Preoperative clinical photos depicting limited range of motion. (a) External rotation at the patient’s side comparing right to left was 25/75. (b) Abduction and forward elevation were severely limited on the patient’s right. Notice the patient’s right arm internally rotated as he attempts to forward elevate
Preoperative standing anterior to posterior (AP), axillary lateral, and scapular Y views showed acromioclavicular and glenohumeral subchondral sclerosis, moderate joint space narrowing, and superior migration of the humeral head with subsequent decreased acromiohumeral distance (Fig. 15.2). Magnetic resonance imaging (MRI) of his right shoulder revealed a substantial tear of the supraspinatus and infraspinatus tendons with 3.2 cm of retraction and grade 3 fatty degeneration (i.e., equal fat and muscle) of supraspinatus and infraspinatus muscles, and grade 4 fatty infiltration of teres minor (i.e., more fat than muscle) (Fig. 15.3) muscle. Having failed previous attempts at conservative management, he was ready to proceed with operative intervention.
Preoperative standing AP, axillary lateral, and scapular Y views. AP radiograph (a) showing joint space narrowing, glenohumeral subchondral sclerosis, and superior migration of the humeral head with subsequent decreased acromiohumeral distance. Axillary lateral view (b). Scapular Y view (c)
Preoperative MRI with coronal, axial, and sagittal views. Coronal view showing severe acromioclavicular and glenohumeral osteoarthritis with a substantial tear of the supraspinatus and infraspinatus tendons with retraction (arrow) (a). Axial cut demonstrating severe fatty degeneration of the infraspinatus (arrowhead) (b). Corresponding sagittal MRI showing subscapularis (c), (1), grade 3 fatty degeneration of the supraspinatus (2) and infraspinatus (3) muscles, and grade 4 fatty degeneration of the teres minor (4). The patient’s MRI also showed severe tendinosis of the long head of the biceps tendon (not shown)
The patient’s history and physical examination are consistent with rotator cuff tear arthropathy and pseudoparalysis of both forward elevation and external rotation. His external rotation weakness, lag deficit, and positive Hornblower’s sign are clinical findings indicative of rotator cuff tear involving the external rotators including the teres minor muscle. The findings of grade 3 and 4 fatty infiltration of the supraspinatus, infraspinatus, and teres minor muscles on MRI are poor prognostic indicators for rotator cuff repair. RSA is indicated for this elderly man with a severe rotator cuff tear and GH joint osteoarthritis and will address the pseudoparalysis of forward elevation but will not restore active external rotation. Without active shoulder external rotators (infraspinatus and teres minor), forward elevation after RSA results in the arm internally rotating toward the trunk and activities of daily living such as combing his hair, brushing his teeth, and eating remain difficult. We give special consideration to the restoration of external rotation in this patient undergoing RSA, and we want to emphasize that to do so, it was important to look for the deficits in external rotation strength preoperatively.
Improvement in active external rotation in patients with massive rotator cuff tears was reported following LD transfers. The history of this begins with Joseph L’Episcopo who described the technique of LD and TM transfer in children with obstetrical palsy in 1934 . He utilized a double-incision technique to transfer both the LD and TM tendons laterally and posteriorly on the humerus effectively changing their function from internal to external rotators. Recently, promising results were reported with LD transfers combined with RSA in patients with pseudoparalysis of both elevation and external rotation. The technique for doing so was described with a single deltopectoral incision .
The patient was placed in the beach-chair position, and the surgical field was prepped with ChloraPrep. Following completion of draping, the free arm was placed in a McConnell arm holder to help with positioning. A deltopectoral incision was utilized, and the subdeltoid, subcoracoid, and subacromial spaces were cleared of adhesions. There was massive rotator cuff tear and retraction of supraspinatus, infraspinatus, and superior 3/4 of the teres minor tendons. The subscapularis was intact.
Working distally, the pectoralis major tendon insertion on the lateral border of the inferior bicipital groove was exposed and the upper half of the pectoralis major was released and tagged (Fig. 15.4). Following release and external rotation of the humerus, the LD and TM are visualized immediately medial to the biceps groove and tagged as a unit with nonabsorbable sutures at their proximal and distal insertion sites (Fig 15.5a). The insertions are released. Drill holes are placed in the biceps groove at the top and bottom of the pectoralis insertion for later repair of the pectoralis and tenodesis of the long head of the biceps. An elevator is used to ensure the distal release of these tendon attachments off the humerus (Fig 15.5b). The subscapularis was then tagged in the superolateral corner and a standard subscapularis peel was performed. Currently, our preference is to now do a lesser tuberosity osteotomy when adequate bone stock is available.
Intraoperative photograph after the upper one halve of the pectoralis major (pm) has been released. The superior and lateral corner is tagged with a permanent suture
Intraoperative photograph of the LD and TM (asterisk) being tagged as a single unit (a). A Cobb elevator is then utilized to elevate the distal insertions of the LD and TM from the humerus (b)
Following anterior and inferior glenohumeral capsular releases, the proximal humerus was brought out easily for inspection (Fig. 15.6). A Cobb elevator was then used to dissect the triceps from the posterior humerus (Fig. 15.7). This facilitated the safe posterior passage of the tendon transfers around the humerus.
Intraoperative photograph of the proximal humerus brought into the field for inspection. Inspection of the humeral head surface revealed grade 3 and 4 cartilage changes
A Cobb is used to retract the triceps off the posterior humerus from the medial (a) and lateral (b) directions. This creates a free pathway for the tendon transfers
Then the most critical part of the procedure was to free the fibrous bands connecting the upper portions of the LD and TM from the inferior capsule and the axillary nerve. We identified the axillary nerve and marked it with a vessel loop to protect it and the fibrous bands between the LD and axillary nerve were released (Fig. 15.8). This ensured that the tendon transfer was not tethered to the axillary nerve. The radial nerve is identified on the belly of the LD but is not released as the tendon transfer moves away from the radial nerve and will not compress it. The traction sutures were then passed posteriorly around the humerus to pull the tendons to their new insertion site at the biceps groove for later anchoring through bone tunnels along with the subscapularis.