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Teres major transfer for irreparable postero-superior RCT.

Authors: L Celli

References: SECEC 2005, Rome

 

The aims of the Teres Major transfer for postero-superior RCT are:

To improve

-        Active range of motion without pain

 

To recover

-        The antero-posterior balance with the Subscapularis muscle

 

To reduce

-        The risk of cuff tear arthropathy

 

Patient’s features

Disability

-        Loss of ROM in particular external rotation and abduction

-        Young patients with high expectations for work and sports requirements

-        High patient compliance

-        Bilateral or dominant side involvement

-        Absence of pre-existing medical conditions

 

Configuration of the rotator cuff tear

-        Irreparable lesions of the sovra and Infraspinatus muscles with or without the Teres minor lesion

-        Preserved Subscapularis and deltoid muscles

-        Absence of gleno-humeral osteoarthritis

 

Clinical features

The patient complaining about:

-        Reduction in daily activities

-        Pain

-        Loss of active external rotation

-        Sometimes weakness in external rotation and abduction

 

Physical exam

-          Loss of active external rotation and abduction

-        Good function of the Subscapularis and deltoid muscles

-        Preserved passive range of motion

 

Imaging assessments

X-Ray

-        Absence of gleno-humeral osteoarthritis

-        Acromion-humeral space >2-3 mm


 

RMN

-        Postero-superior irreparable rotator cuff tear

-        Fatty degeneration (stage III, IV) of the infra and sovraspinatus muscles

-        Subscapularis muscle is well preserved

-        Teres minor is conserved (better outcome)

 

Surgical technique

-          Patient in beach chair position

-        Paracromial skin incision

-        Exposure of the rotator cuff

-        Exam of the tear (tenodesis of the bicipites and retention of the superior part of the Subscapularis muscle)

-        Second skin incision runs to the posterior pillar of the armpit

-        The Teres major muscle is identified and separated from the latissimus dorsi

-        The axillary and radial nerve is identified below and above the tendon transfer

-        The Teres major tendon is detached from the humerus, leaving the latissimus dorsi tendon attached

-        The tendon is passed under the deltoid muscle

-        To the subacromion space

-        Inserted in the Infraspinatus area with the arm adducted and in neutral rotation

 

Our experience

We analyzed the results obtained in the first 20 patients at two different follow-ups at 35 months and 92 months.

Males: 11      Females: 9

Mean age: 61 years old

The Constant score was used to calculate the dates

Mean score:   Preoperative                               32 points

                   Postoperative (35 months)   66.5 points

                   Postoperative (92 months)   67.8 points

 

PAIN:

Stable during the two follow-ups, 14 points according to the Constant score

 

MOTION:

The active abduction improved with an average of 51° (from 89° in preop, to 140 in postop) stable during the two follow-ups

The active external rotation in adduction had a mean arch of 20° (preoperative 7° postoperative 27°) at the first follow-up and it improved to 26.4° in the second follow-up.

The active external rotation in abduction at 90° had a mean arch of 35° (preoperative 33° postoperative 68°) at the first preoperative evaluation and 30° in the second follow-up.


 

X-RAY:

Moderate osteoarthritis was found in two patients at the last follow-up and also one patient with severe osteoarthritis was observed, but with a good range of motion without pain.

 

MRI:

One patient had secondary rupture of the tendon transfer from its insertion on the great tuberosity.

 

Discussion

The Teres major transfer is able to restore a shoulder function without pain.

According to our experience, its advantages are:

-        It is a scapular thoracic muscle like the Infraspinatus

-        Its neuro-vascular pedicle is long enough to be transferred

-The muscle has sufficient strength to substitute the Infraspinatus muscle

-        Good pain relief

-        High satisfaction rate with a long follow-up

Its disadvantages are:

-        Its tendon is short and bulky

-        The tendon is very close to the axillary and radial nerves

-        It is difficult to obtain the correct tension on the tendon muscle

-        High patient compliance

-        Long postoperative rehabilitation program

 

Conclusion

Our experience reveals that using the Teres Major transfer in the irreparable postero-superior rotator cuff tear allows recovery, pain relief and a good active range of motion which permits the restoration of the functional shoulder according to the patient’s age.

This tendon transfer can be used as good alternative to other muscular transfers reporting good long term outcomes.

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