Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm

Abstract

Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70 degrees to 148 degrees (+78 degrees ) and external rotation from -18 degrees to 18 degrees (+36 degrees ). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.

Fig. 1A–E

An example of a disappointed patient after RSA because of absence of active external rotation. (A) Although the postoperative radiograph shows a well positioned RSA and (B) consent active forward elevation is restored, the patient is disappointed because of (C) persistent hornblower’s sign with inability to control the position of the arm in space. (D) She has negative external rotation with the arm at the side and (E) her preoperative CT scan demonstrated complete fatty infiltration of the teres minor muscle.

Fig. 2A–B

Principles of the surgical procedure are shown. The reverse prosthesis restores active elevation and the latissimus dorsi and teres major (LD/TM) transfer improves active external rotation. The two tendons that are located at the medial border of the humerus are harvested after partial section of the pectoralis major tendon (A). Because of the lowered, medialized position of the humerus in front of the glenosphere, the course of the rerouted tendons is short and horizontal, facilitating reattachment to the posterior aspect of the humerus (B).

Fig. 3A–B

Intraoperative photographs are shown of (A) the two tendons (latissimus dorsi and teres major [LD/TM]) after correct release, ready for transfer; and (B) the tendon transfer around the humerus may be facilitated by dislocation of the reverse prosthesis.

Fig. 4

Postoperative immobilization with 30° of abduction and 30° of external rotation is mandatory after RSA and tendon transfer.

Fig. 5A–F

A patient with a combined loss of active elevation and external rotation (A) and associated cuff tear arthritis, Hamada and Fukuda [24] stage 3 (B); a reverse prosthesis associated with LD/TM transfer (C) allows restoration of both active elevation (D) and external rotation with the arm at the side (E) and in abduction (negative hornblower’s sign) (F).