Tendon transfer is a widely used surgical approach for managing irreparable rotator cuff tears (IRCTs) and nerve-related shoulder dysfunctions when direct repair is not feasible. By restoring shoulder stability and function, tendon transfers compensate for lost muscle activity through biomechanically strategic reattachments. Common procedures include latissimus dorsi (LD) transfer, with or without teres major (TM), and lower trapezius (LT) transfer for posterior-superior IRCTs. For anterior-superior IRCTs, LD transfer with or without TM and pectoralis major (PM) transfer are commonly performed. Middle trapezius (MT) transfer has emerged as an option for irreparable supraspinatus tears. In complex cases, dual tendon transfers combining multiple tendons have been introduced to optimize shoulder biomechanics, particularly in patients with extensive deficits. Despite their benefits, tendon transfers pose significant challenges. Complications include neurovascular injury, improper tensioning leading to altered biomechanics, infection, tendon rupture, and graft failure. Careful patient selection, precise surgical execution, and structured postoperative rehabilitation are critical for minimizing complications and achieving favorable outcomes. This review explores the fundamental concepts of tendon transfer, focusing on its indications, biomechanical considerations, clinical outcomes, and associated complications. A comprehensive understanding of these principles is essential for optimizing functional recovery and ensuring long-term success in shoulder reconstruction.

Quantifying the influence of radiation therapy on functional shoulder health indicators in breast cancer patients: An exploratory study.

The brachial artery is a key vessel supplying the upper limb, and its anatomical variations can have significant clinical implications. One of the most common variations of this vessel is a high division of the brachial artery. This can occur at various levels of the arm and lead to the formation of a brachioradial artery, a brachioulnar artery, or their superficial variants. The study was based on the analysis of a case observed during a routine autopsy of a 64-year-old woman, conducted as part of the Normal Anatomy course for medical students at the Department of Normal and Radiological Anatomy of the Medical University of Lublin. The analysis revealed an atypical course of the arteries in the left upper limb. The brachial artery divided at the level of the upper third of the arm, 2 cm below the lower border of the teres major muscle, giving rise to the brachioradial artery and the brachioulnar artery. The common interosseous artery branched off from the brachioulnar artery in the cubital fossa. The vascular course in the right upper limb was confirmed as typical. A high division of the brachial artery is a relatively common anatomical variation, occurring in 10.05% of the population, and therefore requires special attention during surgical and diagnostic procedures. Its most frequent variant is the division of the brachial artery into a brachioradial artery and a brachioulnar artery. The presence of this variation can affect the efficacy and safety of procedures such as angiography, vascular surgeries, or reconstructive surgeries. Further research should aim to standardize the descriptions of anatomical variations in upper limb arteries and establish a unified nomenclature system.

Muscle activation variability in relation to functional internal rotation in reverse total shoulder arthroplasty.

In upper brachial plexus (C5-C6) avulsion injuries, deltoid reinnervation via radial-to-axillary nerve transfer is standard. However, fracture-dislocations around the shoulder complicate surgical exposure due to fibrosis and distorted anatomy. Fifteen male patients (mean age: 26.1 years) with C5-C6 avulsion injuries and concomitant shoulder fractures were treated between October 2019 and April 2022 using a modified posterior approach. The "teres major first" technique utilized the inferior border of the teres major muscle as a consistent landmark to identify and mobilize the long head triceps branch and anterior axillary nerve. A vertical slit in the teres major tendon improved access and allowed tension-free coaptation. All patients also received spinal accessory to suprascapular nerve transfers, and partial ulnar and/or median nerve transfers for elbow flexion restoration. All patients had fibrous adhesions in the quadrangular space, and 3 had distal axillary nerve injuries. The teres major landmark enabled safe dissection in all cases. Twelve of 15 patients achieved deltoid reinnervation with active shoulder abduction between 110° and 170° (mean 156°; MRC grade III-IV). Three patients (2 with proximal humerus fractures and 1 with lateral clavicle fracture with coracoclavicular disruption) showed limited recovery (70°-80° abduction). Triceps donor site weakness (MRC grade ≥3 in 14/15) was tolerated well, and full elbow flexion was restored in all patients. EMG evidence of reinnervation appeared by week 21 (deltoid) and week 23 (infraspinatus), with improvement in active shoulder abduction from week 27 onward. The "teres major first" approach enables rapid and safe identification of target nerves in brachial plexus injuries complicated by shoulder fractures and dislocations. This technique minimizes dissection in fibrotic areas, ensures tension-free repair, and achieves reliable functional outcomes. However this study is limited by the relatively small sample size and a reduced statistical power.

Effect of eccentric muscle force on shoulder internal impingement in a cadaveric model of throwing.

Objectives: To describe the prevalence of a high bifurcation of the brachial artery and a superficial ulnar artery in a donor population of 17 individuals, the rare occurrence of both variations in one of the 17 individuals, and to explore the clinical, surgical, and embryological significance of both types of anatomical variations. Methods: During routine anatomical dissection of 17 formalin-fixed cadavers at Rocky Vista University College of Osteopathic Medicine- Southern Utah, 34 upper limbs were examined bilaterally for vascular anomalies. Standard dissection techniques were used to assess the origin, course, and branching of the brachial, radial, and ulnar arteries. Results: A unilateral case was identified with a high bifurcation of the brachial artery occurring approximately 2.54 cm distal to the teres major muscle. The ulnar artery coursed superficially over the forearm flexor mass before rejoining its typical path. The common interosseous artery originated anomalously from the radial artery. This combined vascular variation was found in one of the 34 upper extremities (2.94%), while high bifurcation alone was present in four of the 34 upper extremities (11.7%). Embryological review suggests abnormal regression or persistence of axial arterial branches may contribute to such variations. Conclusion: Although rare, recognition of a high bifurcation of the brachial artery with a superficial ulnar artery is critical for preventing complications during venipuncture, catheterization, and vascular surgery. This case underscores the importance of anatomical education and preoperative imaging when encountering vascular anomalies.

Combined Latissimus Dorsi/Teres Major Transfer and Superior Capsular Reconstruction Using Autogenous Biceps Tendon Effectively Relieves Pain and Improves Shoulder Function for Posterosuperior Irreparable Rotator Cuff Tears

PurposeManaging irreparable subscapularis tears poses a challenge. Traditionally, pectoralis major transfer has been the gold standard, but alternative methods including anterior latissimus dorsi (LD) and teres major (TM) tendon transfers have shown promise. This study evaluates the clinical outcome of full arthroscopic combined LDTM transfers for irreparable subscapularis tears.MethodsPatients with irreparable subscapularis tears who underwent full arthroscopic combined LDTM transfers from October 2020 to August 2022 were retrospectively reviewed. The inclusion criteria comprised failure of conservative treatment, irreparable subscapularis tears (Lafosse grade ≥ 4), and no to minimal glenohumeral arthritis (Hamada grade < 3). The exclusion criteria included patients with missing clinical data. Clinical assessments included the visual analogue scale (VAS), the Constant score, the Subjective Shoulder Value (SSV), active range of motion (ROM), and internal rotation strength. A total of 11 patients met the inclusion criteria and were included in this study.ResultsOut of 14 patients, 11 met the inclusion criteria, with a mean age of 65.9 ± 6.0 years and a follow‐up duration of 25.9 ± 6.2 months. Postoperative results demonstrated significant pain relief, with the VAS score improving from 8.1 ± 0.9 to 2.1 ± 2.1 (p < 0.001). Functional outcomes improved significantly, with the Constant score increasing from 29.9 ± 3.9 to 62.6 ± 15.9 (P < 0.001) and the SSV improving from 25.3 ± 8.7 to 66.5 ± 20.1 (p < 0.001). ROM significantly increased in forward elevation, abduction, and internal rotation, while internal rotation strength also improved significantly. There were no complications or progression of arthritis observed.ConclusionFull arthroscopic combined LDTM transfer demonstrates promising clinical and radiological short‐term outcomes for patients with irreparable subscapularis tears. The procedure resulted in substantial improvements in pain relief and functional outcomes, particularly in internal rotation for both ROM and strength. Importantly, no significant complications or progression of glenohumeral arthritis were observed by the final follow‐up.Level of EvidenceLevel IV, retrospective case series.

Samples of pork teres major muscle were salted and tumbled with 0.9%, 1.3% & 1.9% sodium chloride respectively. The emission fluorescence (exc. 275nm) of intramuscular connective tissue and of muscle fibre subtypes I, IIA and IIB-IIX was investigated by Synchrotron deep UV fluorescence microspectroscopy in order to characterize the change of the macromolecular structure of proteins. On emission spectra, tryptophan fluorescence was predominant and an additional peak assigned to dityrosine was detected around 395nm. The fluorescence emission spectra vary depending on salt level both on intramuscular connective tissue and muscle fibres which subtypes were discriminated for one animal among the set of four. This result is encouraging in the perspective of developing sensors for meat evolution during the salting process. However, no noticeable prediction law linking the fibre autofluorescence to salt level could be deduced.

Transfer of intercostal nerves to the radial nerve branch innervating the long head of the triceps muscle for elbow extension is indicated in patients with traumatic brachial plexus palsy that is either the pan-plexus type or C5-C7 palsy with no triceps muscle function. The procedure aims to restore triceps muscle function through the use of the intercostal nerves, which are expendable nerves, as donors. The procedure is performed by first identifying the third to fifth intercostal nerves and coaptating them to the radial nerve branch innervating the long head of the triceps muscle. Three intercostal nerves are utilized because our previous study revealed that the use of 2 intercostal nerves resulted in poor outcomes1. Additionally, 3 intercostal nerves are comparable in size to the recipient nerve2. To identify the intercostal nerves, a curved incision is made over the sixth rib to the medial side of the arm, detaching the pectoralis major and minor from their distal insertion. The intercostal nerves are dissected from the inferior border of the third to fifth ribs. The radial nerve branch innervating the long head of the triceps muscle can be found distal to the teres major muscle as the first branch from the radial nerve via the same incision, at the medial side of the arm3. Subsequently, the 3 intercostal nerves are coaptated to the radial nerve branch to the long head of the triceps muscle. A deficit in active elbow extension may be deemed acceptable for certain patients who are amenable to utilizing gravity for performing such extensions. Nonoperative treatment could be contemplated for individuals falling into this category. Alternative surgical approaches may include nerve transfers utilizing other donor nerves, such as the ulnar or thoracodorsal nerves, or tendon transfer procedures. Although active elbow extension may not be the primary focus when treating brachial plexus injury, a lack of active elbow extension affects various daily activities, such as overhead tasks, the use of a walking aid, and reaching for objects on a table4. Consequently, reanimating the muscle through the use of expendable donor nerves appears to be a suitable approach, particularly in young and active patients, aiming to restore function and enhance overall quality of life. Therefore, we recommend this procedure as an adjunct to other surgical interventions in active patients who would benefit from restored elbow extension to perform daily activities. The procedure demonstrated satisfactory results in our prior study1,2, consistent with findings from other studies that reported good results in 57% to 80% of patients5,6. In our prior study, 65% of patients achieved favorable motor function (Medical Research Council grade 3 to 4), with no observed donor-site morbidity or respiratory complications2. Factors negatively impacting satisfactory outcomes include being overweight (body mass index > 25 kg/m2)7,8, the operative hand being the nondominant hand2, and a prolonged duration from injury to surgery9. The procedure is recommended for patients presenting with pan-plexus palsy and upper-plexus palsy lacking triceps function. In the latter scenario, confirmation of the triceps muscle deficit is essential through serial examinations, electromyography, and intraoperative nerve stimulation.Previous rib fracture(s) do not serve as a contraindication for surgery10. However, caution should be exercised in patients with a history of chest drain insertion because of the possibility of damage to the intercostal nerves.In cases of root avulsion injury, early surgical intervention is advisable.The use of fibrin glue may be considered to facilitate the coaptation of nerves.Patients undergoing this and other brachial plexus procedures should be thoroughly informed regarding the associated risks and benefits.The patient's commitment to participate in rehabilitation after surgery is imperative. ICN = intercostal nerveMRC = Medical Research Council.

Ultrasound imaging is vital for musculoskeletal assessment due to its real-time, high-resolution capabilities and safety. While protocols exist for rotator cuff evaluation, comprehensive guidelines for imaging the latissimus dorsi and teres major muscles are lacking. This article fills this gap by presenting a detailed ultrasound protocol for these muscles, essential for shoulder stability and movement in overhead athletes. We review their anatomy, propose a standardized examination approach, and discuss clinical indications, aiming to improve diagnostic accuracy and management of these injuries.

Digital muscle reconstructions have gained attraction in recent years, serving as powerful tools in both educational and research contexts. These reconstructions can be derived from various 2D and 3D data sources, enabling detailed anatomical analyses. In this study, we evaluate the efficacy of surface scans in accurately reconstructing the volumes of the rotator cuff and teres major muscles across a diverse sample of hominoids. Additionally, we investigate whether muscle origin area, as a dissection‐based observation, can reliably predict muscle volume. Our findings reveal that surface scans provide sufficient coverage to accurately reproduce the in situ volumes of the rotator cuff muscles. However, the volume of the teres major was estimated less reliably, suggesting that muscles with less distinct skeletal boundaries may present challenges for accurate reconstruction. Future studies will explore whether such muscles can be reconstructed with greater precision. Furthermore, we identify a significant correlation between the origin area and muscle volume for the supraspinatus, infraspinatus, and subscapularis muscles. These results suggest that muscle origin area can serve as a reliable predictor of muscle volume, offering a skeletal indicator for estimating muscle size in both extant and extinct hominoids. These insights are particularly valuable for paleontological reconstructions, where direct soft tissue evidence is often lacking. By establishing a relationship between skeletal traits and muscle volume, our study provides a framework for evaluating the accuracy of soft tissue reconstructions in hominoid species. This approach not only enhances our understanding of hominoid anatomy but also offers new avenues for exploring the functional morphology of extinct taxa.

Background: The transfer of latissimus dorsi (LD) and teres major (TM) have been described for restoration of external rotation (ER) and shoulder abduction in neonatal brachial plexus palsy (NBPP). The aim of this prospective randomised study is to compare the outcomes of LD versus TM transfer in the treatment of internal rotation contracture of the shoulder in children with NBPP. Methods: The study was conducted from February 2014 to January 2018 and included NBPP patients with internal rotation contracture of the shoulder. Patients were randomised to either LD (Group 1) or TM (Group 2) tendon transfer. Patients were followed up for at least 38 months and assessed for improvements in the arc of shoulder abduction and ER. Results: The study included 30 patients with 15 patients randomised to each group respectively. Group 1 (n = 15) included 4 boys and 11 girls with a mean age of 2 years and 8 months (range: 1.5-5) and a mean follow-up of 62 months (range: 38-68). Group 2 (n = 15) included 6 boys and 9 girls with a mean age of 2 years and 6 months (range: 1.5-4.8) and a mean follow-up of 58 months (range: 38-68). All patients showed improvement in shoulder abduction and active and passive ER. There were no differences in shoulder abduction (p = 0.467), active ER (p = 0.124) and passive ER (p = 0.756) between both groups. Conclusions: Both LD and TM tendon transfers improved shoulder function in NBPP patients with internal rotation contracture of the shoulder. Level of Evidence: Level II (Therapeutic).

Learning ordinary anatomy is an essential part of medical training. New knowledge about anatomical variations helps surgeons to improve their surgical techniques and avoid complications. The posterior circumflex humeral artery usually arises from the axillary artery and passes through the quadrilateral space along with the axillary nerve. In our study, we introduce a human cadaver specimen with unusual arterial variation. In this case, instead of passing through the quadrilateral space, the posterior circumflex humeral artery coursed along the lower edge of the teres major muscle to the surgical neck of the humerus. In our data, the posterior circumflex humeral artery arose from brachial artery and the branches of this artery supplied the deltoid muscle, teres minor and infraspinatus tendons, and the lower part of the long head of the triceps brachii muscle.

The axillary artery (AA) branches into six vessels within the axilla. The brachial artery then continues at the teres major muscle's lower border. The brachial artery (BA) splits into the ulnar and radial terminal branches at the level of the radius neck or the cubital fossa. The underlying BA is an uncommon variant of the axillary artery that can have an impact on neural structures. This study aims to analyze the morphological relationship between the superficial brachial artery (SBA) originating from the AA and the segmental variation of the AA. : The research done in the Anatomy Department of Zydus Medical College and Hospital in Dahod involved the examination of the 16 upper limb of 8 cadavers. These cadavers were obtained over the course of one year and were used for undergraduate study in the First MBBS program. The dissection was done in the axilla and the arm. During the routine anatomy, dissection was observed a variant of the SBA and its termination.For this investigation, six Arm specimens were dissected. We have noticed a superficial brachial artery with an axillary origin in 2 cadavers. In the left arm, there was only one case (1.0%) of the SBA, which assets the arm muscles. There was only one case (1.0%) of SBA in the right arm merging with the deep brachial artery (DBA) in the Cubital fossa and extending as the radial artery (RA) of the forearm. Variations of SBA have significance essential during surgical procedures. Morphological variations, as well as topographical variations, are significant factors in surgery of “upper limb as well asregular clinical practice. The use of surgical techniques is crucial in order to prevent injury to arteries, particularly in the upper limb as well as axilla regions.

Objective: To study the contribution of the transfer of the latissimus dorsi and teres major muscles to the teres minor muscle in correcting the sequelae abduction deficit of OBPP and to evaluate the factors influencing the final outcome. Materials and Methods: A retrospective study was conducted on 75 patients followed in the Pediatric Trauma-Orthopedics B department at the Children’s Hospital of the Ibn Sina University Hospital Center in Rabat, over a period of 10 years. The Mallet score was adopted for the functional evaluation of the children. All patients were treated with the transfer of the Latissimus dorsi and Teres major muscles to the Teres minor to restore abduction, with postoperative immobilization in abduction-external rotation plaster for 4 weeks, followed by well-adapted rehabilitation with regular follow-up. Results: The average age at diagnosis was 22 months, and the average age at intervention was 4.20 years. 52% of the patients were female. In 71% of the cases, the affected side was the right, and the predominant form was the total form C5-T1. After the transfer, in terms of abduction, 64% of cases had excellent results (≥150°), 8% had good results (120°-150°), 21% had average results (90°-120°), and 7% had poor results (≤ 90°). Active external rotation improved by 47.67°, with an average of 50.94° (range: 10°-90°). Our average follow-up period was 6.68 years (ranging from 1 to 10 years), demonstrating the stability of the results. However, 2 patients experienced a recurrence of abduction limitation related to pectoralis major contracture and poorly followed rehabilitation.

Shoulder ultrasound is a key tool used by musculoskeletal practitioners to diagnose and treat a variety of upper girdle diseases. While magnetic resonance imaging is the cornerstone of shoulder imaging, sonography is readily available, practical and superior in its ability for dynamic assessment of musculoskeletal pathologies. The subscapularis, teres major and latissimus dorsi muscles are commonly involved in a myriad of pathology including myofascial pain and spasticity. There is scarce literature on the assessment of these muscles for diagnostic and therapeutic purposes. Conventional approaches to shoulder ultrasound have not included a dedicated assessment of the subscapularis muscle due to its inherent anatomical location deep to the scapular blade which blocks sound wave penetration. We describe an approach to visualizing the subscapularis muscle as a short addition to the established shoulder sonography format, which also permits assessment of both the latissimus dorsi and teres major muscles, which are important muscles for shoulder spasticity. The patient is imaged in a semi-recumbent position with the arms elevated above and behind the head in the ABduction and External Rotation (ABER) position. The relative ease of positioning and sonographic access to the musculature coupled with the potential for assessment and intervention makes this approach extremely desirable to the musculoskeletal practitioner looking to diagnose or treat muscle belly pathologies of the subscapularis, teres major or latissimus dorsi.

Nerve During the dissection of the axillae and upper limbs of an 80-year-old male donor, multiple vascular and neural variations were encountered. On the right side, the thoracoacromial artery and the lateral thoracic artery were absent. On the left side the subscapular artery was absent, and the posterior cord of the brachial plexus gave branch to two upper subscapular nerves and then divided into radial nerve and a common stem that branched into thoracodorsal nerve, lower subscapular nerve, nerves to teres major and minor muscles and the axillary nerve. Additionally, in the left arm there was a variant communication between the musculocutaneous nerve and the median nerve. Although the existence of these variations is well documented in the literature as individual entities or few combinations, the occurrence of such multiple variations in a single cadaver in a limited area of the body involving vessel and nerves is not common. A multitude of variations in a small area of the body such as this can be a source of diagnostic and imaging interpretation errors. Unpredictable iatrogenic injuries can also occur during various procedures in the area such as during preparation of muscle flap, mastectomy with axillary lymph node dissection, reconstructive and aesthetic plastic surgery of the breast and other clinical procedures including shoulder arthroplasty.

A 58-year-old, very active man sustained bilateral isolated teres major (TM) tendon tears when his arms were forcefully elevated overhead while wakeboarding. Staged surgical repair was performed. A progressive rehabilitation protocol was followed, and he returned to high-level activities 7 months postoperatively. At 1-year follow-up, outcome measures for bilateral shoulders were DASH 0, SST 12, ASES 100, and EQ-5D 1.0. Despite literature supporting conservative treatment, this case demonstrates that operative treatment of acute, isolated TM tears can result in highly successful outcomes for motivated active patients.