Clinical Review

Reverse Shoulder Arthroplasty and Latissimus Dorsi Tendon Transfer

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In a systematic review, we critically examined and synthesized the results of individual studies on reverse shoulder arthroplasty (RSA) with latissimus dorsi tendon transfer. Two electronic databases were searched. For each included study, 2 reviewers evaluated the quality of its methods and retrieved data. In cases in which outcomes data were similar between studies, data were pooled using frequency-weighted (FW) mean values to generate summary outcomes.

Seven studies met the inclusion and exclusion criteria, and 133 patient cases were reviewed. FW mean age was 69.5 years. Patients were followed up an FW mean of 39.9 months. FW mean Constant score improved from 28.7 before surgery to 64.4 afterward (P = .0001). External rotation improved from an FW mean of –4° to 25° (P < .0001). The overall complication rate was 22.8%.

RSA combined with latissimus dorsi tendon transfer can improve function and external rotation in patients with cuff tear arthropathy and teres minor dysfunction. Its overall complication rate appears to be similar to that of RSA alone, though the rate of neuropraxia may be increased.



Take-Home Points

  • CTA with loss of teres minor has been associated with worse clinical outcomes.
  • Combined RSA and LDTT has been proposed and studied as a solution to this problem.
  • LD tendon can be transferred to native teres minor insertion or lateral bicipital groove.
  • Published studies have shown significant improvements in various subjective values, active forward elevation, external rotation, and abduction strength.
  • Overall complication rates appear similar to RSA alone, however rates of neuropraxia may be higher.

Reverse shoulder arthroplasty (RSA) is a proven procedure that typically improves pain and function in patients with rotator cuff tear arthropathy. 1 Worse clinical outcomes are seen in patients with loss of teres minor function. 2,3 The teres minor is often the last important external rotator of the shoulder left in cuff tear arthropathy. When its function is lost, the ability to achieve active external rotation may become diminished. This phenomenon was termed combined loss of active elevation and external rotation (CLEER) by Boileau and colleagues. 4 Patients with CLEER typically exhibit weakness with external rotation of the shoulder—most pronounced with the arm in an abducted position. Clinical examination may reveal a positive Hornblower test, and magnetic resonance imaging (MRI) of the shoulder often shows atrophy in the teres minor muscle. 5

Patients with CLEER often do not exhibit the same degree of clinical improvement after RSA, largely because the external rotation strength deficit remains unchanged, causing persistent difficulty in completing activities of daily living (eg, combing hair, brushing teeth, eating). 6 One option for treating patients with CLEER is to combine RSA with latissimus dorsi tendon transfer (LDTT) with or without teres major (TM)tendon transfer. In 1934, L’Episcopo 7 was the first to describe performing LDTT with TM tendon transfer in an attempt to restore external rotation in patients with brachial plexus palsy. This procedure typically is used for irreparable posterior-superior rotator cuff tears in younger patients. 8 Although the transfer was originally popularized with use of 2 incisions, 9 Boileau and colleagues 4 described a modified technique that allows the transfer to be performed through a single deltopectoral approach during RSA.

Although several authors have described the outcomes of RSA with LDTT, the expected clinical outcomes and complication rates remain elusive because of the relatively small number of patients in each case series. In a systematic review, we critically examined and synthesized the results of individual studies on RSA with LDTT. We had 3 questions: What are the demographics of patients treated with RSA-LDTT? What outcomes are associated with this combined procedure? What are the associated complications, and how often do they occur?


PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. PubMed and Scopus computerized literature databases were searched through July 2015. Articles were identified with keyword searches ( Figure). In our review, we included only studies that were reported in English, that included a minimum of 10 patients at baseline, and that had follow-up of at least 12 months; we excluded review papers, case reports, and technique papers without patient data. Mr. Sheth performed the initial search, and he and Dr. Namdari reviewed the qualifying abstracts. If one of the authors selected a paper, it was moved to the next phase of the review process. At the final phase (full-text review), there were no disagreements about which articles ultimately would be included (Figure).


We obtained 36 articles from PubMed and 12 from Scopus (Figure). Of these 48 articles, 15 were removed on the basis of their titles (reviews or editorials), and 8 for being duplicates. The remaining 25 articles underwent abstract review, which eliminated 17: reviews, case reports, technique articles, instructional articles, and reports on small case series (<10 patients) or studies lacking the minimum 12-month follow-up. The remaining 8 articles underwent full-text review. Inclusion/exclusion criteria removed 1 article, leaving 7 qualifying articles for analysis.

None of the studies compared outcomes with those of a control (nonoperative) group or an alternative surgical treatment. One study reported outcomes of RSA with and without LDTT; in this instance, we included only the data specific to the RSA-with-LDTT cases. Data from the individual studies were compiled to obtain demographic statistics. In cases in which outcomes data were consistently reported between studies, results were pooled for calculation of percentages and frequency-weighted (FW) means. FW means and grouped standard deviations were used to generate P values, using the number of “subjects” as the number of studies. As a result, comparative statistics for each variable were reported as means that

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