Tendon transfers around the shoulder

1. Tendon Transfers around
the Shoulder
Mr Puneet Monga
Consultant Orthopaedic Shoulder Surgeon

2. Rules for tendon transfer
• Synergistic
• One motor = One function
• Straight line pull
• Mobile joint
• Donor function expendable
• Loss of one MRC power

3. Pre-requisite
• Intact Antagonist (Force couple)
• Working deltoid
• Mobile shoulder
• Patient compliance

4. Context
Brachial Plexus Injuries
Irreparable Rotator Cuff tears
Combined transfer with
Arthroplasty

5. Brachial Plexus Injury
• Key operations
• Nerve Repair
• Nerve Transfer
• Tendon Transfer
• Joint Fusion

6. Irreparable Cuff tears
• Postero-Superior- Supraspinatus, Infraspinatus
+/- Teres Minor
• Anterior - Subscapularis

7. TT in Irreparable Rotator
Cuff
History
• Lattisimus Dorsi Transfer for Irreparable
postero-superior Rotator cuff
• Earlier used for Brachial Plexus Injuries
• Gerber 1998
Lattisimus Dorsi transfer for treatment of Massive tears of the rotator cuff: Gerber et al. 1998

8. Options
• Tendon Transfer
• Partial repair
• Arthroscopic Debridement
• Superior Capsular reconstruction
• Interpositional Balloon
• Suprascapular Nerve Neurectomy
• Reverse geometry replacement

9. Treatment Author No Outcome Comments
Biceps
tenotomy/Tenodes
is
Boileau et al
2007
68 78%good Good for pain relief.
Contraindicated in Pseudoparalysis
Tendon Transfer Tauber et al,
2010
42 10-27% poor
results
Not applicable with subscap / teres minor tears
Dermal Subsitute Gupta et al, 2012 24 76% intact All reported pain relief.
Costly.
Role in psudopralysis ?
InSpace Balloon Savarese et al 20 ? Scores improved on average. Under trial.
Role in pseudoparalysis
Suprascapular
nerve ablation
Nizian et al 2009 20 75% good to
excellent
Indication intractable shoulder pain
No effect on pseudopralysis
Reverse geometry Ek et al, 2013 46 37.5% had
complications
Salvage option

10. Indication for Tendon
Transfer
• Young Active
• Large (irreparable) tear
• Weakness / Functional Loss

11. Role of Subscap
• Absent Subscap = poor results
• Biomechanically- improves joint stability
and balances the force couple

12. Technique
• Classic Gerber 2 incision
• First incision- Donor incision axillary-
Lattisimus Dorsi dissected from the
humerus
• Second incision - Deltoid split-
superior; for insertion

13. Single Incision
Habermeyer JBJS 2006

14. Arthroscopic
• Mini open Graft
harvest
• Arthroscopic fixation
• Suture anchors
• Interference screw
(tubularised tendon)

15. Outcomes
• LDT improves movements but not
strength
• LDT outcomes better with Subscap
intact
• LDT outcomes inferior with Teres Minor
Tears

16. Outcomes
• Continued Improved outcome scores
over time
• Good outcomes for failed RC repair
• Comparable outcomes with
arthroscopic technique

17. Anterior Cuff
Deficiency

18. Subscap deficiency
Indications
• Chronic FT subscap tears
• Retears
• Advanced Fatty degeneration

19. Combined deficiency
• Combined Posterosuperior and
Anterior deficiency
• 11 patients
• 5 good / 2 average / 4 no better
Aldridge, Atkinson, Mallon JSES. 2004 . 13(6): 621

20. Tendon Transfer in
Arthroplasty

21. Active ER is not restored in reverse
geometry arthroplasty

22. Tendon transfer in
arthroplasty
Modified L’Episcopo transfer
• Lattisimus Dorsi and Teres Major
released via the deltopectoral
approach
• Routed around and re-attached
• Restores Active ER

23. Outcomes
• LD transfer- 7 degree ER
gain.
• LD and Ter Maj combined
transfer - 34 degree ER gain

24. Serratus Palsy

25. LT Nerve Palsy
• Initial period of observation
• Neurolysis
• Tendon transfer
Split Pec Major to Medial border of scapula using allograft

26. Trapezius Palsy

27. Spinal Accessory N
• LN biopsy Post triangle of neck
• Penetrating trauma to Neck

28. Eden Lange
transfer
• Lev Scap to Lateral Spine
• Rh Minor to S Fossa
• Rh Major to I Fossa