Reverse Delta-III Total Shoulder Replacement Combined with Latissimus Dorsi Transfer

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.