Irreparable Subscapularis Tears: Current Tendon Transfer Options

Clinical outcomes of full arthroscopic combined latissimus dorsi and teres major transfers for irreparable subscapularis tears

Purpose

Managing irreparable subscapularis tears poses a challenge. Traditionally, pectoralis major transfer has been the gold standard, but alternative methods including anterior latissimus dorsi (LD) and teres major (TM) tendon transfers have shown promise. This study evaluates the clinical outcome of full arthroscopic combined LDTM transfers for irreparable subscapularis tears.

Methods

Patients with irreparable subscapularis tears who underwent full arthroscopic combined LDTM transfers from October 2020 to August 2022 were retrospectively reviewed. The inclusion criteria comprised failure of conservative treatment, irreparable subscapularis tears (Lafosse grade ≥ 4), and no to minimal glenohumeral arthritis (Hamada grade < 3). The exclusion criteria included patients with missing clinical data. Clinical assessments included the visual analogue scale (VAS), the Constant score, the Subjective Shoulder Value (SSV), active range of motion (ROM), and internal rotation strength. A total of 11 patients met the inclusion criteria and were included in this study.

Results

Out of 14 patients, 11 met the inclusion criteria, with a mean age of 65.9 ± 6.0 years and a follow-up duration of 25.9 ± 6.2 months. Postoperative results demonstrated significant pain relief, with the VAS score improving from 8.1 ± 0.9 to 2.1 ± 2.1 (p < 0.001). Functional outcomes improved significantly, with the Constant score increasing from 29.9 ± 3.9 to 62.6 ± 15.9 (P < 0.001) and the SSV improving from 25.3 ± 8.7 to 66.5 ± 20.1 (p < 0.001). ROM significantly increased in forward elevation, abduction, and internal rotation, while internal rotation strength also improved significantly. There were no complications or progression of arthritis observed.

Conclusion

Full arthroscopic combined LDTM transfer demonstrates promising clinical and radiological short-term outcomes for patients with irreparable subscapularis tears. The procedure resulted in substantial improvements in pain relief and functional outcomes, particularly in internal rotation for both ROM and strength. Importantly, no significant complications or progression of glenohumeral arthritis were observed by the final follow-up.

Level of Evidence

Level IV, retrospective case series.

Clinical Outcomes of Fully Arthroscopic Versus Arthroscopically Assisted Latissimus Dorsi Transfer for Irreparable Subscapularis Tear

BACKGROUND

Untreated chronic subscapularis (SSC) tears pose a challenging problem to treat owing to the resultant tendon retraction, atrophy, fatty infiltration, and changes in humeral head position, which complicate surgical options. Anterior latissimus dorsi (LD) transfer has shown effective results in treating these tears without glenohumeral arthritis.

PURPOSE/HYPOTHESIS

This study introduces and evaluates fully arthroscopic and arthroscopically assisted anterior LD transfer techniques for reconstructing irreparable SSC tears. The authors hypothesize that both methods will yield promising and comparable clinical outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This retrospective study reviewed patients who underwent anterior LD tendon transfer between February 2014 and April 2022. Indications for surgery included persistent shoulder pain and functional limitations unresponsive to nonoperative treatment, irreparable SSC tears (Lafosse grade ≥4), significant fatty infiltration (Goutallier grade ≥3), and minimal glenohumeral arthritis (Hamada stage <3). Patients were excluded if they had <2 years of follow-up or if data were lost. For comparison, the study divided patients into 2 groups based on the surgical methods: fully arthroscopic LD tendon transfer and arthroscopically assisted LD tendon transfer. Clinical assessments included pain levels (visual analog scale), Constant score, Subjective Shoulder Value score, and range of motion. Radiologic measurement and complications were assessed.

RESULTS

The study included 34 patients (mean ± SD age, 62.4 ± 7.5 years; follow-up, 35.4 ± 15.9 months). Significant improvements were observed in all patient-reported outcomes (pre- to posttest visual analog scale, 7.5 ± 1.2 to 1.2 ± 1.6; Constant score, 28.3 ± 6.0 to 68.8 ± 15.8; Subjective Shoulder Value, 23.2 ± 8.7 to 65.3 ± 22.0; all P < .001), range of motion in all directions, and internal rotation strength. Fully arthroscopic (n = 18) and arthroscopically assisted (n = 16) LD tendon transfers produced comparable clinical outcomes. Complications included 3 retears, 3 infections, and 5 cases of arthritis progression.

CONCLUSION

Fully arthroscopic and arthroscopically assisted anterior LD transfers significantly reduce pain, enhance range of motion, and strengthen internal rotation in patients with irreparable SSC tears, with no significant differences in complications. These techniques offer comparable clinical outcomes, providing different options for surgeons.

Arthroscopically Assisted Pectoralis Minor Transfer for Anterosuperior Massive Rotator Cuff Tear With Irreparable Subscapularis Tears Leads to Significant Improvement in Pain and Function at Short-Term Follow-Up

PURPOSE

To report the results of an arthroscopically assisted pectoralis minor transfer with an expanded indication to include Lafosse type 4 cases. In addition, prognostic factors for pectoralis minor transfer, including the Lafosse classification, were explored.

METHODS

Outcomes of arthroscopically assisted pectoralis minor tendon transfer for anterosuperior massive rotator cuff tear with irreparable subscapularis tears with a minimum follow-up of 24 months were retrospectively reviewed. Severe pseudoparesis with flexion of less than 30° was not indicated. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) score, active range of motion, and the visual analog pain scale. Multiple regression models were used to determine predictors for UCLA score and elevation.

RESULTS

Seventy-four consecutive patients (mean, 69.4 years; 65 men) were evaluated. The mean UCLA score increased from 15.3 preoperatively to 30.9 postoperatively (P < .001). The mean active elevation increased from 104° preoperatively to 148° postoperatively (P < .001). The mean active external rotation increased from 47° preoperatively to 57° postoperatively (P < .001). The visual analog pain scale improved from 62 to 11 mm postoperatively (P < .001). There were no serious complications, but 1 was revised with reverse shoulder due to ongoing pain. In multiple regression analysis, the positive predictors of UCLA and elevation were the preoperative external rotation angle (P = .0028) and elevation angle (P = .00067), respectively. Lafosse classification was not a significant factor.

CONCLUSIONS

Arthroscopically assisted pectoralis minor transfer led to significant improvement in overall shoulder pain and function. Better preoperative range of motion was a significant predictor of better clinical outcomes; Lafosse classification was not significant as a prognostic factor.

LEVEL OF EVIDENCE

Level IV, retrospective therapeutic case series.

Comparison of clinical outcomes of anterior combined latissimus dorsi and teres major tendon transfer for anterior superior irreparable rotator cuff tear between young and elderly patients

BACKGROUND

Anterior combined latissimus dorsi and teres major (aLDTM) tendon transfer has shown promise as a treatment for anterior superior irreparable rotator cuff tears (ASIRCTs). Our study aimed to compare aLDTM clinical outcomes for ASIRCTs between young and elderly patients.

METHODS

This retrospective study reviewed data from patients who underwent aLDTM tendon transfer for ASIRCTs with minimum 2-year follow-up. Clinical evaluations included visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), active range of motion (aROM), strength, and complications. Radiologic assessments included acromiohumeral distance, Hamada classification, and integrity of transferred tendon. Patients were divided into group total (all ages), group old (≥70 years), and group young (≤60 years).

RESULTS

A total of 123 patients were enrolled with 39 in group young (mean age, 56.6±4.9 years) and 27 in group old (mean age, 73.6±2.3 years). Postoperatively, both groups showed significant improvements in VAS, ASES, and SANE scores and improved aROM for forward elevation, abduction, and internal rotation. No significant differences in clinical coutcomes were noted between the groups. Furthermore, similar rates of complications, including retears and postoperative infections, were observed across all three groups.

CONCLUSIONS

Our study highlights the effectiveness of aLDTM transfer for ASIRCTs with minimal glenohumeral arthritis, demonstrating similar outcomes in both group young and group old patients. Moreover, patients in these distinct age groups showed comparable clinical results when compared to group total. Level of evidence: III.

Pectoralis Major Transfer For Anterior Recurrent Dislocation of Reverse Total Shoulder Arthroplasty: A Case Report

Introduction

Reverse total shoulder arthroplasty (RTSA) has revolutionized the treatment landscape for a spectrum of shoulder pathologies, extending its indications from rotator cuff arthropathy to encompass irreparable rotator cuff lesions, fractures, inflammatory arthritis, and tumors. However, the exponential increase in RTSA usage has brought a proportional rise in associated complications, with dislocation being one of the most common early post-operative complications.

Case Report

This case report details a 65-year-old right-hand dominant male patient presenting with chronic pain and weakness in the right shoulder, diagnosed with advanced glenohumeral arthritis and massive irreparable rotator cuff tears. The patient underwent a Bony Increased- Offset RTSA (BIO-RTSA) procedure, coupled with subscapularis repair. Postoperatively, the patient experienced pain and instability, culminating in an atraumatic anterior dislocation at 4 months. Despite conservative management, recurrent dislocations persisted. Revision surgery was performed with an increase in the linear component size for containment. About 1 year postoperative of the revision surgery, recurrent dislocation reoccurred. Re-revision surgery was performed with secondary pectoralis major (PM) transfer for subscapularis deficiency due to re-tear from recurrent dislocation, and with an increased humeral tray size for better containment. About 1-year and 6-month post-operative to the re-revision surgery, the patient achieved restored stability, improved range of motion, and reported satisfaction with the outcome.

Conclusion

This case report underscores the challenges of managing recurrent anterior dislocation after RTSA. The successful use of secondary PM transfer highlights its efficacy as a salvage procedure in restoring stability for persistent anterior dislocation after RTSA. Yet, further clinical studies are warranted to establish the role of such interventions in the management for RTSA-associated complications.

Level of Evidence IV

Case report.

Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee

PURPOSE

Irreparable rotator cuff tears are disabling and can severely affect daily life activities, especially when young and active patients are involved. The definition is still debated, and they can have several clinical presentations. The treatment depends on the clinical presentation and the patient's age.

METHODS

The survey was developed by the ESSKA U45 Committee and was uploaded on the ESSKA website. Fifty-seven questionnaires were returned. Several aspects of the diagnosis and treatment of massive irreparable cuff tears were investigated. Moreover, treatment options for specific clinical scenarios were given for posterior-superior and anterior-superior cuff tears in young and old patients.

RESULTS

Fatty degeneration of the muscles was the most common criterion to define an irreparable tear (59.7%). In young patients with external rotation with the arm at side lag, partial repair of the cuff was the most common option (41.8%); in case of external rotation with the arm at side + external rotation at 90° of abduction lag without pseudoparalysis, the most common option was partial repair of the cuff + latissimus dorsi or lower trapezius transfer (39.3%), and in case of external rotation with the arm at side + external rotation at 90° of abduction lag with pseudoparalysis, partial repair of the cuff + latissimus dorsi or lower trapezius transfer was still the most common option (25.5%). The same scenarios in old patients yielded the following results: reverse prosthesis (49.1%), reverse prosthesis (44.6%) and reverse prosthesis ± latissimus dorsi or lower trapezius transfer (44.6%), respectively.

CONCLUSIONS

The present survey clearly confirms that biological options (partial cuff repairs and tendon transfers) are the reference in the case of young patients with deficient cuffs (both posterior and anterior). Reverse shoulder prosthesis is the most common treatment option in old patients in all clinical scenarios.

LEVEL OF EVIDENCE

Level IV.