Massive irreparable rotator cuff tears: Treatment options, indications, and role of fully arthroscopic latissimus dorsi transfer

Tendon transfers for the management of irreparable subscapularis tears

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Middle trapezius tendon transfer using Achilles allograft for irreparable isolated supraspinatus tendon tears effectively restores the superior stability of the humeral head without restricting range of motion: a biomechanical study

BACKGROUND

Middle trapezius tendon (MTT) transfer has been suggested for promising treatment of irreparable isolated supraspinatus tendon tears (IISTTs). However, there have been no attempts to assess the biomechanical efficacy of MTT transfer. This study aims to evaluate the biomechanical efficacy of MTT transfer in the setting of IISTTs.

METHODS

Eight fresh frozen cadaveric shoulders were tested in 3 conditions: (1) intact rotator cuff, (2) IISTT, and (3) MTT transfer using Achilles allograft for IISTTs. Total humeral rotational range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were measured at 0°, 20°, and 40° glenohumeral abduction (representing 0°, 30°, and 60° shoulder abduction). Superior translation and subacromial contact pressures were measured at 0°, 30°, 60°, and 90° external rotation (ER). Two different MTT muscle loading conditions were investigated. A linear mixed effects model and Tukey post hoc test were used for statistical analysis.

RESULTS

Total ROM was significantly increased after IISTT at 20° abduction (P = .037). There were no changes in total ROM following MTT transfer compared to the IISTT condition (P > .625 for all comparisons). The IISTT condition significantly increased superior translation compared to the intact rotator cuff condition in 0° and 20° abduction with all ER angles (P < .001), 40° abduction-30° ER (P = .016), and 40° abduction-60° ER (P = .002). MTT transfer significantly decreased superior translation of the humeral head at all abduction angles compared to the IISTT condition (P < .026). MTT transfer significantly decreased peak contact pressure by 638.7 kPa (normal loading) and 726.8 kPa (double loading) at 0° abduction-30° ER compared to the IISTT condition (P < .001). Mean contact pressure was decreased by 102.8 kPa (normal loading) and 118.0 kPa (double loading) at 0° abduction-30° ER (P < .001) and 101.0 kPa (normal loading) and 99.2 kPa (double loading) at 0° abduction-60° ER (P < .001). MTT transfer at 20° abduction-30° ER with 24 N loading significantly decreased contact pressure by 91.2 kPa (P = .035).

CONCLUSIONS

The MTT transfer biomechanically restored the superior humeral head translation and reduced the subacromial contact pressure in a cadaveric model of IISTT, while not restricting total ROM. These findings suggest that MTT transfer may have potential as a surgical treatment for IISTTs.

Biomechanical Comparison Between Superior Capsular Reconstruction and Lower Trapezius Tendon Transfer in Irreparable Posterosuperior Rotator Cuff Tears

BACKGROUND

Superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) have recently been used to manage irreparable posterosuperior rotator cuff tears (PSRCTs). There has been a paucity of comparative biomechanical considerations between the 2 procedures.

PURPOSE

To compare the glenohumeral stability and biomechanical properties between SCR and LTT in PSRCTs involving the entire infraspinatus tendon region.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen cadaveric shoulders were tested at 0°, 20°, and 40° of shoulder abduction. Maximum internal, external, and total humeral range of motion (ROM), superior translation of the humeral head, and subacromial contact characteristics were compared among 4 conditions: (1) intact rotator cuff, (2) PSRCTs involving the entire infraspinatus tendon region, (3) LTT using Achilles allograft (12 N and 24 N of loading), and (4) SCR using fascia lata allograft.

RESULTS

Although a decrease in total ROM was noted in LTT with 12 N compared with the tear condition, LTT with both 12 N and 24 N as well as SCR did not restrict total rotational ROM compared with the intact condition. LTT had decreased total ROM compared with tear condition at 20° of abduction (P = .042), while no significant decrease was confirmed at all abduction angles after SCR. SCR and LTT with 24 N decreased superior translation compared with the PSRCT condition at 0° and 20° of abduction (P < .037) but not significantly at 40° of abduction, whereas LTT with a 24-N load decreased glenohumeral superior translation at all abduction angles (P < .039). Both SCR and LTT decreased subacromial contact pressure compared with the tear condition (P < .014) at all abduction angles. SCR decreased subacromial contact pressure at 0° and 40° of abduction (P = .019 and P = .048, respectively) compared with LTT with 12 N of loading, while there was no difference between SCR and LTT with 24 N of loading in all abduction angles. SCR increased the contact area compared with the PSRCT condition at all abduction angles (P < .023), whereas LTT did not increase the contact area.

CONCLUSION

SCR and LTT decreased glenohumeral superior translation and contact pressure compared with PSRCT conditions. The LTT was superior to SCR in terms of superior translation of the humeral head at a higher shoulder abduction angle, whereas the SCR showed more advantageous subacromial contact characteristics compared with LTT.

CLINICAL RELEVANCE

These biomechanical findings provide insights into these 2 fundamentally different procedures for the treatment of young and active patients with PSRCTs involving the entire infraspinatus tendon region.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction

BACKGROUND

Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures.

PURPOSE

To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure.

RESULTS

The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M.

CONCLUSION

Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

Biomechanical comparison of combined latissimus dorsi and teres major tendon transfer vs. latissimus dorsi tendon transfer in shoulders with irreparable anterosuperior rotator cuff tears

BACKGROUND

Irreparable anterosuperior rotator cuff tears (IASRCTs) can result in a gradual loss of active elevation and internal rotation, superior and anterior translation of the humeral head, and cuff tear arthropathy. Joint-preserving treatment options for IASRCTs in young and high-demand elderly patients remain a subject of ongoing debate. The aim of the study was to evaluate the biomechanical efficacy of the combined latissimus dorsi and teres major tendon (LDTM) transfer and compare it to an isolated latissimus dorsi (LD) transfer in a cadaveric IASRCT model.

METHODS

Eight cadaveric shoulders (mean age, 68.3 ± 5.2 years; range 58-71) were tested with a custom shoulder testing system. All specimens were tested at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane under 4 conditions: (1) intact, (2) IASRCT, (3) combined LDTM transfer, and (4) isolated LD transfer. The superior and anteroinferior translation and subacromial contact pressure were measured. The effects of 3 different LD and LDTM muscle loading conditions were investigated to determine the effectiveness of the muscle transfer conditions. A linear mixed effect model was used for statistical analysis, followed by a Tukey post hoc test.

RESULTS

IASRCTs significantly increased superior translation, anteroinferior translation, and subacromial peak contact pressure. Combined LDTM transfer significantly decreased superior and anteroinferior translation compared with IASRCTs in all positions and muscle loadings. Isolated LD transfer did not significantly decrease superior (P > .115) and anteroinferior translation (P > .151) compared to IASRCT at any abduction and muscle loads except superior translation at 60° abduction and 90° of external rotation (ER) (P < .036). LDTM transfer also significantly decreased peak contact pressure from the IASRCT condition at every abduction angle (P < .046). However, isolated LD transfer significantly decreased subacromial peak contact pressure only at 30° abduction and 0° and 30° of ER with triple loading (P < .048), as well as at 60° abduction and 90° of ER (P < .003).

CONCLUSIONS

Combined LDTM transfer decreased superior translation, anteroinferior translation, and subacromial contact pressure compared with the IASRCT condition. Isolated LD transfer did not improve glenohumeral translation and subacromial contact pressure. Combined LDTM transfer may be a more reliable treatment option than isolated LD transfer in patients with an IASRCT.

Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up

INTRODUCTION

Middle trapezius tendon (MTT) transfer has been proposed as a feasible option for managing isolated irreparable supraspinatus tears (IISTTs). However, no clinical study has been attempted. This study aimed to evaluate clinical and radiologic outcomes of arthroscopic-assisted MTT transfer in patients with IISTTs.

METHODS

This retrospective study included patients who underwent arthroscopic-assisted MTT transfer using fascia lata autograft for IISTTs. Clinical outcomes, including pain visual analog scale (VAS), Constant, American Shoulder and Elbow Society (ASES), University of California Los Angeles (UCLA) shoulder scores and active range of motion (aROM), were assessed. Radiographic analyses included the acromiohumeral distance (AHD), Hamada grade, and transferred tendon integrity at the final follow-up.

RESULTS

Twenty-two patients (mean age: 63.3 ± 6.8 [51‒74] years; mean follow-up period: 28.9 ± 4.9 [24‒44] months) met the study criteria. The mean VAS, Constant, ASES, and UCLA scores improved postoperatively at the final follow-up (p < 0.001). The mean aROMs for forward flexion and abduction were significantly increased postoperatively. No significant changes of AHD (p = 0.105) and Hamada grade (p = 0.815) were observed postoperatively. One patient had a re-tear of the transferred tendon at the footprint site at the final follow-up.

CONCLUSION

In this minimum 2-year follow-up study of the novel aMTT transfer using fascia lata autograft, we found significant improvement in pain relief, clinical scores, and active forward flexion and abduction. Additionally, no significant progression of cuff tear arthropathy was observed at the final follow-up. Therefore, aMTT transfer could be a promising treatment option for patients with IISTTs. However, further multicenter and long-term trials are needed to verify its effectiveness.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Restoration of active internal rotation following reverse shoulder arthroplasty: anterior latissimus dorsi and teres major combined transfer

BACKGROUND

Reverse shoulder arthroplasty (RSA) for irreparable massive rotator cuff tear (mRCT) and cuff tear arthropathy (CTA) demonstrates satisfactory clinical outcomes. However, many studies have reported no significant improvements in internal and external rotation. To our knowledge, there have been no studies on new attempts to restore active internal rotation following RSA. The purpose of this study was to compare RSA alone and RSA with anterior latissimus dorsi and teres major (aLDTM) tendon transfer in patients with CTA and mRCT with combined loss of active elevation and internal rotation (CLEIR).

METHODS

This retrospective cohort study included patients who underwent RSA with a lateralized design and had CLEIR between October 2014 and January 2019. Two groups were classified: patients who underwent RSA alone (group R, n = 36) and patients who underwent RSA with aLDTM tendon transfer (group T, n = 24). Clinical outcomes, including the visual analog scale score, Constant score, American Shoulder and Elbow Surgeons score, active range of motion, score for activities of daily living requiring active internal rotation (ADLIR), and ability to perform toileting activity, were compared. Moreover, radiologic outcomes and complications were compared.

RESULTS

The mean follow-up period was 36.8 ± 11.6 months (range, 24-67 months). Both group R and group T showed significant improvements in clinical scores and active range of motion preoperatively and postoperatively. In group T, the Constant score (65.2 ± 7.5 vs. 58.1 ± 12.3, P = .008), ADLIR score (26.1 ± 3.1 vs. 20.3 ± 5.0, P < .001), internal rotation level with the arm behind the back (P < .001), and subscapularis-specific physical examination findings (P < .001) were significantly better than in group R. However, no significant difference in the American Shoulder and Elbow Surgeons score, forward flexion, and external rotation at 0° and 90° of abduction were found at final follow-up. Transient axillary nerve palsy was found in 2 patients in group T. However, there were no significant differences in complication rates between 2 groups.

CONCLUSION

Lateralized RSA with aLDTM tendon transfer for patients with CTA and mRCT with CLEIR restored shoulder function and improved clinical outcomes, especially the ability to perform ADLIR and toileting activity.

Superior capsular reconstruction - A systematic review and meta-analysis

BACKGROUND

Since Mihata's 2012 proposal to arthroscopically reconstruct the superior capsule of patients with massive irreparable cuff tears, many studies have reported the clinical results of this technique using different types of grafts (fascia lata autograft, dermal allograft, porcine dermal xenograft or long head of biceps autograft).

PURPOSE

The objective of this meta-analysis was to report the clinical and radiological results of these superior capsule reconstructions.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) recommendations were used to conduct this systematic review. A bibliographic search was performed of the electronic databases MEDLINE, Scopus, Embase and the Cochrane Library. The quality of the studies was assessed according to the MINORS criterion (Methodological Index for Nonrandomized Studies). The inclusion criteria were studies in English evaluating superior capsular reconstruction.

RESULTS

No level I or II studies met the inclusion criteria. Eighteen studies were selected from the 97 identified, including 637 shoulders (64% male) with a mean age of 62 years [95% CI: 60.3-63.5]. At the mean follow-up of 24.3 months (12-60), the range of motion was significantly increased from 82.6° [60.0-105.2] to 141.9° [109.9-173.8] in abduction, from 113.1° [98.3-127.9] to 153.3° [147.4-159.2] in elevation, from 35.5° [30.9-40.2] 43.4° [35.4-51.3] in external rotation and from 7.2 [5.4-9] to 9.9 [8.9-10.9] in internal rotation. Functional scores were significantly improved from 5.4 [4.8-5.9] to 1.3 [0.9-1.7] points for VAS, from 42.5 [15.7-69.3] to 59.3 [30.1-88.6] points for Constant, from 39.0% [38.1-39.8] to 79.8% [76.4-83.3] for the SSV, and from 48.2 [45.2-51.1] to 81.2 [77.2-85.1] points for the ASES. The healing rate was 76.1% [64.4-84.9]. The complication rate was 5.6% [1.8-16.3] and the reverse shoulder arthroplasty revision rate was 7.1% [3.8-12.8].

CONCLUSION

Superior capsule reconstructions allow satisfactory clinical and radiological results to be obtained at 2 years of follow-up. Due to the small number of high quality comparative studies available, its true place in the therapeutic arsenal cannot be fully confirmed. However, it seems that the best indication for this technique is isolated irreparable rupture of the supraspinatus, in cases of medical treatment failure.

LEVEL OF EVIDENCE

III; meta-analysis of heterogeneous studies.

Biomechanical effectiveness of tendon transfers to restore active internal rotation in shoulder with deficient subscapularis with and without reverse shoulder arthroplasty

BACKGROUND

Loss of active shoulder internal rotation can be very disabling. Several tendon transfers have been described for the management of an irreparable subscapularis (SSC) tear. The purpose of this study was to determine and compare the internal rotation moment arm (IRMA) of the sternal head of the pectoralis major (PM), latissimus dorsi (LD), and teres major (TM) when transferred to different insertion sites to restore shoulder internal rotation with and without reverse shoulder arthroplasty (RSA).

METHODS

Six fresh-frozen right hemithoraces were prepared and evaluated using a custom tendon transfer model to determine the IRMA of different tendon transfers using the tendon and joint displacement method. Five tendon-transfer pairs were modeled using a single suture and tested before and after implantation of an RSA (Comprehensive; Zimmer-Biomet, Warsaw, IN, USA): PM to the insertion site of the SSC, LD to the anterior insertion site of the supraspinatus (SSP) tendon on the greater tuberosity, LD to SSC, TM to SSP, and TM to SSC. The SSC was not repaired at the end of the RSA procedure to simulate an SSC deficiency. The PM transfer was passed under the conjoined tendon when tested on the intact shoulder and above the conjoined tendon when tested with an RSA.

RESULTS

Tendon transfers were shown to have a significant effect on IRMA. The effect of transferred tendons was significantly affected by the position of the humerus. With the humerus adducted, the IRMA of the TM-SSP (14.1 mm ± 3.1 mm) was significantly greater than the other transfers. With the humerus abducted to 90°, the IRMAs of the LD-SSP (30.0 mm ± 5.4 mm) and TM-SSP (28.4 mm ± 6.6 mm) were significantly greater than the IRMAs of other transfer options. The IRMA of the native shoulder differed significantly from that of the RSA state for all tendon transfers. With the humerus adducted to the side of the body, the IRMA of the RSA PM-SSC transfer was significantly greater than that without an RSA (19.0 mm ± 6.4 mm vs. 7.1 mm ± 0.9 mm), demonstrating increased efficiency for internal rotation in the RSA state.

CONCLUSION

Tendon transfers to restore shoulder internal rotation differ in effectiveness and may be affected by arm position and by implantation of a lateralized humerus/lateralized glenoid RSA. The LD potentially results in superior restoration of shoulder internal rotation in a native shoulder (given the risk of nerve compression with the TM transfer) compared with PM and should be considered as a potential tendon transfer to restore internal rotation in selected patients. In combination with a lateralized humerus/lateralized glenoid RSA, the fulcrum provided by the biomechanics of the semiconstrained implant allows the PM transfer to become a more efficient tendon transfer to restore active internal rotation.

Risk of latissimus dorsi tendon rupture after arthroscopic transfer for posterior superior rotator cuff tear: a comparative analysis of 3 humeral head fixation techniques

BACKGROUND

To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques.

METHODS

One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), "over the top" onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture.

RESULTS

Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%).

CONCLUSION

Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate.

Tendon transfers in rotator-cuff surgery

Indications and techniques for tendon transfer in irreparable rotator-cuff tear have greatly progressed and are no longer restricted to external rotation deficit. The present article first reviews the various types of tear and corresponding tendon transfers and the biomechanics of the pseudoparalytic shoulder. The indication of choice for tendon transfer is iterative tear following failure of isolated long biceps tenotomy or partial repair. Latissimus dorsi, inferior trapezius and pectoralis major transfer are the 3 types to be used after failure of primary surgery. Latissimus dorsi transfer is indicated for partial loss of active limb elevation or isolated loss of internal rotation. Inferior trapezius transfer is best indicated for isolated active external rotation deficit. In pseudoparalytic shoulder with total loss of active elevation or combined loss of elevation and active external rotation, isolated transfer is insufficiently powerful to restore active range of motion and should be associated to reverse arthroplasty. We describe the various transfer techniques and report their results.

Combined Fully Arthroscopic Transfer of Latissimus Dorsi and Teres Major for Treatment of Irreparable Posterosuperior Rotator Cuff Tears

Many treatment options have been proposed for treatment of irreparable posterosuperior rotator cuff tears. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before development of glenohumeral arthritic changes, aiming at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The technique was recently adapted from open to arthroscopically assisted with numerous advantages. We propose a combined fully arthroscopic technique for transfer of latissimus dorsi and teres major in which the tendons are fixed in a flat manner at the junction of supraspinatus and infraspinatus to decrease failure rate.