Loss Of Active External Rotation Research Articles

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

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.

Understanding shoulder pseudoparalysis. Part II: Treatment

Decision-making for the treatment of pseudoparalytic shoulders is complex and a high level of experience in shoulder surgery and outcome evaluation is required.Management and results depend on clinical findings, tear and tissue quality, patient and surgeon criteria. Clinical findings determine the exact definition and direction of pseudoparesis and pseudoparalysis.Tear pattern and tissue quality determine if the rotator cuff is repairable or irreparable. Age and general health are important patient factors.Non-operative treatment is the first option for patients with a higher risk profile for reconstruction or arthroplasty, but delineation of its value requires better evidence.Tendon transfers are used for irreparable loss of the horizontal force couple balance (rotation). Options include latissimus dorsi, pectoralis minor and major for loss of active internal rotation, and latissimus dorsi ± teres major and lower trapezius for loss of active external rotation (AER).Partial cuff repair with or without superior capsular reconstruction using allograft or biceps tendon is an option for loss of active forward elevation.Treatment for the combined loss of elevation and external rotation patients is still not clear. Options include lateralised reverse shoulder arthroplasty (RSA) alone or combined RSA with a tendon transfer.RSA with loss of AER can be revised by adding a tendon transfer.

Modified L'Episcopo tendon transfer for isolated loss of active external rotation

Patients with isolated loss of active external rotation (ILER) but preserved active forward elevation have recently been identified as a rare and distinct clinical entity. The modified L'Episcopo procedure attempts to restore horizontal muscle balance and restore active external rotation. A retrospective study was performed for all patients with ILER and preserved forward elevation with Hamada stage ≤2 changes undergoing the modified L'Episcopo tendon transfer. Preoperative rotator cuff fatty infiltration and morphology was reported. Clinical, radiographic, and functional outcomes were recorded preoperatively and compared to postoperative outcomes at a minimum of 24 months' follow-up. Nine patients (8 male, 1 female) with a mean age of 58.4 years(range, 51-67 years) were evaluated at a mean follow-up of 64.3 months (range, 24-126 months). Significant improvement was demonstrated in active external rotation with the arm at the side (mean increase of 47°; range, 30°-60°, P = .004) and at 90° abduction(mean increase of 41°; range, 20°-70°, P = .004). The mean Constant score and pain score significantly improved at final follow-up (P = .004). All patients were either very satisfied or satisfied, with a mean subjective shoulder value of 74% (range, 60%-99%). In appropriately selected patients with ILER and preserved active forward elevation, the modified L'Episcopo procedure can restore horizontal muscle balance and produce significant improvements in active external rotation, Constant score, and pain.

How to Optimize Reverse Shoulder Arthroplasty for Irreparable Cuff Tears.

Reverse shoulder arthroplasty (RSA) is commonly considered as one of the options for surgical management of the functionally irreparable rotator cuff tear (FIRCT). This article reviews tips and tricks to optimize the outcome of RSA when performed specifically for this indication. RSA has been reported to provide satisfactory outcomes in a large proportion of patients with FIRCTs. However, subjective satisfaction is lesser in patients with well-maintained preoperative motion as well as those with isolated loss of active external rotation. The popularity of implants that provide some degree of global lateralization continues to increase. Optimizing the outcome of RSA for FIRCTs requires a careful balance between minimizing perimeter impingement and enhancing the function of intact muscles, in particular the deltoid and any remaining rotator cuff. Controversy continues regarding the benefits and disadvantages of subscapularis repair at the time of RSA. Tendon and muscle transfers performed at the time of RSA have the potential to optimize the outcome in selected patients with profound weakness in external rotation or those with severe deltoid dysfunction. When RSA is considered for patients with a FIRCT without arthritis, careful attention to indications and technical pearls may contribute to optimize outcomes.

Massive irreparable rotator cuff tears

Management of massive irreparable posterosuperior rotator cuff tears is a surgical challenge, particularly in young active patients without any signs of osteoarthritis. Different surgical techniques have been described. To the three main deficits of active range of motion previously reported for a massive irreparable cuff tear, i.e., isolated loss of active elevation (ILEA), isolated loss of active external rotation (ILER), and combined loss of elevation and external rotation (CLEER), we add two new entities: isolated loss of active internal rotation (ILIR) and combined loss of active elevation and active internal rotation (CLEIR). We suggest that a combined deficit (CLEER or CLEIR) could lead to a new definition of a pseudoparalytic shoulder and propose a novel algorithm to redefine the role of latissimus dorsi transfer in each of these situations. We also describe a fully arthroscopic latissimus dorsi transfer technique that prevents any deltoid muscle insult, offers better visualization of the neighboring neurovascular structures at risk, and allows simultaneous management of biceps pathology and partial rotator cuff repair.

Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer

The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance. During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months). Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery. ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.

Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion

Management of massive chronic rotator cuff tears remains controversial, with no clearly defined clinical presentation as yet. The purpose of the study was to evaluate the effect of tear size and location on active motion in patients with chronic and massive rotator cuff tears with severe muscle degeneration. One hundred patients with massive rotator cuff tears accompanied by muscle fatty infiltration beyond Goutallier stage 3 were prospectively included in this study. All patients were divided into 5 groups on the basis of tear pattern (supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor). Active range of shoulder motion was assessed in each group and differences were analyzed. Active elevation was significantly decreased in patients with 3 tear patterns involved. Pseudoparalysis was found in 80% of the cases with supraspinatus and complete subscapularis tears and in 45% of the cases with tears involving the supraspinatus, infraspinatus, and superior subscapularis. Loss of active external rotation was related to tears involving the infraspinatus and teres minor; loss of active internal rotation was related to tears of the subscapularis. This study revealed that dysfunction of the entire subscapularis and supraspinatus or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis or involvement of more than 2 rotator cuff muscles.

Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder

Reverse total shoulder arthroplasty (RTSA) allows correction of pseudoparesis of elevation caused by irreparable rotator cuff tear but does not address loss of active external rotation. Latissimus dorsi transfer (LDT) is an established procedure for correction of pseudoparesis of external rotation. Forty-one shoulders of 40 consecutive patients, who were a mean age of 70 years old (range 47-85 years), underwent RTSA combined with LDT for irreparable rotator cuff failure with severe shoulder dysfunction. Nine orthopedic complications occurred in 7 of the 41 shoulders. Four shoulders were lost to follow-up, and 5 were excluded from the functional analysis. The mean follow-up of the eligible 32 shoulders with the prosthesis still in place was 53 months (range, 24-105 months). The age-related Constant score increased significantly from a preoperative mean of 45% (range, 16%-80%) to 89% (range, 25%-100%). The mean subjective shoulder value increased from 33% (range, 0%-70%) to 75% (range, 30%-100%). Active external rotation significantly improved from a mean of 4° (range, -30° to 40°) to 27° (range, -10° to 70°). A preoperative external rotation lag sign could be corrected in 25 of the 32 shoulders. For the 16 shoulders with at least 5 years of follow-up, the Constant scores were 47% (range, 16%-80%) preoperatively, 92% (range, 51%-100%) at 2 years, and 94% (range, 57%-100%) at the latest follow-up, and the respective subjective shoulder values were 32% (range, 0%-70%), 73% (range, 30%-100%), and 80% (range, 60%-100%). If treated with RTSA combined with LDT, patients with pseudoparesis of elevation and pseudoparesis of external rotation can expect an excellent clinical outcome for a period beyond 5 years, provided that complications that require removal of the prosthesis can be prevented.

Results of latissimus dorsi tendon transfer for irreparable cuff tears

Rupture of the supraspinatus and infraspinatus tendon (and teres minor) can cause loss of active external rotation (ER), entailing severe functional disability in daily activities. Latissimus dorsi tendon transfer (LDTT), proposed by Gerber in 1988, appears to be the best adapted solution in these cases of irreparable posterior and superior cuff tears. Between 2001 and 2004, 30 patients were operated on by the technique described by Gerber, with the transfer fixed anteriorly to the subscapularis tendon and laterally to the greater tuberosity by transosseous suture. One patient, subsequently requiring revision with a reversed prosthesis, was considered as a failure. Twenty-six patients were reviewed with a mean follow-up delay of 34+/-12 months. There were 14 men and 13 women. Mean age was 55.5 years (36 to 71 years). Preoperatively, active ER was symmetric in seven cases, loss of active ER was moderate with positive lag sign in five cases, significant with positive dropping sign in six cases, and severe in nine cases. Fatty muscular degeneration was present and significant in all cases for the infraspinatus muscle and in 14 cases for the teres minor muscle (associated with significant ER loss). Subjectively, 85% of the patients were very satisfied or satisfied and the Subjective Shoulder Value (SSV) was 68+/-17%. The pain score improved from 4.8+/-3 preoperatively to 12.2+/-2 postoperatively, strength from 3.7+/-2 kg to 4.2+/-1.8 kg, mean Constant score from 50+/-12 to 74+/-9, and Constant score adjusted for age and gender from 62+/-15% to 91+/-11%. Mean active ER gain was 7 degrees (-30 degrees to +50 degrees). The loss of active ER was aggravated in one case, unchanged in three, improved in nine and corrected in six. Hornblower sign was corrected in six cases and persisted in nine. Postoperatively, 8% of the patients were unable to eat and drink, compared to 64.7% preoperatively. The results of this series are comparable to those found in the literature for first-intention cases. LDTT restored active ER, but the results were incomplete and variable. Improvement was better in case of severe preoperative active ER deficit and insufficiency of the teres minor muscle. Recovery of strength was not observed in the present series. A narrow subacromial space and grade-3 Hamada classification had negative impact. In spite of an expected tenodesis effect, LDTT did not recenter the humeral head. LDTT compensates the deficient teres minor muscle rather than the infraspinatus muscle. The optimal indication for LDTT is irreparable superior and posterior rotator cuff rupture with loss of active ER associated with a deficient teres minor muscle. It is debatable whether LDTT is indicated in the absence of active motion deficiency: improvement was observed in these cases, but only in terms of subjective criteria.

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

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.

Latissimus Dorsi and Teres Major Transfer With Reverse Total Shoulder Arthroplasty for a Combined Loss of Elevation and External Rotation

Loss of active external rotation of the shoulder, related to absent or fatty infiltrated rotator cuff muscles, results in a patient's inability to move the hand to the mouth or to the top of the head. When this condition is combined with pseudoparalysis of the shoulder (active flexion <90 degrees), the patient has a limb that is only functional at waist level. Although the reverse prosthesis restores active elevation, it does not enhance external rotation and tremendous disability, and patient dissatisfaction persists. To restore active external rotation for the patient who has a combined loss of active flexion and external rotation, we have modified the L'Episcopo procedure, transferring both the latissimus dorsi and teres major, to perform it through a deltopectoral approach. The procedure can be performed alone for isolated loss of external rotation or in conjunction with a reverse prosthesis for combined loss of elevation and external rotation.

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Background: Patients with irreparable rotator cuff tears who present with loss of active external rotation of the shoulder lose their ability to perform activities of daily living, like shaving, brushing teeth, combing hair, feeding, drinking or dressing. While the reverse prosthesis may restore active elevation, it does not enhance internal or external rotation. We describe a modification of the L’Épiscopo procedure with transfer of the latissimus dorsi and teres major (LD/TM) through a single delto-pectoral approach in order to restore active external rotation.

Brachial plexus palsy secondary to birth injuries

We describe the long-term results in ten patients with obstetric brachial plexus palsy of anterior shoulder release combined with transfer of teres major and latissimus dorsi posteriorly and laterally to allow them to act as external rotators. Eight patients had a lesion of the superior trunk and two some involvement of the entire brachial plexus. The mean age at operation was six years, and the mean follow-up was 30 years. Before operation, the patients were unable actively to rotate the arm externally beyond neutral, although this movement was passively normal. All showed decreased strength of the external rotator, but had normal strength of the internal rotator muscles. Radiologically, no severe bony changes were seen in the glenohumeral joint. No clinically detectable improvement of active abduction was noted in any patient. The mean active external rotation after operation was 36.5°. This was maintained for a mean of ten years, and then deteriorated in eight patients. At the latest follow-up the mean active external rotation was 10.5°. The early satisfactory results of the procedure were not maintained. In the long term there was loss of active external rotation, possibly because of gradual degeneration of the transferred muscles, contracture of the surrounding soft tissues and degenerative changes in the glenohumeral joint.