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Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged less than 65 years

Open AccessPublished:September 19, 2022DOI:https://doi.org/10.1016/j.jseint.2022.08.020

      Abstract

      Background

      Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.

      Methods

      We reviewed the records of patients aged less than 65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients’ Constant score (CS), Disabilities of the Arm, Shoulder and Hand (DASH) score and the Visual Analogue Scale (VAS) for pain were calculated before the procedure and at 5 and 10 years.

      Results

      There were 24 consecutive patients aged less than 65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean CS was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (p = 0.0001 and p = 0.25). The mean DASH scores were 62.2 preoperatively, and respectively 7.8 and 9.3 at 5 and 10 years (p = 0.0009 and p = 0.1). The mean VAS scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (p = 0,0003 and p = 0.1). Based on Hamada’s classification, at 5 years 3 patients showed grade 2 changes and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes and one showed grade 3 changes.
      Complications (8%) developed after the 10-year evaluation and included pain in one patient and secondary rupture of the transfer in another.

      Discussion

      Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years.
      Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

      Keywords

      Massive rotator cuff tears are considered irreparable when tendon-to-bone or tendon-to-tendon continuity with the arm in adduction cannot be restored and the lesion is concomitant with the loss or degeneration of tendon tissue or with muscle atrophy
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures : pre- and postoperative evaluation by CT scan.
      with fatty degeneration and tendon retraction.
      The clinical implications of this type of lesion include impairment or loss of active movement and variable and often persistent pain that limits daily living activities.
      Patients often ask for pain mitigation and restoration of essential daily activity function. In some cases, examination after injection of a local anaesthetic into the subacromial space allows to determine whether an acceptable level of daily activity function can be restored with a rehabilitation program. Such patients are amenable to conservative treatment or to the less demanding surgical techniques, such as débridement associated with subacromial bursectomy and long head of biceps tenotomy
      • Koh K.H.
      • Laddha M.S.
      • Lim T.K.
      • Park J.H.
      • Yoo J.C.
      Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?.
      ,
      • Rockwood C.A.
      • Burkhead W.Z.
      Management of patients with massive rotator cuff defects by acromioplasty and rotator cuff debridement.
      , partial cuff repair
      • Koh K.H.
      • Laddha M.S.
      • Lim T.K.
      • Park J.H.
      • Yoo J.C.
      Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?.
      ,
      • Rockwood C.A.
      • Burkhead W.Z.
      Management of patients with massive rotator cuff defects by acromioplasty and rotator cuff debridement.
      ,
      • Rockwood Jr., C.A.
      • Williams Jr., G.R.
      • Burkhead W.Z.
      Debridement of degenerative irreparable lesions of the rotator cuff.
      , tendon transfer
      • Buijze G.A.
      • Keereweer S.
      • Jennings G.
      • Vorster W.
      • Debeer J.
      Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?.
      ,
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      • Cofield R.H.
      Subscapular muscle transposition for repair of chronic rotator cuff tears.
      • Collin P.G.
      • Gain S.
      • Nguyen Huu F.
      • Lädermann A.
      Is rehabilitation effective in massive rotator cuff tears?.

      Combes JM, Mansat M. Lambeau du muscle grand rond dans les ruptures massives de la coiffe des rotateurs. Etude expérimentale. In : L’epaule. de Bonnel F, Blotman F, Mansat M, editors. Springer-Verlag ; 1993 p. 318-330.

      ,
      • Gerber C.
      Latissiumus dorsi transfer for the treatment of irreparable tears of the rotator cuff.
      ,
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      and joint replacement 55. Elderly patients with rotator cuff lesions and degenerative glenohumeral arthropathy can often be managed by reverse total shoulder arthroplasty 55, a procedure that is not recommended for younger subjects with higher functional demands. Younger patients with irreparable posterosuperior rotator cuff tears who complain of pain and functional impairment but do not suffer from glenohumeral arthropathy may benefit from tendon transfer using the teres major, latissimus dorsi or the lower portion of the trapezius
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      ,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      ,
      • Gerber C.
      Latissiumus dorsi transfer for the treatment of irreparable tears of the rotator cuff.
      ,
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      .
      We hypothesize that in patients aged less than 65 years, massive irreparable posterosuperior rotator cuff tears can be repaired with teres major muscle-tendon transfer, which can restore motor function (in particular, abduction, external rotation and stability), stabilize the shoulder and slow down the progression of degenerative joint arthritis.
      This retrospective study was undertaken to evaluate the 5-year and 10-year clinical and radiographic records of 24 such patients (12 men and 12 women), who underwent teres major tendon transfer at our institution after a failed conservative treatment.

      Materials and Methods

      Patient demographics

      Inclusion criteria were age less than 65 years at the time of the transfer and no prior shoulder surgery. Indications for muscle transfer were posterosuperior rotator cuff tears with infraspinatus and supraspinatus fatty degeneration
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures : pre- and postoperative evaluation by CT scan.
      but without cuff tear arthropathy or degenerative joint disease
      • Hamada K.
      • Fukuda H.
      • Mikasa M.
      • Kobayashi Y.
      Roentgenographic findings in massive rotator cuff tears: a long-term observation.
      , and a well-preserved subscapularis muscle, including the upper portion.
      Exclusion criteria were shoulder instability, rotator cuff surgery, shoulder joint fracture, glenohumeral osteoarthritis, rheumatoid arthritis, poor motivation, general comorbidities and psychiatric illness.
      These criteria allowed identifying 24 consecutive patients, 12 men and 12 women, who underwent teres major tendon transfer at our Institution from 1998 to 2008 (Table 1). Their mean age at the time of surgery was 59 years (range, 43-65). The dominant arm was involved in 21 cases.
      Table 1Preoperative evaluation: Constant score (CS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) at rest and during motion and Hamada grade.
      CaseGenderSideAge (Years)Constant scoreAbduction (degrees)Flexion (degrees)External rotation adduction (degrees)External rotation abduction (degrees)DASH scoreVAS at restVAS on movementHamada grade
      1MR481745450060681
      2FR6123801100060,8591
      3MR6533110130205062,5781
      4MR51317511004068,3481
      5FR613510011006064,2691
      6ML5824757505075,8881
      7FR6220707010075,8791
      8FR6520707003070781
      9MR6320808002067,5881
      10MR6230808020044,2471
      11FR613310010001053,3681
      12MR642912090102056,7671
      13MR53349090405050,8461
      14MR65319011003048,3671
      15FR61286060103068,3561
      16FL62261109006058,3881
      17FR64324575304061,7461
      18MR65249090205061,7881
      19MR61234060206065,8671
      20FR4327090206070,8681
      21FL65246090105065,8891
      22ML623311090205062,5571
      23FR59235050106060,8671
      24FR50229090303060,8881
      The study was performed in accordance with the 1964 Declaration of Helsinki Ethical Standards as updated in 2004.
      All patients reported being unable to perform daily living activities due to pain and loss of shoulder function. According to the clinical records, all patients had received a local anaesthetic injection into the subacromial space and had subsequently followed a rehabilitation program that had improved their clinical condition but had provided inadequate pain relief and daily activity function. They all had a preserved passive range of motion (ROM) compared with the contralateral side and intact subscapularis and teres minor tendons and reduced acromion-humeral distance (6 mm, Hamada grade 1)
      • Hamada K.
      • Fukuda H.
      • Mikasa M.
      • Kobayashi Y.
      Roentgenographic findings in massive rotator cuff tears: a long-term observation.
      ; however, fatty degeneration of the muscles
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures : pre- and postoperative evaluation by CT scan.
      associated with tendon retraction
      • Patte D.
      Classification of rotator cuff lesions.
      prevented restoration of tendon-to-bone or tendon-to-tendon continuity with the arm adducted.

      Patient evaluation

      We evaluated the patients’ clinical history and compared their preoperative and postoperative clinical status including pain, ROM, and satisfaction, based on records collected at 5 and 10 years.
      The diagnosis of massive irreparable posterosuperior rotator cuff tears was based on physical examination and x-ray, magnetic resonance imaging (MRI) and computed tomography (CT) scans.
      Electromyography (EMG) was performed to exclude a peripheral nerve deficit.
      The Constant score (CS)

      Constant CR Constant score technique for shoulder function SECEC information- January 1991 n.3 pag 26-29

      ,
      • Constant C.R.
      • Murley A.H.
      A clinical method of functional assessment of the shoulder.
      , the Disabilities of the Arm, Shoulder and Hand (DASH)
      • Gummesson C.
      • Ward M.
      • Atroshi I.
      The shortened disabilities of the arm, shoulder and hand questionnaire (Quick DASH): validity and reliability based on responses within the full-length DASH.
      score and the Visual Analogue Scale (VAS)
      • Johnson E.
      Visual analog scale (VAS).
      for pain at rest and during movement were obtained from the clinical records.

      Radiographic evaluation

      X-ray, MRI and CT scans were obtained before the procedure and at 5 and 10 years. All patients had grade 3 or 4 according to the Goutallier classification system
      • Goutallier D.
      • Postel J.M.
      • Bernageau J.
      • Lavau L.
      • Voisin M.C.
      Fatty muscle degeneration in cuff ruptures : pre- and postoperative evaluation by CT scan.
      and grade 3 tendon retraction according to the Patte classification
      • Patte D.
      Classification of rotator cuff lesions.
      . The irreparable nature of the tears was also evaluated intraoperatively before the tendon transfer.

      Statistical analysis

      Data are reported as mean ± standard deviation. The normal distribution of data was tested with Shapiro-Wilk’s test and homoscedasticity with the F test for homogeneity of variances. Wilcoxon’s signed-rank test was used to compare the variables between the two follow-up evaluations. A p-value < 0.05 (2-tailed) was considered significant. Analyses were performed using STATA software package (2009, release 11; Stata Corp, College Station, TX, USA).

      Surgical technique

      In these patients, the teres major transfer was performed by the senior author (LC) according to the original open technique
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      from 1998 to 2008
      The patient under general anesthesia is placed in the beach chair position with the trunk at a 60°-70° angle from the horizontal position (Figure 1)
      Figure thumbnail gr1
      Figure 1The patient, under general anaesthesia, is placed in beach chair position with the trunk angled 60°-70° from the horizontal position.
      The first step involves an anterior to posterior skin incision beginning on the anterior corner of the acromion and running for 5 cm along the lateral edge of the acromion.
      The deltoid fibers are divided longitudinally between the anterior and middle portions, to enable the acromioplasty and expose the subacromial space. All 24 patients underwent biceps tenotomy.
      If the anterior subacromial exposure demonstrates supraspinatus and infraspinatus tendon retraction and muscle atrophy, which prevent tendon repair, but no degenerative joint alterations (Figure 2), a curved skin incision is performed above the posterior pillar of the armpit, from the external margin of the scapula to the upper third of the humerus (Figure 3).
      Figure thumbnail gr2
      Figure 2In patients with irreparable posterosuperior lesion with tendon retraction and muscle atrophy but without joint degenerative changes, a posterior skin incision running above the posterior pillar of the armpit is added to the acromion incision.
      Figure thumbnail gr3
      Figure 3The posterior skin incision is curved and runs above the posterior pillar of the armpit, from the external margin of the scapula to the upper third of the humerus; the posterior border of the deltoid, the long head of the triceps and the teres major are identified. The teres major is isolated from its scapular origin to the humeral insertion and its tendon is divided from the latissimus dorsi tendon.
      The teres major is isolated from its scapular origin to its humeral insertion and its tendon is divided from the latissimus dorsi tendon (Figure 3).
      At this time, the axillary nerve in the quadrilateral space and the radial nerve running under the teres major tendon are identified and protected (Figure 4).
      Figure thumbnail gr4
      Figure 4The axillary nerve in the quadrilateral space and the radial nerve under the teres major tendon are identified and protected.
      With the arm in maximum internal rotation, to gain a clearer view of the humeral insertion of the teres major tendon, the tendon is detached from the humerus, sparing the latissimus dorsi insertion.
      The muscle is mobilized by soft tissue dissection as close to the muscle origin as necessary, to ensure adequate proximal migration.
      Once the neurovascular pedicle has been isolated at the level of the medial third of the muscle (Figure 5), tetanization allows evaluating maximum muscle contraction (Figure 6). In these 24 patients, the mean fiber excursion from resting length to maximum contraction was 8 cm (range, 6-11).
      Figure thumbnail gr5
      Figure 5The neurovascular pedicle has been isolated at the level of the medial third of the muscle.
      Figure thumbnail gr6
      Figure 6Tetanization of the neurovascular pedicle allowed evaluating maximum muscle contraction.
      After the axillary nerve has been visualized and protected to avoid injury, the teres major and its pedicle are prepared, preserving the scapular insertion, and the tendon is brought to the subacromial space by passing it under the deltoid muscle using a long curved clamp.
      The tendon is anchored to the bone in the infraspinatus area, in a position that is halfway between the resting length and the maximum contraction of the muscle. The tendon is fixed using transosseous non-absorbable sutures according to the original technique (Figures 7 and 8), with the arm in 40° of abduction and neutral rotation, to avoid excessive tension on the tendon when the arm is internally rotated. Where possible, the remaining portion of the cuff is attached to the tendon transfer ( Figure 9).
      Figure thumbnail gr7
      Figure 7The tendon transfer is brought to the subacromial space by passing it under the deltoid muscle using a long curved clamp and anchored to bone in the infraspinatus area with two non-absorbable sutures.
      Figure thumbnail gr8
      Figure 8Posterior view of the teres major transferred into the subacromial space.
      Figure thumbnail gr9
      Figure 9MRI scan of the teres major transfer.

      Postoperative management

      The arm is placed in 45° of abduction and neutral rotation in an abduction splint. After 3 weeks, passive ROM exercises are begun, avoiding internal rotation. The splint is removed after 6 weeks. Active abduction and external rotation exercises similar to those performed for massive rotator cuff rehabilitation are begun, with progressive stretching and strengthening. Recovery usually takes 10-12 months.

      Results

      Patients were evaluated at mean follow-up times of 64 months (60 to 75) and 125 months (120 to 144).
      There were no perioperative infections, skin problems or neurological or vascular complications. Axillary and radial nerve function was normal in all patients. Complications (8%) developed after the 10-year evaluation and included pain in one patient and secondary rupture of the transfer in another

      Range of motion

      ROM improved significantly from the preoperative evaluation to the first follow-up (p < 0.05) and became stable between the first and second follow-up visits (p > 0.05). The improvements in active forward elevation, 90° shoulder abduction and external rotation were substantially stable at the two follow-up evaluations (Table 2, Table 3). Pain diminished and remained consistently low. A similar degree of patient satisfaction was recorded at both follow-up visits.
      As regards the mean arc of active motion, abduction increased from 76° (± 27.69) to 143° (± 29.21; p = 0.0001) at 5 years to 142° (± 39.04; p = 0.4) at 10 years. Flexion rose from 85° (± 20.55) to 150° (± 24.42; p = 0,0005) at 5 years and to 152° (± 26.42; p = 0.3) at 10 years. External rotation in adduction increased from 11° (± 11.91) to 34°(± 25.73; p = 0,0003) at 5 years to 39° (± 28.69; p = 0.26) at 10 years. Active external rotation at 90° of abduction improved from 35° (± 21.46) to 65° (± 18.08; p = 0.0004) at 5 years and fell slightly to 62° (± 21.62; p = 0.30) at 10 years.

      Functional assessment

      The preoperative values of the functional scores are reported in Table 1, the 5-years values are reported in Table 2 and the 10-year values are reported in Table 3.
      Table 2Postoperative evaluation at 5-year follow-up: Constant score (CS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) at rest and during motion and Hamada grade.
      CaseF-U (mths)Constant scoreAbduction (degrees)Flexion (degrees)External rotation adduction (degrees)External rotation abduction (degrees)DASH scoreVAS at restVAS at movementsHamada gradePatient's satisfaction
      16062110110404012,5011yes
      261731701700606,7011yes
      36366160160308012,5232yes
      4627616016010703,3001yes
      5647917016025803,3001yes
      6617715017010705011yes
      7606312015020302,5001yes
      8707013015055757,5022yes
      9607514016020705,8001yes
      10616110012020409,2021yes
      11637217017040708,3011yes
      1266761501400205001yes
      13686917017050903,3001yes
      1460741601700705011yes
      15645080120205014,2031yes
      16613511011008020463no
      176859135135407010011yes
      18706916016030755,8001yes
      197169809050806,7011yes
      20697817017070854,2001yes
      21737216016070709,2011yes
      227562150150605013,3351yes
      236172160180806010022yes
      24647718018080805,8001yes
      Table 3Postoperative evaluation at 10-year follow-up: Constant score (CS), Disabilities of the Arm, Shoulder and Hand (DASH) score, Visual Analogue Scale (VAS) at rest and during motion and Hamada grade.
      CaseF-U (mths)Constant scoreAbduction (degrees)Flexion (degrees)External rotation adduction (degrees)External rotation abduction (degrees)DASH scoreVAS at restVAS on movementsHamada gradePatient's satisfaction
      112459110110404012,5232yes
      2121691701700607,5001yes
      312464160160308013,3232yes
      41307111011010705001yes
      51207618018080805,8011yes
      61237215017010705,8021yes
      71446312015020303,3001yes
      81237013015055757,5022yes
      91227514016020705,8001yes
      101306918018080806,7001yes
      111267217017040708,3001yes
      12120681501400208,3021yes
      131236917017050906,7011yes
      14128691601700709,2001yes
      151325880120205014,2022yes
      16120210700035,8563no
      171276716016080805001yes
      181256916016030755011yes
      1913065130150356010,8022yes
      201207417017070855,8001yes
      2112268150150707010341yes
      2212556150150605014,2012yes
      2312072160180806010,8012yes
      241247216016060607,5001yes
      The mean CS was 26.75 (± 5.27) before the procedure, 68.17 (± 10.04) at 5 years (p = 0.0001) and 66.17 (± 10.9; p = 0.25) at 10 years .
      The mean DASH score was 62.28 (± 7.85) before the procedure, 7.88 (± 4.26; p = 0.0009) at the first follow-up evaluation and 9.37 (± 6.42; p = 0.1) at the second.
      The mean VAS score at rest was 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (p = 0,0003 and p = 0.1). One patient (#21) did not achieve relief from pain.

      Radiographic outcomes

      At the first follow-up, the MRI scans depicted a secondary rupture of the tendon transfer from its insertion on the great tuberosity (case #16). This was the only patient who also had fatty degeneration in the transfer
      The x-rays taken before the procedure and at 5 and 10 years allowed assessing the evolution of secondary degenerative changes of the glenohumeral joint. Based on Hamada’s classification, at the first follow-up 3 patients showed grade 2 changes and showed grade 3 changes (case #16). At the second follow-up, 7 patients had grade 2 changes and patient #16 still had grade 3 changes.
      At the 10-year follow–up visit, patients also underwent dynamic ultrasonography and EMG, which allowed to determine the contraction capacity acquired by the teres major transfer in external rotation. We were able to document that in 23 of the 24 patients the reduced but preserved internal rotation was however synergistic with the activity of the latissimus dorsi muscle, also in resisted movements. The remaining patient (case #16) was the one who had experienced failure of the tendon transfer due to secondary rupture, which prevented EMG analysis during shoulder motion.

      Discussion

      Surgical repair of massive posterosuperior rotator cuff tears fails in 21-91% of cases
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      due to atrophy with irreversible fatty degeneration and retraction of the torn muscles.
      Conservative treatment for six months should always be attempted before considering surgery, since it can increase the arc of motion and relieve pain. The aims of rehabilitation are overall strengthening of the deltoid and periscapular muscles
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      ; if this treatment does not provide sufficient improvement, the success rate of further non-operative management declines and surgery may be considered.
      An irreparable posterosuperior rotator cuff tear can be salvaged by surgical treatment if the patient does not suffer from degenerative joint changes or tendon retraction.
      One surgical option is tenotomy of the long head of biceps with/without partial cuff repair. Its aims are to repair the rotator cuff tendon, which can be sutured back to the tuberosities without excessive tension, and to address any causes of pain or factors threatening the repair. A partial repair tries to restore the force couples and the ‘suspension bridge’ and to prevent secondary extension of the tear
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      • Delsol P.
      • Barth J.
      Long head of the biceps as a suitable available local tissue autograft for superior capsular reconstruction: “The Chinese Way”.
      can prevent the superior migration of the humeral head and restore the shoulder force couples. Denard et al
      • Denard P.J.
      • Brady P.C.
      • Adams C.R.
      • Tokish J.M.
      • Burkhart S.S.
      Preliminary results of arthroscopic superior capsule reconstruction with dermal allograft.
      have reported an increase in shoulder motion and a 55% failure rate in a series of 59 patients treated with a dermal allograft with a follow-up of at least 12 months. An alternative procedure involves implanting a balloon-shaped biodegradable spacer between the acromion and the humeral head. The spacer is designed to create a physical barrier between the tissues in the subacromial space and keep the humeral head depressed in patients with an insufficient rotator cuff, to facilitate deltoid action
      • Deranlot J.
      • Herisson O.
      • Nourissat G.
      • Zbili D.
      • Werthel J.D.
      • Vigan M.
      • et al.
      Arthroscopic subacromial spacer implantation in patients with massive irreparable rotator cuff tears: clinical and radiographic results of 39 retrospectives cases.
      . The failure risk of this salvage technique is related to patient activities and age.
      Another method to restore shoulder function and reduce pain in relatively young patients involves replacing the lost muscle with a muscle-tendon transfer.
      Steindler (1939)

      Steindler A Tendon transplantation in the upper extremity 1939 American Journal of Surgery 44;260

      argued that any upper limb muscle could be transferred to serve a different function, because “movements, not muscles are represented in the cerebral cortex”. If the transfer allows to recover muscle strength and the range, amount and direction of tendon sliding, a muscle transfer can function like the muscle that is being replaced. If the injured muscle cannot be repaired, a muscle-tendon unit transfer has the potential to restore the lost motor function, either specific movements and joint stability. In shoulder surgery, we distinguish local from regional tendon transfers.
      Local tendon transfers are actually rotation flaps raised from the intact tendons of the cuff, usually the subscapularis or the teres minor

      Neviaser RJ, Neviaser TJ. Transfer of subscapularis and teres minor for massive defects of the rotator cuff. In: Shoulder surgery. Berlin: Springer-Verlag; 1982. pp. 60-69

      . They are simple to prepare and allow covering the humeral head with innervated and vascularized tissue while restoring continuity with the residual cuff tendons

      Neviaser RJ, Neviaser TJ. Transfer of subscapularis and teres minor for massive defects of the rotator cuff. In: Shoulder surgery. Berlin: Springer-Verlag; 1982. pp. 60-69

      . However, they involve the risk of a worse functional status compared with before the procedure, particularly where the functions that rely on subscapularis and teres minor muscle-tendon unit integrity are concerned.
      Regional tendon transfers are collected from the thoracic scapulohumeral region and can replace one or more cuff muscles
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      ,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      ,
      • Cofield R.H.
      Subscapular muscle transposition for repair of chronic rotator cuff tears.
      ,
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      ,

      Mikasa M. Trapezius transfer for global tear of the rotator cuff. In: Bateman JE, Welsh RP, editors. Surgery of the shoulder. St Louis: CV Mosby; 1988 p. 196

      ,
      • Resch H.
      • Pavocz P.
      • Ritter E.
      • Matschi W.
      Transfer of the pectoralis major muscle for the treatment of the irreparable rupture of the subscapularis tendon.
      ,
      • Takagishi N.
      The new operation for the massive rotator cuff rupture.
      ,

      Warner JJP, Gerber C Massive tears of the posterosuperior rotator cuff. In: Warner JJP, Iannotti JP, Gerber C (ed) (1997) Complex and revision problems in shoulder surgery. Lippincott-Raven, Philadelphia, pp.177-201

      . A variety of regional tendon transfers can be used for irreparable posterosuperior massive cuffs: latissimus dorsi, teres major and the lower portion of the trapezius. In 1976, Beevor
      Beevor A Quoted by Boyes.
      wrote: “the brain only knows function, not individual muscle action”. In irreparable rotator cuff tears, good results can be obtained with regional tendon transfers, provided that the surgeon performs a meticulous operative technique and has a good understanding of the biomechanical principles involved.
      Selection of the suitable muscle must is based on the excursion and synergism of the transfer and the contraction and strength of the antagonist muscles
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      ,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      . Moreover, if the tendon transfer crosses two joints in succession, its resultant force vector exerts an effect on each joint in proportion to the moment arm of each axis. Replacing the infraspinatus muscle in patients with posterosuperior lesions requires considering the resultant force vector close to the infraspinatus muscle.
      Latissimus dorsi transfer was originally described by Gerber in 1988
      • Gerber C.
      Latissiumus dorsi transfer for the treatment of irreparable tears of the rotator cuff.
      to restore humeral head depression and external rotation in young, active patients without glenohumeral arthritis or significant static migration of the humeral head. These indications are similar to those of teres major transfer. The procedure essentially restores posterior muscle strength. At 10-year follow-up, Gerber was able to document the durability of the reconstruction, with good to excellent outcomes and preserved functional scores, including CS.
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years.
      Complications include stiffness, traumatic failure of the transfer, nerve dysesthesia and failure of the deltoid reattachment
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years.
      . El-Azab et al reported similar results with a long-term failure rate of 10% and a conversion rate to reverse shoulder arthroplasty of 4%
      • El-Azab H.M.
      • Rott O.
      • Irlenbusch U.
      Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.
      . We had a similar complication rate (8%), with transfer failure and severe pain.
      Lower trapezius tendon transfer has recently been described to manage irreparable posterosuperior rotator cuff tears
      • Elhassan B.
      Technique of tendon transfers about the shoulder in patients with brachial plexus injury.
      ,
      • Elhassan B.
      • Bishop A.T.
      • Hartzler R.U.
      • Shin A.Y.
      • Spinner R.J.
      Tendon transfer options about the shoulder in patients with brachial plexus injury.
      . Elhassan et al
      • Elhassan B.
      • Wagner E.
      • Werthel J.D.
      Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.
      followed 32 patients for at least two years and found that the better outcomes correlated with preoperative status, but a longer follow-up is clearly required to compare outcomes.
      We have been performing teres major transfer based on the consideration that the resultant force vector of the transfer acting on the glenohumeral joint can be altered by scapulohumeral movements, but not by scapulothoracic movements; this entails a scapulohumeral muscle such as the infraspinatus or the teres major is required.
      The teres major arises from the dorsal border of the inferior angle of the scapula. It is physiologically and biomechanically similar to the posterosuperior rotator cuff muscles. The line of action of a teres major transfer in relation to the glenoid is similar to that of the infraspinatus
      • Buijze G.A.
      • Keereweer S.
      • Jennings G.
      • Vorster W.
      • Debeer J.
      Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?.
      ,
      • de Groot J.H.
      • van de Sande M.A.
      • Meskers C.G.
      • Rozing P.M.
      Pathological teres major activation in patients with massive rotator cuff tears alters with pain relief and/ or salvage surgery transfer.
      ,
      • Magermans D.J.
      • Chadwick E.K.
      • Veeger H.E.
      • van der Helm F.C.
      • Rozing P.M.
      Biomechanical analysis of tendon transfers for massive rotator cuff tears.
      .
      The length of the neurovascular pedicle of the teres major is sufficient for suturing to the greater tuberosity
      • de Groot J.H.
      • van de Sande M.A.
      • Meskers C.G.
      • Rozing P.M.
      Pathological teres major activation in patients with massive rotator cuff tears alters with pain relief and/ or salvage surgery transfer.
      . Intraoperative stimulation allows to determine its adequate tension and anchoring site on the tuberosity, which should be halfway between maximum contraction to resting length. We also believe that teres major transfer can restore the couple force vectors with the subscapularis muscle, restoring scapulohumeral joint stability and active motion in abduction and external rotation, as described in the recent literature
      • Buijze G.A.
      • Keereweer S.
      • Jennings G.
      • Vorster W.
      • Debeer J.
      Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?.
      ,
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      ,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      ,
      • Henseler J.F.
      • Nagels J.
      • van der Zwaal P.
      • Nelissen R.G.
      Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: short-term clinical results.
      ,

      Mansat P, Dotziz A, Bellumore Y, Mansat M. Teres major flap: surgical anatomy, technique of harvesting, methods of fixation, postoperative management. In: Valenti P, ed. Tendon transfer for irreparable rotator cuff tear. Paris: Springer-Verlag France, 2011:49-64. DOI :10.1007/978-2-8178-0049-3

      ,
      • Steenbrink F.
      • Nelissen R.G.
      • Meskers C.G.
      • J van de Sande M.A.
      • Rozing P.M.
      • de Groot J.H.
      Teres major muscle activation relates to clinical outcome in tendon transfer surgery.
      . This anatomical aspect of the teres major has also been assessed by Henseler et al
      • Henseler J.F.
      • Nagels J.
      • van der Zwaal P.
      • Nelissen R.G.
      Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: short-term clinical results.
      , who demonstrated that it is physiologically closer to the infraspinatus muscle. Even though the teres major is relatively short and thick, it is however sufficiently long and can provide a transfer with a suitable amount of tension and contractility
      • Henseler J.F.
      • Kolk A.
      • Zondag B.
      • Nagels
      • de Groot J.H.
      • Nelissen R.G.H.H.
      Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears.
      .
      We believe that the evaluation of muscle excursion by intraoperative stimulation of the neurovascular pedicle is important to establish the correct anchoring point of the tendon on the humerus. In particular, finding the midpoint between maximum muscle extension and contraction allows defining the average excursion, which has always been used to establish transplant tension and its more or less anterior site on the humerus. We consider this step a critical factor for the success of the transfer, since it reduces the risk of excessive tensioning of the transfer, particularly of secondary failure, as reported by Kany et al
      • Kany J.
      • Sekaran P.
      • Grimberg J.
      Risk of latissimus dorsi tendon rupture after arthroscopic transfer for posterior superior rotator cuff tear: a comparative analysis of 3 humeral head fixation techniques.
      .
      The second critical factor affecting the risk of secondary rupture is that the teres major is a scapulohumeral muscle and that during shoulder motions it remains in the same position, tension and direction as the teres minor and the infraspinatus, unlike the latissimus dorsi, which is a thoracohumeral muscle.
      Our patients experienced a significant improvement in active abduction and its stabilization over the two follow-up visits. A similar improvement has already been described in other works, which show that this muscle transfer is suitable to restore shoulder motion 6,10,11,31,40,51,54.
      All our patients but two (cases #16 and # 21) achieved relief from pain, which became stable over time.
      In addition, daily activity function improved in 23 of the 24 patients, who were satisfied with their outcome. The last patient (case #16) achieved relief from pain but not active shoulder function and was not satisfied with her outcome. Comparison of her preoperative and postoperative x-rays documented a severe superior migration of her humeral head, which demonstrates that the teres major tendon transfer had insufficient strength to depress the humeral head and was unable to restore the balance with the subscapularis muscle and to reduce the risk of evolution to cuff tear arthropathy.
      The electrical activity of the tendon transfer, documented by EMG, was maximal in external rotation, particularly in 90° of abduction, which explains the greater improvements of 23/24 patients in external rotation and abduction than in adduction, as also reported in the literature
      • Buijze G.A.
      • Keereweer S.
      • Jennings G.
      • Vorster W.
      • Debeer J.
      Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: teres major or latissimus dorsi?.
      ,
      • Celli A.
      • Marongiu M.C.
      • Rovesta C.
      • Celli L.
      Transplant of the teres major in the treatment of irreparable injuries of the rotator cuff (long-term analysis of results).
      ,
      • Celli L.
      • Rovesta C.
      • Marongiu M.C.
      • Manzieri S.
      Transplantation of teres major muscle for infraspinatus muscle in irreparabile rotator cuff tears.
      ,
      • Henseler J.F.
      • Nagels J.
      • van der Zwaal P.
      • Nelissen R.G.
      Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: short-term clinical results.
      ,

      Mansat P, Dotziz A, Bellumore Y, Mansat M. Teres major flap: surgical anatomy, technique of harvesting, methods of fixation, postoperative management. In: Valenti P, ed. Tendon transfer for irreparable rotator cuff tear. Paris: Springer-Verlag France, 2011:49-64. DOI :10.1007/978-2-8178-0049-3

      ,
      • Steenbrink F.
      • Nelissen R.G.
      • Meskers C.G.
      • J van de Sande M.A.
      • Rozing P.M.
      • de Groot J.H.
      Teres major muscle activation relates to clinical outcome in tendon transfer surgery.
      . Electrical activity was also documented in resisted internal rotation and in the synergistic movements that recruit the latissimus dorsi. This confirms Steindler’s view

      Steindler A Tendon transplantation in the upper extremity 1939 American Journal of Surgery 44;260

      that when a muscle is transferred, the mind can alter the activity of the muscle, which greatly contributes to the effect of rehabilitation.
      Comparison of the preoperative values to those of the two follow-up time points highlighted significant differences at 5 years, whereas functional improvement and pain relief between 5 and 10 years were not significantly different, since the gains had become stable.
      Altogether, the teres major muscle has useful anatomical and biomechanical features that enable its use as a muscle transfer in patients with irreparable posterosuperior rotator cuff tears. The direction of the resultant vector contraction force of the transfer is similar to the resultant force vector of the infraspinatus and teres minor muscles; in addition, the transfer has sufficient relative strength and contraction length to replace the torn muscle 10,11,54.
      Biomechanically, the teres major is a scapulohumeral muscle like the infraspinatus, and the resultant force is not altered by the scapulothoracic movements during shoulder abduction.
      The length of the muscle-tendon unit is sufficient for insertion into the greater tuberosity 14,54. The fixation site in the infraspinatus area depends on the excursion length of the muscle, which can be established by intraoperative stimulation. The transfer restores the balance with the upper portion of the subscapularis muscle.
      The neurovascular pedicle is sufficiently long to be transposed, usually at the medial third of the muscle
      • Schoierer O.
      • Herzberg G.
      • Berthonnaud E.
      • Dimnet J.
      • Aswad R.
      • Morin A.
      Anatomical basis of latissimus dorsi and teres major transfer in rotator cuff tear surgery with particular reference to the neurovascular pedicles.
      .
      After teres major transfer, scapular lateral rotation gradually increased, whereas this has not been reported after latissimus dorsi transfer
      • Henseler J.F.
      • Kolk A.
      • Zondag B.
      • Nagels
      • de Groot J.H.
      • Nelissen R.G.H.H.
      Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears.
      . Greater scapular lateral rotation after teres major transfer indicates a glenohumeral rotation to achieve the final position of the shoulder joint, considering that humeral abduction is the result of scapulothoracic and glenohumeral motion
      • Henseler J.F.
      • Kolk A.
      • Zondag B.
      • Nagels
      • de Groot J.H.
      • Nelissen R.G.H.H.
      Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears.
      . The teres major transfer, which becomes a scapulohumeral muscle, has a moment arm around the glenohumeral center of rotation.
      • Henseler J.F.
      • Kolk A.
      • Zondag B.
      • Nagels
      • de Groot J.H.
      • Nelissen R.G.H.H.
      Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears.
      Therefore, the teres major is physiologically more similar to the infraspinatus muscle.
      Using the approach described above, the procedure does not present major technical difficulties. Two steps require special attention: the teres major tendon should be detached close to the humeral shaft and the radial and axillary nerves should carefully be protected.
      The main disadvantages of using the teres major include the shortness and thickness of the tendon and the fact that the suture needs to be done on the muscle fibers.
      Tensioning of the transfer is challenging. The suture on the greater tuberosity must ensure passive internal rotation, whereas excessive tensioning induces a tenodesis effect on the muscle.

      Conclusion

      Teres major transfer is a salvage procedure for irreparable posterosuperior rotator cuff tears, restoring motion, providing pain relief and reducing the risk of evolution to cuff tear arthropathy.
      In our experience it can achieve good long-term results.
      Patient selection, an accurate surgical technique and adequate rehabilitation are all critical for success.

      Uncited reference

      • Wang A.A.
      • Strauch R.J.
      • Flatow E.L.
      • LU Bigliani
      • Rosenwasser M.P.
      The teres major muscle: an anatomic study of its use as a tendon transfer.
      .

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