The Role of Tendon Transfers in Massive Rotator Cuff Tears

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Massive irreparable rotator cuff tears (RCT) continue to pose a unique challenge. We will limit our focus to the role of cuff reconstruction utilizing latissumus dorsi (LD) and/or pectoralis major (PMaj) transfer in an attempt to restore pain-free shoulder function.

Rationale

A massive RCT is defined as a tear exceeding 5 cm or one that involves at least two tendons.1 Late repair of such a large tear has been associated with a high failure rate.2 Goutallier has noted a positive correlation between the chronicity of the cuff tear and the presence of both atrophy and increasing muscular infiltration by fat.3 Unfortunately, once established, these changes have been shown to be irreversible following repair.3-6

The individual rotator cuff (RC) muscles act collectively to centre the humeral head upon the glenoid, providing a stable fulcrum for efficient deltoid function. This collective balance provided by the RC has been termed the “force couple.”7 Biomechanical contribution to the force couple is asymmetric: the subscapularis contributes the majority (52%), while the posteriosuperior RC contributes the remainder (supraspinatus 15%, infraspinatus and teres minor 33%).7-9 Based on these principles, it is apparent that restoration of the force couple is critical during cuff surgery.

In situations not amenable to complete repair, marginal convergence may provide satisfactory glenohumeral joint balance, allowing optimal deltoid activity.10 If, however, a significant area of posterosuperior/antersuperior tendon is dysfunctional or absent (irreparable), the centralizing vector of the tendon(s) is lost and superior humeral migration will occur. This may lead to suboptimal deltoid function and pain.

The purpose of a vascularized tendon transfer is to behave in part as a humeral head depressor while, secondarily, providing a biomechanical vector that restores as close to normal shoulder mechanics as possible.11

Latissumus Dorsi

The ideal patient for LD tendon transfer is a young male labourer with shoulder pain and a documented irreparable posterosuperior RCT.12-15 On exam, active forward elevation, although laboured, should be maintained,  while external rotation (ER) strength is notably reduced (positive ER lag sign, positive Hornblower’s sign).

Absolute contraindications include:

  • Active infection
  • Advanced arthritis
  • Static proximal humeral migration with or without arthritis (cuff tear arthropathy)
  • Associated pseudoparalysis
  • Older patients unable to comply with rehabilitation

Appropriate investigations for potential candidates include plain radiography and MRI (Figure 1).


Figure 1. A. Sagittal MRI with fatty infiltration of supraspinatus (SS) and infraspinatus (IS) and normal musculature of subscapularis (SSc); note infraspinatus with significant fat infiltration on this medial cut; however, ideal cross-sectional image best taken 1-2 saggital sections medial to the glenoid face. Supraspinatus appears well preserved on this image although is often similarly affected in most cases B. Axial MRI with deficient posterosuperior RC (arrow) and retraction to glenoid face.


LD transfer, originally described for Erb’s Palsy, utilizes autogenous, innervated and vascularized tissue16 in an attempt to recreate the absent posterior force couple normally provided by the posterosuperior rotator cuff 17 (Figures 2a-e). Gerber,11 observed pain-free motion and restoration of flexion, abduction, and external rotation 12-15 months postoperatively. The authors attributed these results to both the tenodesis effect of the transfer as well as active contraction of the transferred muscle.18 Literature supporting the use of LD tendon transfer has shown the procedure to be of benefit 5 years after surgery.19 Other authors have also documented reduced pain and functional improvement following transfer.11-13,15,19


Figures 2a-b.


Figures 2c-d.


Figure 2e.

Figures 2a-e. Illustration of latissimus dorsi transfer to posterosuperior greater tuberosity. A. Posterior view of teres minor, deltoid, and latissimus dorsi. B. Identification of the anterior insertion of the latissimus dorsi. C. Tendon passage subdeltoid and onto the (D.) posterosuperior greater tuberosity. E. Clinical photo of latissimus dorsi tendon ready for transfer. Images courtesy of Dr. C. Gerber and Dr. D. Drosdowech.


Poor predictors of outcome following tendon transfer include:

  • Females
  • Preoperative range of motion/strength deficits
  • Out-of-phase LD contraction15

Other negative prognosticators include:

  • Associated upper fiber subscapularis tears20
  • Advanced fatty atrophy of the teres minor21
  • Transfer for previously failed repair22

These variables continue to be debated.13,19,23

Pectoralis Major

Chronic, irreparable tears of the subscapularis can be addressed by transfer of the PMaj tendon. This tendon is thought to provide an anterior buttress while providing a vector of pull similar to that of the subscapularis.

To maximize the function of this transfer, the ideal position (subcoracoid vs supracoracoid) remains controversial24,25 (Figures 3a-c). Jost et al employed this transfer in 11 patients and noted that more than 80% had symptomatic improvement postoperatively26. Others have reported similar results25, 27.


Figure 3a.


Figure 3b.


Figure 3c.

Figures 3a-c. A. Preoperative axial MRI demonstrating complete and retracted tear of the subscapularis (arrow heads), biceps tendon (asterix) and infraspinatus (arrow). B Sagittal MRI of fat infiltrated subscapularis (arrow heads), supraspinatus (single asterix) and infraspinatus (double asterix) with near normal muscle. C. Clinical picture of supra-coracoid pectoralis major transfer; coracoid (CC), conjoint tendon (CT), and pectoralis major (PM)

Combined Transfers

Combined transfer of the LD and the PMaj for massive rotator cuff tears can be attempted in the face of a global, massive RCT in a younger, active individual. This may well be the only reconstructive option in this group of patients to restore active function and pain control without resorting to salvage-type procedures such as glenohumeral arthrodesis or reverse total shoulder arthroplasty.

Aldridge et al followed 11 patients (mean age 53.4 years) for 24-42 months following combination tendon transfer. The authors noted 7 of the 11 patients demonstrated functional improvements following combined transfer28. To date, we have rarely used this approach in our practice and any conclusions remain anecdotal.

Conclusion

If restoration of normal glenohumeral mechanics remains the primary goal in the management of massive, irreparable RCTs, then autogenous tendon transfer remains the only reasonable option. The ideal patient in our experience is the younger, active labourer who is willing to comply with an extensive, customized rehabilitation programme under the guidance of a well-informed therapist. Provided these prerequisites are met, the literature suggests that improved and durable patient outcomes may be obtained.

References

  1. Cofield R.H. Rotator cuff disease of the shoulder. J Bone Joint Surg Am. Jul 1985;67(6):974-979.
  2. DeOrio J.K., Cofield R.H. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. Apr 1984;66(4):563-567.
  3. Goutallier D., Postel J.M., Bernageau J., Lavau L., Voisin M.C. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. Jul 1994(304):78-83.
  4. Gladstone J.N., Bishop J.Y., Lo I.K., Flatow E.L. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med. May 2007;35(5):719-728.
  5. Rubino L.J., Sprott D.C., Stills H.F., Jr., Crosby L.A. Fatty infiltration does not progress after rotator cuff repair in a rabbit model. Arthroscopy. Aug 2008;24(8):936-940.
  6. Gerber C., Schneeberger A.G., Hoppeler H., Meyer D.C. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients. J Shoulder Elbow Surg. Nov-Dec 2007;16(6):691-696.
  7. Inman V.T., Saunders J.B., Abbott L.C. Observations of the function of the shoulder joint. 1944. Clin Orthop Relat Res. Sep 1996(330):3-12.
  8. Burkhart S.S., Esch J.C., Jolson R.S. The rotator crescent and rotator cable: an anatomic description of the shoulder's "suspension bridge". Arthroscopy. 1993;9(6):611-616.
  9. Burkhart S.S. Biomechanics of rotator cuff repair: converting the ritual to a science. Instr Course Lect. 1998;47:43-50.
  10. Burkhart S.S., Lo, I.K.Y., Brady, P.C. Burkhart's View of the Shoulder: A Cowboy's Guide to Advanced Shoulder Arthroscopy. 2005.
  11. Gerber C., Vinh T.S., Hertel R., Hess C.W. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res. Jul 1988(232):51-61.
  12. Warner J.J. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect. 2001;50:63-71.
  13. Elhassan B., Endres N.K., Higgins L.D., Warner J.J. Massive irreparable tendon tears of the rotator cuff: salvage options. Instr Course Lect. 2008;57:153-166.
  14. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. Feb 1992(275):152-160.
  15. Iannotti J.P., Hennigan S., Herzog R., et al. Latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears. Factors affecting outcome. J Bone Joint Surg Am. Feb 2006;88(2):342-348.
  16. L'Episcopo J.B. Tendon transplantation in obsetrical paralysis. Am J Surg. 1934;25:122.
  17. Morelli M., Nagamori J., Gilbart M., Miniaci A. Latissimus dorsi tendon transfer for massive irreparable cuff tears: an anatomic study. J Shoulder Elbow Surg. Jan-Feb 2008;17(1):139-143.
  18. Irlenbusch U., Bernsdorf M., Born S., Gansen H.K., Lorenz U. Electromyographic analysis of muscle function after latissimus dorsi tendon transfer. J Shoulder Elbow Surg. May-Jun 2008;17(3):492-499.
  19. Miniaci A., MacLeod M. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review. J Bone Joint Surg Am. Aug 1999;81(8):1120-1127.
  20. Aoki M., Okamura K., Fukushima S., Takahashi T., Ogino T. Transfer of latissimus dorsi for irreparable rotator-cuff tears. J Bone Joint Surg Br. Sep 1996;78(5):761-766.
  21. Costouros J.G., Espinosa N., Schmid M.R., Gerber C. Teres minor integrity predicts outcome of latissimus dorsi tendon transfer for irreparable rotator cuff tears. J Shoulder Elbow Surg. Nov-Dec 2007;16(6):727-734.
  22. Warner J.J., Parsons I.M. Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg. Nov-Dec 2001;10(6):514-521.
  23. Birmingham P.M., Neviaser R.J. Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation. J Shoulder Elbow Surg. Nov-Dec 2008;17(6):871-874.
  24. Klepps S.J., Goldfarb C., Flatow E., Galatz L.M., Yamaguchi K. Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers. J Shoulder Elbow Surg. Sep-Oct 2001;10(5):453-459.
  25. Resch H., Povacz P., Ritter E., Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am. Mar 2000;82(3):372-382.
  26. Jost B,. Puskas G.J. Lustenberger A., Gerber C. Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears. J Bone Joint Surg Am. Oct 2003;85-A(10):1944-1951.
  27. Galatz L.M., Connor P.M., Calfee R.P., Hsu J.C., Yamaguchi K. Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency. J Shoulder Elbow Surg. Jan-Feb 2003;12(1):1-5.
  28. Aldridge J.M., 3rd, Atkinson T.S., Mallon W.J. Combined pectoralis major and latissimus dorsi tendon transfer for massive rotator cuff deficiency. J Shoulder Elbow Surg. Nov-Dec 2004;13(6):621-629.

Reprinted with permission from the Spring 2009 issue of COA Bulletin

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