J Shoulder Elbow Surg (2023) 32, 1016–1021

www.elsevier.com/locate/ymse

Concomitant latissimus dorsi tendon transfer

during reverse total shoulder arthroplasty does
not improve active external rotation or clinical
outcomes in patients with external rotation
deficit
J. Michael Wiater, MDa,*, Olamide Oshikoya, MDa, Edward Shields, MDb,
Alexander D. Vara, MDc, Leonardo Cavinatto, MDa, Denise M. Koueiter, MSa

a
Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI, USA
b
Orthopaedic Associates of Muskegon, Muskegon, MI, USA
c
Palmetto General Hospital, Hialeah, FL, USA

Background: To assess the role of latissimus dorsi tendon transfer (LDT) concomitant with reverse total shoulder arthroplasty in pa-
tients with external rotation (ER) deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis.
Methods: Patients with a positive external lag sign and <10
of active external rotation (aER) treated with reverse shoulder arthroplasty
at a single institution with a minimum 12-month follow-up were retrospectively identified from a prospective database. Basic demo-
graphic information along with preoperative and postoperative range of motion (ROM) measures, American Shoulder and Elbow Sur-
geons score (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value scores were obtained. Statistical analysis was
performed to compare ROM and functional outcomes between patients who underwent concomitant LDT and those with no transfer
(NT).
Results: The LDT (n ¼ 31) and NT (n ¼ 33) groups had similar age, sex distributions, and follow-up length average (24 vs. 30 months).
No differences were found between groups at baseline, final follow-up, or magnitude of change for ASES, VAS pain, and Subjective
Shoulder Value scores. Baseline ROM measures were similar, except for the LDT group having slightly less aER (8
vs. 0
;
P ¼ .004). In addition, all postoperative ROM measures including aER were similar, except for a slight improvement in active internal
rotation in the NT group. The majority of patients were satisfied with their outcome (LDT 84% (n ¼ 26); NT 87% (n ¼ 27); P ¼ .72).
Conclusion: Patients with ER deficit secondary to severe rotator cuff deficiency with and without glenohumeral arthritis undergoing
reverse total shoulder arthroplasty do not have significantly improved ER or patient-reported outcome measures with LDT.
Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study
Ó 2022 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Keywords: Reverse shoulder arthroplasty; latissimus dorsi tendon transfer; external rotation lag; posterior rotator cuff; humeral rotation;
functional outcomes

This study was approved under Beaumont Health institutional review *Reprint requests: J. Michael Wiater, MD, Department of Orthopaedic
board protocol # 2006-088. Surgery, Beaumont Health System, 3535 W 13. Mile Road, Suite 744,
Royal Oak, MI 48073, USA.
E-mail address: j.michael.wiater@beaumont.org (J.M. Wiater).

1058-2746/Ó 2022 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
https://doi.org/10.1016/j.jse.2022.11.011
Concomitant latissimus dorsi tendon transfer for RTSA
Reverse total shoulder arthroplasty (RTSA) results in
consistent improvements in shoulder function and pain for
patients with severe rotator cuff deficiency with and
without glenohumeral arthritis.8,10,20-24 Although restora-
tion of forward elevation and improved patient-reported
outcomes have been repeatedly demonstrated after RTSA,
external rotation (ER) is less reliably restored.7,22,23
Preoperative deficits in ER with dysfunction of the poste-
rior rotator cuff may not be compensated for by deltoid
function,7 and lower functional outcomes scores have been
reported after RTSA in patients with preoperative teres
minor fatty infiltration.22,23
The latissimus dorsi tendon transfer (LDT) was initially
described for restoration of ER in the setting of massive and
irreparable posterosuperior rotator cuff injuries.11,27 This
tendon transfer, either isolated or combined with teres
major transfer (TMT), has subsequently been modified for
use during RTSA in the setting of posterior rotator cuff
deficits.5,10 Results after tendon transfers for improving ER
in the setting of RTSA are conflicting. While Gerber et al,
Boileau et al, and others have reported significant ER
improvement and functional gains in patients undergoing
RTSA concomitant with LDT or LDT and TMT,5,10,20,21 a
recent high-quality comparative study did not find signifi-
cant differences in outcomes or ER improvement when
LDT and TMT were performed in addition to RSTA.26
The purpose of this study was to assess the role of LDT
concomitant with RTSA in patients with ER deficit sec-
ondary to severe rotator cuff deficiency with and without
glenohumeral arthritis. We hypothesized that patients with
a LDT would have increased active external rotation (aER)
gains and improved functional outcome scores.
Methods
Patients
A retrospective review of a prospectively collected shoulder
arthroplasty registry was queried for patients diagnosed with se-
vere rotator cuff deficiency and clinically decreased ER. From
2007 through 2014, patients undergoing RTSA by the senior
author were offered enrollment in a prospective, international
review board-approved database. Patients were asked to return
postoperatively at 3 months, 1 year, and yearly thereafter for
radiographic analysis and outcomes data collection. Inclusion
criteria were patients indicated for reverse total shoulder arthro-
plasty due severe rotator cuff deficiency with or without arthritis
as documented via plain radiography and/or magnetic resonance
imaging and who had ER deficit with a minimum 12-month
follow-up. ER deficit was defined as a positive ER lag sign and
minimal (less than 10
) aER. The ER lag sign was conducted by
the examiner passively flexing the patient’s elbow to 90
with the
arm in slight abduction and then passively rotating the arm to
maximal ER. The patient was then asked to actively hold the arm
at this position. When the patient was unable to hold the maxi-
mally externally rotated position, the resulting involuntary internal
1017
drift of the arm after release was considered positive, signifying
posterior rotator cuff dysfunction.
Later in the study period after the senior author became aware
of published reports of LDT showing benefit in RTSA patients
with ER deficiency, patients were indicated for LDT after
demonstrating a positive ER lag sign and minimal aER. Thirty-
one consecutive patients meeting the inclusion criteria underwent
RTSA with concomitant LDT. All patients in the LDT group
received a Zimmer trabecular metal reverse humeral stem
(Zimmer, Warsaw, IN, USA) with either a Zimmer reverse gle-
nosphere/baseplate (n ¼ 23) or a DJO Encore reverse glenosphere/
baseplate (n ¼ 10 [Enovis, Lewisville, TX, USA]). The LDT
group was compared to a matched cohort of RTSA patients treated
earlier in the study period who met inclusion criteria, but did not
undergo concomitant LDT, the non-transfer (NT) group. All pa-
tients in the NT group received a Zimmer reverse humeral stem
and glenosphere/baseplate. Patients were excluded from this study
if they were treated for fracture, malunions, nonunions, revision
arthroplasty surgery, or had a prior infection.
All procedures were performed by a single surgeon through a
standard deltopectoral approach. The subscapularis tendon was
tenotomized if present. The LDT was performed during the RTSA
by harvesting the isolated latissimus dorsi tendon through a single
deltopectoral incision. Approximately 1.5 cm of the upper pec-
toralis major tendon was released to gain access to the latissimus
dorsi tendon. The tendon was then detached from the humerus,
tagged with heavy braided sutures, and shuttled to the postero-
lateral aspect of the humerus after identification and protection of
the radial and axillary nerves. The teres major tendon was iden-
tified deep to the latissimus dorsi tendon and left intact to preserve
extension and internal rotation (IR) of the shoulder. Two running,
locked heavy nonabsorbable sutures were placed in the latissimus
dorsi tendon, which were secured through bone tunnels at the
posterolateral aspect of the bicipital groove after implantation of
the humeral stem and prior to wound closure. The subscapularis
tendon, if present, was not repaired due to concern for limitation
of ER from the subscapularis serving as a checkrein. The pec-
toralis major tendon was repaired at the end of the case. Post-
operatively, the arm was protected in an abduction pillow
immobilizer for 4 weeks.
Clinical evaluation
One independent clinical research nurse examined all patients
both preoperatively and postoperatively. Functional outcomes
were assessed using the American Shoulder and Elbow Surgeons
(ASES) score, ASES Activities of Daily Living (ADL) score,17
Visual Analog Scale (VAS) for pain (0 (none) to 10 (highest
possible)), and Subjective Shoulder Value (SSV).12,15,17
A standard goniometer was used to measure active forward
elevation (aFE) and aER range of motion (ROM) with the
shoulder in 0 degrees of abduction. Active internal rotationaIR
ROM was assessed as the highest spinal level that the patient’s
thumb was able to reach. Additional patient demographics were
obtained directly from the database. The primary outcome mea-
sure was the change in aER. Secondary outcomes measures
included ASES score, VAS pain, SSV score, and ROM measures.
IR was coded as follows: 1 point for end of thumb to lateral thigh,
2 points to the buttock, 3 points to lumbosacral junction, 4 points
at L3, 5 points to T12, and 6 points to T7.
1018
Table I Basic demographics for study groups
Latissimus transfer (n ¼ 31)
Age 68  10
Gender (female) 52%
Follow-up length (mo) 30  15
Statistical analysis
All statistical analyses were performed using SPSS (version 22;
IBM, Armonk, NY, USA). First, the equal variance and normality
assumptions of continuous data were assessed using Levene’s test
and the Shapiro-Wilk test, respectively. Unpaired t-test and
Mann–Whitney U tests were used to assess differences in nor-
mally distributed and non-normally distributed independent
outcome variables, respectively. Since all patients in the LDT
group did not have the same glenoid implant, a sub analysis was
run comparing the degree of improvement in the NT,
LDT þ Zimmer baseplate, and LDT þ DJO baseplate. For this
sub analysis a 1-way ANOVA was used to compare change from
preoperative to postoperative for all variables. Aggregate results
are reported as mean [95% confidence interval] or  Standard
Deviation.
Results
During the later study period, 31 consecutive patients who
met inclusion criteria underwent RTSA with concomitant
LDT. These patients were compared to a matched cohort of
patients treated earlier in the study period before the senior
author was performing LDT, who met inclusion criteria and
received reverse total shoulder arthroplasty without an LDT
(no transfer [NT] group). There were 64 patients included
in the analysis, 31 with a LDT, and 33 with NT. Average
age (LDT 68  10; NT 70  8; P ¼ .34), sex distributions,
and length of follow-up (LDT 30  15 vs. NT
24  14 months; P ¼ .134) were similar between groups
(Table I).
Preoperative aFE and aIR were similar for both groups,
with aER being slightly lower in the LDT group (LDT 8
12
vs. NT 0  9
; P ¼ .004). At final follow-up, all ROM
measures except for aIR were similar for both groups,
including the primary outcome measure (aER). Change in
aIR was significantly worse in the LDT group (LDT aIR
change 0.29 levels vs. NT 0.77 levels; P ¼ .01; Table II).
The majority of patients were satisfied with their outcome
(LDT 84% [n ¼ 26]; and NT 87% [(n ¼ 27]; P ¼ .72).
Since 10 of the patients in the LDT group also had a
slightly more lateralizing glenoid implant (DJO Encore
glenosphere/baseplate), a sub analysis was run comparing
the degree of improvement in the NT, LDT þ Zimmer
glenosphere/baseplate, and LDT þ DJO glenosphere/
baseplate, to assess if the baseplate impacted the overall
results. The degree of change did not vary amongst sub-
groups for the ASES score (P ¼ .629), ASES ADL
J.M. Wiater et al.
No transfer (n ¼ 33) P value
70  8 .34
70% .20
24  14 .13
(P ¼ .442), Pain (P ¼ .847), SSV (P ¼ .584), aFE
(P ¼ .229), aER (P ¼ .350), or aIR (P ¼ .069).
There were no differences in patient-reported outcome
measures between the LDT and NT groups regarding pre-
operative, postoperative, and overall changes in ASES
score, ASES ADL score, VAS pain score, and SSV score
(Table III). Complication rate was not different between
groups.
Discussion
The principal finding of this study was that LDT during
RTSA in patients with ER deficit did not result in
improvement in the primary outcome measure or secondary
outcome measures. aER and functional outcome scores
were not significantly different between the study group
and control group after one year.
Increased Disabilities of the Arm, Shoulder, and Hand
and poor VAS have been shown in patients with aER
restriction.16 Several studies have documented poor
improvement or even worsening of humeral rotation
following RTSA.7,19,24 Poor rotation following RTSA can
be attributed to multiple factors, such as the deltoid fibers
assuming a more vertical line of pull, the medialized center
of rotation reducing tension on remaining rotator cuff
muscles, and the potential of mechanical impingement.1,14
LDT is a technique first described in 1947 for the treat-
ment of neonatal brachial plexus palsy26 and involves
transferring the native insertion of the tendon from the
medial intertubercular groove, where it acts as an internal
rotator and adductor, to the greater tuberosity posteriorly
around the humerus, where it then can act as an external
rotator. Multiple studies have documented its efficacy in
restoring aER in irreparable rotator cuff tears.2,4,13
Gerber et al10 first introduced LDT in conjunction with
RTSA in 2007 with a 2-incision technique, utilizing a
deltopectoral approach with a second incision lateral to the
posterior axilla. The latissimus dorsi tendon is passed from
the inferior incision into the deltopectoral incision, and the
tendon is secured transosseously to the posterolateral aspect
of the greater tuberosity.10 The strands of tagged suture are
passed through bone tunnels into the medullary canal and
tied over a 7-hole button plate inside the medullary canal.10
In this series of 12 patients, there was significant
improvement in forward flexion, abduction, strength, SSV,
relative Constant score, score for ADL, and pain.10 aER
increased on average by only 7
and was not significantly
Concomitant latissimus dorsi tendon transfer for RTSA 1019

Table II Range of motion measure comparisons

Latissimus transfer (n ¼ 31) No transfer (n ¼ 33) P value
Preoperative
aFE 72  36
74  33
.83
aIR 3.5  1.3 2.8  1.4 .23
aER 8  12
0  9
.004*
Postoperative
aFE 123  24
115  30
.26
aIR 3.2  1.6 3.7  1.4 .31
aER 14  13
17  15
.43
Change from baseline
aFE 50  40
37  49
.25
aIR 0.29  1.7 0.77  1.9 .014*
aER 22  15
17  15
.15
aFE, active forward elevation; aIR, active internal rotation; aER, active external rotation.
All measures in degrees, except active internal rotation coded based on level reached by upper thumb, see Methods.
* Denotes P < .05.

Table III Functional outcome measures

Latissimus transfer (n ¼ 31) No transfer (n ¼ 33) P value
Preoperative
ASES 25.6  15 25.3  15 .95
ASES ADL 7.5  4 8.3  4 .41
VAS pain 7.4  2 7.7  2 .38
SSV score 19  19 16  16 .56
Postoperative
ASES 69.5  22 71.3  28 .34
ASES ADL 17.6  7 18.8  10 .29
VAS pain 2.0  3 2.0  3 .65
SSV score 71  23 71  29 .50
Change from baseline
ASES 44  23 46  31 .76
ASES ADL 10  7 10  11 .89
VAS pain 5.4  3 5.7  3 .71
SSV score 53  26 55  31 .81
ASES, American Shoulder and Elbow Surgeons score; ADL, activities of daily living; VAS, Visual Analog Scale; SSV, Subjective Shoulder Value.

different from baseline.10 Subsequently, Boileau et al5
modified the L’Episcopo procedure by transferring both
latissimus dorsi and teres major through a single delto-
pectoral approach. The 2 tendons were rerouted and reat-
tached laterally on the humerus.5 There were 11 patients in
their series and they reported an average 28
increase of
aER.5 Puskas et al reported longer-term follow-up in a
larger series of 41 shoulders at 53 months average follow-
up and found that at final follow-up aER improved from 4

to 27
(P <.001) and ER lag sign was successfully elimi-
nated in 25 of 32 shoulders.20 Shi et al reported on 21
patients with a minimum 2-year follow-up after RTSA with
LDT.21 The authors reported forward flexion increased
from 50
to 120
, aER with the arm at the side increased
from 6
to 38
, and improved pain and functional outcome
scores.21 Although these reports show improvement of ER
following LDT, they are case series with no control group
for comparison.
Recently, Young et al conducted a randomized trial of 28
patients with rotator cuff tear arthropathy and loss of
elevation and ER who underwent RTSA with or without
LDT þ TMT.26 With a follow-up of 2 years, the authors did
not find differences in aIR, aFE, passive forward elevation,
and aER with the elbow at 90
of abduction.25 There was
also no difference in patient-reported outcomes, however,
they did find resolution of the Hornblower sign post-
operatively in 58.3% of patients in the control group and
73.3% of those in the treatment group.26 In addition to
1020
controversy over the magnitude of clinical benefit obtained
by LDT, the additional procedure increases the overall
surgery time, is technically demanding, and risks potential
nerve injury, stress risers in bone from drill holes, and
potential loss of IR or decreased potential IR gains.
In the current study, we used a single incision technique to
transfer exclusively the LDT, leaving the TMT intact. We
believe this technique minimizes IR weakness, particularly
when the subscapularis tendon is not repaired. In our study
design, the addition of a control group with similar aER
dysfunction allows for a more meaningful analysis regarding
the effect of LDT in these patients. The procedures were done
by a single surgeon, using the same technique consistently.
Although the LDT group did gain an average of 22 degrees of
aER, this was not significantly different than the NT group’s
gain of 17
(P > .05). Additionally, the secondary outcome
measures were similar preoperatively and at final follow-up
between groups, along with all other subjective patient
outcome measures, save for aIR. One possible reason for the
slight increase in aER in the NT group may be related to the
glenosphere size utilized.3 M€ uller et al reported midterm
results on 68 patients who underwent reverse shoulder
arthroplasty with glenosphere sizes of 36 mm and 44 mm.18
At 1 year, the group who received the size 44 mm glenosphere
achieved an average increase of 12
ER.18 Berglund et al
demonstrated that patients with preoperative ER deficit could
achieve improved ER after reverse shoulder arthroplasty
through lateralization of the glenosphere center of rotation
without the use of LDT.4
The only significant finding in the current study was an
improvement in aIR in the NT group (þ0.77 vertebral
levels), compared to a slight decrease in aIR in the LDT
group (0.29 vertebral levels). Boileau et al reported
decreased IR strength after latissimus dorsi and teres major
tendon transfer with reverse shoulder arthroplasty.6,9 This
may be due to the loss of the IR function of the latissimus
and teres major by converting them to external rotators, the
expected loss of IR inherent to the design of the prosthesis,
or as a result of the over-tensioning the transfer.6 In our
series, the senior author attempted to maximize ER in the
presence of a positive ER lag sign and limited ER by not
transferring the TMT with the LDT, and by not repairing
the subscapularis tendon. In the LDT group, the lack of
repair of the subscapularis tendon, in combination with loss
of the latissimus dorsi function as an internal rotator, may
compromise IR while attempting to improve ER. Further-
more, a tenodesis effect of the transfer may contribute to
diminished aIR.10 This may explain the difference in aIR
gain over baseline between groups, although the changes in
both groups were small and likely not clinically significant.
The gains in aER for patients in this study (22
) are lower
than some previously described (range 7-32
).5,10,20,21 A
possible reason for this is that only the latissimus dorsi was
transferred, while the teres major was preserved.
J.M. Wiater et al.
Weaknesses of this study include its nonrandomized
design, in which patients were retrospectively selected from
a prospectively collected data registry, likely introducing
some selection bias into the study. In addition, all proced-
ures were performed by a single surgeon. While this design
strengthens internal validity of the study, it may reduce the
generalizability of the results. There was a small baseline
difference in preoperative aER between the groups, which
could be a confounding factor. However, this difference
was small (<8
) and likely clinically insignificant, and no
differences were identified for any patient-reported
outcome measures preoperatively. Since both groups had an
average aER below 0
at baseline, this difference should
have minimal impact on results interpretation. Additional
weaknesses include the addition of 2 different glenosphere
designs in the LDT group. A separate sub analysis, how-
ever, showed that the hybrid construct did not result in
different outcomes, possibly due to the small difference in
glenoid lateral offset between the 2 designs (16.7 mm DJO
vs. 11.5 mm Zimmer).25 However, the sub analysis was
likely underpowered to detect a difference due to prosthetic
design.
Conclusion
Patients with ER deficit undergoing reverse total
shoulder arthroplasty for severe rotator cuff deficiency
with and without glenohumeral arthritis do not have
significantly improved aER or patient-reported outcome
measures with concomitant LDT.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: J. Michael Wiater reports personal
fees from Biomet and Depuy, A Johnson and Johnson
Company, stock options from Eleven Blade Solutions,
paid consultant and stock options from Catalyst Ortho-
Science, stock options from Coracoid Solutions, stock
options from Hoolux Medical, stock options from Ignite
Orthopedics, paid consultant for Lima Corporate, stock
options from Mpirik, intellectual property royalties from
Innomed, intellectual property royalties from Smith and
Nephew, nonfinancial research support from Synthes,
nonfinancial research support from Tornier, personal
fees, and nonfinancial support from Zimmer, outside the
submitted work. The other authors, their immediate
families, and any research foundation 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.
Concomitant latissimus dorsi tendon transfer for RTSA
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