Clinical and functional outcomes of reverse total shoulder arthroplasty supplemented with latissimus dorsi transfer: a systematic review and meta-analysis

Reverse shoulder arthroplasty with isolated latissimus-dorsi transfer/additional teres-major transfer for combined loss of elevation and external rotation: A systematic review and meta-analysis

Background

The relative clinical advantages of reverse shoulder arthroplasty (RSA) with latissimus dorsi transfer (LDT) in direct comparison to RSA with latissimus dorsi and teres major (LD and TM) transfer for the treatment of combined loss of elevation and external rotation (CLEER) are not well understood. The objective of this study was to conduct a systematic review and meta-analysis to compare the two surgeries with regards to (1) preoperative severity/indications, (2) range of motion (ROM) outcomes, (3) functional and patient-reported outcomes (PROs), and (4) complications.

Methods

Following screening of three databases in accordance with PRISMA guidelines, 13 studies were included, consisting of 91 and 115 shoulders having received RSA with LDT and with LD and TM, respectively. The primary outcome was the change in external rotation. Secondary outcomes included preoperative Hamada grade and Goutallier score, abduction, forward elevation, and internal rotation, American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley Score (CMS), Simple Shoulder Test (SST), Simple Shoulder Value (SSV), Visual Analog Score (VAS) for pain, and major/minor complications, where available. Meta-analysis was performed using a random-effects model. P-values less than 0.05 were considered statistically significant.

Results

RSA with LD and TM was utilized more often than RSA with LDT for patients with higher preoperative Hamada grade (p = 0.010) and lower subscapularis Goutallier score (p = 0.015). RSA with LDT was associated with a greater improvement in abduction compared to RSA with LD and TM (75.3 versus 55.6°, p < 0.010), but had comparable changes in external rotation, forward elevation, or internal rotation. RSA with LDT was associated with a greater improvement in CMS compared to RSA with LD and TM (44.1 versus 36.4 points, p < 0.010). RSA with LDT was associated with a lower rate of major complications compared to RSA with LD and TM (7.1 versus 20.2 %, p = 0.032).

Conclusions

While improvements of external rotation were comparable, RSA with LDT may offer superior improvement in abduction and CMS, and lower rates of major complications compared to RSA with LD and TM in patients with CLEER. Orthopaedic surgeons may consider these findings in their surgical plan according to a patient's unique anatomy and clinical indications.

Level of evidence

IV, Systematic Review and Meta-analysis of Level I-IV Studies.

Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee

PURPOSE

Irreparable rotator cuff tears are disabling and can severely affect daily life activities, especially when young and active patients are involved. The definition is still debated, and they can have several clinical presentations. The treatment depends on the clinical presentation and the patient's age.

METHODS

The survey was developed by the ESSKA U45 Committee and was uploaded on the ESSKA website. Fifty-seven questionnaires were returned. Several aspects of the diagnosis and treatment of massive irreparable cuff tears were investigated. Moreover, treatment options for specific clinical scenarios were given for posterior-superior and anterior-superior cuff tears in young and old patients.

RESULTS

Fatty degeneration of the muscles was the most common criterion to define an irreparable tear (59.7%). In young patients with external rotation with the arm at side lag, partial repair of the cuff was the most common option (41.8%); in case of external rotation with the arm at side + external rotation at 90° of abduction lag without pseudoparalysis, the most common option was partial repair of the cuff + latissimus dorsi or lower trapezius transfer (39.3%), and in case of external rotation with the arm at side + external rotation at 90° of abduction lag with pseudoparalysis, partial repair of the cuff + latissimus dorsi or lower trapezius transfer was still the most common option (25.5%). The same scenarios in old patients yielded the following results: reverse prosthesis (49.1%), reverse prosthesis (44.6%) and reverse prosthesis ± latissimus dorsi or lower trapezius transfer (44.6%), respectively.

CONCLUSIONS

The present survey clearly confirms that biological options (partial cuff repairs and tendon transfers) are the reference in the case of young patients with deficient cuffs (both posterior and anterior). Reverse shoulder prosthesis is the most common treatment option in old patients in all clinical scenarios.

LEVEL OF EVIDENCE

Level IV.