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LATISSIMUS DORSI TENDON TRANSFER FOR IRREPARABLE POSTEROSUPERIOR ROTATOR CUFF TEARS: FACTORS AFFECTING OUTCOME

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... ► lesões do manguito rotador ► transferência de tendão ► ombro ► procedimentos ortopédicos them, several authors have demonstrated the possibility of obtaining good outcomes. 2,[9][10][11]19,20 However, up to 36% of clinical failures (as well as 38% of transfer tears) were found. 21 In addition to that, findings about the predictive factors of bad results are still scarce and controversial. ...
... As shown in the results, all of these objectives have been met. The improvements obtained in active external rotation, internal rotation, and FF ROM were similar to those of other published works, 1,2,[9][10][11]19,20 with average gains of 39 degrees (p < 0.001), 3 vertebral levels (p ¼ 0.017) and 24 degrees (p < 0.001), respectively (►Table 2). ...
... This technique seems effective in improving pain relief, considering the average gain of 4.53 points (p < 0.001) to the UCLA score criterion for pain (which ranges from 0-10), besides also being efficient to improve shoulder function, as we can see with the average gain of 3.71 points (p < 0.001) to the UCLA score criterion for function (which ranges from 0-10). Both findings were similar to those of most other works, 1,2,[9][10][11]19,20 such as Grimberg et al., 8 which reported an average gain of 28.4 points (from 37.0-65.4) to the overall Constant score, as well as an average gain of 10.9 points (from 1.7 preop to 12.6 postop) to pain as a Constant subscore. ...
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Resumo Objetivo O objetivo primário do presente trabalho é avaliar os resultados funcionais de uma modificação na transferência do grande dorsal no ombro para o tratamento de lesões póstero-superiores irreparáveis do manguito rotador. O objetivo secundário é avaliar as variáveis que podem influenciar os resultados. Técnica cirúrgica Por meio de uma única abordagem deltopeitoral, o tendão do músculo grande dorsal é desinserido reforçado e alongado com um enxerto tendíneo homólogo, transferido para o úmero e fixado em posição superolateral ao tubérculo maior e anterior ao músculo subescapular. Métodos Avaliação funcional retrospectiva de 16 casos. O período médio de acompanhamento foi de 21 meses (12–47 meses). Os resultados pós-operatórios (no último acompanhamento) foram comparados aos pré-operatórios, bem como a outras variáveis pré, intra e pós-operatórias. Resultados Todos os pacientes ficaram satisfeitos (exceto um). A pontuação média da University of California, Los Angeles (UCLA) aumentou de 11,6 (8–16) para 27,3 (17–30) (p < 0,001). A dor, a função e a força do ombro apresentaram melhora estatisticamente significativa (p < 0,001). A força, porém, não voltou ao valor normal. A amplitude de movimento ativa média apresentou as seguintes melhoras: elevação frontal, de 106° (60–140°) para 145° (130–160°) (p < 0,001); rotação externa, de 30° (0–60°) para 54° (40–70°) (p < 0,001); e rotação interna, de L1 (glúteo a T7) para T10 (T12–T3) (p < 0,05). Nenhuma complicação foi observada. A pseudoparesia pré-operatória foi revertida em todos os seis casos em que foi observada. Nenhuma das variáveis analisadas influenciou os desfechos, nem mesmo a pseudoparesia. Conclusões A curto prazo essa técnica é segura e eficaz na recuperação da pseudoparesia e na melhora da dor, da função e da força do ombro.
... A patient with a FIRCT without arthritis may be offered a variety of treatment options, including partial repair [12][13][14][15][16], augmentation or bridging with allografts [17][18][19][20][21][22], superior capsular reconstruction [23][24][25][26], subacromial balloon [27], shoulder tendon transfers [28][29][30][31][32][33][34][35][36][37][38][39], and reverse shoulder arthroplasty [40][41][42][43]. The ultimate goal of all of these treatment options involves providing a stable fulcrum for the humeral head to rotate, either through an implant, static graft, or restoration of the anterior-posterior force couple. ...
... Tendon transfers represent a promising option to treat patients with FIRCTs, providing a dynamic replacement for the posterior aspect of the force couple. Although the latissimus dorsi transfer (LDT) historically has been historically associated with reliable outcomes in selected patients with posterosuperior FIRTCs [28][29][30][31][32][33][34][35][36], the lower trapezius transfer has emerged as a promising alternative that is potentially biomechanically superior and easier for patients to retrain [35,37,38,44]. ...
... There are many options for surgeons when treating FIRCTs without arthritis, including partial repair [15,66], augmentation or bridging with allografts [17][18][19][20][21][22], superior capsular reconstruction [23][24][25][26], subacromial balloon [27], reverse shoulder arthroplasty [40][41][42][43], and tendon transfers including the latissimus dorsi [28][29][30][31][32][33][34][35][36]67] and lower trapezius transfer [37,38,44]. The results of partial repair [15] deteriorate with time, while the reported outcomes of graft augmentation and superior capsular reconstruction are limited to relatively small case series with short-term follow-up. ...
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Purpose of the review: Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure. Recent findings: The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.
... Boileau el al 10 and Walch et al 11 showed satisfactory results after tenotomy of the long head of the biceps (LHB) alone in elderly patients. Other procedures have been reported, including rotator-cuff debridement (with or without concomitant suprascapular nerve release), 12 partial cuff repair, 13-15 tendon transfers, [16][17][18][19] and reverse shoulder arthroplasty (RSA). 20 The latter, however, is probably not the best option in younger and physically-active patients, because the longevity of these implants in this population is yet unknown, and also because RSAs can still be used as a salvage procedure after the failure of other techniques. ...
... 30 Despite being relatively difficult surgical procedures and requiring accurate patient selection, tendon transfers can significantly improve the quality of life of the patients. 16,18,31 This is especially important for young and physically-active patients with lesions graded as Hamada et al 32 stages 1 and 2 (that is, without both glenohumeral arthritis and static proximal humeral head migration), because they may be the only feasible definitive (that is, long-term) treatments available. 30 The aim of the present paper is to review the literature regarding tendon transfers for irreparable posterosuperior RCTs (that is, the ones involving the supra-and infraspinatus tendons), as the posterosuperior is by far the most common type of RCT. 1 In this context, the latissimus dorsi tendon (LDT) -accompanied or not by the teres major tendon (TMT) -is the most commonly transferred tendon. ...
... Many other subsequent papers 18,19,31,33,[41][42][43][44][45][46][47][48] have also shown that satisfactory results following LDT transfer could be achieved. However, these satisfactory results could not be easily predicted. ...
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Resumo As grandes lesões posterossuperiores irreparáveis do manguito rotador são debilitantes e, de modo geral, requerem tratamento cirúrgico. Embora não haja consenso sobre a melhor técnica cirúrgica, as transferências tendíneas no ombro são os procedimentos mais realizados. O tendão do grande dorsal continua a ser o mais utilizado, mas diferentes modificações na técnica original têm minimizado as complicações e melhorado os resultados funcionais e a satisfação com o procedimento. Outras técnicas, como a transferência do tendão do trapézio inferior, são promissoras e devem ser consideradas, principalmente em pacientes com perda isolada da rotação externa. Este artigo é uma revisão da literatura a respeito da transferência de tendões para tratamento das lesões posterossuperiores irreparáveis do manguito rotador.
... It has yet to be elucidated whether favourable clinical outcome after LDTT is due to the active muscle contraction rather than the passive tenodesis effect. To the best of our knowledge, ten studies are available on electromyographic (EMG) activity of transferred LD [1,10,14,15,18,20,[22][23][24]40]. These studies suggest that in some cases the transfer is truly active, whereas in others the patient cannot actively synchronize the transferred LD with supra-and infraspinatus activity. ...
... Irlenbusch et al. [24] published on the largest available series (i.e. 45 patients) treated with LDTT and evaluated through electromyography; the authors reported inconsistent EMG activity for the external rotation in 0° abduction. In 14 patients after LDTT, Iannotti et al. [22] measured isometric and active external rotation and 6 patients out of 14 showed some activity during external rotation with the arm at the side, and none showed EMG activity during isometric external rotation with the arm in 90° of abduction. Gerber et al. [14] evaluated the EMG activity of the transferred LD in a group of 11 patients and reported activity during external rotation with the arm at the side in 7 patients, but only 2 had activity in 90° of abduction. ...
... We acknowledge some methodological weaknesses in the present study. Similar to previous studies, we did not perform preoperative assessments [18,22,24], which make it difficult to understand how LD muscle activity changed over time relative to its initial condition. The lack of evaluation for the active external rotation represents a major limitation of the study. ...
Article
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Purpose Latissimus dorsi tendon transfer is a surgical option for the treatment of massive irreparable posterosuperior rotator cuff tear. Whether a favourable clinical outcome is due to the latissimus dorsi muscle contraction rather than the passive tenodesis effect remains to be confirmed. The purpose of the current case–control study was to evaluate the shoulder kinematics and latissimus dorsi activation after latissimus dorsi tendon transfer. Methods Eighteen patients suffering from irreparable rotator cuff tear that underwent latissimus dorsi tendon transfer and 18 healthy individuals were examined using a 3D kinematic tracking system and electromyography. Active maximal flexion–extension and abduction–adduction of the humerus were measured for the operated and the contralateral shoulder of the patients and the shoulder of healthy individuals to evaluate the range of motion (ROM) and scapulohumeral rhythm. Electromyographic comparison of isometric contraction between the latissimus dorsi of the operated and contralateral shoulder was carried out. Results After arthroscopic-assisted latissimus dorsi tendon transfer, patients showed comparable flexion and abduction ROM to their asymptomatic contralateral shoulders and to the shoulders of healthy individuals. Significantly higher scapular ROM values were found between the latissimus dorsi tendon transfer side and the shoulders of healthy individuals. While performing external rotation with 0° shoulder abduction, a greater percentage of the electromyographic peak value (p = 0.047) and a higher latissimus dorsi internal/external rotation ratio (p = 0.004) were noted for the transferred muscle in comparison to the contralateral shoulder. Conclusion Although the arthroscopic-assisted latissimus dorsi tendon transfer failed to normalize scapulothoracic joint movements of patients, a functional latissimus flap and a shoulder ROM similar to the contralateral side or the shoulder of healthy individuals can be expected after this procedure in patients with massive irreparable posterosuperior rotator cuff tear. Level of evidence III.
... A post-operative period of 4-6 weeks of immobilization with the arm in A) The skin incision run along the lateral border of the LD; B) the muscle is identified and the tendon is released from the humeral shaft taking care to identify and separate the LD belly (white arrow) from teres major (TM) that is laterally retracted. slight abduction and externally rotated is required 10,35,36,39 . Gentle passive range of motion in abduction can begin immediately, but internal rotation and adduction are restricted until 6 weeks after surgery. ...
... At 6 weeks the brace may be removed and active range of motion is started. Strengthening exercises can be started in the third month 10,35,36,39 . ...
... When the LD tendon is transferred to the greater tuberosity, the muscle's internal rotator torque is removed and the function of the muscle changes into an external rotator 36 . This external rotation is accomplished by either a synergistically active tendon transfer or a tenodesis effect: electromyographic studies have suggested that in some cases the transfer is truly active whereas in others the patient cannot actively synchronize LD muscle activity with supraspinatus and infraspinatus muscle activity 39,40 . ...
... This external rotation is accomplished by either a synergistically active tendon transfer or a tenodesis effect [16] . Electromyographic studies have suggested that in some cases the transfer is truly active whereas in others the patient cannot actively synchronize latissimus dorsi muscle activity with supraspinatus and infraspinatus muscle activity [11,18,26] . In either case, the improved balance between the anterior and posterior soft tissue structures of the shoulder is believed to be biomechanically important to serve as a balanced fulcrum as described by Burkhart [27] . ...
... Iannotti et al. [18] found female sex, generalized muscle weakness and poor preoperative shoulder function to be negative predictors of outcome. They also noted that poor electrical activity of the Latissimus Dorsi Tendon Transfer at follow-up was a negative factor. ...
... The basic working principle of tendon transfer in massive RC tears is to separate a tendon of a muscle near the humerus head and fix it to the RC insertion [5]. Due to the previously mentioned anatomical features, the LD tendon can help close the defect in massive RC tears as a wide, vascularized tendon [11]. Functionally, the LD allows for deltoid activity on the one hand, and on the other hand, restores the shoulder's external rotation [11]. ...
... Due to the previously mentioned anatomical features, the LD tendon can help close the defect in massive RC tears as a wide, vascularized tendon [11]. Functionally, the LD allows for deltoid activity on the one hand, and on the other hand, restores the shoulder's external rotation [11]. LD transfer has been a frequently used tendon transfer technique in posterosuperior RC tears for many years [7]. ...
Article
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Several latissimus dorsi tendon transfer techniques for shoulder problems have been previously described and developed. These techniques involve the transfer in obstetric palsy, transfer in irreparable posterosuperior rotator cuff tears and subscapularis tears, and transfer in reverse shoulder arthroplasty. We detail the differences in planning and surgery and the need for different approaches. This historical and technical description provided in this study will benefit surgeons wishing to use the procedure.
... The open LDT transfer was originally described by Gerber et al in 1988, and subsequent reports by this group have demonstrated predictable and reliable improvements in patients pain and function over a long-term follow-up period. 14-16 30 However, poor predictors of outcomes after the open LDT, including difficulty retraining the transfer, 27 teres minor or subscapularis pathology 14 17 31 and prior failed rotator cuff repair, 17 31 32 has led surgeons to innovate novel modifications to improve on these outcomes including avoiding the acromial osteotomy or deltoid take-down to gain exposure to the greater tuberosity, by performing an 'arthroscopic-assisted' approach to anchoring the tendon. The open lower trapezius tendon transfer has been proposed as an alternative treatment option. ...
... 20 The LDT requires patients to retrain an 'out of phase' muscle to fire during shoulder abduction and external rotation, instead of internal rotation and adduction. 27 A second consideration when comparing the two transfers involves the line of pull. The LTT line of pull closely mimics the infraspinatus. ...
Article
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Objectives The purpose of this study is to compare early postoperative recovery following open and arthroscopic-assisted latissimus dorsi tendon (aa-LDT) transfer to arthroscopic-assisted lower trapezius tendon (aa-LTT) transfer for patients with massive irreparable posterosuperior rotator cuff pathology. Methods A multicentre retrospective analysis comparing the postoperative outcomes after open LDT, arthroscopic-assisted LDT (aa-LDT) or arthroscopic-assisted LTT (aa-LTT) was performed. Active range of motion and patient-reported subjective outcomes were reported preoperatively and postoperatively. Overall, there were 10 patients who underwent open LDT transfer, 16 aaLDT transfers and 8 aa-LTT transfers with mean age of 55±3, 57±6 and 53±13, respectively. Mean follow-up was 22±10 months. Results Arthroscopic-assisted LDT had significantly improved postoperative forward flexion (85–124, p<0.003) and external rotation (29–38, p<0.005), whereas aa-LTT had significantly improved postoperative forward flexion (101–146, p<0.04). Arthroscopic-assisted LDT and aa-LTT transfers improved American Shoulder and Elbow Surgeons (ASES) Shoulder Function scores and Single Assessment Numeric Evaluation (SANE) at 2 years (p<0.03). Arthroscopic-assisted LTT compared with open LDT demonstrated significantly improved ASES Shoulder Index score (20.0 vs 12.6; 84.8 vs 55.6) and visual analogue scale (VAS) (0.66 vs 4.14; 1.17 vs 3.88) at postoperative 6 months and 2 years, respectively. Arthroscopic-assisted LDT transfer compared with open LDT had improved VAS at 6 months (0.66 vs 2.11, p<0.05). In total, 6 (17.6%) complications were noted. These included two infections with Cutibacterium acnes , two axillary nerve injuries, complex regional pain syndrome and a postsurgical adhesive capsulitis. Conclusions Arthroscopic-assisted LDT and aa-LTT transfers provided improvement in pain and function at 2-year follow-up. The aa-LTT transfer provided significantly improved outcomes at 2 years compared with the open-LDT (latissimus dorsi tendon transfer) transfer. This study demonstrates superiority of arthroscopic-assisted tendon transfer techniques over traditional open techniques while establishing the aa-LTT transfer as a safe and effective alternative in the management of massive irreparable rotator cuff tears. Level of evidence IV.
... Worse outcomes were also reported by Warner and Parsons for revision procedures but the satisfaction rate in their series was 73% with rupture of the transferred tendon in the other 23% (69). Iannotti et al. showed that female patients with low shoulder function and strength prior to surgery had a higher risk of poor outcomes after surgery (71). Birmingham and Nevaiser showed improvement in functional scores at shortterm follow-up in a small group of patients who underwent latissimus transfer in the revision setting (72). ...
Article
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The management of massive rotator cuff tears (MRCT) presents a unique challenge to many orthopedic specialists. Unlike tears that are predicted to do well with primary, complete repair, MRCT are affected by tissue retraction, in-elasticity, bursal scarring, muscle atrophy, and fatty degeneration; operative repair thus portends worse healing rates than smaller tears and is associated with recurrent tear rates of up to 91% based on ultrasonography and magnetic resonance imaging (MRI). Rotator cuff tears are a common condition in patients over the age of 50. Thus, multiple advances in treatment strategies have been made to combat the limited efficacy of complete or partial rotator cuff repair in the setting of a massive or irreparable rotator cuff tears. It is of utmost importance that the operating orthopedic surgeon be familiar with these various treatment modalities to best serve the patient and that they harbor these skills within their armamentarium. This article details a review of the current literature including nonoperative and operative treatments for the management of massive and irreparable rotator cuff tears. The primary objective is to propose a literature-based algorithm for the treatment of massive and often irreparable rotator cuff tears to allow for informed ease in the decision-making process.
... [33] In an observational study conducted 10 years after surgery, the results showed that LDT has a good function in the treatment of IRCTs. [34] A review of the literature found that for patients with IRCTs, active flexion of the shoulder joint before tendon transposition > 120° had better postoperative results, [31] and patients with preoperative SSV scores <40 points had poor postoperative function, [35] which indicates that LDT may be more effective for patients with better shoulder joint function. ...
Article
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Background: To evaluate the effect of different surgical methods in the treatment of patients with irreparable rotator cuff tears (IRCTs) using a network meta-analysis. Methods: A search of the PubMed, EMbase, The Cochrane Library, VIP, WanFang Data, and CNKI databases was performed in January 2023 to search for randomized controlled trials and cohort studies of different surgical methods in the treatment of IRCTs. Risk assessment of the included randomized controlled trials was conducted using the risk of bias assessment tool recommended by the Cochrane Manual, and the Newcastle-Ottawa Scale was used for the risk assessment of cohort studies. Data were analyzed and plotted using Stata 15.0 software. Results: A total of 17 studies involving 2123 patients and 10 surgical methods were included in this study. According to the surface under the cumulative ranking curve, the probability ranking in descending order is latissimus dorsi transfer (LDT) + partial repair > LDT > reverse total shoulder arthroplasty > superior capsular reconstruction > patch > partial repair > debridement + tenotomy of the long head of the biceps > debridement > in space subacromial balloon spacer + tenotomy of the long head of the biceps > in space subacromial balloon spacer. Conclusion: Among the multiple surgical treatments for patients with IRCTs, LDT + partial repair may have the best effect, and more randomized controlled trials with larger sample sizes are needed for further verification.
... Most of the series include some patients that meet the criteria for pseudoparesis with mixed results. In Iannotti series, patients with the lowest rate of preoperative active elevation appear to provide the worst results, conversely to the results reported by Valenti suggesting the opposite (Iannotti et al., 2006). It is worth noting that in Valenti's series patients with active elevation < 80° and "antero-superior instability" were excluded. ...
Article
The definition of pseudoparalysis in shoulder is controversial. Gwschend initially described pseudoparalysis as an appearance of paralysis with severe rotator cuff tear. Later, Werner described pseudoparesis as active elevation under 90° caused by an irreparable massive cuff tear. Since these descriptions, many articles across the literature make the confusion between pseudoparesis and pseudoparalysis who differ in term of lesion and treatment options. Subsequently, this adds confusion to confusion when evaluating the results to determine the optimal therapeutic strategy. Conservative and arthroplasty options are discussed but the reverse arthroplasty appears to be the treatment of choice in a true pseudoparalyzed shoulder.
... [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Factors such as pre-operative shoulder function and general strength may influence outcome. 28 However, given the transferred latissimus will provide an inferior force that must be counterbalanced by the deltoid and subscapularis, 12 an intact subscapularis at the time of surgery has been considered imperative. 29 The inferior outcomes reported in patients undergoing LDTT with concomitant subscapularis insufficiency have been reported. ...
Article
Background Latissimus dorsi tendon transfer (LDTT) remains a surgical option for massive irreparable rotator cuff tears. Despite a lack of comparative studies, subscapularis insufficiency has been reported as a contraindication. This study investigated the clinical outcome at a minimum 2-years post-surgery, in patients undergoing LDTT with varied subscapularis integrity. Methods This retrospective study included 48 patients, of which 22 underwent LDTT with an intact subscapularis (age 56.9 years, review time 79.6 months, males 68.2%) and 26 with partial (16 patients) or full-thickness (10 patients) subscapularis tearing (age 57.4 years, review time 73.3 months, males 73.1%) between 2004 and 2018. Pre-operative imaging ascertained subscapularis status. Outcomes included the Upper Extremity Functional Index (UEFI), Global Rating of Change (GRC) and patient satisfaction. Results No significant group differences were observed in age (p = 0.617) or review time (p = 0.555), nor the UEFI (intact 69.6, not intact 67.0, p = 0.265) or GRC (intact 3.6, not intact 2.9, p = 0.265). High levels of patient satisfaction were observed in both groups for pain relief, improving the ability to undertake daily and recreational activities, and overall satisfaction (intact 95.5–100.0%, not intact 92.3–96.2%). Conclusion LDTT resulted in encouraging clinical scores and high satisfaction levels, irrespective of the degree of untreated, underlying subscapularis integrity. Level of evidence Therapeutic Level III.
... In einem systematischen Review von Millett et al. liegt der durchschnittliche Constant Score nach Rotatorenmanschettenrekonstruktion zwischen 75 und 86 Punkten [26], sodass der Latissimustransfer in Anbetracht des Verletzungsausmaßes akzeptabel abschneidet. Ein Einfluss des Geschlechts auf das Outcome ist nicht eindeutig belegt [27,28]. Interessant war, dass Patienten mit präoperativ bestehendem Außenrotations-Lag-Sign im Vergleich zu Patienten ohne Außenrotationsproblematik einen geringeren Bewegungsumfang für die Außenrotation erreichten (32°vs. ...
Article
Objective: Latissimus dorsi transfer aims to reduce pain and improve function for irreparable tears of the posterosuperior rotator cuff by restoring the transversal force couple to improve external rotation and delaying superior migration of the humeral head. Indications: Surgery is advocated in patients with unbearable shoulder pain and limited external rotation caused by an irreparable posterosuperior rotator cuff tear. Usually, a latissimus transfer is recommended in the presence of superior migration of the humeral head, higher grade fatty infiltration of the rotator cuff and a restriction of range of motion and strength for abduction and external rotation. Advantages of the arthroscopically assisted technique are the missing need of detaching the deltoid from its origin, smaller incisions and therapy of concomitant intraarticular lesions. Contraindications: Little pain and sufficient shoulder function in massive posterosuperior rotator cuff tears do not necessitate latissimus transfer. In the presence of subscapularis tears, osteoarthritis and deltoid dysfunction as well as shoulder stiffness tendon transfer are associated with inferior clinical outcomes. Surgical technique: Surgery is performed in prone position. The incision is made about 5 cm caudal of the posterolateral corner of the acromion and extends over 6 cm at the inferior border of the deltoid muscle. After exploration and protection of the axillary and radial nerve the latissimus tendon is peeled off of the humerus. The medial part of the latissimus is then mobilized to gain length for the later transfer. Afterwards the footprint of the infraspinatus is visualized and debrided. Two or three suture anchors are placed into the posterosuperior aspect of the greater tuberosity. The sutures are stitched through the tendon in a horizontal mattress stitch configuration and the tendon tied onto the bone. In arthroscopic advancement, the patient is placed in an upright beach-chair position with the arm attached to an arm holder. After debridement of the supraspinatus and infraspinatus footprint, arthroscopic preparation at the anterior border of the subscapularis tendon is performed. The latissimus tendon is visualized and detached with electrocautery. Afterwards the interval between posterior rotator cuff and deltoid muscle is prepared to allow the transfer of the latissimus tendon to the posterosuperior footprint. This marks the transition to the open approach, in which the arm is placed in a flexed and internally rotated position. Postoperative management: Immobilization in a shoulder sling for 3 weeks. Early passive range of motion (ROM: flexion 30°, internal rotation 60°, abduction 0°, external rotation 0°) was immediately allowed. After 3 weeks, passive ROM was increased to 90° of flexion, 60° of abduction, whereas external rotation was still restricted. After 7 weeks, free passive ROM and after 8 weeks active ROM (assisted) were allowed. Results: In all, 67 patients (mean age 63 years) were examined 54 months (± 28) after open transfer of the latissimus dorsi tendon. Constant score improved from 24 (± 6) points to 68 (± 17) points. Active flexion increased from 83° (± 47°) to 144° (± 35°), abduction from 69° (± 33°) to 134° (± 42°) and external rotation from 24° (± 18°) to 35° (± 21°). The VAS score decreased from 6.3 (± 1.1) to 1.8 (± 2). However, osteoarthritis worsened over time and the Hamada-Fukuda stage increased from 1.4 to 2.1 and the acromihumeral distance decreased from 7.9 (± 2.6) to 5.1 (± 2.2) at final follow-up.
... Each participant completed an orthopedic injury history form and Penn Shoulder Score to identify selfreported level of shoulder function. 21 Active shoulder range of motion of both shoulders was tested with a standard goniometer. Arm dominance was recorded and determined by which arm was used to participate in each sport. ...
... Also, massive cuff tears with subscapularis involvement cannot be treated with a single transfer. Latissimus dorsi transfers 11 have traditionally been used for postero-superior cuff deficiency, but more recently lower trapezius transfers have also been described. 12 Pectoralis major transfers, on the other hand, are commonly utilised for subscapularis defects 13 with a modified latissimus dorsi transfer being described recently. ...
Article
The treatment of symptomatic irreparable rotator cuff tears poses significant challenges to both patients and shoulder surgeons. Although reverse shoulder arthroplasty provides reliably good outcomes in the elderly, it is not a good option in younger patients. Various surgical techniques have been proposed for the treatment of irreparable rotator cuff tears; however, no gold standard currently exists. Interposition grafting is used when the rotator cuff cannot be fully repaired onto its footprint, and the remaining defect is bridged with either an allograft, autograft, xenograft or a synthetic graft. This review aims to present the literature on the use of various interposition grafts and techniques to treat large or massive irreparable rotator cuff tears and provide a specialist practice report.
... [1][2][3][4][5][6] In patients with goals of improved strength and/or return to manual labor, tendon transfer is commonly considered. The latissimus dorsi tendon transfer was initially described by Gerber 7 with successful clinical results; however, Iannotti et al. 8 demonstrated that the latissimus uncommonly fired in-phase during external rotation after transfer. Because the natural force vector of the lower trapezius muscle better recreates the pull of the insufficient or absent infraspinatus as compared with the latissimus dorsi tendon, 9,10 lower trapezius tendon transfer (LTT) has been proposed as an alternative option for irreparable posterosuperior rotator cuff tears. ...
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Purpose: To evaluate functional outcomes, return to work, and reoperations associated with lower trapezius tendon transfer (LTT) for irreparable rotator cuff tears. Methods: This is a retrospective study performed by a single surgeon with minimum 1-year follow-up. LTT was performed using an open (n = 9; 60%) or arthroscopically assisted (n = 6, 40%) technique. Outcomes included failure rate, range of motion, satisfaction, return to work, and pre- and postoperative functional scores, as well as American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, and the Simple Shoulder Test. Results: Fifteen patients were included. LTT was performed using an open or arthroscopically assisted technique. Mean age was 52 (range 31-62 years), 13 (92.9%) were manual laborers, and 9 (60%) had a worker's compensation claim. Three patients (20%) underwent conversion to reverse shoulder arthroplasty. Of the remaining 12 patients, there were significant improvements in American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and Simple Shoulder Test at 24.1 ± 9.6 (range 12-38.5) months. Active forward elevation, abduction, and external rotation were all significantly improved. Postoperative satisfaction ratings indicated 67% of the revision-free cohort was "very satisfied" and 33% was "somewhat satisfied" with their outcome. Seven (50%) returned to full duty, 4 (28.6%) returned to modified duty, and 3 (21.4%) were unable to return to work. Two patients (open techniques) underwent a superficial wound debridement for seroma and wound breakdown. Conclusions: LTT results in successful clinical outcomes with a high rate of return to work in a challenging patient population. However, only 67% of patients rated themselves as "very satisfied," and 20% of patients were revised to reverse shoulder arthroplasty before 1 year. Limited preoperative active forward elevation (<90°) appears to predict poor functional results and risk for reoperation. Level of evidence: Level IV, therapeutic case series.
... Irlenbusch et al. [20], Nove-Josserand et al. [21] and Gerhardt et al. [22] found similar results, consistent with those mentioned in a recent review by Namdari et al. [2] (see Table 2). Only two studies measured external rotation in abduction: Moursy et al. [23] measured 35 • active external rotation and Iannotti et al. [24] determined 50 • external rotation; these are similar to the results of the present study, considering the difference of measurement technique of 3D motion analysis and goniometric measurement. The 3D-motion analysis allow for a more accurate measrument of the range of motion. ...
Article
Background: Massive irreparable posterosuperior rotator cuff tears may result in a loss of external rotation. Most of these patients lose their ability to perform activities of daily living (ADLs), especially where external rotation and abduction are needed. Latissimus dorsi tendon transfer (LDTT) is a method to restore abduction and external rotation in patients with posterosuperior rotator cuff tears. There are no objective data concerning whether LDTT can restore range of motion (ROM), especially in performing ADLs and if proprioception changes after LDTT. Methods: We examined 12 patients 4.2 years (1-9 years) after LDTT with simultaneous 3D motion analysis; the opposite, nonaffected side was assessed as control. The measurement protocol included maximum values in flexion/extension, abduction/adduction, internal/external rotation in 0° and in 90° flexion and in 90° abduction. To evaluate competences, we measured seven activities of daily life and examined the proprioceptive ability using an active angle reproduction test. Results: In total, 4.2 years (1-9 years) after LDTT there was no significant difference in flexion/extension and abduction/adduction compared to the healthy side. Maximum external rotation was significantly reduced compared to the opposite side. Eleven patients (85%) were able to perform all ADL. Proprioceptive ability did not differ from the healthy side. Conclusion: LDTT cannot fully restore a patient's ability for external rotation after a posterosuperior rotator cuff tear. However, 4.2 years after surgery, 85% of the patients are able to perform all ADLs. Proprioceptive ability is not affected by the transfer.
... Improvement in external rotation is thought to be due to either tenodesis effect or active muscle contraction, but EMG studies have shown conflicting evidence regarding muscle activation after LDTT. 38,39 LDTT can either be performed with a single-incision or two-incision technique. 40,41 Arthroscopic-assisted techniques for LDTT have recently been developed, providing smaller surgical incisions, improved visualization, lower infection rate, and preservation of the deltoid origin, theoretically facilitating faster rehabilitation. ...
Article
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Rotator cuff disease is one of the most common causes of shoulder pain, yet controversy still exists regarding treatment of “irreparable” tears. Nonoperative management, including physical therapy and steroid injections, should be reserved for those without significant pain or functional impairment. Debridement may be used for low-demand patients, and should be performed with partial cuff repair, subacromial decompression, and/or acromioplasty to maximize outcomes. Biceps tenotomy and/or tenodesis have been shown to reduce postoperative pain and improve satisfaction when performed in conjunction with rotator cuff repairs, with no difference in functional outcome comparatively. Tendon transfers have been advocated with the potential benefit to improve function and decrease pain. More recently, extracellular matrix and human-derived dermal allografts have been used off-label as patch grafts in irreparable tears. Superior capsular reconstructive techniques and subacromial balloon spacers serve a similar function by acting to depress the humeral head in a cuff-deficient shoulder, however long-term data is needed before widespread adoption of these procedures. Finally, reverse shoulder arthroplasty serves as a salvage option for low demand elderly patients.
... In the majority of patients LD tendon transfer is very effective in reducing pain; however, the functional outcome is more variable. 43 Correct indications and patient selection are crucial. ...
Article
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Irreparable rotator cuff tears are common conditions seen by shoulder surgeons, characterized by a torn and retracted tendon associated with muscle atrophy and impaired mobility. Direct fixation of the torn tendon is not possible due to the retracted tendon and lack of healing potential which result in poor outcome. Several treatment options are viable but correct indication is mandatory for a good result, pain improvement, and restoration of shoulder function. Patient can be treated either with a conservative program or surgically when necessary, by different available modalities like arthroscopic debridement, partial reconstruction, subacromial spacer, tendon transfer, and shoulder replacement with reverse prosthesis. The aim of this study was to review literature to give an overview of the available possible solutions, with indications and expected outcomes.
... inferior results to those without pseudoparalysis, subse- quent studies have found good results in patients under- going arthroscopic-assisted LDTT. 5,18 Both De Casas et al 8 and Kanatli et al 19 reported successful outcomes in 75% and 93% of their patients, respectively, who expe- rienced preoperative pseudoparalysis. Additionally, Petriccioli et al 28 reported that 5 of their patients with preoperative pseudoparalysis experienced an average increase in forward flexion by 105 , remarking that pseudoparalysis resolved postoperatively and that arthroscopic-assisted LDTT may have a beneficial role in this population. ...
Article
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Background: Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has shown promising results with good outcomes in patients with massive rotator cuff tears (MRCTs), as reported by individual studies. However, to the best of the authors' knowledge, no systematic review has been performed to assess the collective outcomes of these individual studies. Purpose/hypothesis: The primary purpose of this study was to assess patient outcomes after arthroscopic-assisted LDTT for the management of MRCTs. The secondary objectives were to report on the management of MRCTs, including diagnostic investigations, surgical decision making, and arthroscopic techniques, as well as to evaluate the quality of evidence of the existing literature. It was hypothesized that nearly all patients were satisfied with arthroscopic-assisted LDTT and that they experienced improvements in pain symptoms, function, and strength after the procedure, with an overall complication rate of less than 10%. Study design: Systematic review; Level of evidence, 4. Methods: The databases MEDLINE, Embase, and PubMed were searched from database inception (1946) until August 18, 2017, with titles, abstracts, and full-text articles screened independently by 2 reviewers. Inclusion criteria were English-language studies investigating arthroscopic-assisted LDTT for the management of MRCTs on patients of all ages. Conference papers, book chapters, review articles, and technical reports were excluded. The quality of the included studies was categorized by level of evidence and the Methodological Index for Non-Randomized Studies (MINORS) checklist. Results: In total, 8 studies (7 case series [median MINORS score, 7 of 16] and 1 prospective comparative study [median MINORS score, 14 of 24]) were identified; the studies included 258 patients (258 shoulders) with MRCTs treated with LDTT using arthroscopic-assisted techniques. The decision to pursue surgery was based on both clinical findings and investigations in 5 studies, investigations only in 2 studies, and clinical findings only in 1 study. Overall, 88% of patients were satisfied with the results of surgery and experienced significant improvement in their symptoms, including shoulder pain, strength, range of motion, and overall function, over a mean follow-up period of 34.3 months. Overall, there was a low rate of complications (7%) associated with the procedure. Conclusion: Arthroscopic-assisted LDTT for MRCTs provides patients with marked improvement in shoulder pain, strength, and function, and the procedure is associated with a low risk of complication. Further high-quality comparative studies are warranted to validate these findings in comparison with other operative techniques.
... Improvement in external rotation is thought to be due to either active muscle contraction or a tenodesis effect. EMG studies have shown conflicting evidence regarding muscle activation after latissimus tendon transfer [26,27]. ...
... Additionally, an intact subscapularis increases glenohumeral stability after latissimus transfer [33]. Preoperative passive and active shoulder range of motion measurement is critical, as poor results have been shown in patients with passive abduction and forward flexion less than 80°as well as shoulder pseudoparalysis [34,35]. ...
Article
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Purpose of review: This review aims to describe the tendon transfer options for treating irreparable rotator cuff tears (RCTs). Options for transfer include latissimus dorsi and lower trapezius transfers for posterior-superior RCTs and pectoralis major and latissimus dorsi transfer for anterior-superior RCTs. Recent findings: While the latissimus dorsi tendon transfer has historically been performed for posterosuperior RCTs, the lower trapezius transfer is a more anatomic option and has demonstrated promising results in recent studies. Similarly, the pectoralis major transfer has historically been the tendon transfer of choice for anterosuperior RCTs. However, the latissimus dorsi tendon transfer has recently been shown to be a safe and anatomic tendon transfer for subscapularis insufficiency. The treatment of irreparable RCTs involves complex decision making. Tendon transfer procedures can restore the glenohumeral joint force couples, allowing restoration of near-normal shoulder kinematics. Benefits include reliable pain relief, increased function, and increased strength. Proper selection of donor tendon is crucial, and the principles of tendon transfer procedures must be adhered to for maximal benefit.
Article
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Introduction Tendon transfers of the latissimus dorsi (LDT) or the lower trapezius (LTT) are treatment options for irreparable posterosuperior rotator cuff tears (PSIRCT). There is still no consensus on which type of tendon transfer is superior in the treatment of PSIRCT. Due to the differences in the anatomy and biomechanics, we hypothesize that there are different clinical situations in which either LDT or LTT should be preferred. The aim of this study was to evaluate the clinical and radiological outcomes of LDT and LTT in patients with PSIRCT to establish a clinical algorithm for the treatment decision. Materials and Methods This is a retrospective, single center observational study. Included were patients who underwent arthroscopically assisted LDT (aaLDT) or arthroscopically assisted LTT (aaLTT) for PSIRCT. In all patients, range of motion (ROM), external rotation strength, Visual Analogue Scale of Pain (VAS) and Subjective Shoulder Value (SSV) were determined pre- and postoperatively. Constant-Murley Score (CS) was evaluated at final follow-up. Complication rate, failure of the tendon transfer and revision rate were analyzed. Results In total, 29 aaLDT (age 64 years, median follow-up time 45 months) and 8 aaLTT (age 54 years, median follow-up time 34 months) were included. Active ROM, VAS and SSV was significantly improved in both cohorts. At follow-up, the median CS was 73 (aaLDT) and 77 (aaLTT), respectively. Failure rate including revision surgery was 14% (aaLDT) and 13% (aaLTT), respectively. Low functional findings preoperatively were correlated to a lower functional outcome at follow-up in both groups. Painful loss of anterior elevation (PLEA) and loss of ER had no significant impact on functional outcomes in aaLDT. Conclusion Following the treatment algorithm based on the clinical examination, clinical outcome parameters, active ROM and pain could be significantly improved. Good preoperative function was associated with a good clinical outcome in both transfers. A low failure and revision rate supports the good decision-making of the algorithm presented.
Article
Aims Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided. Methods This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively. Results There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high. Conclusion The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91–96.
Article
Purpose The purpose of this study to determine the patient-acceptable symptom state (PASS) values for American Shoulder and Elbow Surgeons (ASES) score and the Constant-Murley (CM) score after arthroscopic-assisted LDTT and to identify potential factors affecting the achievement of PASS. Methods Fifty consecutive patients who underwent arthroscopic-assisted LDTT between 2015 and 2020 were retrospectively analyzed. 42 patients met the inclusion criteria with minimum follow-up of one year postoperatively. Patients were evaluated preoperatively and postoperatively one year with multiple clinical measurements including ASES, CM score and PASS. The primary outcome was identified as patient satisfaction which assessed with achievement of a PASS. Potential factors affecting the patient satisfaction including age, sex, body mass index (BMI), previous surgery, presence of pseudoparalysis, critical shoulder angle, shoulder abduction moment index, acromiohumeral interval (AHI) reversibility, Hamada grade, fatty infiltration were evaluated for their association with PASS value by stepwise logistic regression analysis. Results A total of 42 patients were evaluated with mean follow-up 27.8 ±8.21 months. The ASES and CM scores improved from preoperative means of 21.6 ±6.5 and 25.2 ±8.5 to 65.6 ±20.7 points and 56.8 ±16.5 points, respectively (p<0.001). The PASS values for the ASES and CM scores were 62.4 and 52.5, respectively. The univariate analysis showed that older age (p=0.021), presence of pseudoparalysis (p<0.001), previous surgery (p=0.016), lower preoperative AHI (p=0.028), and lower AHI reversibility (p<0.001) were all significantly associated with worse patients satisfaction. The multivariable logistic regression analysis showed that pseudoparalysis (p=0.038) and AHI reversibility (p=0.021) were independent prognostic factors affecting the achievement of a PASS after arthroscopic-assisted LDTT. The cutoff value for AHI reversibility to predict an achievement of PASS was found to be 4.0 mm. Conclusions Arthroscopic-assisted LDTT led to satisfactory results in patients with MRCT. However, pseudoparalysis and AHI reversibility were the most important independent prognostic factors that consistently reduced and increased, respectively, the odds of achieving a PASS.
Article
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Background Surgical management of massive irreparable rotator cuff tears (iRCT) remains controversial. Arthroscopic débridement has shown promising results especially in the population greater than 65 years of age; however, there is no consensus on the benefits of various arthroscopic débridement procedures. The aim of this systematic review was to evaluate the functional mid- to long-term outcomes in patients treated with arthroscopic débridement (AD) in combination with subacromial decompression, biceps tenotomy, tuberoplasty, or bursectomy, without repair of the rotator cuff tear. Methods A comprehensive search was performed of the PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases for studies reporting clinical outcomes of arthroscopic débridement of massive rotator cuff tears. Quality was determined using the MINORS (Methodological Index for Nonrandomized Studies) criteria by two independent reviewers. Pooled frequency-weighted means and standard deviations were calculated for patient reported outcomes. Results Sixteen articles containing 643 patients and 662 shoulders met eligibility criteria. The mean age at time of surgery was 65.9± 4.4 years of age with a mean follow-up time of 46.5 ± 27.3 months. There was notable clinically significant improvement across all patient reported outcome scores postoperatively: Constant 70.4 ± 8.9 (p-value=.06), UCLA 26.7 ± 5.2 (p-value=0.001), ASES 71.7 ±2.1 (p-value=0.12), DASH 35.3, and VAS 1.7 ± 0.9. Forty-nine patients (7%) required reoperation, which most commonly was a reverse total shoulder arthroplasty for development of rotator cuff arthropathy. Conclusion Arthroscopic débridement with a combination of subacromial decompression, tuberoplasty, subacromial bursectomy, and/or biceps tenotomy, for treatment of massive irreparable rotator cuff tears, produces good functional outcomes and improvement in pain at mid to long term follow-up for the low-demand population greater than 65 years of age looking for pain relief over substantial increase in function.
Chapter
Peripheral nerve and brachial plexus injuries are life-altering events, given the extensive compromise in shoulder, arm, and hand function. When these injuries do not recover, or attempts at nerve reconstructions fail to restore various functions of the upper extremity, patients are often left quite limited in their daily lives. Tendon transfers have been established in the hand and wrist as very successful options for many patients with peripheral nerve injuries isolated to one specific nerve or motor distribution. In recent years, tendon transfers around the shoulder and elbow have shown tremendous promise in restoring function what was traditionally very hard to treat proximal peripheral nerve lesions or upper trunk brachial plexus injuries. There are many important considerations when deciding on the appropriate tendon transfer option for these patients. Keeping these considerations in mind, we will review various types of shoulder, elbow, and hand functional deficits and the various tendon transfer options to reconstruct each one.
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Aim To determine the feasibility of lower trapezius and rhomboid minor transfer to reconstruct irreparable subscapularis tendon tears. 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. 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 was 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 ER2 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, due to the risk of tendon luxation after external rotation of the shoulder.
Article
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Article
Irreparable posterosuperior rotator cuff tears are a challenging treatment problem. Several tendon transfers have been described for the treatment of irreparable tears. Recently the lower trapezius (LT) tendon transfer has grown in popularity. This procedure has shown promise in biomechanical studies, improving the external rotation moment arm at the side. This transfer may be done in several ways, including an open approach with an acromial osteotomy, mini-open, and arthroscopic-assisted. The purpose of this paper is to review the current evidence and rationale for the use of the LT transfer and to describe the available techniques.
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Background. One of the leading causes of restriction in daily-living activities in patients with arthrogryposis is severe hypoplasia (or aplasia) of the biceps brachii. Latissimus dorsii muscle transfer to the biceps brachii is one of the most used methods for the reconstruction of active elbow flexion in patients with arthrogryposis. Aim. The aim of the study is to identify neurophysiological correlates for evaluating the result of the transposition of the latissimus dorsii muscle to the biceps in patients with multiple congenital arthrogryposis. Materials and methods. From 2011 to 2018, we performed monopolar latissimus dorsii muscle transfer to the biceps for the restoration of active elbow flexion in 30 patients with arthrogryposis (44 upper extremities). The follow-up results were studied in 14 cases. For this purpose, we used clinical examination, surface electromyography (sEMG), and statistical analysis. The patients were examined before and from 1 month to 96 months (7 months; 224.5 months) after the surgery. The age of patients was from 1 to 10 years at the time of surgery (4.89 2.42 years). Results. Our study showed that the age of the child at the time of surgery does not significantly change the index of activation of the latissimus dorsii muscle. A decrease of coactivation of the latissimus dorsii muscle in the long term after surgery correlates with an increase in the strength of the displaced latissimus dorsii muscle, and an improvement in active flexion in the elbow. If the value of the index of coactivation of the latissimus dorsii muscle is less 42%, the muscle strength after surgery reaches 4 points. It was found that the index of coactivation of the latissimus dorsii muscle does not depend on the level of segmental damage to the spinal cord. However, the strength of the muscle depends on the level of spinal cord damage. Conclusion. The determination of the index coactivation of the latissimus dorsii muscle after surgery can be used to evaluate the results of the latissimus dorsii muscle transfer to the biceps in patients with arthrogryposis. The index of activation of the latissimus dorsii muscle must be less than 42% for effective elbow active flexion.
Article
Hypothesis and/or background Management of irreparable postero-superior rotator cuff tears (RCT) presents a significant challenge to the shoulder surgeons. Previous studies on latissimus dorsi transfer (LDT) have demonstrated good to excellent outcomes in younger patients but this indication is debatable in the elderly. The main objective of this study was to compare the results of LDT in a group of patient under 55 versus a group over 75 years of age. We hypothesized that LDT could give equally good results in the elderly as in the younger population. Methods Between 2014 to 2017, 153 patients who underwent LDT either for irreparable posterior-superior RCT or for failed prior repair were enrolled. All LDTs were performed by a single surgeon, were arthroscopically assisted and fixed onto the humeral head with two anchors. A retrospective comparative clinical study was conducted. Patients with a minimum of twenty-four months of follow-up were divided into two groups: group A (≤55 years old at surgery) and group B (≥75 years old at surgery). The age-adjusted Constant-Murley score (aCMS), Subjective Score Value (SSV), Simple Shoulder Test (SST), ADLER score, Visual Analogue pain Scale (VAS), American Shoulder and Elbow Surgeons score (ASES), patient’s satisfaction and rate of LDT rupture at last follow-up were compared. Results A total of sixty-six patients met inclusion criteria. Four in sixty-six patients (6%) were lost to follow-up. There were thirty-one patients in group A and thirty-one patients in group B. The mean age was 52 and 77 years for the respective groups. Preoperatively, the two groups were comparable with respect to other characteristics like the mean number of ruptured tendons, mean preoperative Hamada stage, mean SST and mean aCMS. The mean follow-up was 33 and 31 months respectively. At last follow-up, there was no significant difference in the scores evaluated between groups A and B with SSV (61 vs 66.7 points), ADLER (23 vs 26.4 points); VAS (2.8 vs 2.2 points); ASES (64.4 vs 72.4 points) respectively except for the aCMS (75 vs 96.3; p<0.001) and the SST (6.2 vs 8.3; p<0.001). Patient’s satisfaction was not significantly different in both groups (81% of either satisfied or very satisfied patients in both groups). The rate of LDT rupture was higher in group A: 10 (33%) vs 8 (26%). Conclusion Posterior transfer of latissimus dorsi tendon could be an effective surgical option for the treatment of massive irreparable postero-superior cuff tears over 75 years of age.
Article
Background The purpose of this study is to report the outcome of arthroscopically assisted lower trapezius transfer to reconstruct irreparable posterior-superior rotator cuff tear. Methods Forty-one consecutive patients with irreparable posterior-superior rotator cuff tears who underwent an arthroscopically assisted transfer of the lower trapezius transfer were included in this study. The patients’ average age was 52 years (range, 37–71) and average follow-up was 14 months (range, 6–19 months). Nineteen patients had true pseudoparalysis preoperatively, while 66% had a prior failed rotator cuff repair. Outcome measures included visual pain analogue score (VAS), range of motion (ROM), subjective shoulder value (SSV), and disabilities of the arm, shoulder, and hand (DASH) score. Results Thirty-seven (90%) patients had significant improvement of all outcome scores: VAS, SSV, and DASH. The presence of a subscapularis tear did not affect the outcome. However, three patients who had preoperative rotator cuff arthropathy changes of the shoulder had persistent pain and limited range of motion of the shoulder after surgery, and two of them underwent reverse shoulder arthroplasty. Two additional patients had a traumatic rupture of the transfer as result of fall (at 5 and 8 months postop). One underwent revision arthroscopic repair and did well after surgery, and the other had good pain relief but recurrent weakness and limited range of motion, and elected not to have a revision surgery. Conclusions Arthroscopic-assisted lower trapezius transfer may lead to a good outcome in patients with massive irreparable posterior-superior rotator cuff tears, including patients with pseudoparalysis. The presence of an associated reparable subscapularis tear did not affect the outcome.
Chapter
Irreparable rotator cuff tears can be especially difficult to manage in young population.
Chapter
Tendon transfers are considered a valid option for surgical treatment of massive irreparable anterosuperior or posterosuperior rotator cuff tears. They are used either as primary procedures, revisions, or as associated procedures with reverse total shoulder arthroplasty. They partially restore active forward flexion, external or internal rotation, and overall function of the shoulder. They are contraindicated in case of pseudoparalytic shoulder, deltoid palsy, and in case of associated osteoarthritis, as an isolated procedure. These surgically challenging procedures are associated with number of intraoperative difficulties and postoperative complications that can be reduced, thanks to proper patient qualification and operative technique.
Chapter
Irreparable posterosuperior rotator cuff tears represent a surgical challenge. Several surgical procedures have been proposed for young patients with irreparable posterosuperior rotator cuff tears, such as rotator cuff debridement, biceps tenotomy/tenodesis, tuberoplasty, partial rotator cuff repair, rotator cuff grafting, latissimus dorsi tendon transfer, and reverse total shoulder arthroplasty. Arthroscopic-assisted latissimus dorsi tendon transfer has been shown to provide satisfactory results with no progression of glenohumeral osteoarthritis and no subacromial space reduction. Here we describe indications, surgical technique, and outcomes of the aforementioned surgical technique.
Article
The term functionally irreparable rotator cuff tear (FIRCT) is intended to capture patients who would experience failure of an attempted primary rotator cuff repair because of the extent of cuff muscle and tendon damage and other patient-related factors. ➤ Debridement, biceps tenodesis, and/or partial repair of the torn rotator cuff may reduce pain and improve function for selected patients with a FIRCT. ➤ Static soft-tissue restraints to abnormal glenohumeral head translation, such as implantation of an absorbable balloon in the subacromial space or superior capsular reconstruction (SCR), appear to reduce pain and improve function, although some have reported a relatively high structural failure rate with SCR. ➤ When improvement of strength is the primary goal of treatment, tendon transfers provide a viable treatment alternative; most tendon transfers for management of a FIRCT are currently performed with arthroscopically assisted techniques. ➤ Transfer of the lower portion of the trapezius has emerged as a successful alternative to transfer of the latissimus dorsi, whereas transfer of the latissimus dorsi to the lesser tuberosity is being explored as an alternative to transfer of the pectoralis major for functionally irreparable subscapularis tears.
Article
When evaluating patients with irreparable rotator cuff tears, orthopaedic surgeons have an increasingly wide array of surgical options, including both established techniques and emerging technologies. However, significant variability exists in the clinical evaluation and surgical indications in this subset, and definitions for pseudoparalysis and tear irreparability are inconsistent. In older patients with symptomatic rotator cuff arthropathy and relatively sedentary demands, the reverse total shoulder arthroplasty has been established as the preferred treatment option, producing reliable improvements in both pain and function. In younger patients without glenohumeral arthritis or pseudoparalysis, joint-preserving options are preferred, with recent literature highlighting alternative options including partial repair, bridging or interpositional graft placement, tendon transfers (ie, latissimus, trapezius, and pectoralis major), superior capsular reconstruction, and subacromial spacer placement. In this review article, we address the topic of irreparable rotator cuff tears, emphasizing the workup, indications for various treatment options, and clinical outcomes.
Chapter
The treatment of massive irreparable posterosuperior rotator cuff tears is especially difficult in relatively young population; in the absence of advanced glenohumeral arthritis, surgeons must be reluctant to offer the reverse shoulder replacement solution because of durability issues. Rotator cuff tears are considered irreparable when two or more tendons are involved and the retraction is up to the glenoid level and/or has fatty infiltration of more than 50% (Goutallier grade 3 or 4) [1, 2]; proximal migration of the humeral head is also considered a criteria for irreparability [3, 4].
Article
Irreparable rotator cuff tears remain one of the most challenging pathologies faced by shoulder surgeons. In both irreparable anterior (subscapularis) and posterosuperior (supraspinatus and infraspinatus) tears, patients experience marked shoulder dysfunction and pain. In this article, we review the surgical considerations for treating patients with these tears, as well as the tendon transfer options. Irreparable rotator cuff tears are associated with advanced fatty infiltration, tendon retraction, and loss of tendon length. Although there are multiple reconstructive options, most are limited to small series with short-term follow-up. Tendon transfers have emerged as very promising reconstructive options for these patients. When considering the ideal tendon transfer, it is critical to consider the four-tendon transfer principles, as well as the ability of patients to retrain the new transfer to perform a different function. The historical option for posterosuperior tears involved a latissimus dorsi transfer, while the lower trapezius transfer emerged in recent years. The historical transfer for irreparable subscapularis tears was the pectoralis major transfer, while the latissimus dorsi emerged in recent years. Further comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for each of these transfers to treat these difficult pathologies.
Article
* For posterosuperior tears, even though these are not absolute contraindications, the following preoperative variables have been found to significantly correlate with poorer outcomes when performing a latissimus dorsi tendon transfer (or possibly even other tendon transfers, but very few data are available concerning these tears): previous shoulder surgical procedure, atrophy and fatty infiltration (Goutallier stage of ≥3) of the teres minor muscle, subscapularis insufficiency (positive lift-off test), pseudoparetic shoulders (defined as those with massive rotator cuff tears and with active elevation of <90°), and passive forward elevation of ≤80°. * For isolated subscapularis failure, pectoralis major tendon transfers have disappointing results, and some data on combined latissimus dorsi and teres major transfers have shown clinical improvement at 2 years. * The following 5 principles of tendon transfers should be respected whenever possible: (1) accurate positioning of the transferred tendon reimplantation site, (2) physiological tensioning of the transferred muscle-tendon unit, (3) strong osseous fixation of the reimplanted tendon, (4) minimally invasive surgery to reduce muscle scarring (so as not to hinder excursion of the transfer), and (5) a synergistic transfer.
Article
* Massive rotator cuff tears that are treated nonoperatively demonstrate increases in tear size, fatty infiltration, muscular atrophy, and arthritis. * The pooled retear rate following complete repair of massive rotator cuff tears is 79%. * Absorbable and nonabsorbable graft augmentation following rotator cuff repair can reduce the retear rate and improve functional outcomes. * Irreparable tears can be predicted preoperatively by evaluating the degree of fatty infiltration, muscular atrophy, and tendon length. * Latissimus dorsi transfer, lower trapezius transfer, and superior capsular reconstruction provide improvements in terms of pain, range of motion, and function in patients with irreparable tears.
Article
Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.
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Background: The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance. Methods: During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months). Results: Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery. Conclusions: ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.
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Massive, irreparable posterosuperior rotator cuff tears in young patients present a difficult clinical problem. While reverse total shoulder arthroplasty remains a viable option for older, lower demand patients, it is often a poor choice in younger, active patients given the risk of component loosening and subsequent revision. The latissimus dorsi tendon transfer has been utilized by some surgeons to compensate for a deficient posterosuperior rotator cuff attempting to provide an active external rotator, but unfortunately the results are variable. The procedure requires careful patient selection, as a motivated, young patient without glenohumeral arthritis and an intact subscapularis is imperative for a successful outcome.
Article
Latissimus dorsi tendon transfer is a therapeutic option for irreparable posterosuperior rotator cuff tears in young and active patients. The procedure has been reported to provide containment and stability of the humeral head with the additional benefit of an external rotation force. It can be transferred with or without the teres major, using a single incision, double incision or an arthroscopically assisted technique. Results in terms of function and pain relief are encouraging; however, there is great variability and the factors that predict outcome are not clearly defined.
Article
Seventeen patients with an average age of fifty-five years (range, thirty-two to seventy-seven years) who had ongoing pain and impaired function following failed operative treatment of a massive tear of the rotator cuff were managed with a transfer of the latissimus dorsi muscle as a salvage operation. The patients were examined at an average of fifty-one months (range, twenty-four to seventy-two months) after the operation. Pain, function, and satisfaction were assessed with use of a questionnaire, visual analog and ordinal scales, physical examination, and the University of California at Los Angeles shoulder score. Fourteen of the seventeen patients were found to have significant relief of pain (p<0.0001) and a significant improvement in function (p<0.001 for all activities except lifting more than fifteen pounds [6.8 kilograms], for which the p value was <0.0036) and were satisfied with the result of the operative procedure. Fifteen patients stated that they would have the operative procedure again under similar circumstances. Seven of eight patients with a detached or nonfunctional anterior portion of the deltoid had substantial improvement. Three operations were classified as failures because the patients were not satisfied with the result and had ongoing pain and impaired function. All three failures were in patients who had a work-related injury. Overall, six patients had a work-related injury, and only three of them had a satisfactory result. There were three complications, all related to contracture of a hypertrophic axillary scar. The results in this series indicate that transfer of the latissimus dorsi muscle is a reasonable approach for salvage after failed operative treatment of a massive tear of the rotator cuff.
Article
Forty-one patients scheduled for shoulder surgery underwent computed tomography (CT) and magnetic resonance imaging (MRI) examination of their affected shoulder to verify whether fatty degeneration of the rotator cuff muscles could reproducibly be assessed by CT or by MRI and whether the grading with the 2 methods was comparable. In addition, rotator cuff muscle cross-sectional areas were measured on parasagittal MRI scans to establish a possible correlation between rotator cuff muscle atrophy and fatty degeneration. Interobserver reproducibility for grading fatty degeneration was good to excellent for CT and for MRI. The correlation between MRI and CT was fair to moderate and remained unsatisfactory, even if the classification system was simplified with only a 3- rather than a 5-grade scale as originally proposed. The degree of fatty degeneration was significantly related to the amount of atrophy of the respective muscles.
Article
On the basis of a modified Constant scoring system, we compared outcomes for 16 patients who underwent latissimus dorsi transfer as a salvage reconstruction for a failed prior rotator cuff repair with outcomes for 6 patients who underwent a primary reconstruction for an irreparable cuff defect. There was a statistically significant difference in Constant score between groups, which measured 55% for the salvage group compared with 70% for the primary group (P <.05). Poor tendon quality, stage 4 muscle fatty degeneration, and detachment of the deltoid insertion each had a statistically significant effect on the Constant score (P <.05). Late rupture of the tendon transfer occurred in 44% of patients in the salvage group compared with 17% in the primary group at a mean of 19 months postoperatively. Rupture had a statistically significant effect on the Constant score, which declined by a mean of 14% (P <.05). We conclude that salvage reconstruction of failed prior rotator cuff repairs yields more limited gains in satisfaction and function than primary latissimus dorsi transfer.