Fig. 11.1
Patient is a 75-year-old male with a 3-year history of shoulder pain without a defined traumatic event. He is able to elevate his arm above his head, but despite physical therapy and steroid injections, the pain continues to interfere with his quality of life. MRI in the coronal plan shows a tear of the supraspinatus with retraction almost to the glenoid and thinning of the tendon (a). Sagittal plan MRI shows atrophy of the supraspinatus and the infraspinatus (b). At the time of arthroscopy, the tendon was retracted and immobile (c). Therefore, a margin convergence-type repair was performed (d). Two years after surgery, the patient is pain free, though still has weakness with lifting objects away from his body
Tendon Transfers
Salvage reconstruction, with a muscle tendon transfer, is a feasible surgical option for an irreparable rotator cuff tear in patients who have primary symptoms which attribute to weakness, pain, and impaired active motion. Various techniques have been described for rotator cuff reconstruction that include local tendon transposition, distant tendon transfer, and muscle flap reconstruction. Donor tendon selection is grounded on a multitude of variables, but typically centers on location of the rotator cuff tear and the specific functional deficits the patient is experiencing. Common tendons utilized include the latissimus dorsi, pectoralis major, teres major, deltoid, triceps, and trapezius. Certain intrinsic factors associated with the donor tissue that must be respected involve length of the muscle and tendon unit, line of action relative to joint rotation, and amplitude of the generated force [41].
It is imperative that patient expectations are appropriately clarified preoperatively, and anyone that undergoes this type of procedure must understand its magnitude and the rigors behind the postoperative physical therapy. Advanced glenohumeral arthritis must be excluded, and the ideal candidate will have symptoms related to weakness and impaired active motion. Manuel laborers with irreparable rotator cuff tears who require strength to resume typical occupational task are often cited as the archetypal patient population [1].
Latissimus Dorsi Transfer
Initially proposed by Gerber in 1988, the latissimus dorsi provides appropriate excursion for the treatment of external rotation deficits in posterosuperior rotator cuff tears [42]. The tendon is thus converted to a humeral head depressor through its vertical orientation and an external rotator via its new relative insertion in the humeral head [41]. A functioning deltoid is a prerequisite for a successful result, and ideally the tendon of the subscapularis must also be intact to provide a balanced force couple in the coronal plane [8]. Gerber was also able to demonstrate technical feasibility and early therapeutic efficacy through cadaveric and clinical studies [43].
Gerber [44] later corroborated his results with long-term studies on the value of latissimus transfers for irreparable posterosuperior rotator cuff tears. He evaluated 63 patients at a mean follow-up of 53 months and demonstrated reliably durable results. Average subjective shoulder value scores increase 35 % postoperatively, and mean Constant scores also increased 20 % from their preoperative value. Furthermore, pain, forward flexion, abduction, external rotation, and strength all improved with statistical significance. Positive results have also been shown by numerous authors in the setting of failed rotator cuff repair [45, 46].
To further evaluate the inherent value and appropriate timing of a proposed latissimus transfer, Warner and Parsons compared outcomes in patients who underwent tendon transfer as a primary reconstruction option to those who underwent transfer for salvage reconstruction [8]. Although patient numbers were small (16 patients in the primary group and 6 patients in the salvage reconstruction group), important findings were noted. At a mean follow-up of 2 years, relative gain of forward flexion was 60° versus 43°, in the primary and salvage reconstruction groups, respectively. The primary group also demonstrated greater improvement in relative Constant score after tendon transfer.
Technical considerations, when performing the transfer, include cognizance of the radial and axillary nerve and their relationship to known anatomic landmarks [47]. Iannotti et al. have identified important patient characteristics that portend a poor outcome – female sex, poor preoperative glenohumeral function, and generalized muscle weakness [48]. Recent modifications to the transfer technique have also been published that include harvesting a small piece of bone with the tendon [49], utilization of a single incision [50], and minimally invasive approaches [51]. None have demonstrated superior clinical results to Gerber’s initial description [9].
Pectoralis Major Transfer
Transfer of the pectoralis major tendon remains a viable treatment option for those patients who have sustained an irreparable tear of the anterosuperior rotator cuff with concomitant deficits in internal rotation power. Recently, much attention has been paid to the line of pull of the pectoralis major, and consequently, modifications of the original technique have been made to improve the vector and fulcrum over which the transferred tendon occurs. Wirth and Rockwood initially reported satisfactory results in 10/13 patients who underwent pectoralis transfer above the coracoid [52]. However, more recent biomechanical and clinical data has suggested an advantage to isolated sternal head transfer, in a subcoracoid fashion, of the pectoralis major tendon [53, 54]. The sternal head can be passed beneath the clavicular head, so that the latter may act as a fulcrum, thus allowing for a more anatomic recreation of the force couple of the torn subscapularis.
Elhassaan et al. reported on 11 patients in whom the sternal head subcoracoid technique was utilized for the treatment of irreparable subscapularis tears. Improvement in pain scores occurred in 7/11 patients at a minimum of 2 years follow-up. Functional improvement also occurred by measurement of postoperative Constant and subjective shoulder scores [53]. Resch et al. were able to demonstrate comparable results in an older cohort (mean age 65 years), utilizing a similar surgical technique. Good to excellent outcomes were reported in 9/12 patients, and mean Constant scores improved from 26.9 to 67.1 points postoperatively. All 12 tendon transfers demonstrated successful healing, as determined by ultrasound examination, at a mean final follow-up of 28 months [54]. In a larger series Jost et al were able to validate reliable results that were not dependent on the routing of the transferred tendon, and 24 of 30 patients demonstrated satisfactory results at a final follow-up of 32 months. Mean relative Constant scores improved by 23 %. Markedly better outcomes were noted in those patients being treated for isolated irreparable subscapularis tears [55].
Author’s Preferred Use of Tendon Transfers
The indications for tendon transfers are narrow. Ideal patients for latissimus dorsi transfer are men under the age of 50, whose chief complaint is weakness. These patients must still maintain the ability to elevate to horizontal and have an intact subscapularis with minimal underlying glenohumeral osteoarthritis. When examining a potential candidate, the examiner can help the patient elevate their arms with two fingers. This additional assistance roughly predicts what a latissimus dorsi transfer can provide. A two-incision technique is utilized and the latissimus dorsi alone is transferred to the greater tuberosity. Often, the tendon is reinforced with a tissue scaffold since it is relatively thin (Fig. 11.2). Recently, the author has been inserting the transferred tendon to the greater tuberosity arthroscopically by using knotless suture anchors. This avoids the added morbidity of deltoid takedown and repair.
Fig. 11.2
Patient is a 45-year-old male with a 2-year history of pain and weakness. He has undergone two previous arthroscopic rotator cuff repairs. He is able to elevate his arm above his head, but it is weak particularly in external rotation. Coronal MRI shows a large rotator cuff tear with humeral head elevation (a). Sagittal MRI shows severe fatty infiltration of his infraspinatus and moderate infiltration of his supraspinatus (b). Patient elected to undergo latissimus dorsi transfer through a two-incision approach (c, d). A xenograft was used to augment the thin latissimus dorsi tendon prior to repair (d). Eighteen months following the surgery, the patient has improved strength and minimal pain
Pectoralis major transfers are reserved for patients with isolated irreparable subscapularis ruptures. The sternal head is transferred under the conjoint tendon and attached to the lesser tuberosity. If the patients have undergone previous surgery in the region, then a hand surgeon is utilized to free the axillary and musculocutaneous nerves prior to transfer.
Both transfers require a long rehabilitation. The first 6 weeks are dedicated to healing so a sling is used and gentle pendulum exercises are started. From 6 to 12 weeks, passive range of motion is achieved. At 12 weeks, strengthening starts and patients are given a biofeedback machine to help retrain the transferred muscles. Patients are told that improvements will continue to be made up to a year out from surgery.
Scaffold Devices
Strategies that involve a tissue engineering approach, to address the problems associated with the unpredictable results following repair of massive rotator cuff tears, have received renewed interest, both bench side and in the clinical arena. Specifically, many studies have investigated the utility of scaffold devices to ensure improved rotator cuff healing. Scaffolds have the unique ability to improve both the mechanical and biologic environment after rotator cuff surgery. Theoretically they can “off-load” repair sites and possibly allow for efficient cellular ingrowth and proliferation [56]. Many devices are currently approved by the US Food and Drug Administration (FDA) for augmentation of rotator cuff repair and can be broadly categorized into extracellular matrix (ECM) devices, synthetic devices, and hybrid devices. Presently, no device is approved for bridging the gap of an irreparable rotator cuff repair, and this use remains off-label [3]. ECM-derived devices offer a distinct biologic advantage to the repair milieu site, whereas synthetic devices will maintain mechanical properties over time and can stabilize repairs while healing occurs [57].
Trials evaluating the results of ECM scaffolds as a bridging interpositional device for rotator cuff repair have demonstrated varying results [58, 59]. Soler et al. investigated the use of porcine dermal collagen implants in four patients at 3–6 months follow-up. The cohort age range was 71–82 years old, and graft disintegration, accompanied by an inflammatory reaction, was noted in all patients [58]. Authors of a similar study showed more promising results, utilizing an analogous construct for the bridging of a rotator cuff defect, in ten patients that were followed for 3–5 years. Mean Constant scores improved from 42 to 62 at final follow-up, while pain, abduction power, and range of motion were all significantly improved. Postoperative ultrasound demonstrated that 8/10 grafts were intact, and no patients sustained any significant adverse events [59]. Dermis-based patches have also been studied for salvage reconstruction of irreparable rotator cuff tears. Bond et al. reviewed 16 patients treated with dermal allograft for contracted immobile rotator cuff tears. At a mean follow-up of 2 years, patients experienced statistically improved measurements in pain level, forward flexion, and external rotation strength. Full incorporation of the graft occurred in 13/16 patients, as measured on MRI, and Constant scores improved a total of 30 points [60].
Author’s Preferred Use of Scaffolds
At this time, scaffolds or patches are not routinely used. There is typically enough tissue to adequately perform a margin convergence repair and thus cover the humeral head with native tissue. The addition of synthetic or foreign material is thought to do little to augment these nonanatomic repairs. Scaffolds are not strong enough to serve as a bridging device.
Arthroplasty
Glenohumeral joint replacement may often be the appropriate primary or salvage option in patients with irreparable rotator cuff tears. Patients who may benefit most from the various arthroplasty options are those patients who have the underlying diagnosis of rotator cuff tear arthropathy, although reliable preliminary results have also been obtained in patients without concomitant arthritis [61].
Hemiarthroplasty
Replacement of the humeral head is best reserved for patients who have maintained balanced mechanics of the glenohumeral joint – preserved coronal plane force couple (intact subscapularis) and continue to have the ability to elevate their affected arm [2]. Anterosuperior escape of the humeral head is generally considered a contraindication to humeral head replacement in patient with cuff tear arthropathy (CTA) [41].
Functional results following hemiarthroplasty for the diagnosis of CTA have been mixed. Sanchez-Sotelo showed successful results in only 67 % of cases at a mean of 5 years follow-up [62]. Active elevation improved 20° postoperatively; however, no strength differences were noted in abduction or flexion. Field et al. reviewed the results of hemiarthroplasty for treatment of CTA in 16 patients followed for a mean of 33 months. Overall results were encouraging, with 63 % of patients displaying satisfactory results. Patients who had undergone a previous acromioplasty were more prone to postoperative anterosuperior escape [63]. These results were confirmed by Zuckerman et al. who retrospectively reviewed 15 cases of humeral head replacement for the diagnosis of CTA. All patients demonstrated improved ability to perform ADLs and 13/15 patients expressed overall satisfaction with their result. Functionally patients exhibited improved forward flexion, external rotation, and UCLA scores.
Reverse Shoulder Arthroplasty (RSA)
Patients with true pseudoparalysis on exam are ideal candidates for an RSA prosthesis, in the setting of massive irreparable rotator cuff tears, with or without underlying osteoarthritis. Recent literature out of France supports the use of the RSA in the absence of arthritis [61]. Wall and colleagues demonstrated a Constant score improvement of 36 points, in 34 such patients. On specific subscales pain improved 8 points, activity level 10 points, mobility 12 points, and strength 6 points. Range of motion improvements were the most dramatic, showing increased elevation from 94° to 143°.
Many authors at multiple institutions have confirmed successful results of the RSA, when used for rotator cuff tear arthropathy. Wener et al. reported on 17 consecutive patients, who were followed for 38 months. Marked functional objective gains were noted, with an overall Constant score improvement of 35–72 points [64]. Active abduction increased from 39° to 84°, and forward flexion followed with a net gain of 60°. Frankle corroborated these results in 60 patients who were treated for CTA and later evaluated at a minimum of 2 years. The average ASES scores improved 34 points postoperatively, and active forward flexion improved from 55° to 105° [65].
It must be noted that short- and midterm results with the reverse prosthesis are promising; however, a substantial complication rate has been noted. Prosthetic survival rate at 8 years has been reported as 30 % [66]. Overall complication rates have been reported as high as 50 %, with 33 % of patients requiring a revision surgery [64].
Author’s Preferred Use of Arthroplasty
Rare patients with advanced cuff tear arthropathy and the preserved ability to elevate are offered hemiarthroplasty. In these situations, every effort is made to preserve the CA arch and the subscapularis – two primary reasons why the patient may still be able to elevate their arm. With the exceptions of very large males, most hemiarthroplasties can be inserted through the superior rotator cuff defect without taking down the subscapularis with a deltopectoral incision. Rehabilitation is fairly rapid, with sling immobilization only until the wound is healed; then aggressive motion and strengthening are undertaken.
Patients with an irreparable rotator cuff tear and true pseudoparalysis are ideal candidates for a reverse shoulder arthroplasty, with or without concomitant arthritis (Fig. 11.3). A deltopectoral approach is used. The subscapularis is reattached if it is present and can be repaired tension free. Rehabilitation consists of sling immobilization for 2 weeks and then a rapid restoration of motion and strength. Therapists are informed not to force internal rotation, since these limitations are most often due to implant impingement and not soft tissue contracture.
Fig. 11.3
Patient is a 69-year-old female with a 2-year history of shoulder pain and weakness. She has undergone one prior rotator cuff repair, but is now unable to elevate her arm above her head even after an injection with local anesthetic. She also has anterosuperior escape with attempts at elevation (a). MRI in the coronal plane shows a massive, retracted tear with humeral head elevation (b). Patient underwent reverse total shoulder arthroplasty (c). Three years after the procedure, she is pain free and able to elevate to 170°
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
