Advertisement

Pectoralis Major Tendon Transfer

  • Jeffrey D. Boatright
  • Austin J. Crow
  • Stephen F. BrockmeierEmail author
Chapter

Abstract

Rotator cuff disease is among the most prevalent musculoskeletal disorders treated by orthopedic surgeons. While supraspinatus tears are far more prevalent, subscapularis tears comprise between 3.5 and 8 % of all rotator cuff tears (Codman EA, Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: The shoulder. Thomas Todd Co, Boston, pp 65–67, 1934; Deutsch et al., Am J Sports Med 25:13–22, 1997; Frankle and Cofield, Rotator cuff tears involving the subscapularis tendon. Techniques and results of repair. In: Proceedings of the fifth international conference on Shoulder Surgery, International Shoulder and Elbow Society, Paris, p 52, 1992) and frequently go undiagnosed (Bennett, Arthroscopy 17:173–80, 2001; Gerber and Krushell, J Bone Joint Surg Br 73:389–394, 1991). Normal shoulder biomechanics depend heavily upon a functional subscapularis for dynamic stability of the glenohumeral joint. Patients with subscapularis insufficiency tend to present with anterior shoulder pain, weakness with internal rotation, increased passive external rotation, and sometimes with anterior glenohumeral instability. Physical examination tests designed to elucidate subscapularis pathology include the lift-off test, internal rotation lag sign, the belly-press test, the belly-off sign, and the bear-hug test. MRI remains the most useful and widely utilized imaging modality to confirm and characterize subscapularis disease. The majority of subscapularis tears can be treated with either arthroscopic or open primary repair. Significant muscle atrophy, fatty infiltration, tendon retraction, and large tear size reduce the chance of successful primary repair, and in extreme cases make such tears irreparable. Management of these tears remains a challenge, with musculotendinous transfer of the pectoralis major being the most commonly employed treatment option. General indications are pain, anterior instability, and/or significant functional limitations after failure of nonoperative management in the setting of an irreparable subscapularis tear. Contraindications include concomitant irreparable supraspinatus tear, advanced patient age, severe glenohumeral joint arthrosis, fixed anterior joint subluxation, an inability to comply with postoperative measures and rehabilitation, and pectoralis major dysfunction/insufficiency. Several techniques have been described and vary primarily upon the amount of tendon transferred as well as the location of tendon passage as it relates to the coracoid process and conjoined tendon. Postoperative rehabilitation protocols generally call for 6 weeks of immobilization with early pendulum exercises and gentle passive external rotation, progressing to active range of motion at 6 weeks, and strengthening beginning at 12 weeks. Robust outcomes data for this procedure is largely lacking in the current orthopedic literature, but many smaller clinical series suggest improvement in pain and incremental functional gains. As such, pectoralis major tendon transfer remains the workhorse salvage procedure for the management of the irreparable subscapularis tear.

Keywords

Rotator Cuff Rotator Cuff Tear Rotator Cuff Repair Coracoid Process Musculocutaneous Nerve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Codman EA. Lesions of the supraspinatus tendon and other lesions in or about the subacromial bursa. In: The shoulder. Boston: Thomas Todd Co; 1934. p. 65–7.Google Scholar
  2. 2.
    Deutsch A, Altchek DW, Veltri DM, Potter HG, Warren RF. Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med. 1997;25:13–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Frankle MA, Cofield RH. Rotator cuff tears involving the subscapularis tendon. Techniques and results of repair. In: Proceedings of the fifth international conference on Shoulder Surgery; 12–15 Jul 1992; Paris. International Shoulder and Elbow Society; 1992. p. 52.Google Scholar
  4. 4.
    Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy: arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001;17:173–80.PubMedCrossRefGoogle Scholar
  5. 5.
    Ticker JB, Burkhart SS. Why repair the subscapularis? A logical rationale. Arthroscopy. 2011;27:1123–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73:389–94.PubMedGoogle Scholar
  7. 7.
    Warner JJ, Higgins L, Parsons 4th IM, Dowdy P. Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2001;10:37–46.PubMedCrossRefGoogle Scholar
  8. 8.
    Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and post-operative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.PubMedGoogle Scholar
  9. 9.
    Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S. Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg. 2003;12:550–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Mellado JM, Calmet J, Olona M, Esteve C, Camins A, Perez Del Palomar L, et al. Surgically repaired massive rotator cuff tears: MRI of tendon integrity, muscle fatty degeneration, and muscle atrophy correlated with intraoperative and clinical findings. Am J Roentgenol. 2005;184:1456–63.CrossRefGoogle Scholar
  11. 11.
    Thomazeau H, Boukobza E, Morcet N, Chaperon J, Langlais F. Prediction of rotator cuff repair results by magnetic resonance imaging. Clin Orthop Relat Res. 1997;344:275–83.PubMedCrossRefGoogle Scholar
  12. 12.
    Elhassan B, Ozbaydar M, Massimini D, Diller D, Higgins L, Warner JJ. Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: does it work? J Bone Joint Surg Br. 2008;90:1059–65.PubMedCrossRefGoogle Scholar
  13. 13.
    Galatz LM, Connor PM, Calfee RP, Hsu JC, Yamaguchi K. Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency. J Shoulder Elbow Surg. 2003;12:1–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Gavriilidis I, Kircher J, Magosch P, Licthenberg S, Habermeyer P. Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. Int Orthop. 2010;34:689–94.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Jost B, Puskas GJ, Lustenberger A, Gerber C. Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears. J Bone Joint Surg Am. 2003;85-A:1944–51.PubMedGoogle Scholar
  16. 16.
    Lederer S, Auffarth A, Bogner R, Tauber M, Mayer M, Karpik S, Matis N, Resch H. Magnetic resonance imaging-controlled results of the pectoralis major tendon transfer for irreparable anterosuperior rotator cuff tears performed with standard and modified fixation techniques. J Shoulder Elbow Surg. 2011;20:1155–62.PubMedCrossRefGoogle Scholar
  17. 17.
    Resch H, Povacz P, Ritter E, Matschi W. Transfer of the pectoralis major muscle for the treatment of irreparable rupture of the subscapularis tendon. J Bone Joint Surg Am. 2000;82:372–82.PubMedGoogle Scholar
  18. 18.
    Wirth MA, Rockwood Jr CA. Operative treatment of irreparable rupture of the subscapularis. J Bone Joint Surg Am. 1997;79:722–73.PubMedGoogle Scholar
  19. 19.
    DePalma AF. Surgery of the shoulder. Philadelphia: Lippincott; 1950. p. 209–20.Google Scholar
  20. 20.
    Li XX, Schweitzer ME, Bifano JA, Lerman J, Manton GL, El-Noueam KI. MR evaluation of subscapularis tears. J Comput Assist Tomogr. 1999;23:713–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Arai R, Sugaya H, Mochizuki T, Nimura A, Moriishi J, Akita K. Subscapularis tendon tear: an anatomic and clinical investigation. Arthroscopy. 2008;24:997–1004.PubMedCrossRefGoogle Scholar
  22. 22.
    Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy. 2006;22:1076–84.PubMedCrossRefGoogle Scholar
  23. 23.
    Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am. 2007;89:1184–93.PubMedGoogle Scholar
  24. 24.
    Neviaser RJ, Neviaser TJ, Neviaser JS. Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J Bone Joint Surg Am. 1988;70:1308–11.PubMedGoogle Scholar
  25. 25.
    Nove-Josserand L, Levigne C, Noel E, Walch G. Isolated lesions of the subscapularis muscle. Apropos of 21 cases. Rev Chir Orthop Reparatrice Appar Mot. 1994;80:595–601. French.PubMedGoogle Scholar
  26. 26.
    Walch G, Boileau P. Rotator cuff tears associated with anterior instability. In: Warner JPJ, Iannotti JP, Gerber C, editors. Complex and revision problems in shoulder surgery. Philadelphia: Lippincott-Raven; 1997. p. 65–70.Google Scholar
  27. 27.
    Garavaglia G, Ufenast H, Taverna E. The frequency of subscapularis tear in arthroscopic rotator cuff repair: a retrospective study comparing magnetic resonance imaging and arthroscopic findings. Int J Should Surg. 2001;5:91–4.Google Scholar
  28. 28.
    Ulrich L, Fullick R, Bongiorno V, Saintmard B, Campens C, Lafosse L. Arthroscopic repair of large subscapularis tendon tears: 2- to 4-year clinical and radiographic outcomes. Arthroscopy. 2013;29:1471–8.CrossRefGoogle Scholar
  29. 29.
    Bennett WF. Arthroscopic repair of isolated subscapularis tears: a prospective cohort with 2- to 4-year follow-up. Arthroscopy. 2003;19:131–43.PubMedCrossRefGoogle Scholar
  30. 30.
    Toussaint B, Audebert S, Barth J, Charousset C, Godeneche A, Joudet T, Lefebvre Y, Nove-Josserand L, Petroff E, Solignac N, Hardy P, Scymanski C, Maynou C, Thelu C-E, Boileau P, Pitermann M, Graveleau N, French Arthroscopy Society (SFA). Arthroscopic repair of subscapularis tears: preliminary data from a prospective multicentre study. Orthop Traumatol Surg Res. 2012;98(8 Suppl):S193–200.PubMedCrossRefGoogle Scholar
  31. 31.
    Gray H. The muscles and fasciae of the shoulder. In: Goss CM, editor. Gray’s anatomy of the human body. 28th ed. Philadelphia: Lea and Febiger; 1968. p. 458–9.Google Scholar
  32. 32.
    Keating JF, Waterworth P, Shaw-Dunn J, Crossan J. The relative strengths of the rotator cuff muscles. A cadaver study. J Bone Joint Surg Br. 1993;75:137–40.PubMedGoogle Scholar
  33. 33.
    Richards DP, Burkhart SS, Tehrany AM, Wirth MA. The subscapularis footprint: an anatomic description of its insertion site. Arthroscopy. 2007;23:251–4.PubMedCrossRefGoogle Scholar
  34. 34.
    Kato K. Innervation of the scapular muscles and its morphological significance in man. Anat Anz. 1989;168:155–68.PubMedGoogle Scholar
  35. 35.
    Iannotti JP, Gabriel JP, Schneck SL, Evans BG, Misra S. The normal glenohumeral relationships. An anatomical study of one hundred and forty shoulders. J Bone Joint Surg Am. 1992;74:491–500.PubMedGoogle Scholar
  36. 36.
    Burkhart SS. Arthroscopic treatment of massive rotator cuff tears: clinical results and biomechanical rationale. Clin Orthop Relat Res. 1991;267:45–56.PubMedGoogle Scholar
  37. 37.
    Burkhart SS. Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model. Clin Orthop Relat Res. 1992;(284):144–52.Google Scholar
  38. 38.
    David G, Magarey ME, Jones MA, Dvir Z, Türker KS, Sharpe M. EMG and strength correlates of selected shoulder muscles during rotations of the glenohumeral joint. Clin Biomech (Bristol, Avon). 2000;15:95–102.CrossRefGoogle Scholar
  39. 39.
    Denard PJ, Lädermann A, Burkhart SS. Arthroscopic management of subscapularis tears. Sports Med Arthrosc. 2011;19:333–41.PubMedCrossRefGoogle Scholar
  40. 40.
    Inman VT, Saunders JB, Abbott LC. Observations on the function of the shoulder joint. J Bone Joint Surg. 1944;26:1–30.Google Scholar
  41. 41.
    Thompson WO, Debski RE, Boardman 3rd ND, Taskiran E, Warner JJ, Fu FH, et al. A biomechanical analysis of rotator cuff deficiency in a cadaveric model. Am J Sports Med. 1996;24:286–92.PubMedCrossRefGoogle Scholar
  42. 42.
    Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. Results of operative repair. J Bone Joint Surg Am. 1996;78:1015–23.PubMedGoogle Scholar
  43. 43.
    Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta‐analysis of individual tests. Br J Sports Med. 2012;46:964–78.PubMedCrossRefGoogle Scholar
  44. 44.
    Hertel R, Ballmer FT, Lambert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307–13.PubMedCrossRefGoogle Scholar
  45. 45.
    Pennock AT, Pennington WW, Torry MR, Decker MJ, Vaishnav SB, Provencher MT, Millett PJ, Hackett TR. The influence of arm and shoulder position on the bear‐hug, belly‐press, and lift‐off tests: an electromyographic study. Am J Sports Med. 2011;39:2338–46.PubMedCrossRefGoogle Scholar
  46. 46.
    Scheibel M, Magosch P, Pritsch M, Lichtenberg S, Habermeyer P. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy. 2005;21:1229–35.PubMedCrossRefGoogle Scholar
  47. 47.
    Ballmer FT, Lambert SM, Hertel R. Napoleon’s sign: a test to assess subscapularis function. J Shoulder Elbow Surg. 1997;6:193.Google Scholar
  48. 48.
    Scheibel M, Tsynman A, Magosch P, Schroeder RJ, Habermeyer P. Postoperative subscapularis muscle insufficiency after primary and revision open shoulder stabilization. Am J Sports Med. 2006;34:1586–93.PubMedCrossRefGoogle Scholar
  49. 49.
    Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: technique and preliminary results. Arthroscopy. 2002;18:454–63.PubMedCrossRefGoogle Scholar
  50. 50.
    Schwamborn T, Imhoff AB. Diagnosis and classification of rotator cuff lesions. In: Imhoff AB, Konig U, editors. Schulterinstabilitat-Rotatorenmanschette. Darmstadt: Steinkopff Verlag; 1999. p. 193–5. German.Google Scholar
  51. 51.
    Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical tests for subscapularis lesions. Knee Surg Sports Traumatol Arthrosc. 2010;18:1712–7.PubMedCrossRefGoogle Scholar
  52. 52.
    Rigsby R, Sitler M, Kelly JD. Subscapularis tendon integrity: an examination of shoulder index tests. J Athl Train. 2010;45:404–6.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff: a comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am. 2000;82A:498–504.Google Scholar
  54. 54.
    Hodler J, Kursunoglu-Brahme S, Snyder SJ, Cervilla V, Karzel RP, Schweitzer ME, et al. Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthroscopic confirmation. Radiology. 1992;182:431–6.PubMedCrossRefGoogle Scholar
  55. 55.
    Palmer EW, Brown JH, Rosenthal DI. Rotator cuff: evaluation with fat-suppressed MR arthrography. Radiology. 1993;188:683–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Jung JY, Yoon YC, Cha DI, Yoo JC, Jung JY. The “bridging sign”: a MR finding for combined full-thickness tears of the subscapularis tendon and the supraspinatus tendon. Acta Radiol. 2013;54:83–8.PubMedGoogle Scholar
  57. 57.
    Fuchs B, Weishaupt D, Zanetti M, Hodler J, Gerber C. Fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. J Shoulder Elbow Surg. 1999;8:599–605.PubMedCrossRefGoogle Scholar
  58. 58.
    Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21:492–501.PubMedCrossRefGoogle Scholar
  59. 59.
    Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect. 2001;50:63–71.PubMedGoogle Scholar
  60. 60.
    Levy O, Mullett H, Roberts S, Copeland S. The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears. J Shoulder Elbow Surg. 2008;17:863–70.PubMedCrossRefGoogle Scholar
  61. 61.
    Cofield R, Parvizi J, Hoffmeyer P, Lanzer W, Ilstrup D, Rowland C. Surgical repair of chronic rotator cuff tears: a prospective long-term study. J Bone Joint Surg Am. 2001;83:71–7.PubMedGoogle Scholar
  62. 62.
    Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505–15.PubMedGoogle Scholar
  63. 63.
    Keener J, Wei A, Kim H, Steger-May K, Yamaguchi K. Proximal humeral migration in shoulders with symptomatic and asymptomatic rotator cuff tears. J Bone Joint Surg Am. 2009;91:1405–13.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Melillo AS, Savoie 3rd FH, Field LD. Massive rotator cuff tears: debridement versus repair. Orthop Clin North Am. 1997;28:117–24.PubMedCrossRefGoogle Scholar
  65. 65.
    Burkart S, Nottage W, Ogilvie-Harris D, Kohn H, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy. 1994;10:363–70.CrossRefGoogle Scholar
  66. 66.
    Flatow E, Connor P, Levine W. Coracoacromial arch reconstruction for anterosuperior subluxation after failed rotator cuff surgery. J Shoulder Elbow Surg. 1997;6:228.Google Scholar
  67. 67.
    Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92:2544–56.PubMedCrossRefGoogle Scholar
  68. 68.
    Flatow E, Bigliani LU, April EW. An anatomic study of the musculocutaneous nerve and its relationship to the coracoid. Clin Orthop Relat Res. 1989;244:166–71.PubMedGoogle Scholar
  69. 69.
    Klepps SJ, Goldfarb C, Flatow E, Galatz L, Yamaguchi K. Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers. J Shoulder Elbow Surg. 2001;10:453–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Jeffrey D. Boatright
    • 1
  • Austin J. Crow
    • 2
  • Stephen F. Brockmeier
    • 3
    Email author
  1. 1.Department of Orthopaedic SurgeryUniversity of Virginia Medical Center, University of VirginiaCharlottesvilleUSA
  2. 2.Department of Orthopedic SurgeryUniversity of VirginiaCharlottesvilleUSA
  3. 3.Department of Orthopedic SurgeryUniversity of VirginiaCharlottesvilleUSA

Personalised recommendations