Long-Term Outcomes of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis Tears

Abstract

BACKGROUND One recognized salvage option in the treatment of an irreparable subscapularis tear is the pectoralis major tendon transfer (PMT). We aimed to analyze the long-term clinical and imaging outcome of PMT for irreparable subscapularis deficiency. METHODS Twenty-eight consecutive patients representing 30 shoulders underwent PMT at a mean age of 53.0 years (range, 35 to 67 years). At a mean of 19.7 years (range, 18 to 22 years) postoperatively, 24 shoulders (80%) were clinically examined and 21 were radiographically and sonographically assessed. The long-term results were compared with preoperative findings and previously published short-term results. RESULTS The mean relative Constant score (percentage of age and sex-matched normal scores; CS%) and the Subjective Shoulder Value (SSV) both improved significantly from preoperatively (CS%, 47%, and SSV, 22%) to postoperatively (CS%, 77%, and SSV, 71%; p < 0.001 for both). All patients rated their results as good or excellent. Active anterior elevation was improved from preoperatively (120°) to postoperatively (131°), but the difference was not significant. Active internal and external rotation decreased significantly from the short-term (32month) follow-up to the time of the latest follow-up (p = 0.005 and p = 0.002, respectively); however, internal rotation remained at 6 points compared with the 8 points recorded at short-term follow-up and external rotation decreased only from a mean of 51°to 39°. Loss of active range of motion was not observed subjectively and was not subjectively limiting, represented by the high ultimate SSV and overall satisfaction. Four shoulders (19%) showed evidence of glenohumeral arthropathy (Samilson and Prieto grade 3), but clinically were mildly symptomatic to asymptomatic at the time of the latest follow-up (CS% range, 67% to 88%; SSV range, 70% to 80%). Rupture of the PMT was sonographically identified in 2 patients (10%) and was associated with radiographic evidence of advanced cuff tear arthropathy (Hamada stages 4). Six (20%) of the initial 30 shoulders were revised, and 1 (4%) of the 24 shoulders that were clinically examined underwent reverse total shoulder arthroplasty. CONCLUSIONS At longterm follow-up, PMT for isolated and combined subscapularis tears is associated with good to excellent clinical results. Although one-third of the shoulders developed mildly symptomatic or asymptomatic osteoarthritis, the need for salvage with use of reverse total shoulder arthroplasty was rare. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Chronic Pseudoparalysis Needs to Be Distinguished From Pseudoparesis: A Structural and Biomechanical Analysis

“…This may include partial RCT repair with or without augmentation, superior capsular reconstruction, or tendon transfers. 14,24,29,40 Although arthroscopic partial repair does not seem to improve abduction strength, 40 partial subscapularis repair may have the potential to preserve a mechanical fulcrum to allow the deltoid muscle to abduct the arm and to retain shoulder function. 5,23,35 Patients with pseudoparesis may also be candidates for tendon transfer, such as latissimus dorsi transfer, 24 as long as the subscapularis tendon is reparable, 42 fatty infiltration of the teres minor muscle is not advanced, 3 and advanced glenohumeral arthropathy or dynamic anterosuperior escape is excluded.…”

Surgical Management of Massive Irreparable Cuff Tears: Latissimus Dorsi Transfer for Posterosuperior Tears

“…Patients with FIRCT who fail nonoperative management can be considered for surgical treatment, which may include arthroscopic debridement with biceps tenotomy or tenodesis, partial RCT repair with or without augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty (RTSA) [8,[35][36][37][38]. Arthroscopic debridement and partial repair have been proved to provide reliable pain relief [39,40], but these procedures do not seem to halt or substantially decrease the progression of glenohumeral OA [40,41].…”

Arthroscopic-Assisted Anterior Latissimus Dorsi Transfer for Irreparable Anterior Rotator Cuff Tear: A Technical Note

“…Several operative techniques have been described for irreparable tears of the SSC tendon, of which the PM tendon transfer is the most frequently used. 4,6 However, the PM muscle originates from the anterior chest wall; thus, the line of pull of the PM muscle forms a Right shoulder in a 49-year-old male patient in the beach-chair position. Intra-articular arthroscopic view from the anterolateral viewing portal.…”

“…Although reverse shoulder arthroplasty is a valuable treatment option in the presence of combined irreparable rotator cuff (RC) tear and osteoarthritis, 1 it should be avoided in young patients with intact cartilage in the glenohumeral joint. Various reconstruction techniques for the treatment of irreparable SSC tears have been described, including transfer of the pectoralis minor tendon, 2 upper trapezius transfer, 3 and pectoralis major (PM) transfer, 4 of which the latter is the most frequently performed procedure. However, although some authors showed good long-term outcomes after transfer of the PM tendon, 4 others reported unsatisfactory clinical results with weakness returning to the preoperative level and diminishing range of motion during long-term follow-up, 5 as well as persistent pain and a high failure rate.…”

“…Various reconstruction techniques for the treatment of irreparable SSC tears have been described, including transfer of the pectoralis minor tendon, 2 upper trapezius transfer, 3 and pectoralis major (PM) transfer, 4 of which the latter is the most frequently performed procedure. However, although some authors showed good long-term outcomes after transfer of the PM tendon, 4 others reported unsatisfactory clinical results with weakness returning to the preoperative level and diminishing range of motion during long-term follow-up, 5 as well as persistent pain and a high failure rate. 6 Therefore, Elhassan et al 7 proposed the anterior latissimus dorsi transfer (ALDT) as an alternative treatment option for irreparable anterior RC tears.…”