title: Reverse shoulder arthroplasty combined with latissimus dorsi transfer using the bone-chip technique.
abstract: OBJECTIVE
  Reverse shoulder arthroplasty (RSA) can restore active elevation in rotator-cuff-deficient shoulders. However, RSA cannot restore active external rotation. The combination of latissimus dorsi transfer with RSA has been reported to restore both active elevation and external rotation. We hypothesised that in the combined procedure, harvesting the latissimus dorsi with a small piece of bone, leads to good tendon integrity, low rupture rates and good clinical outcome.
  
  
  METHODS
  Between 2004 and 2010, 13 patients (13 shoulders) were treated with RSA in combination with latissimus dorsi transfer in a modified manner. The mean follow-up was 65.4 months, and the mean age at index surgery was 71.1 years. All patients had external rotation lag sign and positive hornblower's sign, as well as radiological signs of cuff-tear arthropathy (Hamada 3, 4 or 5) and fatty infiltration grade 3 according to Goutallier et al. on magnetic resonance imaging (MRI). The outcome measures included the Constant Murley Score, University of California-Los Angeles (UCLA) shoulder score, Simple Shoulder Test (SST), visual analogue scale (VAS) and the Activities of Daily Living Requiring External Rotation (ADLER) score. Tendon integrity was evaluated with dynamic ultrasound. All patients were asked at final follow-up to rate their satisfaction as excellent, good, satisfied or dissatisfied.
  
  
  RESULTS
  The overall mean Constant-Murley Shoulder Outcome Score (CMS) improved from 20.4 to 64.3 points (p < 0.001). Mean VAS pain score decreased from 6.8 to 1.1 (p < 0.001)., mean UCLA score improved from 7.9 to 26.4 (p < 0.001), mean SST score improved from 2.3 to 7.9 (p < 0.001) and mean postoperative ADLER score was 26 points. The average degree of abduction improved from 45° to 129° (p < 0.001), the average degree of anterior flexion improved from 55° to 138° (p < 0.001) and the average degree of external rotation improved from -16° to 21° (p < 0.001). Eight patients rated their results as very satisfied, three as satisfied and two as dissatisfied.
  
  
  CONCLUSIONS
  This modified technique, which avoids cutting the pectoralis major tendon and involves harvesting the tendon together with a small piece of bone, leads to good or even better functional results compared with the results reported in the literature, and also has high patient satisfaction and low failure rates.
authors.affiliation: Department of Traumatology and Sports Injuries, Paracelsus Medical University, Müllner Hauptstraße 48, A-5020, Salzburg, Austria, r.ortmaier@gmail.com.
authors.forename: Reinhold
authors.initials: R
authors.lastname: Ortmaier
authors.forename: Herbert
authors.initials: H
authors.lastname: Resch
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Hitzl
authors.forename: Michael
authors.initials: M
authors.lastname: Mayer
authors.forename: Martina
authors.initials: M
authors.lastname: Blocher
authors.forename: Imre
authors.initials: I
authors.lastname: Vasvary
authors.forename: Georg
authors.initials: G
authors.lastname: Mattiassich
authors.forename: Ottokar
authors.initials: O
authors.lastname: Stundner
authors.forename: Mark
authors.initials: M
authors.lastname: Tauber
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D001178:Arthroplasty / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010027:Osteotomy / Q000379:methods*; D017063:Outcome Assessment, Health Care; D010147:Pain Measurement; D017060:Patient Satisfaction; D016059:Range of Motion, Articular / Q000502:physiology; D012189:Retrospective Studies; D017006:Rotator Cuff / Q000601:surgery*; D000070636:Rotator Cuff Injuries; D012785:Shoulder Joint / Q000503:physiopathology / Q000601:surgery*; D064171:Superficial Back Muscles / Q000601:surgery / Q000637:transplantation*; D016896:Treatment Outcome