Reverse shoulder arthroplasty as salvage procedure after deltoid muscle flap transfer for irreparable rotator cuff tear: A case report Michael C. Glanzmann, MD*, Matthias Flury, MD, Beat R. Simmen, MD Schulthessclinic, Upper Extremity Group, Lengghalde 2, 8008, Zurich, Switzerland Treatment of patients with severe shoulder dysfunction with rotator cuff deficiency is challenging. The reverse shoulder arthroplasty was developed by Grammont and is a semiconstrained implant. The fixed, medialized center of rotation should lower the insertion of the deltoid muscle. 3,4 Patients with cuff deficiency may benefit substantially with pain relieve and functional improvement due to reverse arthrosplasty reconstruction based on intact deltoid func- tion. Concerns may arise in cases of impaired integrity of the deltoid muscle. We present a case of a patient with cuff tear arthropathy who was treated with reverse shoulder arthroplasty 12 years after deltoid muscle flap transposition for irreparable rotator cuff tear. Case report A 64-year-old, independent woman was treated with a deltoid muscle flap transposition for a massive posterosuperior rotator cuff tear 14 years ago. At that time, a defect of 2 x 4 cm of the supraspinatus and superior two-thirds of the infraspinatus tendon was documented intraoperatively, while both the subscapularis and teres minor tendons were intact. Four years after rotator cuff surgery, her global Constant score had improved from 21 to 48 points while superior migration of the humeral head had pro- gressed. Ultrasound exam could not confirm any remnants of the deltoid flap. The patient’s shoulder status deteriorated over time and did not respond to nonoperative measures. Twelve years after deltoid muscle flap transposition, she presented clinically with a pseudoparalytic shoulder but negative external rotation lag sign. Cuff tear arthropathy was confirmed radiographically (Figure 1). A decision was made to implant a Delta lllâ reverse, ball-and- socket prosthesis (DePuy Switzerland, LeLocle, Switzerland), despite the altered integrity of the deltoid muscle (Figure 2). Postoperative rehabilitation was fast and highly satisfactory. Her absolute Constant score improved from 22 to 62 points 2 years after the reconstruction, a higher value than her best result after the deltoid flap transfer. The previous deltoid muscle flap transfer had no adverse effect on the clinical outcome. Discussion Several studies have reported encouraging results after reverse total shoulder arthroplasty for patients with painful pseudoparalysis resulting from different etiologies. 6,7 Improvement in function after a reverse prosthesis is reported to be independent of etiology, 6 and survival rates of arthroplasties 10 years after operation are reported as high as 84%. 5 The mean relative Constant score had increased from 29% to 64% in a series of 58 patients treated with a reverse shoulder arthroplasty for irreparable rotator cuff tears. 2 Primary procedures resulted in higher scores than revision cases. Deltoid flaps from the anterior third of the middle portion of the muscle were introduced in 1985 as a surgical option for massive posterosuperior rotator cuff tears. 1 To our knowl- edge, this is the first report of a reverse shoulder prosthesis in a patient who previously had a deltoid muscle flap transfer for a massive rotator cuff tear. Because this implant requires an *Reprint requests: Michael C. Glanzmann, MD, Schulthessclinic, 8008 Zurich, Switzerland. E-mail address: mcglanzmann@sunrise.ch (M.C. Glanzmann). J Shoulder Elbow Surg (2009) 18, e1-e2 www.elsevier.com/locate/ymse 1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2008.09.013