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Tendon transfers around the shoulder
This document discusses tendon transfers around the shoulder for conditions such as brachial plexus injuries and irreparable rotator cuff tears. It provides guidelines for tendon transfers, including using synergistic muscles with a straight line of pull. It describes procedures like the latissimus dorsi transfer to restore shoulder function for massive rotator cuff tears. The document also discusses tendon transfers combined with shoulder arthroplasty to restore shoulder rotation.
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Tendon transfers around the shoulder
- 1. Tendon Transfers around theShoulder Mr Puneet Monga Consultant Orthopaedic Shoulder Surgeon
- 2. Rules for tendontransfer • 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 IrreparableRotator 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 IrreparableRotator 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 NoOutcome 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 Gerber2 incision • First incision- Donor incision axillary- Lattisimus Dorsi dissected from the humerus • Second incision - Deltoid split- superior; for insertion
- 13.
- 14. Arthroscopic • Mini openGraft harvest • Arthroscopic fixation • Suture anchors • Interference screw (tubularised tendon)
- 15. Outcomes • LDT improvesmovements but not strength • LDT outcomes better with Subscap intact • LDT outcomes inferior with Teres Minor Tears
- 16. Outcomes • Continued Improvedoutcome scores over time • Good outcomes for failed RC repair • Comparable outcomes with arthroscopic technique
- 17.
- 18. Subscap deficiency Indications • ChronicFT subscap tears • Retears • Advanced Fatty degeneration
- 19. Combined deficiency • CombinedPosterosuperior and Anterior deficiency • 11 patients • 5 good / 2 average / 4 no better Aldridge, Atkinson, Mallon JSES. 2004 . 13(6): 621
- 20.
- 21. Active ER isnot restored in reverse geometry arthroplasty
- 22. Tendon transfer in arthroplasty ModifiedL’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.
- 25. LT Nerve Palsy •Initial period of observation • Neurolysis • Tendon transfer Split Pec Major to Medial border of scapula using allograft
- 26.
- 27. Spinal Accessory N •LN biopsy Post triangle of neck • Penetrating trauma to Neck
- 28. Eden Lange transfer • LevScap to Lateral Spine • Rh Minor to S Fossa • Rh Major to I Fossa