Pectoralis major transfer for treatment of irreparable subscapularis tear: a systematic review

Pectoralis major tendon transfer in reverse total shoulder arthroplasty with irreparable subscapularis: surgical technique and preliminary clinical and radiological results

Hypothesis/Background

Addressing irreparable subscapularis in conjunction with reverse total shoulder arthroplasty (RTSA) presents challenges. RTSA without subscapularis repair leads to similar clinical results compared to those with a subscapularis repair but with less range of motion in internal rotation (IR). Optimization of IR and anterior stability after RTSA, in the setting of an irreparable subscapularis may be achieved with a pectoralis major (PM) tendon transfer. This study aims to describe a novel surgical technique involving PM transfer in RTSA for irreparable subscapularis and report the initial clinical and radiological outcomes.

Methods

This study included 13 patients with an average of 65.5 years (range, 52-82 years). All patients underwent a lateralized RTSA with concurrent PM transfer, associated to an irreparable subscapularis, performed by a single surgeon (PV). Preoperative and postoperative range of motion, including internal rotation 1, internal rotation 2, external rotation 1 (ER1) and forward elevation, were measured. The absolute Constant score, the age and sex-adjusted Constant Murley score, Visual Analog Scale and subjective shoulder value were evaluated by the same surgeon. Standard X-rays, preoperative magnetic resonance imaging, and computed tomography scan were performed for all patients.

Results

With an average follow-up of 37 months, the mean Constant score improved from 17.7 preoperatively to 61 postoperative (P < .05). Postoperative clinical outcomes significantly improved across the study group. Mean internal rotation 2 increased from 44.6° to 61.5° (P < .05), while internal rotation 1 improved from 2.6 to 5 (P < .05). The Gerber test yielded positive results for all patients, while the belly press test was negative for eleven patients. Postoperative imaging assessment of the transferred PM tendon transfer showed intact repair, a good cicatrization on the lesser tuberosity with excellent trophicity of the muscle without any fatty infiltration in all patients.

Conclusion

PM transfer combined with a lateralized RSTA in cases of irreparable subscapularis leads to improved shoulder range of motion, particularly in IR, increased strength and pain relief.

Combined Anterior Latissimus Dorsi and Teres Major Tendon Transfer (aLDTM) for Irreparable Anterosuperior Rotator Cuff Tears

Background

Transfer of the anterior latissimus dorsi and teres major (LDTM) tendons has demonstrated favorable outcomes in patients with irreparable anterosuperior rotator cuff tears1. The objective of this procedure is to restore internal rotation strength, enhance active range of motion, and provide pain relief while preserving the glenohumeral joint.

Description

The incision extended from the coracoid to the inferior border of the pectoralis major tendon, following the deltopectoral interval located laterally to the coracoid. While preserving the pectoralis major tendon, the latissimus dorsi (LD) and teres major (TM) tendons are identified and detached from the humerus without separating the tendons. The LDTM tendons are grasped, and nonabsorbable sutures are placed in a continuous running-locking suture fashion. Traction is applied to the sutures while bluntly releasing the adhesions surrounding the LDTM muscles in order to enable further mobilization and excursion. With the patient's arm positioned in full internal rotation and at 45° of abduction for physiological tensioning, the LDTM tendons are attached 2 cm distal to the lateral edge of the greater tuberosity and lateral to the biceps groove with use of 1 medial anchor and 3 lateral anchors.

Alternatives

Arthroscopic partial repair, superior capsular reconstruction, pectoralis major tendon transfer, and isolated LD tendon transfer are potential alternative treatments. In cases in which these options are not feasible or have been unsuccessful, reverse total shoulder arthroplasty can be considered as a treatment option.

Rationale

Arthroscopic partial repair can provide pain relief, but its effectiveness in improving range of motion and muscle strength is limited2,3. Additionally, there is a high risk of retear, with reported rates as high as 52%4. Superior capsular reconstruction is considered a viable treatment, but it is not recommended in cases involving irreparable subscapularis tears5-7. Pectoralis major transfer may lead to less favorable clinical outcomes in cases in which an irreparable subscapularis tear and an irreparable supraspinatus tear are simultaneously present8-10. In cases of irreparable anterosuperior rotator cuff tears, the transfer of the LD tendon alone may not fully restore the superior migration and anterior subluxation of the humeral head.11. Reverse total shoulder arthroplasty may be another option in these cases, but it does not preserve the glenohumeral joint.

Expected Outcomes

The procedure involves stabilizing the superior translation of the humeral head by rebalancing the force couple, as the TM tendon exhibits scapulohumeral kinematics similar to the subscapularis tendon. Additionally, the procedure effectively reduces anterior glenohumeral subluxation through the combined effect of the posterior line of pull from the combined LDTM tendons and the scapulohumeral kinematics of the teres minor tendon. Also, by fixing the transferred LDTM tendons just distal to the greater tuberosity, the vector becomes less vertical, thereby preventing axillary nerve impingement and achieving appropriate tendon tensioning. The use of this procedure is supported by a study of 30 patients who were followed for a minimum of 2 years1. Significant improvements were observed in various scoring systems, including the pain VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons), UCLA (University of California-Los Angeles), SANE (Single Assessment Numeric Evaluation), and ADLIR (Activities of Daily Living requiring active Internal Rotation) scores. Importantly, there was no significant progression of cuff tear arthropathy observed during the final follow-up. Additionally, preoperative anterior glenohumeral subluxation (15 of 30 patients) was restored in all patients after LDTM tendon transfer.

Important Tips

Careful attention should be paid to the anterior humeral circumflex vessels to prevent bleeding.The radial nerve, passing through the anteroinferior surface of the LDTM tendons, should be carefully identified and protected to avoid iatrogenic injury.To maintain physiologic tension, the patient's arm should be positioned in full internal rotation and 45° of abduction.To avoid axillary nerve impingement, the LDTM tendons should be fixed just distal to the greater tuberosity and lateral to the biceps groove.

Acronyms and Abbreviations

SCR = superior capsular reconstructionLDTM = latissimus dorsi combined with teres majorASRCTs = anterosuperior rotator cuff tearsA/S = arthroscopicROM = range of motionTM = teres majorTm = teres minorLD = latissimus dorsiSSC = subscapularisSSP = supraspinatusPM = Pectoralis majorPm = Pectoralis minorRSA = reverse total shoulder arthroplastyASES = American Shoulder and Elbow SurgeonsUCLA = University of California-Los AngelesADLIR = Activities of Daily Living requiring active Internal RotationGT = greater tuberosityACR = anterior capsular reconstructionFF = forward flexionER = external rotationIR = internal rotationAHD = acromiohumeral distanceMRI = magnetic resonance imagingISP = infraspinatusPEEK = polyetheretherketonePOD = postoperative dayEMG = electromyographySD = standard deviationBMI = body mass indexDM = diabetes mellitusHTN = hypertensionVAS = visual analogue scaleSANE = Single Assessment Numeric EvaluationaROM =active range of motion.

Irreparable Subscapularis Tears: Current Tendon Transfer Options

PURPOSE OF REVIEW

Irreparable subscapularis tears, especially in younger patients with higher functional demands, present a challenging entity. Pectoralis major and latissimus dorsi tendon transfers are commonly considered for surgical management of this pathology, yet no consensus exists regarding the superior option. The purpose of this article is to review the most current tendon transfer techniques for irreparable subscapularis tears.

RECENT FINDINGS

For decades, transfer of the pectoralis major has been considered the gold standard technique for irreparable subscapularis tears. This transfer was found to reduce pain and improve functional outcome scores, yet range of motion and force of internal rotation were not maintained in long-term follow-up studies. The latissimus dorsi tendon transfer for the same indications has demonstrated biomechanical superiority in recent cadaveric studies with promising short-term results clinically. Both pectoralis major and latissimus dorsi tendon transfers improve outcomes of patients with irreparable subscapularis tears. Future comparative studies are still needed to determine superiority amongst techniques.

Anterior capsular reconstruction with acellular dermal allograft for subscapularis deficiency: a report of two cases

Anterior glenohumeral instability with an irreparable subscapularis tear is a challenging problem for the orthopedic shoulder surgeon. Current techniques, including tendon transfers, yield inconsistent results with high rates of recurrent instability. Acellular dermal allografting has been used in young patients with massive superior rotator cuff tears with early success, but acellular dermal allografting is comparatively unstudied in anterior deficiency. We present two cases of anterior capsular reconstruction with an acellular dermal allograft in patients ages 66 and 58 years with irreparable subscapularis tendon tears. Follow-up for both patients exceeded 4 years, with forward flexion >140°, external rotation exceeding 60°, a Single Assessment Numeric Evaluation score >90 points, a visual analog scale score of 0 points, and an American Shoulder and Elbow Score of 98 points. In conclusion, acellular dermal allografting can be used to reconstruct the anterior capsule in patients with massive irreparable subscapularis tears, similar to its use in superior capsular reconstruction in patients with massive posterosuperior rotator cuff tears.

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Influence of the rotator cuff tear pattern in shoulder stability after arthroscopic superior capsule reconstruction: a computational analysis

OBJECTIVES

To assess the ability of the arthroscopic superior capsule reconstruction (SCR) in restoring glenohumeral stability in the presence of different preoperative patterns of irreparable rotator cuff tears (RCTs).

METHODS

A computational musculoskeletal (MSK) model of the upper limb was used to simulate isolated SCR and to estimate the stability of the shoulder. Four patterns of preoperative irreparable RCTs were modeled: Supraspinatus (SSP); SSP ​+ ​Subscapularis (SSC); SSP ​+ ​Infraspinatus (ISP); and SSP ​+ ​SSC ​+ ​ISP. The muscles involved in the irreparable RCT were removed from the MSK model to simulate an irreparable full-thickness tear. In the MSK model, the muscle and joint forces were estimated for a set of upper limb positions, from four types of motions (abduction in the frontal plane, forward flexion in the sagittal plane, reaching behind the back, and combing the hair) collected in a biomechanics laboratory, through inverse dynamic analysis. The stability of the shoulder was estimated based on the tangential and compressive components of the glenohumeral joint reaction force. The comparison of pre- and post-operative conditions, for the four patterns of irreparable RCTs, with the healthy condition, was performed using ANOVA and Tukey's tests (statistical level of p ​< ​0.05).

RESULTS

In the setting of an isolated irreparable SSP tear, SCR statistically significantly improved stability compared with the preoperative condition (p ​< ​0.001). For the irreparable SSP ​+ ​SSC pattern, a statistically significant loss in stability was observed (p ​< ​0.001) when SCR was applied. For the irreparable SSP ​+ ​ISP and SSP ​+ ​SSC ​+ ​ISP patterns, the postoperative condition increased shoulder stability, compared to the preoperative condition; however, the improvement was not statistically significantly different.

CONCLUSION

Isolated SCR for irreparable RCTs extending beyond the SSP does not statistically significantly improve the stability of the glenohumeral joint.

LEVEL OF EVIDENCE

Level IV.

Evaluation of spin in systematic reviews on the use of tendon transfer for massive irreparable rotator cuff tears

PURPOSE

To identify, describe and account for the incidence of spin in systematic reviews and meta-analyses of tendon transfer for the treatment of massive, irreparable rotator cuff tears. The secondary objective was to characterize the studies in which spin was identified and to determine whether identifiable patterns exist among studies with spin.

METHODS

This study was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Each abstract was assessed for the presence of the 15 most common types of spin derived from a previously established methodology. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, preregistration of the study protocol, and methodologic quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

RESULTS

The search yielded 53 articles, of which 13 were included in the final analysis. Articles were excluded if they were not published in a peer reviewed journal, not written in English, utilized cadaveric or nonhuman models, or lacked an abstract with accessible full text. 53.8% (7/13) of the included studies contained at least 1 type of spin in the abstract. Type 5 spin ("The conclusion claims beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was the most common, appearing in 23.1% (3/13) of included abstracts. Nine of the spin categories did not appear in any of the included abstracts. A lower AMSTAR 2 score was significantly associated with the presence of spin in the abstract (P < .006).

CONCLUSION

Spin is highly prevalent in the abstracts of systematic reviews and meta-analyses concerning tendon transfer for massive rotator cuff tears. A lower overall AMSTAR 2 rating was associated with a higher incidence of spin. Future studies should continue to explore the prevalence of spin in orthopedic literature and identify any factors that may contribute to its presence.

Pectoralis major tendon transfer for management of subscapularis failure after anatomic total shoulder arthroplasty: technique and results

Background

Subscapularis tendon failure after anatomic total shoulder arthroplasty can lead to pain, dysfunction, and early component failure. The purpose of this study was to report on the results of pectoralis major tendon transfer for treatment of irreparable subscapularis tendon failure in the setting of prior shoulder arthroplasty.

Methods

Patients who underwent pectoralis major muscle transfer for treatment of subscapularis failure in the setting of prior total shoulder arthroplasty or hemiarthroplasty were included in the study. The entirety of the pectoralis major tendon was transferred superficial to the conjoined tendon and placed lateral to the bicipital groove.

Results

Eight patients were included in the study. All 7 patient who experienced pain in their shoulder had improvement in their pain postoperatively. Those patients with preserved active motion were able to regain that motion postoperatively. Radiographically, anterior translation was found to be temporarily improved; however, anterior instability would later recur in most cases, though this did not correlate with increased pain or decreased function.

Discussion

Management options ranging from continued observation, revision repair, pectoralis muscle transfer, or revision to reverse total shoulder arthroplasty should be considered in a setting of subscapularis failure after shoulder arthroplasty. Decision-making should be based on physiological age of the patient as well as symptoms present as well as the position and stability of the arthroplasty components.

Conclusion

Pectoralis muscle transfer can provide pain relief, improve subjective instability, and preserve function in physiological young patients with an irreparable subscapularis who have well-positioned and well-fixed anatomic shoulder arthroplasty components.

Management of Subscapularis Insufficiency After Total Shoulder Arthroplasty

The functional success of anatomic total shoulder arthroplasty (TSA) relies heavily on the healing integrity of the subscapularis tendon. Access to the glenohumeral joint is performed through a deltopectoral approach, and takedown of the subscapularis tendon is necessary in most surgeons' hands. Although initially described as a tenotomy, lesser tuberosity osteotomy and subscapularis peel are two techniques more commonly used today. Both of these options offer good results as long as proper repair is done. A subscapularis-sparing approach has more recently been advocated but is technically demanding. Failure of tendon repair can lead to early failure of anatomic total shoulder arthroplasty with accelerated glenoid loosening, decreased function, and anterior instability. Treatment options for subscapularis insufficiency include nonsurgical management, revision tendon repair, tendon reconstruction or transfer, or conversion to reverse shoulder arthroplasty. As shoulder arthroplasty continues to become increasingly prevalent, subscapularis insufficiency, too, will become more common. Accordingly, a surgeon's knowledge of subscapularis management in an arthroplasty setting must encompass treatment options for postoperative subscapularis insufficiency.

The clinical outcomes of infraspinatus rotational transfer for irreparable posterosuperior rotator cuff tears: a preliminary report

Background

This study aimed to examine the preliminary clinical results of the infraspinatus rotational transfer procedure for irreparable posterosuperior rotator cuff tears.

Methods

This study included 34 patients (mean age, 68.4 years). Their mean tear width and length measurements were 50.9 mm and 50.6 mm, respectively. The functional outcomes, including physician-determined and patient-reported scores, were evaluated before and at 1 year after surgery. The structural outcomes determined using the magnetic resonance imaging examination results were also assessed.

Results

The clinical scores significantly improved after surgery compared with the scores before surgery: the Constant-Murley score (53.3±21.1 to 76.8±10.5), University of California at Los Angeles Shoulder score (15.6±3.6 to 27.8±6.7), American Shoulder and Elbow Surgeons Shoulder score (51.8±18.3 to 89.1±13.5), and WORC score (925.0±436.8 to 480.3±373.2) (all p<0.001). Postoperative re-tears were noted in two patients (5.9%).

Conclusions

One year postoperatively, the patient’s clinical scores significantly improved, with a re-tear rate of 5.9%.

[Treatment of subscapularis tendon lesions]

The further development of minimally invasive techniques in recent years, enables adequate intraoperative visualization, mobilization and stable reconstruction even of larger subscapularis tears resulting in good to excellent clinical and structural results. Chronic tears of the subscapularis tendon with high grade muscle atrophy and advanced fatty infiltration can be treated with a muscle tendon transfer (e.g. pectoralis major or latissimus dorsi transfer). If pseudoparalysis and/or signs of anterosuperior decentration of the humeral head or defect arthropathy are present, in most cases a reverse shoulder arthroplasty represents the only surgical option.

Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

BACKGROUND

Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear.

PURPOSE

To systematically review and compare the outcomes of LDT and PMT for ISScT.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05).

RESULTS

Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV.

CONCLUSION

In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.

Pectoralis major and pectoralis minor transfer for irreparable subscapularis tendon tears

OBJECTIVE

Irreparable rotator cuff injuries in young patients with moderate to high levels of physical activity remain a challenging pathology for shoulder surgeons. Irreparable anterior rotator cuff injuries require treatment that seeks to restore the dynamic anterior forces of the glenohumeral joint. Among surgical treatment options, transfer of the pectoralis major and minor muscle, have shown good functional outcomes. This technique attempts to reproduce the vector of the subscapular muscle in cases with irreparable tear. Restoration of the dynamic external and internal couple forces to maintain the humeral head in the center of rotation.

INDICATIONS

Pectoralis major transfer (PMa): Irreparable subscapularis tendon (SSC) tear in active patients without osteoarthritis. Pectoralis minor transfer (PMi): Irreparable superior SSC tear with concomitant irreparable supraspinatus tendon (SSP) tear in active patients with no osteoarthritis.

CONTRAINDICATIONS

Primary osteoarthritis Samilson grade C, cuff tear arthropathy Hamada III-V, infection, axillary nerve palsy, older patients with low physical demand, combination with irreparable SSP/infraspinatus tendon (ISP) tear for PMa or combination with irreparable ISP tear for PMi.

SURGICAL TECHNIQUE

General anesthesia and beach-chair position with the arm freely mobile in an arm holder. Deltopectoral approach. Exposure of the humeral head and confirmation of the irreparability of the subscapularis tendon. PMa: Detachment of the tendon to be transferred from the humeral insertion, blunt anatomic dissection medially. Exposure of the conjoined tendon and coracoid process. PMi: Detachment of the tendon with an osteotomy at the coracoid process. Passing the PMa or PMi tendon under the conjoined tendon. The PMa tendon is fixed in a 2-row configuration, the PMi in a single row with suture anchors to the lesser tuberosity.

POSTOPERATIVE MANAGEMENT

Shoulder abduction sling (30°) for 6 weeks. Assisted range-of-motion (ROM) exercises with abduction/adduction 60-0-0°, internal/external rotation free-0-0° for 6 weeks. Free active ROM exercises after 6 weeks, muscle strengthening after 12 weeks.

RESULTS

The pectoralis major and minor transfer shows an improvement in strength and range of motion in young active patients and an improved Constant score (CS) in long-term follow-up examinations.

Computational analysis of subscapularis tears and pectoralis major transfers on muscular activity

BACKGROUND

Pectoralis major is the most common muscle transfer procedure to restore joint function after subscapularis tears. Limited information is available on how the neuromuscular system adjusts to the new configuration, which could explain the mixed outcomes of the procedure. The purpose of this study is to assess how muscles activation patterns change after pectoralis major transfers and report their biomechanical implications.

METHODS

We compare how muscle activation change with subscapularis tears and after its treatment by pectoralis major transfers of the clavicular, sternal, or both these segments, during three activities of daily living and a computational musculoskeletal model of the shoulder.

FINDINGS

Our results indicate that subscapularis tears require a compensatory activation of the supraspinatus and is accompanied by a reduced co-contraction of the infraspinatus, both of which can be partially recovered after transfer. Furthermore, although the pectoralis major acts asynchronously to the subscapularis before the transfer, its activation pattern changes significantly after the transfer.

INTERPRETATION

The capability of a transferred muscle segment to activate similarly to the intact subscapularis is found to be dependent on the given motion. Differences in the activation patterns between intact subscapularis and the segments of pectoralis major may explain the difficulty in adapting psycho-motor patterns during the rehabilitation period. Thereby, rehabilitation programs could benefit from targeted training on specific motion and biofeedback programs. Finally, the condition of the anterior deltoid should be considered to improve joint function.

Treatment Options for Massive Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.

RECENT FINDINGS

Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Feasibility of lower trapezius and rhomboid minor transfer for irreparable subscapularis tears: an anatomic cadaveric study

Background

Previously reported outcomes after tendon transfers to reconstruct the subscapularis are unpredictable and often unsatisfactory, especially in the presence of anterior humeral head subluxation. We studied the anatomic feasibility of the lower trapezius and the rhomboid minor transfer to reconstruct irreparable tendon tears of the subscapularis. The aim of this study was to determine the feasibility of lower trapezius and rhomboid minor transfer to reconstruct irreparable subscapularis tendon tears.

Materials and methods

We measured the tendons dimensions, muscles excursions, distances to pedicles, and dissection needed to complete a successful lower trapezius and/or rhomboid minor transfer to the subscapularis footprint in 10 cadaveric shoulders. The transferred muscles were detached distally, augmented with a semitendinosus and gracilis autograft, and passed anteriorly between the scapula and the subscapularis remnant through a small serratus window to reach the lesser tuberosity. The risk of pedicle compression was subjectively assessed in all cases.

Results

The trapezius and rhomboid tendons were asymmetric with an average length of 37.6 mm and 21.7 mm, an average width of 63 mm and 33.4 mm, respectively. The mean distances from each distal insertion to the lesser tuberosity were 109 mm for the trapezius and 144 mm for the rhomboid. Mean distances from tendon to pedicle were 57.9 mm and 33.1 mm, respectively. The mean size of the necessary serratus window was 49.4 mm, which was measured at maximal excursion achieved at maximal external rotation 90° representing two digitations. All of the tendon transfers were feasible, and the risk of pedicle compression was 20% for the trapezius and 10% for the rhomboid. Superior migration of the transfer was observed during passive external rotation if the insertion point was too high.

Conclusions

Transfer of the lower trapezius and rhomboid minor to the lesser tuberosity to reconstruct an irreparable subscapularis tear is feasible without extensive dissection and with a low risk of nerve compression. We recommend not to transfer the rhomboid minor routinely, owing to the risk of tendon luxation after external rotation of the shoulder.

Tendon transfers for irreparable rotator cuff tears

Symptomatic irreparable rotator cuff tears pose a challenge for shoulder surgeons. Whilst reverse polarity shoulder arthroplasty is an effective option for older symptomatic patients who have exhausted conservative management, the optimal treatment for younger patients remains controversial. In this article we outline the main tendon transfer options, including anatomical considerations, indications, contraindications, surgical technique, complications and a review of the evidence. Tendon transfers provide an alternative joint-preserving surgical option, but the evidence so far is limited, with a clear need for well-designed comparative studies to confirm their effectiveness.

Biomechanical effectiveness of tendon transfers to restore active internal rotation in shoulder with deficient subscapularis with and without reverse shoulder arthroplasty

BACKGROUND

Loss of active shoulder internal rotation can be very disabling. Several tendon transfers have been described for the management of an irreparable subscapularis (SSC) tear. The purpose of this study was to determine and compare the internal rotation moment arm (IRMA) of the sternal head of the pectoralis major (PM), latissimus dorsi (LD), and teres major (TM) when transferred to different insertion sites to restore shoulder internal rotation with and without reverse shoulder arthroplasty (RSA).

METHODS

Six fresh-frozen right hemithoraces were prepared and evaluated using a custom tendon transfer model to determine the IRMA of different tendon transfers using the tendon and joint displacement method. Five tendon-transfer pairs were modeled using a single suture and tested before and after implantation of an RSA (Comprehensive; Zimmer-Biomet, Warsaw, IN, USA): PM to the insertion site of the SSC, LD to the anterior insertion site of the supraspinatus (SSP) tendon on the greater tuberosity, LD to SSC, TM to SSP, and TM to SSC. The SSC was not repaired at the end of the RSA procedure to simulate an SSC deficiency. The PM transfer was passed under the conjoined tendon when tested on the intact shoulder and above the conjoined tendon when tested with an RSA.

RESULTS

Tendon transfers were shown to have a significant effect on IRMA. The effect of transferred tendons was significantly affected by the position of the humerus. With the humerus adducted, the IRMA of the TM-SSP (14.1 mm ± 3.1 mm) was significantly greater than the other transfers. With the humerus abducted to 90°, the IRMAs of the LD-SSP (30.0 mm ± 5.4 mm) and TM-SSP (28.4 mm ± 6.6 mm) were significantly greater than the IRMAs of other transfer options. The IRMA of the native shoulder differed significantly from that of the RSA state for all tendon transfers. With the humerus adducted to the side of the body, the IRMA of the RSA PM-SSC transfer was significantly greater than that without an RSA (19.0 mm ± 6.4 mm vs. 7.1 mm ± 0.9 mm), demonstrating increased efficiency for internal rotation in the RSA state.

CONCLUSION

Tendon transfers to restore shoulder internal rotation differ in effectiveness and may be affected by arm position and by implantation of a lateralized humerus/lateralized glenoid RSA. The LD potentially results in superior restoration of shoulder internal rotation in a native shoulder (given the risk of nerve compression with the TM transfer) compared with PM and should be considered as a potential tendon transfer to restore internal rotation in selected patients. In combination with a lateralized humerus/lateralized glenoid RSA, the fulcrum provided by the biomechanics of the semiconstrained implant allows the PM transfer to become a more efficient tendon transfer to restore active internal rotation.

Anterior Capsular Reconstruction with Dermal Allograft in Combination With Anatomic Glenohumeral Arthroplasty: A Case Report

CASE

A 43-year-old man with chronic right shoulder pain and dysfunction due to recurrent anterior instability, irreparable subscapularis tear, and glenohumeral arthritis presented to our practice. After workup and counseling, he was treated with anatomic total shoulder arthroplasty augmented by anterior capsular reconstruction using human acellular dermal allograft. At 15 months postoperatively, his forward elevation, external rotation, and internal rotation were 160, 45, and T12, nearly equal to contralateral values. His glenohumeral joint remained reduced, and no complications were encountered.

CONCLUSION

We report the first known anterior capsular reconstruction performed in combination with anatomic shoulder arthroplasty.

Pectoralis major tendon transfer for subscapularis deficiency following multiple failed instability surgeries: A case report

Here, we report a case of a 30-year-old man with a diagnosis of complex shoulder instability, who was treated successfully by pectoralis major transfer following a series of failed instability correction surgeries. The patient was admitted to our outpatient clinic with an approximately 6-year history of chronic shoulder instability following several failed operations, including open Bankart repair, open capsular plication and Bankart repair, open capsule repair, arthroscopic Bankart repair, and Bristow-¬Latarjet procedure. Physical examination revealed persistent shoulder pain, weakness, and a limited range of motion. Imaging studies demonstrated complete subscapularis muscle atrophy with Goutallier grade 4 fatty infiltration. The decision for revision surgery was made owing to his shoulder findings and clinical symptoms. The intra-operative assessment revealed the subscapularis muscle to be fully atrophic and irreparable. The pectoralis major muscle was transferred from the intertubercular groove of the humerus to the lesser tuberosity. Postoperatively, the patient had 4 weeks of shoulder immobilization. Physical examination demonstrated an improved shoulder range of motion without evidence of recurrent shoulder instability. The authors encountered no sign of dislocation for 2.5 years of follow-up after the surgery. In conclusion, subscapularis muscle atrophy or insufficiency should be considered in the differential diagnosis of patients with failed shoulder instability surgeries. Pectoralis major tendon transfer may be successfully performed for the surgical treatment of such patients.

Pectoralis Major and Anterior Latissimus Dorsi Transfer for Subscapularis Tears

PURPOSE OF REVIEW

Irreparable subscapularis tears represent a challenging entity, especially when they occur in younger patients with high functional demands. Tendon transfers are one of the options considered for surgical management for this pathology. The purpose of this article is to review the surgical technique and outcome of the two most common tendon transfers considered for irreparable subscapularis tears: pectoralis major and latissimus dorsi.

RECENT FINDINGS

Transfer of the pectoralis major has been considered for decades the transfer of choice for irreparable subscapularis tears. Recently, a series with long-term follow-up (over 18 years) supported the reduction in pain and improvement in functional scores and patient satisfaction after pectoralis major transfer. However, the range of motion and the force in internal rotation were not maintained over time. Transfer of the latissimus dorsi to the lesser tuberosity has been recently described as an alternative with a sound biomechanical rationale and encouraging short-term results. Transfer of the pectoralis major and the transfer of latissimus dorsi to the lesser tuberosity are the two transfers most commonly considered for patients with irreparable subscapularis tears. Transfer of the pectoralis major has a much longer track record. Both procedures seem to improve outcomes. Comparative studies are needed to determine the relative indications of these two procedures.

The Postoperative Rotator Cuff

MR imaging interpretation following rotator cuff repair can be challenging and requires familiarity with various types of rotator cuff tear, their surgical treatments, normal postoperative MR imaging appearance, and complications. This article reviews the common surgical procedures for the reparable and nonreparable massive rotator cuff tears, their expected postoperative MR imaging findings, and imaging appearance of a range of complications.

Anterior Capsular Reconstruction Using a Dermal Allograft for an Irreparable Subscapularis Tear After Shoulder Arthroplasty: A Case Report

CASE

A 51-year-old man was noted to have an irreparable subscapularis tear after total shoulder arthroplasty (TSA). Owing to positive reported results with superior capsular reconstruction, his insufficiency was addressed with anterior capsular reconstruction with use of a dermal allograft. Two-year follow-up results demonstrate good functional outcomes, no recurrent instability, and excellent patient satisfaction.

CONCLUSIONS

Anterior shoulder insufficiency after TSA can significantly alter glenohumeral function and is an important cause of patient morbidity. This novel technique exhibits a good outcome and provides an alternative to previous methods of repair.

Everything pectoralis major: from repair to transfer

Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 and 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand the proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures.Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management.Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer, and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment.Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6 and 8 weeks. The chronicity of the rupture (>8 weeks) increases the likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction, and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.

Editorial Commentary: Anterior Capsular Reconstruction for Subscapularis Deficiency: The Definitive Treatment or a Helpful Adjunct?

Anterior glenohumeral instability in the setting of irreparable subscapularis deficiency represents a difficult clinical scenario for the treating shoulder surgeon. Anterior capsular reconstruction with humeral dermal allograft improved glenohumeral translation stability and range of motion to near-normal values whereas pectoralis major tendon transfer was unable to do so. However, placement of a static spacer does not restore the dynamic force couple or shoulder kinematics. Further research is needed to evaluate the functional outcomes using this reconstruction technique.

Anterior Capsule Reconstruction Versus Pectoralis Major Transfer for Irreparable Subscapularis Tears Involving the Anterior Capsule: A Comparative Biomechanical Cadaveric Study

PURPOSE

To compare the biomechanical effectiveness of human dermal allograft (HDA) anterior capsular reconstruction (ACR) and pectoralis major tendon transfer (PMTT) for treating irreparable subscapularis tears with capsular insufficiency in human cadaver shoulders.

METHODS

Glenohumeral rotational range of motion and translation were measured in 6 cadaveric shoulders under the following 5 conditions: intact, deficient subscapularis/anterior capsule, ACR using HDA, HDA ACR with concomitant PMTT, and PMTT alone.

RESULTS

The deficient subscapularis/anterior capsule condition significantly increased external and total rotational range of motion at 0° (P < .001, P < .001) and 30° (P = .005, P = .002) abduction as well as anterior-inferior translation (P ≤ .001 to .03). HDA ACR, both with and without PMTT, restored anterior-inferior stability to that of the intact condition; however, PMTT alone did not restore anterior-inferior translation or rotational range of motion.

CONCLUSIONS

HDA ACR for treating irreparable subscapularis tears with capsular insufficiency restored anterior-inferior glenohumeral translation and rotational range of motion at time 0 in human cadaver shoulders.

CLINICAL RELEVANCE

Anterior capsule reconstruction may be a viable option for treating massive irreparable subscapularis tears with capsular insufficiency.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

Latissimus dorsi transfer for irreparable subscapularis tendon tears

BACKGROUND

There are several tendon transfers for reconstruction of irreparable subscapularis tears. The latissimus dorsi (LD) could be used because its direction and function are similar to those of the subscapularis. We performed LD transfers for irreparable subscapularis tears and evaluated clinical outcomes.

METHODS

The study enrolled 24 consecutive patients who underwent LD transfers. Clinical and functional outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, pain visual analog scale, and range of shoulder motion preoperatively and at last follow-up. The lift-off and belly-press tests were performed to assess subscapularis integrity and function. Magnetic resonance imaging was performed preoperatively and 1 year postoperatively to evaluate tendon integrity.

RESULTS

Mean Constant, American Shoulder and Elbow Surgeons, and pain scores improved from 46 ± 6 to 69 ± 5 (P < .001), from 40 ± 3 to 70 ± 5 (P < .001), and from 6 ± 1 to 2 ± 1 (P = .006), respectively. The mean range of motion for forward elevation and internal rotation increased from 135° ± 17° to 166° ± 15° (P = .016) and from L5 to L1 (P = .010), respectively. Improvement in the range of motion for external rotation was not significant (51° ± 7° to 68° ± 7°; P = .062). At final follow-up, the belly-press test results were negative for 18 of 24 patients, and the lift-off test results were negative for 16 of 20 patients. No complications related to tendon transfer, including axillary and radial nerve injuries, were found. No retearing of the transferred LD was observed.

CONCLUSIONS

LD transfer resulted in pain relief and restoration of shoulder range of motion and function. LD transfer could be considered an effective and safe salvage treatment for irreparable subscapularis tears.

Qualitative and Quantitative Anatomy of the Proximal Humerus Muscle Attachments and the Axillary Nerve: A Cadaveric Study

PURPOSE

To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve.

METHODS

Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured.

RESULTS

Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm).

CONCLUSIONS

The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm.

CLINICAL RELEVANCE

Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.

Arthroscopic-Assisted Pectoralis Minor Transfer for Irreparable Anterosuperior Massive Rotator Cuff Tear

An irreparable anterosuperior massive rotator cuff tear with an irreparable subscapularis tear is not common; however, once symptomatic, it would become a challenging situation. Tendon transfer is a choice and the pectoralis major is a commonly selected graft source. However, there are theoretical concerns over its use: high invasiveness and low reproducibility, different force vector from the subscapularis, unsuitability for the arthroscopic modification, and difficulty in conversion to the reverse shoulder arthroplasty due to adhesions and scar formation in the anterior shoulder. Recently, open pectoralis minor transfer has been advocated as an alternative reconstruction option. We describe an arthroscopic-assisted technique of pectoralis minor transfer for irreparable anterosuperior massive rotator cuff tear.

Orthopedic resident's learning curve for arthroscopic subscapularis tendon repair: short-term clinical and radiographic outcomes

BACKGROUND

Arthroscopic subscapularis (SSC) repair is a technically demanding procedure with a long learning curve. As effective completion of resident's practical experience remains controversial, a prospective clinical study was performed to assess the functional and anatomical outcomes of subscapularis (SSC) arthroscopic repair by orthopedic residents. The pathological anatomy of the tears, the surgical approach and the difficulties encountered at the beginning of the learning curve were reported.

MATERIALS AND METHODS

Between June 2009 and June 2010, 30 patients with rotator cuff tear were preoperatively evaluated with clinical exam, Constant and UCLA scores. Surgery was performed under arthroscopy by a team of three orthopedic surgeons in training. A SSC tear, if present, was recorded and treated. The same clinical exam and functional scores were repeated at minimum 6 months of follow-up. Subscapularis strength recovery and tendon healing were investigated with arthromagnetic resonance imaging.

RESULTS

A SSC tear was observed in 11 cases out of 30 and treated arthroscopically. The clinical scores improved in all patients: the average Constant score increased from 34 ± 14 to 77 ± 11 and the UCLA score from 11 ± 5 to 29 ± 3. The SSC tests were negative in all patients with the exception of one. Tendon healing was observed in 10 out of 11 cases.

CONCLUSIONS

Arthroscopic SSC repair performed by educated residents is possible and leads to good clinical and anatomical results. Surgery duration progressively improved as the learning curve advanced.

LEVEL OF EVIDENCE

Level 2.

Anterior Capsule Reconstruction for Irreparable Subscapularis Tears

A subscapularis complete tear presents its own challenges in management. The glenohumeral biomechanics and force couple are reliant on a competent and functioning subscapularis muscle. An irreparable subscapularis makes those same challenges even more difficult to address. Traditionally, this problem has been addressed with tendon transfers, including pectoralis major or latissimus dorsi. These techniques can alter the ideal biomechanics of the shoulder and have high rates or failure. Iliotibial autograft or tibialis anterior have also been wrought with high failure rates. Recently, the superior capsular reconstruction has been described for irreparable tears of the supraspinatus and infraspinatus. Theoretically, this procedure can act as a check rein against subluxation, and may serve to reconnect the force couples of the rotator cuff. Anterior escape may represent a similar challenge when the irreparable rotator cuff tendon is the subscapularis. To address this, we describe an open anterior capsule reconstruction technique with an acellular dermal graft. We theorize that this procedure may serve in a similar capacity to its superior capsular counterpart.

Anterior Capsule Reconstruction Technique With an Acellular Dermal Allograft

An irreparable subscapularis may have a debilitating influence on glenohumeral joint biomechanics. Traditional treatment approaches are focused on tendon transfers, among which the most popular are pectoralis major and latissimus dorsi transfers. However, these techniques present significant retear rates, possible nerve injuries, and altered biomechanics. Other techniques like tibialis anterior or iliotibial autograft grafting also have many reported failures. We describe an all-arthroscopic anterior capsule reconstruction technique with an acellular dermal graft.

Anterior Capsular Reconstruction for Irreparable Subscapularis Tears

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

Long-Term Outcome After Pectoralis Major Transfer for Irreparable Anterosuperior Rotator Cuff Tears

BACKGROUND

Promising short-term outcomes after pectoralis major tendon transfer for the treatment of an irreparable anterosuperior rotator cuff tear have been reported. The purpose of this study was to evaluate the long-term outcome.

METHODS

Twenty-seven consecutive patients with irreparable anterosuperior rotator cuff tears without advanced cuff arthropathy or advanced humeral head migration were treated with a partial subcoracoid pectoralis major tendon transfer between 2004 and 2005. At an average of 10 years (range, 9 to 11 years) postoperatively, 22 patients (82%) with an average age of 62 years (range, 42 to 74 years) at the time of surgery had a long-term follow-up examination that included the pain score, strength and range-of-motion assessment, Constant score, Simple Shoulder Test (SST), as well as radiographic and ultrasonographic imaging. The long-term results were compared with the preoperative findings as well as the short-term results that were collected from a previous evaluation.

RESULTS

The adjusted Constant score increased from 54% to 87% at the short-term follow-up (p < 0.001) and remained improved at the long-term follow-up, with a mean score of 83% (p = 0.001). While the significant improvement of the pain level at the short-term follow-up was maintained at the time of final follow-up (p = 0.001), the increase in strength returned to the preoperative level (p = 0.178), and the improvement in range of motion diminished again over time despite remaining significantly improved (p = 0.029), especially with regard to internal rotation (p < 0.001). At the long-term follow-up, 77% of the patients were very satisfied with the procedure. A third of the patients had no progression of cuff arthropathy, a third had progression by 1 grade, and a third had progression by ≥2 grades. At the time of final follow-up, 1 patient (5%) had undergone revision surgery to reverse shoulder arthroplasty.

CONCLUSIONS

Pectoralis major tendon transfer for the treatment of irreparable anterosuperior rotator cuff tears results in a significant clinical improvement even 10 years after surgery, especially with respect to pain and internal rotation. Despite long-term radiographic progression of cuff arthropathy, patient satisfaction remains high over time, with a low rate of salvage with reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers

Background:

Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis.

Conclusion:

Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.