Arthroscopic-Assisted Anterior Latissimus Dorsi Transfer for Irreparable Anterior Rotator Cuff Tear: A Technical Note

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.

Fully Arthroscopic Pectoralis Minor Tendon Transfer with Bone Fragment for Irreparable Subscapularis Tears

Several techniques to treat irreparable subscapularis (SSC) tendon tear have been described. We introduce a fully arthroscopic technique for pectoralis minor tendon with bone fragment transfer. This procedure starts with glenohumeral exploration and evaluation of the remaining SSC mobility. Then we detach and release the pectoralis minor (PMi) tendon with bone fragment from the coracoid, protecting the plexus structures. Next, the PMi tendon with bone fragment is fixed on the lesser tuberosity passing under the coracoid. This procedure is technically demanding and could be performed safely with low invasiveness and high reproducibility by understanding the regional anatomy and the well-described technique.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.