Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: As an isolated procedure or with a reverse arthroplasty

Abstract

Definitive loss of active external rotation of the shoulder impacts an individual's ability to perform ADL's, creating severe disability. To restore active external rotation, we modified the L'Episcopo procedure by transferring both the latissimus dorsi and teres major (LD/TM) through a single delto-pectoral approach. The two tendons were rerouted and reattached laterally on the humerus to the stump of the pectoralis major which was partially transected to the posterior epiphysis. Fifteen consecutive patients who underwent this procedure; (mean age 63.2 years), have been followed for at least one year (range 14-63). The transfer was indicated alone in 7 patients with an isolated loss of active external rotation (ILER) related to an irreparable postero-superior cuff tear. It was associated with a reverse shoulder prosthesis in 8 patients with combined loss of active elevation and external rotation (CLEER): 6 cases of rotator cuff tear arthropathy and 2 of tumor reconstruction. For the series as a whole, the mean increase in active elevation was 34.7 degrees . The gain in active external rotation was +27 degrees for ILER patients and +28 degrees for CLEER patients. Constant score improved to 65.6 (range, 51-79). Subjective shoulder value (SSV) was significantly improved from 34% to 72% (P < .0009). All but one patient was satisfied or very satisfied with the result. The major contributor to their satisfaction was the ability to control the spatial positioning of the arm, eliminating the tendency of the forearm to swing in toward the trunk. One patient had a return of a lag sign after a fall. The modified tendon transfer, performed in the beach chair position through a delto-pectoral approach, is less invasive than the classic two-incisions procedure and provides good functional results in patients with absent or atrophic infraspinatus and teres minor. When the modified LD/TM transfer is associated with a reverse shoulder arthroplasty, it allows to restore both active elevation and external rotation.