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Massive Rotator Cuff Tears: The Role of Tendon Transfers
Danny P. Goel, M.D., FRCSC
Darren S. Drosdowech, M.D., FRCSC
London, ON
Massive irreparable rotator cuff tears (RCT) continue to pose a unique challenge. We will limit our focus to the role of cuff reconstruction utilizing latissumus dorsi and/or pectoralis major transfer in an attempt to restore pain-free shoulder function.
Rationale
A massive RCT is defined as a tear exceeding 5cm or one that involves at least two tendons1. Late repair of such a large tear has been associated with a high failure rate2. Goutallier has noted a positive correlation between the chronicity of the cuff tear and the presence of both atrophy and increasing muscular infiltration by fat3. Unfortunately, once established, these changes have been shown to be irreversible following repair3-6.
The individual rotator cuff (RC) muscles act collectively to centre the humeral head upon the glenoid providing a stable fulcrum for efficient deltoid function. This collective balance provided by the RC has been termed the 'force couple'7. Biomechanical contribution to this force couple is asymmetric as the subscapularis contributes the majority (52%) while the posteriosuperior RC contributes the remainder (supraspinatus 15%, infraspinatus and teres minor 33%)7-9. Based on these principles, it is apparent that restoration of the force couple is critical during cuff surgery. In situations not amenable to complete repair, marginal convergence may provide satisfactory glenohumeral joint balance allowing optimal deltoid activity10. If however, a significant area of posterosuperior/antersuperior tendon is dysfunctional or absent (irreparable), the centralizing vector of the tendon(s) is lost and superior humeral migration will occur. This may lead to suboptimal deltoid function and pain. The purpose of a vascularized tendon transfer is to behave in part as a humeral head depressor while, secondarily, providing a biomechanical vector that restores as close to normal shoulder mechanics as possible11.
Latissumus Dorsi (LD)
The ideal patient for LD tendon transfer is a young male labourer with shoulder pain and a documented irreparable posterosuperior RCT12-15. On exam, active forward elevation, although laboured, should be maintained while external rotation (ER) strength is notably reduced (positive ER lag sign, positive Hornblower's sign). Absolute contraindications include those patients with active infection, advanced arthritis, static proximal humeral migration with or without arthritis (cuff tear arthropathy), associated pseudoparalysis and elderly patients unable to comply with rehabilitation. Appropriate investigations for potential candidates include plain radiography and MRI (Figure 1).
Figure 1
A. Sagital MRI with fatty infiltration of supraspinatus (SS) and infraspinatus (IS) and normal musculature of subscapularis (SSc); note infraspinatus with significant fat infiltration on this medial cut, however ideal x-sectional image best taken 1-2 saggital sections medial to the glenoid face. Supraspinatus appears well preserved on this image although is often similarly affected in most cases. B. Axial MRI with deficient posterosuperior RC (arrow) and retraction to glenoid face.
LD transfer, originally described for Erb's Palsy, utilizes autogenous, innervated and vascularized tissue16 in an attempt to recreate the absent posterior force couple normally provided by the posterosuperior rotator cuff17. Gerber,11 found that after 12-15 months postoperatively, pain-free motion and restoration of flexion, abduction and external rotation was observed. The authors attributed these results to both the tenodesis effect of the transfer as well as active contraction of the transferred muscle18. Literature supporting the use of LD tendon transfer has shown it to be of benefit five years following surgery19. Others have also documented reduced pain and functional improvement following transfer11-13, 15, 19.
Poor predictors of outcome following tendon transfer include: females, preoperative range of motion/strength deficits and out of phase LD contraction15. Other negative prognosticators include associated upper fiber subscapularis tears20, advanced fatty atrophy of the teres minor21, and transfer for previously failed repair22. These variables continue to be debated13, 19, 23.
Figure 2
Illustration of latissimus dorsi transfer to posterosuperior greater tuberosity. A. Posterior view of teres minor (t.m.), deltoid (d) and latissimus dorsi (l.d.). B. Identification of the anterior insertion of the latissimus dorsi. C. Tendon passage subdeltoid and onto the D. posterosuperior greater tuberosity. E. Clinical photo of l.d. tendon ready for transfer. Images courtesy of Dr. C. Gerber and D. Drosdowech.
Pectoralis Major (PMaj)
Chronic, irreparable tears of the subscapularis can be addressed by transfer of the PMaj tendon. This tendon is thought to provide an anterior buttress while providing a vector of pull similar to that of the subscapularis. To maximize the function of this transfer, the ideal position (subcoracoid vs supracoracoid) remains controversial24,25 (Figure 3). Jost et al employed this transfer in 11 patients and noted that more than 80% had symptomatic improvement postoperatively26. Others have reported similar results25, 27. 
Figure 3
A. Preoperative axial MRI demonstrating complete and retracted tear of the subscapularis (arrow heads), biceps tendon (asterix) and infraspinatus (arrow). B. Sagittal MRI of fat infiltrated subscapularis (arrow heads), supraspinatus (single asterix) with near normal muscle. C. Clinical picture of supra-coracoid pectoralis major transfer, coracoid (CC), conjoint tendon (CT) and pectoralis major (PM).
Combined Transfers
Combined transfer of both pectoralis major and latissimus dorsi for massive rotator cuff tears can be attempted in the face of a global, massive RCT in a younger, active individual. This may well be the only reconstructive option in this group of patients to restore active function and pain control without resorting to more salvage-type procedures such as glenohumeral arthrodesis or reverse total shoulder arthroplasty. Aldridge et al followed 11 patients (mean age 53.4 years) for 24-42 months following combination tendon transfer. The authors noted seven of the 11 patients demonstrated functional improvements following combined transfer28. To date, we have rarely used this approach in our practice and any conclusions remain anecdotal.
Conclusion
If restoration of normal glenohumeral mechanics remains the primary goal in the management of massive, irreparable RCT's, then autogenous tendon transfer remains the only reasonable option. The ideal patient in our experience is the younger, active labourer who is willing to comply with an extensive, customized rehabilitation programme under the guidance of a well-informed therapist. Provided these prerequisites are met, the literature suggests that improved and durable patient outcomes may be obtained.
References
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