Anterior Capsule Reconstruction Versus Pectoralis

Major Transfer for Irreparable Subscapularis Tears

Involving the Anterior Capsule: A Comparative
Biomechanical Cadaveric Study
Kazimierz W. Komperda, M.D., Gregory J. Adamson, M.D., Yasuo Itami, M.D.,
Michelle H. McGarry, M.S., Adam Kantor, B.A., Charles C. Lin, B.S.E., and
Thay Q. Lee, Ph.D.

Purpose: To compare the biomechanical effectiveness of human dermal allograft (HDA) anterior capsular reconstruction
(ACR) and pectoralis major tendon transfer (PMTT) for treating irreparable subscapularis tears with capsular insufficiency
in human cadaver shoulders. Methods: Glenohumeral rotational range of motion and translation were measured in
6 cadaveric shoulders under the following 5 conditions: intact, deficient subscapularis/anterior capsule, ACR using HDA,
HDA ACR with concomitant PMTT, and PMTT alone. Results: The deficient subscapularis/anterior capsule condition
significantly increased external and total rotational range of motion at 0
(P < .001, P < .001) and 30
(P ¼ .005, P ¼ .002)
abduction as well as anterior-inferior translation (P  .001 to .03). HDA ACR, both with and without PMTT, restored
anterior-inferior stability to that of the intact condition; however, PMTT alone did not restore anterior-inferior translation
or rotational range of motion. Conclusions: HDA ACR for treating irreparable subscapularis tears with capsular insuf-
ficiency restored anterior-inferior glenohumeral translation and rotational range of motion at time 0 in human cadaver
shoulders. Clinical Relevance: Anterior capsule reconstruction may be a viable option for treating massive irreparable
subscapularis tears with capsular insufficiency.

A nterior glenohumeral stability is maintained by

the subscapularis and anterior capsule. End-stage
anterior glenohumeral instability results from failure
of the anterior capsule and subscapularis. This difficult
problem typically occurs in patients with multiple
From the Orthopaedic Biomechanics Laboratory, Congress Medical Foun-
dation (K.W.K., G.J.A., Y.I., M.H.M., T.Q.L.), Pasadena, California, U.S.A.;
the Orthopaedic Biomechanics Laboratory, Tibor Rubin VA Medical Center
(M.H.M., A.K., C.C.L., T.Q.L.), Long Beach, California, U.S.A.; and the
Department of Orthopaedic Surgery, University of California, Irvine (T.Q.L.),
Irvine, California, U.S.A.
The authors report the following potential conflicts of interest or sources of
funding: T.Q.L. reports board membership and grants from Arthrex, and
partial funding by Congress Medical Foundation, VA Rehabilitation Research
and Development Merit Review, and the John C. Griswold Foundation. Full
ICMJE author disclosure forms are available for this article online, as
supplementary material.
Received May 21, 2018; accepted May 23, 2019.
Address correspondence to Gregory J. Adamson, M.D., Congress Medical
Foundation, 800 South Raymond Ave, Pasadena, CA 91105, U.S.A. E-mail:
cagjamd@aol.com
Ó 2019 by the Arthroscopy Association of North America
0749-8063/18604/$36.00
https://doi.org/10.1016/j.arthro.2019.05.046
operations, rotator cuff/labral deficiency, soft tissue/
collagen disorders, or electrothermal capsular necro-
sis.1-3 If primary repair is not possible, numerous
anatomic and nonanatomic reconstructive techniques
have been described. These include latissimus dorsi
tendon transfer,4 pectoralis major tendon transfer
(PMTT),5 and direct soft tissue procedures such as
various capsular shifts and anterior capsular shoulder
stabilization using hamstring tendon autograft,6 tibialis
tendon allograft,7 and human dermal allograft (HDA)
reinforcement.8 To date, however, these techniques
have shown limited clinical success and a variety of
subsequent complications.9,10
Among nonanatomic procedures, although not
consistent,11,12 PMTT was shown to improve shoulder
function, strength, and pain relief for irreparable sub-
scapularis tear in a recent systematic review based on
frequency-weighted means.13 Among more anatomic
procedures, anterior capsule reconstruction (ACR) us-
ing HDA has been proposed for treating subscapularis
and anterior capsule insufficiency.14 This technique is
based on the concept and the clinical success of superior
capsule reconstruction restoring superior translation

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2019: pp 1-7 1
2 K. W. KOMPERDA ET AL.
Fig 1. Photograph of a right shoulder mounted on the custom
testing system.
and stability by centering the humeral head.15
Although indications continue to evolve, this salvage
procedure is intended for patients with minimal gle-
nohumeral arthritis (Hamada 1 or 2) and an irreparable
subscapularis tear with retraction to the level of the
glenoid with fatty infiltration (grade III to IV) on
preoperative imaging.
The biomechanical effects of treating subscapularis
and anterior capsule insufficiency with HDA ACR have
not been completely described. Therefore, the purpose
of this study was to compare the biomechanical effec-
tiveness of HDA ACR and PMTT for treating irreparable
subscapularis tears with capsular insufficiency in
human cadaver shoulders. We hypothesized that an
ACR to treat an irreparable subscapularis tear with
anterior capsule deficiency would improve anterior-
inferior glenohumeral stability.
Methods
Six fresh cadaveric shoulders (mean age 61.7 
9.4 years; all male) obtained from the University of
California Willed Body Program were tested using a
custom shoulder testing system (Fig 1). Biomechanical
testing on human cadaver shoulders with no identifiers
was determined to be exempt by the institutional
review board. The sample size was determined based on
expected differences and standard deviations in our
previous studies. Based on a power analysis using a
power of 0.8 and an alpha of 0.5, 6 specimens were
needed to show a statistically significant difference in
range of motion (ROM) and translation.
All specimens were macroscopically intact with no
history of trauma, degenerative joint disease, or prior
surgery. All skin and subcutaneous tissue were
removed from each specimen, and the humerus was
transected 2 cm distal to the deltoid tuberosity. The
tendinous insertions of the pectoralis major, latissimus
dorsi, deltoid (anterior, middle, and posterior), teres
minor, infraspinatus, supraspinatus, and subscapularis
were preserved, as were the remaining joint capsule
(according to experimental condition) and cor-
acoacromial ligament. Each specimen was checked for
rotator cuff tears before testing.
A no. 2 FiberWire suture was used to tie a Krackow
running locking stitch to the tendinous insertions for
muscle loading during testing. The scapula was fixed to a
custom metal plate by using 3 large bolts. The transected
humerus was fixed to an intramedullary rod and 6 sur-
rounding screws that pressed on the cortical bone. The
scapular plate was fixed to a custom testing jig in 20
of
anterior tilt in the sagittal plane. The humeral rod was
attached to a custom device in an arc that enabled axial
rotation of the humerus and glenohumeral abduction
and was also attached to an arc that allowed controlled
horizontal and vertical abduction. The arc was positioned
to align the humerus in the scapular plane. A goniometer
was placed at the distal end of the humeral cylinder to
measure humeral rotation. A torque wrench was used to
apply a predetermined torque for measuring rotational
ROM. Muscle forces were simulated via a fishing line
(braided low-stretch Dacron fishing line; Izor-line)
attached to no. 2 FiberWire sutures, which were
attached directly to the tendons. Adjustable pulleys and a
positioning plate were used to approximate physiological
muscle force vectors without friction.
The biomechanical testing was performed for the
following 5 conditions: 1) subscapularis/anterior
capsule intact; 2) subscapularis/anterior capsule defi-
cient; 3) ACR using HDA; 4) HDA ACR and PMTT; and
5) PMTT alone.
For the subscapularis/anterior capsule deficient
condition (Fig 2A), the subscapularis and anterior
capsule were sharply released concurrently from their
anatomic footprint on the lesser tuberosity laterally.
Medially, the subscapularis, capsule, and associated
glenohumeral ligaments (middle glenohumeral
ligament/anterior band inferior glenohumeral liga-
ment) were resected off the glenoid from the 1 o’clock
to 5 o’clock positions, medial to the labrum. This
resulted in a complete defect of the subscapularis and
anterior capsule. The labrum was left intact.
For ACR using HDA (Fig 2B), two 3.0-mm metal
SutureTak anchors preloaded with no. 2 FiberWire
(Arthrex) were inserted on the anterior glenoid at the 1
 ANTERIOR CAPSULE RECON FOR SUBSCAPULARIS TEAR
Fig 2. Experimental conditions. (A) Subscapularis/anterior capsule defect. (B) Anterior capsular reconstruction. (C) Anterior
capsular reconstruction with concomitant pectoralis major transfer.
o’clock and 5 o’clock positions (in a right shoulder)
medial to the labrum. Two bone tunnels were created
at the medial edge of the lesser tuberosity, 5 mm apart
from the tear edge of the subscapularis tendon, to
perform transosseous fixation. The size of the HDA graft
(JRF Ortho, Centennial, CO; and Community Tissue
Services, Dayton, OH) was quantified based on the lo-
cations of the glenoid anchors and bone tunnels on the
lesser tuberosity using a MicroScribe 3DLX at 30
gle-
nohumeral abduction and the midpoint of the total
ROM for each specimen. Tensioning in this arm posi-
tion has been previously shown to most closely recreate
the passive joint motion in the normal shoulder and
avoid overconstraint.16 In preparing the HDA graft for
the ACR, the graft was oversized 5 mm superiorly and
10 mm inferiorly to provide adequate coverage of the
capsular defect. Laterally, it was oversized 10 mm
lateral to the bone tunnel sites to cover the footprint on
the lesser tuberosity. The mean graft height in the
superior-inferior direction was 34.1 mm on the glenoid
and 22.8 mm on the lesser tuberosity, and medial-
lateral widths were 42.5 mm superiorly and 45.5 mm
inferiorly. Mean graft thickness was determined to be
2.6 mm using a digital caliper. For the reconstruction,
the graft was first fixed to the glenoid via a double
pulley suture construct and then fixed to the lesser
tuberosity using a transosseous technique, 1 horizontal
mattress suture medially, and 2 simple stitches laterally.
To achieve consistent capsular tensioning, the arm was
held at 30
abduction, 30
forward flexion, and 30

external rotation (ER) while performing the lateral
fixation.
For HDA ACR and PMTT (50% tendon) (Fig 2C), after
biomechanical testing was completed with the HDA
ACR described above, a subcoracoid PMTT was added
to the reconstruction.5,17-19 The pectoralis major
tendon was isolated at its insertion onto the lateral
aspect of the bicipital groove of the humerus, and the
superior 50% of the tendon was detached from the
humerus and released in its entirety from the humerus
and mobilized medially. The pectoralis major tendon
was passed under the conjoined tendon. The transferred
3
tendon was secured with two no. 2 FiberWire sutures,
passed through the drill holes on the lateral edge of
lesser tuberosity, and fixed with 2 standard simple
stitches.
For PMTT (50% tendon) alone, after biomechanical
testing was completed for the above condition, the HDA
ACR was carefully taken down by cutting the medial
and lateral sutures of the repair and removing the
dermal allograft. Care was taken not to disrupt the
pectoralis major transfer. Thus, only the pectoralis
major transfer remained.
Biomechanical Testing
Measurements were performed at 0
, 30
, and 60
of
glenohumeral abduction, which corresponded to 0
,
45
, and 90
of shoulder abduction. The rotator cuff and
conjoined tendons were loaded based on physiological
cross-sectional area ratios with multiple lines of pull to
create a balanced force couple.20 Two lines of pull were
used for the supraspinatus (10 N), 2 for the sub-
scapularis (10 N), 2 for the infraspinatus/teres minor
(10 N), 3 for the deltoid (12 N), 2 for the latissimus dorsi
(10 N), 4 for the pectoralis major (10 N), and 1 for the
conjoined tendon (5 N). A string was attached to the
humerus at the proximal pectoralis major insertion for
application of anteroinferior translation force. The
string passed through a pulley positioned perpendicular
and anterior to the humerus with a 20
inferior pull.
Three anteroinferior loads, 20, 30, and 40 N, were
applied to simulate an anteroinferior dislocation force.
Glenohumeral translation was quantified using a
MicroScribe 3DLX. To ensure a consistent reference
point for digitizing measurements, 1 small screw was
placed on the anterolateral edge of the acromion.
Additionally, 1 screw was placed on the greater tuber-
osity just lateral to the acromion when the arm was in
60
abduction and 60
ER. These 2 screws were
digitized at each position and loading condition, and the
change in position of the humerus relative to the
scapula was calculated. Maximum ER was defined as
the amount of rotation reached with 2.2 Nm of torque.
This amount of torque is adequate to provide a
4 K. W. KOMPERDA ET AL.

Table 1. Humeral External Rotation and Total Range of Motion for Each Testing Condition

Anterior Capsule
Reconstruction and
Subscapularis/Anterior Anterior Capsule Pectoralis Major Pectoralis Major
Intact Capsule Deficient Reconstruction Tendon Transfer Tendon Transfer
External rotation (
)
0
abduction 83.2  9.1 125.3  6.6* 82.4  3.5y 81.9  3.5y 129.5  6.6*zx
30
abduction 102.3  6.4 126.7  5.1* 92.9  5.2y 94.5  5.4y 128.8  5.0*zx
60
abduction 104.2  5.5 116.6  5.5 104.4  3.9 103.5  3.9 115.1  5.2
Total rotational range of motion (
)
0
abduction 87.7  13.5 131.3  13.5* 85.8  5.6y 85.1  6.3y 134.4  12.6*zx
30
abduction 108.8  11.0 135.3  9.5* 99.3  5.7y 101.7  5.8y 138.1  9.2*zx
60
abduction 97.1  9.2 111.9  10.0 97.7  7.0 98.6  7.5 112.3  10.2
NOTE. Data are mean  standard error of the mean.
P < .05: *vs intact; yvs subscapularis/anterior capsule deficient; zvs anterior capsule reconstruction; xvs anterior capsule reconstruction and
pectoralis major tendon transfer.

consistent endpoint of rotation while not damaging the

capsular tissue or anterior capsular repair.21 Anterior-
inferior translation was measured with the humerus
locked at 0
, 30
, and 60
abduction and both 30
or 60

ER as the difference in the humeral head position
centered in the glenoid and after the addition of 20-,
30-, and 40-N anterior-inferior directed loads.
The 5 experimental conditions described above were
tested sequentially. Throughout testing, the specimens
were kept moist with 0.9% saline. All data were
collected for 2 trials. If the points were not repeatable
within 1.0 mm, a third trial was carried out. The
average value for the 2 most repeatable trials was
used.22,23 A repeated-measures analysis of variance
with a significance level of .05 was used. If significance
was shown, a Tukey post hoc test was used to deter-
mine the areas where significance occurred.

Results
Rotational ROM
The subscapularis/anterior capsuleedeficient
condition significantly increased ER and total ROM at
0
(P < .001, P < .001) and 30
(P ¼ .005, P ¼ .002)
abduction (Table 1). HDA ACR, both with and without
PMTT, restored ER and total ROM to the intact condi-
tion at all abduction angles (P ¼ .6 to .9). However,
PMTT alone resulted in ER and total ROM similar to
the intact condition in 60
of abduction only (P ¼ .5,
P ¼ .2).

Anterior-Inferior Glenohumeral Translation

The humeral rotation position of 60
ER, where the
anterior capsule becomes tighter compared with 30

ER, resulted in more statistically significant changes.
Specifically, there were significant increases in anterior-
inferior translation after a subscapularis/anterior
capsule defect when 40- and 60-N loads were applied
(Fig 3). HDA ACR, both with and without PMTT,
restored anterior-inferior stability to the intact
Fig 3. Anterior-inferior glenohumeral translation for each
testing condition. (A) 0
abduction and 60
external rotation.
(B) 30
abduction and 60
external rotation. (C) 60
abduc-
tion and 60
external rotation. Abbreviations: ACR, anterior
capsule reconstruction; PMTT, pectoralis major tendon
transfer; Subscap/AC, subscapularis/anterior capsule. P < .05:
*vs intact; #vs subscapularis/anterior capsule deficient; þvs
ˇ
anterior capsule reconstruction; vs anterior capsule recon-
struction and pectoralis major tendon transfer.
 ANTERIOR CAPSULE RECON FOR SUBSCAPULARIS TEAR
condition. PMTT did not affect anterior-inferior trans-
lation when combined with HDA ACR (P ¼ .7 to .9 for
all comparisons). Compared with the intact condition,
PMTT alone showed significantly larger anterior-
inferior translation with 60 N at 0
(P < .001) and
30
(P ¼ .003) abduction.
Discussion
In this biomechanical model, HDA ACR was effective
in restoring rotational ROM to the intact state. Specif-
ically, ER at 0
abduction increased 42.1
from the
native to the defect state but was restored to intact ER
with ACR, with or without added PMTT. There was a
loss of 0.8
ER with ACR, but this was not statistically
significant. It may be inferred from this that the graft
was not overtightened with our fixation technique.
At 30
abduction and 60
ER, there was a statistically
significant increase in anterior-inferior translation in
the subscapularis-deficient state with 40- and 60-N
loads. HDA ACR restored anterior glenohumeral sta-
bility to the native state. PMTT did not appear to confer
any significant added stability when combined with
HDA ACR (P ¼ 1.00). There were no significant dif-
ferences in the amount of anterior-inferior translation
when PMTT was added to the HDA ACR. PMTT alone
also did not restore anterior stability to the native state.
These results trended similarly throughout the range of
observed abduction angles. It should be noted, how-
ever, that restoration of anterior-inferior stability
reached greater significance when tested at 60
ER
versus 30
ER, possibly because the ACR is tighter at
higher ER angles.
When PMTT was performed in isolation, it failed to
replicate the translation and rotation of the intact state.
Furthermore, PMTT alone showed significantly
increased anterior-inferior translation in comparison to
the intact state. PMTT in theory should dynamically
restrict ER; however, our data failed to show decreased
ER compared with the tear condition at all testing po-
sitions and with all anterior forces. Although our results
failed to find statistically significant improvements with
PMTT, a biomechanical study by Konrad et al.18
comparing supracoracoid with subcoracoid PMTT in
subscapularis-deficient shoulders did show partial
restoration of glenohumeral kinematics in the sub-
coracoid PMTT group. Although their study examined a
complete subscapularis tendon tear, it is unclear
whether the underlying static stabilizers (capsule and
glenohumeral ligaments) were left intact, which could
cause the discrepancy with our results. Their study
examined ER and translations at maximum abduction
angles, whereas ours measured rotational motion at 3
specified points of abduction (0
, 30
, and 60
), trans-
lations at multiple points of abduction, and ER with a
series of applied loads, thus making direct comparisons
between our results difficult.
5
Several reports have detailed modest short-term
clinical outcomes for ACR using various grafts and
techniques.1,6,7 Our study, however, sought to show
the biomechanical plausibility of a more anatomic
approach to address chronic subscapularis/anterior
capsular insufficiency using a technique developed by
Pogorzelski et al.14 Anterior static stabilizers of the
glenohumeral joint are important for providing an
anterior restraint to translation as well as a check rein
to rotation. This may explain, in part, why HDA ACR,
a more anatomic reconstruction of the static shoulder
stabilizers, exhibited better anteroinferior stability
than PMTT, which is inherently a nonanatomic
technique and relies on dynamic stabilization from
the transferred tendon. The HDA ACR repair, how-
ever, does not recreate the anterior force couple
provided by the subscapularis. Although the anterior
force couple may be restored with the PMTT, the
muscle force vector of the pectoralis is altered after
transferring the tendon, resulting in a more inferior
pull on the humerus, which may have allowed for
more translation in this biomechanical study. Also,
the muscle function after PMTT is unknown and
could not be simulated in this study.
HDA has become a popular graft choice for recon-
structive shoulder surgery. Its clinical efficacy, at least in
the short term, has been shown most notably with
superior capsular reconstruction.24 Given its proven
biomechanical and emerging positive clinical profile, it
was chosen as the preferred graft for this study.
Although HDA has been shown to act as a biologic
scaffold to promote cellular ingrowth and tissue
remodeling, little is known with respect to tendon
regeneration and remodeling in vivo after its use as a
biologic repair construct. Limited case reports have
corroborated bench research and animal models
regarding the potential for acellular human dermal
matrix allograft to exhibit biologic factors of the
remodeling process when used to augment rotator cuff
repairdnamely cellular proliferation, collagen fiber
alignment, revascularization, minimal inflammatory
response, and incorporation with surrounding tissue.25
This has yet to be histologically shown when HDA is
used as an independent repair construct, however.
Many cite subcoracoid PMTT as superior to supra-
coracoid transfer because it more closely simulates the
subscapularis line of action. There is, however, a “ringer
effect” that occurs when the pectoralis major, a thoracic
muscle, has its tendon rerouted underneath the cora-
coid, thus impeding its excursion. HDA ACR avoids a
muscle transfer entirely, thereby avoiding these addi-
tional concerns. Recently, Elhassan et al.4 proposed
using a latissimus dorsi tendon transfer to reconstruct
irreparable subscapularis tears. The authors argued that
the posterior thorax pull of the latissimus dorsi more
accurately replicates the pull of the subscapularis.
6 K. W. KOMPERDA ET AL.
Further research should be performed to evaluate the
biomechanical effect of the latissimus dorsi transfer.
Limitations
This study is certainly not without its limitations. It is
a biomechanical cadaveric study that cannot account
for biological and remodeling effects such as scarring or
contracture that can occur after surgical procedures,
altering ROM. Also, a constant muscle load was applied
for all conditions based on the ratio of the physiological
cross-sectional area and to balance the force couples in
the shoulder. The effects of PMTT transfer on function
of the muscle cannot be evaluated in a cadaveric study.
The ideal arm position for HDA tensioning in ACR has
not been elucidated. In this study, we chose to tension
our graft at 30
of glenohumeral abduction at the
midpoint of total rotational ROM. We found this tech-
nique to be the most reproducible in the laboratory.
Graft tensioning with more or less ER may alter rota-
tional and translational data. Additionally, we tested
each specimen using the same testing protocol and did
not randomize the order of testing conditions; however,
preliminary testing was performed to evaluate the
effects of sequential testing on the cadaveric tissues, and
the final testing protocols were developed to minimize
the creep effects of the tissues. Also, performing multiple
trials and repeating a trial if the difference is larger than
a predetermined error is a protocol used in our labora-
tory to ensure reproducibility of the measurements.
Numerous PMTT techniques have been described and
quantified. Once again, we chose a commonly used
subcoracoid PMTT technique that was reliably repro-
ducible in our laboratory. Using a different technique
may have altered the resulting data. Another limitation
of the study is the thickness of the graft used. We chose
to use a single-layer dermis graft based on the tech-
nique described by Pogorzelski et al.14 Because of the
functional demands of the anterior capsule needing to
be more flexible than the superior capsule, a thicker
graft may not be beneficial for ACR.
Conclusions
HDA ACR for treating irreparable subscapularis tears
with capsular insufficiency restored anterior-inferior
glenohumeral translation and rotational ROM at time
0 in human cadaver shoulders. ACR may be a viable
option for treating massive irreparable subscapularis
tears with capsular insufficiency.
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