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.