Boileau (2007) — Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty.

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

·J Shoulder Elbow Surg·2007·235 citations·Shoulder & Elbow

Boileau describes the 'Nice L'Episcopo' — a modified tendon transfer rerouting both latissimus dorsi and teres major through a single deltopectoral approach to restore active external rotation. The procedure is used alone for isolated ER deficit (ILER) or combined with reverse arthroplasty for patients who have lost both elevation and ER (CLEER). This is a technique description with preliminary outcomes in 15 patients followed a mean of 38 months.

Study Snapshot

Design

Prospective case series

Setting: Single center, University of Nice, France

Funding: None

Objective

Whether modified LD/TM transfer through a single deltopectoral approach restores active external rotation safely and effectively.

Outcome(s)

Active external rotation gain in degrees at minimum 12 months

Subjects

15 patients

7ILER
6CLEER/CTA
2Tumor

Inclusion

Loss of active ER treated with LD/TM deltopectoral transfer
Minimum 12 months follow-up
Goutallier stage 3-4 infraspinatus and teres minor

Exclusion

Neutral or positive active ER at baseline
Less than 12 months follow-up

Follow-up

Minimum 12 months (mean 38 months, range 14-63)

Statistics

Wilcoxon paired t-test

Key Findings

Active ER improved +27° in ILER patients (isolated transfer) and +28° in CLEER patients (combined with reverse arthroplasty), with both groups reaching statistical significance. The gains are roughly 4x larger than the +7° reported by Gerber for isolated latissimus dorsi transfer alone, supporting the use of both tendons together.
The single deltopectoral approach had zero neurovascular complications, compared to a 20% axillary nerve palsy rate reported by Strecker et al. With the classic two-incision technique. This safety advantage is the primary reason to prefer the anterior approach.
In the CLEER group, mean active elevation increased +75° after the combined procedure, while ER increased +28°. The reverse arthroplasty restores elevation; the tendon transfer restores ER — neither accomplishes both goals alone.
The ADLER score (a 10-item ADL questionnaire specific to ER-dependent tasks: combing hair, eating, shaking hands, writing, etc.) improved from 4 to 27 out of 30 points. Crucially, tasks must be performed without trunk compensation or hornblower positioning. This score captures the functional deficit more specifically than the Constant score.
SSV improved from 34% to 72% (P < .0009) across the full series. The primary driver of patient satisfaction was restored spatial arm control. The ability to stop the forearm from swinging toward the chest during attempted elevation.
Two strict prerequisites must be met before proceeding: (1) negative active ER on exam with positive dropping, lag, and hornblower signs, AND (2) Goutallier stage 3-4 fatty infiltration of both infraspinatus and teres minor on MRI/CT. The procedure is contraindicated if the patient has neutral or positive active ER at baseline.
The teres minor contributes 40% of external rotation strength. When absent or atrophic, reverse arthroplasty alone yields a mean active ER of 0° and Constant score of 46 points versus 15° and 66 points when the teres minor is intact. This is why teres minor status predicts RSA outcomes and why the tendon transfer is needed.

Board PearlCombined LD/TM transfer through a single deltopectoral approach restores +27-28° of active external rotation with zero neurovascular complications versus 20% axillary nerve palsy with the classic two-incision technique.

Clinical Relevance

Reverse shoulder arthroplasty reliably restores elevation in pseudoparalytic shoulders, but it cannot recover external rotation when the infraspinatus and teres minor are gone. Before this technique, surgeons had no reliable single-stage solution for patients with combined elevation and ER loss.

When you encounter a patient with positive dropping, lag, and hornblower signs and Goutallier stage 3-4 posterior cuff infiltration, the decision tree splits cleanly: preserved elevation with no arthritis (ILER) gets isolated LD/TM transfer; pseudoparalysis with arthritis or cuff tear arthropathy (CLEER) gets reverse arthroplasty plus transfer in the same session through the same incision.

Do not perform acromioplasty or sacrifice the coracoacromial ligament in ILER patients — the CA arch is the fulcrum preserving elevation, and removing it risks converting a manageable ER deficit into complete pseudoparalysis.

Postoperative protocol is non-negotiable: 4-6 weeks in 30° abduction and 30° ER splint, with internal rotation restricted to neutral through week 9. One patient in this series who ignored rehab lost 30° of elevation permanently.

Reference

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

Boileau, Trojani, et al.·J Shoulder Elbow Surg·2007·235 citations·Shoulder & Elbow

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Modified Latissimus Dorsi and Teres Major Transfer through a Single Delto-Pectoral Approach for External Rotation Deficit of the Shoulder: as an Isolated Procedure or with a Reverse Arthroplasty.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles