Restoration of External Rotation Following Reverse Shoulder Arthroplasty without Latissimus Dorsi Transfer

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.

Tendon transfers in reverse total shoulder arthroplasty: A systematic review and descriptive synthesis of biomechanical studies

BACKGROUND

The role of tendon transfer and ideal insertion sites to improve axial rotation in reverse total shoulder arthroplasty (RTSA) is debated. We systematically reviewed the available biomechanical evidence to elucidate the ideal tendon transfer and insertion sites for restoration of external and internal rotation in the setting of RTSA and the influence of implant lateralization.

PATIENTS AND METHODS

We queried the PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify biomechanical studies examining the application of tendon transfer to augment shoulder external or internal rotation range of motion in the setting of concomitant RTSA. A descriptive synthesis of six included articles was conducted to elucidate trends in the literature.

RESULTS

Biomechanics literature demonstrates that increasing humeral-sided lateralization optimized tendon transfers performed for both ER and IR. The optimal latissimus dorsi (LD) transfer site for ER is posterior to the greater tuberosity (adjacent to the teres minor insertion); however, LD transfer to this site results in greater tendon excursion compared to posterodistal insertion site. In a small series with nearly 7-year mean follow-up, the LD transfer demonstrated longevity with all 10 shoulders having>50% ER strength compared to the contralateral native shoulder and a negative Hornblower's at latest follow-up; however, reduced electromyography activity of the transferred LD compared to the native contralateral side was noted. One study found that transfer of the pectoralis major has the greatest potential to restore IR in the setting of lateralized humerus RTSA.

CONCLUSION

To restore ER, LD transfer posterior on the greater tuberosity provides optimal biomechanics with functional longevity. The pectoralis major has the greatest potential to restore IR. Future clinical investigation applying the biomechanical principles summarized herein is needed to substantiate the role of tendon transfer in the modern era of lateralized RTSA.

LEVEL OF EVIDENCE

IV; systematic review.

Outcomes of lateralized reverse total shoulder arthroplasty versus latissimus dorsi transfer for external rotation deficit: a systematic review and meta-analysis

BACKGROUND

To compare clinical outcomes following lateralized reverse shoulder arthroplasty (RSA) versus RSA with latissimus dorsi transfer (LDT) in patients with poor preoperative active external rotation (ER).

METHODS

We performed a systematic review per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We queried PubMed/Medline, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of RSA with LDT or lateralized RSA alone performed in patients with preoperative ER ≤0°. Our primary outcomes were active ER, active forward elevation (FE), Constant score, and the incidence of complications.

RESULTS

We included 12 RSA with LDT studies with 188 shoulders and 4 lateralized RSA without transfer studies with 250 shoulders. Mean preoperative ER in RSA with LDT was -14°, while mean preoperative ER in lateralized RSA alone was -11°. Lateralized RSA alone was associated with superior postoperative ER (28° vs. 22°, P=0.010) and Constant score (69 vs. 65, P=0.014), but similar postoperative FE (P=0.590). Pre- to postoperative improvement in ER and FE was similar between cohorts. RSA with LDT had a higher incidence of nerve-related complications (2.1% vs. 0%) and dislocation (2.8% vs. 0.8%) compared to lateralized RSA alone.

CONCLUSIONS

Both RSA with LDT and lateralized RSA are reliable options to restore ER in patients with significantly limited preoperative ER. Our analysis suggests that lateralized RSA alone is superior to RSA with LDT in patients with either a medialized or lateralized implant design and confers a lower risk of complications, particularly nerve injury and dislocation. However, the addition of an LDT may still be indicated in certain patient populations with very severe ER loss. Level of evidence: IV.

Anatomic Versus Reverse Total Shoulder Arthroplasty for Primary Osteoarthritis With an Intact Rotator Cuff: A Midterm Comparison of Early Top Performers

BACKGROUND

Several surgeons state that their best anatomic total shoulder arthroplasty (aTSA) outperforms their best reverse total shoulder arthroplasty (rTSA) when performed for rotator cuff-intact glenohumeral osteoarthritis. We identified the top-performing aTSAs and rTSAs at short-term follow-up and compared their clinical performance at midterm follow-up to validate this common claim.

METHODS

A retrospective review of a multicenter shoulder arthroplasty database was conducted. All shoulders undergoing primary aTSA or rTSA for rotator cuff-intact glenohumeral osteoarthritis between 2007 and 2020 were reviewed. Shoulders with a follow-up clinical visit between 2 and 3 years and a clinical follow-up of minimum 5 years were included. Two separate cohorts were identified: patients with a top 20% (1) American Shoulder and Elbow Surgeons (ASES) score and (2) Shoulder Arthroplasty Smart (SAS) score at 2 to 3 years of follow-up. Clinical outcomes including range of motion, outcome scores, and rates of complications and revision surgeries were compared at minimum 5-year follow-up.

RESULTS

The ASES score cohort comprised 185 aTSAs (mean age 67 years, 42% female) and 49 rTSAs (mean age 72 years, 45% female). The SAS score cohort comprised 145 aTSAs (mean age 67 years, 59% female) and 42 rTSAs (mean age 71 years, 57% female). Active external rotation (ER) was greater after aTSA at midterm follow-up in both ASES and SAS score cohorts; however, preoperative to postoperative improvement was equivalent. Postoperative ER and SAS scores were greater after aTSA in both cohorts ( P < 0.05); however, no other significant differences in any preoperative or postoperative clinical outcomes were present ( P > 0.05), and patients achieved the minimal clinically important difference and substantial clinical benefit at similar rates for all outcomes. No difference was found in the incidence of complications and revision surgeries between top-performing aTSAs and rTSAs.

CONCLUSION

Among top-performing shoulder arthroplasties at early follow-up, aTSA does not appear to outperform rTSA, except superior ER at midterm follow-up.

LEVEL OF EVIDENCE

Retrospective comparative cohort study, Level Ⅲ.

Insertion sites of latissimus dorsi tendon transfer performed during reverse shoulder arthroplasty: A systematic review and meta-analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) with concurrent latissimus dorsi transfer (LDT) is a potential treatment option for restoration of external rotation (ER). Biomechanical studies have emphasized the importance of the insertion site location for achieving optimal outcomes. In this systematic review and meta-analysis, we aimed to describe what insertion sites for LDT are utilized during concomitant RSA and their associated clinical outcomes.

METHODS

A systematic review and meta-analysis were performed per PRISMA guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on patients who received RSA with LDT to restore ER and specified the site of tendon transfer insertion on the humerus. We first describe reported insertion sites in the literature. Secondarily, we present preoperative and postoperative range of motion and Constant score for different insertion sites as well as reported complications.

RESULTS

Sixteen studies, analyzed as 19 separate cohorts (by insertion site and tendon-transfer), reporting on 264 RSAs with LDT (weighted mean age 66 years, follow-up 39 months, 61% female) were evaluated. Of these, 143 (54%) included a concomitant teres major transfer (LDT/TMT) and 121 (46%) were LDT-only. Fourteen cohorts (14/19, 74%) reported insertion at the posterolateral aspect of the greater tuberosity, four cohorts (4/19, 21%) reported insertion site at the lateral bicipital groove, and one cohort (1/19, 5%) reported separate LDT and TMT with insertion of the TMT to the posterolateral aspect of the greater tuberosity and LDT to the lateral bicipital groove. Meta-analysis revealed no differences in range of motion or Constant score based on humeral insertion site or whether the LDT was transferred alone or with TMT. Leading complications included dislocation, followed by infection and neuropraxia. No discernible correlation was observed between postoperative outcomes and the strategies employed for tendon transfer, prosthesis design, or subscapularis management.

CONCLUSION

The posterolateral aspect of the greater tuberosity was the most-utilized insertion site for LDT performed with RSA. However, in the current clinical literature, LDT with or without concomitant TMT result in similar postoperative ROM and Constant score regardless of insertion site. Analysis of various proposed transfer sites reinforce the ability of LDT with RSA to restore both FE and ER in patients with preoperative active elevation and external rotation loss. Meta-analysis revealed significant improvements in range of motion and Constant score regardless of humeral insertion site or whether the LDT was transferred alone or with TMT, although future studies are needed to determine whether an ideal tendon transfer technique exists.

LEVEL OF EVIDENCE

IV.

Tendon Transfers in Reverse Total Shoulder Arthroplasty: A Systematic Review

PURPOSE

The purpose of this study was to evaluate clinical outcomes after tendon transfers in the setting of reverse total shoulder arthroplasty (RTSA).

METHODS

PubMed and Embase were searched according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to find primary clinical studies of any type of tendon transfer in the setting of RTSA.

RESULTS

Overall, 17 studies (level of evidence [LOE] I: 1, LOE II: 0, LOE III: 3, LOE IV: 13) met inclusion criteria, with 300 shoulders. Most patients were female (56.7%), with an average age of 68.7 years (range 19 to 89) and a mean follow-up of 46.2 months (range 6 to 174). 11 studies reported outcomes after combined latissimus dorsi and teres major transfer (LDTM) while eight studies reported on latissimus dorsi transfer only (LD). Improvements in commonly reported subjective and functional outcome measures were as follows: external rotation +32° (LDTM) and +30° (LD), flexion +65° (LDTM) and +59° (LD), Visual Analog Score -5.4 (LDTM) and -4.5 (LD), subjective shoulder value +43.8% (LDTM) and +46.3% (LD), and overall Constant score +33.8 (LDTM) and +38.7 (LD). The overall complication rate was 11.3%, including tendon transfer ruptures (0.7%), instability (3.0%), infection (2.0%), and nerve injury (0.3%). The all-cause repeat operation rate was 7.3%, most commonly for arthroplasty revision (5.3%). Subgroup analysis revealed that lateralized implants with tendon transfer resulted in markedly greater improvements in Constant score, flexion, ER1, and ER2 while medialized implants with tendon transfer had markedly greater improvements in Visual Analog Score, subjective shoulder value, and abduction.

CONCLUSION

Patients undergoing tendon transfer of either combined LDTM or latissimus dorsi alone in the setting of RTSA have markedly improved subjective and functional outcomes. A moderate incidence of complications (11.3%) was noted in this patient population.

Latin American formal consensus on the indications for the surgical treatment of massive and irreparable rotator cuff tears

OBJECTIVES

To implement the Formal Consensus Method among a group of experts in shoulder surgery in Latin America, in order to establish appropriate indications for the surgical treatment of massive and irreparable rotator cuff injuries.

METHODS

The Formal Consensus Method was used to develop surgical treatment recommendations for massive and irreparable rotator cuff tears (MIRCT). Three independent groups of experts in shoulder surgery were confirmed. The steering group conducted a systematic literature review and constructed a voting matrix consisting of 348 clinical scenarios. The rating group, composed of 15 members, rated each scenario on two occasions: first anonymously and then during an in-person discussion meeting. The median and voting ranges were used to classify each scenario as inappropriate, uncertain, or appropriate for each surgical technique. Finally, the reading group, consisting of 10 surgeons, reviewed, evaluated and rated the recommendations derived from the detailed analysis of the voting grids.

RESULTS

The main finding of the study reveals a high percentage (70%) of clinical scenarios in which consensus was achieved regarding the appropriateness or inappropriateness of different surgical alternatives for the treatment of massive and irreparable rotator cuff injuries. Through a detailed analysis of the voting grids, a total of 20 recommendations were elaborated concerning the appropriateness of various surgical techniques in addressing irreparable rotator cuff tears.

CONCLUSIONS

The indications for the operative treatment of MIRCT were determined based on expert consensus and the best available evidence, they seek to provide guidance on the appropriateness of various surgical techniques for different clinical scenarios.

LEVEL OF EVIDENCE

V.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit: A Systematic Review and Meta-Analysis

BACKGROUND

Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed.

RESULTS

Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9).

CONCLUSIONS

RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Challenges for Optimization of Reverse Shoulder Arthroplasty Part I: External Rotation, Extension and Internal Rotation

A detailed overview of the basic science and clinical literature reporting on the challenges for the optimization of reverse shoulder arthroplasty (RSA) is presented in two review articles. Part I looks at (I) external rotation and extension, (II) internal rotation and the analysis and discussion of the interplay of different factors influencing these challenges. In part II, we focus on (III) the conservation of sufficient subacromial and coracohumeral space, (IV) scapular posture and (V) moment arms and muscle tensioning. There is a need to define the criteria and algorithms for planning and execution of optimized, balanced RSA to improve the range of motion, function and longevity whilst minimizing complications. For an optimized RSA with the highest function, it is important not to overlook any of these challenges. This summary may be used as an aide memoire for RSA planning.

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

Background

To optimize patients' functional external rotation outcomes, reverse total shoulder arthroplasties (rTSAs) including a latissimus dorsi tendon transfer were undertaken with promising early results and no significant increase in complications in comparison to traditional rTSAs. This was especially utilized for patients with a pronounced combined loss of elevation and external rotation. The purpose of this study is to evaluate and synthesize the findings of all relevant publications assessing the outcomes of rTSAs with associated latissimus dorsi transfer.

Methods

We thoroughly searched the literature within the PubMed database using a standardized methodology. For our inclusion criteria, we included any study regarding rTSAs that contained functional outcome scores for postoperative range of motion (such as elevation, external rotation, etc.) or postoperative outcomes such as complications (reoperation, infection, etc.) and patient satisfaction. For the extraction of data, we used pilot-tested Google Forms to record extracted data. These data were then converted to spreadsheets (Microsoft Excel [Microsoft, Redmond, WA, USA]). This was done on 2 separate scenarios by 2 authors to ensure accuracy. We used the modified Coleman Methodology Score to assess the methodological quality of the studies in our samples. Meta-analysis mathematics and statistical analysis were performed using Stata software 17 (StataCorp, College Station, TX, USA).

Results

Our search returned a total of 12 studies containing data of 213 shoulders receiving RTSAs with a latissimus dorsi transfer. Functional outcomes were available for 160 shoulders. The mean preoperative elevation of the affected shoulder was 73.57 degrees, and the mean postoperative elevation was 141.80 degrees. For external rotation, the mean preoperative average was -6.71 degrees, and the mean postoperative average was 22.73 degrees. The absolute Constant score average was 31.56 preoperatively, while the postoperative value was 68.93. In our sample, 25 patients (11.73%) required a revision of the RTSA implant due to complications.

Discussion

Combined loss of elevation and external rotation can be a severely debilitating condition for those with a glenohumeral pathology. Latissimus dorsi transfer for this condition has been proven to be an effective modality. The reoperation and complication rate appears to be sizable, and as such surgeons should consider this when considering this modality for their patients.

Does improved external rotation following reverse shoulder arthroplasty impact clinical outcomes in patients with rotator cuff pathology and external rotation less than 0°?

BACKGROUND

The purpose of this study was to (1) evaluate whether improved external rotation (ER) in patients with preoperative ER <0° impacts their clinical outcomes following reverse shoulder arthroplasty (RSA) for rotator cuff (RC) pathology and (2) describe the differences in preoperative factors and postoperative outcomes in this patient population. Our hypothesis was that clinical outcomes would not be affected by improvement in ER using a lateralized glenosphere design.

METHODS

We retrospectively reviewed 55 patients with preoperative ER <0° who underwent primary RSA for RC pathology with lateralized glenosphere. Pre- and postoperative physician-reported ER was blindly measured using a videographic review of patients externally rotating their arm at the side. Patients were evaluated using 5 different patient-reported outcome score thresholds, measured at 12 months postoperatively: (1) minimal clinically important difference (MCID) for American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (ie, ≥20-point increase); (2) MCID for Simple Shoulder Test (SST) scores (≥2.4-point increase); (3) visual analog scale (VAS) for pain score >0; (4) mean ASES score (≥75); and (5) mean SST score (≥6.8), each of which was used to stratify the patients into 2 groups-greater than or equal to vs. less than the threshold. This resulted in 5 different evaluations comparing the 2 groups for any difference in postoperative ER or preoperative factors, including Hamada and Goutallier scores.

RESULTS

Regardless of the measured outcome, there was no difference in either postoperative physician- or patient-reported ER between patients who achieved scores higher or lower than the thresholds. Both Hamada and Goutallier score distributions were not different between groups across all the evaluated outcomes. Patients who achieved the MCID for ASES had worse preoperative VAS pain (7 vs. 4, P = .011) and SST (1 vs. 3, P = .020) scores. Across all outcome thresholds, except MCID for SST, pain reduction (ΔVAS) was significantly more pronounced in patients exceeding the thresholds. Improved forward flexion rather than ER was observed in those who achieved the ASES (160° vs. 80°, P = .020) and SST MCIDs (150° vs. 90°, P = .037). Finally, patients who exceeded the thresholds experienced higher satisfaction rates.

CONCLUSION

Improvement in ER does not appear to impact patient-reported outcome measures, including ASES and SST in patients with preoperative ER <0° undergoing RSA with a lateralized glenosphere. Patients with more severe pain and worse function at baseline experience less postoperative pain and clinically significant improvement in their reported outcomes.

The influence of preoperative rotator cuff cross-sectional area and strength on postoperative outcomes in reverse shoulder arthroplasty

BACKGROUND

Although preoperative function and range of motion (ROM) are determinants of postoperative outcome following reverse shoulder arthroplasty (RSA), there is limited data on the influence of preoperative rotator cuff status. The purpose of this study was to evaluate the relationship between preoperative rotator cuff physiologic cross-sectional area (PCSA) and strength on postoperative RSA outcome.

METHODS

A retrospective review was conducted on 53 primary RSAs from a multicenter database performed between 2015 and 2019 using a 135° humeral neck-shaft angle. Preoperative magnetic resonance imaging and computed tomographic scans were used to assess the PCSA of the subscapularis, supraspinatus, infraspinatus, and teres minor. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, ROM, and strength were measured preoperatively and at a minimum of 2 years postoperatively. Correlation coefficients were used to determine the relationship between variables.

RESULTS

There were no significant correlations between preoperative PCSA of any rotator cuff muscles and postoperative ASES scores. Preoperative subscapularis PCSA positively correlated with change in belly press (BP) strength following RSA (⍴ = 0.37, P = .006). Preoperative abduction strength was significantly correlated with postoperative abduction strength (⍴ = 0.297, P = .006). Preoperative external rotation (ER) strength was significantly correlated with postoperative ER (⍴ = 0.378, P = .005) and abduction (⍴ = 0.304; P = .032) strength. Preoperative BP strength negatively correlated with postoperative ASES (⍴ = -0.283, P = .042) but positively correlated with postoperative BP (⍴ = 0.411, P = .001) and abduction (⍴ = 0.367, P = .009) strength.

CONCLUSION

With the use of a 135° humeral implant, there is limited correlation between preoperative PCSA and postoperative outcomes 2 years following RSA; the only significant correlation was between preoperative subscapularis PCSA and postoperative BP strength. Preoperative strength is positively correlated with postoperative strength but not ROM or ASES scores.

Reverse shoulder arthroplasty with isolated latissimus dorsi or combined with teres major transfer for lack of external rotation: a comparative study

PURPOSE

The objective of this study was to evaluate the clinical and radiological outcomes of reverse shoulder arthroplasty (RSA) associated with two techniques: L'Episcopo procedure (combined teres major and latissimus dorsi transfer) and modified L'Episcopo procedure (isolated latissimus dorsi transfer).

METHODS

A retrospective review of 36 RSAs (mean age 69.8 years; SD 8.9) associated with either L'Episcopo procedure (Group 1, 21 cases) or modified L'Episcopo procedure (Group 2, 15 cases) was performed between 2007 and 2020. Clinical outcome measures consisted of range of motion (ROM), SSV, VAS, and Constant-Murley scores. These scores were compared between the two groups. Radiographs were assessed for transfer site bony lesions.

RESULTS

With a mean follow-up of 40.8 months (6-98; SD 28.8), no significant differences were revealed in the clinical outcomes: Constant score, SSV, VAS, ROM. The entire study group demonstrated a significant improvement in post-operative functional outcome scores and ROM parameters compared to their pre-operative state, IR measures being the only exception (p = 0.26). Radiographs demonstrated transfer site bony lesions in 60% of the patients (18/30). Three complications (8.3%) were noted in the study.

CONCLUSION

At the short-term follow-up, RSA combined with either latissimus dorsi (LD) transfer in isolation or in association with teres major proved to be equally effective in restoring external rotation in the settings of an irreparable postero-superior cuff tear treated with RSA. Although the LD transfer group displayed a tendency towards superior ROM, this was not supported statistically. Post-operative radiographs confirmed the presence of bony lesions at the transfer fixation sites in both groups of patients (52% vs. 72%).

Biomechanical comparison of 3 latissimus dorsi transfer sites for reverse total shoulder arthroplasty in the absence of teres minor

BACKGROUND

Reverse total shoulder arthroplasty is often performed to treat rotator cuff tear arthropathy with irreparable rotator cuff tears. Patients with full-thickness tears involving the posterior cuff and teres minor specifically lose active external rotation of the humerus, limiting activities of daily living. A latissimus dorsi transfer has been described as one potential solution, but few studies have compared different latissimus dorsi transfer sites. This study assesses the biomechanics of 3 latissimus dorsi transfer sites, examining external rotation, deltoid muscle forces, and force across the glenoid for specific activities.

METHODS

The Newcastle Shoulder Model was modified to include a Delta III reverse shoulder arthroplasty and was used to model the effects of 3 latissimus dorsi transfer sites-anterior, posterolateral, and posterodistal-in the setting of teres minor deficiency. The latissimus dorsi was represented by 5 muscle elements approximating anatomic fascicle divisions. Kinematic data sets representing common activities were input into the model, allowing calculation of muscle forces and glenoid loads.

RESULTS

Each of the 3 latissimus dorsi transfer sites demonstrated a change of moment arm from internal to external rotation with increased magnitude. Average maximum deltoid muscle forces and glenoid loading across all motions decreased for each of the 3 transfer sites, with the greatest decreased force noted for the posterior deltoid. This decrease in deltoid force and glenoid loading was significantly greater with the anterior and posterolateral transfer sites, relative to the posterodistal site.

DISCUSSION

Latissimus dorsi transfer to all 3 sites in the setting of reverse total shoulder arthroplasty and posterior rotator cuff deficiency resulted in large external rotation moment arms. The transferred latissimus dorsi shared the external rotation load and resulted in decreased deltoid forces and glenoid loading with very small differences between the 3 transfer sites. The posterodistal location reduced deltoid force and glenoid loading to a lower degree compared with other sites, but it also showed that it did not alter the tendon length compared with the native shoulder.

Humeral offset as a predictor of outcomes after reverse shoulder arthroplasty

INTRODUCTION

The Grammont-style reverse shoulder arthroplasty (RSA) relies on medialization and distalization of the shoulder center of rotation. Lateralized designs have recently gained popularity. The amount of lateralization, however, remains a controversial topic. The purpose of this study was to correlate the change in humeral offset (HO) with outcomes and complications following RSA. We hypothesized that a lateralized HO following RSA would be associated with improved range of motion (ROM), better patient-reported outcomes (PROs), and fewer complications.

MATERIALS AND METHODS

A consecutive series of 104 patients (109 shoulders) was retrospectively evaluated. All patients underwent primary RSA by 2 shoulder and elbow fellowship-trained orthopedic surgeons at 2 different centers. Inclusion criteria was a primary RSA with at least 1-year follow-up. All patients had the HO measured on a preoperative and a postoperative Grashey radiograph, and the change in HO was calculated (ΔHO = _PostHO-_PreHO). A negative value was defined as a medialized HO and a positive value as a lateralized HO. ROM and primary outcomes, including forward elevation (FE), external rotation (ER), internal rotation (IR), Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, were collected. Complications and revisions were also reported.

RESULTS

The mean age was 72 years with a mean follow-up of 22.3 months. The average FE (92° vs. 148°), ER (34° vs. 44°), SSV (35% vs. 87%), and ASES score (37.2 vs. 81.2) increased significantly (all P < .01) compared with preoperative values. The HO was medialized postoperatively in 63 shoulders and lateralized in 46 shoulders. No statistically significant differences in the mean values for postoperative FE (147° vs. 146°, P = .892), ER (43° vs. 45°, P = .582), IR (L3 vs. L3, P = .852), SSV (88% vs. 85%, P = .476), and ASES score (81.3 vs. 81.1, P = .961) were found between the groups. However, there was significantly more improvement in ER in the lateralized HO cohort than the medialized cohort (16° vs. 7°, P = .033). Six shoulders, 5 medialized and 1 lateralized HO, demonstrated scapular notching and remained asymptomatic. Five shoulders, 4 medialized and 1 lateralized HO, experienced at least 1 instability incident, and 2 shoulders with medialized HO had an acromion/scapular spine fracture. Overall, 2 shoulders with medialized HO underwent revision surgery because of instability.

CONCLUSIONS

Although RSA provides significant improvement in ROM and PROs regardless of postoperative HO, restoring baseline HO or lateralization beyond baseline may be favorable for improving ER and decreasing complications following RSA.

Mid-term outcomes after reverse total shoulder arthroplasty with latissimus dorsi transfer

Background

Reverse total shoulder arthroplasty is a common treatment for patients with rotator cuff arthropathy who have failed a prior rotator cuff repair. Latissimus dorsi transfer can be performed simultaneously to reverse total shoulder arthroplasty for patients with preoperative external rotation deficiency. Current literature is limited with several studies providing functional and pain improvements at short-term follow-up; however, there is a deficit in data regarding mid-term outcomes. The purpose of this study was to evaluate the clinical and radiographic outcomes following reverse total shoulder arthroplasty with latissimus dorsi transfer with mid-term follow-up. We hypothesized significant improvement in external rotation and shoulder functionality for patients with preoperative external rotation lag.

Methods

We retrospectively reviewed patients who underwent reverse total shoulder arthroplasty with latissimus dorsi transfer. Preoperative and postoperative changes in range of motion were assessed. American Shoulder and Elbow Surgeon Score and the Simple Shoulder Test were used to evaluate changes in shoulder function while pain scores were assessed using the Visual Analog Scale (VAS). Radiographs were reviewed for rotator cuff arthropathy, fatty infiltration, scapular notching, baseplate loosening, and osteolysis. We reported frequency and mean ± standard deviation for categorical and continuous variables, respectively. Means were compared using the paired Student's t-test and proportions using the Chi-square test.

Results

Fifteen patients met the inclusion criteria. The mean age of the cohort was 71.7 ± 8.4 years (range 51.2-87.8 years) with a mean follow-up of 6.3 ± 4.1 years (range 1.0-14.5 years). Reverse total shoulder arthroplasty with latissimus dorsi transfer improved external rotation (-7 ± 21.3° to 38 ± 15.8°; p value = 0.001). There was no statistically significant difference regarding forward flexion (116.3 ± 45.4° to 133.7 ± 14.7°; p value = 0.17) and internal rotation (T12 to L2; p value = 0.57). The procedure led to an increase in American Shoulder and Elbow Surgeon Score scores (37 ± 19 to 62 ± 22; p = 0.005) and Simple Shoulder Test scores (2 ± 2 to 6 ± 3; p value = 0.001) with a significant reduction in Visual Analog Scale scores (5 ± 3 to 2 ± 3; p value = 0.022). The procedure corrected external rotation lag in 10 patients. Radiographically, rotator cuff arthropathy was found to be grade 3 in two patients, grade 4 A in four patients, grade 4B in eight patients, and grade 5 in one patient. On postoperative imaging, scapular notching was found in six patients (40%). Twelve patients had cortical humeral erosion at the site of the latissimus dorsi transfer. Only one patient experienced a shoulder-related complication which was aseptic baseplate loosening and required a revision reverse total shoulder arthroplasty with allograft.

Conclusions

In this study, patients undergoing reverse total shoulder arthroplasty with latissimus dorsi transfer experienced improvements in range of motion, functional scores, and pain at mid-term follow-up. The shoulder-related complication rate was low.Level of evidence: IV; Case series.

Proximal humeral bone defect in reverse shoulder arthroplasty combined with latissimus-dorsi transfer is not related with a poor outcome

BACKGROUND

Reverse total shoulder arthroplasty (RSA) associated with modified L'Episcopo (isolated LD) or L'Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome.

MATERIAL AND METHODS

A retrospective review of 24 RSAs (mean age 68.71 years, range 52-83) associated with modified L'Episcopo procedure (9) and L'Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores.

RESULTS

With a mean follow-up of 44.71 months (12-97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34).

CONCLUSION

At short-term follow-up, RSA combined with L'Episcopo or modified l'Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\TM tendon transfer.

LEVEL OF EVIDENCE

IV; retrospective study.

Reverse total shoulder arthroplasty with latissimus dorsi and teres major transfer: biomechanical and electromyographical outcomes

PURPOSE

There is controversy regarding the optimal treatment for patients with rotator cuff arthropathy with external rotation deficit (CLEER group). This study analyzes the biomechanical and electromyographical outcomes of reverse total shoulder arthroplasty (RTSA) with latissimus dorsi and teres major transfer. The primary objective of this study is to compare the biomechanical and electromyographical outcomes between the treated and contralateral shoulder. Secondary objective is to define clinical and functional outcomes, and to report the radiological findings. Our hypothesis is that with this technique patients regain at least 50% of the strength in external rotation of the contralateral shoulder, and that the transferred muscles remain EMG active over time.

MATERIALS AND METHODS

All patients who underwent RTSA with latissimus dorsi and teres major transfer in our hospital between 2007 and 2015 were included. From 16 eligible patients, 10 were finally reviewed. Biomechanical assessment of rotation strength was performed postoperatively in both shoulders, and fine needle EMG of latissimus dorsi and teres major muscles was recorded at the same time in both shoulders. Constant test and clinical evaluation (Lag sign and Hornblower test) were obtained preoperative and at final follow up. Radiological (X-ray, US) assessment was also obtained for both shoulders at final follow up.

RESULTS

External rotation strength of the operated shoulder was higher than 50% the strength of the contralateral shoulder, and the differences were statistically significant (p < 0.05). No statistically differences were found regarding to internal rotation. The electromyographic assessment found no significant differences (p > 0.05) between the treated and contralateral shoulders. The mean Constant-Murley score significantly increased (30.9 points) after surgery (p < 0.01). Lag sign and Hornblower test were negative in all patients.

CONCLUSIONS

Performing RTSA with latissimus dorsi and teres major transfer is an effective procedure improve function and to restore ER strength in patients in CLEER group. The EMG records shows that transposed latissimus dorsi and teres major adapt to their new function and remain functional over time, even in elderly patients.

Medialized versus Lateralized Center of Rotation in Reverse Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis

One of the original biomechanical principles of reverse total shoulder arthroplasty (RTSA) is medialization of the center of rotation (COR) relative to the native level of the glenoid. Several authors have proposed the lateralized center of rotation, which is characterized by a lateralized (L) glenoid and medialized (M) humeral component. The aim of this review is to compare the clinical and functional outcomes of COR in medialized (M-RTSA) and lateralized (L-RTSA) RTSA in patients with uniform indications and treatment through a meta-analysis. A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Clinical Answers was conducted from April to May 2021. Twenty-four studies were included in the qualitative synthesis, and 19 studies were included in the meta-analysis. Treatment with RTSA resulted in positive post-operative outcomes and low complication rates for both groups. Statistically relevant differences between L-RTSA group and M-RTSA group were found in post-operative improvement in external rotation with arm-at-side (20.4° and 8.3°, respectively), scapular notching rates (6.6% and 47.7%) and post-operative infection rates (1% and 7.7%). Both lateralized and medialized designs were shown to improve the postoperative outcomes. Nevertheless, a lateralized COR resulted in greater post-operative external rotation.

Lateralization in Reverse Shoulder Arthroplasty

Indications for Reverse Shoulder Arthroplasty (RSA) have been extended over the last 25 years, and RSA has become the most frequently implanted shoulder arthroplasty worldwide. The initial Grammont design with medialization of the joint center of rotation (JCOR), placement of the JCOR at the bone–implant interface, distalization and semi-constrained configuration has been associated with drawbacks such as reduced rotation and range of motion (ROM), notching, instability and loss of shoulder contour. This review summarizes new strategies to overcome these drawbacks and analyzes the use of glenoid-sided, humeral-sided or global bipolar lateralization, which are applied differently by surgeons and current implant manufacturers. Advantages and drawbacks are discussed. There is evidence that lateralization addresses the initial drawbacks of the Grammont design, improving stability, rates of notching, ROM and shoulder contour, but the ideal extent of lateralization of the glenoid and humerus remains unclear, as well as the maximal acceptable joint reaction force after reduction. Overstuffing and spine of scapula fractures are potential risks. CT-based 3D planning as well as artificial intelligence will help surgeons with planning and execution of appropriate lateralization in RSA. Long-term follow-up of lateralization with new implant designs and implantation strategies is needed.

A kinematic and electromyographic comparison of a Grammont-style reverse arthroplasty combined with a l'Episcopo transfer compared to a lateralized humeral component reverse for restoration of active external rotation

PURPOSE

To assess kinematic and electromyographic findings of two designs of reverse total shoulder arthroplasty (RTSA). We tested two hypotheses: (H₁) Grammont-style (RTSA) with l'Episcopo tendon transfer gains similar postoperative kinematic findings of a lateralized humeral component RTSA without a tendon transfer; (H₂) RTSA with lateralized humeral component induces earlier shoulder muscle activation during shoulder motion compared with standard Grammont prosthesis with l'Episcopo transfer.

METHODS

Twenty-five patients with a cuff tear arthropathy, pseudoparalysis, and a positive dropping sign were sequentially included. A Grammont-style RTSA with a l'Episcopo tendon transfer was implanted in 13 patients (medialized humerus and transfer group) and an on-lay curved-stem RTSA in 12 (lateralized humerus group). Constant score; the disabilities of the arm, shoulder, and hand (DASH) score; and active shoulder range of motion (flexion, abduction, external rotation, and internal rotation) were measured pre- and postoperatively. Upper limb kinematic and surface electromyography (EMG) (anterior and posterior deltoid; upper, middle, and lower trapezius; and the upper and lower latissimus dorsi muscles) were recorded during active range of motion.

RESULTS

At > 24 months of follow-up, the Constant and DASH scores and active shoulder range of motion improved in both groups (p < 0.0001). Internal rotation was significantly higher in the lateralized humerus group than in the medialized humerus and transfer group (p = 0.004). The dropping sign was found in 0/12 patients in the lateralized humerus group and in 5/13 patients in the medialized humerus and transfer group (p < 0.001). Kinematic findings were similar between groups (p = 0.286). A pattern of earlier muscle activation in the lateralized humerus group was found as compared to the transfer group as follows: (i) posterior deltoid during external rotation (p = 0.004); (ii) upper latissimus dorsi and middle and lower trapezius during flexion (p = 0.004, p = 0.005, and p = 0.042, respectively); (iii) lower latissimus dorsi during abduction (p = 0.016).

CONCLUSION

RTSA with a lateralized humeral component provided similar active external rotation restoration to a Grammont-style RTSA with a l'Episcopo procedure in patients with a dropping sign. The posterior deltoid muscle underwent earlier activation during active external rotation in the lateralized humerus RTSA group as compared to the tendon transfer group. Our findings demonstrated the H₁ and only partially demonstrated the H₂ of the study.

Does preoperative diagnosis impact patient outcomes following reverse total shoulder arthroplasty? A systematic review

BACKGROUND

The indications for reverse total shoulder arthroplasty (rTSA) have expanded to include the treatment of a wide variety of shoulder pathologies, and there may be significant differences in patient outcomes based on preoperative diagnosis.

METHODS

A systematic review of the orthopedic literature contained in the PubMed, Cochrane, and Embase databases was performed on November 14, 2019. Studies investigating rTSA indicated for 7 distinct preoperative diagnoses (massive rotator cuff tear [MCT] without glenohumeral osteoarthritis [GHOA], MCT with GHOA or cuff tear arthropathy, primary GHOA, inflammatory arthritis with MCT, failed shoulder arthroplasty, proximal humeral fracture [PHF], and sequelae following PHF) were included. The main outcomes of interest included functional outcomes (abduction, external rotation, and forward flexion) and patient-reported outcome measures (American Shoulder and Elbow Surgeons shoulder score and Constant-Murley score). Because of significant variation in measurement and reporting, data on internal rotation were not extracted. In addition, radiographic outcomes and complication rates were extracted and recorded for each of the included studies.

RESULTS

In total, 47 studies, comprising 2280 patients, met the inclusion criteria. Significant improvements in functional outcomes and patient-reported outcome measures were found across the preoperative diagnostic groups. There were no significant differences between the diagnostic groups regarding improvement between preoperative and postoperative values for the outcomes of interest, with the exception that the inflammatory arthropathy group had significantly less improvement in the Constant-Murley score than the primary GHOA and revision arthroplasty groups. Although there were few differences in improvement between groups, there were significant differences regarding the level of postoperative functional performance, which was not as consistent in the context of trauma or revision operations (ie, complex PHF, fracture sequela, and revision arthroplasty groups).

CONCLUSION

Reverse total shoulder arthroplasty can provide reliable improvement in clinical outcomes regardless of preoperative diagnosis, with few differences across diagnostic groups regarding preoperative to postoperative improvement. The groups with primary GHOA and MCTs with or without GHOA demonstrated the most reliable postoperative functional outcomes of the examined diagnostic groups. Postoperative outcomes were not as consistent in the context of trauma or revision operations, and these groups may benefit from a variety of modern advancements in rTSA, although further research into these modalities for these groups is needed. Finally, rTSA remains an important treatment option in the context of rheumatoid arthritis, with similar outcomes and complication rates compared with the 6 other operative indications.

Restoration of External Rotation Following a Lateral Approach for Glenoid Bony Increased-Offset Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty (RSA) is a recognized therapeutic modality for a massive rotator cuff tear. Some authors recommend lateralization of the center of rotation by bony increased offset (BIO) of the glenoid for improvement of external rotation, while others refute its effects. RSA through the conventional deltopectoral approach sacrifices the subscapularis tendon during the approach. We hypothesized that a lateral approach (LA) for RSA, with less soft-tissue resection, would restore external rotation by allowing retensioning of the remaining rotator cuff with use of a BIO graft.

The effect of body mass index on internal rotation and function following anatomic and reverse total shoulder arthroplasty

BACKGROUND

The exact relationship between body mass index (BMI) and internal rotation (IR) before and after total shoulder arthroplasty has not been studied to date. The purpose of this study was to determine the effects of BMI on the preoperative and postoperative shoulder range of motion and function in anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA), and specifically how IR affects patient ability to perform IR-related activities of daily living (ADLs).

METHODS

Patients from a prospective multicenter international shoulder arthroplasty registry who underwent primary rTSA (n=1171) and primary aTSA (n=883) were scored preoperatively and at latest follow-up (2-10 years, mean = 3 years) using the Simple Shoulder Test, University of California-Los Angeles shoulder score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Constant score, and Shoulder Pain and Disability Index patient-reported outcome measures (PROMs). Measured active abduction, forward flexion, IR, and active and passive external rotation were recorded, and BMI was evaluated as a predictor of motion and patient-reported outcomes. Patient responses to questions regarding the difficulty level of IR-related ADLs were studied. The relationships between BMI, IR, and ability to perform IR-related ADLs were quantified through analysis of variance with post hoc comparisons by Tukey honestly significant difference tests, where significance was denoted as P < .05.

RESULTS

BMI was found to be inversely correlated with IR in patients undergoing both aTSA and rTSA, both preoperatively (P < .001 and P = .002) and postoperatively (P < .001 and P < .001). BMI affected the range of motion parameters of forward flexion abduction and external rotation but to a lesser extent than that of IR. Nonobese patients demonstrated significantly greater IR than overweight, obese, and morbidly obese patients postoperatively for aTSA (P < .001). For rTSA, nonobese patients had a significantly greater postoperative IR than obese and morbidly obese patients (P < .001 and P = .011, respectively). For both aTSA and rTSA patients, mean IR scores significantly differed between patients reporting normal function vs. patients reporting slight difficulty, considerable difficulty, or inability to perform IR-related ADLs. Increasing IR demonstrated a significant, positive correlation with all PROMs for both aTSA and rTSA patients (Pearson correlation, P < .001).

CONCLUSIONS

BMI is an independent predictor of IR, even when controlling for age, gender, glenosphere size, and subscapularis repair. BMI was inversely correlated with the degree of IR, and decreased IR significantly negatively affected the ability to perform IR-related ADLs.

CLINICAL RELEVANCE

Increasing BMI adversely affects shoulder ROM, particularly IR. IR is correlated with the ability to perform ADLs requiring IR in both aTSA and rTSA patients.

Mid- to long-term outcomes after reverse shoulder arthroplasty with latissimus dorsi and teres major transfer for irreparable posterosuperior rotator cuff tears

AIM

The objective of this study was to describe the outcome of reverse shoulder arthroplasty (RSA) combined with modified L'Episcopo procedure at long-term follow-up (5 to 12 years).

METHODS

A retrospective review of 17 RSAs (mean age 67.2 years) with the modified L'Episcopo procedure conducted between 2006 and 2016 was performed. All patients had a combined loss of active elevation and external rotation with an irreparable posterosuperior rotator cuff tear. Clinical assessment was performed with a minimum follow-up of five years (mean 97.3 months). Outcome measures included range of motion, subjective shoulder value (SSV), visual analogue scale (VAS), and Constant-Murley scores.

RESULTS

All patients (16) demonstrated a significant improvement in all clinical and functional parameters. VAS pain scores improved from 6 ± 2.6 to 1 ± 1; SSV improved from 35 ± 14 to 72 ± 10; active forward elevation increased from 66° ± 34 to 125° ± 29; and active external rotation arm at the body increased from -11° ± 22 to 21° ±11 and in 90° of abduction from -10° ± 17 to 37° ± 24. The mean Constant score improved from 25 ± 11 to 59 ± 8. Active internal rotation did not significantly change (p = 0.332).

CONCLUSION

At long-term follow-up, RSA combined with modified L'Episcopo procedure resulted in significant improvements in pain, range of motion, and functional scores for patients with shoulder pseudoparalysis and a lack of active external rotation caused by a massive posterosuperior cuff tear with a teres minor deficiency.

Preoperative external rotation deficit does not predict poor outcomes or lack of improvement after reverse total shoulder arthroplasty

INTRODUCTION

The purpose was to compare postoperative outcomes and functional improvement between patients with preoperative aER deficits vs. preserved aER function.

RESULTS

There were 115 patients in the <0° aER group and 314 in the ≥30° aER group. Preoperative patients in the <0° group were worse for all measures except subjective pain while post-operatively, they had significantly greater improvement for all measures of motion. Postoperatively, both groups achieved comparable scores for forward elevation, pain, SST and ASES.

CONCLUSION

This study demonstrates that patients with a complete aER deficit can recover substantial and comparable function after RTSA.

How to Optimize Reverse Shoulder Arthroplasty for Irreparable Cuff Tears

PURPOSE OF THE REVIEW

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.

RECENT FINDINGS

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.

Reverse shoulder arthroplasty with and without latissimus and teres major transfer for patients with combined loss of elevation and external rotation: a prospective, randomized investigation

BACKGROUND

Latissimus dorsi (LD) and teres major (TM) tendon transfers have been performed concurrently with reverse shoulder arthroplasty (RSA) to address combined loss of elevation and external rotation (CLEER) at the shoulder. The purpose of this prospective, randomized study was to compare RSA with and without LD-TM tendon transfer in patients with rotator cuff tear arthropathy and CLEER.

METHODS

Patients undergoing RSA for rotator cuff tear arthropathy who also had CLEER were randomized into the group undergoing RSA with tendon transfer or the group undergoing RSA without tendon transfer. The primary outcome measure was the Activities of Daily Living and External Rotation (ADLER) score 2 years after surgery. Secondary outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Simple Shoulder Test (SST) score.

RESULTS

Both the treatment and control groups showed significant improvements in the ability to perform activities of daily living requiring active external rotation measured by the ADLER score postoperatively. No significant difference in the ADLER, DASH, ASES, or SST score was found between the 2 groups at final follow-up. Resolution of the Hornblower sign occurred postoperatively in 58.3% of patients in the control group and 73.3% of those in the treatment group.

CONCLUSION

No differences in the ADLER, DASH, ASES, and SST results were found between patients treated with RSA alone and those treated with RSA with LD-TM transfer for rotator cuff tear arthropathy and CLEER. Both groups showed significant improvements in all clinical outcome assessments including functional tasks that require active external rotation.

Lateralization in reverse shoulder arthroplasty: A review

Reverse shoulder arthroplasty, as originally designed by Grammont, has revolutionized the treatment of rotator cuff arthropathy as well as fractures about the proximal humerus. The original design consisted of glenoid and humeral components with a medialized center or rotation compared to the native shoulder. Long term outcome studies on this design demonstrated high rates of scapular notching as well as significant loss of external rotation. To combat these flaws, prosthesis design has evolved to include the concept of lateralization whereby the center of rotation is moved laterally compared to the Grammont prosthesis via either the glenoid or humeral components. Lateralization via the glenoid component has sought to reduce scapular notching, however, concerns over early loosening have been raised secondary to increasing stress at the glenosphere/glenoid interface. Lateralization via the humeral component has been theorized to improve the mechanics of the remaining rotator cuff and deltoid musculature while avoiding the problems inherent with glenoid lateralization. While limited clinical evidence is available currently to support one design over the other, multiple biomechanical studies have shown improvements in rates of scapular notching and post-operative external rotation for lateralized humeral and glenoid components. Future research should aim to delineate advantages of one design over the other or optimal combinations of the two designs.

Reverse Shoulder Prosthesis With a Lateralized Glenosphere: Early Results of a Prospective Multicenter Study Stratified by Diagnosis

Background

We report here on the results, stratified by diagnosis, of a multicenter prospective study by surgeons unaffiliated with the design team of reverse shoulder arthroplasty (RSA) performed using a lateralized glenosphere. We hypothesized that outcomes would be comparable to those reported previously.Methods: A total of 245 patients underwent RSA for cuff tear arthropathy or glenohumeral arthritis with rotator cuff tear, rotator cuff tear with instability or escape and without glenohumeral arthritis, or failed shoulder arthroplasty. Clinical, radiographic, and self-assessed outcome measures were obtained preoperatively and at standardized time points postoperatively. At 2 years, 173 patients were available as 23 patients were deceased, 12 had undergone revision, and 37 were unavailable.Results: Range of motion and outcomes improved, irrespective of diagnosis. Active forward flexion, abduction, and external rotation improved (73°–127°, 65°–109°, and 24°–37°, respectively, P < .0001 for all). Simple Shoulder Test (3.2–8.5) and American Shoulder and Elbow Surgeons scores (45–86) also improved. Scapular notching occurred in 13.3%; scapular spine/acromial fractures in 6.5%. Patients undergoing revision shoulder arthroplasty improved more modestly.Conclusion: In this multicenter study, surgeons unaffiliated with the design team obtained clinical improvements comparable to those reported previously and that exceeded minimal clinically important differences for RSA. Improvements in external rotation and low scapular notching rates potentially relate to the lateralized design.