Long-term outcomes of teres major transfer for irreparable posterosuperior rotator cuff tears in patients aged <65 years

Abstract

Background: Massive rotator cuff tears are defined as irreparable when tendon-to-bone or tendon-to-tendon continuity with the adducted arm cannot be restored and severe muscle fatty infiltration is present. Tendon transfer is a palliative procedure that improves shoulder function and relieves pain.

Methods: We reviewed the records of patients aged <65 years, whose irreparable posterosuperior rotator cuff tears had been managed with teres major tendon transfer at our institution. Their 5- and 10-year clinical and radiographic follow-up records were examined to assess long-term outcomes. Patients' Constant Score, Disabilities of the Arm, Shoulder, and Hand score, and the visual analog scale for pain were calculated before the procedure and at 5 and 10 years.

Results: There were 24 consecutive patients aged <65 years (mean, 59; 12 men and 12 women) who had received no prior treatment except rehabilitation. All patients underwent teres major tendon transfer due to the failure of conservative treatment. The mean Constant Score was 26 preoperatively and 68 and 66 at 5 and 10 years, respectively (P = .0001 and P = .25). The mean Disabilities of the Arm, Shoulder, and Hand scores were 62.2 preoperatively and 7.8 and 9.3 at 5 and 10 years, respectively (P = .0009 and P = .1). The mean visual analog scale scores at rest were 6.1 preoperatively, and 0.3 and 0.5 at 5 and 10 years, respectively (P = .0003 and P = .1). Based on Hamada's classification, at 5 years, 3 patients showed grade 2 changes, and another had grade 3 changes; at 10 years, 7 patients showed grade 2 changes, and one showed grade 3 changes. Complications (8%) developed after the 10-year evaluation and included pain in 1 patient and secondary rupture of the transfer in another.

Discussion: Improving shoulder function and reducing pain in relatively young patients with irreparable posterosuperior cuff tears involves replacing the lost muscle with a muscle-tendon transfer. The chief aims of the procedure are to restore the balance with the subscapularis muscle, achieve joint stability, keep the humeral head in the glenoid cavity, and improve shoulder abduction and external rotation. Teres major tendon transfer can achieve these goals. Altogether, 22 of our 24 patients experienced improved daily activity function and pain relief that became stable after 5 years. Teres major transfers are useful surgical procedures, particularly in younger patients and in those with high functional demands, providing good and stable long-term results.

Keywords: Glenohumeral joint degenerative change; Irreparable rotator cuff tears; Local tendon transfer; Long-term follow-up; Muscle-tendon transfer; Regional tendon transfer; Rotator cuff tears; Teres major muscle transfer.

Figure 1

The patient, under general anesthesia, is placed in beach chair position with the trunk angled 60°-70° from the horizontal position.

Figure 2

In patients with irreparable posterosuperior lesion with tendon retraction and muscle atrophy but without joint degenerative changes, a posterior skin incision running above the posterior pillar of the armpit is added to the acromion incision.

Figure 3

The posterior skin incision is curved and runs above the posterior pillar of the armpit, from the external margin of the scapula to the upper third of the humerus; the posterior border of the deltoid, the long head of the triceps, and the teres major are identified. The teres major is isolated from its scapular origin to the humeral insertion and its tendon is divided from the latissimus dorsi tendon.

Figure 4

The axillary nerve in the quadrilateral space and the radial nerve under the teres major tendon are identified and protected.

Figure 5

The neurovascular pedicle has been isolated at the level of the medial third of the muscle.

Figure 6

Tetanization of the neurovascular pedicle allowed evaluating maximum muscle contraction.

Figure 7

The tendon transfer is brought to the subacromial space by passing it under the deltoid muscle using a long curved clamp and anchored to bone in the infraspinatus area with 2 nonabsorbable sutures.

Figure 8

Posterior view of the teres major transferred into the subacromial space.

Figure 9

MRI scan of the teres major transfer. MRI, magnetic resonance imaging.