Discussion: [J.P. Warner] "L’episcopo or Latissimus Dorsi (Double Incision) Transfer?" on
Dear CSS Members and Colleagues:
The discussion below reflects some controversy as to the need for tendon transfer along with Reverse prosthesis in patients with profound ER weakness. Enclosed is a video (https://www.vumedi.com/video/failed-reverse-lag-sign/) and an article from Hartzler, Frankle and colleagues which deals with this. Perhaps you can decide for yourselves about the need for tendon transfer. Eric Wagner has suggested a multicenter study and this is a great question for the CSS to address going forward.
“JP” Warner, MD
Here is the prior discussion:
Thank you JP!
I completely agree with you that, in the posteriorly deficient cuff patients with a significant lag, lateralization alone does not result in reproducibly satisfactory functional results. Thank you for saying this!
Happy New Year!
Dear JP and Reuben
I do agree with both of you.
I do have a number of patients who came to me complaining of ER lag after RSA performed elsewhere and all of them had lateralized implants.
Jon JP Warner
Thank you Reuben and Bassem: This is a small number of patients but very important group to identify. JPW
I just completed the recent AAOS shoulder/elbow Self assessment exam for scored cme credit. 1 question was a case with rotator cuff arthropathy With significant Er lag (30 deg) but Negative hornblowers sign. They asked for the best treatment with their answer as reverse shoulder replacement (without tendon transfer)!
In my experience which has been published in peer review
If the patient can sustain the arm at neutral rotation with arm at their side they will improve er function .if the they are unable to sustain this (er lag at Neutral rotation) they will not regain er without a muscle transfer.
However Jp ‘s rate of a transfer of 14 percent is much higher then mine which is more around one percent.
We video tape all of our patient pre and postoperatively, I’ll be happy to have skeptics review as many of these as they would like, but it seems like prosthetic geometry can improve muscle function by restoring proper length if the muscle is present and functions at some level. If there is no external rotators, then (no infra or teres) then geometry has not helped me improve external rotation.
Jon JP Warner
This reflects the lack of consensus and an eminence based approach. Clearly there are two camps. In favor of transfer for ER lag (Gerber, Walch, Boileau, me others). Not in favor or rarely needed (Frankle, Jawa, Levy, others). I will try to find the video I have of a symptomatic patient who had a Reverse without Lat transfer and has significant lag. I have had several. In one I revised with a Lower Trapezius Transfer a la ELHassan. The other preferred to live with it but could not put her hand on her head. On had a DJO prosthesis and one had a Tornier Reverse.
Perhaps or that distinction of preoperative external rotation weakness represents a spectrum and the cutoff in which prosthetic geometry is unlikely to improve function is more a relative variable then absolute. It’s like trying to get consensus when you are grading something with multiple different levels, the extreme are usually highly agreeable but the ones in the middle render separation improbable.
Drs. Frankle, Warner and others,
Thank you for sending out this fascinating discussion for the benefit of all of us! This is also quite timely for me personally, as I was speaking with my partner (Michael Gottschalk) about these patients and what are the true evidence-based indications, particularly given most of us now use some version of a lateralized implant. Given my background, I tend to be more aggressive performing the transfers, but definitely have lots of questions about the true cut-offs and indications, including pathology, extent of tear and fatty infiltration, presence and degree of lag, role in revision setting, etc.
I think this would set up for an excellent multicenter, prospective, observational study; given the relative rarity of the pathology. It would be one where we could standardize preoperative, intraoperative and postoperative data collection between the sites, including videos and various imaging modalities. We would be happy to run it through our IRB at Emory, and participating centers would then just have to complete IRBs for retrospective reviews of prospectively collected information combined with de-identified data transfer agreements (to make is easier to participate). The only requirement for participation is to agree to collect the necessary information in a timely fashion and follow the patients beyond 2 years.
If anyone is interested in participating, please reach out to me personally and we can begin the planning phases. Thank you for your consideration and thank you to leaders like Drs. Warner and Frankle at stimulating these great questions and discussions.
I am interested, JSS.
Jon JP Warner
Thank you Eric and all who have contributed. The reality is we all suffer from Cognitive Bias that what we believe to be true is actually true. Bhandari, who was our speaker several years ago (See our Meeting section for his presentation), pointed out that much of our evidence is flawed due to study design and most importantly, retrospective small cohort studies that are “fragile”. This means we have an insufficient “N” to accurately determine an answer likely to be correct. Thus a multicenter study would be important. A few requests:
There should be preoperative and postoperative video documentation and the format for these should be standardized for investigators. Of course all patient identity should be blocked with video.
There should be an accounting for the type of reverse used and some measurement of the degree of lateralization, or whatever Mark Frankle things is best to measure. Otherwise we may be comparing apples to oranges if we look at geometry as a confounding variable. Maybe. Dr. Frankle is correct with a lateralized prosthesis and maybe we are correct when not lateralized.
I’d like this to be organized under the Codman Logo even though the IRB will need to be initially at one center and then multiple centers.
This, I hope, could be one of many studies which is performed according to our Mission in Codman Shoulder Society and in compliance with good Evidence Based Medicine principles as discussed by Bhandari.
JP Warner, MD
Happy to participate as this gets off the ground.
I attached the paper Dr. Frankle is referencing. Keep in mind these were rTSA done for massive cuff tears without arthritis.
ROM as reported were by video assessment.