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Tendon transfers for rotator cuff pathologies

Wagner, Eric R., MDa; Elhassan, Bassem T., MDb

doi: 10.1097/BCO.0000000000000757
Special Focus: Upper Extremity Rotation
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SDC

Irreparable rotator cuff tears remain one of the most challenging pathologies faced by shoulder surgeons. In both irreparable anterior (subscapularis) and posterosuperior (supraspinatus and infraspinatus) tears, patients experience marked shoulder dysfunction and pain. In this article, we review the surgical considerations for treating patients with these tears, as well as the tendon transfer options. Irreparable rotator cuff tears are associated with advanced fatty infiltration, tendon retraction, and loss of tendon length. Although there are multiple reconstructive options, most are limited to small series with short-term follow-up. Tendon transfers have emerged as very promising reconstructive options for these patients. When considering the ideal tendon transfer, it is critical to consider the four-tendon transfer principles, as well as the ability of patients to retrain the new transfer to perform a different function. The historical option for posterosuperior tears involved a latissimus dorsi transfer, while the lower trapezius transfer emerged in recent years. The historical transfer for irreparable subscapularis tears was the pectoralis major transfer, while the latissimus dorsi emerged in recent years. Further comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for each of these transfers to treat these difficult pathologies.

aEmory University, Atlanta, GA

bMayo Clinic, Rochester, MN

Financial Disclosure: The authors report no conflicts of interest.

Correspondence to Bassem T. Elhassan, MD, Mayo Clinic Minnesota, Orthopedics, 200 First Street SW, Rochester, MN 55905 Tel: +507-255-5123; fax: +617-724-9904; e-mail: elhassan.bassem@mayo.edu.

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INTRODUCTION

Irreparable rotator cuff pathologies are a common cause of marked shoulder pain and loss of function. They are characterized by their tendon retraction, poor tendon quality, and fatty muscle infiltration, all leading to the shoulder dysfunction and morbidity experienced by patients.1–8 Although the definition of irreparability is controversial, many studies have shown re-tear rates ranging from 20% to 94%, often associated with poor clinical outcomes.9–12 Therefore, when the tear is thought to be irreparable, patients in whom nonoperative management fails are left with options either involving joint-sparing reconstructions, such as tendon transfers or superior capsular reconstruction, or joint replacements involving the reverse shoulder arthroplasty.

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DEFINITION OF IRREPARABILITY

The definition of an irreparable rotator cuff tear is controversial given the multiple factors to consider when evaluating these complex pathologies. These can be separated into patient factors, chronicity, imaging findings, and previous surgeries. However, all of these are critical to consider when deciding on whether or not to attempt a rotator cuff repair.

Many patient-specific factors can lead to increased rates of rotator cuff re-tears or impair the ultimate healing of the repair, including diabetes, smoking, older age, inflammatory arthritis, and immunocompromised status.13–17 Furthermore, certain physical examination maneuvers can provide insight regarding the size and chronicity of the tears. For example, a positive external rotation lag sign has been shown to correlate with the size of the rotator cuff tear.18 Although these factors should not be taken alone as the definition of an irreparable tear, they should be considered when combined with other imaging and pathologic characteristics.

The chronicity of the tear is another very important consideration that contributes to a tear being considered irreparable. After a rotator cuff tear, the tendon and associated muscle undergo progressive degeneration over time, with increased muscular fatty infiltration and tendon degeneration. 19 This degenerative process has been shown to progress as fast as 3-4 yr20 after massive posterosuperior rotator cuff tears treated nonoperatively.20 This degenerative process influences the reparability of the tendon and its intrinsic ability to be reduced to the humerus without excessive tension, to ultimately heal to the bone, and to be able to contract to produce reasonable shoulder motion. For example, repairs performed within 6 mo of a traumatic event are associated with better healing and lower rates of re-tears.7,21,22

A critical part of the degenerative process associated with chronic rotator cuff tears involves the fatty infiltration into the muscle. This concept was first introduced by Goutallier et al.23 using CT arthrograms and later by Fuchs et al.24 using MRI. This might be the most important aspect of the degenerative process because higher grades of fatty infiltration are associated with worse outcomes and rates of rotator cuff healing.7,21,25,26 An additional aspect often associated with fatty infiltration is tendon retraction, quantified by the Patte Classification and tendon length. A Patte grade 327 and a tendon length shorter than 15 mm26 also have been associated with higher re-tear rates. Furthermore, when all of the above mentioned factors are present together, it has been shown to predict irreparability with up to 98% specificity.27

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SURGICAL OPTIONS FOR IRREPARABLE ROTATOR CUFF PATHOLOGY

When a tear is deemed irreparable by the treating surgeon, the patient is left with various reconstruction options to improve his or her shoulder pain and dysfunction. Many of the potential options include partial repair,28–32 graft augmentation or bridging with allografts,33–38 superior39,40 or anterior41,42 capsular reconstruction, subacromial balloon,43 or various shoulder tendon transfers.1–6,8,44–59 Although many of these strategies are promising, most are limited in the literature to case series with short-term follow-up. Furthermore, the reverse shoulder arthroplasty was originally introduced for the treatment of massive rotator cuff tears by Paul Grammont60 and have been demonstrated to be a very successful option for these patients.61–66 Ultimately, there remains a paucity of high-quality comparative trials comparing these various treatments for patients with irreparable rotator cuff tears.

Although tendon transfers around the shoulder are some of the most well-established options of all those mentioned above, they have started to gain popularity in recent years with the emergence of new transfer options and innovations in surgical technique. In this review, we highlight the tendon transfer options for irreparable anterior and posterosuperior rotator cuff tears.

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BIOMECHANICS

Shoulder and Rotator Cuff

To understand the role of tendon transfers in irreparable rotator cuff pathologies, it is critical to understand the glenohumeral and scapulothoracic biomechanics, as well as the role of the rotator cuff and other dynamic stabilizers. The shoulder is made of three joints, including the glenohumeral, acromioclavicular, and sternoclavicular joints. The glenohumeral joint is a shallow, nonconstrained articulation with multiple plains of mobility, controlled by the four rotator cuff muscles (there are eight muscles that control the movements of the glenohumeral joint, including the supraspinatus, infraspinatus, teres minor, subscapularis) and four additional muscles (teres major, latissimus dorsi, deltoid, pectoralis major). All of these muscles, in particular the rotator cuff, not only drive most of the glenohumeral motion but also act as dynamic stabilizers.67 The remainder of the shoulder motion is from the scapulohumeral rhythm involving the scapulothoracic articulation, coordinated by the six scapular stabilizers, including the serratus anterior, trapezius, levator scapulae, rhomboid minor, rhomboid major, and pectoralis minor.

Glenohumeral motion requires a balance of dynamic stabilizers, creating a force-couple to allow compression against the glenoid67 and a coordinated equilibrium for humeral rotation.68 When pathology of one or more of the rotator cuff tendons is present, the contact pressure is altered, as well as the anterior-posterior force couple, leading to translation of the humeral head during attempted motion.69 This alters the motion and resultant function, underlying a large part of the patient’s morbidity.

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Tendon Transfers

Tendon transfers around the shoulder have gained popularity because of their potential ability to re-establish the lost anterior-posterior force couple that causes the shoulder dysfunction in irreparable rotator cuff tears. By transfer, a dynamic stabilizer and muscle can be trained to be synergistic to the pathologic tendon, balancing the remaining intact muscles around the shoulder and restoring the patient’s force-couple. By both dynamically stabilizing the shoulder and providing either an internal or external rotation force, much of the lost motion and function can be overcome. Furthermore, the increased stability and decreased translation are the likely reasons for the improvements seen in the pain levels.

However, whenever planning to perform a tendon transfer, there are a couple important principles to follow:70,71

  • Similar excursion between transferred and recipient muscle.
  • The transferred muscle must be expendable without compromising the shoulder’s function.
  • There should be a similar line of pull between the transferred tendon and the recipient muscle.
  • Each tendon transfer should be designed to replace one function of the recipient.

Given these considerations, cases of subscapularis irreparable tears were traditionally treated with the pectoralis major transfer (PMT) but now more recently can also be treated with the latissimus dorsi transfer (LDT). In cases of infraspinatus irreparable tears, the LDT has traditionally been used, while the lower trapezius transfer (LTT) has emerged in recent years.

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POSTEROSUPERIOR IRREPARABLE TEARS

Surgical treatment of irreparable posterosuperior rotator cuff tears involving the supraspinatus and infraspinatus is much debated. Options include arthroscopic debridement,72,73 partial repair,31,74 patch or interposition grafting,75,76 superior capsular reconstruction,39 subacromial balloon,43 and tendon transfers including the latissimus dorsi45,48,53,77–79 and lower trapezius transfer.54,55 However, lack of evidence remains for many of these techniques and no comparative trials are available. The concern with many of these techniques is that they deteriorate over time, as in the case of the arthroscopic debridement72,73 and partial repair.32 Alternatively, tendon transfers have been shown to maintain long-term clinical improvements,47,48 likely from a dynamic restoration of the anterior and posterior force couple.

The two main tendon transfer options for irreparable posterosuperior rotator cuff tears include the latissimus dorsi and lower trapezius transfer.

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Latissimus Dorsi Transfer (LDT)

The latissimus dorsi transfer (LDT) was originally described by Gerber et al.77 in 1998 in the treatment of irreparable posterosuperior rotator cuff tears. In this open technique, the latissimus dorsi tendon is harvested through a posterior axillary approach, released from its insertion on the anterior aspect of the humerus and transferred to the superolateral humeral head via an open approach to the greater tuberosity. This transfer then converts function of the large muscular contractions of the latissimus dorsi from adduction and internal rotation to abduction and external rotation. It also functions as a humeral head depressor, especially in the absence of a subscapularis. Subsequent reports have demonstrated excellent long-term outcomes with this transfer.44–49 For example, at a minimum 10-year follow-up in 46 patients, one series found long-term improvements in pain, subjective shoulder value (SSV) (29% to 70%) and Constant pain (7 to 13 points) and function scores (56% to 80%).46 Similar to other studies, worse outcomes were seen in patients with insufficiency of the subscapularis,44,45,48 fatty infiltration of the teres minor, and a critical shoulder angle over 36 degrees. These considerations were reinforced by a systematic review, demonstrating worse outcomes in patients with subscapularis insufficiency, teres minor fatty infiltration, and prior rotator cuff repairs.80

Recently, the LDT has been modified to be performed with an arthroscopic-assisted (aaLDT) approach. This involves the open harvest of the latissimus dorsi tendon, but now it is anchored arthroscopically with two to three anchors placed over the anterior greater tuberosity after transferring it posteriorly. There have been multiple studies that have demonstrated very promising short-term results with this technique.50–53 In one series of 55 aaLDT, including 30 with prior failed repairs, there were significant improvements in all clinical outcome measures examined at 29 mo follow-up.81 Another series of 29 aaLDT found similar results at 27 mo follow-up.52 In all of these series, similar factors seem to predict worse outcomes, including subscapularis pathology and prior rotator cuff repair. Nonetheless, this minimally invasive approach has shown incredible promise in the short-term, similar or even potentially superior to the open technique.

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Lower Trapezius Transfer (LTT)

Initially described for the paralytic shoulder,71,82–84 the lower trapezius transfer (LTT) has emerged as a promising alternative for massive irreparable posterosuperior cuff tears. The LTT procedure involves an open harvest of the lower trapezius tendon off the medial scapular spine through a horizontal incision (Figure 1). A large allograft tendon (such as the Achilles) is then transferred into the joint arthroscopically through the anterolateral portal (Figure 2). An Achilles allogaft is then anchored onto the anterior and superior aspects of the greater tuberosity with suture anchors. The allograft is then woven into the lower trapezius tendon (Figure 3).

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

FIGURE 3

FIGURE 3

In the only published series of the LTT using an open technique, Elhassan et al.55 demonstrated at a mean 47-month follow-up that 33 patients who underwent the open LTT had significant improvements in pain, shoulder abduction, and external rotation, SSV, and Disability of Arm Shoulder Hand (DASH) scores. The biggest factor predicting poor outcomes was preoperative flexion of less than 60 degrees. A recent article described the arthroscopic-assisted technique,54 but there has yet to be a clinical series on this technique. This technique involves anchoring the allograft using an arthroscopic approach instead of an acromial osteotomy.

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Considerations

Although there are no published comparison studies comparing these two techniques, there are multiple considerations when choosing the optimal transfer to perform. The LTT has a couple distinct advantages over the LDT:

  • “In-phase” muscle function: The trapezius naturally contracts during shoulder abduction and external rotation.85 This is in contrast to the LDT which naturally functions as an adductor and internal rotator, and therefore does not naturally fire during external rotation or abduction. This requires the muscle to be retrained, something that does not always occur and potentially underlies cases of poor postoperative outcomes.86 This disadvantage can be overcome using a biofeedback rehabilitation protocol that may help facilitate LD retraining to become in-phase.
  • Line of pull: The line of pull of the LT almost completely mimics the infraspinatus.

Alternatively, LDT has a distinct advantage of not requiring an allograft tendon to perform the transfer. Furthermore, its large muscle belly and excursion potentially creates a greater force to power shoulder abduction.

Despite the lack of clinical series, there is a biomechanical comparison study comparing the LDT and LTT to superior and inferior positions on the greater tuberosity.87 This study demonstrated the LTT was superior in 0 degrees of abduction, while there were similar moment arms in 90 degrees of abduction. Another biomechanical comparison study found the LTT to better restore native shoulder biomechanics and joint reaction forces in most positions of the shoulder.88

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SUBSCAPULARIS IRREPARABLE TEARS

Irreparable tears of the subscapularis have similar characteristics defining their “irreparability” to the supraspinatus and infraspinatus, including tendon retraction, poor tendon quality, and fatty muscle infiltration.1–8 However, unlike the posterosuperior irreparable rotator cuff tears, there are limited options for patients with irreparable anterior (subscapularis) or anterosuperior (subscapularis and supraspinatus) rotator cuff tears. Historically, patients were either treated with a graft augmentation of the retracted tendon or a pectoralis major transfer (PMT),1–6,8 as well as pectoralis minor,56,57 and upper trapezius.58 In recent years surgeons have utilized the reverse shoulder arthroplasty in the setting of an irreparable subscapularis tear associated with arthritis. Two novel techniques that have also emerged in recent years involve the anterior capsular reconstruction50,57 and the latissimus dorsi transfer (LDT)50,57 as options for patients without arthritis who want to preserve their joint.

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Pectoralis Major Transfer (PMT)

The pectoralis major transfer (PMT) involves transferring either the sternal or clavicular head from its insertion lateral to the bicipital groove, superiorly and medially to the insertion of the subscapularis on the lesser tuberosity. This is performed through an open approach, utilizing the deltopectoral interval. The pectoralis major can be transferred either below or above the conjoined tendon. Some surgeons have suggested that transferring the pectoralis major below the conjoined tendon more closely replicates the subscapularis line of pull. This notion is supported by a biomechanics cadaveric study,89 but there are no clinical studies to date that have demonstrated this finding.

The PMT has been associated with variable outcomes,1–6,8 especially when there is static anterior glenohumeral subluxation.2 Given these outcomes and multiple potential techniques, there has been a lot of investigation into optimizing this technique. One study found no difference in clinical outcomes when comparing the sternal to clavicular heads utilized in the transfer.90 Multiple other studies have demonstrated similar outcomes when transferring the PMT above 2,5,7 or below the conjoined tendon.3,4,6 Nonetheless, there is a paucity of high-quality comparison studies or large series with long-term follow-up.

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Latissimus Dorsi Transfer (LDT)

In recent years, the latissimus dorsi transfer (LDT) has emerged as an option for patients with anterior or anterosuperior irreparable rotator cuff tears (Figure 4). This involves either an open harvest of the latissimus dorsi tendon from its insertion inferior to the subscapularis insertion (Figure 5). The latissimus dorsi is then mobilized to obtain adequate excursion off the teres major, chest wall and inferior angle of the scapula, to be transferred up to the lesser tuberosity at the superior aspect of the subscapularis insertion (Figure 5). The anchoring of the tendon can be performed either open or arthroscopically, using two to four anchors, into the lesser tuberosity (Figure 6). In the setting of an irreparable supraspinatus tear as well, the tendon can be anchored into the anterior aspect of the greater tuberosity (Figure 7). Furthermore, this technique could be combined with an anterior capsular reconstruction using a dermal allograft in the setting of static anterior subluxation.

FIGURE 4

FIGURE 4

FIGURE 5

FIGURE 5

FIGURE 6

FIGURE 6

FIGURE 7

FIGURE 7

This technique was developed to overcome the variable findings associated with the PMT. It was initially described in an anatomic feasibility study,59 demonstrating that the latissimus dorsi transfer was feasible in all aspects of the lesser tuberosity. There was no impingement on the axillary, radial, or musculocutaneous nerves. There has been one small case series of five patients with 1-year follow-up after arthroscopic-assisted LDT demonstrating good outcomes in four of the five patients.50 The one patient who did not improve had an infection and associated tendon rupture, but this was the only complication.

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Considerations

There is currently a lack of comparative studies between these two techniques. However, when evaluating which technique is preferable in the setting of an irreparable subscapularis tear, it is important to keep in mind the principles of tendon transfers (see above). One of the principles is a similar line of pull from the donor and recipient tendons. This is not the case for the pectoralis major, as the origin on the anterior chest wall is 90 degrees from the subscapularis origin on the undersurface of the scapula. Alternatively, the latissimus dorsi originates just caudal to the subscapularis on the same side of the body.

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CONCLUSION

Tendon transfers have emerged in recent years as very promising treatment options for patients with irreparable posterosuperior and anterior rotator cuff tears. Advances in surgical technique now allow most of these transfers to be performed arthroscopically, potentially improving patient recovery with early functional gains. When considering the ideal tendon transfer, it is critical to consider the four tendon transfer principles, as well as the ability of patients to retrain the new transfer to perform a different function. The historical option for posterosuperior tears involves the latissimus dorsi transfer, while the lower trapezius transfer has emerged in recent years. The historical transfer for irreparable subscapularis tears was the pectoralis major transfer, while the latissimus dorsi has emerged in recent years. Further comparative trials with larger patient numbers and longer follow-up are needed to better understand the indications for each of these transfers to treat these difficult pathologies.

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Keywords:

arthroscopic; tendon transfers; irreparable rotator cuff tears

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