total shoulder arthroplasty. Nonetheless, we would repair the subscapularis if possible, as we would during any other reverse total shoulder arthroplasty.

We believe that our preliminary results confirm that combining a reverse total shoulder arthroplasty with a latissimus dorsi tendon transfer in the presence of teres minor dysfunction combines the benefits of a reverse total shoulder arthroplasty with those of a latissimus dorsi transfer. Like any preliminary work, this study has weaknesses, including a small number of patients and a relatively short follow-up. Also, the surgery is not simple and requires familiarity with reverse total shoulder arthroplasty as well as with latissimus dorsi transfer. In our hands, no procedure has lasted more than three hours. We have not treated patients who have had a prior infection or multiple previous operations and scarring with a very high probability of prior contamination. A deep infection developed in one patient with diabetes and obesity, which cautions us to limit the indication to patients in good medical condition and with a limited number of risk factors. We think that the results not only with regard to functional external rotation but also with regard to anterior elevation, which depends on automatic external rotation, provide substantial evidence that latissimus dorsi transfer can alleviate the external rotation problem substantially. Ultimately it may be possible to apply the same principle of tendon transfer by performing this combined procedure through a single anterior approach³⁷, in a fashion similar to how it was originally described by L'Episcopo³⁸. Nonetheless, the results obtained with the current concepts and technique are such that we believe that this procedure must be studied further, as it appears to substantially alleviate the key problem that sometimes persists after reverse total shoulder arthroplasty—namely, the loss of active external rotation. ?

Acknowledgements

Materials and Methods | Results | Discussion | Acknowledgements | References

Note: The authors thank Prof. B. Seifarth, PhD, Biomedical Statistician, University of Zurich, for statistical analysis of the data.

References

Materials and Methods | Results | Discussion | Acknowledgements | References

Grammont P, Trouilloud P, Laffay JP, Deries X. Etude et réalisation d'une nouvelle prothèse d'epaule. Rhumatologie. 1987;10: 407-18.10407 1987

Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics. 1993;16: 65-8.1665 1993 [PubMed]

Baulot E, Chabernaud D, Grammont PM. [Results of Grammont's inverted prosthesis in omarthritis associated with major cuff destruction. Apropos of 16 cases]. Acta Orthop Belg. 1995;61Suppl 1: 112-9. French.61112 1995 [PubMed]

Renaud P, Wahab H, Bontoux L, Dauty M, Richard I, Bregeon C. [Total inverted shoulder prosthesis and rotator cuff insufficiency: evaluation and determination of anatomical parameters predictive of good functional outcome in 21 shoulders]. Ann Readapt Med Phys. 2001;44: 273-80. French.44273 2001 [CrossRef]

Jacobs R, Debeer P, De Smet L. Treatment of rotator cuff arthropathy with a reversed Delta shoulder prosthesis. Acta Orthop Belg. 2001;67: 344-7. Erratum in: Acta Orthop Belg. 2002;68:preceding 100.67344 2001 [PubMed]

De Wilde L, Mombert M, Van Petegem P, Verdonk R. Revision of shoulder replacement with a reversed shoulder prosthesis (Delta III): report of five cases. Acta Orthop Belg. 2001;67: 348-53.67348 2001 [PubMed]

Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics. 2002;25: 129-33.25129 2002 [PubMed]

Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86: 388-95.86388 2004 [CrossRef]

Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S): 147S-161S.14147S 2005 [PubMed][CrossRef]

Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87: 1476-86.871476 2005 [PubMed][CrossRef]

Simovitch RW, Helmy N, Zumstein MA, Gerber C. Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty. J Bone Joint Surg Am. 2007;89: 934-9.89934 2007 [CrossRef]

Gerber C, Vinh TS, Hertel R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res. 1988;232: 51-61.23251 1988 [PubMed]

Warner JJ, Parsons IM 4th. Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg. 2001;10: 514-21.10514 2001 [CrossRef]

Gerber C, Maquieira G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am. 2006;88: 113-20.88113 2006 [PubMed][CrossRef]

Habermeyer P, Magosch P, Rudolph T, Lichtenberg S, Liem D. Transfer of the tendon of latissimus dorsi for the treatment of massive tears of the rotator cuff: a new single-incision technique. J Bone Joint Surg Br. 2006;88: 208-12.88208 2006 [PubMed][CrossRef]

Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5: 307-13.5307 1996 [CrossRef]

Walch G, Boulahia A, Calderone S, Robinson AH. The `dropping' and `hornblower's' signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br. 1998;80: 624-8.80624 1998 [PubMed][CrossRef]

Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214: 160-4.214160 1987

Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304: 78-83.30478 1994 [PubMed]

Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8: 599-605.8599 1999 [CrossRef]

Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am. 1997;79: 715-21.79715 1997 [PubMed]

Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am. 1995;77: 857-66.77857 1995 [PubMed]

Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg Am. 2001;83: 1814-22.831814 2001 [PubMed]

Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-deficient shoulders. J Shoulder Elbow Surg. 1996;5: 362-7.5362 1996 [CrossRef]

Moore DR, Cain EL, Schwartz ML, Clancy WG Jr. Allograft reconstruction for massive, irreparable rotator cuff tears. Am J Sports Med. 2006;34: 392-6.34392 2006 [PubMed][CrossRef]

Arntz CT, Matsen FA 3rd, Jackins S. Surgical management of complex irreparable rotator cuff deficiency. J Arthroplasty. 1991;6: 363-70.6363 1991 [CrossRef]

Post M, Jablon M. Constrained total shoulder arthroplasty. Long-term followup observations. Clin Orthop Relat Res. 1983;173: 109-16.173109 1983

Post M. Constrained arthroplasty: its use and misuse. Semin Arthroplasty. 1990;1: 151-9.1151 1990 [PubMed]

Coughlin MJ, Morris JM, West WF. The semiconstrained total shoulder arthroplasty. J Bone Joint Surg Am. 1979;61: 574-81.61574 1979

Nwakama AC, Cofield RH, Kavanagh BF, Loehr JF. Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing. J Shoulder Elbow Surg. 2000;9: 302-7.9302 2000 [CrossRef]

Neer CS 2nd, Craig EV, Fukuda H. Cuff tear arthropathy. J Bone Joint Surg Am. 1983;65: 1232-44.651232 1983 [PubMed]

Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3: 39-46.339 1988 [PubMed][CrossRef]

Brostrom LA, Wallensten R, Olsson E, Anderson D. The Kessel prosthesis in total shoulder arthroplasty. A five-year experience. Clin Orthop Relat Res. 1992;277: 155-60.277155 1992 [PubMed]

Constant CR. Age related recovery of shoulder function after surgery [thesis]. Cork, Ireland: University College. 1986. 1986

Iannotti JP, Hennigan S, Herzog R, Kella S, Kelley M, Leggin B, Williams GR. Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Factors affecting outcome. J Bone Joint Surg Am. 2006;88: 342-8.88342 2006 [PubMed][CrossRef]

Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. 1992;275: 152-60.275152 1992

Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Reverse prosthesis design, rationale and biomechanics. In: Walch G, Boileau P, Molé D, Favard L, Lévigne C, Sirveaux F, editors. Reverse shoulder arthroplasty: clinical results, complications, revision. Montpellier, France: Sauramps Medical; 2006. p 25-55.25 2006

L'Episcopo JB. Tendon transplantation in obstetrical paralysis. Am J Surg. 1934;25: 122-5.25122 1934 [CrossRef]

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Christian Gerber, Scott D. Pennington, Erich J. Lingenfelter, Atul Sukthankar; Reverse Delta-III Total Shoulder Replacement Combined with Latissimus Dorsi TransferA Preliminary Report. The Journal of Bone & Joint Surgery. 2007 May;89(5):940-947.

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