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Combined pectoralis major and latissimus dorsi tendon transfer for massive rotator cuff deficiency
Combined pectoralis major and latissimus dorsi tendon transfer for massive rotator cuff deficiency J. Mack Aldridge III, MD,a Todd S. Atkinson, MD,a and William J. Mallon, MD,b Durham, NC
This report is a retrospective review of 11 consecutive patients treated with a combined transfer of the latissimus dorsi and pectoralis major tendons for massive rotator cuff deficiency. Each patient’s chief complaint was diminished shoulder function and motion with little or no accompanying pain. The primary operative objective was to increase active shoulder motion. All 11 patients were followed up for at least 2 years (range, 24 to 42 months). The mean active elevation improved from 42° preoperatively to 86° postoperatively. The mean active external rotation improved from 0° to 13°. On the basis of the Medical Research Council scale, the mean abduction strength improved from 2.3 to 3.1 and the mean external rotation strength improved from 2.1 to 2.7. Overall, 4 patients made no improvement, 2 improved slightly, and 5 improved significantly. We conclude that a combined transfer of the latissimus dorsi and pectoralis major is a reasonable and safe procedure that may restore active elevation and external rotation in some patients’ shoulders with a massive rotator cuff deficiency that have not responded favorably to traditional nonoperative and operative techniques. However, it is difficult to conclude, based on our experience, for which patients this surgery can be predictably successful. (J Shoulder Elbow Surg 2004;13:621-629.)
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n addition to providing strength, the rotator cuff stabilizes the glenohumeral joint dynamically. The muscular forces of the posterior cuff (infraspinatus and teres minor) balance those of the anterior cuff (subscapularis) to provide stability in the transverse plane.4,9 The inferior vector of the infraspinatus, teres minor, and subscapularis also provides stability in the coronal plane as it counteracts the deltoid’s tendency to pull the humeral head superiorly.3,9,31 From the Division of Orthopaedic Surgery, Duke University Medical Center, and Triangle Orthopaedic Associates. Reprint requests: Julian M. Aldridge III, MD, PO Box 3000, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710. (E-mail: [email protected]) Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.04.003
Rotator cuff tears involving only the supraspinatus tendon are often either asymptomatic or responsive to nonoperative treatment.10,33,42 However, if the tear extends into the posterior or anterior cuff, the balanced fulcrum is disturbed, leaving the humeral head prone to subluxation.10 As a result, the patient often has pain and weakness, neither of which responds well to nonoperative treatment.12,15,48 Rotator cuff repair, either open or arthroscopic, is the standard treatment for most rotator cuff tears unresponsive to nonoperative management (eg, physical therapy, nonsteroidal anti-inflammatory drugs, activity modification).11,14,17 When the tear is acute or subacute or involves less than two tendons, the procedure is relatively easy40 and enjoys a high success rate.1,5,12,13,19,20 Conversely, repair of a chronic, retracted tear involving two or more tendons is technically more difficult39,40 and associated with a less predictable success rate.6,8,12,16,30,34,43 Mobilization of the contracted musculotendinous unit necessitates medial release of adhesions, the coracohumeral ligament, and cuff-glenoid attachments, placing the suprascapular nerve at risk as it travels underneath the supraspinatus and infraspinatus muscles.53 In addition, repair often requires the arm to be abducted and the tendon to be repaired under tension. This may explain why 50% to 70% of massive rotator cuff repairs retear postoperatively.23,26,27,28,44 Magnetic resonance imaging (MRI) studies suggest that even a successful repair (ie, one that does not retear) may not be the ideal solution for a chronic, massive tear, in that weakness and/or pain may persist. Gerber et al26 showed that fatty degeneration continues to occur in the cuff’s musculature even after an adequate repair. They also showed that muscular atrophy in the repaired infraspinatus, subscapularis, and teres minor tendons was irreversible.26 These technical difficulties and persistent anatomic and pathologic changes help explain why many authors report inferior results with repair of chronic, massive tears compared to smaller more acute tears.6,16,38,47,50 As such, some authors favor debridement of massive and irreparable rotator cuff tears with simultaneous subacromial decompression.7,9,21,37,46 Unfortunately, this still leaves the humeral head at risk for anterosuperior escape, partic-
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ularly if the surgeon excises the coracoacromial ligament during the subacromial decompression. Although initial studies described satisfactory results for repair of chronic massive and retracted cuff tears,7,18,35,45 more recent studies have shown that the results deteriorate with time.22,54 In addition, the patients’ functional gain is limited by, and dependent on, the degree of pain relief afforded by the repair. In salvage situations, in an attempt to restore active shoulder motion, we began reconstructing massive, retracted rotator cuff tears. Transferring the pectoralis major for patients with anterior cuff tears49,51 and the latissimus dorsi for patients with posterior cuff tears2,24,36 has been documented. The purpose of this study is to report a series of patients in whom we simultaneously transferred the latissimus dorsi and pectoralis major muscles for shoulders with massive rotator cuff deficiencies involving both the posterior and the anterior cuff. MATERIALS AND METHODS We reviewed retrospectively 11 consecutive patients who underwent the operation between 1993 and 1996. The indications for surgery were either a massive (⬎5 cm) cuff tear with posterior and anterior extension or complete rotator cuff deficiency. In addition, all were unresponsive to nonoperative management and/or had failed previous attempts at rotator cuff repair. All of the tears involved less than 50% of the subscapularis. There were 10 patients with MRI-documented massive rotator cuff tears and 1 patient with Parsonage-Turner syndrome who clinically demonstrated complete rotator cuff deficiency. Inclusion criteria were (1) massive rotator cuff deficiency, (2) an inability to elevate the arm effectively about the glenohumeral joint, and (3) a chief complaint of weakness. Preoperatively, all patients stated that they had either mild or no pain at rest or with activities. Exclusion criteria included the presence of glenohumeral joint osteoarthritis and/or a predominant complaint of pain either at rest or with activities. We did not exclude patients with preoperative superior subluxation of the humeral head on shoulder radiographs. Preoperatively, we emphasized three points to the patients. First, we established that the principal purpose of the operation was to restore function, not to relieve pain. Second, we outlined realistic but limited goals. We chose as a good result the ability to elevate the arm actively to 90° and the ability to place one’s open palm actively to the back of one’s head, indicating restoration of both active elevation and external rotation. Finally, we explained the necessity for a very long and diligent rehabilitation period. The operative procedure is shown in Figures 1 through 5. It combines elements of the Sever-L’Episcopo procedure32 for brachial plexus birth palsies with the pectoralis major transfer for subscapularis deficiency. We originally performed the transfer through two incisions, with the primary approach through a standard deltopectoral interval. Through this approach, the entire pectoralis major tendon (sternocostal and clavicular heads) is removed from its insertion lateral to the intertubercular groove, and the latissimus dorsi tendon is re-
Figure 1 Anterior extension of rotator cuff tear.
Figure 2 Mobilization of pectoralis major.
moved from its insertion medial to the groove. The pectoralis major is transferred and repaired to the anterolateral-superior aspect of the humeral head and to the superior remnant of the subscapularis tendon. This is usually over the superior aspect of the intertubercular groove. Mobilization of the pectoralis tendon is facilitated by both sharp and blunt dissection with control of the tendinous stump imparted by a large (No. 2) grasping braided suture. The latissimus dorsi tendon is passed posteriorly through the quadrilateral space inferior to the axillary nerve and posterior humeral circumflex artery by approx-
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Figure 3 Pectoralis major transfer. Note advancement superiorly to restore active elevation.
Figure 4 Posterior extension of rotator cuff tear.
imately 1 cm (usually 1 fingerbreadth) and then transfixed to the posterolateral aspect of the humerus. The latissimus transfer is performed for function only; we did not attempt to cover the humeral head as in the transfer described by Gerber et al.24,25 Care is taken to protect the axillary nerve and the posterior humeral circumflex artery when passing the latissimus dorsi tendon through the quadrilateral space. The quadrangular space is expanded with digital pressure only. The latissimus dorsi tendon is then repaired to the posterosuperior aspect of the humeral head and to the remnant of the infraspinatus or teres minor tendon via a smaller posterolateral incision. The posterior incision was omitted in the last 3 patients because the latissimus dorsi could be repaired through the
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Figure 5 Latissimus dorsi tendon transfer. The latissimus transfer is attached to any residual cuff of tissue from the teres minor or infraspinatus to restore active external rotation.
deltopectoral approach with exaggerated internal rotation of the humeral head. The humeral head was maintained in neutral rotation and 20° of abduction when the transposed tendons were reattached to their new location. Drill holes or suture anchors were used when fixing the tendons to bone, and figure-of-eight stitches were used when repairing the tendons to soft tissue. A large (No. 2) braided nonabsorbable suture was used in all repairs. Postoperatively, each patient’s arm was kept in an abduction brace for 6 weeks. Earlier in the study, a full shoulder-arm orthosis was used, but more recently, the Ultra-Sling (DonJoy) has been the favored means of immobilization. Patients’ arms were then placed in a sling for 3 weeks, during which time physical therapy was initiated. Rehabilitation initially consisted of passive and active-assisted range-of-motion exercises. A monitored physical therapy program continued for at least 3 months after surgery. We actively followed up the patients at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year and, thereafter, at 3- to 6-month intervals. Elevation, external rotation, strength in abduction, and strength in external rotation were tested and recorded by the senior author at each visit. Statistical analysis on the results was performed with an Excel spreadsheet statistical program.
RESULTS Patients’ ages, number of previous surgeries, diagnoses, and length of follow-up are summarized in Table I. The mean age was 53.4 years (range, 40 to 71 years). There were 9 men and 2 women. Follow-up averaged 30.5 months (range, 24 to 42 months). The cohort averaged 1.9 previous surgeries (range, 0 to 3). All previous surgeries involved repair of the rotator cuff. The mean preoperative active
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Table I Patient demographics
Patient No. 1 2 3 4 5 6 7 8 9 10 11 Mean SD
Age (y)
Sex
Condition
42 68 58 46 60 45 71 67 40 44 46 53.36* 11.08*
F F M M M M M M M M M
PTS MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT
Follow-up (mo)
No. of previous surgeries
Preoperative pain score
Postoperative pain score
24 24 42 36 24 24 36 39 36 24 27 30.545 6.867
0 2 2 3 2 2 0 2 3 3 2 1.909 0.996
0 0 0 4 0 8 2 0 2 0 0 1.45 2.43
0 0 0 6 0 6 2 0 2 0 0 1.46 2.27
PTS, Parsonage-Turner syndrome; MRCT, massive rotator cuff tear. *Scale from 1 to 10 (least to most severe pain).
Figure 6 Measurement of shoulder motion before and after tendon transfers.
elevation was 42° (range, 30° to 60°), whereas the mean preoperative active external rotation was 0° (range, ⫺10° to 20°). All elevation preoperatively was obtained through scapulothoracic motion via a shoulder shrug. Preoperative strength, on the basis of the Medical Research Council scale, averaged 2.3 for abduction (range, 2 to 3) and 2.1 for external rotation (range, 1 to 3). Postoperatively, the mean active elevation improved to 86° (range, 40° to 130°; P ⫽ .0013), whereas the mean active external rotation improved to 13° (range, 0° to 30°; P ⫽ .0033). The extent of improvement in active elevation and active external rotation is represented graphically in Figure 6. Postoperatively, the mean abduction strength improved to
3.1 (range, 2 to 4; P ⫽ .0011) and the mean external rotation strength improved to 2.7 (range, 2 to 4; P ⫽ .0107) (Figure 7). All of these improvements were statistically significant at P ⬍ .05. Correlation was observed between gains in strength and gains in shoulder motion (improvement in strength of elevation correlated to degrees gained in elevation; r ⫽ 0.75, P ⫽ .008; improvement in strength of external rotation correlated to degrees gained in external rotation; r ⫽ 0.55, P ⫽ .80) (Figure 8). Constant and UCLA shoulder scores were determined for all patients both preoperatively and postoperatively. The mean Constant scores improved from 21 to 36 (P ⫽ .0020), whereas the mean UCLA scores improved from 13 to 19 (P ⫽ .0014) (Figure 9).
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Figure 7 Measurement of shoulder elevation (SAB) and external rotation strength (SER) preoperatively (Pre) and postoperatively (Post).
The results reveal a bimodal distribution. Of the 11 patients, 4 effectively made no improvement, 2 improved slightly, and 5 improved significantly, achieving the functional preoperative goals (elevation to 90° and the ability to place the hand behind the head). Statistical analysis of these two groups was carried out separately with a t test. The improved group (patients 5-11) showed statistically significant improvement, whereas the unimproved group (patients 1-4) showed almost no change from preoperative values. The two groups did not differ with regard to age, length of follow-up, activity level, or number of previous surgeries. Of the 11 patients, 7 stated that they were satisfied with their results whereas 4 were dissatisfied. Only 1 of 4 patients in the unimproved group stated that he was satisfied with the result of the operation, compared with 6 of 7 patients in the improved group. The one dissatisfied patient in the improved group attributed his dissatisfaction to continued pain, although he initially denied having preoperative pain. However, he did state that his pain had decreased from its preoperative level. There were no complications of infection or neurologic damage. The only complication occurred in the patient with Parsonage-Turner syndrome (patient 1). Her neurologic disease left her with significant atrophy about the shoulder, although her latissimus dorsi and pectoralis major were intact per a postoperative MRI. Transfer of the pectoralis major also left a defect in the anterior axillary fold, which she found cosmetically displeasing. This latter sequela was the predominant complaint of the patient.
DISCUSSION Massive tears of the rotator cuff are a challenge for even the most seasoned shoulder surgeon.16,29,50 Many of these tears will be immobile, contracted, and irreparable.41 Those amenable to repair face the risk of retearing, increased pain, and limited motion. The prognosis is even more guarded for patients who have undergone several failed surgeries. In an effort to treat this difficult condition, Gerber et al24,25 reconstructed the cuff with the latissimus dorsi tendon to re-establish external rotation. Gerber25 noted that those with massive posterior cuff tears gained 50° of active elevation and 13° of active external rotation. We transferred the latissimus dorsi to the posterosuperior aspect of the humerus as well. However, because the tears in our study also involved the anterosuperior cuff, reconstruction of the posterior cuff alone would likely have resulted in unequal anterior and posterior forces. The biomechanical importance of a balanced fulcrum has been well described by Burkhart.9,10 Its clinical importance can also be demonstrated when examining the results of Gerber.25 Despite a transferred latissimus dorsi, those patients with a torn subscapularis, which was not adequately repaired, failed to benefit from the transfer. This markedly contrasts with the superior results Gerber obtained in patients with a functioning subscapularis. It appears that strengthening the posterior forces is inadequate if the anterior forces remain deficient. We, therefore, included transfer of the pectoralis major to the anterosuperior aspect of the humerus. This transfer has been used by other investigators in the past to treat anterior cuff tears49,51 and was
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Figure 8 A, Changes in strength of shoulder elevation and external rotation. B, Changes in shoulder motion (elevation and external rotation [ER]).
added in an effort to maintain a balanced fulcrum and to avoid the failures seen in the study of Gerber.25 The benefits of the pectoralis major transfer are 2-fold. First, as stated above, restoration of glenohumeral balance is approximated. Second, and perhaps equally if not more important, is the gain in active shoulder elevation imparted by such a transfer. Because of this latter benefit, we did not consider the
amount of subscapularis tear an important determinant in whether to transpose the pectoralis. The patients in our study increased their mean external rotation from 0° to 13°. This closely matches the results of Gerber,25 in which the patients increased their external rotation from 10° to 23°. Our patients gained a mean of 44° of active elevation, similar to the 50° gain obtained by Gerber’s patients.
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Figure 9 Functional grading: UCLA scores (A) and Constant scores (B).
Despite improvement in elevation and external rotation in several of our patients, this procedure is not for everyone with seemingly irreparable cuff tears. Patients must be informed that although this procedure may increase their function, it has not been proven to alleviate pain. The patient also must be
prepared for a lengthy (3 to 6 months) and difficult rehabilitation with a structured physical therapy program. Patients must further understand that only about 50% of them will obtain a good result, which is defined as the ability to elevate the arm to 90° and place the hand behind the head.
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All patients in our study had severe functional limitations preoperatively. Postoperatively, their results were less uniform. In fact, there was a clear bimodal distribution, which we cannot explain or predict. The function of 5 patients increased remarkably such that they achieved the preoperative goal of elevating the arm to 90° and placing the hand behind the head. In contrast, the function of 4 patients did not improve at all. A statistical analysis of the results between the improved group and the unimproved group did not show a difference when controlling for follow-up, the number of previous surgeries, or age. Despite a lack of statistical support, we contend that age should remain an important variable. We attempted, in our study, to limit this to persons aged 60 years or younger. The older patient will likely have more difficulty undergoing the extensive rehabilitation required, especially retraining neurons. Though not statistically significant, it is interesting to note that both women in the study had poor results, but both had possible confounders. One woman had ParsonageTurner syndrome, which was chronic and static. The other had a glenohumeral hemiarthroplasty for an old cuff tear arthropathy. The other 9 patients had massive rotator cuff tears with the native humeral head intact. If the inclusion criteria are narrowed to exclude patients with Parsonage-Turner syndrome or with previous arthroplasties, the results show that 7 of 9 patients improved. Future studies on tendon transfers in patients with neuropathic cuff deficiencies or with glenohumeral arthroplasties due to cuff tear arthropathy would help elucidate whether this particular subset of patients can be helped by this type of procedure. Future studies on massive rotator cuff tears with tighter inclusion criteria would also help identify who would benefit most from a repair or other reconstructive procedure. A review of the literature shows that the results of massive rotator cuff repair not only are unpredictable but also vary greatly between studies. This is, in part, because of the lack of uniformity among studies. Some studies exclude shoulders with chronic, immobile tears as well as those with shortened acromiohumeral distances, whereas others do not. In addition, different authors vary (1) in their definition of massive and (2) in their technique of measuring the tear. These variations make direct comparisons between studies difficult. However, certain studies on massive rotator cuff repairs deserve mention. Gerber et al26 repaired rotator cuff tears involving at least two tendons and noted an increase in elevation of 55°, which is slightly higher than that obtained in our study. Even more impressive is the study of Bigliani et al,6 which showed patients gaining 76° of flexion. In evaluating UCLA scores after massive rotator cuff repairs, Worland et al52 noted that their patients’ scores improved
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from 9 to 30.9, which is markedly better than the increase from 13.3 to 19.2 seen in our study. We did not routinely obtain postoperative images (MRI) of the shoulders in those patients who were either dissatisfied or not improving significantly. We believe that the integrity of the transposed pectoralis can be determined clinically. With that said, such imaging would be of interest and should perhaps be addressed in further studies. Statistical analysis of the results from the improved and unimproved groups does not indicate which patients with massive tears and limited function are most likely to benefit from this procedure. On the basis of our results, we cannot recommend this procedure for those with Parsonage-Turner syndrome or with glenohumeral hemiarthroplasties. Given the superior results seen with massive rotator cuff repair as noted by Gerber,26 Bigliani,5 Worland,52 and others, we also cannot recommend this procedure as a first-line surgical treatment for massive reparable rotator cuff tears. However, we believe that a combined tendon transfer is a viable option for those shoulders either with irreparable rotator cuff tears or in which multiple attempts at repair have failed. We currently recommend a combined pectoralis major and latissimus dorsi transfer in patients aged younger than 60 years, with a tear involving the anterior and posterior cuff, which causes markedly limited function but with minimal to no pain. We view this as a salvage procedure, with the chance to restore active elevation and external rotation in some patients with a serious condition. REFERENCES
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This report is a retrospective review of 11 consecutive patients treated with a combined transfer of the latissimus dorsi and pectoralis major tendons for massive rotator cuff deficiency. Each patient’s chief complaint was diminished shoulder function and motion with little or no accompanying pain. The primary operative objective was to increase active shoulder motion. All 11 patients were followed up for at least 2 years (range, 24 to 42 months). The mean active elevation improved from 42° preoperatively to 86° postoperatively. The mean active external rotation improved from 0° to 13°. On the basis of the Medical Research Council scale, the mean abduction strength improved from 2.3 to 3.1 and the mean external rotation strength improved from 2.1 to 2.7. Overall, 4 patients made no improvement, 2 improved slightly, and 5 improved significantly. We conclude that a combined transfer of the latissimus dorsi and pectoralis major is a reasonable and safe procedure that may restore active elevation and external rotation in some patients’ shoulders with a massive rotator cuff deficiency that have not responded favorably to traditional nonoperative and operative techniques. However, it is difficult to conclude, based on our experience, for which patients this surgery can be predictably successful. (J Shoulder Elbow Surg 2004;13:621-629.)
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n addition to providing strength, the rotator cuff stabilizes the glenohumeral joint dynamically. The muscular forces of the posterior cuff (infraspinatus and teres minor) balance those of the anterior cuff (subscapularis) to provide stability in the transverse plane.4,9 The inferior vector of the infraspinatus, teres minor, and subscapularis also provides stability in the coronal plane as it counteracts the deltoid’s tendency to pull the humeral head superiorly.3,9,31 From the Division of Orthopaedic Surgery, Duke University Medical Center, and Triangle Orthopaedic Associates. Reprint requests: Julian M. Aldridge III, MD, PO Box 3000, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710. (E-mail: [email protected]) Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.04.003
Rotator cuff tears involving only the supraspinatus tendon are often either asymptomatic or responsive to nonoperative treatment.10,33,42 However, if the tear extends into the posterior or anterior cuff, the balanced fulcrum is disturbed, leaving the humeral head prone to subluxation.10 As a result, the patient often has pain and weakness, neither of which responds well to nonoperative treatment.12,15,48 Rotator cuff repair, either open or arthroscopic, is the standard treatment for most rotator cuff tears unresponsive to nonoperative management (eg, physical therapy, nonsteroidal anti-inflammatory drugs, activity modification).11,14,17 When the tear is acute or subacute or involves less than two tendons, the procedure is relatively easy40 and enjoys a high success rate.1,5,12,13,19,20 Conversely, repair of a chronic, retracted tear involving two or more tendons is technically more difficult39,40 and associated with a less predictable success rate.6,8,12,16,30,34,43 Mobilization of the contracted musculotendinous unit necessitates medial release of adhesions, the coracohumeral ligament, and cuff-glenoid attachments, placing the suprascapular nerve at risk as it travels underneath the supraspinatus and infraspinatus muscles.53 In addition, repair often requires the arm to be abducted and the tendon to be repaired under tension. This may explain why 50% to 70% of massive rotator cuff repairs retear postoperatively.23,26,27,28,44 Magnetic resonance imaging (MRI) studies suggest that even a successful repair (ie, one that does not retear) may not be the ideal solution for a chronic, massive tear, in that weakness and/or pain may persist. Gerber et al26 showed that fatty degeneration continues to occur in the cuff’s musculature even after an adequate repair. They also showed that muscular atrophy in the repaired infraspinatus, subscapularis, and teres minor tendons was irreversible.26 These technical difficulties and persistent anatomic and pathologic changes help explain why many authors report inferior results with repair of chronic, massive tears compared to smaller more acute tears.6,16,38,47,50 As such, some authors favor debridement of massive and irreparable rotator cuff tears with simultaneous subacromial decompression.7,9,21,37,46 Unfortunately, this still leaves the humeral head at risk for anterosuperior escape, partic-
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ularly if the surgeon excises the coracoacromial ligament during the subacromial decompression. Although initial studies described satisfactory results for repair of chronic massive and retracted cuff tears,7,18,35,45 more recent studies have shown that the results deteriorate with time.22,54 In addition, the patients’ functional gain is limited by, and dependent on, the degree of pain relief afforded by the repair. In salvage situations, in an attempt to restore active shoulder motion, we began reconstructing massive, retracted rotator cuff tears. Transferring the pectoralis major for patients with anterior cuff tears49,51 and the latissimus dorsi for patients with posterior cuff tears2,24,36 has been documented. The purpose of this study is to report a series of patients in whom we simultaneously transferred the latissimus dorsi and pectoralis major muscles for shoulders with massive rotator cuff deficiencies involving both the posterior and the anterior cuff. MATERIALS AND METHODS We reviewed retrospectively 11 consecutive patients who underwent the operation between 1993 and 1996. The indications for surgery were either a massive (⬎5 cm) cuff tear with posterior and anterior extension or complete rotator cuff deficiency. In addition, all were unresponsive to nonoperative management and/or had failed previous attempts at rotator cuff repair. All of the tears involved less than 50% of the subscapularis. There were 10 patients with MRI-documented massive rotator cuff tears and 1 patient with Parsonage-Turner syndrome who clinically demonstrated complete rotator cuff deficiency. Inclusion criteria were (1) massive rotator cuff deficiency, (2) an inability to elevate the arm effectively about the glenohumeral joint, and (3) a chief complaint of weakness. Preoperatively, all patients stated that they had either mild or no pain at rest or with activities. Exclusion criteria included the presence of glenohumeral joint osteoarthritis and/or a predominant complaint of pain either at rest or with activities. We did not exclude patients with preoperative superior subluxation of the humeral head on shoulder radiographs. Preoperatively, we emphasized three points to the patients. First, we established that the principal purpose of the operation was to restore function, not to relieve pain. Second, we outlined realistic but limited goals. We chose as a good result the ability to elevate the arm actively to 90° and the ability to place one’s open palm actively to the back of one’s head, indicating restoration of both active elevation and external rotation. Finally, we explained the necessity for a very long and diligent rehabilitation period. The operative procedure is shown in Figures 1 through 5. It combines elements of the Sever-L’Episcopo procedure32 for brachial plexus birth palsies with the pectoralis major transfer for subscapularis deficiency. We originally performed the transfer through two incisions, with the primary approach through a standard deltopectoral interval. Through this approach, the entire pectoralis major tendon (sternocostal and clavicular heads) is removed from its insertion lateral to the intertubercular groove, and the latissimus dorsi tendon is re-
Figure 1 Anterior extension of rotator cuff tear.
Figure 2 Mobilization of pectoralis major.
moved from its insertion medial to the groove. The pectoralis major is transferred and repaired to the anterolateral-superior aspect of the humeral head and to the superior remnant of the subscapularis tendon. This is usually over the superior aspect of the intertubercular groove. Mobilization of the pectoralis tendon is facilitated by both sharp and blunt dissection with control of the tendinous stump imparted by a large (No. 2) grasping braided suture. The latissimus dorsi tendon is passed posteriorly through the quadrilateral space inferior to the axillary nerve and posterior humeral circumflex artery by approx-
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Figure 3 Pectoralis major transfer. Note advancement superiorly to restore active elevation.
Figure 4 Posterior extension of rotator cuff tear.
imately 1 cm (usually 1 fingerbreadth) and then transfixed to the posterolateral aspect of the humerus. The latissimus transfer is performed for function only; we did not attempt to cover the humeral head as in the transfer described by Gerber et al.24,25 Care is taken to protect the axillary nerve and the posterior humeral circumflex artery when passing the latissimus dorsi tendon through the quadrilateral space. The quadrangular space is expanded with digital pressure only. The latissimus dorsi tendon is then repaired to the posterosuperior aspect of the humeral head and to the remnant of the infraspinatus or teres minor tendon via a smaller posterolateral incision. The posterior incision was omitted in the last 3 patients because the latissimus dorsi could be repaired through the
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Figure 5 Latissimus dorsi tendon transfer. The latissimus transfer is attached to any residual cuff of tissue from the teres minor or infraspinatus to restore active external rotation.
deltopectoral approach with exaggerated internal rotation of the humeral head. The humeral head was maintained in neutral rotation and 20° of abduction when the transposed tendons were reattached to their new location. Drill holes or suture anchors were used when fixing the tendons to bone, and figure-of-eight stitches were used when repairing the tendons to soft tissue. A large (No. 2) braided nonabsorbable suture was used in all repairs. Postoperatively, each patient’s arm was kept in an abduction brace for 6 weeks. Earlier in the study, a full shoulder-arm orthosis was used, but more recently, the Ultra-Sling (DonJoy) has been the favored means of immobilization. Patients’ arms were then placed in a sling for 3 weeks, during which time physical therapy was initiated. Rehabilitation initially consisted of passive and active-assisted range-of-motion exercises. A monitored physical therapy program continued for at least 3 months after surgery. We actively followed up the patients at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year and, thereafter, at 3- to 6-month intervals. Elevation, external rotation, strength in abduction, and strength in external rotation were tested and recorded by the senior author at each visit. Statistical analysis on the results was performed with an Excel spreadsheet statistical program.
RESULTS Patients’ ages, number of previous surgeries, diagnoses, and length of follow-up are summarized in Table I. The mean age was 53.4 years (range, 40 to 71 years). There were 9 men and 2 women. Follow-up averaged 30.5 months (range, 24 to 42 months). The cohort averaged 1.9 previous surgeries (range, 0 to 3). All previous surgeries involved repair of the rotator cuff. The mean preoperative active
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Table I Patient demographics
Patient No. 1 2 3 4 5 6 7 8 9 10 11 Mean SD
Age (y)
Sex
Condition
42 68 58 46 60 45 71 67 40 44 46 53.36* 11.08*
F F M M M M M M M M M
PTS MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT MRCT
Follow-up (mo)
No. of previous surgeries
Preoperative pain score
Postoperative pain score
24 24 42 36 24 24 36 39 36 24 27 30.545 6.867
0 2 2 3 2 2 0 2 3 3 2 1.909 0.996
0 0 0 4 0 8 2 0 2 0 0 1.45 2.43
0 0 0 6 0 6 2 0 2 0 0 1.46 2.27
PTS, Parsonage-Turner syndrome; MRCT, massive rotator cuff tear. *Scale from 1 to 10 (least to most severe pain).
Figure 6 Measurement of shoulder motion before and after tendon transfers.
elevation was 42° (range, 30° to 60°), whereas the mean preoperative active external rotation was 0° (range, ⫺10° to 20°). All elevation preoperatively was obtained through scapulothoracic motion via a shoulder shrug. Preoperative strength, on the basis of the Medical Research Council scale, averaged 2.3 for abduction (range, 2 to 3) and 2.1 for external rotation (range, 1 to 3). Postoperatively, the mean active elevation improved to 86° (range, 40° to 130°; P ⫽ .0013), whereas the mean active external rotation improved to 13° (range, 0° to 30°; P ⫽ .0033). The extent of improvement in active elevation and active external rotation is represented graphically in Figure 6. Postoperatively, the mean abduction strength improved to
3.1 (range, 2 to 4; P ⫽ .0011) and the mean external rotation strength improved to 2.7 (range, 2 to 4; P ⫽ .0107) (Figure 7). All of these improvements were statistically significant at P ⬍ .05. Correlation was observed between gains in strength and gains in shoulder motion (improvement in strength of elevation correlated to degrees gained in elevation; r ⫽ 0.75, P ⫽ .008; improvement in strength of external rotation correlated to degrees gained in external rotation; r ⫽ 0.55, P ⫽ .80) (Figure 8). Constant and UCLA shoulder scores were determined for all patients both preoperatively and postoperatively. The mean Constant scores improved from 21 to 36 (P ⫽ .0020), whereas the mean UCLA scores improved from 13 to 19 (P ⫽ .0014) (Figure 9).
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Figure 7 Measurement of shoulder elevation (SAB) and external rotation strength (SER) preoperatively (Pre) and postoperatively (Post).
The results reveal a bimodal distribution. Of the 11 patients, 4 effectively made no improvement, 2 improved slightly, and 5 improved significantly, achieving the functional preoperative goals (elevation to 90° and the ability to place the hand behind the head). Statistical analysis of these two groups was carried out separately with a t test. The improved group (patients 5-11) showed statistically significant improvement, whereas the unimproved group (patients 1-4) showed almost no change from preoperative values. The two groups did not differ with regard to age, length of follow-up, activity level, or number of previous surgeries. Of the 11 patients, 7 stated that they were satisfied with their results whereas 4 were dissatisfied. Only 1 of 4 patients in the unimproved group stated that he was satisfied with the result of the operation, compared with 6 of 7 patients in the improved group. The one dissatisfied patient in the improved group attributed his dissatisfaction to continued pain, although he initially denied having preoperative pain. However, he did state that his pain had decreased from its preoperative level. There were no complications of infection or neurologic damage. The only complication occurred in the patient with Parsonage-Turner syndrome (patient 1). Her neurologic disease left her with significant atrophy about the shoulder, although her latissimus dorsi and pectoralis major were intact per a postoperative MRI. Transfer of the pectoralis major also left a defect in the anterior axillary fold, which she found cosmetically displeasing. This latter sequela was the predominant complaint of the patient.
DISCUSSION Massive tears of the rotator cuff are a challenge for even the most seasoned shoulder surgeon.16,29,50 Many of these tears will be immobile, contracted, and irreparable.41 Those amenable to repair face the risk of retearing, increased pain, and limited motion. The prognosis is even more guarded for patients who have undergone several failed surgeries. In an effort to treat this difficult condition, Gerber et al24,25 reconstructed the cuff with the latissimus dorsi tendon to re-establish external rotation. Gerber25 noted that those with massive posterior cuff tears gained 50° of active elevation and 13° of active external rotation. We transferred the latissimus dorsi to the posterosuperior aspect of the humerus as well. However, because the tears in our study also involved the anterosuperior cuff, reconstruction of the posterior cuff alone would likely have resulted in unequal anterior and posterior forces. The biomechanical importance of a balanced fulcrum has been well described by Burkhart.9,10 Its clinical importance can also be demonstrated when examining the results of Gerber.25 Despite a transferred latissimus dorsi, those patients with a torn subscapularis, which was not adequately repaired, failed to benefit from the transfer. This markedly contrasts with the superior results Gerber obtained in patients with a functioning subscapularis. It appears that strengthening the posterior forces is inadequate if the anterior forces remain deficient. We, therefore, included transfer of the pectoralis major to the anterosuperior aspect of the humerus. This transfer has been used by other investigators in the past to treat anterior cuff tears49,51 and was
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Figure 8 A, Changes in strength of shoulder elevation and external rotation. B, Changes in shoulder motion (elevation and external rotation [ER]).
added in an effort to maintain a balanced fulcrum and to avoid the failures seen in the study of Gerber.25 The benefits of the pectoralis major transfer are 2-fold. First, as stated above, restoration of glenohumeral balance is approximated. Second, and perhaps equally if not more important, is the gain in active shoulder elevation imparted by such a transfer. Because of this latter benefit, we did not consider the
amount of subscapularis tear an important determinant in whether to transpose the pectoralis. The patients in our study increased their mean external rotation from 0° to 13°. This closely matches the results of Gerber,25 in which the patients increased their external rotation from 10° to 23°. Our patients gained a mean of 44° of active elevation, similar to the 50° gain obtained by Gerber’s patients.
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Figure 9 Functional grading: UCLA scores (A) and Constant scores (B).
Despite improvement in elevation and external rotation in several of our patients, this procedure is not for everyone with seemingly irreparable cuff tears. Patients must be informed that although this procedure may increase their function, it has not been proven to alleviate pain. The patient also must be
prepared for a lengthy (3 to 6 months) and difficult rehabilitation with a structured physical therapy program. Patients must further understand that only about 50% of them will obtain a good result, which is defined as the ability to elevate the arm to 90° and place the hand behind the head.
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All patients in our study had severe functional limitations preoperatively. Postoperatively, their results were less uniform. In fact, there was a clear bimodal distribution, which we cannot explain or predict. The function of 5 patients increased remarkably such that they achieved the preoperative goal of elevating the arm to 90° and placing the hand behind the head. In contrast, the function of 4 patients did not improve at all. A statistical analysis of the results between the improved group and the unimproved group did not show a difference when controlling for follow-up, the number of previous surgeries, or age. Despite a lack of statistical support, we contend that age should remain an important variable. We attempted, in our study, to limit this to persons aged 60 years or younger. The older patient will likely have more difficulty undergoing the extensive rehabilitation required, especially retraining neurons. Though not statistically significant, it is interesting to note that both women in the study had poor results, but both had possible confounders. One woman had ParsonageTurner syndrome, which was chronic and static. The other had a glenohumeral hemiarthroplasty for an old cuff tear arthropathy. The other 9 patients had massive rotator cuff tears with the native humeral head intact. If the inclusion criteria are narrowed to exclude patients with Parsonage-Turner syndrome or with previous arthroplasties, the results show that 7 of 9 patients improved. Future studies on tendon transfers in patients with neuropathic cuff deficiencies or with glenohumeral arthroplasties due to cuff tear arthropathy would help elucidate whether this particular subset of patients can be helped by this type of procedure. Future studies on massive rotator cuff tears with tighter inclusion criteria would also help identify who would benefit most from a repair or other reconstructive procedure. A review of the literature shows that the results of massive rotator cuff repair not only are unpredictable but also vary greatly between studies. This is, in part, because of the lack of uniformity among studies. Some studies exclude shoulders with chronic, immobile tears as well as those with shortened acromiohumeral distances, whereas others do not. In addition, different authors vary (1) in their definition of massive and (2) in their technique of measuring the tear. These variations make direct comparisons between studies difficult. However, certain studies on massive rotator cuff repairs deserve mention. Gerber et al26 repaired rotator cuff tears involving at least two tendons and noted an increase in elevation of 55°, which is slightly higher than that obtained in our study. Even more impressive is the study of Bigliani et al,6 which showed patients gaining 76° of flexion. In evaluating UCLA scores after massive rotator cuff repairs, Worland et al52 noted that their patients’ scores improved
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from 9 to 30.9, which is markedly better than the increase from 13.3 to 19.2 seen in our study. We did not routinely obtain postoperative images (MRI) of the shoulders in those patients who were either dissatisfied or not improving significantly. We believe that the integrity of the transposed pectoralis can be determined clinically. With that said, such imaging would be of interest and should perhaps be addressed in further studies. Statistical analysis of the results from the improved and unimproved groups does not indicate which patients with massive tears and limited function are most likely to benefit from this procedure. On the basis of our results, we cannot recommend this procedure for those with Parsonage-Turner syndrome or with glenohumeral hemiarthroplasties. Given the superior results seen with massive rotator cuff repair as noted by Gerber,26 Bigliani,5 Worland,52 and others, we also cannot recommend this procedure as a first-line surgical treatment for massive reparable rotator cuff tears. However, we believe that a combined tendon transfer is a viable option for those shoulders either with irreparable rotator cuff tears or in which multiple attempts at repair have failed. We currently recommend a combined pectoralis major and latissimus dorsi transfer in patients aged younger than 60 years, with a tear involving the anterior and posterior cuff, which causes markedly limited function but with minimal to no pain. We view this as a salvage procedure, with the chance to restore active elevation and external rotation in some patients with a serious condition. REFERENCES
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