Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears

Rotator cuff repair augmentation with local autogenous bone marrow via humeral cannulation in a rat model

BACKGROUND

Growth factors have been shown to improve healing after rotator cuff repair. Bone marrow is a potential vehicle for growth factor augmentation, yet methods of delivering marrow to cuff repair sites are still under-researched. We hypothesized that a cannulated humeral implant would deliver local bone marrow and thereby improve healing in a rat model.

METHODS

Twenty-eight rats underwent bilateral rotator cuff injury and repair. Each rat acted as its own control, randomized to a cannulated humeral implant in one shoulder and a solid implant in the other. Rats were euthanized at 4 and 8 weeks to create 4 time-treatment cohorts. Tendon healing was evaluated by dimensional measurements, biomechanical testing, and histology.

RESULTS

Tendon thickness, all biomechanical measures, and semi-quantitative histologic scores improved over time (P < .05) but not with treatment. The most common site of biomechanical tendon failure was midsubstance in the 8-week cannulated cohort and at the tendon footprint in the other 3 cohorts. Intraluminal bone growth was evident in all cannulated implants.

CONCLUSIONS

Humeral cannulation did not quantifiably improve tendon-to-bone healing in a rat model. The diminutive size of implants in rats, however, may have prevented sufficient delivery of local autogenous bone marrow; hence, further study in a larger animal is recommended.

Time to surgery in acute rotator cufftear: A systematic review

Aims

We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes.

Methods

The MEDLINE, Embase, CINAHL, Web of Science, Cochrane Libraries, controlled-trials.com and clinicaltrials.gov databases were searched using the terms: ‘rotator cuff’, or ‘supraspinatus’, or ‘infraspinatus’, or ‘teres minor’, or ‘subscapularis’ AND ‘surgery’ or ‘repair’. This gave a total of 15 833 articles. After deletion of duplicates and the review of abstracts and full texts by two independent assessors, 15 studies reporting time to surgery for ARCT repair were included. Studies were grouped based on time to surgery < 3 months (group A, seven studies), or > 3 months (group B, eight studies). Weighted means were calculated and compared using Student’s t-test.

Results

Group B had a significantly higher pre-operative Constant score (CS) (p < 0.001), range of movement in external rotation (p = 0.003) and abduction (p < 0.001) compared with group A. Both groups showed clinical improvement with surgical repair; group A had a significantly improved Constant score, University of California, Los Angeles (UCLA) shoulder score, abduction and elevation post-operatively (all p < 0.001). Group B had significantly improved Constant score (p < 0.001) and external rotation (p < 0.001) post-operatively. The mean Constant score improved by 33.5 for group A and by 27.5 for group B.

Conclusion

These findings should be interpreted with caution due to limitations and bias inherent to case-series. We suggest a trend that earlier time to surgery may be linked to better Constant score, and active range of movement in abduction and elevation. Additional prospective studies are required.

Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: Short-term clinical results

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.

Latissimus dorsi tendon transfer for irreparable tears of the rotator cuff: An anatomical study to assess the neurovascular hazards and ways of improving tendon excursion

Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon.

Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears

PURPOSE

The objective of this study was to investigate the clinical outcome and radiographic findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears.

METHODS

From 2007 to 2009, 24 shoulders in 23 consecutive patients (mean, 65.1 years) with irreparable rotator cuff tears (11 large, 13 massive) underwent ASCR using fascia lata. We used suture anchors to attach the graft medially to the glenoid superior tubercle and laterally to the greater tuberosity. We added side-to-side sutures between the graft and infraspinatus tendon and between the graft and residual anterior supraspinatus/subscapularis tendon to improve force coupling. Physical examination, radiography, and magnetic resonance imaging (MRI) were performed before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter. Average follow-up was 34.1 months (24 to 51 months) after surgery.

RESULTS

Mean active elevation increased significantly from 84° to 148° (P < .001) and external rotation increased from 26° to 40° (P < .01). Acromiohumeral distance (AHD) increased from 4.6 ± 2.2 mm preoperatively to 8.7 ± 2.6 mm postoperatively (P < .0001). There were no cases of progression of osteoarthritis or rotator cuff muscle atrophy. Twenty patients (83.3%) had no graft tear or tendon retear during follow-up (24 to 51 months). The American Shoulder and Elbow Surgeons (ASES) score improved from 23.5 to 92.9 points (P < .0001).

CONCLUSIONS

ASCR restored superior glenohumeral stability and function of the shoulder joint with irreparable rotator cuff tears. Our results suggest that this reconstruction technique is a reliable and useful alternative treatment for irreparable rotator cuff tears.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Biomechanical effect of latissimus dorsi tendon transfer for irreparable massive cuff tear

BACKGROUND

The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear.

METHODS

Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis.

RESULTS

The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction.

CONCLUSION

Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles.

Latissimus dorsi tendon transfers for rotator cuff deficiency

Purpose:

Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency.

Materials and Methods:

At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation.

Results:

Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05).

Conclusion:

Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term.

Level of Evidence:

Level 4.

Biomechanical effectiveness of different types of tendon transfers to the shoulder for external rotation

BACKGROUND

Our purpose was to determine and compare the external rotation moment arm (ERMA) of the latissimus dorsi (LD), teres major (TM), and lower trapezius (LT) when transferred to selected locations on the proximal humerus. We hypothesize that the LT transfer has a higher ERMA compared with LD or TM.

MATERIALS AND METHODS

Six fresh frozen cadaveric hemithoraces were used in a novel experimental design. The tendon and joint displacement method was used to calculate ERMA for 6 transfer pairs: LD to superolateral humeral head (SHH), LD to proximal-lateral humeral diaphysis (LHD), TM to SHH, TM to LHD, LT to infraspinatus insertion (ISI), and LT to teres minor insertion (TMI).

RESULTS

Tendon transfer pair had a significant effect on ERMA (P < .001), with a significant interaction effect between tendon transfer and position of the humerus (P < .0001). With the humerus at 0° abduction, the ERMAs of the LT-ISI (28.1 mm) or LT-TMI (22.3 mm) transfers were significantly higher than the ERMAs of LD-SHH (10.6 mm; P = .0001, P = .04) or LD-LHD (6.5 mm; P < .0001, P < .001). Also, ERMAs of LT-ISI and LT-TMI transfers were significantly higher than ERMA of TM-LHD (10.4 mm; P = .0001, P = .03).

CONCLUSIONS

Shoulder external rotation tendon transfers differ in effectiveness and may be affected by arm position. LT potentially results in superior restoration of shoulder external rotation with the arm at the side compared with LD and should be considered as a potential tendon transfer to restore external rotation in selected patients.

Arthroscopically assisted latissimus dorsi transfer with a minimally invasive harvesting technique: surgical technique and anatomic study

Latissimus dorsi musculotendinous transfer has been described for the treatment of massive rotator cuff defects. The aim of this paper is to present the relevant surgical anatomy of an arthroscopically assisted technique associated with a modified harvesting of the tendon. For tendon harvesting, a skin incision of about 5-6 cm in length is made in the axillary crease orthogonal to the longitudinal axis of the upper arm. For the musculotendinous transfer, we propose to increase vector action of the latissimus dorsi by passing the transferred tendon ahead the triceps muscle under or over the Teres Major and fixing the transferred tendon behind the humeral head center of rotation in a more posterolateral position. In order to check the feasibility and safety of this new surgical technique, two fresh-frozen adult cadaveric hemithorax specimens with an intact upper extremity were dissected, and the relationships between the tendons and local neurologic structures were described during various steps of the latissimus dorsi transfer procedure.

Rotator cuff tears treated with a modified deltoid flap repair technique

BACKGROUND

Few options exist in the treatment of irreparable rotator cuff tears, especially in younger patients. The purpose of this study was to present our experience with deltoid flap repairs combined with acromion elevation osteotomy increasing the space for the flap.

METHODS

We retrospectively reviewed the outcome of 57 patients with a mean age of 60 years who had undergone the modified anterolateral deltoid flap technique for the treatment of large and massive rotator cuff tears. Follow-up was performed after a mean of 6 years.

RESULTS

At follow-up, 84% of patients considered the condition of their shoulder as better or much better compared with before surgery. The mean Constant score was 88% (range, 45-122). Before surgery, all shoulders were significantly painful. At latest follow-up, 91% of the patients had no or mild pain. Elevation of the arm above 90° was possible in 38 patients before surgery and in 53 patients at latest follow-up. Tears involving 3 tendons were associated with inferior results. Retears of the deltoid flap occurred in 8 patients (14%); 1 of them was successfully treated with a reverse total shoulder replacement, and 6 had a repair of the flap, with only 1 satisfactory outcome.

CONCLUSIONS

The modified deltoid flap yielded reliable pain relief and a high rate of patient satisfaction, as well as satisfactory function in the majority of the patients. Especially in younger patients, this technique might be considered a viable alternative for the treatment of irreparable rotator cuff tears.

The management of rotator cuff tears in the elderly

Rotator cuff tears occur commonly in the elderly causing significant pain and disability. In light of new treatment options developed over recent years, this article reviews the diagnosis and operative options available for this condition.

Treatment of irreparable rotator cuff tears

Irreparable rotator cuff tears are a challenging problem for patients and surgeons. There are several treatment options, but deciding the correct one for each patient can be difficult. Treatment options include physical therapy, arthroscopy, muscle transfers, reverse shoulder arthroplasty, and hemiarthroplasty. An understanding of the patient's chief complaint and their functional ability to elevate their arm above horizontal should guide the treatment. This article reviews the current literature on various treatment options for irreparable rotator cuff tears, then outlines an algorithm for determining treatment.

Tendon fixation in arthroscopic latissimus dorsi transfer for irreparable posterosuperior cuff tears: an in vitro biomechanical comparison of interference screw and suture anchors

BACKGROUND

The fixation of the tendon to the bone remains a challenging problem in the latissimus dorsi tendon transfer for irreparable cuff tears and can lead to unsatisfactory results. A new arthroscopic method of tendon to bone fixation using an interference screw has been developed and the purpose of this study was to compare its biomechanical properties to the ones of a standard fixation technique with anchors.

METHODS

Six paired fresh frozen cadaveric human humeri were used. The freed latissimus dorsi tendon was randomly fixed to the humeral head with anchors or with interference screw after a tubularization procedure. Testing consisted to apply 200 cycles of tensile load on the latissimus dorsi tendon with maximal loads of 30 N and 60 N, followed by a load to failure test. The stiffness, displacements after cyclic loadings, ultimate load to failure, and site of failure were analysed.

FINDINGS

The stiffness was statistically higher for the tendons fixed with interference screws than for the ones fixed with anchors for both 30 N and 60 N loadings. Likewise, the relative bone/tendon displacements after cyclic loadings were lower with interference screws compared to anchors. Load to failure revealed no statistical difference between the two techniques.

INTERPRETATION

Compared to the standard anchor fixation, the interference screw fixation technique presents higher or similar biomechanical performance. These results should be completed by further biomechanical and clinical trials to confirm the interest of this new technique as an alternative in clinical use.

The effect of local use of nandrolone decanoate on rotator cuff repair in rabbits

OBJECTIVE

There is still controversy about the effect of anabolic steroid on connective tissue. This study examines the hypothesis that the local use of nandrolone decanoate, an anabolic steroid on rotator cuff, facilitates the healing process when used in combination with surgical repair.

METHODS

Forty-eight male rabbits were divided in four groups with anabolic steroids (Nandrolone Decanoate 10 mg/kg) and immobilization as variables. The groups were the following: first group, nonsteroid use-immobilization (NSI); second group, nonsteroid use-nonimmobilization (NSNI); third group, steroid use-immobilization (SI); fourth group steroid use-nonimmobilization (SNI). Every rabbit underwent a rotator cuff incision and reconstruction. Fifteen days later the tendons were sent for biomechanical and histological evaluation.

RESULTS

Groups that did not receive anabolic steroids showed better healing and more tendon strength in comparison to groups that received anabolic steroids. Microscopic examination of specimens from the groups without the use of anabolic steroid showed extensive fibroblastic activity whereas the specimens from those groups with anabolic steroid use showed focal fibroblastic reaction and inflammation. Immobilization provided better results in the groups with anabolic steroid use but it did not influence healing in groups without steroids.

CONCLUSIONS

The effect of local nandrolone decanoate use on a rotator cuff tear is detrimental, acting as a healing inhibitor.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique to improve tendon transfer integrity: surgical technique

BACKGROUND

Latissimus dorsi tendon transfer is a well-established method for the treatment of massive irreparable posterosuperior defects of the rotator cuff. Subsequent rupture of the transferred tendon may contribute to the rate of failure of the index procedure. We hypothesized that modification of our technique of tendon harvesting would lead to greater fixation stability and a reduced failure rate.

METHODS

Forty-two patients (mean age, fifty-eight years) with a massive irreparable posterosuperior tear of the rotator cuff were managed with a latissimus dorsi tendon transfer. Sharp separation of the latissimus tendon from the humerus was performed in twenty-two patients (Group A), whereas the tendon harvest was carried out with a modified technique that involved removal of some bone along with the tendon at the humeral insertion in a subsequent group of twenty patients (Group B). The mean duration of follow-up was forty-seven months. Outcome measures included the Constant and American Shoulder and Elbow Surgeons (ASES) scores and a patient subjective satisfaction scale. Standard radiographs were made to determine the stage of osteoarthritis and proximal migration of the humeral head, and magnetic resonance imaging was performed to assess the integrity of the transferred muscle.

RESULTS

In Group A, the mean Constant score improved from 43.4 preoperatively to 64.8 points at the time of follow-up and the mean ASES score improved from 49.3 to 69.6 points (p < 0.05). In Group B, the mean Constant score increased from 40.2 to 74.2 points and the mean ASES score, from 47.2 to 77.1 points (p < 0.05). The Constant pain score improved from 5.6 to 11.9 points in Group A and from 5.2 to 13.8 points in Group B. The results in Group B were significantly superior to those in Group A (p < 0.05). Magnetic resonance imaging revealed complete rupture at the tendon insertion with tendon retraction in four patients in Group A and none in Group B. The final outcome was rated as poor in 27% of the patients in Group A and in 10% in Group B.

CONCLUSIONS

Latissimus dorsi tendon transfer achieves satisfactory clinical results in most patients who have a massive irreparable posterosuperior tear of the rotator cuff. Harvesting the tendon along with a small piece of bone enables direct bone-to-bone transosseous fixation, resulting in better tendon integrity and clinical results.

Massive tears of the rotator cuff

Repair of massive rotator cuff tears is technically difficult but often feasible. Technical and biological challenges to a successful repair include inelastic poor-quality tendon tissue, scarring, muscle atrophy, and fatty infiltration. Fatty infiltration of the involved rotator cuff muscles has been identified as an important negative prognostic factor for the outcome after repair of massive rotator cuff tears. Tendon transfer is a good option for young patients and manual laborers with an irreparable massive rotator cuff tear. Arthroplasty can be considered for the treatment of symptomatic massive rotator cuff tears in patients who have glenohumeral arthritis.

Results of latissimus dorsi tendon transfer in primary or salvage reconstruction of irreparable rotator cuff tears

INTRODUCTION

This study intends to evaluate latissimus dorsi tendon transfer outcomes inpatients with irreparable rotator cuff tears, irrespective of the fact that this procedure had been used primarily in 17 patients (Group I) or as a revision of a previously shoulder surgery in eight patients (Group II).

PATIENTS AND METHODS

Twenty-five patients (14 males and 11 females), mean age 55.8 years were treated using this procedure. Tears involved both supraspinatus and infraspinatus in 21 cases. The latissimus dorsi flap was harvested through an axillary approach and reattached on the greater tuberosity, using suture anchors. Outcome was assessed at a mean follow-up duration of 22 months (12 to 60 months) based on objective measures (Constant and Murley scores) as well as on subjective criteria (patient's satisfaction).

RESULTS

Active forward elevation (AFE) improvement as well as external rotation and absolute Constant score gains were all significant. This amelioration was more important in patients with a preoperative AFE below 80 grades and this without any significant difference between group I and II. Subjectively, 84% of the Group I patients were satisfied with their outcome versus 50% of patients in Group II.

DISCUSSION AND CONCLUSION

In patients with irreparable rotator cuff tears, clinical results of latissimus dorsi tendon transfer showed significant pain level reduction, and gains in active range of motion both in forward elevation and external rotation. We did not find a significant difference between primary or revision repairs.

LEVEL OF EVIDENCE

Level IV retrospective therapeutic study.

Teres major muscle activation relates to clinical outcome in tendon transfer surgery

BACKGROUND

In massive rotator cuff tears a teres major (TMj) tendon transfer to the insertion of the supraspinatus (SSp) reverses its adduction moment arm into abduction which is supposed to be an adequate salvage procedure. Analysis of muscle function to find biomechanical ground of such success is scarce.

METHODS

We compared pre- and postoperative clinical outcome of TMj transfer, i.e. Range of Motion, pain, Constant Shoulder scores and arm force. TMj activation was evaluated in 14 patients suffering massive cuff tears using activation ratios to describe the desired 'in-phase' and undesired 'out-of-phase' contribution to the external arm moment. Additionally, we analyzed activation of the latissimus dorsi (LD) and the medial part of the deltoids (DE). The activation ratios were compared to controls and TMj activation ratios were related to clinical outcome.

FINDINGS

TMj tendon transfer improved arm function. Pre-operatively, we observed 'out-of-phase'abduction activation of TMj and LD. After transfer patients activated TMj according to its new anatomical position. 'Out-of-phase' LD abduction activation persisted. The clinical improvements coincided with changes in activation ratio of TMj.

INTERPRETATION

'Out-of-phase' TMj adductor activation is associated with compromised arm function in patients with irreparable cuff tears. After transfer, TMj is activated in correspondence with its new anatomical function, which was supportive for the improved arm function.

Latissimus dorsi transfer for treatment of irreparable rotator cuff tears

Massive rotator cuff tendon ruptures are not uncommon in older patients. We propose the transfer of the latissimus dorsi muscle for treatment of irreparable ruptures associated with functional impairment and chronic pain. Five women and 11 men were so treated and reviewed with an average follow-up of 26 months. The mean age was 60 years. Four patients also had subscapularis deficiency. Results were assessed with the Constant score and the Oxford shoulder score. Humeral head position was analysed. Statistical analysis was performed by the Wilcoxon non-parametrical test. The Constant score increased by 24.2% (p = 0.001) with all parameters showing improvement. Nine patients showed improved humeral head positioning in internal rotation. Three of four patients with a deficient subscapularis had unfavourable results. Latissimus dorsi transfer for the treatment of irreparable massive rotator cuff tears leads to a substantial clinical improvement. An intact subscapularis tendon is mandatory.

Two patients with a complete proximal rupture of the hamstring

Two men visited our Emergency Room because of a water-ski-accident. At physical examination, there was hematoma at the upper leg with loss of strength at extension of the hip and flexion of the knee. Both patients had a palpable gap just distal of the ischial tuberosity. Further imaging by sonography and MR-scan showed a rupture of the proximal hamstring tendon. Treatment was operative refixation of the hamstring tendons at the ischial tuberosity. After treatment consisted of brace for 4 weeks after operation. Both patients returned to their pre-operatively sports, though at a lower level. Surgical treatment of a complete proximal rupture of the hamstrings is recommended in case of sportive patients.

Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage

PURPOSE

The purpose of this study was to evaluate the clinical results and healing status of rotator cuff repairs with less than 50% footprint coverage.

METHODS

During the 18-month period from October 2005 to March 2007, 89 large to massive rotator cuff tears were arthroscopically repaired. Among them, 23 consecutive large to massive rotator cuff tears were repaired completely but with less than 50% of the original footprint. All tears were arthroscopically repaired with suture anchors. Preoperative and postoperative clinical assessments were performed with the Constant score, American Shoulder and Elbow Surgeons score, and pain visual analog scale. The healing status of repaired tendon was evaluated by postoperative magnetic resonance imaging with a focus on tendon integrity, muscle fatty degeneration, and muscle atrophy.

RESULTS

The mean follow-up period was 30.2 months (range, 24 to 41 months). At final follow-up visits, American Shoulder and Elbow Surgeons score, Constant score, and score on pain visual analog scale were found to have improved significantly from 40.1, 35.9, and 57.7 to 82.4, 86.6, and 12.3, respectively (P < .01). The overall retear rate was 45.5% (10 cases). However, clinical results showed no difference between the retear group and no retear group. Furthermore, rerupture size was smaller than original tear size in all 10 patients, and no significant progression of fatty degeneration or muscle atrophy of rotator cuff muscles was observed.

CONCLUSIONS

Less-than-optimal coverage of the original greater tuberosity footprint during arthroscopic repair of large to massive rotator cuff tears was found to be associated with a relatively high retear rate (45.5%). However, clinical results improved significantly, and no significant difference was observed in the clinical results between the retear and no retear groups.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique to improve tendon transfer integrity

BACKGROUND

Latissimus dorsi tendon transfer is a well-established method for the treatment of massive irreparable posterosuperior defects of the rotator cuff. Subsequent rupture of the transferred tendon may contribute to the rate of failure of the index procedure. We hypothesized that modification of our technique of tendon harvesting would lead to greater fixation stability and a reduced failure rate.

METHODS

Forty-two patients (mean age, fifty-eight years) with a massive irreparable posterosuperior tear of the rotator cuff were managed with a latissimus dorsi tendon transfer. Sharp separation of the latissimus tendon from the humerus was performed in twenty-two patients (Group A), whereas the tendon harvest was carried out with a modified technique that involved removal of some bone along with the tendon at the humeral insertion in a subsequent group of twenty patients (Group B). The mean duration of follow-up was forty-seven months. Outcome measures included the Constant and American Shoulder and Elbow Surgeons (ASES) scores and a patient subjective satisfaction scale. Standard radiographs were made to determine the stage of osteoarthritis and proximal migration of the humeral head, and magnetic resonance imaging was performed to assess the integrity of the transferred muscle.

RESULTS

In Group A, the mean Constant score improved from 43.4 preoperatively to 64.8 points at the time of follow-up and the mean ASES score improved from 49.3 to 69.6 points (p < 0.05). In Group B, the mean Constant score increased from 40.2 to 74.2 points and the mean ASES score, from 47.2 to 77.1 points (p < 0.05). The Constant pain score improved from 5.6 to 11.9 points in Group A and from 5.2 to 13.8 points in Group B. The results in Group B were significantly superior to those in Group A (p < 0.05). Magnetic resonance imaging revealed complete rupture at the tendon insertion with tendon retraction in four patients in Group A and none in Group B. The final outcome was rated as poor in 27% of the patients in Group A and in 10% in Group B.

CONCLUSIONS

Latissimus dorsi tendon transfer achieves satisfactory clinical results in most patients who have a massive irreparable posterosuperior tear of the rotator cuff. Harvesting the tendon along with a small piece of bone enables direct bone-to-bone transosseous fixation, resulting in better tendon integrity and clinical results.

Massive rotator cuff tears in patients younger than 65 years. What treatment options are available?

Management of massive rotator cuff tears is a therapeutic challenge in patients younger than 65 years, particularly if still working. According to our hypothesis, choice of the most appropriate treatment option mainly depends on the patient's functional status and on two predictive factors: height of the subacromial space and fatty muscle infiltration. This is a retrospective, multicenter study of a series of 296 patients younger than 65 years, including 176 males and 120 females with extensive or massive cuff tear. Patients had loss of elevation or external rotation or both in 162 cases. Four types of management of massive rotator cuff tear were performed in this study: anatomical watertight repairs, palliative treatments and partial repairs, watertight repairs using flaps or cuff prostheses and reverse shoulder prostheses. At follow-up, the Constant score (65.6+/-3.4) and active elevation (147.7 degrees +/-32 degrees) had significantly improved. Active external rotation with elbow at the side, and acromiohumeral interval (AHI) were unchanged. Work-related injuries, previous surgeries and complications were correlated with a poorer Constant score. At follow-up, the anatomical repair sub-group had a significantly better Constant score than the three other treatment groups but involved patients with unchanged AHI and a low degree of fatty infiltration of the infraspinatus muscle. The reverse shoulder prostheses sub-group showed better outcomes in terms of function benefits. The presence of a long biceps was correlated with the use of a palliative treatment. In the light of the results and literature, an approach to treatment is suggested related to the functional capacity of patients, the AHI and the degree of fatty infiltration of the infraspinatus and subscapularis muscles.

Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including debridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.

Reverse total shoulder arthroplasty after failed rotator cuff surgery

BACKGROUND

The purpose is to report the results of reverse shoulder arthroplasty (RSA) after previous failed rotator cuff surgery.

MATERIALS AND METHODS

A retrospective multicenter study of 42 RSA in 40 patients (mean age, 71 years) with a mean follow-up of 50 months. Thirty shoulders presented with a pseudoparalytic shoulder and 12 with a painful shoulder with maintained active anterior elevation (AAE >or= 90 degrees).

RESULTS

Five complications (12%) occurred and 2 patients (5%) underwent re-operation. In pseudoparalytic shoulders, AAE increased from 56 degrees to 123 degrees and 7% were disappointed or dissatisfied. In painful shoulders, AAE decreased from 146 degrees to 122 degrees and 27% were disappointed or dissatisfied.

DISCUSSION

RSA can improve function in patients with cuff deficient shoulders after failure of previous cuff surgery. However, results are inferior to primary RSA. RSA when the patient maintains greater than 90 degrees of preoperative AAE risks loss of AAE and lower patient satisfaction.

Modified minimally invasive latissimus dorsi transfer in the treatment of massive rotator cuff tears: a two-year follow-up of 26 consecutive patients

Since its inauguration by Gerber in 1988, the latissimus dorsi transfer has become an established surgical option for non-reconstructable, massive posterosuperior rotator cuff tears. We describe 26 consecutive patients, all of whom underwent a latissimus dorsi transfer using a modified single incision mini-invasive Herzberg transfer. The primary focus of this paper was to compare the applied clinical results of this new technique with the published results of the Gerber technique. Following transfer of the latissimus dorsi to restore external rotation, 26 patients were evaluated. The mean age was 60 +/- 18 years. The patients were examined after surgery at an average of 24 months (range: 12-41). The unweighted Constant score rose from 20 (range: 13-34) to 56 (range: 63-81). The acromiohumeral distance remained statistically unchanged from an initial value of 4.7 mm (1-9 mm) to a postoperative value of 4.8 (2-11 mm). In the Hamada classification the level of rotator cuff defect arthropathy increased from 1.7 (1-3) to 1.8 (1-3). On the basis of its low morbidity rate, the latissimus dorsi transfer in Herzberg's modified technique is a sensible alternative to the technique initially described by Gerber, especially when the initial situation exhibits pre-existing weakness of the deltoid muscle.

Results of latissimus dorsi tendon transfer for irreparable cuff tears

Rupture of the supraspinatus and infraspinatus tendon (and teres minor) can cause loss of active external rotation (ER), entailing severe functional disability in daily activities. Latissimus dorsi tendon transfer (LDTT), proposed by Gerber in 1988, appears to be the best adapted solution in these cases of irreparable posterior and superior cuff tears. Between 2001 and 2004, 30 patients were operated on by the technique described by Gerber, with the transfer fixed anteriorly to the subscapularis tendon and laterally to the greater tuberosity by transosseous suture. One patient, subsequently requiring revision with a reversed prosthesis, was considered as a failure. Twenty-six patients were reviewed with a mean follow-up delay of 34+/-12 months. There were 14 men and 13 women. Mean age was 55.5 years (36 to 71 years). Preoperatively, active ER was symmetric in seven cases, loss of active ER was moderate with positive lag sign in five cases, significant with positive dropping sign in six cases, and severe in nine cases. Fatty muscular degeneration was present and significant in all cases for the infraspinatus muscle and in 14 cases for the teres minor muscle (associated with significant ER loss). Subjectively, 85% of the patients were very satisfied or satisfied and the Subjective Shoulder Value (SSV) was 68+/-17%. The pain score improved from 4.8+/-3 preoperatively to 12.2+/-2 postoperatively, strength from 3.7+/-2 kg to 4.2+/-1.8 kg, mean Constant score from 50+/-12 to 74+/-9, and Constant score adjusted for age and gender from 62+/-15% to 91+/-11%. Mean active ER gain was 7 degrees (-30 degrees to +50 degrees). The loss of active ER was aggravated in one case, unchanged in three, improved in nine and corrected in six. Hornblower sign was corrected in six cases and persisted in nine. Postoperatively, 8% of the patients were unable to eat and drink, compared to 64.7% preoperatively. The results of this series are comparable to those found in the literature for first-intention cases. LDTT restored active ER, but the results were incomplete and variable. Improvement was better in case of severe preoperative active ER deficit and insufficiency of the teres minor muscle. Recovery of strength was not observed in the present series. A narrow subacromial space and grade-3 Hamada classification had negative impact. In spite of an expected tenodesis effect, LDTT did not recenter the humeral head. LDTT compensates the deficient teres minor muscle rather than the infraspinatus muscle. The optimal indication for LDTT is irreparable superior and posterior rotator cuff rupture with loss of active ER associated with a deficient teres minor muscle. It is debatable whether LDTT is indicated in the absence of active motion deficiency: improvement was observed in these cases, but only in terms of subjective criteria.

Biomechanics of latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Latissimus dorsi transfer is the treatment most frequently used for restoring function in shoulders with irreparable posterosuperior rotator cuff tears. Yet, functional outcomes of the transfers are unpredictable and vary among patients.

METHODS

A three-dimensional upper-extremity computational model was used to simulate and analyze the biomechanical consequences of transferring the latissimus dorsi to four attachment sites: the infraspinatus, supraspinatus, subscapularis and teres minor insertions. Functions of a normal shoulder were simulated, as well as those and of a shoulder with a posterosuperior rotator cuff tear before and after muscle transfers were simulated. Parameters such as active and passive moment-generating capacity, and the moment arm and fiber excursion ratio of the transferred muscle were analyzed.

FINDINGS

All muscle transfers resulted in a large increase in shoulder external rotation strength. The latissimus dorsi was an external rotator after the transfer, but the fiber excursion ratio decreased accordingly. When the latissimus dorsi was transferred to the infraspinatus, supraspinatus or subscapularis insertion, it changed from extensor to flexor at the beginning of flexion. The flexion moment arm of the latissimus dorsi after the transfers was generally decreased. Shoulder abduction strength did not improve. Decrease in fiber excursion ratio during abduction and flexion was observed after the transfer. Side effects of the muscle transfers, such as the reduction of active adduction, extension and internal rotation of the shoulder, were explored.

INTERPRETATION

A transfer to teres minor insertion was not recommended. Infraspinatus insertion was found to be a preferred attachment site in latissimus dorsi transfer, provided that the patient had a strong deltoid.

The use of split deltoid-flap in the treatment of massive rotator cuff defects: a retrospective study of 61 patients

Massive and irreparable rotator cuff tears are a challenge for the orthopaedic surgeon. The purpose of this study was to report our experience with the treatment of massive and irreparable defects of the rotator cuff with a modified deltoid split transfer. Between 1996 and 2004, for all patients suffering from full-thickness tears of the rotator cuff (> 5 cm tears in diameter, involving two or more tendons) were operated with a modified deltoid split transfer. A total of 61 patients (39 females and 22 males; age 61.9: range 49-75 years) were operated. Duration of symptoms before surgery averaged 9.6 months (range 3.5-14 months). The patients were followed for an average of 46 months (range 24-64 months). The operation included an arthroscopic evaluation, acromioplasty with resection of the lateral clavicular end, resection of the acromioclavicular joint and where necessary biceps tenodesis. The cuff defect was repaired by transfer of half thickness anterior deltoid-flap (3 cm x 5 cm) into the defect. All patients were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily life, range of motion, strength and satisfaction. The patients subjectively rated their results--49 (80%) excellent or good outcome, seven moderate and five poor. Preoperatively, the Constant amounted 33.5 +/- 7.74 points. At follow-up, the score significantly increased to 77.57 +/- 19.74 points. The acromiohumeral distance increased from 5.1 +/- 1.4 mm to 9.1 +/- 1.5 mm. Pain free flexion improved from an average 90 degrees to an average 165 degrees (P < 0.01), and abduction improved from an average 110 degrees to an average 160 degrees (P < 0.01). The mean external rotation increased from 40 degrees to 65 degrees (P < 0.01), and internal rotation increased from 50 degrees to 70 degrees (P = 0.06). In the MRI and ultrasound examination, all patients had intact flap, except the three patients with flap necrosis. There were eight complications--three haematomas, two superficial wound infections which did not influence the outcome, and three fibrotic transformation after an early aseptic necrosis of the deltoid flap, which were re-operated. This technique is easy to perform, and it is possible to obtain a satisfactory outcome after repair of massive tears of the rotator cuff. A substantial decrease of pain, increased stability, an increase range of motion and strength can be achieved, with proper rehabilitation.

Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation

Eighteen patients, referred from an outside institution with massive, irreparable rotator cuff tears and loss of elevation, were treated with a latissimus dorsi tendon transfer as a salvage procedure for failed, prior, attempted rotator cuff repair. Clinical outcomes were measured by the American Shoulder and Elbow Surgeon's (ASES) score, pain level, and active range of motion. The average postoperative ASES score was 61, an increase from 43 pre-operatively (P = .05). Active elevation improved to an average of 137 degrees compared to 56 degrees pre-operatively (P < .001). The average post-operative pain level was 22 mm, down from 59 (P = .001), and the average post-operative active external rotation at the side was 45 degrees, improved from 31 degrees (P < .001). We conclude that latissimus transfer, as a salvage procedure for failed rotator cuff repair with loss of elevation, allows for significant return of active elevation and function with minimal post-operative pain.

Latissimus dorsi transfer for irreparable rotator cuff tears: a longitudinal study

Latissimus dorsi transfer is indicated for isolated posterior superior defects of the rotator cuff. Additional lesions limit the success of the outcome, but they are relatively frequent in revision surgery. We analyzed their influence on the postoperative function in 52 patients with an irreparable tear of the rotator cuff (35 primary operations, 17 revision surgeries). We observed a continuous improvement in the Constant score from 36 to 69 points, also in ROM, strength, relief of pain and of different subjective parameters for the entire group in consecutive examinations at 11.1, 35.7 and 50.2 months. We found increased osteoarthritis (from 1.0 to 1.5 mm), as well as a decrease in the acromiohumeral distance (from 5.6 to 4.7 mm). In contrast, we detected a slight decrease in the values in the revision group and in the presence of an additional subscapularis lesion.

Latissimus dorsi transfer to restore external rotation with reverse shoulder arthroplasty: a biomechanical study

In patients with pseudoparesis of the shoulder resulting from irreparable rotator cuff tears, reverse shoulder arthroplasty (RSA) can restore active elevation, but external rotation remains less predictable. Latissimus dorsi transfer (LDT) has been shown to be effective in restoring external rotation in patients with posterosuperior tears of the rotator cuff. The aim of this study is to determine the capacity of the LDT to restore external rotation in combination with RSA and to investigate the mechanical advantage produced by 3 different insertion sites. A biomechanical model was created using a reverse total shoulder prosthesis with 3 different transfer insertions. Moment arms were measured for 2 static positions and 1 motion of the humerus. The moment arm analysis showed that LDT can improve active external rotation in the setting of a reverse prosthesis. An insertion site on the posterior side of the greater tuberosity (adjacent to the teres minor insertion) produced a greater external rotation moment arm.

Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff

The objective of this paper was to determine the outcome of the transfer of the latissimus dorsi tendon in patients with massive irreparable rotator cuff tears. Eighteen patients of mean age 54 years (range 37-72 years) with massive irreparable rotator cuff tears were studied. The mean follow-up was 28 months (range 12-58 months). The postoperative Constant score was higher by an average of 21.15 points compared to the preoperative score (P=0.002); 88.8% of patients reported significant pain relief and improved mobility, particularly on external rotation. Postoperative resting antero-posterior radiography in neutral rotation revealed a mean 3.2-mm depression of the humeral head, due to the tenodesis effect of tendon transfer, thus, increasing the deltoid lever arm. These clinical results suggest that latissimus dorsi transfer is a useful surgical technique for treating massive irreparable postero-superior tears of the rotator cuff in young and/or active patients, providing significant pain relief and improved shoulder strength.

Electromyographic analysis of muscle function after latissimus dorsi tendon transfer

The latissimus dorsi transfer is an established method for irreparable tears of the rotator cuff. The original task of the muscle is to move the arm downward and to rotate it internally. After the transfer, it has to perform the completely new function of elevating the arm. We used surface electromyography to calculate the mean values of the activity pattern in relation to the Constant score in 45 patients. We assessed patients after 6 weeks and at 6, 9, and 19 months. After the operation, most patients showed a typical activity pattern of the latissimus dorsi on electromyography, which improved in the course of the study. We also found a strong correlation between the activity pattern on electromyography and the Constant score in different areas. We conclude that the functional improvement is due to an active muscle contraction as shown on electromyography and is not just an interposition or tenodesis effect.

Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm

Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70 degrees to 148 degrees (+78 degrees ) and external rotation from -18 degrees to 18 degrees (+36 degrees ). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.

[Open reconstruction of the rotator cuff]

Success rates relating to relief from pain and improved function following open reconstruction of the rotator cuff have been documented in many studies. At least for small to medium-size tears the question currently arises of whether an arthroscopic repair would not also give good treatment results. At present, however, the results of arthroscopic repair are not yet comparable to those yielded by the open techniques, at least in terms of recurrent defects especially in the case of massive tears (affecting more than two tendons). Open surgical repair is currently still recommended for all patients who require maximal postoperative function and strength and for elderly patients. Open repairs have a lower rate of re-rupture than arthroscopic repairs, but arthroscopic repair offers the benefits of lower morbidity. The decision on which technique is indicated should be made by an experienced surgeon with special training in this area and with due consideration for newer aspects in diagnostic imaging techniques, so as to avoid unsatisfactory results. In certain cases of irreparable cuff tears affecting two tendons and with fatty infiltration of the muscle and substantial loss of function muscle transfer can be considered in active patients; this can offer some functional improvement in the medium to long term, but do not lead to full restoration of function.

Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?

Irreparable posterior cuff tears can cause pain and lack of shoulder function. Surgical treatment includes musculotendinous transfers of either latissimus dorsi (LD) or teres major (TM). This study aimed to give a detailed description of the morphology of these two muscles with particular regard to their suitability for use in transfers. Sixty-two shoulders in 31 cadaveric specimens (mean age 50 years) were dissected. The mean length of the TM was 13.7 cm at its superior edge while the distance from the muscle origin to the greater tuberosity (GT) was 19.2 cm. The tendon of the TM had a length of 1.5 cm, a width of 3.4 cm, and a thickness of 1.3 mm. The mean length of the LD was 26.0 cm and the distance from its origin to the GT was 32.9 cm. The mean length of the LD tendon was 5.2 cm, its width 2.9 cm, and its thickness 1.0 mm. The increased length required to achieve transfer was 47% (of the original length) for TM and 33% for LD. Both TM and LD could reach the GT with ease, according to the potential muscle excursions. Tension of the neurovascular bundle is more probable with LD because it enters the muscle relatively closer to the tendon. Problems with regard to reattachment may be more likely to occur in a transfer of the TM because of its short tendon.

Influence of psychomotor skills and innervation patterns on results of latissimus dorsi tendon transfer for irreparable rotator cuff tears

This investigation was performed to analyze the influence of innervation and psychomotor skills on the outcome of latissimus dorsi transfer. Patients with the 10 best and 10 worst results after latissimus dorsi transfer for irreparable rotator cuff tears were selected. All patients meeting the inclusion criteria (n = 12) were subject to a psychomotor test battery (Motorische Leistungsserie) and electromyographic innervation assessment. There was no statistical difference between the 2 groups preoperatively in terms of the commonly tested factors known to influence the results of this procedure adversely. There was a significant difference in both the pattern and selectivity of innervation in the group that had better clinical results. The psychomotor findings were negatively correlated with the range of motion and the strength of the operative shoulder. Function of the operative shoulder could also be predicted by psychomotor function of the uninjured contralateral side. Psychomotor skills testing appears to be a new, potential method by which to predict the outcome of latissimus dorsi transfer.

Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study

The purpose of this study was to describe landmarks for latissimus dorsi tendon transfer in massive irreparable tears of the rotator cuff. Nine pairs of embalmed cadaveric shoulders were dissected. Crucial structures were identified, and their relationship with various bony and soft-tissue reference points was documented. Identification of the dense fibrous band, at the confluence of the teres major and latissimus dorsi musculotendinous unit, facilitates localization of the radial nerve, which crosses deep to this landmark. The axillary nerve can be seen to exit the quadrangular space 27 mm medial to the latissimus dorsi insertion into the proximal humerus, whereas the thoracodorsal neurovascular pedicle inserts into the latissimus dorsi 110 mm from the humeral tendon's humeral attachment. Harvest of the latissimus dorsi tendon can be safely accomplished by identifying the dense fibrous band and releasing the tendon within 2 cm of its humeral attachment.

Teres minor integrity predicts outcome of latissimus dorsi tendon transfer for irreparable rotator cuff tears

In patients with irreparable rotator cuff tears, latissimus dorsi tendon transfer (LDTT) can be effective in improving pain and function. However, the results are variable, and the factors that predict good outcomes are poorly understood. The purpose of this study was to investigate whether the integrity of the teres minor musculotendinous unit is predictive of outcome following LDTT. Twenty-two consecutive patients who underwent LDTT for massive, irreparable posterosuperior rotator cuff tears were retrospectively reviewed. Sixteen men and 6 women with a mean age of 58 years (range, 40-68) were analyzed at an average follow-up of 34 months (range, 24-57). Standardized MRI images of all patients were reviewed by 3 independent reviewers. Fatty infiltration of the teres minor was Goutallier stage 0 in 5 patients; stage 1 in 6; stage 2 in 4; stage 3 in 6; and stage 4 in 1. Eleven patients (50%) had partial tears and 2 (9%) had complete tears of the teres minor tendon. Following LDTT, the mean absolute constant score improved from 48 to 62 points (P = .003), age-adjusted constant score improved from 56% to 72% (P = .002), and the subjective shoulder value improved from 24% to 68% (P < .001). Fatty infiltration of the teres minor less than or equal to stage 2 was associated with a better postoperative constant score (67 vs 53, P = .015); age-adjusted constant score (78% vs 59%, P = .012); active external rotation (36 degrees vs 16 degrees , P = .016); and active elevation (143 degrees vs 115 degrees , P = .012) relative to patients with fatty infiltration greater than stage 2. The presence or absence of a tear of the tendon had no significant effect on outcome. In conclusion, when performing LDTT for massive irreparable posterosuperior rotator cuff tears, fatty infiltration of the teres minor should be considered prior to surgery, as it is predictive of outcome.