Pectoralis Major Tendon Transfer Research Articles

Treatment of massive irreparable rotator cuff tears by different surgical technigues: comparative analysis of early outcomes

Background. Massive rotator cuff tears are up to 40% and can progress to the stage of irreparable ones. Nowadays, there are many treatment options available for irreparable rotator cuff injuries, from conservative treatment and arthroscopic reconstructions to reverse shoulder arthroplasty. Currently, the comparative effectiveness of various treatment methods remains uncertain, and therefore there is no clear algorithm for choosing treatment tactics of such orthopedic shoulder pathologies. The aim of the study is to compare short-term treatment outcomes of patients with irreparable rotator cuff tears using arthroscopic partial rotator cuff repair, latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Methods. The study enrolled 75 patients who underwent the following types of surgical interventions: partial arthroscopic repair, posterior and anterior arthroscopically assisted latissimus dorsi tendon transfer, pectoralis major tendon transfer and reverse shoulder arthroplasty. Treatment results were assessed using measurements of the range of active movements in the shoulder joint, the ASES and Constant-Murley Score (CMS) questionnaires, the Visual Analog Scale (VAS), assessment of radiographs and MRI. The assessments were performed preoperatively and at 6 and 12 months after surgery. Results. In all groups, there was a statistically significant improvement by all indicators (p0.05). Clinical and functional results at the short-term follow-up after partial rotator cuff repair and various options of latissimus dorsi tendon transfer are largely comparable, while at the same time superior to the results of reverse shoulder arthroplasty and pectoralis major tendon transfer. Conclusions. The use of partial rotator cuff repair and musculotendinous transfers at the short-term follow-up gives comparable and better results in comparison with the use of reverse shoulder arthroplasty, which allows to consider “joint-preserving” interventions as an option in patients with massive irreparable rotator cuff tears.

Combined Anterior Latissimus Dorsi and Teres Major Tendon Transfer (aLDTM) for Irreparable Anterosuperior Rotator Cuff Tears.

Transfer of the anterior latissimus dorsi and teres major (LDTM) tendons has demonstrated favorable outcomes in patients with irreparable anterosuperior rotator cuff tears1. The objective of this procedure is to restore internal rotation strength, enhance active range of motion, and provide pain relief while preserving the glenohumeral joint. The incision extended from the coracoid to the inferior border of the pectoralis major tendon, following the deltopectoral interval located laterally to the coracoid. While preserving the pectoralis major tendon, the latissimus dorsi (LD) and teres major (TM) tendons are identified and detached from the humerus without separating the tendons. The LDTM tendons are grasped, and nonabsorbable sutures are placed in a continuous running-locking suture fashion. Traction is applied to the sutures while bluntly releasing the adhesions surrounding the LDTM muscles in order to enable further mobilization and excursion. With the patient's arm positioned in full internal rotation and at 45° of abduction for physiological tensioning, the LDTM tendons are attached 2 cm distal to the lateral edge of the greater tuberosity and lateral to the biceps groove with use of 1 medial anchor and 3 lateral anchors. Arthroscopic partial repair, superior capsular reconstruction, pectoralis major tendon transfer, and isolated LD tendon transfer are potential alternative treatments. In cases in which these options are not feasible or have been unsuccessful, reverse total shoulder arthroplasty can be considered as a treatment option. Arthroscopic partial repair can provide pain relief, but its effectiveness in improving range of motion and muscle strength is limited2,3. Additionally, there is a high risk of retear, with reported rates as high as 52%4. Superior capsular reconstruction is considered a viable treatment, but it is not recommended in cases involving irreparable subscapularis tears5-7. Pectoralis major transfer may lead to less favorable clinical outcomes in cases in which an irreparable subscapularis tear and an irreparable supraspinatus tear are simultaneously present8-10. In cases of irreparable anterosuperior rotator cuff tears, the transfer of the LD tendon alone may not fully restore the superior migration and anterior subluxation of the humeral head.11. Reverse total shoulder arthroplasty may be another option in these cases, but it does not preserve the glenohumeral joint. The procedure involves stabilizing the superior translation of the humeral head by rebalancing the force couple, as the TM tendon exhibits scapulohumeral kinematics similar to the subscapularis tendon. Additionally, the procedure effectively reduces anterior glenohumeral subluxation through the combined effect of the posterior line of pull from the combined LDTM tendons and the scapulohumeral kinematics of the teres minor tendon. Also, by fixing the transferred LDTM tendons just distal to the greater tuberosity, the vector becomes less vertical, thereby preventing axillary nerve impingement and achieving appropriate tendon tensioning. The use of this procedure is supported by a study of 30 patients who were followed for a minimum of 2 years1. Significant improvements were observed in various scoring systems, including the pain VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons), UCLA (University of California-Los Angeles), SANE (Single Assessment Numeric Evaluation), and ADLIR (Activities of Daily Living requiring active Internal Rotation) scores. Importantly, there was no significant progression of cuff tear arthropathy observed during the final follow-up. Additionally, preoperative anterior glenohumeral subluxation (15 of 30 patients) was restored in all patients after LDTM tendon transfer. Careful attention should be paid to the anterior humeral circumflex vessels to prevent bleeding.The radial nerve, passing through the anteroinferior surface of the LDTM tendons, should be carefully identified and protected to avoid iatrogenic injury.To maintain physiologic tension, the patient's arm should be positioned in full internal rotation and 45° of abduction.To avoid axillary nerve impingement, the LDTM tendons should be fixed just distal to the greater tuberosity and lateral to the biceps groove. SCR = superior capsular reconstructionLDTM = latissimus dorsi combined with teres majorASRCTs = anterosuperior rotator cuff tearsA/S = arthroscopicROM = range of motionTM = teres majorTm = teres minorLD = latissimus dorsiSSC = subscapularisSSP = supraspinatusPM = Pectoralis majorPm = Pectoralis minorRSA = reverse total shoulder arthroplastyASES = American Shoulder and Elbow SurgeonsUCLA = University of California-Los AngelesADLIR = Activities of Daily Living requiring active Internal RotationGT = greater tuberosityACR = anterior capsular reconstructionFF = forward flexionER = external rotationIR = internal rotationAHD = acromiohumeral distanceMRI = magnetic resonance imagingISP = infraspinatusPEEK = polyetheretherketonePOD = postoperative dayEMG = electromyographySD = standard deviationBMI = body mass indexDM = diabetes mellitusHTN = hypertensionVAS = visual analogue scaleSANE = Single Assessment Numeric EvaluationaROM =active range of motion.

Pectoralis major tendon transfer in reverse total shoulder arthroplasty with irreparable subscapularis: surgical technique and preliminary clinical and radiological results

Hypothesis/BackgroundAddressing irreparable subscapularis in conjunction with reverse total shoulder arthroplasty (RTSA) presents challenges. RTSA without subscapularis repair leads to similar clinical results compared to those with a subscapularis repair but with less range of motion in internal rotation. Optimization of internal rotation and anterior stability after RTSA, in the setting of an irreparable subscapularis may be achieved with a pectoralis major tendon transfer (PM). This study aims to describe a novel surgical technique involving PM transfer in RTSA for irreparable subscapularis and report the initial clinical and radiological outcomes. MethodsThis study included 13 patients with an average of 65.5 years (range, 52-82 years). All patients underwent a lateralized RTSA with concurrent PM transfer, associated to an irreparable subscapularis, performed by a single surgeon (PV). Preoperative and postoperative range of motion, including internal rotation 1 (IR1), internal rotation 2 (IR2), external rotation 1 (ER1) and forward elevation, were measured. The absolute Constant score, the age and sex-adjusted Constant Murley score, Visual Analog Scale (VAS) and subjective shoulder value (SSV) were evaluated by the same surgeon. Standard X-rays, preoperative magnetic resonance imaging (MRI), and computed tomography (CT-Scan) were performed for all patients. ResultsWith an average follow-up of 37 months, the mean Constant score improved from 17.7 preoperatively to 61 postoperative (p<0.05). Postoperative clinical outcomes significantly improved across the study group. Mean IR2 increased from 44.6° to 61.5° (p<0.05), while IR1 improved from 2.6 to 5 (p<0.05). The Gerber test yielded positive results for all patients, while the belly press test was negative for eleven patients. Postoperative imaging assessment of the transferred PM tendon transfer showed intact repair, a good cicatrization on the lesser tuberosity with excellent trophicity of the muscle without any fatty infiltration in all patients. ConclusionPM transfer combined with a lateralized RSTA in cases of irreparable subscapularis leads to improved shoulder range of motion, particularly in internal rotation, increased strength and pain relief.

Pectoralis Major Tendon Transfer for Subscapularis Insufficiency: An Operative Technique

Background: Pectoralis major tendon (PMT) transfer is an effective surgical treatment for addressing subscapularis insufficiency in younger, active patients. Indications: The primary indication for a PMT transfer is subscapularis insufficiency or irreparable tear in an active, young patient that is not a candidate for reverse shoulder arthroplasty. In addition, patients should have an intact posterosuperior rotator cuff. In this case, the patient is a 41-year-old male with chronic anterior shoulder instability after failed open Bankart stabilization with subscapularis incompetency. Technique Description: The patient was placed in the beach-chair position and a standard deltopectoral approach was utilized. The conjoint tendon and adjacent musculocutaneous nerve were identified and retracted. Subsequently, the sternal head of the PMT was isolated from the clavicular head at the humeral insertion. It was then released, mobilized and passed inferior to the conjoined tendon for reapproximation at the lesser tuberosity with a suture anchor. Results: A previous systematic review demonstrated that patients with isolated subscapularis insufficiency who undergo PMT transfer have significant increase in Constant Score, range of motion, and internal rotation strength. Additionally, a retrospective case series evaluating 22 patients at a 10-year follow-up revealed maintained improvements in Constant Score, Simple Shoulder test, and Visual Analog scale for Pain. However, they found that strength on internal rotation and range of motion significantly regressed to baseline, preoperative levels. Discussion/Conclusion: PMT transfer for subscapularis insufficiency is a viable treatment option for symptomatic subscapularis tendon tears not amenable to repair. It allows for excellent long-term improvements in strength, range of motion and patient reported outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Options in Tendon Transfers for Anterior-Superior Rotator Cuff Tears: Review

Background. Irreparable anterior-superior rotator cuff tears can cause significant shoulder dysfunction due to the failure of normal biomechanics of the joint, because of the loss of compressive effect of the rotator cuff on the humeral head. Muscle-tendon transfers are an alternative to standard surgical treatment options: debridement of injured tendons, arthroscopic anchor suture, and reverse shoulder arthroplasty. Currently, several options of muscle-tendon transfers are described in the foreign literature, and there is an active discussion over the results of the already proposed techniques, and their improvements, while these techniques are practically not covered in the domestic literature.&#x0D; The aim to describe modern surgical technique options of the muscle-tendon transfers for the treatment of patients with anterior-superior rotator cuff tears based on a review of foreign literature sources.&#x0D; Methods. The search for publications from 1988 to 2022 was carried out in the PubMed/MEDLINE and Google Scholar databases.&#x0D; Results. Nowadays, the most common muscle-tendon transfers options for patients with anterior-superior rotator cuff tears are the sternocostal portion of the of pectoralis major tendon transfer and the latissimus dorsi tendon transfer. A review of foreign literature showed that muscle-tendon transfers are a well-described alternative to standard methods of treating profile patients with a predictable result.&#x0D; Conclusion. Currently, there is no consensus on clear indications for certain types of muscle-tendon transfers in case of anterior-superior rotator cuff tears, there is a lack of data on long-term results. This determines the need of study of the long-term clinical results of use of these methods and develop an algorithm for choosing the tactics of surgical treatment of relevant patients.

Tendon Transfers in Rotator Cuff Deficiency

Massive irreparable rotator cuff tears (MIRCT) is a difficult clinical problem to treat in young, active individuals with minimal arthritis. Tendon transfers allow for donation of muscle units that can power the shoulder and restore kinematics. Posterosuperior rotator cuff deficiency can be treated with either a latissimus dorsi tendon or lower trapezius tendon transfer. The authors preferred method for treating irreparable supraspinatus and infraspinatus tears is with an arthroscopic assisted lower trapezius tendon transfer. The advantage of the lower trapezius tendon is that its vector is directly in line with the infraspinatus tendon allowing for better external rotation and abduction moment arms. The tendon is harvested from the spine of the scapula and augmented with an Achilles tendon allograft for length which is then secured at the footprint of the rotator cuff. Anterosuperior rotator cuff deficiency can be treated with a pectoralis major tendon or anterior latissimus tendon transfer. For subscapularis deficiency, our preferred method is an open versus arthroscopic latissimus tendon transfer. The tendon is harvested in the posterior axilla and augmented with an Achilles tendon allograft at the tendon interface to provide bulk. The tendon is passed arthroscopically to the anterior humerus and secured at the lesser tuberosity. Tendon transfers are a safe, reliable and reproducible technique when treating MIRCTs.

Pectoralis major tendon transfer for management of subscapularis failure after anatomic total shoulder arthroplasty: technique and results

Subscapularis tendon failure after anatomic total shoulder arthroplasty can lead to pain, dysfunction, and early component failure. The purpose of this study was to report on the results of pectoralis major tendon transfer for treatment of irreparable subscapularis tendon failure in the setting of prior shoulder arthroplasty. Patients who underwent pectoralis major muscle transfer for treatment of subscapularis failure in the setting of prior total shoulder arthroplasty or hemiarthroplasty were included in the study. The entirety of the pectoralis major tendon was transferred superficial to the conjoined tendon and placed lateral to the bicipital groove. Eight patients were included in the study. All 7 patient who experienced pain in their shoulder had improvement in their pain postoperatively. Those patients with preserved active motion were able to regain that motion postoperatively. Radiographically, anterior translation was found to be temporarily improved; however, anterior instability would later recur in most cases, though this did not correlate with increased pain or decreased function. Management options ranging from continued observation, revision repair, pectoralis muscle transfer, or revision to reverse total shoulder arthroplasty should be considered in a setting of subscapularis failure after shoulder arthroplasty. Decision-making should be based on physiological age of the patient as well as symptoms present as well as the position and stability of the arthroplasty components. Pectoralis muscle transfer can provide pain relief, improve subjective instability, and preserve function in physiological young patients with an irreparable subscapularis who have well-positioned and well-fixed anatomic shoulder arthroplasty components.

Muscle Tendon Transfers Around the Shoulder: Diagnosis, Treatment, Surgical Techniques, and Outcomes.

Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency. The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle. When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications. For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes. Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes. The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty. The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training.

Anterior Capsule Reconstruction Versus Pectoralis Major Transfer for Irreparable Subscapularis Tears Involving the Anterior Capsule: A Comparative Biomechanical Cadaveric Study

To compare the biomechanical effectiveness of human dermal allograft (HDA) anterior capsular reconstruction (ACR) and pectoralis major tendon transfer (PMTT) for treating irreparable subscapularis tears with capsular insufficiency in human cadaver shoulders. Glenohumeral rotational range of motion and translation were measured in 6cadaveric shoulders under the following 5 conditions: intact, deficient subscapularis/anterior capsule, ACR using HDA, HDA ACR with concomitant PMTT, and PMTT alone. The deficient subscapularis/anterior capsule condition significantly increased external and total rotational range of motion at 0° (P < .001, P < .001) and 30° (P= .005, P= .002) abduction as well as anterior-inferior translation (P ≤ .001 to .03). HDA ACR, both with and without PMTT, restored anterior-inferior stability to that of the intact condition; however, PMTT alone did not restore anterior-inferior translation or rotational range of motion. HDA ACR for treating irreparable subscapularis tears with capsular insufficiency restored anterior-inferior glenohumeral translation and rotational range of motion at time 0 in human cadaver shoulders. Anterior capsule reconstruction may be a viable option for treating massive irreparable subscapularis tears with capsular insufficiency.

Long-Term Outcomes of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis Tears: Results After a Mean Follow-up of 20 Years.

One recognized salvage option in the treatment of an irreparable subscapularis tear is the pectoralis major tendon transfer (PMT). We aimed to analyze the long-term clinical and imaging outcome of PMT for irreparable subscapularis deficiency. Twenty-eight consecutive patients representing 30 shoulders underwent PMT at a mean age of 53.0 years (range, 35 to 67 years). At a mean of 19.7 years (range, 18 to 22 years) postoperatively, 24 shoulders (80%) were clinically examined and 21 were radiographically and sonographically assessed. The long-term results were compared with preoperative findings and previously published short-term results. The mean relative Constant score (percentage of age and sex-matched normal scores; CS%) and the Subjective Shoulder Value (SSV) both improved significantly from preoperatively (CS%, 47%, and SSV, 22%) to postoperatively (CS%, 77%, and SSV, 71%; p < 0.001 for both). All patients rated their results as good or excellent. Active anterior elevation was improved from preoperatively (120°) to postoperatively (131°), but the difference was not significant. Active internal and external rotation decreased significantly from the short-term (32-month) follow-up to the time of the latest follow-up (p = 0.005 and p = 0.002, respectively); however, internal rotation remained at 6 points compared with the 8 points recorded at short-term follow-up and external rotation decreased only from a mean of 51° to 39°. Loss of active range of motion was not observed subjectively and was not subjectively limiting, represented by the high ultimate SSV and overall satisfaction. Four shoulders (19%) showed evidence of glenohumeral arthropathy (Samilson and Prieto grade 3), but clinically were mildly symptomatic to asymptomatic at the time of the latest follow-up (CS% range, 67% to 88%; SSV range, 70% to 80%). Rupture of the PMT was sonographically identified in 2 patients (10%) and was associated with radiographic evidence of advanced cuff tear arthropathy (Hamada stages ≥4). Six (20%) of the initial 30 shoulders were revised, and 1 (4%) of the 24 shoulders that were clinically examined underwent reverse total shoulder arthroplasty. At long-term follow-up, PMT for isolated and combined subscapularis tears is associated with good to excellent clinical results. Although one-third of the shoulders developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with use of reverse total shoulder arthroplasty was rare. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Direct Pectoralis Major Tendon Transfer for Elbow Flexion: A Novel Surgical Technique and Outcomes

Direct Pectoralis Major Tendon Transfer for Elbow Flexion: A Novel Surgical Technique and Outcomes

Pectoralis Major Muscle Transfer With the Sternal Head and Hamstring Autograft for Scapular Winging

Medial scapular winging is often due to dysfunction of the serratus anterior muscle as a result of injury to the long thoracic nerve. Impairment of the serratus anterior muscle may cause uncoordinated scapulohumeral rhythm during shoulder elevation and subsequent subscapular or shoulder pain, subacromial impingement, and glenohumeral joint instability. Although long thoracic nerve injury typically resolves in 12 to 18 months after a physical therapy regimen, surgical intervention is indicated in patients who fail conservative management. Both direct and indirect pectoralis major tendon transfer techniques have been described in the literature as surgical options for these patients. Indirect transfer of the pectoralis major and augmentation with either allograft or autograft has been shown to successfully restore scapular functioning and glenohumeral stability. We describe a technique that uses hamstring autograft to augment a pectoralis major transfer with the sternal head to correct medial scapular winging due to dysfunction of the long thoracic nerve and serratus anterior muscle atrophy.

Long-Term Outcome After Pectoralis Major Transfer for Irreparable Anterosuperior Rotator Cuff Tears.

Promising short-term outcomes after pectoralis major tendon transfer for the treatment of an irreparable anterosuperior rotator cuff tear have been reported. The purpose of this study was to evaluate the long-term outcome. Twenty-seven consecutive patients with irreparable anterosuperior rotator cuff tears without advanced cuff arthropathy or advanced humeral head migration were treated with a partial subcoracoid pectoralis major tendon transfer between 2004 and 2005. At an average of 10 years (range, 9 to 11 years) postoperatively, 22 patients (82%) with an average age of 62 years (range, 42 to 74 years) at the time of surgery had a long-term follow-up examination that included the pain score, strength and range-of-motion assessment, Constant score, Simple Shoulder Test (SST), as well as radiographic and ultrasonographic imaging. The long-term results were compared with the preoperative findings as well as the short-term results that were collected from a previous evaluation. The adjusted Constant score increased from 54% to 87% at the short-term follow-up (p < 0.001) and remained improved at the long-term follow-up, with a mean score of 83% (p = 0.001). While the significant improvement of the pain level at the short-term follow-up was maintained at the time of final follow-up (p = 0.001), the increase in strength returned to the preoperative level (p = 0.178), and the improvement in range of motion diminished again over time despite remaining significantly improved (p = 0.029), especially with regard to internal rotation (p < 0.001). At the long-term follow-up, 77% of the patients were very satisfied with the procedure. A third of the patients had no progression of cuff arthropathy, a third had progression by 1 grade, and a third had progression by ≥2 grades. At the time of final follow-up, 1 patient (5%) had undergone revision surgery to reverse shoulder arthroplasty. Pectoralis major tendon transfer for the treatment of irreparable anterosuperior rotator cuff tears results in a significant clinical improvement even 10 years after surgery, especially with respect to pain and internal rotation. Despite long-term radiographic progression of cuff arthropathy, patient satisfaction remains high over time, with a low rate of salvage with reverse shoulder arthroplasty. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty after failed pectoralis major tendon transfer with a minimum follow-up of 5 years. A case series.

Treatment strategies after failed pectoralis major tendon transfer (PMTT) are scarce in literature and no information is available for patients treated with reverse shoulder arthroplasty (RSA) for failed PMTT. We performed a retrospective outcome study of all patients who underwent revision with RSA after failed PMTT at our institution. From 1999 to 2009 we included 8 patients (8 shoulders). The minimum follow-up was 5 years with a mean follow-up time of 97 months (range, 64-134). Clinical and radiological evaluation comprised range of motion, Constant Murley score (CMS), Simple Shoulder Test (SST) as well as standard X-rays in 2 planes. Pain was measured using VAS pain scale. The patients were asked to rate their satisfaction at final follow-up. All outcome measures improved significantly post-surgical compared to pre-surgical, including the CMS (17.8-62.8), SST (1.8-7.3) and VAS (7.1-1). Active abduction and anterior flexion improved significantly (p<.001) from 65.6° to 125° and from 62.5° to 136.3°, respectively. There were 2 complications. One patient sustained transient musculocutaneous nerve palsy that resolved completely after 5 months and one patient sustained postoperative hematoma and had to be revised 4 days after surgery. 4 (50%) patients rated their results as excellent and 4 (50%) rated them as good. RSA is a good option for treating patients after failed pectoralis major tendon transfer. After a minimum follow-up of 5 years, functional outcome is good and patient satisfaction is high. Level IV, Case series, Treatment study.

Tendon transfers for irreparable rotator cuff tears: An update.

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

Entire pectoralis major tendon transfer with the hamstring tendon autograft for the treatment of scapular winging due to long thoracic nerve injury

Aim The aim of this study was to evaluate the results of treatment of patients with scapular winging due to long thoracic nerve (LTN) injury through the indirect transfer of the entire pectoralis major tendon (PMT) using the hamstring autograft. Patients and methods Between November 2011 and October 2012, six patients with painful scapular winging due to LTN injury underwent PMT transfer at Mansoura University Hospital and a private hospital. All patients were male with a mean age of 35.2 years at the time of surgery. All patients underwent clinical examination. All patients underwent plain radiography of the shoulder and electromyography and nerve conduction for the LTN. All patients were treated with the indirect transfer of the entire PMT to the inferior angle of the scapula using the hamstring autograft. Results The mean preoperative to postoperative results included increases in active forward flexion from 142.5° to 167.5° and active external rotation from 50° to 65°, and improvement in the American Shoulder and Elbow Surgeons score from 30 to 71.6 and Visual Analog Scale pain score from 6.3 to 1.8. Conclusion Entire PMT transfer with the hamstring tendon autograft is effective for restoring shoulder function, relieving shoulder pain, and treating scapular winging caused by serratus anterior paralysis due to electromyography-confirmed LTN injury.

Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction: A Retrospective Study of Functional Outcome and Results

Background: Twenty-six patients (12 male and 14 female) with symptomatic scapular winging caused by serratus anterior dysfunction were managed by split pectoralis major tendon transfer (sternal head) with autogenous hamstring tendon augmentation from 1998 to 2006. Methods: Twenty-five patients showed positive results upon long thoracic nerve palsy on electromyography. The mean duration of symptoms until surgery was 48 months (range, 12–120 months). Four patients had non-traumatic etiologies and 22 patients had traumatic etiologies. On follow-up assessment for functional improvement, a Constant-Murley score was used. Twenty-one patients were completely evaluated, while five patients who had less than 12 months of follow-up were excluded. Results: Pain relief was achieved in 19 of the 21 patients, with 20 patients showing functional improvement. The pain scores improved from 6.0 preoperatively to 1.8 postoperatively. The mean active forward elevation improved from 108o (range, 20°–165°) preoperatively to 151° (range, 125°–170°) postoperatively. The mean Constant-Murley score improved from 57.7 (range, 21–86) preoperatively to 86.9 (range, 42–98) postoperatively. A recurrence developed in one patient. Of the 21 patients, ten had excellent results, six had good results, four had fair results, and one had poor results. Conclusions: Most patients with severe symptomatic scapular winging showed functional improvement and pain relief with resolution of scapular winging.

Modified pectoralis major tendon transfer for reanimation of elbow flexion as a salvage procedure in complete brachial plexus injury: a case report.

Traumatic brachial plexus injuries rarely recover spontaneously and if the window period for neurotisation has elapsed, the only option for restoration of function lies in a salvage procedure. Many such salvage procedures have been described in the literature with variable functional results. We report the case of a 16-year-old boy who presented after unsuccessful treatment for a complete brachial plexus injury; we performed a pectoralis major tendon transfer to attain elbow flexion. Postoperatively, the elbow was splinted with flexion at 100°. After 4 weeks of immobilization the splint was removed and the patient could actively flex his elbow from 30° to 100°. brachial plexus injury, salvage procedure, pectoralis major tendon transfer.

Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques

Irreparable ruptures of the subscapularis tendon lead to impaired function of the shoulder joint. In such cases, transfer of the pectoralis major tendon has led to encouraging results. The procedure fails periodically, typically associated with insufficient in-growth of the transferred tissue. We hypothesized that tendon harvest with chips of cancellous bone would improve the tendon-bone interface. Of 62 consecutive pectoralis tendon transfers, 54 shoulders were followed-up at an average of 35 months. In all shoulders, the transferred tendon was rerouted behind the conjoint tendon and fixed by transosseous sutures. In 29 shoulders, the tendon was harvested with a cuff of cancellous bone. In 25 shoulders, the conventional technique with sharp detachment of the tendon was used. Apart from detailed clinical examination of all shoulders, a magnetic resonance image (MRI) was available in 52 shoulders. The overall Constant score had improved from an average of 38.8 points preoperatively to 63.4 points at follow-up. Shoulders treated with the new fixation technique scored 64.4 compared with 62.2 for the conventional fixations. The MRI showed intact tendons and muscles in 80.8% of shoulders. In 7 shoulders (13.5%), the transferred tendon was ruptured. Two of these were treated with the new fixation technique. Mean patient satisfaction score was 8.2 points. A secure method of fixation that avoids secondary ruptures despite insufficiency of the transferred tendon is of great importance. Also the rerouting of the transferred tendon under the conjoined tendon is essential to imitate the natural force vector and the function of an intact subscapularis tendon. Patients in this investigation were also monitored by MRI to verify the integrity of the transferred tendon. As a salvage procedure, the pectoralis major tendon transfer provides good results in most cases. Sufficient in-growth of the transferred tissue is essential for the success of the procedure. This seems to be facilitated by both methods.

난치성 익상 견갑의 대흉근 이전술 - 증례 보고 -

Purpose: We wanted to evalulate the clinical results of pectoris major tendon transfer for a neglected winged scapula that was caused by paralysis of the serratus anterior due to injury to the long thoracic nerve. Materials and Methods: A patient had neglected winged scapula that followed an arthroscopic operation for multi-directional instability of the shoulder joint, which was caused by traumatic dislocation. The patient was treated with pectoralis major tendon transfer using the modified Eden-Lange procedure. The range of a motion was improved from forward flexion and external rotation to and respectively. Results and Conclusion: There were no complications or recurrence and the patient`s psychological satisfaction was also high. If the shoulder girdle muscles are intact, except for the serratus anterior, then pectoralis tendon transfer is a satisfactory method that can provide normal scapulo-thoracic motion.