Article

Tendon transfers for irreparable rotator cuff tears

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Abstract

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

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... Rotator cuff (RC) tears are one of the most common shoulder disorders. 1 They are characterized by pain and disability, 1 and their incidence is higher in the elderly population. 2 Massive RC tears may represent as high as 40% of all RC tears (no criteria specified) 3 and can be a challenging clinical problem. 2 Currently, it is difficult to establish a consensus to define a massive RC tear. However, some authors propose an injury of two or more tendons, 4 whereas others propose an injury with a diameter >5 cm 5 as a classification criteria. ...
... Rotator cuff (RC) tears are one of the most common shoulder disorders. 1 They are characterized by pain and disability, 1 and their incidence is higher in the elderly population. 2 Massive RC tears may represent as high as 40% of all RC tears (no criteria specified) 3 and can be a challenging clinical problem. 2 Currently, it is difficult to establish a consensus to define a massive RC tear. However, some authors propose an injury of two or more tendons, 4 whereas others propose an injury with a diameter >5 cm 5 as a classification criteria. ...
... 12 After tendon transfer surgery for a massive RC tear, integration of physical therapy interventions is necessary to promote optimal muscle performance, improve shoulder function, and restore participation in activities of daily living. 16 Although the details of the tendon transfer surgical interventions have been widely described, 1,11,17 the physical therapy interventions used after RC tendon transfer surgery are unclear. 11 Furthermore, advances in surgical techniques, 1 type of tendon transfer, 7 and knowledge of possible complications 1 warrant the need to identify physical therapy interventions (ie, therapeutic exercises and physical agents), physical therapy parameters after surgery (ie, dosage and recovery time), and outcomes. ...
Article
Objective To identify tendon transfer surgeries and post‐surgical physical therapy interventions in people with massive rotator cuff (RC) tears. Methods The literature search was conducted in the MEDLINE, Science Direct, Scopus, Web of Science, and PEDro databases from inception to September 2022. Studies with patients diagnosed with massive RC tears undergoing tendon transfers that reported physical therapy interventions after surgery were included. Two reviewers pooled the data into ad hoc summary tables with the following information: authors, year, study characteristics (sample size, tendon transfer surgical used, approach type, preoperative risk, deficit addressed, additional surgical interventions), and physical therapy interventions (early stage, intermediate stage, and advanced stage). Results Forty‐four articles (59.0% case series) were included, with a total sample of 1213 participants. The most frequently used surgery was the isolated tendon transfer of the latissimus dorsi (49.1%). Most of the studies reported three main stages of physical therapy interventions after tendon transfer surgery: early stage (lasting 5–6 weeks), intermediate stage (started at 7–12 weeks), and advanced stage (started at 12 weeks). Physical therapy interventions included passive, active‐assisted, resisted therapeutic exercise, and hydrotherapy. Conclusions The evidence regarding physical therapy interventions after RC tendon transfer surgery is limited to the number and duration of the stages and general characteristics without specifying the type and dose of the interventions. Future research with high methodological quality should integrate more detailed rehabilitation protocols to better guide therapeutic decisions after RC transfer surgery. This article is protected by copyright. All rights reserved.
... МСТ являются альтернативой для молодых, активных пациентов с невосстановимыми разрывами ВМПС. Для передневерхних разрывов ВМПС используют трансфер сухожилия большой грудной мышцы, трансфер сухожилия малой грудной мышцы и трансфер сухожилия широчайшей мышцы спины [2,6,7,8]. ...
Article
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Background. Irreparable anterior-superior rotator cuff tears can cause significant shoulder dysfunction due to the failure of normal biomechanics of the joint, because of the loss of compressive effect of the rotator cuff on the humeral head. Muscle-tendon transfers are an alternative to standard surgical treatment options: debridement of injured tendons, arthroscopic anchor suture, and reverse shoulder arthroplasty. Currently, several options of muscle-tendon transfers are described in the foreign literature, and there is an active discussion over the results of the already proposed techniques, and their improvements, while these techniques are practically not covered in the domestic literature. The aim to describe modern surgical technique options of the muscle-tendon transfers for the treatment of patients with anterior-superior rotator cuff tears based on a review of foreign literature sources. Methods. The search for publications from 1988 to 2022 was carried out in the PubMed/MEDLINE and Google Scholar databases. Results. Nowadays, the most common muscle-tendon transfers options for patients with anterior-superior rotator cuff tears are the sternocostal portion of the of pectoralis major tendon transfer and the latissimus dorsi tendon transfer. A review of foreign literature showed that muscle-tendon transfers are a well-described alternative to standard methods of treating profile patients with a predictable result. Conclusion. Currently, there is no consensus on clear indications for certain types of muscle-tendon transfers in case of anterior-superior rotator cuff tears, there is a lack of data on long-term results. This determines the need of study of the long-term clinical results of use of these methods and develop an algorithm for choosing the tactics of surgical treatment of relevant patients.
... Latissimus dorsi and trapezius tendon transfers show encouraging results in specific patient groups. Recent reviews report large increases in shoulder scores across several series [16,101,102]; improved shoulder function may persist over 10 years [103]. A comparative study by Cavalier demonstrated an inferior Constant score at 12 months with latissimus dorsi tendon transfer compared to PCR and RSA, and a randomised trial of 42 patients reported inferior functional scores for LDTT compared to SCR [16,68]. ...
Article
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Background Multiple non-arthroplasty surgical techniques are described for the management of large and massive irreparable rotator cuff tears. There is currently no consensus on the best management strategy. Our aim was to compare clinical outcomes following arthroscopic debridement, arthroscopic partial cuff repair, superior capsule reconstruction, balloon spacers or graft interposition for the management of large and massive irreparable rotator cuff tears. Methods A comprehensive search was performed of the following databases: Medline, Embase, CINAHL and Cochrane Database of Systematic Reviews. Data were extracted from relevant studies published since January 2000 according to the pre-specified inclusion criteria. The primary outcome was the post-operative improvement in shoulder scores. Meta-analysis of the primary outcome was performed. Secondary outcomes included retear rates and complications. Results Eighty-two studies were included reporting the outcomes of 2790 shoulders. Fifty-one studies were included in the meta-analysis of the primary outcome. The definition of an irreparable tear varied. All procedures resulted in improved shoulder scores at early follow-up. Shoulder scores declined after 2 years following balloon spacers, arthroscopic debridement and partial cuff repair. High retear rates were seen with partial cuff repairs (45%), graft interposition (21%) and superior capsule reconstruction (21%). Conclusions Large initial improvements in shoulder scores were demonstrated for all techniques despite high retear rates for reconstructive procedures. Shoulder scores may decline at mid- to long-term follow-up.
... Indeed, this reveals the extent and the desire to combat the challenge. 3 A recent search (on 15th May 2021), using the key word 'rotator cuff' revealed that on PubMed (14,491) and the SCOPUS (18,964), research articles were published on this topic; more so in the last decade, and there is an increasing trend of publications over the years. ...
Article
Humans' evolutionary advance is linked closely to the shoulder joint's ability to achieve a wide range of circumduction and the ability to throw. A wide range of motion allows the hand to be placed in a maximal advantage position, hence achieving complex tasks with great dexterity. On the other hand, the ability to throw has allowed humans to defend themselves in hostile environments and hunt for animals who would otherwise outrun them. The rotator cuff has played a central role in achieving this evolutionary development. Understanding the rotator cuff's functional anatomy and physiology highlights how the shoulder achieves a rather remarkable feat of stability and strength throughout the greatest range of movement seen in a major joint. As the shoulder joint proudly assumes its nuanced role in the quality of life of modern humans, it becomes imperative for health care professionals to understand the biomechanics of the rotator cuff in health and disease.
Article
Massive rotator cuff tears (MRCTs) represent up to 20% of all rotator cuff tears and, if left untreated, may result in cuff tear arthropathy, which causes shoulder disability owing to the loss of glenohumeral biomechanics and progressive arthritis. A variety of treatments have been proposed. Among the surgical options, in the case of an irreparable tendon lesion without osteoarthritis in younger patients, joint-preservation techniques are needed, and tendon transfer represents a reconstructive technique that may restore power and function. The aim of this review is to summarize the indications, outcomes, and complications of tendon transfer techniques to treat irreparable MRCT. The goal of each tendon transfer is to restore the force couples in the shoulder. Latissimus dorsi tendon transfer is used for massive posterosuperior rotator cuff tears involving the supraspinatus and infraspinatus with an intact or reparable subscapularis tendon. Teres major tendon transfer is used for irreparable posterosuperior cuff tears in patients with isolated infraspinatus deficiency. The lower trapezius has a force vector in the same direction as the infraspinatus, and it is often used in posterosuperior cuff tears. Pectoralis major tendon transfer is indicated for irreparable anterosuperior cuff tears or isolated subscapularis tears. Overall, satisfactory functional results can be expected even though the normal kinematics of the shoulder are not always restored. Careful selection of both the patient and the type of tendon transfer to be performed is necessary to optimize the outcome of this surgery.
Article
Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.
Article
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Massive rotator cuff tears (MRCTs) present a particular challenge due to high rates of retear that can range from 18 to 94%, failure of healing after repair, and potential for irreparability. Management of MRCTs must take into consideration the patient's characteristics, clinical examamination and expectation, number and quality of muscle tendons units involved. Conservative treatment, arthroscopic long head of the biceps tenotomy, cuff debridement, partial repair, and superior capsule reconstruction are viable solutions to treat selected patients. The goal of tendon transfers is to achieve stable kinematic by restoring rotational strength and force coupling of the shoulder joint. The ideal candidate is a young, motivated patient with small degenerative changes of the glenohumeral joint, a massive irreparable cuff tear, significant atrophy, fatty infiltration, and functional deficit. Patients with posterosuperior massive tears have impaired shoulder function with external rotation weakness and eventually lag sign If the teres minor is affected. Latissimus dorsi transfer is the most used with results lasting for long follow-up and lower Trapezius transfer is becoming a surgical option. For anterosuperior tears, there is still controversial if pectoralis major is the best option when compared to latissimus dorsi although this last has a similar vector force with the supraspinatus tendon. Complications associated with tendon transfers include neurovascular injury, infection, and rupture of the transferred tendon.
Article
Background Tendon transfers (TT) can be successful for the management of selected functional posterosuperior irreparable cuff tears (FIRCT). However, when these procedures fail to provide adequate pain relief or functional improvements, reverse shoulder arthroplasty (RSA) is commonly considered as the next treatment option. The effect of prior TT on RSA remains largely unknown. The purpose of this investigation was to evaluate the outcomes of RSA after previous TT performed for posterosuperior FIRCTs, and to determine the effect of various TT types on RSA. Methods A retrospective review of two institutional databases identified 33 patients who underwent a RSA implantation between 2006 and 2019 with a previous failed tendon transfer (FTT) of the shoulder, and at least two-years of clinical follow-up. FTTs included 21 latissimus dorsi transfers (LDT), 6 latissimus dorsi and teres major transfers (LD-TM), and 6 lower trapezius transfers (LTT). RSA were performed at an average of 5.5 years (range, 0.3 to 28 years) after FTT with a mean follow-up of 4.1 ± 2.0 years. Outcomes evaluated included visual analog scale (VAS) for pain, range of motion (ROM), Constant-Murley-Score absolute (aCS) and relative (rCS) scores, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), complications, and implant survivorship free of reoperation or revision. Results RSA significantly improved pain and function, with improvements in pain (VAS 6.2 preoperatively vs. 2.2 at most recent follow-up, P < .001), active elevation (85 vs. 111 degrees, P < .001), ASES score (51 vs. 74, P = .001), aCS (34 vs. 48, P = .003), and rCS (42 vs. 59, P = .002), exceeding the minimal clinically important difference threshold. There were 7 (21%) complications across entire cohort with dislocation (n = 3; 9.1%) as the most common complication. When compared across TT groups, LD-TM had the highest complication (3 shoulders, 50%), followed by LTT (1 shoulder, 16.7%), and LDT with the lowest rate (3 shoulders, 14.3%; p=0.037). Survivorship free of revision or reoperation was estimated to be 90.1% at 1 year, 84.9 at 2 years, and 71.2% at 5 years, with no differences among TT groups (p = 0.654). Conclusions Reverse shoulder arthroplasty can serve as a viable salvage option for failed tendon transfer procedures. At mid-term follow-up, RSA led to significant improvements in pain, ROM, and patient-reported outcomes. Patients with prior LD-TM transfers may have a higher complication rate, but no other differences were found between tendon transfer groups.
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.
Article
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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.
Article
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Abstract Many treatment options have been proposed for treatment of irreparable posterosuperior rotator cuff tears. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before development of glenohumeral arthritic changes, aiming at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The technique was recently adapted from open to arthroscopically assisted with numerous advantages. We propose a combined fully arthroscopic technique for transfer of latissimus dorsi and teres major in which the tendons are fixed in a flat manner at the junction of supraspinatus and infraspinatus to decrease failure rate.
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.
Article
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Background Lower trapezius transfer can restore external rotation in brachial plexus palsies. In some cuff tear arthropathies, there is lack of active external rotation with a preservation of forward elevation. We evaluated the clinical outcomes of a lower trapezius transfer extended with a semitendinosus tendon and fixed to the insertion of the infraspinatus via arthroscopy. Methods Between 2013 and 2016, we operated on 14 patients (8 men, 6 women; mean age of 62 years, range: 50–70) to reconstruct irreparable posterosuperior rotator cuff tear. A vertical incision of 6 cm following the medial border of the spine was made to harvest the lower trapezius in extension with the semitendinosus tendon. The extension band of the lower trapezius was fixed laterally via arthroscopy on the great tuberosity at the level of the insertion of the infraspinatus. The proximal stump of this extension band was then fixed medially into the muscle of the lower trapezius with the arm in maximum external rotation. Outcomes were evaluated with the Constant–Murley score, simple shoulder test (SST), and subjective shoulder value (SSV). Results Over a mean follow-up of 24 months (range: 12–36 months), the gain in external rotation with the arm at the side was 24° and 40° in 90° of abduction. The Constant–Murley score improved from 35 to 60 points, the SST from 3.5 to 7.5, the SSV from 30 to 60%, and the pain decreased from 7 to 2 (visual analogue scale, 0–10). Both the lag sign and hornblower sign were negative after this transfer. There were two cases of hematomas, and one was revised because of infection. Conclusion Lower trapezius transfer is a therapeutic option for irreparable posterosuperior cuff tears with a lack of active external rotation and a good subscapularis. Patients can expect improvements in pain and in active external rotation without any loss of active anterior elevation.
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.
Article
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Background: Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers1-12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD)1-6and the lower trapezius (LT)12. Description: The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon. Alternatives: In addition to tendon transfer, options include:Partial or complete attempted repair13-17.Augmentation or bridging with allografts18-23.Superior capsular reconstruction24.Subacromial balloon25. Rationale: There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome:The recipient and transferred tendons must have similar musculotendinous excursion.The recipient and transferred tendons should have similar lines of pull.One tendon (the transferred) should be designed to replace 1 function (of the recipient).The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity.The strength of the transferred muscle must be at least grade 4.When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up1-6. Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of "in-phase" muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.
Article
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Latissimus dorsi tendon transfer is an effective option for young and active patients with massive irreparable posterosuperior rotator cuff tears and intact subscapularis tendon. This approach has been shown to relieve pain and improve shoulder function in both the short and long term. We describe a surgical technique using an acromial osteotomy to better expose the greater tuberosity for the tendon transfer without disrupting the deltoid muscle. The latissimus dorsi tendon is reinforced with a human dermal collagen matrix (GraftJacket; Wright Medical Group) for additional augmentation of the muscle to gain more excursion for the tendon transfer to the greater tuberosity. The transferred tendon is fixed to the supraspinatus and infraspinatus footprints on the greater tuberosity using suture anchors. The acromial osteotomy is repaired back anatomically with several No. 5 braided sutures (FiberWire; Arthrex).
Article
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Tendon transfer options to reconstruct a massive irreparable posterior-superior rotator cuff tear include latissimus dorsi, teres major, or lower trapezius transfer. We previously described the lower trapezius transfer using a 2-incision approach, which includes a medial incision to harvest the lower trapezius and lateral transacromial incision to expose the rotator cuff and then perform the transfer through a deep tunnel connecting these 2 sites. In this report, we describe an arthroscopic-assisted technique of lower trapezius transfer augmented with an Achilles tendon allograft to reconstruct an irreparable posterior-superior rotator cuff tear.
Article
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Massive irreparable rotator cuff tears are often associated with severe functional impairment and disabling pain. One viable treatment option is a latissimus dorsi tendon transfer. We propose an all-arthroscopic technique that we believe avoids insult to the deltoid musculature while reducing morbidity from open harvest of the tendon. The operation is performed with the patient in the lateral decubitus position, by use of a combination of viewing and working portals in the axilla. The initial viewing portal is placed along the anterior belly of the latissimus muscle in the axilla. The latissimus and teres major are identified, as is the thoracodorsal neurovascular pedicle. The tendons are carefully separated, and the inferior and superior borders of the latissimus are whipstitched using a suture passer, which helps facilitate subsequent mobilization of the muscle. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the supraspinatus footprint with suture anchors. Our preliminary data suggest that this surgical technique results in improvement in pain, range of motion, and function.
Article
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Few salvage procedures have been described in case of irreparable subscapularis tear and with variable outcomes. Latissimus dorsi transfer has been widely proposed as a transfer for irreparable posterio-superior rotator cuff tear with good outcomes. The anatomic feasibility of the latissimus dorsi to reconstruct the antero-superior irreparable rotator cuff tear has been suggested, but no clinical study has ever been published. We hypothesized that it was possible to use an arthroscopic-assisted latissimus dorsi transfer to reconstruct the subscapularis function. Five patients were enrolled. A 5–7-cm axillary incision was performed to release the latissimus dorsi tendon from its humeral insertion, the teres major muscle and the apex of the scapula. Afterwards, under arthroscopic control, a 7-mm-diameter tunnel was drilled at the anterior and superior part of the humeral head with an oblique inferior and posterior direction. The tubularized latissimus dorsi tendon was introduced into the tunnel and fixed with a ZipLoop on the posterior humeral cortex. The authors show overall good experience with this technique. Level of evidence Level IV-a, case series.
Article
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Background: Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors. Methods: The study reviewed 86 patients (aged 59.8 � 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 � 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients’ functionality preoperatively and at follow-up. Results: As a group, the CMS improved with surgery from 35.5 � 6.1 to 69.5 � 12.3 (P <.001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P ¼.044 and P ¼.007, respectively) and CMS (P ¼.042 and P ¼.018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P ¼.009). Gender and age did not affect the clinical outcomes. Conclusions: Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT. Level of evidence: Level IV, Case Series, Treatment Study. Keywords: Arthroscopic-assisted latissimus dorsi transfer; outcome predictors; Constant and Murley score; failed rotator cuff repair; irreparable massive rotator cuff tears
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.
Article
Background There is a paucity of information on latissimus dorsi transfer (LDT) for subscapularis insufficiency. The purpose of this study is to report the outcome of LDT to reconstruct an irreparable subscapularis tear. Methods Excluding patients with prior failed latarjet procedures, we examined 56 consecutive patients who underwent open (n=14) or arthroscopic (n=42) LDT. The average age was 53 years (range, 23–79), and 46 patients had a prior surgery. Outcome measures included visual pain analogue score, range of motion (ROM), subjective shoulder value (SSV), and Constant shoulder score (CSS). Results At a mean 13 months follow-up (7–51 months), patients had significant improvements in their pain, ROM, SSV, and CSS when compared to preoperatively. At final follow-up, 26% of patients continued to have proximal migration, and 11% of patients had anterior subluxation. The patients with frank anterior escape had a higher likelihood of having proximal migration and anterior subluxation, but this was not statistically significant. Stages of arthritis did not progress. Revision surgeries included two patients who revised to a reverse shoulder arthroplasty for rupture of the tendon transfer. Furthermore, three patients had LDT ruptures, but did not elect to undergo further surgery. Conclusions LDT for irreparable subscapularis tears has the potential to lead to significant clinical improvements. Most patients improve in many of the signs of subscapularis insufficiency, including anterior and/or proximal subluxation, clinical examination maneuvers, and shoulder function. Overall, this transfer represents a reasonable option for this difficult pathology.
Chapter
Isolated ruptures of the subscapularis or combined with a supraspinatus tear are not as numerous as posterosuperior rotator cuff tears. Reconstruction of the anterosuperior tendons may not always be possible because of fatty infiltration or poor tendon quality. Tendon transfer may represent a surgical option for treatment. The pectoralis major tendon transfer is not the best biomechanical one to supply the deficient subscapularis, but it can be an acceptable salvage option to decrease pain even beyond a 10-year postoperative period but with limited function.
Article
PurposeThe primary objective of this retrospective study was to validate electrophysiological results of latissimus dorsi tendon transfer (LDTT) to determine if this transfer is active for different daily living tasks, and the secondary objective was to correlate these clinical results.Methods With a mean follow-up of 4.7 years, 14 latissimus dorsi tendon transfers were retrospectively reviewed. Patients were clinically evaluated with the constant score and the SSV. Healing of the tendon on the greater tuberosity and atrophy of the LDTT muscle was determined by ultrasound and compared with the contralateral side. Electrical activity was analyzed by electromyography in active elevation, abduction, and external rotation.ResultsTwelve patients are satisfied (SSV). At the last follow-up, the EMG found a significant electrical activity in the abduction and external rotation and a lower activity in adduction and internal rotation. The mean constant score increased from 29 to 51, the mean forward elevation increased from 89° to 135°, the mean abduction from 92° to 105°, and the external rotation from 12° to 24°. The ultrasound found 12 healed tendons and two ruptures at the myotendinous junction.Conclusion Electrical activity in abduction and external rotation testifies that the LDT transfer acts as an active muscle transfer and acts not only a muscle tenodesis that covers the humeral head.
Article
Background Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs. Methods MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated. Results Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation. Conclusion This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.
Article
Purpose: To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. Methods: We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1 year were included in the study. The indications for inclusion were large (≥2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (Δ in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure. Results: A total of 22 patients (mean age, 53 ± 6 years) were included in the study, with a mean follow-up time of 3.4 ± 1.1 years. Over 63% of patients (n = 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 ± 21.9 preoperatively to 55.8 ± 22.9 postoperatively, P = .001), Simple Shoulder Test scores (from 3.5 ± 3.1 preoperatively to 5.2 ± 3.4 postoperatively, P = .002), and pain scores (from 5.9 ± 2.8 preoperatively to 4.6 ± 4.3 postoperatively, P = .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n = 3) after a mean of 2.7 years, and the clinical failure rate was 41% (n = 9) at final follow-up. An acromiohumeral interval of less than 7 mm (P = .04) and high-grade fatty infiltration (grade 3 or greater, P = .004) were significant preoperative risk factors for clinical failure. Conclusions: Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure. Level of evidence: Level IV.
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.
Article
Background: One recognized salvage option in the treatment of an irreparable subscapularis tear is the pectoralis major tendon transfer (PMT). We aimed to analyze the long-term clinical and imaging outcome of PMT for irreparable subscapularis deficiency. Methods: Twenty-eight consecutive patients representing 30 shoulders underwent PMT at a mean age of 53.0 years (range, 35 to 67 years). At a mean of 19.7 years (range, 18 to 22 years) postoperatively, 24 shoulders (80%) were clinically examined and 21 were radiographically and sonographically assessed. The long-term results were compared with preoperative findings and previously published short-term results. Results: The mean relative Constant score (percentage of age and sex-matched normal scores; CS%) and the Subjective Shoulder Value (SSV) both improved significantly from preoperatively (CS%, 47%, and SSV, 22%) to postoperatively (CS%, 77%, and SSV, 71%; p < 0.001 for both). All patients rated their results as good or excellent. Active anterior elevation was improved from preoperatively (120°) to postoperatively (131°), but the difference was not significant. Active internal and external rotation decreased significantly from the short-term (32-month) follow-up to the time of the latest follow-up (p = 0.005 and p = 0.002, respectively); however, internal rotation remained at 6 points compared with the 8 points recorded at short-term follow-up and external rotation decreased only from a mean of 51° to 39°. Loss of active range of motion was not observed subjectively and was not subjectively limiting, represented by the high ultimate SSV and overall satisfaction. Four shoulders (19%) showed evidence of glenohumeral arthropathy (Samilson and Prieto grade 3), but clinically were mildly symptomatic to asymptomatic at the time of the latest follow-up (CS% range, 67% to 88%; SSV range, 70% to 80%). Rupture of the PMT was sonographically identified in 2 patients (10%) and was associated with radiographic evidence of advanced cuff tear arthropathy (Hamada stages ≥4). Six (20%) of the initial 30 shoulders were revised, and 1 (4%) of the 24 shoulders that were clinically examined underwent reverse total shoulder arthroplasty. Conclusions: At long-term follow-up, PMT for isolated and combined subscapularis tears is associated with good to excellent clinical results. Although one-third of the shoulders developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with use of reverse total shoulder arthroplasty was rare. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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
Background: To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques. Methods: One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), "over the top" onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture. Results: Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%). Conclusion: Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate.
Article
Background: The management of irreparable posterosuperior rotator cuff tears (IPSRCTs) in young active individuals is still a challenge. The aim of this study was to evaluate the influence of sex, surgical technique, previous surgical procedures, tear genesis, and presence of a preoperative external rotation lag sign on the functional outcome after latissimus dorsi transfer (LDT) for IPSRCTs. Methods: Retrospectively, all patients with IPSRCTs treated with LDT during a 10-year period were followed up. Preoperative evaluation included the visual analog scale (VAS) score, range of motion, and the Constant score (CS). Postoperatively, the VAS score, range of motion, CS, American Shoulder and Elbow Surgeons score, and Subjective Shoulder Value were recorded. Preoperative and postoperative radiologic evaluation was performed using the Hamada-Fukuda classification and the acromiohumeral interval. Results: In total, 67 of 79 patients (85%), with a mean age of 63 years, were available for follow-up at 54 ± 28 months. The CS improved from 24 ± 6 points preoperatively to 68 ± 17 points at follow-up (P < .001). 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°. Postoperatively, the Subjective Shoulder Value was 69% ± 19% and the American Shoulder and Elbow Surgeons score was 76 ± 21. The VAS score decreased from 6.3 ± 1.1 to 1.8 ± 2 (P < .001). Abduction strength increased from 0.4 ± 0.4 kg to 3.6 ± 2.2 kg (P < .001). The acromiohumeral interval decreased from 7.9 ± 2.6 mm to 5.1 ± 2.2 mm, and arthropathy worsened from Hamada-Fukuda stage 1.4 to stage 2.1. The rate of conversion to a reverse prosthesis was 6%. Conclusion: LDT represents a reliable and reproducible treatment option with good clinical midterm results after surgical treatment. Sex, genesis, preoperative presence of an external rotation lag sign, and previous surgical procedures do not affect the overall clinical outcome.
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.
Article
The treatment of the massive irreparable rotator cuff tear poses a challenging problem. Tendon transfers offer a solution for irreparable posterosuperior rotator cuff tears. The lower trapezius tendon transfer with incorporation of an Achilles tendon allograft has emerged as an effective way to restore strength and function in select patients. Both open and arthroscopic-assisted techniques have been described.
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
Objective Is transfer of the latissimus dorsi muscle (LDT) a good option in older patients with irreparable posterosuperior rotator cuff tears? Material and method In 2010–2016 a total of 25 patients without glenohumeral arthritis and non-reconstructable supraspinatus and infraspinatus tendons, a recentered glenohumeral joint with remaining function in anteversion and irreparable posterosuperior rotator cuff defects were treated using LDT at the Rummelsberg Hospital. Of the patients 9 (36%) had in the past 1 or more attempts at reconstruction of the rotator cuff. All other patients (64%) underwent a primary reconstruction using LDT. The patients had an average age of 61 years and average follow up of 32 months. Of the 25 patients 24 (96%) were clinically followed up with the constant score (CS) and the visual analogue scale (VAS). The operation was performed in the technique described by Gerber to raise the latissimus dorsi but in the beach-chair position. Follow-up treatment was performed for 6 weeks using the ACRO-Assist splint (shoulder brace) in 90 ° abduction with daily limited external rotation exercises, followed by a regular regular rehabilitation on an outpatient basis. Results The average operating time was 112 min (68–199 min). Postoperatively the only complication was an tightly sutured drainage. The preoperative Constantpoint averaged 25 (2–59). The postoperative Constantpoint was 60. The average gain of improvement was 35 points. The age-corrected relative CS was 74 after surgery. Pain perception improved significantly from preoperatively severe to very severe pain to postoperatively minor to no pain. In the VAS score there was a reduction from preoperatively 6 to postoperatively 3 VAS points. The external rotation improved from average 3 points in the CS to 6 points in the CS. The preoperative Constantpoint in patients <60 years (n = 12) was 20, the postoperative 51. The gain was 31 Constantpoints. In patients ≥60 years (n = 12), the preoperative Constantpoint was 31, the postoperative 60. The gain was 29 points. The difference between the age groups was not significant. Previously operatively treated patients (arthroscopic or mini-open reconstruction) all showed an improvement in Constantpoints (26 vs. 32 in primarily non-reconstructed patients); however, on a lower level (45 points in previously operated patients vs. 69 CS points). Conclusion With appropriate patient selection, a high gain in CS can be achieved even in older patients using latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. The VAS score and external rotation significantly improved. Previously attempts in rotator cuff reconstruction demonstrated a negative influence on the clinical outcome.
Article
Isolated injury to the latissimus dorsi is rare. Partial tendon tears may be successfully treated nonsurgically. Complete tendon ruptures require surgical repair. Tendon repair can be approached either through an anterior deltopectoral incision with a secondary small posterior axillary incision or through a long posterior axillary incision. Suture anchors can be used to repair the latissimus dorsi to the humeral attachment. Although the literature is limited to single-patient case series, most patients have returned to full athletic activity after surgical repair.
Article
Irreparable rotator cuff tears are challenging in the young, active, high-demand patient with limited degenerative changes. The goal of treating irreparable rotator cuff tears is to re-establish the transverse and coronal force couples in an effort to balance the glenohumeral joint. Tendon transfer surgery is a viable option in patients desiring not only pain relief, but also for improvements in range of motion, strength, and function. Isolated posterosuperior tears can effectively be addressed with a lower trapezius tendon transfer. The procedure has the ability to reverse external rotation pseudoparalysis with restoration of strength. An arthroscopically assisted lower trapezius tendon transfer has recently been described and is the senior author's Bassem T. Elhassan (B.T.E.) preferred technique to address irreparable posterosuperior rotator cuff tears. The advantages of the arthroscopically assisted compared to the open technique are its less invasive nature, which decreases the risk of hematoma and seroma, speeds recovery, and avoids the need for an acromial osteotomy or detachment of the deltoid muscle. Nonetheless, a thorough understanding of the anatomy around the shoulder girdle, sufficient arthroscopic skill, and careful patient selection are imperative for optimizing outcomes.
Article
Background: Treatment of rotator cuff (RC) tears has not included bipolar muscle-tendon transfers to date. The objective of this study was to verify the feasibility of pedicled bipolar teres major (TM) transfer over and under the long head of the triceps brachii (LHT) and compare its versatility with monopolar transfer in a model of supraspinatus (SS) tears in cadavers. Methods: In 6 shoulders of cryopreserved cadavers, we re-created complete SS tears, conducting monopolar and bipolar TM transfers over and under LHT. We compared the morphology of the SS and TM, defect coverage, angle between the transferred TM and major SS axis, and axillary nerve overlap with each technique. Results: The TM and SS were morphologically similar. Defect coverage was significantly lower with monopolar transfer (12 ± 4 mm) than with bipolar transfer (39 ± 9 mm under the LHT, P = .003, and 38 ± 8 mm over the LHT, P = .004). The bipolar transfer course over the LHT was the nearest to the SS axis (39° ± 11°, P = .005). We found a greater axillary nerve overlap with bipolar transfer under the LHT (27 ± 8 mm) than with bipolar transfer over the LHT (1 ± 2 mm, P = .005) or monopolar transfer (0 mm, P < .001). Conclusion: Bipolar TM transfer is possible without neurovascular pedicle interference, obtaining greater RC defect coverage and the closest path to the SS axis when conducted over the LHT compared with monopolar or bipolar transfer under the LHT. Accordingly, it can be considered an alternative option for the treatment of posterosuperior RC defects.
Article
Aims: Since long-term outcome of teres major tendon transfer surgery for irreparable posterosuperior rotator cuff (RC) tears is largely unknown, the primary aim of this study was to evaluate the long-term outcome of the teres major transfer. We also aimed to report on the results of a cohort of patients with a similar indication for surgery that underwent a latissimus dorsi tendon transfer. Patients and methods: Patients and Methods In this prospective cohort study, we reported on the long-term results of 20 consecutive patients with a teres major tendon transfer for irreparable massive posterosuperior RC tears. Additionally, we reported on the results of the latissimus dorsi tendon transfer (n = 19). The mean age was 60 years (47 to 77). Outcomes included the Constant score (CS), and pain at rest and during movement using the Visual Analogue Scale (VAS). Results: At a mean of ten years (8 to 12) following teres major transfer, the CS was still 23 points (95% confidence interval (CI) 14.6 to 30.9, p < 0.001) higher than preoperatively. VAS for pain at rest (21 mm, 95% CI 4.0 to 38.9, p = 0.016) and movement (31 mm, 95% CI 16.0 to 45.1, p < 0.001) were lower than preoperatively. We also found an increase in CS (32 points, 95% CI 23.4 to 40.2, p < 0.001) and reduction of pain (26 mm, 95% CI 9.9 to 41.8, p = 0.001) six years after latissimus dorsi transfer. Conclusion: Teres major tendon transfer is a treatment option to gain shoulder function and reduce pain in patients with an irreparable posterosuperior RC tear at a mean follow-up of ten years. The teres major tendon might be a valuable alternative to the commonly performed latissimus dorsi tendon transfer in the treatment of irreparable posterosuperior RC tears. Cite this article: Bone Joint J 2018;100-B:309-17.
Article
Background: There are several tendon transfers for reconstruction of irreparable subscapularis tears. The latissimus dorsi (LD) could be used because its direction and function are similar to those of the subscapularis. We performed LD transfers for irreparable subscapularis tears and evaluated clinical outcomes. Methods: The study enrolled 24 consecutive patients who underwent LD transfers. Clinical and functional outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, pain visual analog scale, and range of shoulder motion preoperatively and at last follow-up. The lift-off and belly-press tests were performed to assess subscapularis integrity and function. Magnetic resonance imaging was performed preoperatively and 1 year postoperatively to evaluate tendon integrity. Results: Mean Constant, American Shoulder and Elbow Surgeons, and pain scores improved from 46 ± 6 to 69 ± 5 (P < .001), from 40 ± 3 to 70 ± 5 (P < .001), and from 6 ± 1 to 2 ± 1 (P = .006), respectively. The mean range of motion for forward elevation and internal rotation increased from 135° ± 17° to 166° ± 15° (P = .016) and from L5 to L1 (P = .010), respectively. Improvement in the range of motion for external rotation was not significant (51° ± 7° to 68° ± 7°; P = .062). At final follow-up, the belly-press test results were negative for 18 of 24 patients, and the lift-off test results were negative for 16 of 20 patients. No complications related to tendon transfer, including axillary and radial nerve injuries, were found. No retearing of the transferred LD was observed. Conclusions: LD transfer resulted in pain relief and restoration of shoulder range of motion and function. LD transfer could be considered an effective and safe salvage treatment for irreparable subscapularis tears.
Article
Purpose: The main objective of this retrospective study was to analyze the rate and modes of failure of latissimus dorsi transfer (LDT). The secondary objective was to evaluate whether a rupture of the transfer was associated with a worse outcome. Methods: During a 2-year period, we performed consecutive LDTs either for irreparable posterior-superior rotator cuff tears (RCTs) or for failed prior repair. All the LDTs were performed by a single surgeon. All transfers were arthroscopically assisted and fixed as a tubularized LD tendon in a bone tunnel inside the humeral head. Three metal clips were placed systematically intraoperatively in the tubularized tendon at a fixed distance of 2, 4, and 6 cm from the tip of the tendon. Immediate postoperative standard anteroposterior radiographs were performed and the position of the metal clips was compared with their position on radiographs performed at 6 weeks and 3 and 24 months postoperatively. Constant, Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), Activities of daily living requiring active external rotation (ADLER), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores and patient's subjective satisfaction (assessed by self-questionnaire) at last follow-up were compared between patients who had a rupture of the transfer and those who did not. Results: Sixty-six patients were included. Six of 66 patients (9%) were lost to follow-up. There were 11 complications (18.3%) in the global series (10 hematoma and 1 subscapularis retear). At a mean 35.2 months (range 24-50 months), there were 23/60 cases of rupture (38%). The 7 scores and the satisfaction reported were significantly lower for patients who had a rupture of the transfer versus those who had an intact transfer: Constant score, 42.8 versus 68.7 (P = .001); SSV, 48.9 versus 71.6 (P = .001); SST, 4.8 versus 8.4 (P = .012); ADLER, 19.7 versus 26.7 (P = .005); VAS, 3.7 versus 2.3 (P = .082); ASES, 55.4 versus 74.8 (P = .056); and 13% of either satisfied or very satisfied patients versus 78% (P < .001). Conclusions: The rate of rupture of LDT is high (38%). With complete healing of LDT, the outcome is significantly lower in those with rupture compared with those without rupture, showing that LDT can efficiently treat massive and irreparable RCT. Level of evidence: Level IV, case series treatment study.
Article
Background: Subscapularis (SSC) tendon tears are a challenging problem because they can significantly alter shoulder mechanics and function. Tendon retraction and advanced fatty degeneration associated with a chronic tear may make it irreparable. Tendon transfers options for such tears are viable, but results in the setting of associated glenohumeral instability are inconsistent. With the potential to recreate the SSC line of pull, the teres major (TM) may be a viable option for transfer. This cadaveric study investigated the feasibility and outlined the steps of a bipolar, pedicled TM transfer for irreparable SSC tendon tears. Methods: Eight fresh frozen cadaver torsos from 4 women and 4 men (average age, 84 years; range, 68-96 years) were dissected. Anatomic details comparing TM to SSC were examined, including muscle width, length, thickness, and line of pull in the scapular plane. In addition, a surgical technique was described for implementing the pedicled TM transfer. Results: Measurements between the TM and SSC were comparable, with the exception of muscle belly width, which was significantly greater in the SSC. With transfer of the TM, there was no impingement or tension on the brachial plexus or the neurovascular pedicle of the TM. The line of pull of the TM relative to the SSC had a difference of 9°. Conclusions: This study demonstrates that a bipolar TM tendon transfer is an anatomically feasible option for reconstruction of an irreparable SSC tendon tear. Further clinical studies are necessary to understand its outcome in in vivo conditions.
Article
Background: Teres major (TM) transfer and latissimus dorsi (LD) transfer are essential treatment options in patients with posterosuperior rotator cuff (RC) tears. The purpose of this study was to quantify shoulder kinematics before and after TM transfer and LD transfer in posterosuperior RC tear patients. Methods: In this prospective cohort study, we quantitatively measured shoulder movements using an electromagnetic tracking device (Flock of Birds) preoperatively and 1 year after either TM (n = 13) or LD (n = 9) tendon transfer. Additional outcome measures included the Constant score (CS), patient-reported pain, and quantitative range of motion. Scapular kinematics were evaluated during arm abduction. Results: By use of a quantitative assessment, forward flexion (from 87° to 106°, P = .007), abduction (from 86° to 106°, P = .010), and external rotation in abduction (from 52° to 70°, P = .019) improved. Both transfers reduced pain (from 50 to 10 mm, P < .001), and the CS improved (from 37 to 62 points, P < .001). No significant differences in postoperative improvement in pain and function were found between TM and LD tendon transfers. The TM transfer group showed increased scapular lateral rotation compared with the LD transfer group (13°; 95% confidence interval [CI], 4.8° to 21.7°; P = .003). We were unable to detect differences between TM transfer and LD transfer in the change in protraction (3.2°; 95% CI, -6.3° to 12.8°; P = .489) and posterior tilt (3.5°; 95% CI, -3.5° to 10.5°; P = .313). Conclusion: Tendon transfer surgery resulted in an overall improvement in CS, pain relief, and quantitative range of motion in the treatment of an irreparable posterosuperior RC tear. Scapular lateral rotation gradually increased after TM transfer, reminiscent of RC function, whereas such an increase was not observed after LD transfer.
Article
Background: Promising short-term outcomes after pectoralis major tendon transfer for the treatment of an irreparable anterosuperior rotator cuff tear have been reported. The purpose of this study was to evaluate the long-term outcome. Methods: Twenty-seven consecutive patients with irreparable anterosuperior rotator cuff tears without advanced cuff arthropathy or advanced humeral head migration were treated with a partial subcoracoid pectoralis major tendon transfer between 2004 and 2005. At an average of 10 years (range, 9 to 11 years) postoperatively, 22 patients (82%) with an average age of 62 years (range, 42 to 74 years) at the time of surgery had a long-term follow-up examination that included the pain score, strength and range-of-motion assessment, Constant score, Simple Shoulder Test (SST), as well as radiographic and ultrasonographic imaging. The long-term results were compared with the preoperative findings as well as the short-term results that were collected from a previous evaluation. Results: The adjusted Constant score increased from 54% to 87% at the short-term follow-up (p < 0.001) and remained improved at the long-term follow-up, with a mean score of 83% (p = 0.001). While the significant improvement of the pain level at the short-term follow-up was maintained at the time of final follow-up (p = 0.001), the increase in strength returned to the preoperative level (p = 0.178), and the improvement in range of motion diminished again over time despite remaining significantly improved (p = 0.029), especially with regard to internal rotation (p < 0.001). At the long-term follow-up, 77% of the patients were very satisfied with the procedure. A third of the patients had no progression of cuff arthropathy, a third had progression by 1 grade, and a third had progression by ≥2 grades. At the time of final follow-up, 1 patient (5%) had undergone revision surgery to reverse shoulder arthroplasty. Conclusions: Pectoralis major tendon transfer for the treatment of irreparable anterosuperior rotator cuff tears results in a significant clinical improvement even 10 years after surgery, especially with respect to pain and internal rotation. Despite long-term radiographic progression of cuff arthropathy, patient satisfaction remains high over time, with a low rate of salvage with reverse shoulder arthroplasty. Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Article
Injuries to the latissimus dorsi and teres major muscles, while rare, are debilitating. They are seen in a variety of sports, although disproportionately in the throwing shoulder of baseball pitchers. There have been 25 case reports and 2 case series published on the nonoperative and operative management of these injuries. Latissimus dorsi and teres major muscle anatomy, function, and common injury patterns are well described in these case reports. Also well detailed are the typical patient presentation, physical examination, and imaging findings. Latissimus dorsi tendon injuries are sometimes treated operatively, whereas latissimus dorsi muscle belly or isolated teres major injuries are treated nonoperatively. Nonoperative treatment includes oral anti-inflammatories and shoulder physical therapy. A number of surgical patient positions, approaches, and fixation constructs have been described, although 2 techniques of positioning and surgical approach are used most commonly. Fixation is most often performed with suture anchors. Return-to-play timing, shoulder strength, and healing on magnetic resonance imaging are variable. No standard of care currently exists for the treatment of latissimus dorsi or teres major injuries. If treating a patient with an injury to either muscle, the clinician should be familiar with accumulated experience as reported in the published literature.
Article
Most rotator cuff tears can be repaired by conventional methods. Even in the case of massive tears, repair or reconstruction is usually feasible and the outcome is usually good1,2. While there is no universal agreement on the definition, in North America Cofield's3 definition of a massive tear as one with a diameter of five centimeters or greater is used. Furthermore, there appear to be two distinct patterns of tears, each with a different epidemiology, mechanism of injury, associated disability, and prognosis4. The more common, posterior-superior configuration involves the supraspinatus and the infraspinatus, and the less common, anterior-superior configuration involves the subscapularis and the supraspinatus. Massive posterior-superior rotator cuff tears are not common. Even in clinical practices limited to the treatment of shoulder problems, less than one-third of all rotator cuff tears are massive. Neer5 reported that, of 340 rotator cuff tears operated on over a thirteen-year period, 145 were massive. Bigliani et al.2 described sixty-one massive rotator cuff tears requiring surgery over a six-year period. Ellman et al.6 reported that nine of fifty-four rotator cuff repairs involved a massive tear. Harryman et al.7 reported that twenty-eight of 105 surgically treated tears were massive. Of 407 rotator cuff tears that I repaired surgically over a period of six years, 146 were massive posterior-superior lesions. Massive anterior-superior rotator cuff tears are even less common. A recent European study included eighty-eight combined subscapularis and supraspinatus tendon tears from seven centers4. Frankle and Cofield reported twenty-four such tears in a series of 301 tears that were repaired over a five-year period4. Of 105 tears reported on by Harryman et al.7, twenty-two involved the subscapularis as well as the supraspinatus. Of the 407 rotator cuff tears that I …
Article
Tendon transfers provide a substitute, either temporary or permanent, when function is lost due to neurologic injury in stroke, cerebral palsy or central nervous system lesions, peripheral nerve injuries, or injuries to the musculotendinous unit itself. This article reviews the basic principles of tendon transfer, which are important when planning surgery and essential for an optimal outcome. In addition, concepts for coapting the tendons during surgery and general principles to be followed during the rehabilitation process are discussed.
Article
Background: Management of massive irreparable posterior-superior rotator cuff tear can be very challenging. This study reports the outcome of the lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear. Methods: Included were 33 patients with an average age of 53 years (range, 31-66 years). All patients had symptomatic massive irreparable rotator cuff tear that failed conservative or prior surgical treatment and underwent reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft. The tear was considered irreparable based on the magnetic resonance imaging finding of ≥2 full-thickness rotator cuff tears associated with shortening and retraction of the tendon to the level of the glenoid and a high grade of fatty infiltration of the muscles. This was confirmed at the time of the surgery. Results: At an average follow-up of 47 months, 32 patients had significant improvement in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder and Hand score and shoulder range of motion, including flexion, 120°; abduction, 90°; and external rotation 50°. One patient, with a body mass index of 36 kg/m(2), required débridement for an infection and then later underwent shoulder fusion. Patients with >60° of preoperative flexion had more significant gains in their range of motion. Shoulder external rotation improved in all patients regardless of the extent of the preoperative loss of motion. Conclusions: Transfer of the lower trapezius prolonged with Achilles tendon allograft to reconstruct massive irreparable posterior-superior rotator cuff tear may lead to good outcome in most patients, specifically for those who have preoperative flexion of >60°.
Conference Paper
Background: Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors. Methods: The study reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 ± 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients' functionality preoperatively and at follow-up. Results: As a group, the CMS improved with surgery from 35.5 ± 6.1 to 69.5 ± 12.3 (P < .001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P = .044 and P = .007, respectively) and CMS (P = .042 and P = .018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P = .009). Gender and age did not affect the clinical outcomes. Conclusions: Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT.
Article
Management of massive irreparable rotator cuff tears can be challenging. In patients who are not candidates for shoulder arthroplasty, either because of age or higher levels of activity, tendon transfers remain a good surgical option to reconstruct the deficient rotator cuff. The latissimus dorsi is the most commonly described tendon transfer for posterior-superior rotator cuff deficiency. Additional options include teres major and lower trapezius transfers. For anterior-superior irreparable rotator cuff tears, the pectoralis major transfer, whether superficial or deep to the conjoined tendon, is the most commonly described transfer. Additional transfers include those of pectoralis minor, teres major, and latissimus dorsi. The purpose of this article is to provide an evidence-based overview of the different types of tendon transfers that have been described to reconstruct massive, irreparable rotator cuff tears.
Article
The purpose of this study was to characterize the biomechanical effects of the lower trapezius transfer and to compare it with the latissimus dorsi transfer in a cadaveric model of a massive posterosuperior rotator cuff tear. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of shoulder abduction. Range of motion, humeral rotational position due to muscle loading, joint reaction forces, and kinematics were measured. All specimens were tested in 4 conditions: intact, massive posterosuperior cuff tear, lower trapezius transfer, and latissimus dorsi transfer. A repeated-measures analysis of variance was used for statistical analysis. Internal rotation due to muscle loading increased with massive cuff tear compared with the intact condition (P < .05). The latissimus transfer corrected this change at 0° abduction, whereas the trapezius transfer corrected this at all abduction angles. The massive cuff tear decreased glenohumeral joint compression forces at all abduction angles; these forces were restored by the lower trapezius transfer (P < .05). At maximum humeral internal rotation and 0° of abduction, the humeral head apex shifted superiorly and laterally with massive cuff tear (P < .05); this shift was more closely restored to intact values by the trapezius transfer compared with the latissimus transfer (P < .05). The lower trapezius transfer is superior to the latissimus transfer at restoring native glenohumeral kinematics and joint reaction forces in our cadaveric model. It may be a promising treatment option for patients with a massive irreparable rotator cuff tear. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Article
Background: Irreparable posterosuperior rotator cuff tears are treated in several ways. Transfer of the latissimus dorsi is an alternative with acceptable mid-term results, but long-term results have rarely been published. Methods: The cases of 108 consecutive patients with 115 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed clinically and radiographically. Ninety-three shoulders in eighty-six patients were included in the follow-up analysis. The mean duration of follow-up was 9.3 years (range, 6.6 to 11.7 years), and the mean age at the operation was fifty-six years (range, forty to seventy-two years). Outcome measures included the Constant-Murley score (Constant score), American Shoulder and Elbow Surgeons (ASES) index, and visual analog scale (VAS) for pain. The progress of cuff tear arthropathy was determined with radiographic evaluation according to the system described by Hamada et al. Results: The mean relative Constant score improved from 44% preoperatively to 71% at the time of follow-up (p < 0.0001, effect size = 0.6), excluding the clinical failures. Similarly, the mean ASES index improved from 30 to 70 (p < 0.0001, effect size = 0.7), and the mean VAS score decreased from 7.8 to 2.4 (p < 0.0001, effect size = 0.8). A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly (p < 0.05). The mean Hamada radiographic grade of cuff tear arthropathy increased from 1.7 (range, 0 to 2) preoperatively to 2.2 (range, 1 to 5) (p < 0.0001, effect size = 0.2). The rate of clinical failure of latissimus dorsi transfer was 10%, and the rate of shoulder prosthetic replacement after latissimus dorsi transfer was 4%. Conclusions: Pain relief and improvement of shoulder function were maintained a mean of 9.3 years after latissimus dorsi transfer for irreparable posterosuperior cuff defects. The younger the patient, the better the outcome.
Article
To evaluate, in a multicenter, prospective study, the clinical, magnetic resonance imaging (MRI), and radiologic results of arthroscopic-assisted latissimus dorsi (LD) tendon transfer for irreparable posterosuperior rotator cuff tears; and to assess the influence of perioperative data on clinical results. Fifty-five patients with irreparable tears of at least the supraspinatus and infraspinatus tendons were managed with arthroscopic-assisted LD tendon transfer and reviewed clinically, with standardized radiographs and MRI, after a mean of 29 months. Outcome measures included the Constant score and the Subjective Shoulder Value. The osteoarthritic stage and acromiohumeral distance were measured on standardized radiographs, and the transferred tendon aspect was evaluated on MRI. Thirty patients had already undergone 1 or more previous surgical procedures. The mean Subjective Shoulder Value increased from 26% preoperatively to 71% postoperatively. The Constant score improved from 37 preoperatively to 65.4 postoperatively. The pain score increased from 1.7 preoperatively to 12.6 postoperatively; the activity score, from 6.4 to 13.8; active forward flexion, from 134° to 157°; active abduction, from 67° to 92.5°; active external rotation, from 29° to 41.5°; and abduction strength, from 1.4 kg to 4.8 kg. The only statistically significant factor negatively influencing the Constant score was previous surgery. Four patients had a ruptured LD tendon on MRI follow-up at 1 year. There was no statistical difference between preoperative and final follow-up acromiohumeral distance. There was no increase in osteoarthritic stage. Arthroscopic-assisted LD tendon transfer improves shoulder pain and function in patients with irreparable posterosuperior cuff tears, with similar clinical and radiologic results compared with results of published series using open techniques. Patients with a history of surgery had lower Constant scores compared with non-previously operated patients. Level IV, therapeutic case series. Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
Article
Purpose The transfer of the pectoralis major in cases of irreparable rupture of the subscapularis has been described through different techniques. The aim of this prospective study was to compare the clinical results of transferring the clavicular or the sternal head of the pectoralis major tendon underneath the conjoint tendon. Methods Fifteen patients underwent the procedure, including eight clavicular head of the pectoralis major tendon transfers and seven sternal head transfers. The mean age at the time of surgery was 57 years (range, 37–66). Each patient had pre-operative MRI and CT scan. The criteria for an irreparable subscapularis tear were retraction at the level of the glenoid and fatty infiltration of the muscle graded III or IV. Pre-operative and postoperative functions were assessed by the Constant score. Patients were finally asked if they were very satisfied, satisfied or unhappy with the functional outcome. Results The average follow-up was 24 months (range, 12–50). The mean absolute Constant score of the entire series increased significantly from 36 preoperatively to 69 at the latest follow up (p
Article
Purpose Irreparable ruptures of the subscapularis tendon lead to impaired function of the shoulder and presents a surgically complex problem. Transfer of the pectoralis major tendon has been reported as a possible treatment option. The purpose of this systematic review is to critically examine the outcomes of pectoralis major transfers for the treatment of irreparable subscapularis tears. Methods A systematic review of the literature was performed using search of electronic databases. No language restrictions were applied. Case reports, review articles, and operative techniques without outcome data were excluded. All the outcomes reported by each study were analyzed and when possible, data were pooled to generate frequency-weighted values to summarize outcomes. Results Eight studies with a total 195 shoulders were included in this systematic review. The mean age of patients was 58.8 years (range 18–81 years) and the mean follow-up was 33.4 months (range 6–80 months). Constant scores improved from a mean pre-operative score of 37.8 ± 6.8, to a mean postoperative score of 61.3 ± 6.5 (p
Article
Background Subscapularis insufficiency is a debilitating condition with few treatment options. Historically, pectoralis major tendon transfer has been suggested when the subscapularis tendon or muscle is deemed irreparable; however, the results of this salvage procedure have been mixed. Methods A comprehensive review of the peer-reviewed literature addressing pectoralis major tendon transfers was performed. The clinical presentation, relevant anatomy, biomechanical rationale, surgical indications, technical considerations, reported outcomes, and significant complications are reviewed in this report. Where possible, attempts at direct comparison of outcomes among surgical techniques and surgical indications have been made. Results and Conclusions Despite the heterogeneous reporting of clinical results, it is clear that surgical indications affect outcomes. Specifically, isolated subscapularis insufficiency shows the best prognosis with pectoralis major tendon transfer. Patients with anterosuperior instability after large rotator cuff tears or shoulder arthroplasty have the least predictable pain relief and worse functional outcomes.