JBJS | Management of Massive Irreparable Rotator Cuff Tears: The Role of Tendon Transfer*†

The Journal of Bone & Joint Surgery, Volume 82, Issue 6

Instructional Course Lecture | June 01, 2000

Management of Massive Irreparable Rotator Cuff Tears: The Role of Tendon Transfer*†

Jon J. P. Warner, M.D‡

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2001 in Instructional Course Lectures, Volume 50. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
‡Massachusetts General Hospital, Professional Office Building, Suite 403, 275 Cambridge Street, Boston, Massachusetts 02114. E-mail address: jwarner@partners.org.

The Journal of Bone & Joint Surgery. 2000; 82:878-878

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The Problem

The Problem | Pathoanatomy and Pathomechanics | Overview | Introduction | References

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 good^1,2. 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 repaired surgically during a period of six years, nineteen were combined supraspinatus and subscapularis tears.

Although most tears that involve two or more tendons can be repaired with good results, in some patients the size of the defect and the quality of the tendon tissue preclude secure repair to bone^7-9. As these tears are, by definition, massive, not all are reparable. An irreparable tear is one in which the quality of the tendon tissue is so poor that direct tendon-to-bone repair is not possible. In such cases, alternative surgical techniques are considered. Both open and arthroscopic dè¡²idement have been suggested; however, while some authors have thought that this provides good pain relief and function, strength is not restored^10-12. Furthermore, the durability of this pain relief has been questioned¹³. In general, this technique is best suited for elderly patients whose predominant symptom is pain.

Tendon allografts and synthetic fabrics have also been used in such patients but without reproducible results^14,15.

Both local tendon transposition and distant tendon transfer have been proposed to manage irreparable rotator cuff tears in patients who have both pain and weakness. The former has included use of a portion of the subscapularis and the teres minor to cover a large superior defect of the rotator cuff^16-18. While some surgeons have reported success with these methods, the results have not been reproducible by others. In Europe, anterior deltoid transposition has also been suggested for the reconstruction of irreparable tears of the cuff^19-21; however, this technique has not gained favor in North America.

Historically, extrinsic tendon transfer about the shoulder has been proposed for the management of paralysis^22-25. Transfer of the trapezius tendon was once recommended for the management of massive rotator cuff tears²⁶; however, the results of this technique were not reproducible. Several authors^27,28 have suggested that the teres major may be a reasonable substitute for an infraspinatus muscle with an irreparable lesion; however, clinically it has been found that this tendon is too short and bulky for transfer⁹. In 1988, Gerber et al.⁹ documented the anatomical potential and clinical effectiveness of latissimus dorsi tendon transfer for the management of the functional deficit associated with a massive irreparable posterior-superior rotator cuff tear. Gerber's²⁹ long-term follow-up study of this series, reported in 1992, added to the enthusiasm for this method. Others^30,31 have reported similarly successful outcomes with this approach. This is currently the favored method for the reconstruction of irreparable massive posterior-superior rotator cuff tears.

The principal problem with management of irreparable anterior-superior tears is the subscapularis component of the tear. This is the most important muscle-tendon unit for both function and stability of the glenohumeral joint^32-36. Although subscapularis rupture has been well recognized as a complication of anterior dislocation, it has only recently been appreciated that disruption of this structure without instability can lead to severe pain and weakness^33,34,37-40. While Gerber et al.^33,34 highlighted the physical findings that allow the detection of subscapularis rupture and the technical steps necessary for repair, little has been written about the management of an irreparable subscapularis tendon tear. Recent anecdotal experience and one published report³² have suggested that transfer of the pectoralis major may be a method for the management of chronic irreparable subscapularis deficiency. No other type of tendon transfer has proved useful in this situation.

Preoperative Considerations

All considerations with regard to treatment must be placed in the context of the individual patient's disability and expectations for pain relief and functional recovery. Concomitant medical problems must also be considered, as they have a bearing on the patient's potential for recovery and for postoperative compliance with therapy.

Pathoanatomy and Pathomechanics

The Problem | Pathoanatomy and Pathomechanics | Overview | Introduction | References

The functional contribution of a muscle to the rotation of a joint is determined by multiplying its physiological cross-sectional area by its leverage. Physiological cross-sectional area is an expression of a muscle's force potential⁴¹. The leverage of a muscle is determined by drawing a perpendicular line from the muscle's line of action to the center of rotation of the joint⁴². If this analysis is applied to the rotator cuff muscles, it is clear that the supraspinatus makes a small (14 percent) contribution to the overall moment arm for abduction of the shoulder^41,42, whereas the infraspinatus and teres minor contribute 32 percent and the subscapularis contributes 52 percent⁴¹. Thus, the anterior and posterior components of the rotator cuff are of primary importance in determining the rotation of this joint.

The excursion of the rotator cuff tendons is also relatively small (range, 0.5 to 4.0 centimeters) during scapular abduction. In comparison, the deltoid muscle has an excursion of 6.5 centimeters during abduction³⁵. The rotator cuff muscles are thus critical stabilizers of the humeral head, providing a fixed fulcrum for rotation powered by the deltoid during abduction³⁵. Disruption of the supraspinatus in combination with either the infraspinatus or the subscapularis can result in loss of the fulcrum for the rotation that is necessary for full abduction^36,43-45.

The role of the long head of the biceps remains a matter of some debate. While some authors^46-48 have provided evidence for its action as a humeral head depressor, others^49,50 have suggested that it does not play an important biomechanical role in the setting of a massive rotator cuff tear.

Clinical^10,12 and experimental^36,37 work has demonstrated that, in some patients who have a massive rotator cuff tear, shoulder function remains good. In these patients, the tear involves the entire supraspinatus and, while it may extend into the subscapularis or the infraspinatus, it does not disrupt these tendons inferior to the equator of the humeral head. Thus, the remaining anterior and posterior aspects of the rotator cuff can exert sufficient force to maintain a fixed fulcrum for rotation of the humeral head in the glenoid. Extension of the tear inferior to the equator results in biomechanical decompensation with loss of containment of the humeral head^9,29,36,37. Paradoxically, some patients with a smaller rotator cuff tear may have very poor function while others with a larger tear may maintain good function. The fact that tear size does not always correlate with function is reflected in the literature in terms of the disparity among treatment outcomes^2,3,10,12. Several surgeons have suggested that this disparity between tear size and function can be explained by the degree of atrophy and fatty degeneration of the muscles of the rotator cuff (Fig. 1)^34,51.

Another important factor that must be considered is the integrity of the coracoacromial arch. This structure may act as a stabilizer against unchecked anterior-superior movement of the humeral head in the setting of a tendon tear involving the supraspinatus and at least one other tendon^52,53. Thus, it is now commonly recommended that the arch be preserved in the operative management of such patients.

Because massive rotator cuff tears are found in a heterogeneous population of patients, it remains difficult to select the optimal form of treatment. The determination that a rotator cuff tear is irreparable can be made prior to surgery. Currently, it is possible to identify individuals who have poor-quality tissue and a large tear that preclude successful primary tendon repair. Factors that predict these findings include profound weakness of external rotation, superior displacement of the humeral head, and magnetic resonance imaging showing not only atrophy but also fatty replacement of the muscles of the rotator cuff. An anteroposterior radiograph that shows an acromiohumeral interval of less than five millimeters usually means that the tear involves at least two tendons of the rotator cuff. Hersche and Gerber⁵⁴ demonstrated that the duration of the tendon tear is associated with the stiffness of the muscle-tendon unit at the time of surgery. I have found that the degree of fatty replacement of the muscle seen on a preoperative magnetic resonance imaging study predicts the quality and stiffness of the tendon tissue as well. Therefore, primary repair or local reconstruction of the torn rotator cuff tendon is not recommended for patients with this combination of findings.

Indications for Tendon Transfer

The clinical experience of several authors provides some guidelines for the appropriate selection of patients for tendon transfer for the reconstruction of an irreparable tear^9,29-31. In general, it is appropriate to consider tendon transfer for patients who have a painful rotator cuff tear that is associated with poor function and in whom there is a low probability that primary reconstruction will be successful.

For patients who have had failure of a prior tendon repair, the indications for tendon transfer are less clear; a number of factors may mitigate against successful improvement of function in this situation^29,30. These factors include disruption of the coracoacromial arch, deltoid deficiency, stiffness, and nerve injury. In addition, with an irreparable tear of the supraspinatus and infraspinatus, disruption of the subscapularis is a relative contraindication for latissimus dorsi tendon transfer⁹. This is due to disruption of the anterior component of the anteroposterior force couple of the rotator cuff.

The Mechanical Basis of Tendon Transfer for Reconstruction of the Rotator Cuff

The anatomical and biomechanical basis of muscle transfer has been previously published⁵⁵. The relative length of a muscle and its line of action relative to the center of rotation of the joint determine its usefulness as a transfer to restore motion. The rotator cuff muscles have a relatively short amplitude compared with extrinsic shoulder muscles such as the deltoid, pectoralis major, and latissimus dorsi. For the most part, the important function of the rotator cuff that needs to be restored is its action as an external and internal rotator of the humeral head. Thus, the function of the infraspinatus or subscapularis is of primary concern. The subscapularis has an amplitude of 7.3 centimeters and is the strongest of the rotator cuff muscles⁵⁵. It acts as a powerful internal rotator, but it also maintains the stability of the humeral head by pulling it both downward and posteriorly during abduction of the arm. It acts in synergy with the infraspinatus both to abduct the shoulder and to provide centering of the humeral head in the glenoid.

Comparison of the orientation of the subscapularis with that of other muscles about the shoulder reveals that there are no tendons available for optimal restoration of function if the subscapularis cannot be repaired. Use of the trapezius and the pectoralis major has been proposed³². Clinical experience with the trapezius has not been reported in the peer-reviewed literature, to my knowledge, but its line of action seems unfavorable as a substitute for subscapularis function. The pectoralis major has a favorable amplitude (14.4 centimeters for the clavicular head and 18.8 centimeters for the sternal head), but its line of action is anterior to the normal orientation of the subscapularis as it originates from the chest wall and thus it cannot pull the humeral head backward^32,55. Several surgeons have suggested that this line of action can be improved if the pectoralis major is transferred underneath the conjoined tendon and to the lesser tuberosity; however, I am aware of no published reports of this technique.

Transfer of the trapezius²⁶ or the lateral head of the deltoid^19,21 has been proposed for the management of supraspinatus tendon insufficiency; however, neither technique has been shown to be effective when there is an irreparable infraspinatus or subscapularis tear.

Disruption of the infraspinatus is always associated with a supraspinatus tear. The combination, which is irreparable, is very disabling for some patients, as they lose not only abduction but also external rotation, which prevents movement of the hand to the mouth or to the top of the head. The two muscles that have been proposed as best suited to restore external rotation and abduction are the teres major and the latissimus dorsi. The maximum potential amplitude of the infraspinatus is 8.6 centimeters, that of the latissimus dorsi is thirty-four centimeters, and that of the teres major is fifteen centimeters. Each of these muscles has sufficient strength to be effective as a transferred muscle. While the teres major appears to qualify as a good substitute on the basis of its line of action, it has a rather bulky short tendon, and experimental study has demonstrated that it may not reach superior to the posterior portion of the greater tuberosity when it is transferred underneath the acromion²⁸. The latissimus dorsi has been shown to have sufficient excursion to be transferred over the humeral head; however, this muscle crosses both the scapulothoracic and the glenohumeral articulation, and its function is completely different from that of the muscle for which it is acting as a substitute. It normally functions as a powerful adductor and extends the humerus.

My personal preference is to use a modified pectoralis major transfer for reconstruction of an irreparable subscapularis tendon tear and to use a latissimus dorsi transfer for reconstruction of an irreparable infraspinatus tear.

Split Pectoralis Major Transfer for Reconstruction of an Irreparable Subscapularis Tear

The technical steps for the mobilization and repair of the subscapularis were described by Gerber et al.⁹. It is important to attempt to mobilize the subscapularis tendon since even a partial repair may be of some advantage. It is sometimes possible to repair the inferior portion of the tendon while the superior one-half remains irreparable. The pectoralis major can then be used to augment the function of the deficient portion.

Wirth and Rockwood³² described use of the superior portion of the pectoralis major for reconstruction. With their technique, this portion is released from the humerus and transferred lateral to the bicipital groove with the arm in internal rotation. My approach modifies this technique for several reasons. First, the sternal portion of the pectoralis is identified and used for the transfer, as this component has sufficient strength and amplitude to act effectively as a transfer. Second, transfer of this component of the pectoralis underneath the remaining clavicular portion of the tendon brings its line of action closer to that of the subscapularis muscle (Fig. 2-A, Fig. 2-B, Fig. 2-C, and Fig. 2-D).

Surgical Technique

An extended deltopectoral approach is utilized. The deltopectoral groove is identified, and the dissection proceeds through this interval to the level of the clavipectoral fascia. The interval underneath the conjoined tendon is developed by both blunt and sharp dissection. There is usually a thin layer of tissue overlying the humeral head; this is not the subscapularis but, rather, scar tissue in continuity with the subscapularis tendon that has retracted medially deep to the conjoined tendon. This layer is detached along the lesser tuberosity from superior to inferior. Often, a few remaining muscle fibers of the subscapularis attached inferiorly to the lesser tuberosity are visible. A humeral head retractor is then inserted into the joint to displace the humeral head posteriorly, improving exposure for mobilization of the scarred subscapularis tendon. A long, thin retractor is then placed underneath the conjoined tendon, and the axillary nerve and the circumflex vessels are identified. The circumflex vessels are mobilized and then controlled with suture ligature, and the axillary nerve is mobilized and a vessel loupe is placed underneath it. Dissection then frees the inferior scar of the subscapularis while protecting the axillary nerve. Sutures are placed through the scarred edge of the subscapularis so that it can be manipulated to allow for release of adhesions. Sharp dissection releases the contracted subscapularis from the labrum, and the muscle is then mobilized from its fossa. Finally, the scarred coracohumeral ligament is released from the base of the coracoid process. When there is fatty replacement of the muscle, the muscle-tendon unit feels stiff. Usually, the entire subscapularis tendon cannot be repaired to the lesser tuberosity, but in some cases its inferior portion can be reattached to the lesser tuberosity with use of a transosseous repair technique^4,34.

The pectoralis major is then exposed, and the dissection is continued medially on its superficial surface. Knowledge of the anatomy of the tendon insertion is important for harvesting the sternal head of the muscle. The sternal portion originates from the inferior part of the sternum and the fifth and sixth ribs. Its tendon courses superiorly underneath that of the clavicular head, so that it twists 180 degrees and inserts superiorly on the humerus. The interval between the two heads and the orientation of the tendon usually can be clearly identified (Fig. 3). This interval is then developed bluntly just medial to the muscle-tendon junction, and a large clamp is placed underneath the sternal portion of the muscle. The clamp is replaced with a Penrose drain. The dissection then proceeds distally, with separation of the two components of the tendon and detachment of the sternal portion from the humerus. Nonabsorbable number-2 braided sutures are placed in the tendon end. The muscle split between the two heads is extended about three to four centimeters medially in order to facilitate transfer of the sternal head underneath the clavicular head. After decortication of the area of the lesser tuberosity and the bicipital groove, the tendon is repaired to bone with use of either bone anchors or a transosseous repair technique. This is done with the arm in neutral rotation and the pectoralis pulled superiorly to the top of the lesser tuberosity. The incision is then closed in layers, and the arm is placed in a shoulder immobilizer.

Aftercare consists of immobilization in a sling for four weeks, during which time passive flexion is performed below the horizontal and passive external rotation is limited to about 30 degrees. After four weeks, active assisted motion is commenced. Strengthening exercises are delayed for four months.

Results

Experience with transfer of the pectoralis major for the reconstruction of irreparable subscapularis tears is limited. Wirth and Rockwood³² reported on thirteen patients with an irreparable subscapularis tendon tear who had had failure of a capsular repair for the treatment of instability. Seven of these patients had transfer of the pectoralis major only, five had transfer of both the pectoralis major and the pectoralis minor, and one had transfer of the pectoralis minor only. Ten patients had a satisfactory outcome, and three had failure of the procedure. All of the patients with a satisfactory outcome had resolution of the instability as well as a marked reduction in pain. Two patients had restoration of a normal lift-off test³². (This test measures the ability to lift the internally rotated arm off of the lower back, and it indicates normal terminal internal rotation performed by the subscapularis.)

My experience with split pectoralis major transfer has included ten patients over the past four years. In five patients, the procedure was done after failure of prior rotator cuff surgery; in three, it was done after failure of surgery for the treatment of instability; and in two, it was done in the setting of instability after hemiarthroplasty. All patients had pain and the perception of instability when the arm was placed either overhead or behind the plane of the body. The results were graded according to pain relief, improved function, and resolution of instability. All patients felt that the shoulder was stable and indicated that the pain had decreased, although only six reported minimal or no pain. Functional gains were more limited, with only two patients indicating marked improvement and the ability to participate in sports such as golf and tennis. Three patients thought that they had much improvement, but they still had limited overhead use of the arm, and five had minimal functional improvement despite relief of pain and of the sense of apprehension. No patient had a normal lift-off test.

Latissimus Dorsi Transfer for Reconstruction of an Irreparable Posterior-Superior Rotator Cuff Tear

The technique for transfer of the latissimus dorsi tendon to reconstruct posterior-superior rotator cuff tears has been described in detail previously^4,9,29. Over the eight years of my experience, it has been modified technically as described below.

Surgical Technique

The patient is placed in the lateral decubitus position and is stabilized on a long beanbag, which is contoured to support the torso (Fig. 4-A). The entire arm and hemithorax are prepared with use of sterile technique and are draped. An anterior-superior incision is made in order to expose the rotator cuff tear. This incision begins on top of the shoulder, over the lateral one-third of the acromion, and continues anteriorly about one centimeter lateral to the coracoid process. In all cases, an attempt is made to preserve the coracoacromial arch. This is done by splitting the deltoid from the lateral aspect of the acromion and elevating it subperiosteally off of the anterior aspect. The interval between the deltoid and the coracoacromial ligament is identified, so that the latter is not detached from the acromion. The lateral deltoid split also allows easier access to the posterior aspect of the rotator cuff, improving exposure for transfer of the tendon. The edges of the rotator cuff are then identified, and steps to mobilize the retracted tendon edges are performed. These steps include release of the coracohumeral ligament, extra-articular lysis of adhesions that may be tethering the tendons, and intra-articular release in the plane between the labrum and the tendon surface. This will increase tendon excursion only modestly, usually less than a centimeter. Braided nonabsorbable number-2 sutures are then placed through the tendon edges.

The greater tuberosity is then prepared by abrading its surface and placing holes from the edge of the tuberosity to the lateral cortex of the humerus. Loops of braided number-2 suture are placed through these holes so that sutures from the transferred tendon can be passed subsequently.

In order to harvest the latissimus dorsi tendon, a separate posterior incision is made over the muscle belly and curved superiorly over the posterior aspect of the deltoid at the level of the joint line. The posterior aspect of the deltoid, the long head of the triceps, the teres major, and the latissimus dorsi muscles are identified. The latissimus is then dissected free from the teres major and the fascia of the chest wall. There are often substantial connections between the latissimus and the teres major, so dissection is easier if it begins at the level of the muscle and continues toward its insertion. The arm is positioned in flexion and internal rotation, which makes access to the tendon insertion easier. Long retractors are used to expose the tendon insertion while an assistant holds the arm in this position. Once the tendon has been detached from its insertion on the humerus, several number-2 braided sutures are placed through the end of the tendon in order to maintain tension on it as it is dissected in a retrograde fashion (Fig. 4-B). The tendon is freed from fascial extensions to the chest wall, and the neurovascular pedicle is isolated and protected. The muscle-tendon unit has been sufficiently mobilized for transfer when the tendon end can reach superior to the posterior aspect of the acromion. Braided nonabsorbable number-2 sutures are then placed through the tendon's lateral edge to be used to repair the tendon to the greater tuberosity once it has been transferred underneath the acromion.

The interval underneath the deltoid and the acromion is developed by both blunt and sharp dissection, and the tendon is then transferred with use of a curved clamp (Fig. 4-C). The arm is positioned in 45 degrees of abduction in the scapular plane and 30 degrees of external rotation and is held in that position with use of a special articulated arm-holder (McConnell Shoulder Holder; McConnell, Greenville, Texas) until the transferred tendon is sutured in place. Use of the arm-holder seems to work better than having an assistant hold the arm, as it allows better exposure of the shoulder because of its thin profile. It also maintains the arm in a consistent position, whereas an assistant might become fatigued and allow the arm position to move during the tendon transfer and repair. At this stage, a lamina spreader placed between the greater tuberosity and the acromion may help with exposure for suturing of the tendon. The tendon is held in position over the greater tuberosity while it is sutured along its medial edge to the remaining cuff tendons and then to the subscapularis as well (Fig. 4-D). Finally, the sutures in the lateral edge of the tendon are transferred through the greater tuberosity with use of the loops of the previously placed suture.

As the latissimus tendon is thin and as I have noted late rupture of the graft in 20 to 30 percent of cases, the tendon is now routinely augmented with autogenous fascia lata (Fig. 5-A). A two-by-four-centimeter strip of iliotibial band is harvested from the ipsilateral thigh and sewn over the tendon in order to reinforce it (Fig. 5-B).

Aftercare is very important following this transfer. For the first six weeks, the patient continually wears an abduction brace that maintains the arm in 45 degrees of abduction and 30 degrees of external rotation in order to allow the tendon to heal without tension. Throughout this period, a therapist performs passive motion with the arm in abduction and external rotation, but internal rotation and adduction are not permitted. This motion ensures that the tendon graft does not adhere to the surrounding soft tissue and that the glenohumeral joint does not become stiff. After six weeks, the brace is removed and the patient is encouraged to perform activities of daily living.

The patient is then taught to initiate and maintain active contraction of the latissimus dorsi during flexion and external rotation of the arm. This is not the normal phase of activity for this musculotendinous unit, so a concerted effort must be made to retrain the muscle. This is achieved in two ways. With the first method, the arm is positioned in the midrange of abduction and the patient is asked to adduct the shoulder toward the midline, which causes the latissimus dorsi to contract. As the latissimus contracts, the arm is guided into flexion and the patient is coached to maintain this contraction in order to facilitate flexion. Gradually, the patient acquires the ability to maintain contraction of the latissimus. Similarly, the patient is asked to maintain contraction as the arm is moved into external rotation.

The second method for retraining the latissimus dorsi is with use of biofeedback. A small biofeedback unit with cutaneous electrode pads is applied over the muscle belly of the latissimus dorsi. This unit provides audible feedback (a higher pitch indicates more muscle activity) and visual feedback (red to green indicates more muscle activity). The patient tries to maintain contraction of the latissimus dorsi during flexion and external rotation and is gradually able to do so through biofeedback. Overall, it may take between six and twelve months for complete training of the transferred muscle.

Results

Gerber et al.⁹ originally reported good-to-excellent short-term results in four patients who were followed for more than one year after a latissimus dorsi transfer. Gerber²⁹ subsequently evaluated sixteen patients who had been followed for an average of thirty-three months after such a transfer; he reported an excellent subjective result in eight patients, a good result in five, a fair result in two, and a poor result in one. The average improvement in flexion was 53 degrees. Aoki et al.³¹ reported on twelve shoulders at an average of thirty-six months after a latissimus dorsi transfer. The subjective improvement was rated as excellent in four shoulders, good in four, fair in one, and poor in three. The average improvement in flexion was 36 degrees. Miniaci and MacLeod³⁰ reported on seventeen patients who had undergone a latissimus dorsi transfer for revision of a failed rotator cuff repair. At an average of fifty-one months postoperatively, fourteen of the seventeen patients had marked relief of pain and increased function. My experience has been more varied. Of 407 rotator cuff repairs performed by myself and my colleagues over six years, twenty-two were latissimus dorsi tendon transfers. Of these twenty-two transfers, six were done to reconstruct an irreparable rotator cuff tear that had not been treated with prior surgery and sixteen were performed after failure of a prior repair of a rotator cuff tear. When the results were analyzed according to these two groups, the outcomes were quite different. Of the sixteen patients who had had a revision, only eight reported a satisfactory outcome, and the average gain in flexion was 44 degrees. Negative prognostic factors included a prior deltoid injury, associated stiffness, and poor tendon quality of the remaining rotator cuff. In contrast, a satisfactory outcome was achieved in five of the six patients who had had the latissimus dorsi transfer as a primary procedure, and the average gain in flexion was 60 degrees. Late rupture of the transferred tendon was thought to have occurred in about 20 to 30 percent of the patients on the basis of the inability of the examiner to palpate contraction of the muscle and on the basis of a decrease in shoulder function. While others have not reported this problem, to my knowledge, I believe that it was due to the relatively small size of the latissimus tendon and the good early results in some patients, which led to increased activity before adequate healing was obtained. This has led me to augment these tendon transfers with autogenous iliotibial band. In the last year, four such procedures have been performed, and none have led to a late rupture at the time of writing.

Overview

The Problem | Pathoanatomy and Pathomechanics | Overview | Introduction | References

The inability to repair a rotator cuff tear is not uncommon, and in practices devoted to the management of shoulder injuries up to 30 percent of rotator cuff tears may be irreparable. The anterior and posterior components of the rotator cuff are the most important deficient areas. In the case of an irreparable subscapularis tendon tear, pain relief and stability appear to be reliably achieved by a split pectoralis major transfer; however, functional improvement is less certain since the biomechanics associated with this tendon transfer do not appear to be optimal. In the case of an irreparable posterior-superior rotator cuff tear, a latissimus dorsi tendon transfer reliably restores flexion and relieves pain; however, its use after failure of prior rotator cuff surgery makes the outcome less predictable. Both anterior and posterior reconstructions with tendon transfer require precise surgical technique and patient compliance with postoperative rehabilitation.

Introduction

The Problem | Pathoanatomy and Pathomechanics | Overview | Introduction | References

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Fig. 1:: Oblique sagittal plane magnetic resonance image of a left shoulder with a chronic massive tear involving the supraspinatus (Ss) and the infraspinatus (Is). These muscles are atrophic and have a signal characterized as fat. The teres minor (Tn) and the subscapularis (Sb) are not torn and do not demonstrate fatty replacement. Scap = scapula.

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Fig. 2-A:: Figs. 2-A through 2-D: Drawings showing the operative technique for the pectoralis major tendon transfer.
Fig. 2-A: The superior and inferior borders of the pectoralis major are exposed.

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Fig. 2-B: The sternal portion is dissected, with preservation of the clavicular portion.

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Fig. 2-C: The sternal portion is transferred underneath the clavicular portion and is repaired into the lesser tuberosity.

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Fig. 2-D: The sternal head of the pectoralis passes underneath the clavicular head, which acts as a pulley, keeping the line of pull of the sternal head closer to the line of the subscapularis tendon.

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Fig. 3:: Photograph showing the interval between the sternal head (SH) and the clavicular head (CH) of the pectoralis major. The sternal head passes posterior to the clavicular head as it approaches its insertion on the humerus. D = deltoid.

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Fig. 4-A:: Figs. 4-A through 4-D: Drawings showing the operative technique for the latissimus dorsi tendon transfer.
Fig. 4-A: The patient is placed in the lateral decubitus position, and an accessory posterior incision is made in order to identify and harvest the latissimus dorsi tendon.

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Fig. 4-B:: The tendon is detached from the humerus and then dissected retrograde to the neurovascular pedicle. The tendon is freed from its fascial connections to the chest wall. Sutures are then placed in the tendon prior to its transfer underneath the acromion.

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Fig. 4-C:: The tendon is transferred underneath the deltoid and the acromion.

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Fig. 4-D:: With the shoulder abducted and in external rotation, the tendon is secured to the remnant of the rotator cuff tendons medially, to the greater tuberosity laterally, and to the subscapularis anteriorly.

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Fig. 5-A:: The latissimus dorsi tendon is often small and thin. The fascia lata autograft that will be used to augment the tendon is shown in the background of the photograph.

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Fig. 5-B:: Photograph showing the latissimus dorsi tendon after the fascia lata autograft has been sewn over it to reinforce it prior to transfer.

References

The Problem | Pathoanatomy and Pathomechanics | Overview | Introduction | References

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