Tendon transfers poor for restoring rotator cuff function

Orthopedist combined Latissimus transfer and reverse arthoplasty to improve external rotation and elevation.

Tendon transfers for massive rotator cuff tears generally produce “disappointing” results despite surgeons’ expectations of improved function, according to an orthopedist who discussed shoulder operations at a recent meeting on joint replacement techniques.

Weakness, poor tissue and muscle atrophy are major challenges in using tendon transfers to deal with severe cuff tears, said New York surgeon Evan L. Flatow, MD. “The real problem you’re dealing with is muscle atrophy,” he said. “And so the time that transfers come into play is when you’re trying to figure out what to do when you have nothing left of a muscle. The hope of tendon transfers ... was the idea of trying to bring a healthy muscle-tendon unit into the shoulder to improve function.”

Transfer techniques for subscapularis deficiency include moving the Latissimus superiorally, moving the teres major superiorally and transferring the sternal head of the pectoralis major under the clavicular head, Flatow said. Surgeons consider the pectoral transfer generally difficult, knowing they must protect the musculocutaneous nerve, the most common complication source for that method.

Unfortunately, there are no good transfer techniques for supraspinatus loss, Flatow added. Subscapularis transfer often is not used because it damages the muscle and does not reproduce the supraspinatus. The Deltoid Flap has inconsistent results and also can damage the muscle. The flap often is not used, even in France where it was developed, he said during his presentation at the Current Concepts in Joint Replacement meeting.

Flatow also advised limited use of tendon grafting. “I think that grafting has been used for many years and is OK to reinforce a repair but not to replace a tendon,” he said.

Combined Latissumus-reverse

One orthopedist is awaiting the results on a hybrid technique designed to improve external rotation and elevation, Flatow said. Swiss orthopedist Christian Gerber, MD, combined Latissimus dorsi transfer and reverse arthroplasty in some older patients. Gerber pioneered the Latissimus transfer, which is considered more effective in improving external rotation than elevation. Reverse arthroplasty improves elevation, not external rotation, according to the consensus.

“There’s a reduced role, if any, for the Latissumus in elderly patients, except perhaps we’ll have to see whether it has value with the reverse [arthroplasty],” Flatow said. “Let’s also remember that the reverse arthroplasty has diminished the use of transfers in most tertiary practices because it has given us another technology, especially in the elderly patient, to deal with cuff deficiency.”

Flatow said the Latissimus transfer is the best way to handle cuff tears with loss of external rotation strength if the subscapularis is intact. Surgeons can also combine the Latissimus transfer with a teres major transfer, though the teres major is a bulky muscle, Flatow said.

Flatow, who has done numerous Latissumus transfers, described the ideal transfer recipient as an active 45-year-old who is otherwise a “terrible” candidate for reverse arthroplasty. Other indications for transfer include weak external rotation, an irreparable infraspinatus and a good scapularis, he said.

For more information:
Flatow W. Tendon transfers for cuff deficiency: Is there a role? #9. Presented at the Current Concepts in Joint Replacement Spring 2005 meeting. May 22-25, 2005. Las Vegas.