JSES International - 2026-05-01 - Journal Article
Optimizing reverse total shoulder arthroplasty for combined loss of elevation and external rotation: latissimus dorsi and teres major transfer, lateralization, or both?
Matsuzawa G, Hatta T, Sasajima K, Itoi E, Aizawa T
Topics
Key Takeaway
In CLEER patients undergoing rTSA, combining onlay (lateralized) humeral component with LD/TM transfer produced the greatest external rotation improvement and was the only strategy to exceed MCID for both rotation planes simultaneously at mean 38 months.
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Summary
This study compared four rTSA strategies for CLEER patients with massive RCT and severe infraspinatus/teres minor fatty infiltration: inlay±LD/TM transfer versus onlay±LD/TM transfer. All four groups achieved significant improvements in forward elevation, ASES, and Constant-Murley scores exceeding MCID. External rotation improved significantly only in transfer groups (InT and OnT, p<0.01), with the greatest gain in OnT; internal rotation declined significantly in inlay groups (In and InT, p<0.05) but was preserved with onlay design, and the In group failed to reach MCID for external rotation.
Key Limitation
With group sizes of 7–12 patients, the study is underpowered for between-group statistical comparisons, and the observed functional score trends did not reach significance across groups, limiting definitive conclusions about superiority.
Original Abstract
BACKGROUND
Large to massive rotator cuff tears (RCTs) can lead to combined loss of active elevation and external rotation (CLEER), particularly when accompanied by severe fatty change of the external rotators. In such cases, reverse total shoulder arthroplasty (rTSA) may be insufficient, and adjunctive latissimus dorsi and teres major (LD/TM) transfer or lateralization is often considered, though their relative benefits remain unclear.
METHODS
This retrospective study included 38 shoulders from 38 patients with combined loss of active elevation and external rotation due to large to massive RCTs and severe fatty change of the infraspinatus and teres minor. All patients underwent rTSA and were followed for a minimum of 2 years. Patients were categorized into 4 groups based on the humeral component design and whether LD/TM transfer was performed: inlay component without muscle transfer (In group), onlay component without muscle transfer (On group), inlay component with muscle transfer (InT group), and onlay component with muscle transfer (OnT group). Lateralization was assessed radiographically by measuring the distance from the glenoid to the humeral component center and the greater tuberosity. Post-operative outcomes were evaluated in terms of active range of motion, the American Shoulder and Elbow Surgeons (ASES) score, and the Constant-Murley score. Radiographic and clinical results were compared across groups. Each outcome was evaluated relative to its minimum clinically important difference (MCID).
RESULTS
The In, On, InT, and OnT groups included 9, 7, 10, and 12 patients, respectively, with a mean follow-up of 38 months (range, 24-61). All groups showed significant improvements in forward elevation, ASES scores, and Constant-Murley scores at 24 months ( P < .01). The range of external rotation improved significantly in the InT and OnT groups ( P < .01), with the greatest improvement in the OnT group ( P < .05). Internal rotation declined significantly in the In and InT groups ( P < .05) but was preserved in the On and OnT groups. Post-operative ASES and Constant-Murley scores exhibited a similar trend to external rotation outcomes. External rotation in the In group and internal rotation in the In and InT groups did not reach their MCIDs, whereas all groups exceeded the MCIDs for the ASES and Constant-Murley scores.
CONCLUSION
LD/TM transfer was associated with restoring external rotation, whereas humeral lateralization seemed related to better post-operative internal rotation. Among the treatment strategies evaluated, rTSA incorporating both LD/TM transfer and humeral lateralization was associated with better outcomes in this challenging patient population.