The Journal of Bone and Joint Surgery (American). 2007;89:940-947.
doi:10.2106/JBJS.F.00955
© 2007 The Journal of Bone and Joint Surgery, Inc.
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 Shoulder/Elbow Test 18: Summer 2007 (publication date August 15, 2007; expi...
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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 and Atul Sukthankar, MD1

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

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

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.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

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.


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