Reverse shoulder arthroplasty combined with anterior latissimus dorsi and teres major transfer for restoration of internal rotation in cuff tear arthropathy: a technical note

Reverse shoulder arthroplasty (rTSA) has become an established surgical treatment for rotator cuff tear arthropathy (CTA), generally providing pain relief and improvement in shoulder elevation.¹⁷ However, restoration of internal rotation (IR) remains unpredictable, particularly in patients with severe subscapularis deficiency. Patients presenting with advanced fatty degeneration of the subscapularis, positive IR lag signs, and poor performance on subscapularis-specific clinical tests are at increased risk of persistent IR weakness following rTSA.^6,19

The necessity and functional benefit of subscapularis repair during rTSA remain controversial.^3,10 While some studies suggest that subscapularis repair does not significantly influence post-operative IR, others have reported inferior IR strength when the tendon is irreparable or left untreated.^3,4,16 Although lateralized rTSA designs have been proposed to enhance rotational strength by modifying shoulder biomechanics, clinical outcomes related to IR recovery remain inconsistent, and IR strength is often underemphasized in routine post-operative evaluation.^13,14 Persistent IR deficiency after rTSA can substantially impair activities of daily living, including reaching behind the back, toileting, and perineal hygiene.^8,9 Because rTSA alone may not adequately compensate for the combined loss of elevation and IR, adjunctive tendon transfer procedures have gained increasing interest.^12,18 Transfer of the latissimus dorsi and teres major (LDTM) in combination with rTSA has been proposed as a potential adjunctive procedure to improve active IR in the setting of irreparable subscapularis deficiency, with prior biomechanical and early clinical studies suggesting possible functional benefit.^1,2 The current technical note provides a detailed, step-by-step description of rTSA combined with anterior LDTM transfer, with particular emphasis on tendon harvest, transfer route, transosseous fixation technique, and intraoperative tensioning considerations in patients with CTA and irreparable subscapularis tears.

Patient selection

Patients considered for rTSA combined with anterior LDTM transfer should meet the following criteria:

• 1.Failed conservative management.
• 2.Glenohumeral arthritis consistent with Hamada⁷ grade 3 or higher.
• 3.A massive irreparable rotator cuff tear with poor muscle quality, defined as Goutallier⁵ grade 3 or greater.
• 4.An irreparable subscapularis tear classified as Lafosse¹¹ grade 4 or higher.
• 5.Preserved deltoid muscle function.
• 6.Functional impairment attributable to IR deficiency, with a strong desire to restore IR strength for activities of daily living.

Relative contraindications include severe shoulder stiffness with limited passive range of motion, substantial proximal humeral bone loss or poor bone quality that may compromise secure tendon fixation, neurologic dysfunction affecting the deltoid or transferred musculature, active infection, and inability to comply with post-operative rehabilitation.

Surgical technique

Patient positioning and surgical approach

The patient is placed in the beach chair position under general anesthesia. A standard deltopectoral approach is used, with the incision extended distally to allow adequate exposure of the proximal humerus and the humeral insertions of the LDTM tendons. The long head of the biceps tendon is routinely tenotomized as part of the exposure.

Harvest tendon

The pectoralis major muscle is retracted using a retractor to expose the humeral insertion of the LDTM unit (Fig. 1A). Formal detachment of the pectoralis major is not routinely required; however, limited partial release of its superior border may occasionally be performed in selected cases to improve exposure and facilitate safe mobilization of the LDTM unit. The LDTM tendons are harvested as a single unit while preserving continuity between the 2 tendons (Fig. 1B). The distal end of the combined tendon is reinforced with 3 nonabsorbable sutures (upper, middle, and lower) placed in a Krackow configuration to enhance fixation strength and reduce the risk of tendon failure. Acellular dermal matrix allograft augmentation is not routinely performed but may be selectively used in cases with poor tendon quality, insufficient tendon thickness, increased transfer tension, or concern regarding the structural integrity of the transferred tendon (Fig. 1C and D). Careful medial release of the muscle belly is performed using sterile gauze to free adhesions and improve tendon excursion, with particular attention to protecting the radial nerve. The harvested tendon is then passed beneath the pectoralis major and directed anteriorly toward the proximal humerus, avoiding excessive medial traction that could place the radial nerve at risk.

Figure 1.

Harvesting and preparation of the latissimus dorsi and teres major (LDTM) tendon in a patient undergoing right shoulder surgery in the beach chair position. (A) The pectoralis major muscle (blueasterisk) is reflected using a retractor, exposing the LDTM unit. (B) The LDTM tendon (white asterisk) is completely detached from its humeral insertion and grasped with 2 long forceps. (C) The harvested LDTM tendon (white asterisk) is augmented with an acellular dermal matrix (yellow asterisk). (D) Final appearance after preparation of the LDTM tendon.

Reverse shoulder arthroplasty

rTSA is performed using a standard technique (Fig. 2A). The humeral head is resected at the cartilage–greater tuberosity junction with approximately 20° of retroversion and an inclination corresponding to the selected implant system. After completion of soft tissue release, the glenoid is prepared, and the baseplate and glenosphere are implanted with a slight inferior tilt to reduce the risk of scapular notching (Fig. 2B). The humeral canal is prepared to achieve stable press-fit fixation of the humeral stem (Fig. 2C). Trial humeral components are inserted to confirm implant stability, range of motion, and appropriate soft tissue tension (Fig. 2D).

Figure 2.

Reverse shoulder arthroplasty performed in the right shoulder. (A) Advanced cartilage wear of the humeral head (red asterisk). (B) Insertion of the glenoid component (blue arrow). (C) Placement of the humeral trial component (white arrow). (D) Reduced glenohumeral joint with trial components in place (blue asterisk).

Tendon transfer

To facilitate tendon transfer and fixation, the trial humeral tray and liner are temporarily removed. A preferred fixation site is identified on the anterior-lateral aspect of the proximal humerus after the LDTM tendon is mobilized and the arm is placed in maximal IR. The fixation site is determined at the location where the most distal portion of the harvested tendon can adequately reach and pass lateral to the bicipital groove without excessive tension. The primary purpose of this fixation strategy is to maximize the tensioning effect of the transferred LDTM tendon. The fixation sites are initially marked to guide creation of the lateral transosseous tunnels. Two parallel transosseous tunnels (upper and lower) are created at the marked fixation site using a 2.0-mm Kirschner wire and drill bit. The tunnel entry points are created adjacent to the bicipital groove, while the exit points are positioned posteriorly at the lateral aspect of the greater tuberosity to allow compression of the transferred tendon over the anterior-lateral proximal humeral surface. During drilling, care should be taken to guide the drill bit to avoid interference with the humeral canal and the implanted humeral stem of the rTSA (Fig. 3A). Each corresponding suture from the LDTM tendon is passed through its respective tunnel using a spinal needle loaded with a looped wire (Fig. 3B). Additional free looped sutures are also shuttled through each tunnel (Figs. 3C and 4A).

Figure 3.

Transfer and fixation of the latissimus dorsi and teres major (LDTM) tendon. (A) Creation of a transosseous tunnel adjacent to the bicipital groove using a drill (blue arrow). The tunnel is directed toward the lateral aspect of the greater tuberosity. (B) Passage of a wire loop through the transosseous tunnel (yellow arrow). (C) Sutures from the prepared LDTM tendon (green arrow) are passed through the wire loop and shuttled through the tunnel. (D) Insertion of the definitive humeral component (red asterisk) before final tendon fixation.

Figure 4.

Schematic illustration of reverse shoulder arthroplasty combined with latissimus dorsi and teres major (LDTM) tendon transfer. (A) Overall schematic demonstrating suture placement in the transferred LDTM tendon (white asterisk). (B) Final suture configuration in the transferred LDTM tendons (white asterisk). (C) Axial view of the proximal humerus implanted with reverse shoulder arthroplasty (green asterisk), illustrating the original insertion site of the LDTM tendons (blue asterisk) and their transfer to the new attachment site (white asterisk).

After reinsertion of the definitive humeral tray and liner, the free looped sutures are first passed through the transferred LDTM tendon using a suture lasso passer and secured with sliding locking knots (NICE knots) to compress the tendon against the anterior-lateral proximal humeral surface (Figs. 3B, and 4 C and D). The corresponding Krackow sutures from the LDTM tendon are then passed through the tendon and tied with simple knots to further reinforce fixation (Figs. 4 and 5). Final intraoperative assessment includes passive and active rotational movements of the humerus to confirm adequate tendon excursion, appropriate tensioning, and the absence of mechanical impingement.

Figure 5.

Final fixation of the latissimus dorsi and teres major (LDTM) tendon transfer. (A) Sutures are tied to secure the transferred tendon (yellow arrow). (B) Final appearance of the combined reverse shoulder arthroplasty (green asterisk) with anterior LDTM transfer (blue asterisk).

Post-operative rehabilitation

The operated arm is immobilized in a shoulder brace for 4 weeks post-operatively. During this period, passive and assisted range-of-motion exercises are permitted within a protected range. At 4 weeks, the brace is discontinued, and active-assisted range-of-motion exercises are initiated. Progressive strengthening exercises are introduced at 3 months post-operatively, while unrestricted activities and heavy labor are delayed until 6 months after surgery.

Discussion

The current technical note describes the surgical technique for rTSA combined with anterior LDTM transfer in patients with CTA and irreparable subscapularis deficiency. Although rTSA reliably improves forward elevation and abduction, recovery of IR remains variable, particularly when the subscapularis is irreparable or absent.^3,4 The subscapularis plays a central role in active IR and anterior stability of the shoulder; therefore, its deficiency can result in substantial functional impairment after rTSA.^6,8,9 In this context, the LDTM tendons represent suitable donor muscles because of their strength, favorable excursion, and synergistic function as internal rotators.² When transferred laterally to the bicipital groove on the proximal humerus, the line of pull of the LDTM tendon may help improve IR torque within the altered biomechanics of rTSA.² Compared with isolated rTSA or reliance on implant lateralization alone, anterior LDTM transfer may provide an additional dynamic contribution to IR function rather than relying solely on implant-related biomechanical compensation.² Although the biomechanical rationale for the described tendon transfer and fixation strategy is supported by prior biomechanical studies, the present technical note does not directly quantify the biomechanical effect or IR moment arm generated by the described fixation construct.

Several technical pearls are critical for successful execution of this procedure (Table I). First, meticulous medial mobilization of the LDTM unit is essential to achieve a tension-free transfer; inadequate release may lead to excessive tension, limited excursion, or early failure. Medial dissection should be performed carefully with blunt techniques to minimize the risk of radial nerve injury. Second, secure fixation is paramount. Transosseous tunnel fixation combined with reinforced suturing allows for broad load distribution and may reduce the risk of tendon pullout or rupture, particularly during early rehabilitation.¹⁵ Temporary removal of the humeral liner and tray during fixation improves visualization, facilitates accurate tunnel placement, and reduces technical complexity. However, potential pitfalls include over-tensioning of the transferred tendon, which may restrict shoulder motion and cause discomfort or fatigue, as well as insufficient tensioning, which may compromise functional gains in IR. Careful intraoperative assessment of the remaining bony stock at the greater tuberosity is essential, as inadequate bone quality or quantity may limit secure fixation and reduce construct strength.

Table I.

Pearls and pitfalls.

Pearls	Pitfalls
Careful patient selection focusing on irreparable subscapularis deficiency and symptomatic internal rotation loss.	Inadequate medial release leading to excessive tension, restricted motion, or early tendon failure.
Adequate medial mobilization of the latissimus dorsi and teres major unit to achieve a tension-free anterior transfer.	Over-tensioning of the transferred tendon, resulting in limited range of motion or post-operative discomfort.
Preservation of tendon continuity between the latissimus dorsi and teres major to maximize force generation.	Insufficient tensioning, which may compromise internal rotation strength gains.
Blunt medial dissection using gauze to improve excursion while minimizing the risk of radial nerve injury.	Excessive medial traction during tendon mobilization, increasing the risk of radial nerve injury.
Temporary removal of the humeral tray and liner to facilitate accurate tunnel placement and tendon fixation.	Poor humeral bone quality, which may reduce fixation strength and increase the risk of tendon pullout.
Anterior fixation lateral to the bicipital groove to optimize the internal rotation moment arm.	Failure to assess rotational motion intraoperatively, potentially leading to post-operative impingement.
Use of transosseous tunnel fixation with reinforced sutures to improve load distribution and fixation strength.
Intraoperative assessment of humeral rotation after final fixation to confirm adequate excursion and avoid over-tensioning.

Several limitations of this technique should be acknowledged. Proximal humeral stress shielding remains a concern, particularly in press-fit stem designs, and may influence long-term tendon-bone healing. In addition, although biomechanical principles strongly support the use of anterior LDTM transfer, clinical outcome data for this combined procedure remain limited, and long-term durability has yet to be fully established.¹ Although a more lateral tendon position may theoretically improve the IR moment arm, the present manuscript does not directly quantify the final biomechanical effect of the described fixation construct, and further biomechanical investigation is warranted. Furthermore, the present manuscript is a technical note and does not include original clinical outcome data, post-operative IR measurements, complication analysis, or imaging confirmation of tendon healing. Therefore, the effectiveness and long-term durability of this technique require further clinical and biomechanical investigation. Lastly, the present technical note does not directly evaluate the applicability of the described tendon transfer and fixation strategy across different rTSA implant designs, humeral configurations, or degrees of lateralization, which may influence both technical feasibility and the final line of pull of the transferred tendon.

Conclusion

rTSA combined with anterior LDTM transfer may represent a technically feasible and reproducible surgical option for improving IR strength in patients with CTA and irreparable subscapularis tears. By restoring an active IR force, this technique has the potential to address a functional deficit that is not reliably corrected by rTSA alone. However, given the limited clinical evidence and lack of long-term outcome data, further studies are required to confirm its safety, durability, and clinical effectiveness.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.