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

Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice

BACKGROUND

The definition of irreparable rotator cuff tear (IRCT) is controversial. This scoping review provides definitions used to describe IRCT in the literature. This scoping review (1) identified criteria used in the definition of IRCT and (2) investigated the current state of those criteria in prospective surgical therapeutic trials.

METHODS

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, Scopus, and Web of Science were searched in March 2023. Studies were screened against predetermined inclusion and exclusion criteria. Criteria regarding clinical symptoms, preoperative images, and intraoperative findings were captured respectively.

RESULTS

A total of 41 prospective studies were eligible for inclusion, and 35 studies (85.4%) defined IRCT. IRCT was defined on the basis of the following main criteria: preoperative image findings (28/35), intraoperative findings (24/35), and symptoms (16/35). With regard to preoperative images, IRCT was mainly defined on the basis of retraction of the tendon in the coronal plane (22/28), the severity of fatty degeneration (19/28), and ruptured tendon number or width of the defect in the sagittal plane (17/28).

CONCLUSION

This scoping review highlights the lack of a standardized definition for IRCT in clinical practice, with common predictive criteria including a duration of over 6 months, retraction beyond 5 cm, Goutallier grade 3 fatty infiltration, and the rupture of two or more tendons. However, surgeons should apply more than one criterion when examining preoperative images and confirm reparability during surgery. A more objective manner of evaluating intraoperative reparability is necessary.

Outcomes of Reverse Total Shoulder Arthroplasty with Latissimus Dorsi Tendon Transfer for External Rotation Deficit: A Systematic Review and Meta-Analysis

BACKGROUND

Latissimus dorsi transfer (LDT) has been purported to restore motion in patients undergoing reverse shoulder arthroplasty (RSA) who have preoperative combined loss of forward elevation (FE) and external rotation (ER). This systematic review summarizes the available evidence for the functional outcomes and complications after RSA with LDT. Furthermore, the effect of implant design and whether a concomitant teres major transfer (TMT) was performed were studied.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting on LDT with RSA to restore ER. Our primary outcomes were ER, FE, Constant score, and complication incidence. Secondarily, we reported postoperative internal rotation (IR) and compared ER, FE, and Constant score based on lateralized versus medialized global implant design and whether concomitant TMT was performed.

RESULTS

Nineteen studies were evaluated; functional outcomes were assessed in 16 articles reporting on 258 RSAs (123 LDT, 135 LDT-TMT). Surgical indication was most commonly cuff tear arthropathy and massive irreparable cuff tear. Mean ER was -12° preoperatively and 25° postoperatively, FE was 72° preoperatively and 141° postoperatively. Mean postoperative Constant score was 65. Of 138 patients (8 studies) describing IR, only 25% reported a mean postoperative IR ≥L3. Subanalysis comparing lateralized versus medialized implants and whether TMT was concomitantly performed demonstrated no significant difference in postoperative ER, FE, and Constant score, nor preoperative to postoperative improvement in ER and FE. The complication rate was 14.1% (of 291 shoulders from 16 studies), including tear in the tendon transfer (n = 3), revision tendon repair (n = 1), nerve-related complication (n = 9), and dislocation (n = 9).

CONCLUSIONS

RSA with LDT is a reliable option to restore motion, with a comparable complication rate with standard RSA. The use of medialized versus lateralized implants and whether the TM was concomitantly transferred may not influence clinical outcomes.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged <65 years

Background

Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.

Methods

We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years.

Results

There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P = .0001 and P = .25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P = .0009 and P = .1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P = .0003 and P = .1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another.

Discussion

Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Nonarthroplasty options for massive, irreparable rotator cuff tears have improvement in range of motion and patient-reported outcomes at short-term follow-up: a systematic review

PURPOSE

To compare various nonarthroplasty treatment options for massive, irreparable rotator cuff tears, including allograft bridging/augmentation, debridement, partial repair, superior capsule reconstruction (SCR), subacromial balloon spacer, and tendon transfer.

METHODS

A comprehensive search was conducted through the PubMed, MEDLINE, and EMBASE databases for all articles pertaining to nonarthroplasty treatment options for irreparable rotator cuff tears. Inclusion criteria included manuscripts published between 2009 and 2020 with at least 1 year follow-up and Level I-IV evidence. Articles were separated into six groups: debridement, arthroscopic and open repair, allograft bridging/augmentation, SCR, subacromial balloon spacer, and tendon transfer. Data points included range of motion (external rotation, abduction, forward flexion, and internal rotation), visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, rate of revision surgery, and rate of conversion to arthroplasty.

RESULTS

A total of 83 studies and 3363 patients were included. All treatment options had statistically significant improvements in postoperative range of motion and patient-reported outcomes. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. The SCR subgroup had the greatest improvement in ASES scores postoperatively. The overall revision rate was 7.2% among all surgical options, with the allograft bridging/augmentation group having the lowest rate of revision at 0-8.3%. The overall rate of conversion to arthroplasty was 7.2%, with debridement having the greatest rate of conversion at 15.4%.

CONCLUSION

All six nonarthroplasty treatment options for irreparable rotator cuff tears resulted in statistically significant improvements in range of motion and patient-reported outcomes at 1 year follow-up or more, with low rates of revision and conversion to arthroplasty. Debridement had statistically significantly greater postoperative abduction and forward flexion range of motion, as well as better VAS pain scores, compared to the other treatment options. However, these conclusions should be interpreted with caution due to the heterogeneous nature of the data, lack of prospective randomized control trials, and short-term follow-up. The findings of this study highlight the complexity of irreparable, massive rotator cuff tears, and the need for an individualized approach when treating these patients.

LEVEL OF EVIDENCE

Level IV.

The metabolic landscape in chronic rotator cuff tear reveals tissue-region-specific signatures

BACKGROUND

Degeneration of shoulder muscle tissues often result in tearing, causing pain, disability and loss of independence. Differential muscle involvement patterns have been reported in tears of shoulder muscles, yet the molecules involved in this pathology are poorly understood. The spatial distribution of biomolecules across the affected tissue can be accurately obtained with matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI). The goal of this pilot study was to decipher the metabolic landscape across shoulder muscle tissues and to identify signatures of degenerated muscles in chronic conditions.

METHODS

Paired biopsies of two rotator cuff muscles, torn infraspinatus and intact teres minor, together with an intact shoulder muscle, the deltoid, were collected during an open tendon transfer surgery. Five patients, average age 65.2 ± 3.8 years, were selected for spatial metabolic profiling using high-spatial resolution (MALDI-TOF) and high-mass resolution (MALDI-FTICR) MSI in negative or positive ion mode. Metabolic signatures were identified using data-driven analysis. Verifications of spatial localization for selected metabolic signatures were carried out using antibody immunohistology.

RESULTS

Data-driven analysis revealed major metabolic differences between intact and degenerated regions across all muscles. The area of degenerated regions, encompassed of fat, inflammation and fibrosis, significantly increased in both rotator cuff muscles, teres minor (27.9%) and infraspinatus (22.8%), compared with the deltoid (8.7%). The intact regions were characterized by 49 features, among which lipids were recognized. Several of the identified lipids were specifically enriched in certain myofiber types. Degenerated regions were specifically marked by the presence of 37 features. Heme was the most abundant metabolite in degenerated regions, whereas Heme oxygenase-1 (HO-1), which catabolizes heme, was found in intact regions. Higher HO-1 levels correlated with lower heme accumulation.

CONCLUSIONS

Degenerated regions are distinguished from intact regions by their metabolome profile. A muscle-specific metabolome profile was not identified. The area of tissue degeneration significantly differs between the three examined muscles. Higher HO-1 levels in intact regions concurred with lower heme levels in degenerated regions. Moreover, HO-1 levels discriminated between dysfunctional and functional rotator cuff muscles. Additionally, the enrichment of specific lipids in certain myofiber types suggests that lipid metabolism differs between myofiber types. The signature metabolites can open options to develop personalized treatments for chronic shoulder muscles degeneration.

Outcomes After Arthroscopic Rotator Cuff Repair Using Margin Convergence Versus Superior Capsular Reconstruction: Should Candidates for Margin Convergence Be Treated With Superior Capsular Reconstruction?

Background

Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR.

Purpose/Hypothesis

To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported.

Results

Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively (P < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) (P = .026).

Conclusion

Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.

Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears

Massive irreparable posterosuperior rotator-cuff tears are debilitating lesions that usually require surgical treatment. Even though there is no consensus regarding the best surgical technique, tendinous transfers around the shoulder are the most commonly performed procedures. The latissimus dorsi tendon remains the most commonly used, but different modifications to the original technique have been shown to minimize complications and to improve functional results and satisfaction. Other techniques, such as the transfer of the lower trapezius tendon, are promising and should be considered, especially for patients with isolated loss of external rotation. The present paper is a literary review regarding tendon transfers for irreparable posterosuperior rotator-cuff tears.

Graft healing does not influence subjective outcomes and shoulder kinematics after superior capsule reconstruction: a prospective in vivo kinematic study

BACKGROUND

A viable treatment option for young patients with massive, irreparable rotator cuff tears is arthroscopic superior capsule reconstruction (SCR). SCR theoretically improves shoulder stability and function and decreases pain. However, no prospective studies to date have correlated magnetic resonance imaging (MRI) healing with in vivo kinematic data. The purpose of this study was to evaluate the association between graft healing and in vivo kinematics, range of motion (ROM), strength, and patient-reported outcomes (PROs).

METHODS

Ten patients (8 men and 2 women; mean age, 63 ± 7 years) with irreparable rotator cuff tears underwent arthroscopic SCR with dermal allograft. Strength was measured with isometric internal rotation and external rotation (ER) at 0° of abduction, ER at 90° of abduction, and scapular-plane abduction, whereas ROM was measured during shoulder flexion, abduction, and ER and internal rotation at 90° of abduction both before and 1 year after SCR. PROs included American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand surveys that were collected before and 1 year after SCR. Synchronized biplane radiographs were collected at 50 images/s before and 1 year after SCR while patients performed 3 trials of scapular-plane abduction. A validated volumetric tracking technique with submillimeter accuracy determined 6-df glenohumeral and scapular kinematics. The acromiohumeral distance (AHD), humeral head translation, and scapulohumeral rhythm (SHR) were calculated from the in vivo kinematics. Healing at 5 locations was evaluated on 1-year postoperative MRI scans: anterior and posterior glenoid, anterior and posterior humerus, and posteriorly along the infraspinatus. Each subject was given a score from 0 to 5 based on number of sites healed.

RESULTS

Of the 10 patients, 9 (90%) had complete (n = 4) or partial (n = 5) healing of the graft whereas 1 (10%) had complete failure at the glenoid. No correlation existed between MRI healing and the AHD, SHR, strength, ROM, or PROs. American Shoulder and Elbow Surgeons, Western Ontario Rotator Cuff Index, and Disabilities of the Arm, Shoulder and Hand scores all significantly improved from before to 1 year after SCR regardless of graft healing.

CONCLUSIONS

The rate of complete or partial graft healing on MRI mimics findings of prior reports in the literature. MRI healing was correlated with humeral head anterior-posterior translation but not with the static and dynamic AHDs, SHR, humeral head superior-inferior translation, ROM, strength, or PROs 1 year after SCR. All PROs improved significantly from before to 1 year after SCR regardless of graft status on MRI. In vivo kinematic changes were small after SCR and not clinically significant, and the data suggest that improvements in clinical and functional outcomes may occur in the absence of full graft healing.

Tendon transfers for irreparable rotator cuff tears

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

Anatomical study of the teres major muscle: description of an additional distal muscle slip

Background

Understanding muscle and tendon anatomy is of tremendous importance to achieve optimal surgical execution and results in tendon transfers around the shoulder. The aim of this study was to introduce and describe an additional distal muscle slip of the teres major (TM).

Methods

Sixteen fresh-frozen cadaver shoulders were dissected with the deltopectoral approach. The ventral latissimus dorsi (LD) tendon was harvested, and the shoulders were analyzed for the presence/absence of a distal teres major slip (dTMs) and its dimensions and relationship with the TM and LD tendons.

Results

The dTMs was identified in 12 shoulders (75%). It was always distal to the TM tendon and visible during the deltopectoral approach. There was a clear separation between the TM proximally and dTMs tendon distally. At the humeral insertion, both tendons had a common epimyseal sheet around the teres major and inserted continuously at the humerus. The mean width of the dTMs tendon at the insertion was 13 ± 4 mm (range, 7–22 mm). The total lengths of the dTMs tendon and LD tendon were 40 ± 7 mm (range, 25–57 mm) and 69 ± 7 mm (range, 57–79 mm), respectively (p < 0.001). The dTMs muscle showed direct adhesions in ten shoulders (83%) with the LD muscle.

Conclusions

This is the first macroscopic description of an additional distal slip of the teres major muscle. The dTMs has a separate (distal) but continuous (mediolateral) insertion at the humerus within a common epimyseal sheet around the TM. The dTMs tendon is visible during the deltopectoral approach and can therefore provide a lead structure, particularly in ventral LD transfers with the deltopectoral approach.

Superior Capsular Reconstruction Using 3-layered Fascia Lata Autograft Reinforced with a Nonresorbable Suture Mesh

Purpose

The purpose of this study was to evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) using a 3-layered fascia lata autograft (FLA) reinforced with a nonresorbable suture mesh, in the treatment of irreparable massive rotator cuff tears (MRCTs).

Methods

Consecutive patients with irreparable MRCTs (Goutallier 4, Hamada grade 1-2, Bateman 3-4) who were treated with arthroscopic SCR using reinforced FLA in 2018 were included. Patients with an irreparable subscapularis/infraspinatus, serious cardiovascular condition, systemic infection, rheumatic disease, and known alcohol/drug abuse were excluded from the study. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months, and at 12 months postoperatively. A simple t test was used to compare the outcomes. P values <.05 were considered significant. Complications and revision surgeries were registered.

Results

A total of 24 consecutive patients (15 males, 9 females) with a mean age of 61 years (range, 41-76) were enrolled. Twenty (83%) patients achieved minimal clinically important difference in the SPADI score (>18) and 14 (58%) experienced substantial clinical benefit in SPADI (>45). The mean SPADI score improved from 59.0 to 9.7 (P < .0001) at 1-year follow-up. Active abduction improved from 59.5° to 154.3° (P < .0001) and active forward flexion improved from 67.0° to 160.3° (P < .0001) at 1-year follow-up. Eighteen (75%) patients achieved substantial clinical benefit in active abduction (>28.5°) and active forward flexion (>35.4°). Complications included progression of osteoarthritis in 2 cases, tear of the graft in 1 case, and pullout of the anchor in another. Two patients experienced donor site morbidity after harvesting the fascia lata autograft.

Conclusions

Eighty-three percent of the patients achieved minimal clinically important difference and were successfully treated with arthroscopic SCR using a FLA reinforced with a suture mesh. The procedure had a complication rate of 17% and 8.5% of the patients experienced donor site morbidity. All complications occurred in patients who were previously treated with an attempted rotator cuff repair.

Level of Evidence

Level IV, therapeutic case series.

Clinical and Imaging Outcomes After Arthroscopic Superior Capsule Reconstruction With Human Dermal Allograft for Irreparable Posterosuperior Rotator Cuff Tears: A Minimum 2-Year Follow-Up

PURPOSE

To report the clinical and structural outcomes for non-pseudoparalytic irreparable posterosuperior rotator cuff tears treated with superior capsule reconstruction (SCR) using dermal allograft (DA).

METHODS

Patients who underwent SCR using DA with a mean thickness of 3 mm for irreparable posterosuperior rotator cuff tears and underwent surgery at least 2 years earlier were included. Outcomes were assessed prospectively by the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; patient satisfaction; and visual analog scale for pain. Structurally, acromiohumeral distances (AHDs) were assessed both preoperatively and postoperatively (standard radiographs). Graft integrity was assessed by magnetic resonance imaging. Clinical failures were reported.

RESULTS

We included 22 patients with a mean age of 56 years (range, 41-65 years) and a mean follow-up period of 2.1 years (range, 2-3 years). The ASES score improved from 54.0 to 83.9 (P < .001); the Single Assessment Numeric Evaluation score improved from 44.9 to 71.4 (P < .001); and Quick Disabilities of the Arm, Shoulder and Hand score (QuickDASH) improved from 37.6 to 16.2 (P = .001). Of the patients, 85% achieved an improvement in the ASES score that exceeded the minimal clinically important difference (11.1 points). The median patient satisfaction rating was 8.5 (range, 1-10). The median preoperative visual analog scale score decreased from 4 to 0 (range, 0-3) postoperatively (P < .001). Complete radiographs of 19 of 22 patients (86%) were obtained at a mean of 5.2 months (range, 1.4-10 months) postoperatively and showed a significant increase in the mean AHD from 7.0 mm preoperatively to 8.3 mm postoperatively (P = .029). Postoperative magnetic resonance imaging scans were obtained in 95% of the patients (21 of 22) at a mean of 2.5 months (range, 0.3-10.2 months) postoperatively and showed graft integrity rates of 100% (21 of 21) on the tuberosity side, 76% (16 of 21) at the midsubstance, and 81% (17 of 21) on the glenoid side. No significant differences in clinical outcome scores (P > 0.930) were found in patients with intact grafts versus those with torn grafts. The number of previous shoulder surgical procedures was a negative predictor of clinical outcome. There was 1 clinical failure.

CONCLUSIONS

SCR using DA for irreparable tears improves outcomes with high satisfaction and high graft integrity at short-term follow-up. Graft integrity, although correlated with an increased AHD, had no correlation with clinical outcomes at final follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

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.

Functional improvements in active elevation, external rotation, and internal rotation after reverse total shoulder arthroplasty with isolated latissimus dorsi transfer: surgical technique and midterm follow-up

HYPOTHESIS

This study investigated the hypothesis that reverse total shoulder arthroplasty (RSA) in combination with an isolated latissimus dorsi tendon (LDT) transfer in patients with pseudoparalysis of abduction and external rotation (combined loss of active elevation and external rotation [CLEER] syndrome) would demonstrate improved postoperative functional results.

METHODS

This study was a retrospective single-surgeon case series of 13 consecutive patients with CLEER who underwent RSA without subscapularis repair and combined with an isolated LDT transfer. We reviewed 10 patients (77%), at a minimum of 2 years, with 3 cases lost to follow-up. Shoulder function was assessed preoperatively and postoperatively using the Constant score and postoperatively using the Oxford Shoulder Score, University of California-Los Angeles score, American Shoulder and Elbow Surgeons score, ADLEIR (activities of daily living [ADLs] requiring active external and internal rotation) score, and ADLIR (ADLs requiring active internal rotation) score. Force in internal rotation (IR) at 0° of abduction, external rotation (ER) at 0° of abduction, and ER at 90° of abduction, as well as IR in the belly-press position, was measured.

RESULTS

The mean postoperative follow-up period was 57 months (range, 31-85 months). We observed improvement in the Constant score (from 29.8 ± 6.64 preoperatively to 71.9 ± 10.45 postoperatively, P < .05), as well as abduction force, ER, and forward elevation (P < .05). Postoperatively, the mean American Shoulder and Elbow Surgeons score was 95.1 ± 3.38 and the mean Oxford Shoulder Score was 46.6 ± 1.57. Mean force in IR at 0° of abduction was 5.45 ± 2.42 kg, and mean force in ER at 90° of abduction was 4 ± 1.20 kg. Mean force in ER at 0° of abduction (3.65 ± 1.24 kg) and IR in the belly-press position (4.5 ± 2.84 kg) demonstrated a positive correlation with ADLs.

CONCLUSIONS

The results of this study demonstrate that RSA without subscapularis repair, combined with an isolated LDT transfer, provides improved postoperative functional outcomes for patients with CLEER while maintaining sufficiently balanced force in IR and ER to effectively perform ADLs.

Arthroscopic Superior Capsular Reconstruction With Acellular Porcine Dermal Xenograft for the Treatment of Massive Irreparable Rotator Cuff Tears

Purpose

To evaluate the short-term clinical outcomes and the complications related to arthroscopic superior capsular reconstruction (SCR) with acellular porcine dermal xenograft for the treatment of irreparable massive rotator cuff tears.

Methods

A prospective observational study of patients treated with arthroscopic SCR for irreparable massive rotator cuff tears in the period from 2016 to 2017 was performed. Range of motion and Shoulder Pain and Disability Index (SPADI) scores were assessed preoperatively, at 6 months postoperatively, and at 12 months postoperatively.

Results

A total of 20 shoulders in 19 patients, with an average age of 60 years, were included in the study. Twelve patients met the criterion for the minimal clinically important difference in the SPADI score. The mean SPADI score showed significant improvement from 51.3% to 10.4% at 1-year follow-up. Active abduction improved from 65.4° to 149.3° and active forward flexion improved from 68.6° to 151.4° at 1-year follow-up. The procedure had a 30% complication rate, including a 15% rate of immunologic rejection of the xenograft. Five patients underwent revision procedures, including arthroscopic debridement and removal of xenograft residuals, implantation of a balloon spacer, and revision SCR with a fascia lata autograft.

Conclusions

Arthroscopic SCR with an acellular porcine dermal xenograft led to a successful outcome in 60% of cases. The procedure showed a quite high complication rate; the most severe cases were related to acute immunologic rejection of the xenograft.

Level of Evidence

Level IV, case series.

Superior Capsular Reconstruction With Arthroscopic Rotator Cuff Repair in a "Functional Biologic Augmentation" Technique to Treat Massive Atrophic Rotator Cuff Tears

Surgical treatment of patients with massive rotator cuff tears is unpredictable because of a low healing rate and high incidence of clinical failure. Arthroscopic superior capsular reconstruction has emerged as a promising technique in treating younger, active patients with massive irreparable rotator cuff tears. Superior capsular insufficiency has been theorized to be a factor in the higher failure rate for repairs of massive tears, and there have been proposals of superior capsular repair in addition to rotator cuff repair to facilitate better healing of massive rotator cuff tears. This article presents our technique of functional rotator cuff augmentation, which is concomitant superior capsular reconstruction with arthroscopic rotator cuff repair, to treat massive, atrophic rotator cuff tears. This technique is used in patients with massive rotator cuff tears and superior capsular insufficiency.

Arthroscopic Superior Capsular Reconstruction With Acellular Dermal Allograft Using Push-In Anchors for Glenoid Fixation

Massive irreparable rotator cuff tears in the younger, active patient can be one of the most challenging pathologies to treat in shoulder surgery. Over the last few years, the superior capsular reconstruction (SCR) technique, which has shown favorable initial clinical results, has emerged as a promising new technique that aims to restore glenohumeral mechanics and improve patient function. SCR can be technically challenging, and improvements have been made consistently to the technique. In this Technical Note, we present our knotless technique of glenoid fixation using push-in anchors and suture tapes. We believe that our procedure offers an improvement to current SCR techniques.

Anatomic study of pedicled bipolar teres major transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Treatment of rotator cuff (RC) tears has not included bipolar muscle-tendon transfers to date. The objective of this study was to verify the feasibility of pedicled bipolar teres major (TM) transfer over and under the long head of the triceps brachii (LHT) and compare its versatility with monopolar transfer in a model of supraspinatus (SS) tears in cadavers.

METHODS

In 6 shoulders of cryopreserved cadavers, we re-created complete SS tears, conducting monopolar and bipolar TM transfers over and under LHT. We compared the morphology of the SS and TM, defect coverage, angle between the transferred TM and major SS axis, and axillary nerve overlap with each technique.

RESULTS

The TM and SS were morphologically similar. Defect coverage was significantly lower with monopolar transfer (12 ± 4 mm) than with bipolar transfer (39 ± 9 mm under the LHT, P = .003, and 38 ± 8 mm over the LHT, P = .004). The bipolar transfer course over the LHT was the nearest to the SS axis (39° ± 11°, P = .005). We found a greater axillary nerve overlap with bipolar transfer under the LHT (27 ± 8 mm) than with bipolar transfer over the LHT (1 ± 2 mm, P = .005) or monopolar transfer (0 mm, P < .001).

CONCLUSION

Bipolar TM transfer is possible without neurovascular pedicle interference, obtaining greater RC defect coverage and the closest path to the SS axis when conducted over the LHT compared with monopolar or bipolar transfer under the LHT. Accordingly, it can be considered an alternative option for the treatment of posterosuperior RC defects.

Quantitative assessment of the growth dynamics of the teres major in human fetuses

PURPOSE

The main objective of the study was to examine the use of teres major (TM) as a flap in the pediatric surgeries from an anatomical perspective by: (1) revealing the growth dynamics of the developing TM; (2) assessing the possible interconnecting structures between TM and latissimus dorsi (LD); (3) exposing the innervation patterns of TM in human fetuses.

METHODS

Study was conducted on 50 fetuses (26 females and 24 males), on a mean gestational age of 22.86 ± 3.21 (range 18-30) weeks. All the measurements were collected with a digital caliper and a digital image analysis software. Additionally, structural relations between TM and LD were examined in detail and further classified.

RESULTS

No significant difference of side and sex was detected on TM measurements (p > 0.05). Linear functions for the surface area, width, length of the superior and inferior margins of TM were detected as follows: y = - 257.142 + 18.334 × age (weeks), y = - 5.497 + 0.545 × age (weeks), y = - 1.621 + 1.068 × age (weeks), and y = - 2.147 + 1.284 × age (weeks), respectively. As classified in five types, a number of 33 muscular or tendinous connections between TM and LD were detected. Musculo-tendinous slips from TM to triceps brachii (TB) were evident in four sides. Innervation of TM was observed to be providing by the lower subscapular nerve in all the cases.

CONCLUSION

First, linear functions, representing the developing fetal morphometry obtained by our study can be adapted for estimating the morphometric of this muscle in early childhood. Besides, acknowledging the diverse appointments of TM with the surrounding muscles such as LD and TB may facilitate the prevention of neurovascular structures and the application of surgical procedures during tendon transfers. In brief, our findings are highly potent to bring the attention of pediatric surgeons.

Options for Failed Rotator Cuff Repair

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.

Teres major tendon transfer in the treatment of irreparable posterosuperior rotator cuff tears: long-term improvement of shoulder function and pain reduction at eight to 12 years’ follow-up

Aims

Since long-term outcome of teres major tendon transfer surgery for irreparable posterosuperior rotator cuff (RC) tears is largely unknown, the primary aim of this study was to evaluate the long-term outcome of the teres major transfer. We also aimed to report on the results of a cohort of patients with a similar indication for surgery that underwent a latissimus dorsi tendon transfer.

Patients and Methods

Patients and Methods In this prospective cohort study, we reported on the long-term results of 20 consecutive patients with a teres major tendon transfer for irreparable massive posterosuperior RC tears. Additionally, we reported on the results of the latissimus dorsi tendon transfer (n = 19). The mean age was 60 years (47 to 77). Outcomes included the Constant score (CS), and pain at rest and during movement using the Visual Analogue Scale (VAS).

Results

At a mean of ten years (8 to 12) following teres major transfer, the CS was still 23 points (95% confidence interval (CI) 14.6 to 30.9, p < 0.001) higher than preoperatively. VAS for pain at rest (21 mm, 95% CI 4.0 to 38.9, p = 0.016) and movement (31 mm, 95% CI 16.0 to 45.1, p < 0.001) were lower than preoperatively. We also found an increase in CS (32 points, 95% CI 23.4 to 40.2, p < 0.001) and reduction of pain (26 mm, 95% CI 9.9 to 41.8, p = 0.001) six years after latissimus dorsi transfer.

Conclusion

Teres major tendon transfer is a treatment option to gain shoulder function and reduce pain in patients with an irreparable posterosuperior RC tear at a mean follow-up of ten years. The teres major tendon might be a valuable alternative to the commonly performed latissimus dorsi tendon transfer in the treatment of irreparable posterosuperior RC tears. Cite this article: Bone Joint J 2018;100-B:309-17.

Variants of latissimus dorsi with a perspective on tendon transfer surgery: an anatomic study

BACKGROUND

The latissimus dorsi (LD) is often used for tendon transfers to treat massive irreparable posterosuperior rotator cuff tears. The operation requires the LD tendon to be mobilized to reduce tension on the tendon. In that respect, any connection between the LD tendon and contiguous muscles may hamper tendon mobility and affect the surgical outcome. The goal of this study was to document the occurrence of connections between the LD and adjacent muscles and nerves.

METHODS

We studied the scapular region on 48 embalmed cadavers. The skin and superficial fascia were removed according to Cunningham's manual of dissection, and the muscle was exposed.

RESULTS

It was found that the LD and teres major (TM) muscles are connected by muscle fibers in 10% of the cadavers studied. Another vital discovery was that in some cadavers, the LD tendon was penetrated by a nerve.

CONCLUSION

Fascial connections between the LD and TM are well known, but these muscle links are comparatively unusual. From the results of this study, one should pay particular attention to muscle links between the LD and TM during dissection of the LD for transfer. It can also be suggested that during transfer surgery, the LD tendon should be cautiously examined for the possibility of a nerve penetrating it.

Management of Failed Rotator Cuff Repair in Young Patients

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears

BACKGROUND

Teres major (TM) transfer and latissimus dorsi (LD) transfer are essential treatment options in patients with posterosuperior rotator cuff (RC) tears. The purpose of this study was to quantify shoulder kinematics before and after TM transfer and LD transfer in posterosuperior RC tear patients.

METHODS

In this prospective cohort study, we quantitatively measured shoulder movements using an electromagnetic tracking device (Flock of Birds) preoperatively and 1 year after either TM (n = 13) or LD (n = 9) tendon transfer. Additional outcome measures included the Constant score (CS), patient-reported pain, and quantitative range of motion. Scapular kinematics were evaluated during arm abduction.

RESULTS

By use of a quantitative assessment, forward flexion (from 87° to 106°, P = .007), abduction (from 86° to 106°, P = .010), and external rotation in abduction (from 52° to 70°, P = .019) improved. Both transfers reduced pain (from 50 to 10 mm, P < .001), and the CS improved (from 37 to 62 points, P < .001). No significant differences in postoperative improvement in pain and function were found between TM and LD tendon transfers. The TM transfer group showed increased scapular lateral rotation compared with the LD transfer group (13°; 95% confidence interval [CI], 4.8° to 21.7°; P = .003). We were unable to detect differences between TM transfer and LD transfer in the change in protraction (3.2°; 95% CI, -6.3° to 12.8°; P = .489) and posterior tilt (3.5°; 95% CI, -3.5° to 10.5°; P = .313).

CONCLUSION

Tendon transfer surgery resulted in an overall improvement in CS, pain relief, and quantitative range of motion in the treatment of an irreparable posterosuperior RC tear. Scapular lateral rotation gradually increased after TM transfer, reminiscent of RC function, whereas such an increase was not observed after LD transfer.

Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review

BACKGROUND

Rotator cuff tears are one of the most common conditions affecting the shoulder. Because of the difficulty in managing massive rotator cuff tears and the inability of standard techniques to prevent arthropathy, surgeons have developed several novel techniques to improve outcomes and ideally alter the natural history.

PURPOSE

To systematically review the existing literature and analyze reported outcomes to evaluate the effectiveness of using a bridging graft reconstruction technique to treat large to massive irreparable rotator cuff tears.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of PubMed, EMBASE, CINAHL, and CENTRAL was employed with the key terms "tear," "allograft," and "rotator cuff." Eligibility was determined by a 3-phase screening process according to the outlined inclusion/exclusion criteria. Data in relation to the primary and secondary outcomes were summarized. The results were synthesized according to the origin of the graft and the level of evidence.

RESULTS

Fifteen studies in total were included in this review: 2 comparative studies and 13 observational case series. Both the biceps tendon and the fascia lata autograft groups had significantly superior structural integrity rates on magnetic resonance imaging at 12-month minimum follow-up when compared with their partial primary repair counterparts (58% vs 26%, P = .036; 79% vs 58%, P < .05), respectively. Multiple noncomparative case series investigating allografts, xenografts, and synthetic materials for bridging reconstruction of large to massive rotator cuff tears demonstrated high structural healing rates (74%-90%, 73%-100%, and 60%-90%, respectively). Additionally, both comparative studies and case series demonstrated a general improvement of patients' functional outcome scores.

CONCLUSION

Using a graft for an anatomic bridging rotator cuff repair results in improved function on objective testing and may be functionally better than nonanatomic or partial repair of large to massive rotator cuff tears. Allograft or xenograft techniques appear to be favorable options, given demonstrated functional improvement, imaging-supported graft survival, and lack of harvest complication risk. More high-quality randomized controlled studies are needed to further assess this technique.

[Irreparable rotator cuff tears. Debridement, partial reconstruction, tendon transfer or reversed shoulder arthroplasty]

Therapeutic options for the treatment of irreparable rotator cuff tears are fluent, are dependent on the patients' claims and demands and on the grade of the ongoing cuff tear arthropathy.A partial rotator cuff reconstruction with sufficient tenolysis combined with interval slide techniques to restore the anterior and posterior force couple may be indicated if there is no fatty degeneration > grade 3 of the rotator cuff muscles in a well-centered joint. The margin convergence technique with side-by-side adaptation of the tendon limbs may reduce the load on the reconstructed tendons.The role of the suprascapular nerve, which can probably be constricted by the retracted rotator cuff, and its therapy has not been completely clarified. When distinct symptoms are present neurolysis may be reasonable.Tendon transfers can be indicated in a cooperative patient < 65 years with a higher grade of muscular atrophy but without degenerative changes > grade II according to Hamada with the loss of active external rotation but performable active flexion. For posterosuperior tears the latissimus dorsi or recently the teres major tendon transfer to the rotator cuff footprint may be appropriate. For nonreconstructable anterosuperior tears a partial transfer of the pectoralis major tendon is possible.Careful subacromial debridement combined with biceps tenotomy and a cautious or reversed decompression may reduce the pain temporarily without having an influence on active motion until with the loss of active elevation the indication for a reversed shoulder arthroplasty is reached.In the mean time, absorbable subacromial spacers may re-center the humeral head, but the effectiveness of this therapy on clinical outcome should be analyzed in further studies.

Tendon transfers for irreparable rotator cuff tears: An update

Shoulder dysfunction in the setting of irreparable rotator cuff tears (RCTs) can be treated successfully with different types of tendon transfer: Latissimus dorsi transfer for irreparable posterosuperior RCTs works best for young, active patients with an intact subscapularis, no pseudoparalysis or previous surgery, and a functioning teres minor.A more anatomical transfer for irreparable posterosuperior RCTs is a lower trapezius transfer, and early results are promising.Isolated irreparable tears of the subscapularis can be successfully managed with pectoralis major tendon transfer with a concentric humeral head. However, restricted external rotation (ER) may occur, depending on technique.Pectoralis minor transfer can successfully address combination irreparable tears of the upper border subscapularis and the supraspinatus without significant loss of ER.Rotator cuff arthropathy with ER lag benefits most from a reverse total shoulder arthroplasty and a combination latissimus dorsi and teres major transfer (LDTMT) regardless of patient age. Cite this article: Axe JM. Tendon transfers for irreparable rotator cuff tears: An update. EFORT Open Rev 2016;1:18-24. doi: 10.1302/2058-5241.1.000003.

Patterns of Age-Associated Degeneration Differ in Shoulder Muscles

Shoulder complaints are common in the elderly and hamper daily functioning. These complaints are often caused by tears in the muscle-tendon units of the rotator cuff (RC). The four RC muscles stabilize the shoulder joint. While some RC muscles are frequently torn in shoulder complaints others remain intact. The pathological changes in RC muscles are poorly understood. We investigated changes in RC muscle pathology combining radiological and histological procedures. We measured cross sectional area (CSA) and fatty infiltration from Magnetic Resonance Imaging with Arthrography (MRA) in subjects without (N = 294) and with (N = 109) RC-tears. Normalized muscle CSA of the four RC muscles and the deltoid shoulder muscle were compared and age-associated patterns of muscle atrophy and fatty infiltration were constructed. We identified two distinct age-associated patterns: in the supraspinatus and subscapularis RC muscles CSAs continuously declined throughout adulthood, whereas in the infraspinatus and deltoid reduced CSA was prominent from midlife onwards. In the teres minor, CSA was unchanged with age. Most importantly, age-associated patterns were highly similar between subjects without RC tear and those with RC-tears. This suggests that extensive RC muscle atrophy during aging could contribute to RC pathology. We compared muscle pathology between torn infraspinatus and non-torn teres minor and the deltoid in two patients with a massive RC-tear. In the torn infraspinatus we found pronounced fatty droplets, an increase in extracellular collagen-1, a loss of myosin heavy chain-1 expression in myofibers and an increase in Pax7-positive cells. However, the adjacent intact teres minor and deltoid exhibited healthy muscle features. This suggests that satellite cells and the extracellular matrix may contribute to extensive muscle fibrosis in torn RC. We suggest that torn RC muscles display hallmarks of muscle aging whereas the teres minor could represent an aging-resilient muscle.

Bipolar Posterior Deltoid Transfer for Massive Rotator Cuff Tears: A Report on 2 Patients

A transfer of the posterior deltoid innervated by the posterior branch of the axillary nerve and vascularized by the posterior circumflex humeral artery is described for irreparable tears of the supra- and infraspinatus muscle tendons. Functionally useful abduction and flexion were restored in 2 patients.

Assessment and treatment strategies for rotator cuff tears

Tears of the rotator cuff are common and becoming an increasingly frequent problem. There is a vast amount of literature on the merits and limitations of the various methods of clinical and radiological assessment of rotator cuff tears. This is also the case with regard to treatment strategies. Certain popular beliefs and principles practiced widely and the basis upon which they are derived may be prone to inaccuracy. We provide an overview of the historical management of rotator cuff tears, as well as an explanation for how and why rotator cuff tears should be managed, and propose a structured methodology for their assessment and treatment.

The minimal detectable change of the Constant score in impingement, full-thickness tears, and massive rotator cuff tears

HYPOTHESIS

The purpose of this study was to determine the minimal detectable change (MDC) for the Constant score in patients with impingement, a supraspinatus tear, or a massive rotator cuff (RC) tear as observed changes smaller than the MDC might be the result of measurement error.

METHODS

The Constant score was recorded in a total of 180 patients, including 34 patients with impingement, 105 with supraspinatus tears, and 41 with massive RC tears. We assessed the MDC in the 3 subgroups and total group using the samples standard deviation (SD), internal consistency (Cronbach α), and standard error of the measurement. Floor and ceiling effects were also reported.

RESULTS

The absolute mean Constant score was 72 (SD, 11.2) in the impingement group, 44 (SD, 14.7) in the supraspinatus tear group, and 46 (SD, 18.9) in the massive RC tear group. There were no floor and ceiling effects for the absolute Constant score. In the total group, the internal consistency was 0.8 and the standard error of the measurement was 8. The MDC was 23 points on the Constant score in the total group and 17, 18, and 23 points on the Constant score for impingement, RC tears, and massive RC tears, respectively.

CONCLUSION

This study demonstrates that the MDCs of the Constant score are different in patients with impingement, supraspinatus tears, and massive RC tears. Studies reporting the Constant score should be interpreted by use of the population-specific MDC and minimal clinical important change.

Multivariate analyses of rotator cuff pathologies in shoulder disability

Background

Disability of the shoulder joint is often caused by a tear in the rotator cuff (RC) muscles. Four RC muscles coordinate shoulder movement and stability, among them the supraspinatus and infraspinatus muscle which are predominantly torn. The contribution of each RC muscle to tear pathology is not fully understood. We hypothesized that muscle atrophy and fatty infiltration, features of RC muscle degeneration, are predictive of superior humeral head translation and shoulder functional disability.

Methods

Shoulder features, including RC muscle surface area and fatty infiltration, superior humeral translation and RC tear size were obtained from a consecutive series of Magnetic Resonance Imaging with arthrography (MRA). We investigated patients with superior (supraspinatus, n = 39) and posterosuperior (supraspinatus and infraspinatus, n = 30) RC tears, and patients with an intact RC (n = 52) as controls. The individual or combinatorial contribution of RC measures to superior humeral translation, as a sign of RC dysfunction, was investigated with univariate or multivariate models, respectively.

Results

Using the univariate model the infraspinatus surface area and fatty infiltration in both the supraspinatus and infraspinatus had a significant contribution to RC dysfunction. With the multivariate model, however, the infraspinatus surface area only affected superior humeral translation (p<0.001) and discriminated between superior and posterosuperior tears. In contrast neither tear size nor fatty infiltration of the supraspinatus or infraspinatus contributed to superior humeral translation.

Conclusion

Our study reveals that infraspinatus atrophy has the strongest contribution to RC tear pathologies. This suggests a pivotal role for the infraspinatus in preventing shoulder disability.

No prosthetic management of massive and irreparable rotator cuff tears

A massive rotator cuff tear is not necessarily irreparable. Number of tendons involved, muscle-tendon unit quality, and decreased acromionhumeral distance (AHD) are as important as tear size in determining reparability of lesion. Massive and irreparable rotator cuff tears cannot be anatomically repaired to the bone and are a common source of pain and disability even in middle-aged patients. In these patients when conservative management has failed, it is possible to perform different surgical techniques. A functional repair can help to restore the horizontal force couple of the cuff on the humeral head and to increase the AHD. Debridement of irreparable tears and biceps tenotomy or tenodesis can have a role in low functional demand patients but results deteriorate over time. Recently, several commercially available tissue-engineered biological and synthetic scaffolds have been developed to augment rotator cuff repairs. The aim is to provide a mechanical improvement in case of poor quality tissue at time zero and give a support to have a better cuff healing. In selected cases, the scaffold can be used also to bridge tendon defect. Patients who not have pseudoparalysis, cuff tear arthropathy and with intact deltoid function can benefit from tendon transfers with satisfactory outcomes. These different procedures should be chosen for each patient with selected criteria and after a satisfactory explanation about the really possible expectation after surgery.

Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation?

HYPOTHESIS

The purpose of this study is to evaluate the muscle activity with surface electromyography (EMG) and the clinical outcome of the latissimus dorsi transfer. It remains unclear whether the clinical results of the latissimus dorsi transfer for massive posterosuperior rotator cuff tears are achieved either by active muscle contractions or by a passive tenodesis effect of the transfer.

METHODS

Eight patients were evaluated preoperatively and at 1 year (SD, 0.1) after the latissimus dorsi transfer. Clinical evaluation of outcomes included active range of motion, Constant score, and visual analog scale (VAS) for pain and activities of daily living (ADL). Muscle activity was recorded with EMG during directional isometric abduction and adduction tasks.

RESULTS

The external rotation in adduction improved from 23° to 51° (P = .03). The external rotation in abduction improved from 10° to 70° (P = .02). The mean Constant score improved from 39 to 62 postoperatively (P = .01). The VAS for pain at rest improved from 3.3 preoperatively to 0.1 (P = .02). The VAS for ADL improved from 4.9 to 2.3 (P = .05). The transferred latissimus dorsi remained active in all cases, as reflected by increased latissimus dorsi EMG activity during abduction tasks. In addition, the latissimus dorsi EMG activity shifted from preoperative antagonistic co-activation in adduction to synergistic activation in abduction.

CONCLUSION

The latissimus dorsi has synergistic muscle activity after transfer. Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. A specific gain was observed for external rotation in elevated arm positions, a motion essential for ADL tasks.