Reverse total shoulder arthroplasty with combined latissimus dorsi and teres major transfer in massive irreparable rotator cuff tear with loss of active external rotation: circumferential suturing technique

Abstract

BackgroundElderly patients with a massive irreparable rotator cuff tear suitable for reverse total shoulder arthroplasty (rTSA), combined with additional loss of active external rotation (ER), experience distress after rTSA alone due to the inability to perform daily tasks that require spatial control of the arm’s position. We hypothesized that performing a combined transfer of Latissimus dorsi (LD) and Teres major (TM) along with rTSA in such patients could lead to improved outcomes after surgery, including those requiring active ER. MethodsThis is a retrospective review of 17 patients with a massive irreparable rotator cuff tear and loss of active ER, managed with rTSA and combined LD and TM transfer using a novel circumferential suturing technique. Eleven patients were female, and 6 were male, with a mean age of 73.2 years (ranging from 60 to 82 years). The mean follow-up was 60.5 months. Preoperative and final follow-up clinical and radiological findings were assessed and compared for all patients. ResultsThe mean forward flexion (FF) increased from 92° to 137° (P = .001). The mean abduction improved from 94° to 106° (P = .025). The mean ER improved from −14° to 8° (P < .001). The mean range of internal rotation decreased from 4.9 to 4.3 points (thoracolumbar junction to L2) (P = .065). The mean improvement of strength expressed as a percentage of the opposite side was significant for FF, abduction, and ER (P < .001). The mean visual analog scale score for pain improved from 5.5 to 1.7 point (P < .001). The mean University of California at Los Angeles shoulder score increased from 12.6 to 26.7 points (P < .001). The mean Constant Murley shoulder score improved from 40.6 to 75.7 (P < .001). The mean activities of daily living score, which requires active ER, increased from 4.5 to 22.3 points (P < .001). There was a reversal of loss of active ER in 15/17 (88.2%) patients. No perioperative complications related to the tendon transfer and fixation were observed. ConclusionThe combination of rTSA with LD and TM transfer leads to gains in FF and ER, improving clinical outcomes, including those requiring active ER. Circumferential suturing of LD and TM transfer avoids problems with suture anchors, interference screws, or bone tunnels. The posterodistal attachment site opposite to the original LD insertion is endorsed to mitigate the loss of internal rotation.