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Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use., Competing Interests: J. L. Ávila Lafuente reports consulting fees, support for attending meetings and/or travel, and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Smith & Nephew, unrelated to this article. B. Elhassan reports royalties or licenses, consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, and support for attending meetings and/or travel from DJO Global, unrelated to this article. A. Hachem reports consulting fees, and support for attending meetings and/or travel from Arthrex and Stryker, unrelated to this article. M. A. Ruiz Ibán reports institutional research grants, and individual speaker payments, from Smith & Nephew and Link, unrelated to this article., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

There is a paucity of information on latissimus dorsi transfer (LDT) for subscapularis insufficiency. The purpose of this study is to report the outcome of LDT to reconstruct an irreparable subscapularis tear., Methods: Excluding patients with prior failed Latarjet procedures, we examined 56 consecutive patients who underwent open (n = 14) or arthroscopic (n = 42) LDT. The average age was 53 years (range, 23-79), and 46 patients had a prior surgery. Outcome measures included visual analog scale score for pain, range of motion (ROM), subjective shoulder value (SSV), and Constant shoulder score (CSS)., Results: At a mean 13-month follow-up (7-51 months), patients had significant improvements in their pain, ROM, SSV, and CSS when compared to preoperatively. At final follow-up, 26% of patients continued to have proximal migration, and 11% of patients had anterior subluxation. The patients with frank anterior escape had a higher likelihood of having proximal migration and anterior subluxation, but this was not statistically significant. Stages of arthritis did not progress. Revision surgeries included 2 patients who revised to a reverse shoulder arthroplasty for rupture of the tendon transfer. Furthermore, 3 patients had LDT ruptures but did not elect to undergo further surgery., Conclusions: LDT for irreparable subscapularis tears has the potential to lead to significant clinical improvements. Most patients improve in many of the signs of subscapularis insufficiency, including anterior and/or proximal subluxation, clinical examination maneuvers, and shoulder function. Overall, this transfer represents a reasonable option for this difficult pathology., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Indications and techniques for tendon transfer in irreparable rotator-cuff tear have greatly progressed and are no longer restricted to external rotation deficit. The present article first reviews the various types of tear and corresponding tendon transfers and the biomechanics of the pseudoparalytic shoulder. The indication of choice for tendon transfer is iterative tear following failure of isolated long biceps tenotomy or partial repair. Latissimus dorsi, inferior trapezius and pectoralis major transfer are the 3 types to be used after failure of primary surgery. Latissimus dorsi transfer is indicated for partial loss of active limb elevation or isolated loss of internal rotation. Inferior trapezius transfer is best indicated for isolated active external rotation deficit. In pseudoparalytic shoulder with total loss of active elevation or combined loss of elevation and active external rotation, isolated transfer is insufficiently powerful to restore active range of motion and should be associated to reverse arthroplasty. We describe the various transfer techniques and report their results., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: To compare latissimus dorsi tendon rupture rates after arthroscopic transfer for posterior superior rotator cuff tear using 3 different humeral head fixation techniques., Methods: One-hundred fifty consecutive latissimus dorsi transfers were included. Inclusion criteria were massive irreparable posterosuperior rotator cuff tear with advanced fatty infiltration associated with persistent pain and limited range of motion after failed conservative treatments or surgery. All transfers were arthroscopically assisted and fixed in a transosseous tunnel with a cortical button (group 1, n = 59), "over the top" onto the footprint of the supraspinatus (group 2, n = 47), or posteriorly onto the footprint of the infraspinatus (group 3, n = 44) with 2 suture anchors. The tendons were marked with 3 metallic clips placed intraoperatively at a fixed distance of 2, 4, and 6 cm from the tip. Immediate postoperative standard anteroposterior radiographs were performed to confirm the position of the clips and to determine whether the clips displaced on subsequent radiographs during follow-up, indicating tendon rupture., Results: Repeat radiographs at 3-month follow-up showed higher risk of latissimus dorsi transfer rupture rate in 27/59 patients in group 1 (46%), 11/47 in group 2 (24%), and 7/44 in group 3 (15%)., Conclusion: Posterior anchor fixation of the latissimus dorsi tendon onto the infraspinatus footprint had the lowest rupture rate., (Copyright © 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: The main objective of this retrospective study was to analyze the rate and modes of failure of latissimus dorsi transfer (LDT). The secondary objective was to evaluate whether a rupture of the transfer was associated with a worse outcome., Methods: During a 2-year period, we performed consecutive LDTs either for irreparable posterior-superior rotator cuff tears (RCTs) or for failed prior repair. All the LDTs were performed by a single surgeon. All transfers were arthroscopically assisted and fixed as a tubularized LD tendon in a bone tunnel inside the humeral head. Three metal clips were placed systematically intraoperatively in the tubularized tendon at a fixed distance of 2, 4, and 6 cm from the tip of the tendon. Immediate postoperative standard anteroposterior radiographs were performed and the position of the metal clips was compared with their position on radiographs performed at 6 weeks and 3 and 24 months postoperatively. Constant, Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), Activities of daily living requiring active external rotation (ADLER), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) scores and patient's subjective satisfaction (assessed by self-questionnaire) at last follow-up were compared between patients who had a rupture of the transfer and those who did not., Results: Sixty-six patients were included. Six of 66 patients (9%) were lost to follow-up. There were 11 complications (18.3%) in the global series (10 hematoma and 1 subscapularis retear). At a mean 35.2 months (range 24-50 months), there were 23/60 cases of rupture (38%). The 7 scores and the satisfaction reported were significantly lower for patients who had a rupture of the transfer versus those who had an intact transfer: Constant score, 42.8 versus 68.7 (P = .001); SSV, 48.9 versus 71.6 (P = .001); SST, 4.8 versus 8.4 (P = .012); ADLER, 19.7 versus 26.7 (P = .005); VAS, 3.7 versus 2.3 (P = .082); ASES, 55.4 versus 74.8 (P = .056); and 13% of either satisfied or very satisfied patients versus 78% (P < .001)., Conclusions: The rate of rupture of LDT is high (38%). With complete healing of LDT, the outcome is significantly lower in those with rupture compared with those without rupture, showing that LDT can efficiently treat massive and irreparable RCT., Level of Evidence: Level IV, case series treatment study., (Copyright © 2017 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Latissimus dorsi tendon transfer is a surgical option for treating irreparable posterosuperior rotator cuff tears, notably when attempting to reconstruct active external rotation. We hypothesized that the positioning of the transfer's point of fixation would differ depending on the desired elbow-to-body external rotation or external rotation with the elbow abducted., Material and Methods: Seven shoulders from four whole frozen cadavers were used. We created two systems to install the subject in a semi-seated position to allow external rotation elbow to body and the arm abducted 90°. Traction sutures were positioned on the latissimus dorsi muscle and a massive tear of the rotator cuff was created. We tested six different transfer positions. Muscle contraction of the latissimus dorsi was stimulated using 10-N and 20-N suspended weights., Results: The point of fixation of the latissimus dorsi on the humeral head had an influence on the elbow-to-body external rotation and with 90° abduction (P<0.001). The fixation point for a maximum external rotation with the elbow to the body was the anterolateral position (P<0.016). The fixation point for a maximum external rotation at 90° abduction was the position centered on the infraspinatus footprint (P<0.078)., Conclusion: The optimal point of fixation differs depending on whether external rotation is restored at 0° or 90° abduction., Level of Evidence: Fundamental study, anatomic study., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Unlabelled: Few salvage procedures have been described after a failed Weaver-Dunn procedure. We hypothesized that it was possible to perform an all-arthroscopic revision with a reflected vascularized conjoint tendon into the distal resected clavicle (Vargas procedure) augmented by an artificial coraco-clavicular ligament. Two patients were enrolled. A minimum of 3-cm proximal conjoint tendon was dissected under arthroscopic control. The half-longitudinal conjoint tendon split, leaving its proximal end attached to the coracoid process, was made and incised transversely near the muscles fibers. While being still vascularized with the tip of the coracoid process, the tendon was tubularized, reflected proximally and transferred into the distal part of the clavicle. An artificial coraco-clavicular ligament augmented the transfer. No complication was described. After a minimum of two-year follow-up, there was no recurrence of AC instability and there was normal ROM; two patients returned to sport., Level of Evidence: Level IV-a, case series., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Purpose: To evaluate, in a multicenter, prospective study, the clinical, magnetic resonance imaging (MRI), and radiologic results of arthroscopic-assisted latissimus dorsi (LD) tendon transfer for irreparable posterosuperior rotator cuff tears; and to assess the influence of perioperative data on clinical results., Methods: Fifty-five patients with irreparable tears of at least the supraspinatus and infraspinatus tendons were managed with arthroscopic-assisted LD tendon transfer and reviewed clinically, with standardized radiographs and MRI, after a mean of 29 months. Outcome measures included the Constant score and the Subjective Shoulder Value. The osteoarthritic stage and acromiohumeral distance were measured on standardized radiographs, and the transferred tendon aspect was evaluated on MRI., Results: Thirty patients had already undergone 1 or more previous surgical procedures. The mean Subjective Shoulder Value increased from 26% preoperatively to 71% postoperatively. The Constant score improved from 37 preoperatively to 65.4 postoperatively. The pain score increased from 1.7 preoperatively to 12.6 postoperatively; the activity score, from 6.4 to 13.8; active forward flexion, from 134° to 157°; active abduction, from 67° to 92.5°; active external rotation, from 29° to 41.5°; and abduction strength, from 1.4 kg to 4.8 kg. The only statistically significant factor negatively influencing the Constant score was previous surgery. Four patients had a ruptured LD tendon on MRI follow-up at 1 year. There was no statistical difference between preoperative and final follow-up acromiohumeral distance. There was no increase in osteoarthritic stage., Conclusions: Arthroscopic-assisted LD tendon transfer improves shoulder pain and function in patients with irreparable posterosuperior cuff tears, with similar clinical and radiologic results compared with results of published series using open techniques. Patients with a history of surgery had lower Constant scores compared with non-previously operated patients., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2015 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The transfer of the pectoralis major in cases of irreparable rupture of the subscapularis has been described through different techniques. The aim of this prospective study was to compare the clinical results of transferring the clavicular or the sternal head of the pectoralis major tendon underneath the conjoint tendon., Methods: Fifteen patients underwent the procedure, including eight clavicular head of the pectoralis major tendon transfers and seven sternal head transfers. The mean age at the time of surgery was 57 years (range, 37-66). Each patient had pre-operative MRI and CT scan. The criteria for an irreparable subscapularis tear were retraction at the level of the glenoid and fatty infiltration of the muscle graded III or IV. Pre-operative and postoperative functions were assessed by the Constant score. Patients were finally asked if they were very satisfied, satisfied or unhappy with the functional outcome., Results: The average follow-up was 24 months (range, 12-50). The mean absolute Constant score of the entire series increased significantly from 36 preoperatively to 69 at the latest follow up (p < 0.01); it improved significantly and similarly in both types of tendon harvested. Nine patients were very satisfied, three were satisfied and three were dissatisfied with the clinical outcome., Conclusion: A clavicular or a sternocostal head transfer of the pectoralis major under the coracoid process reduced pain, and improved the strength and function of the shoulder.