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Pectoralis major and pectoralis minor transfer for irreparable subscapularis tendon tears

Transfer von Pectoralis major und Pectoralis minor bei irreparabler Subscapularissehnenruptur

  • Surgical Techniques
  • Published:
Operative Orthopädie und Traumatologie Aims and scope Submit manuscript

Abstract

Objective

Irreparable rotator cuff injuries in young patients with moderate to high levels of physical activity remain a challenging pathology for shoulder surgeons. Irreparable anterior rotator cuff injuries require treatment that seeks to restore the dynamic anterior forces of the glenohumeral joint. Among surgical treatment options, transfer of the pectoralis major and minor muscle, have shown good functional outcomes. This technique attempts to reproduce the vector of the subscapular muscle in cases with irreparable tear. Restoration of the dynamic external and internal couple forces to maintain the humeral head in the center of rotation.

Indications

Pectoralis major transfer (PMa): Irreparable subscapularis tendon (SSC) tear in active patients without osteoarthritis. Pectoralis minor transfer (PMi): Irreparable superior SSC tear with concomitant irreparable supraspinatus tendon (SSP) tear in active patients with no osteoarthritis.

Contraindications

Primary osteoarthritis Samilson grade C, cuff tear arthropathy Hamada III–V, infection, axillary nerve palsy, older patients with low physical demand, combination with irreparable SSP/infraspinatus tendon (ISP) tear for PMa or combination with irreparable ISP tear for PMi.

Surgical technique

General anesthesia and beach-chair position with the arm freely mobile in an arm holder. Deltopectoral approach. Exposure of the humeral head and confirmation of the irreparability of the subscapularis tendon. PMa: Detachment of the tendon to be transferred from the humeral insertion, blunt anatomic dissection medially. Exposure of the conjoined tendon and coracoid process. PMi: Detachment of the tendon with an osteotomy at the coracoid process. Passing the PMa or PMi tendon under the conjoined tendon. The PMa tendon is fixed in a 2-row configuration, the PMi in a single row with suture anchors to the lesser tuberosity.

Postoperative management

Shoulder abduction sling (30°) for 6 weeks. Assisted range-of-motion (ROM) exercises with abduction/adduction 60–0–0°, internal/external rotation free–0-0° for 6 weeks. Free active ROM exercises after 6 weeks, muscle strengthening after 12 weeks.

Results

The pectoralis major and minor transfer shows an improvement in strength and range of motion in young active patients and an improved Constant score (CS) in long-term follow-up examinations.

Zusammenfassung

Operationsziel

Irreparable Verletzungen der Rotatorenmanschette bei jungen, körperlich mäßig bis sehr aktiven Patienten sind nach wie vor eine Herausforderung für Schulterchirurgen. Irreparable Verletzungen der vorderen Rotatorenmanschette erfordern eine Behandlung, die auf die Wiederherstellung der dynamischen anterioren Kräfte des Glenohumeralgelenks abzielt. Unter den chirurgischen Therapieoptionen hat der Transfer des M. pectoralis major und minor gute funktionelle Ergebnisse gezeigt. Mit dieser Technik wird versucht, den Vektor des M. subscapularis bei einer irreparablen Ruptur zu reproduzieren.

Indikationen

Pectoralis major (PMa): irreparable SCC(Subscapularis)-Ruptur bei aktiven Patienten ohne Arthrose. Pectoralis minor (PMi): irreparable superiore SSC-Ruptur in Kombination mit einer irreparablen SSP(Supraspinatus)-Ruptur bei aktiven Patienten ohne Arthrose.

Kontraindikationen

Primäre Arthrose Samilson Grad C, Rotatorenmaschettendefektarthropathie Hamada III–V, Infektion, N.-axillaris-Parese, ältere Patienten mit geringer körperlicher Beanspruchung, Kombination mit irreparabler SSP/ISP(Infraspinatus)-Ruptur für PMa oder Kombination mit irreparabler ISP-Ruptur für PMi.

Operationstechnik

Intubationsnarkose und Beach-Chair-Lagerung mit frei beweglichem Arm im Armhalter. Deltoideopektoraler Zugang. Darstellung des Humeruskopfes und Bestätigung der Irreparabilität der Subscapularissehne. PMa: Ablösung der zu übertragenden Sehne vom Humerusansatz, stumpfe anatomische Dissektion nach medial. Freilegung von „conjoined tendon“ und Processus coracoideus. PMi: Ablösung der Sehne mit einer Osteotomie am Processus coracoideus. Vorschieben der PMa- bzw. der PMi-Sehne unter die „conjoined tendon“. Die PMa-Sehne wird in einer 2‑reihigen Konfiguration fixiert, die PMi-Sehne einreihig mit Nahtankern am Tuberculum minus.

Weiterbehandlung

Schulterabduktionsschlinge (30 °) für 6 Wochen. Assistierte Bewegungsübungen (ROM) mit Abduktion/Adduktion 60-0-0°, Innen‑/Außenrotation frei-0-0° für 6 Wochen. Freie, aktive ROM-Übungen nach 6 Wochen, Kräftigung der Muskulatur nach 12 Wochen.

Ergebnisse

Der Transfer von PMa und PMi führt bei jungen, aktiven Patienten zu einer Verbesserung von Kraft und Bewegungsumfang sowie zu einem Constant-Score (CS) in langfristigen Nachuntersuchungen.

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Authors and Affiliations

  1. Department of Orthopedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany

    José Fernando Sánchez Carbonel,  Maximilian Hinz, Benjamin Daniel Kleim MBBS, M.D., Andreas B. Imhoff Univ. Prof. Dr. med. &  Sebastian Siebenlist

  2. Clinica Angloamericana, C. Alfredo Salazar 350, San Isidro, 15073, Lima, Peru

    Christian Lozano

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  1. José Fernando Sánchez Carbonel
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  2. Maximilian Hinz
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  4. Benjamin Daniel Kleim MBBS, M.D.
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  5. Andreas B. Imhoff Univ. Prof. Dr. med.
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Correspondence to José Fernando Sánchez Carbonel.

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J.F. Sánchez Carbonel, M. Hinz, C. Lozano, B.D. Kleim, A. Imhoff and S. Siebenlist declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Ulrich Bosch, Hannover

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Rüdiger Himmelhan, Mannheim

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Sánchez Carbonel, J.F., Hinz, M., Lozano, C. et al. Pectoralis major and pectoralis minor transfer for irreparable subscapularis tendon tears. Oper Orthop Traumatol 34, 45–54 (2022). https://doi.org/10.1007/s00064-021-00760-5

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