Tendon Transfers for the Rotator Cuff Deficient Shoulder

Chapter 37

Tendon Transfers for the Rotator Cuff Deficient Shoulder

Bassem T. Elhassan, and Chelsea C. Boe


Massive irreparable rotator cuff tears are a difficult problem to treat. Previously described treatments such as debridement alone or in conjunction with partial repair with the goal of pain relief have been inconsistent at best and often do not address or improve functional deficiencies. The younger active patient population is often unwilling to accept the lifelong limitations imposed by reverse total shoulder arthroplasty. Thus, tendon transfer is the preferred treatment in this subset of patients with higher functional demands. Initially, the latissimus dorsi transfer was ubiquitously used to cover the defect and restore motion; however, more recent data have suggested that alternate transfers may be better suited to addressing the complex role of the rotator cuff in the multiplanar motions of the glenohumeral joint.


Although many transfers have been described, our preference is the lower trapezius (LT) transfer for posterosuperior rotator cuff tears and the latissimus dorsi (LD) to address anterior deficiency. The ipsilateral LT is harvested from the medial scapular spine, augmented with Achilles allograft, and inserted at the superior aspect of the infraspinatus footprint to restore external rotation (ER) and the posterior force couple of the rotator cuff. The anterior force couple is addressed with LD harvested from its humeral insertion and transferred to the superior aspect of the subscapularis footprint.

Patient History

Patient Examination


Treatment Options

  1. • Nonoperative management with pain control, activity modifications.
  2. • Physical therapy is the mainstay of treatment with the goals of maintaining passive range of motion and strengthening of surrounding musculature. Antiinflammatory medications and/or injections are useful adjuncts for pain control and optimization of function. Despite conservative measures, tear progression, fatty infiltration, and progression of arthritis are to be expected.
  3. • Debridement.
  4. • May result in short-term pain relief; however, it has been shown that, especially in younger patients, symptoms may progressively worsen as a result of tear progression, superior migration of the humeral head, and progressive degeneration of the glenohumeral articular cartilage.
  5. • Partial rotator cuff repair.
  6. • The goal is to restore the anterior and posterior force couples and create an “anatomically deficient but biomechanically intact” construct. Although results of partial repair have been superior to debridement alone, progression of arthritis is frequently seen.
  7. • Reverse total shoulder arthroplasty.
  8. • For older patients with limited functional demands, this is a reliable operation for pain relief. However, this operation requires lifelong restrictions and involves the complications associated with arthroplasty, including lifelong infection risk, and is thus not commonly desired by a younger active patient.
  9. • Tendon transfer.
  10. • Numerous transfers have been described, including the pectoralis major or LD to restore IR and the LD, TM, or LT to restore ER. LD is the traditionally used transfer for posterosuperior tears, and sustained improvement in pain relief and motion have been demonstrated, though this has been less successful in more patients with underlying osteoarthritis, subscapularis insufficiency, or paralytic shoulders (<90 degrees of flexion preoperatively). LT has been shown to reliably increase ER and restore the posterior force couple in massive and paralytic shoulders. Likewise, LD transfer is ideal for restoration of the anterior force couple in irreparable subscapularis tears.

Surgical Anatomy

  1. • LT
  2. • Originates from the lumbothoracic spine and inserts on the medial aspect of the scapular spine (Fig. 37.3).
  3. • The spinal accessory nerve is consistently found 2 cm medial to the medial aspect of the scapula on the deep surface of the muscle (Fig. 37.4).
  4. • LD
  5. • Originates from the thoracolumbar fascia, iliac crest, inferior three ribs, and inferior angle of the scapula and inserts on the floor of the intertubercular groove of the humerus anterior to the TM (Fig. 37.5) either independently or loosely bound or as a conjoint tendon (Fig. 37.6).
  6. • Axillary and radial nerves lie within 3 cm of the insertion site of the LD (Fig. 37.7), though these distances are dependent on arm position and may be less than 2 cm.

  7. • TM
  8. • Originates from the inferior angle of the scapula and inserts on the medial lip of the intertubercular groove slightly posterior and distal to the LD, with similar relationships to surrounding neurovascular structures at its insertion

  9. • Supraspinatus, infraspinatus, and subscapularis footprints

Surgical Indications

Surgical Technique Setup


Possible Pearls

Possible Pitfalls


Surgical Exposure for LT Transfer (Open)

For exposure for trapezius harvest, the border of the scapula, origin of the LT from T4 to T12, and its insertion on medial 2 to 3 cm of the spine of the scapula are marked before incision (Figs. 37.10 and 37.11). A 5-cm vertical skin incision is made from the upper to lower borders of the LT approximately 1 cm medial from the medial border of the scapula (Fig. 37.12). Alternatively, the procedure can also be performed with a 4- to 5-cm transverse incision along Langer lines just inferior to the scapular spine from 1 cm medial to 3 cm lateral to the medial border of the spine of the scapula. The lateral border of the trapezius is identified above a triangular fat area, and dissection is performed medially and laterally to free it from the deep fascial tissues. The LT tendon is dissected up to its insertion in the medial aspect of the spine of the scapula (Fig. 37.13).

Exposure of the rotator cuff is through a saber incision placed just medial to the lateral acromion, and the interval between the anterior middle deltoid and the middle deltoid is developed. The acromion is debrided of soft tissue just medial to the origin of the middle deltoid, and an osteotomy of 5-mm thickness is made. The bone and middle deltoid are reflected, allowing excellent visualization of the lateral humeral head and glenohumeral joint.

Surgical Exposure for LT Transfer (Arthroscopically Assisted)

Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Tendon Transfers for the Rotator Cuff Deficient Shoulder

Full access? Get Clinical Tree

Get Clinical Tree app for offline access