Review Question - QID 213962

Patients with irreparable posterosuperior rotator cuff tears and rotator cuff arthropathy may require a latissimus dorsi transfer at the time of reverse shoulder arthroplasty (RTSA) due an external rotation functional deficit.

Rotator cuff arthropathy is a combination of rotator cuff insufficiency, glenohumeral cartilage destruction, superior migration of the humeral head, subchondral osteoporosis, humeral head collapse, femoralization of the humeral head, and acetabularization of the coracoacromial arch. Patients with an external rotation deficit may require a latissimus dorsi transfer. This is clinically evaluated by assessing for the presence of an external rotation lag sign or Hornblower’s sign. While the deltoid allows for the restoration of forward elevation with use of the RTSA, it may not adequately address the external rotation due to infraspinatus and teres minor dysfunction.

Puskas et al. review the use of latissimus dorsi transfer (LDT) with RTSA for patients with a combined Pseudoparalysis of forward elevation and external rotation. In their review of 41 shoulders that underwent RTSA combined with LDT for irreparable rotator cuff tears resulting in severe shoulder dysfunction, they reported a mean active external rotation improvement of 4 to 27°. They concluded that those patients treated with RTSA combined with LDT, patients with pseudoparesis of elevation and external rotation can expect an excellent clinical outcome for a period beyond 5 years.

Shi et al. review use of latissimus dorsi and teres major tendon transfers with reverse shoulder arthroplasty.....in patiens with posterosuperior rotator cuff function deficiency. They report a mean improvement of active forward flexion and active external rotation of 64° and 30-44°, respectively. They concluded that in patients with posterior and superior cuff deficiency, reverse shoulder arthroplasty combined with latissimus dorsi and teres major transfer through a single deltopectoral incision can reliably increase active forward flexion and external rotation.

Illustration A is a clinical image demonstrating a latissimus dorsi transfer

Incorrect Answers:

Answer 1: An axillary nerve neurotmesis would be a contraindication to perform an RSA
Answer 2: A positive (not negative) Hornblower sign would suggest external rotation weakness
Answer 4: Pseudoparalysis of internal rotation would not be restored with a traditional latissimus dorsi transfer
Answer 5: Supraspinatus retraction medial to the glenoid may be an indication for an RTSA, but by itself is not an indication for a latissimus dorsi transfer and an external rotation deficit may not be present