Teres Major Transfer Research Articles

Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer

One possible sequela of obstetric brachial plexus palsy (OP) is impaired external rotation (ER) of the shoulder which, in addition to its functional consequences, can generate a posterior humeral head subluxation or dislocation. The goal of the present study was to assess medium-term clinical and radiological results of release of the subscapularis muscle with transfer of the latissimus dorsi and teres major muscles. From 1985 to 1995, a continuous series of 32 OP patients underwent subscapularis muscle release, associated in 24 cases to muscle transfer. Mean age was 2.5 years (range, 1-9.2 years). Shoulder function was assessed by measurement of passive ER and graded according to the modified Mallet classification at 1, 5 and 10 years' follow-up or before revision. The evolution of the glenohumeral deformity was assessed on CT images of glenoid retroversion and the humeral head subluxation (% of humeral head covered), before and 5 years after surgery. Mean postoperative follow-up was 9.5+/-5.6 years. Treatment brought significant improvement in passive ER (mean preoperative and 1-year follow-up values: -10 degrees and 52 degrees, respectively). This explained the good modified Mallet score at 1 year: mean=18.4/25. Subsequent significant progressive degradation was noted: 10 years postoperatively, mean ER amplitude and modified Mallet score were respectively 13 degrees and 15.8. The CT study showed correction of the glenoid retroversion (mean preoperative and 5-year follow-up values: 29 degrees and 18 degrees, respectively), and of the humeral head subluxation (mean preoperative and 5-year follow-up values: 25 and 39%, respectively). Surgical revision was indicated six times (five patients): two latissimus dorsi and teres major transfers (not performed initially) and four derotational humeral osteotomies. Three-quarters of the patients who did not initially have muscle transfer had to be reoperated or else showed ER insufficiency at last follow-up. Surgical treatment produces objective functional gain, even if this diminishes over time. Moreover, it prevents or corrects posterior subluxation of the shoulder. It is indicated when passive ER amplitude is negative. It seems advisable to associate release to muscle transfer. Level IV Retrospective study.

Soft tissue rebalancing procedures with and without internal rotation osteotomy for shoulder deformity in children with persistent obstetric brachial plexus palsy

Children with obstetric brachial plexus palsy (OBPP) frequently have problems related to their shoulder. The aim of the investigation was to determine our results in treating shoulder deformity with tendon transfers and soft tissue releases with and without internal rotational osteotomy. We also evaluated the relationships between neurological status, age and selected clinical parameters. We reviewed data of 25 patients (12 girls) after latissimus dorsi and teres major tendon transfers to the rotator cuff. Internal rotation osteotomy was performed in ten children. The mean age of patients at the time of operation was 3.2 years (range from 10 months to 7.7 years). Patients were followed up for a mean of 3.8 years (minimum 2 years). Mallet score improved 4.7 points at last follow-up (p = 0.00002). No patient had shoulder function deterioration. Active and passive external rotation increased significantly after operation: p < 0.00001, p < 0.00001, respectively. Statistically significant reduction in active internal rotation was noted (p = 0.04). The other movements have not statistically changed after operation. Active internal rotation difference after internal rotation osteotomy was significantly better than without osteotomy (p = 0.03). Neurological involvement and age had neither positive nor negative influence on final range of motion and outcome. Soft tissue rebalancing procedures significantly improve shoulder function in children with persistent OBPP. Addition of internal rotational osteotomy to muscle transfers for severe cases allows maintaining of stabile joint, prevents loosening of internal rotation and does not influence other movements of the shoulder.

Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy

We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy. Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months). Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05). Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.

Teres major muscle activation relates to clinical outcome in tendon transfer surgery

Background In massive rotator cuff tears a teres major (TMj) tendon transfer to the insertion of the supraspinatus (SSp) reverses its adduction moment arm into abduction which is supposed to be an adequate salvage procedure. Analysis of muscle function to find biomechanical ground of such success is scarce. Methods We compared pre- and postoperative clinical outcome of TMj transfer, i.e. Range of Motion, pain, Constant Shoulder scores and arm force. TMj activation was evaluated in 14 patients suffering massive cuff tears using activation ratios to describe the desired ‘in-phase’ and undesired ‘out-of-phase’ contribution to the external arm moment. Additionally, we analyzed activation of the latissimus dorsi (LD) and the medial part of the deltoids (DE). The activation ratios were compared to controls and TMj activation ratios were related to clinical outcome. Findings TMj tendon transfer improved arm function. Pre-operatively, we observed ‘out-of-phase’ abduction activation of TMj and LD. After transfer patients activated TMj according to its new anatomical position. ‘Out-of-phase’ LD abduction activation persisted. The clinical improvements coincided with changes in activation ratio of TMj. Interpretation ‘Out-of-phase’ TMj adductor activation is associated with compromised arm function in patients with irreparable cuff tears. After transfer, TMj is activated in correspondence with its new anatomical function, which was supportive for the improved arm function.

The Early Effects of Tendon Transfers and Open Capsulorrhaphy on Glenohumeral Deformity in Brachial Plexus Birth Palsy

Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint dysplasia in patients with brachial plexus birth palsy. The objective of the present investigation was to determine the effects of tendon transfers and open glenohumeral reduction on shoulder function and dysplasia in patients with preexisting joint deformity secondary to brachial plexus birth palsy. Twenty-three patients with preexisting glenohumeral deformity underwent latissimus dorsi and teres major tendon transfers to the rotator cuff with concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis and open glenohumeral joint reduction for the treatment of internal rotation contracture and external rotation weakness. Shoulder function was assessed with use of the modified Mallet classification system and the Active Movement Scale. Glenoid version and humeral head subluxation were quantified radiographically, and glenohumeral deformity was appropriately graded. The mean duration of clinical and radiographic follow-up was thirty-one and twenty-five months, respectively. Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 10 points preoperatively to 18 points postoperatively (p < 0.01). The mean modified Mallet score for external rotation improved from 2 to 4 (p < 0.01). Similarly, the mean Active Movement Scale score for external rotation improved from 3 to 6 (p < 0.01). The mean Mallet hand-to-spine score improved from 1 to 2 (p < 0.01). The mean Active Movement Scale score for internal rotation remained constant at 6. Radiographically, the mean glenoid version improved from -39 degrees preoperatively to -18 degrees postoperatively (p < 0.01). The mean percentage of the humeral head anterior to the middle of the glenoid similarly improved from 13% to 38% (p < 0.01). The mean glenohumeral deformity score improved from 3 to 2 (p < 0.01). Nineteen (83%) of the twenty-three patients demonstrated glenohumeral remodeling; one patient had progressive worsening of glenohumeral deformity. Tendon transfers to the rotator cuff, combined with musculotendinous lengthenings and open reduction of the glenohumeral joint, improve global shoulder function and lead to glenohumeral joint remodeling in the majority of selected patients with mild-to-moderate preexisting glenohumeral dysplasia secondary to brachial plexus birth palsy. Future study of the long-term outcomes of these procedures will help to clarify the ultimate effect on glenohumeral joint function.

Modified L'Episcopo Tendon Transfers for Irreparable Rotator Cuff Tears: 5-year Followup

Patients with posterosuperior cuff tears lose functional external rotation of the shoulder. Latissimus dorsi and teres major transfer is performed to restore external rotation. Twenty patients with a mean age was 55.8 +/- 6 years underwent this procedure and were examined at averages of 24.7 (n = 17) and 70.6 (n = 13) months. Two patients did not improve presumably because of failure of the transfer. The Constant and Murley score increased from 55.6 to 90.4 after 2 years and to 87.9 after 5 years. The mean active flexion increased from 119.4 degrees to 169.3 degrees and reached 170 degrees after 5 years, and mean external rotation increased from 12 degrees to 35 degrees , finally reaching 23 degrees . The grade of cuff arthritis progressed from initially Grade 1 in 17% and Grade 2 in 28% to Grade 2 in 8%, Grade 3 in 69%, and Grade 4 in 15% at final followup. The acromiohumeral distance increased from 4.5 mm to 6 mm and decreased to 3.8 mm after 5 years. Electromyographic analysis showed activity during isometric internal and external rotation in the transferred muscle in all patients. The L'Episcopo procedure can restore shoulder function, but cuff arthropathy may progress. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The Early Effects of Tendon Transfers and Open Capsulorrhaphy on Glenohumeral Deformity in Brachial Plexus Birth Palsy

Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint dysplasia in patients with brachial plexus birth palsy. The objective of the present investigation was to determine the effects of tendon transfers and open glenohumeral reduction on shoulder function and dysplasia in patients with preexisting joint deformity secondary to brachial plexus birth palsy. Twenty-three patients with preexisting glenohumeral deformity underwent latissimus dorsi and teres major tendon transfers to the rotator cuff with concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis and open glenohumeral joint reduction for the treatment of internal rotation contracture and external rotation weakness. Shoulder function was assessed with use of the modified Mallet classification system and the Active Movement Scale. Glenoid version and humeral head subluxation were quantified radiographically, and glenohumeral deformity was appropriately graded. The mean duration of clinical and radiographic follow-up was thirty-one and twenty-five months, respectively. Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 10 points preoperatively to 18 points postoperatively (p < 0.01). The mean modified Mallet score for external rotation improved from 2 to 4 (p < 0.01). Similarly, the mean Active Movement Scale score for external rotation improved from 3 to 6 (p < 0.01). The mean Mallet hand-to-spine score improved from 1 to 2 (p < 0.01). The mean Active Movement Scale score for internal rotation remained constant at 6. Radiographically, the mean glenoid version improved from -39 degrees preoperatively to -18 degrees postoperatively (p < 0.01). The mean percentage of the humeral head anterior to the middle of the glenoid similarly improved from 13% to 38% (p < 0.01). The mean glenohumeral deformity score improved from 3 to 2 (p < 0.01). Nineteen (83%) of the twenty-three patients demonstrated glenohumeral remodeling; one patient had progressive worsening of glenohumeral deformity. Tendon transfers to the rotator cuff, combined with musculotendinous lengthenings and open reduction of the glenohumeral joint, improve global shoulder function and lead to glenohumeral joint remodeling in the majority of selected patients with mild-to-moderate preexisting glenohumeral dysplasia secondary to brachial plexus birth palsy. Future study of the long-term outcomes of these procedures will help to clarify the ultimate effect on glenohumeral joint function. Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Reverse Shoulder Arthroplasty Combined with a Modified Latissimus Dorsi and Teres Major Tendon Transfer for Shoulder Pseudoparalysis Associated with Dropping Arm

Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70 degrees to 148 degrees (+78 degrees ) and external rotation from -18 degrees to 18 degrees (+36 degrees ). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.

Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: As an isolated procedure or with a reverse arthroplasty

Definitive loss of active external rotation of the shoulder impacts an individual's ability to perform ADL's, creating severe disability. To restore active external rotation, we modified the L'Episcopo procedure by transferring both the latissimus dorsi and teres major (LD/TM) through a single delto-pectoral approach. The two tendons were rerouted and reattached laterally on the humerus to the stump of the pectoralis major which was partially transected to the posterior epiphysis. Fifteen consecutive patients who underwent this procedure; (mean age 63.2 years), have been followed for at least one year (range 14-63). The transfer was indicated alone in 7 patients with an isolated loss of active external rotation (ILER) related to an irreparable postero-superior cuff tear. It was associated with a reverse shoulder prosthesis in 8 patients with combined loss of active elevation and external rotation (CLEER): 6 cases of rotator cuff tear arthropathy and 2 of tumor reconstruction. For the series as a whole, the mean increase in active elevation was 34.7 degrees . The gain in active external rotation was +27 degrees for ILER patients and +28 degrees for CLEER patients. Constant score improved to 65.6 (range, 51-79). Subjective shoulder value (SSV) was significantly improved from 34% to 72% (P < .0009). All but one patient was satisfied or very satisfied with the result. The major contributor to their satisfaction was the ability to control the spatial positioning of the arm, eliminating the tendency of the forearm to swing in toward the trunk. One patient had a return of a lag sign after a fall. The modified tendon transfer, performed in the beach chair position through a delto-pectoral approach, is less invasive than the classic two-incisions procedure and provides good functional results in patients with absent or atrophic infraspinatus and teres minor. When the modified LD/TM transfer is associated with a reverse shoulder arthroplasty, it allows to restore both active elevation and external rotation.

Surgical Technique and Anatomic Study of Latissimus Dorsi and Teres Major Transfers

BACKGROUND: Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. METHODS: Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. RESULTS: The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. CONCLUSIONS: Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons. CLINICAL RELEVANCE: The present study provides important anatomic findings for the safe mobilization and transfer of the latissimus dorsi and teres major tendons during the surgical treatment of irreparable rotator cuff tears. ORIGINAL ABSTRACT CITATION: “Surgical Technique and Anatomic Study of Latissimus Dorsi and Teres Major Transfers” (2006;88:).

Surgical Technique and Anatomic Study of Latissimus Dorsi and Teres Major Transfers

Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons.

Latissimus Dorsi and Teres Major Transfer With Reverse Total Shoulder Arthroplasty for a Combined Loss of Elevation and External Rotation

Loss of active external rotation of the shoulder, related to absent or fatty infiltrated rotator cuff muscles, results in a patient's inability to move the hand to the mouth or to the top of the head. When this condition is combined with pseudoparalysis of the shoulder (active flexion <90 degrees), the patient has a limb that is only functional at waist level. Although the reverse prosthesis restores active elevation, it does not enhance external rotation and tremendous disability, and patient dissatisfaction persists. To restore active external rotation for the patient who has a combined loss of active flexion and external rotation, we have modified the L'Episcopo procedure, transferring both the latissimus dorsi and teres major, to perform it through a deltopectoral approach. The procedure can be performed alone for isolated loss of external rotation or in conjunction with a reverse prosthesis for combined loss of elevation and external rotation.

Surgical Technique and Anatomic Study of Latissimus Dorsi and Teres Major Transfers

Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons. The present study provides important anatomic findings for the safe mobilization and transfer of the latissimus dorsi and teres major tendons during the surgical treatment of irreparable rotator cuff tears.

SURGICAL TECHNIQUE AND ANATOMIC STUDY OF LATISSIMUS DORSI AND TERES MAJOR TRANSFERS

Background: Combined latissimus dorsi and teres major musculotendinous transfer has been described for the treatment of massive rotator cuff deficits. The procedure is technically complex because of the proximity of the radial nerve, the axillary nerve and its posterior branches, and the neurovascular bundles to the muscles. The purpose of the present cadaveric study was to examine surgically relevant relationships for latissimus dorsi and teres major tendon transfers. Methods: Twelve cadaveric shoulder girdles were dissected, and the latissimus dorsi, the teres major, and the posterior cord of the brachial plexus and its branches were identified. The relationships between the tendons and local neurologic structures were measured during various steps of the latissimus dorsi/teres major transfer procedure. The effect of humeral rotation on the exposure of the latissimus dorsi and teres major tendons through the posterior approach was quantified, and relevant surgical landmarks were described. Results: The radial nerve passed directly anterior to the tendons at an average of 2.9 cm medial to the superior aspect and 2.3 cm medial to the inferior aspect of the humeral insertions. From the posterior axillary approach, maximal internal rotation facilitated exposure for tenotomy by delivering the tendon insertions on the humerus into the surgical field. During axial mobilization of the musculotendinous units, the neurovascular pedicles to the latissimus dorsi and teres major were identified at an average of 13.1 and 7.4 cm axial to the humeral insertions, respectively. The posterior branch of the axillary nerve was noted to cross superficially over the transferred tendons as they were tunneled under the posterior deltoid. Conclusions: Multiple steps of the combined latissimus dorsi and teres major musculotendinous transfer place local neurologic structures at risk. These steps include tendon release, musculotendinous axial mobilization, and tendon tunneling in the plane between the infraspinatus-teres minor and the posterior deltoid. We have quantified and described the relationship of the axillary and radial nerves to the tendons during tenotomy, the distance from the tendons' insertions to their neurovascular bundle that must be identified during axial mobilization, and the course of the posterior branch of the axillary nerve in relation to the tunneled path of the tendons. Clinical Relevance: The present study provides important anatomic findings for the safe mobilization and transfer of the latissimus dorsi and teres major tendons during the surgical treatment of irreparable rotator cuff tears.

Pathological Teres Major activation in patients with massive rotator cuff tears alters with pain relief and/or salvage surgery transfer

Massive rotator cuff tears impose restraints on overhand arm functionality and are often accompanied by pain. After musculotendinous Teres Major transfer, overhand arm function is generally restored and pain is reduced. The assumed mechanical abduction insufficiency and Teres Major muscle function adaptation will be experimentally verified. Principal Teres Major muscle activation (surface IEMG averaged over 3s) is recorded for 12-24 isometric and isotonic force directions perpendicular to the 60 degrees forward flexed humerus in three conditions: prior to surgery (n = 6 patients), prior to surgery and after subacromial anaesthetic (n = 6) and post-surgery (n = 3). Principal direction and on-, offset directions were estimated. Teres Major activation adapts both to pathological and post surgery conditions: the normal activation during adduction changes into activation during forward flexion or abduction. Glenohumeral stabilisation, not abduction torque, seems to be the explanation for post surgery Teres Major transfer success. The pathological absence of Supraspinatus and Infraspinatus forces during forward flexion result in increased upward glenohumeral instability. The superior translations are compensated for by Teres Major activity during forward flexion. This translation-'force' function conflicts with the adduction-generating rotation-'torque' function. This may explain the pain-induced reduction of arm elevation in these patients. Musculotendinous transfer solves the force-torque conflict by changing the moment arm of the Teres Major from adduction to abduction. Teres Major can now both compensate for the loss of Supraspinatus and Infraspinatus forces needed for glenohumeral stabilisation and contribute to forward flexion of the arm.

Brachioradialis Transposition for Elbow Extension in Obstetrical Brachial Plexus Palsy

Disorders of elbow extension occur following traumatic or neurologic injuries of the triceps muscle. Restoration of elbow extension is an integral part of the entire upper extremity surgical reconstruction to improve the following daily activities: bringing down an object from above, handwriting, using the hand in the supine position, steering a wheelchair, driving a car, and swimming. The transfer of the posterior head of the deltoid muscle to triceps (Moberg procedure) and the transfer of the biceps to triceps (Friedenberg procedure) are previously described procedures for the functional restoration of triceps function. In conditions where these procedures cannot be used, we describe a new technique for restoration of elbow extension. In 4 cases with obstetrical palsy sequela, where shoulder abduction was established with the latissimus dorsi and teres major transfer, restoration of elbow extension was planned to aid in activities performed while the hand is above the head. To achieve this goal, the brachioradialis muscle was transposed bipedically to the triceps muscle.

Effect of Tendon Transfers and Extra-Articular Soft-Tissue Balancing on Glenohumeral Development in Brachial Plexus Birth Palsy

Persistent muscle imbalance and soft-tissue contractures can lead to progressive glenohumeral joint deformity in patients with brachial plexus birth palsy. The objective of this investigation was to determine the effects of correction of external rotation weakness and internal rotation contractures with tendon transfers and extra-articular soft-tissue releases on glenohumeral development in patients with brachial plexus birth palsy. Twenty-five patients with brachial plexus birth palsy who underwent latissimus dorsi and teres major tendon transfers to the rotator cuff-with or without concomitant musculotendinous lengthenings-were evaluated clinically and radiographically before the operation and at a minimum of two years (average, forty-three months) postoperatively. Shoulder function was prospectively assessed with use of the modified Mallet classification system, in which aggregate shoulder function is assigned a score of 5 to 25 points. Glenoid version and humeral head subluxation were quantified with magnetic resonance imaging or computed tomography, and glenohumeral deformity was graded. Clinically, all patients demonstrated improved global shoulder function, with the mean aggregate Mallet score improving from 13 points preoperatively to 18 points postoperatively (p < 0.01). As seen radiographically, the mean glenoid retroversion improved from 22 degrees preoperatively to 16.5 degrees postoperatively (p = 0.012). The mean posterior humeral head subluxation improved from 30% to 37% (p = 0.03). No patient had progressive worsening of the glenohumeral deformity. Latissimus dorsi and teres major tendon transfers to the rotator cuff, combined with appropriate extraarticular musculotendinous lengthenings, significantly improved global shoulder function but led to only modest improvements in glenoid retroversion and humeral head subluxation. No profound glenohumeral remodeling occurs after these extra-articular rebalancing procedures, even when they are performed in patients of a young age. While the long-term clinical and radiographically apparent effects at skeletal maturity are uncertain, soft-tissue rebalancing procedures alone were found to have halted the progression of, but not to have markedly decreased, glenohumeral dysplasia at the time of a two to five-year follow-up.

Does preoperative abduction value affect functional outcome of combined muscle transfer and release procedures in obstetrical palsy patients with shoulder involvement?

BackgroundObstetric palsy is the injury of the brachial plexus during delivery. Although many infants with plexopathy recover with minor or no residual functional deficits, some children don't regain sufficient limb function because of functional limitations, bony deformities and joint contractures. Shoulder is the most frequently affected joint with internal rotation contracture causing limitation of abduction, external rotation. The treatment comprises muscle release procedures such as posterior subscapularis sliding or anterior subscapularis tendon lengtening and muscle transfers to restore the missing external rotation and abduction function.MethodsWe evaluated whether the preoperative abduction degree affects functional outcome. Between 1998 and 2002, 46 children were operated on to restore shoulder abduction and external rotation. The average age at surgery was 7.6 years and average follow up was 40.8 months. We compared the postoperative results of the patients who had preoperative abduction less than 90° (Group I: n = 37) with the patients who had preoperative abduction greater than 90° (Group II: n = 9), in terms of abduction and external rotation function with angle measurements and Mallet classification. We inquired whether patients in Group I needed another muscle transfer along with latissimus dorsi and teres major transfers.ResultsIn Group I the average abduction improved from 62.5° to 131.4° (a 68.9° ± 22.9°gain) and the average external rotation improved from 21.4° to 82.6° (a 61.1° ± 23°gain). In Group II the average abduction improved from 99.4°to 140°(a40.5° ± 16°gain) and the average external rotation improved from 33.2°to 82.7° (a 49.5° ± 23.9° gain). Although there was a significant difference between Group I and II for preoperative abduction (p = 0.000) and abduction gain in degrees (p = 0.001), the difference between postoperative values of both groups was not significant (p = 0.268). There was also no significant difference between the two groups in the preoperative external rotation, the external rotation gain and the postoperative external rotation (p = 0.163, p = 0.181 and p = 0.803, respectively).ConclusionsObstetric palsy patients with shoulder sequela who had a preoperative abduction less than 90°hadas good functional results using latissimus dorsi, teres major muscle transfer and subscapularis muscle release as the patients who hada preoperative abduction greater than 90°.

Split Pectoralis Major and Teres Major Tendon Transfers for Reconstruction of Irreparable Tears of the Subscapularis

Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. In certain circumstances, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. A pectoralis major tendon transfer is an acceptable salvage option for irreparable subscapularis tendon ruptures. Although limited functional goals may be expected in most cases, the majority of patients obtain a good pain relief, which improves their function below chest level. Addition of the teres major component to the transfer may be beneficial in cases where both the upper and lower portion of the subscapularis muscle is irreparable. Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. 1

Results of the latissimus dorsi and teres major tendon transfer on to the rotator cuff for brachial plexus palsy at birth.

Brachial plexus palsy at birth remains a serious problem. Although most cases resolve during the first few months by spontaneous regeneration, several operations have been used to correct the residual deformity. In the present study we describe the results of the latissimus dorsi and teres major tendons transfer on to the rotator cuff to improve shoulder function. Six patients were included in the study: three girls and three boys; four right shoulders, and two left. The types of palsy were four Erb's palsy (C5, C6) and two C5-C7 palsy. The median age at the time of operation was 11 years and 1 month and the median follow-up period was 54.2 months. Median preoperative passive external rotation was 51 degrees, and active abduction 67 degrees. Median postoperative active external rotation was 72 degrees, and postoperative active abduction 109 degrees. This procedure increased the ranges of external rotation and abduction, and provided considerable improvement in shoulder function.