Massive Posterosuperior Rotator Cuff Tears Research Articles

Combined Subscapularis Tears in Massive Posterosuperior Rotator Cuff Tears

Background: Previous studies on massive rotator cuff tears have not addressed the outcomes of tears extending to the subscapularis tendon. Hypothesis: The retear rate in patients with a massive posterosuperior rotator cuff tear combined with a subscapularis tear is higher than that in patients with a massive posterosuperior rotator cuff tear with an intact subscapularis tendon. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected and analyzed from 92 consecutive patients who underwent arthroscopic repair of a massive posterosuperior rotator cuff tear. Patients were divided into 3 groups according to the status of the subscapularis tendon: intact subscapularis tendon (I-massive tear; n = 42), tear involving half or less than half of the subscapularis tendon (S-massive tear; n = 22), and tear involving more than half of the subscapularis tendon (L-massive tear; n = 28). The integrity of the rotator cuff was determined by ultrasonography at 4.5 and 12 months or later after surgery. Clinical evaluations were performed using the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and active shoulder range of motion. Data were collected on the day before surgery and at final follow-up (at least 24 months postoperatively). Results: A total of 25 retears (27%) were identified based on an ultrasonographic evaluation. Although statistical significance was not found, there was a trend toward a higher retear rate in patients with an L-massive tear (43%) compared with those with an S-massive tear (18%; P = .050) or I-massive tear (21%; P = .059) at final follow-up. The subclassification of retears according to the involved tendons revealed that subsequent retears of the subscapularis tendon were noted only in patients with an L-massive tear. In patients with an L-massive tear, postoperative data comparison between patients with intact subscapularis tendons and those with failed subscapularis tendons revealed that a significant difference was noted in the VAS (1.1 vs 3.8, respectively) and ASES (90.6 vs 58.5, respectively) scores. The improvement in clinical scores after repair was statistically significant in all groups but not different between the groups. Conclusion: The arthroscopic repair of massive tears results in substantial improvements in shoulder function, regardless of the presence of combined subscapularis tears. However, this study showed a trend toward a high failure rate for the repair of massive posterosuperior rotator cuff tears extending over half of the subscapularis tendon. Therefore, other treatment options should also be considered for this type of rotator cuff tear.

Patch-Augmented Latissimus Dorsi Transfer and Open Reduction–Internal Fixation of Unstable Os Acromiale for Irreparable Massive Posterosuperior Rotator Cuff Tear

Latissimus dorsi transfer is a reasonable treatment option for massive posterosuperior rotator cuff tears that can substantially improve chronically painful and dysfunctional shoulders. This report and accompanying video describe the treatment of an active 43-year-old man with severe pain and weakness in the right shoulder after 3 failed rotator cuff repairs. Preoperative imaging showed a massive posterosuperior rotator cuff tear retracted to the glenoid as well as a hypermobile os acromiale likely causing dynamic impingement and recurrent rotator cuff tears. After diagnostic arthroscopy, the latissimus tendon is harvested and augmented with a 3-mm human acellular dermal patch (ArthroFlex; Arthrex, Naples, FL). The native rotator cuff tissue is repaired as much as possible, and the latissimus tendon is passed underneath the deltoid and posterior to the teres minor. The patch-augmented tendon is then integrated into a double-row SpeedBridge repair of eight 4.75-mm BioComposite SwiveLock anchors (Arthrex). The bony surface of the os acromiale is prepared and then fixed to the acromion with 2 cannulated partially threaded screws and additional tension-band wiring. Postoperative rehabilitation initially focuses on early passive range of motion, followed by active and active-assisted motion and a biofeedback program starting at 6 weeks postoperatively.

Biomechanical comparison between the trapezius transfer and latissimus transfer for irreparable posterosuperior rotator cuff tears

The purpose of this study was to characterize the biomechanical effects of the lower trapezius transfer and to compare it with the latissimus dorsi transfer in a cadaveric model of a massive posterosuperior rotator cuff tear. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of shoulder abduction. Range of motion, humeral rotational position due to muscle loading, joint reaction forces, and kinematics were measured. All specimens were tested in 4 conditions: intact, massive posterosuperior cuff tear, lower trapezius transfer, and latissimus dorsi transfer. A repeated-measures analysis of variance was used for statistical analysis. Internal rotation due to muscle loading increased with massive cuff tear compared with the intact condition (P<.05). The latissimus transfer corrected this change at 0° abduction, whereas the trapezius transfer corrected this at all abduction angles. The massive cuff tear decreased glenohumeral joint compression forces at all abduction angles; these forces were restored by the lower trapezius transfer (P<.05). At maximum humeral internal rotation and 0° of abduction, the humeral head apex shifted superiorly and laterally with massive cuff tear (P<.05); this shift was more closely restored to intact values by the trapezius transfer compared with the latissimus transfer (P<.05). The lower trapezius transfer is superior to the latissimus transfer at restoring native glenohumeral kinematics and joint reaction forces in our cadaveric model. It may be a promising treatment option for patients with a massive irreparable rotator cuff tear.

Clinic and electromyographic results of latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.

BackgroundThis study examines the clinical and electromyographic results of latissimus dorsi transfer (LDT) using a combined open and arthroscopic technique for the treatment of symptomatic irreparable posterosuperior rotator cuff tears.MethodsBetween 2006 and 2009, LDT was performed in 14 patients (mean age 59 years) with massive and symptomatic irreparable posterosuperior rotator cuff tear. The patients were examined preoperatively and postoperatively with mean follow-up of 52 months using the Constant score, and the integrity of the latissimus dorsi (LD) transfer was assessed by ultrasound in all cases and by MRI in ten cases. The functional activity of the LD transfer was compared to the non-operated side using surface electromyography.ResultsAll patients demonstrated a significant improvement in the Constant score (p = 0.001), from a preoperative score of 33 points (range 10–55 points) to a postoperative score of 59 points (range 13–80 points). The subjective assessment score was good to excellent in 12 patients (85%), and 11 patients (78%) would be willing to undergo surgery again. Integrity of the transferred tissue was confirmed in 13 of the 14 cases using ultrasound and MRI. Surface electromyographic signal showed increased activation of the transferred latissimus dorsi when performing active movements of external rotation (p = 0.002) and abduction-elevation (p = 0.009).ConclusionsOur results indicate that LDT significantly improves function and diminishes pain in patients with a massive posterosuperior rotator cuff tear. The combined open and arthroscopic technique preserves the deltoid muscle and controls the LD tendon reinsertion. Surface electromyographic signal confirms the active function of the transferred muscle.Electronic supplementary materialThe online version of this article (doi:10.1186/s13018-014-0083-6) contains supplementary material, which is available to authorized users.

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

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. Eight patients were evaluated preoperatively and at 1year (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. 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. 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.

Tendon Transfers for Irreparable Rotator Cuff Tears

Tendon transfer is one treatment option for patients with massive irreparable rotator cuff tears. Although surgical indications are not clearly defined, the traditional thought is that the ideal candidate is young and lacks significant glenohumeral arthritis. The proposed benefits of tendon transfers are pain relief and potential increase in strength. The biomechanical rationale for the procedure is to restore the glenohumeral joint force couple and possibly to restore normal shoulder kinematics. The selection of donor tendon depends on the location of the rotator cuff deficiency. Transfers of latissimus dorsi and pectoralis major tendons have been shown to consistently improve pain; however, functional benefits are unpredictable. Trapezius tendon transfer may be an alternative in patients with massive posterosuperior rotator cuff tears, although longer-term follow-up is required.

Biomechanical effect of latissimus dorsi tendon transfer for irreparable massive cuff tear

The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear. Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis. The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction. Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles.

Deltoid flap reconstruction for massive rotator cuff tears: Mid- and long-term functional and structural results

Various open and arthroscopic techniques for irreparable massive rotator cuff tears have been described. Muscle-tendon transfers may be considered in order to improve range of motion and strength. We assessed retrospectively the functional and structural results of 31 deltoid flap transfers for massive postero-superior rotator cuff tears at 2 time points: Mid- and long-term follow-up exams were performed after a mean of 53 and 175 months, respectively. Functional gains were minor, but improvement in pain and patient satisfaction was high. The mean Constant score improved from 31 preoperatively to 46 points at mid-term follow-up. At long-term follow-up, 16 shoulders were still available for exam and presented with a mean Constant score of 66 points. Survival rates of the deltoid flap, confirmed by ultrasound, were 16.5% at mid-term and 12.5% at long-term follow-up, and correlated with better clinical outcome. Cranial migration of the humeral head progressed in all cases and could not be prevented by the interposition of a deltoid flap. Based on the results of this series, we no longer use nor recommend this technique.

Modified minimally invasive latissimus dorsi transfer in the treatment of massive rotator cuff tears: a two-year follow-up of 26 consecutive patients

Since its inauguration by Gerber in 1988, the latissimus dorsi transfer has become an established surgical option for non-reconstructable, massive posterosuperior rotator cuff tears. We describe 26 consecutive patients, all of whom underwent a latissimus dorsi transfer using a modified single incision mini-invasive Herzberg transfer. The primary focus of this paper was to compare the applied clinical results of this new technique with the published results of the Gerber technique. Following transfer of the latissimus dorsi to restore external rotation, 26 patients were evaluated. The mean age was 60 +/- 18 years. The patients were examined after surgery at an average of 24 months (range: 12-41). The unweighted Constant score rose from 20 (range: 13-34) to 56 (range: 63-81). The acromiohumeral distance remained statistically unchanged from an initial value of 4.7 mm (1-9 mm) to a postoperative value of 4.8 (2-11 mm). In the Hamada classification the level of rotator cuff defect arthropathy increased from 1.7 (1-3) to 1.8 (1-3). On the basis of its low morbidity rate, the latissimus dorsi transfer in Herzberg's modified technique is a sensible alternative to the technique initially described by Gerber, especially when the initial situation exhibits pre-existing weakness of the deltoid muscle.

Arthroscopically Assisted Latissimus Dorsi Transfer for Irreparable Rotator Cuff Tears

Massive posterosuperior rotator cuff tears are traditionally repaired by open latissimus dorsi transfer. Latissimus dorsi transfer can substantially improve chronically painful, dysfunctional shoulders. We present a technique of arthroscopically assisted latissimus dorsi transfer which avoids an incision through the deltoid. By preserving the deltoid, a better and faster clinical outcome may be obtained.

Massive tears of the rotator cuff treated with a deltoid flap.

We retrospectively reviewed the charts of 29 patients younger than 65 years at surgery treated with deltoid flap reconstruction for massive postero-superior rotator cuff tears. All tears involved supraspinatus and infraspinatus tendons and were associated with tendon stump retraction to the glenoid rim, a preservable long biceps tendon, and an intact subscapularis tendon. Mean follow-up was 10.5 years. Patient satisfaction rate was 89%. Mean global Constant score improved from 43 to 71.5 points, mean pain score from 6.3 to 13.2, mean anterior flexion from 100 to 157 degrees, and force in elevation from 2.3 to 3 kg. Two thirds of patients had no humeral head migration. Of the 18 patients whose flap was examined by magnetic resonance imaging, 15 had no tear and 12 had a flap signal of muscle intensity; mean flap thickness was 5 mm. Pre-operative factors associated with poorer outcomes were upwards humeral head migration with a subacromial space smaller than 6 mm, presence of glenohumeral osteoarthritis, and supraspinatus amyotrophy greater than 40%. Deltoid flap reconstruction is a valid option in this patient population.