Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Evan L. Flatow, MD, and Bradford Parsons, MD*,
The Mount Sinai Hospital, New York, NY
Posted May 2007
Reverse total shoulder arthroplasty has been reported to
offer both pain relief and functional gains for patients with cuff-deficient
shoulder arthritis1,2,3. The ideal candidate for reverse
arthroplasty is a healthy, elderly patient who puts low demand on the shoulder
and who has an irreparable rotator cuff tear, painful glenohumeral arthropathy,
superior migration of the humeral head and pseudoparesis of elevation, and intact
active external rotation. Reverse arthroplasty has proved reliable in restoring
active elevation, but (as has been insufficiently emphasized at courses and
meetings) does not improve and may even worsen weakness of external rotation3.
Unfortunately, patients with cuff-deficient arthropathy
often have some degree of external rotation dysfunction. This can vary from
mild weakness to overt lag signs such as the hornblower's sign or the dropping
sign. In large cuff tears involving the supraspinatus and the infraspinatus, an
intact teres minor may allow for maintenance of functional external rotation.
The more difficult patients to treat with this prosthesis are those in whom teres
minor function has also been lost, as weakness in external rotation can be
profound and will not be improved by reverse arthroplasty alone.
The senior author (C.G.) of the current study has previously
introduced latissimus dorsi transfer as a treatment for loss of active external
rotation in patients with massive rotator cuff tears4. He and his
colleagues now report promising preliminary results of combining reverse
arthroplasty and latissimus dorsi transfer to treat arthritic shoulders that
have deficits of both active elevation and external rotation. Although a
significant 5° loss (p = 0.04) of active external rotation was noted after
reverse arthroplasty alone in a prior study from the same institution3,
no significant loss of active external rotation was noted in the present study (in
fact, a trend toward improvement was noted) and there was a significant
increase (p = 0.024) in functional active external rotation in abduction, which
is probably more important functionally to most patients5.
It must be emphasized that this is a preliminary report with
early follow-up, and that this is a case series without contemporaneous controls.
The authors note in their discussion that randomized, prospective trials are
needed to fully evaluate the risks and benefits of adding latissimus transfer
to reverse arthroplasty. The use of historical controls is always difficult, as
subtle shifts in operative technique or patient selection can have unexpectedly
large effects. The authors included patients with "functional" pseudoparesis,
who were weak but could actively elevate the limb above the horizontal
(preoperative active abduction ranged as high as 170°), while the prior
published report by the senior author included only those with active elevation
of <90°3. However, the focus in the current study on patients
with profound external rotation deficiency, all of whom had stage-2 or greater
fatty infiltration of the teres minor, is commendable, and makes the reported
results all the more impressive, given the association of loss of teres minor
function with reduced function after reverse arthroplasty2.
This is not a simple operation; it should be performed by
surgeons who are skilled in reverse shoulder arthroplasty and familiar with
latissimus dorsi transfer. The reported technique includes an additional
posterior incision (although the authors note that Boileau et al. have reported
performing the transfer through the same type of anterior deltopectoral
incision), and it is logical to worry that hematoma formation and infection
might be higher than with reverse arthroplasty alone. There was only one
infection in this small series, and a larger study will be needed to definitively
assess these risks.
In summary, these results suggest that, for patients who are
otherwise candidates for reverse shoulder arthroplasty but who have profound
external rotation weakness, the addition of a latissimus dorsi transfer by
experienced surgeons may improve functional external rotation. This is an
important original contribution.
*The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Zimmer Inc.). Also, a commercial entity (Zimmer Inc.) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
References
1. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.
2. 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 multicenter study of 80 shoulders. J Bone Joint Surg Br. 2004;86:388-95.
3. 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.
4. 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 Rel Res. 1988;232:51-61.
5. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Rel Res. 1987;214:160-4.
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