Leitthema
Orthopäde 2018 · 47:103–112
https://doi.org/10.1007/s00132-017-3516-1
Published online: 29 January 2018
© Springer Medizin Verlag GmbH, ein Teil von
Springer Nature 2018
Irreparable rotator cuff tears are not fre-
quent but always represent a challenge for
the surgeon. Clinical manifestations are
variable from no symptoms with good
mobility to high pain and pseudopara-
lytic shoulder. Regarding the definition
of irreparable rotator cuff tears, we have
to remember that a massive tear is not
necessarily an irreparable tear and an ir-
reparable tear is not always a massive tear
[12, 19]. The definition of an irrepara-
ble cuff tear is a perioperative definition
[52]: this is the inability to achieve di-
rect repair of native tendon to the great
tuberosity despite an intra- and extra-
articular release of the remaining tissue.
These tears are often chronic, character-
ized by an atrophic muscle and a fatty
infiltration more than 3 according to the
Goutallier classification [24].
»fromClinical manifestation ranges
no symptoms to significant
pain and dysfunction
We can define three distinct anatomic
patterns: a posterosuperior irreparable
cuff tear which involves the supraspina-
tus, the infraspinatus and the teres minor;
the posterosuperior tear can be extended
to the teres minor with a lack of active
external rotation and a positive drop sign
and a horn blower sign; an anterosupe-
rior irreparable cuff tear which involves
the subscapularis and the supraspinatus.
Very uncommon is the posterosuperior
tear which can extend anteriorly to the
subscapularis and is defined as a “global”
irreparable rotator cuff tear.
In the posterosuperior group, which is
more frequent, the humeral head escapes
P. Valenti
Paris Shoulder Unit, Clinique Bizet, Paris, France
Joint-preserving treatment
options for irreparable rotator
cuff tears
posteriorly and superiorly with an eleva-
tion or abduction around 100° but with
a lack of external rotation and frequently
a horn blower sign. In the anterosuperior
group, the loss of the coracoacromial arch
may lead to subcutaneous humeral head
escape superiorly and anteriorly, which is
defined as the pseudoparalytic shoulder.
This last clinical situation is an indication
of total reverse shoulder arthroplasty and
a contraindicationtononarthroplastyop-
tions.
»fattyAtrophic muscle and
infiltration are often
characteristic for chronic
irreparable cuff tears
Management of symptomatic irreparable
rotator cuff tears is extremely challeng-
ing and controversial. Nonarthroplasty
therapeutic options for joint preservation
include surgical and nonsurgical treat-
ments. Several surgical options have been
proposed toaddress this condition. These
include debridement with subacromial
bursectomy and tenotomy or tenodesis
of the long head of the biceps [2], partial
repair of the residual cuff [5], supraspina-
tus advancement [8], deltoid flap [22],
lower trapezius transfer [15], latissimus
dorsi transfer (LDT; [20]), and more re-
cently the interposition of a subacromial
spacer [9] or superior capsule reconstruc-
tion [40]. Nowadays, there is no ev-
idence-based consensus, but a chronic
pseudoparalytic shoulder with anterior
humeral head escape is a contraindica-
tion of nonarthroplasty options. The
choice of the procedure in irreparable
cuff tear without osteoarthritis depends
on many criteria, including age, degree
of motivation, level of activity, and joint
stability. Standards X-rays, computed to-
mography (CT), and magnetic resonance
imaging (MRI) are mandatory to evalu-
ate the shape of the acromion, the size of
subacromial space, the status of the long
head of the biceps, the trophicity of the
remaining cuff (teres minor, subscapu-
laris), the position of the humeral head
and the bone stock (. Fig. 1).
Conservative treatment
Conservative treatment is indicated to re-
lieve pain and stabilize the humeral head.
Frequently, the shoulder is stiff and the
first goal of the physiotherapist is to re-
store complete passive range of motion.
Secondary, specific strengthening exer-
cises of the external rotators, the remain-
ing cuff, and the periscapular muscles is
crucial to restore a stabile fulcrum for del-
toid contraction. This treatment includes
Abbreviations
ASCR Arthroscopic superior capsular
reconstruction
ASES score American Shoulder and Elbow
Surgeons score
CT Computed tomography
LD Latissimus dorsi
LDT Latissimus dorsi transfer
MRI Magnetic resonance imaging
SST Simple shoulder test
SSV Shoulder subjective value
UCLA University of California Los
Angeles
Der Orthopäde 2 · 2018 103
 Leitthema
Fig. 1 8 a Perioperative arthroscopic view of an irreparable posterosuperior cuff tear. b The magnetic
resonance image (MRI) shows atrophy of the supra- and infraspinatus, and fatty infiltration stage 3 for
supraspinatus, and stage 4 for infraspinatus
nonsteroidal anti-inflammatory medica-
tion and steroid injection in the subacro-
mial space under fluoroscopy control.
The time to achieve a success of a conser-
vative treatment takes 3–6 months [38].
Subacromial debridement and
tenotomy or tenodesis of the
long head of the biceps
The surgical technique can be performed
in an outpatient setting using arthroscopy
followed by immediate physiotherapy
and without any immobilization. All or
any of the following procedures can be
performed: bursectomy, debridement
of the rotator cuff edge, tenotomy or
tenodesis of the long head of the biceps,
smooth acromioplasty to spare the cora-
coacromial ligament, a tuberoplasty of
the great tuberosity and acromioclavic-
ular resection.
Many authors [4, 17, 34, 44, 54] re-
ported excellent results with pain relief
and no loss of range of motion but no
increase of strength or a worsening of
results with a long follow-up with a de-
crease of the subacromial space. In 2005,
Walch et al. [51] reported a long-term
follow-up (2–14 years) in a large series
with 307 patients who had undergone
tenotomy of the biceps in irreparable cuff
tear with an effective pain relief without
any loss of range of motion with a de-
crease of the acromiohumeral distance
of 1.3 mm during the follow-up period.
Pejorative results were correlated with an
atrophic teres minor, fatty infiltration of
the infraspinatus and subscapularis. In
this series, no arthritic change was noted
104 Der Orthopäde 2 · 2018
at the long-term follow-up and in one
third of the patients an acromioplasty
was performed. To avoid a cosmetic de-
formity after a biceps tenotomy (half of
Walch’s patients), Boileau et al. [2] pre-
ferred to perform a biceps tenodesis in
patients who were active, had thin arms
and were less than 65 years old to reduce
the risk to create a pseudoparalytic shoul-
der after an acromioplasty and a violation
of the coracoacromial ligament. In 2002,
Fenlin et al. [16] reported a series of
19 patients who had successfully under-
gone tuberoplasty of the great tuberosity.
Nowadays, there is no evidence based re-
garding the technique to treat long head
of the biceps.
This procedure is indicated in elderly
low-demand patients with glenohumeral
stability, a painful shoulder, an active for-
ward elevation, and good control of the
descent of the shoulder. If the symp-
toms decrease after injection of a cor-
tisone into the subacromial space, the
patient is a good candidate for this pro-
cedure.
Partial repair
Based on the biomechanical concept of
“the suspension bridge system” Burkhart
introduced the partial repair in 1994 [5].
The goal of this partial repair is to recre-
ate a transverse force of the rotator cuff
to provide a stable fulcrum for the gleno-
humeral joint. In a biomechanical study,
Handler et al. [26] noted the importance
of restoring the rotator cuff cable (ante-
rior and posterior) to obtain a balanced
force couple and proved that even after
complete repaired of a small or medium
tear, the muscles forces were transmitted
through the rotator cuff cable. Tech-
nically, after release of adhesions and
mobilization of the tendon, the remain-
ing infraspinatus could be advanced but
not completely to the greater tuberos-
ity; a chondroplasty is done to medialize
the reinsertion of the infraspinatus com-
bined with a tenodesis of the biceps. A
review of the literature reported satis-
factory results after partial repair of ir-
reparable cuff tears: all the patients except
one of the Burkhart series were satisfied
[5]. In 2005, Durable and Bair [10] re-
ported 67% of patients with a good to
excellent results with satisfactory pain re-
lief, an improvement of active elevation,
and 92% of patients were satisfied with
the results of surgery. More recently in
2012, Kim et al. reported [35] on a se-
ries of 27 patients in whom there was an
improvement in short-term outcomes of
all functional scores: the Simple Shoul-
der Test improved from 5.1 ±1.2 to 8.8 ±
2.1 (P = 0.001), the Constant score from
43.6 ±7.9 to 74.1 ± 10.6 (P = 0.001), and
the University of California, Los Angeles
score from 10.5 ± 3.0 to 25.9 ± 5.0 (P =
0.001). Boileau et al. [2] and Liem et al.
[39] reported a decrease of the acromio-
humeral distance after debridement and
biceps tenotomy.
This procedure is indicated for young
patients, with atrophy and fatty infiltra-
tion in all supraspinatus, infraspinatus
and teres minor less than 3 regarding
Goutallier’s classification. The fulcrum
of the shoulder should be spared and
the pseudoparalytic shoulder is a con-
traindication. It is possible to combine
this technique with a tendon transfer as
cuff augmentation.
Tendons transfer
Manytendons transferfrom the periscapu-
lar muscles have been described but the
difficulty is: which tendon transfer for
which clinical deficiency? One way to
avoid a mistake is to remember the
contraindications of the tendon transfer:
4 Older patients with a low demand
4 Patients with a good range of motion
and no pain after physiotherapy
 Abstract · Zusammenfassung
Orthopäde 2018 · 47:103–112 https://doi.org/10.1007/s00132-017-3516-1
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018
P. Valenti
Joint-preserving treatment options for irreparable rotator cuff tears
Abstract
An irreparable cuff tear is defined as the inabi-
lity to achieve direct repair of native tendon to
the great tuberosity despite intra- and extra-
articular release of the remaining tissue. Three
distinct anatomic patterns are identified:
posterosuperior cuff tears which involve
the supraspinatus, infraspinatus and teres
minor; anterosuperior tears which involve the
supraspinatus and subscapularis; and global
tears which comprise both. Subacromial
debridement and tenotomy or tenodesis of
the long head of the biceps are proposed
for older patients with a functional but very
painful shoulder. Partial repair—particularly
Gelenkerhaltende Behandlungsoptionen bei irreparablen Rotatorenmanschettenrupturen
Zusammenfassung
Eine irreparable Rotatorenmanschettenruptur
ist definiert durch die fehlende Möglichkeit,
eine direkte Refixation der nativen Sehne
am Tuberculum majus zu erreichen trotz
einer intra- und extraartikulären Freisetzung
des verbleibenden Gewebes. Drei unter-
schiedliche anatomische Muster wurden
identifiziert: posterosuperiore Rotatoren-
manschettenrupturen unter Beteiligung von
Supraspinatus, Infraspinatus und Teres minor;
anterosuperiore Rupturen unter Beteiligung
von Supraspinatus und Subscapularis sowie
umfassende Rupturen unter Beteiligung aller
genannten Strukturen. Ein subakromiales
Débridement und eine Tenotomie oder
Tenodese der langen Bizepssehne werden bei
älteren Patienten mit funktionsfähiger, aber
sehr schmerzhafter Schulter vorgeschlagen.
4 Pseudoparalytic shoulder (active
anterior elevation less than 60°)
with an escape of the humeral head
anteriorly and superiorly underneath
the coracoacromial arch
4 Deltoid palsy
4 Glenohumeral arthritis (Samilson II
or III) but tendon transfer (latissimus
dorsi ± teres major) can be combined
with a reverse shoulder prosthesis
to restore active external rotation in
patients with an atrophic teres minor.
Tendon transfer may be proposed in
young patients who have both pain and
the infraspinatus and the subscapularis—is
indicated for young patients if the muscle is
still trophic with a fatty infiltration less than 3.
It can be combined with a tendon transfer. In
irreparable posterosuperior tears, latissimus
dorsi or lower trapezius transfer has been
reported to improve active elevation and
external rotation. In anterosuperior cuff tears,
pectoralis major or latissimus transfer has
been used. If the lack of external rotation is
isolated with good active forward elevation,
the L’Episcopo procedure is the procedure of
choice. New techniques with a short follow-up
have been proposed recently: implantation of
Eine Teilrekonstruktion – insbesondere
Infraspinatus und Subscapularis – ist bei
jungen Patienten indiziert, wenn der Muskel
noch trophisch ist und eine Fettinfiltration
unter 3 vorliegt. Die Teilrekonstruktion ist
mit einem Sehnentransfer kombinierbar. Bei
irreparablen posterosuperioren Rupturen
wurde berichtet, dass ein Latissimus-dorsi-
Transfer oder der Transfer des unteren Trape-
zius die aktive Elevation und Außenrotation
verbessert. Bei anterosuperioren Rotatoren-
manschettenrupturen wurde ein Pectoralis-
major- oder Latissimus-Transfer angewendet.
Liegt eine fehlende Außenrotation isoliert
bei guter aktiver Anteversion vor, ist das
L’Episcopo-Verfahren die Methode der Wahl.
Neue Verfahren mit einem kurzen Follow-
up wurden in jüngerer Zeit vorgeschlagen:
weak shoulder and/or a loss of active
anterior elevation and/or a loss of active
external rotation.
Two types of anatomic patterns can
be managed:
A posterosuperior tear (involves supra-
spinatus and infraspinatus) can be re-
paired currently with a latissimus dorsi
transfer. The lower trapezius, initially
used in the paralytic shoulder to restore
active external rotation, can be used in
posterosuperior an irreparable tear with
a lack of active external rotation (. Fig. 2).
a balloon-shaped, biodegradable spacer in the
subacromial space to maintain the position
of the humeral head and to facilitate deltoid
action; capsular superior reconstruction with
a fascia lata or an artificial graft implanted
between the superior glenoid rim and the
great tuberosity to reproduce the natural
capsule of the supra- and infraspinatus and to
stabilize the humeral head.
Keywords
Subacromial debridement · Tenotomy ·
Episcopo procedure · Subacromial balloon-
shaped spacer · Tenodesis
Implantation eines ballonförmigen, biologisch
abbaubaren Spacers in den subakromialen
Raum zur Erhaltung der Position des
Humeruskopfs und zur Erleichterung der
Deltoideusfunktion; Rekonstruktion der
oberen Gelenkkapsel mit einem Fascia-lata-
oder einem künstlichen Graft implantiert
zwischen den oberen Glenoidrand und das
Tuberculum majus, um die natürliche Kapsel
des Supra- und Infraspinatus nachzubilden
und den Humeruskopf zu stabilisieren.
Schlüsselwörter
Subakromiales Débridement · Tenotomie ·
L’Episcopo-Verfahren · Subakromialer
ballonförmiger Spacer · Tenodese
Less frequently in Europe, deltoid flap
or a teres major were proposed. As de-
scribed in the 1999 work of Herzberg et
al. [28], the location of the insertion of
the tendon transfer depends on the func-
tion to be restored; if there is a lag sign
or an hornblower’s sign, we fix it at the
insertion of the infraspinatus, whereby
if the lack is in the sector of active an-
terior elevation, it will be fixed at the
insertion of supraspinatus close to the
subscapularis. A teres major transfer is
a reasonable choice for an infraspinatus
tear or posterosuperior tear with a loss of
active external rotation but the aponeu-
Der Orthopäde 2 · 2018 105
 Leitthema
Fig. 2 8 In the magnetic resonance image (MRI)
and sagittal view, there is an atrophy and fatty
infiltration greater than 3. Clinically, the patient
has no active external rotation with a lag sign
and a hornblower’s sign
rosis band is short and the excursion is
limited. The deltoid flap is used more
commonly in the supraspinatus and an-
terior part of the infraspinatus retracted
at the level of the glenoid with pain. Al-
though the results regarding the range
of motion and the strength were good,
this flap was abandoned due to the im-
portance of preserving the integrity of
the deltoid. If the posterosuperior tear
is associated with glenohumeral arthritis
and a pseudoparalytic shoulder, the re-
verse shoulder arthroplasty is the method
of choice to restore active forward ele-
vation. Reverse shoulder arthroplasty is
not able to restore external rotation if
there is an atrophic teres minor; thus,
we reroute the latissimus dorsi and teres
major around the humerus at the same
level to fix them on the lateral aspect of
the humerus (L’Episcopo procedure).
An anterosuperior tear (involves supra-
spinatus and subscapularis) can be re-
paired with the pectoralis minor, pec-
toralis major or more recently with
a latissimus dorsi or teres major. The
pectoralis minor is preferred for partial
irreparable lesions of the subscapularis
(Lafosse grade 3; [37]). Complete, sternal
or clavicular band of the pectoralis ma-
jor is the method of choice in chronic,
isolated complete subscapularis tears
(Lafosse grade 4). Therefore, in Lafosse
grade 5 with an anterior subluxation of
106 Der Orthopäde 2 · 2018
the humeral head, latissimus dorsi or
Teres major as described by Elhassan
[11], is preferred in which the pull is
from posterior to anterior. Regarding
the pectoralis major there is no signif-
icant difference clinically between over
or underneath the conjoint tendon and
complete or sternal head and clavicular
head [49].
Tendons transfer to repair
irreparable posterosuperior cuff
tears
Latissimus dorsi transfer
In 1998, Gerber et al. [18] proposed
this tendon transfer to treat irrepara-
ble tears of the supra- and infraspina-
tus. Since this first description, many
publications have proven its reliability to
improve function and to decrease pain
in patients with massive irreparable tears
of the posterosuperior cuff [29, 30, 48].
Recently, some authors have proposed
to fix onto the humeral head this trans-
fer by arthroscopy in combination with
a minimally invasive axillary approach
to harvest the tendon [21, 23] or even
completely under arthroscopy [7]. Pari-
belli et al. [42] compared a group of
patients undergoing arthroscopically as-
sisted LDT to others undergoing arthro-
scopic partial rotator cuff repair. Both
procedures were found to be effective
but the LDT provided a better modi-
fied UCLA score improvement and bet-
ter strength at last follow-up. In a 2012
biomechanical study, Hartzler et al. [27]
demonstrated better function to restore
external rotation with the lower trapez-
ius when the arm is at the body and with
the latissimus dorsi when the arm is in
90° of abduction.
Surgical technique
A minimally invasive axillary approach
of 5–7 cm was performed along the lat-
eral border of the scapula. The first key
point was to identify the white aponeu-
rotic band of the latissimus dorsi which
leads to the insertion of the latissimus
dorsi on the humerus and which helps in
differentiating the latissimus dorsi from
the teres major which is more muscu-
lar. Posteriorly, the latissimus dorsi was
detached from the teres major and the
anterior border of the latissimus dorsi
was carefully dissected to release its neu-
rovascular pedicle which penetrates into
the deep part of the muscle at 10 cm from
the insertion. To obtain a good excur-
sion of the latissimus dorsi, the muscle
was released distally from the angle of
the scapula and from subcutaneous tis-
sue. The arm was then placed in maximal
internal rotation to expose its insertion
on the humerus and to keep the radial
and axillary nerves at distance. The ten-
don was then detached from the humeral
diaphysis between the tendon of the pec-
toralis major and of the teres major as
close as possible to the bone to provide the
maximal length possible for the transfer.
A passage was made between the poste-
rior deltoid and the remaining posterior
cuff using blunt scissors. The tendon of
the latissimus dorsi was then retrieved in
the shoulder joint using a grasper through
a posterior portal under arthroscopic vi-
sualization through a posterolateral por-
tal.
The fixation of the aponeurotic band is
done with two anchors closed to the supe-
rior border of the subscapularis to allow
good coverage of the footprint (a pos-
terior anchor is used to avoid a gliding
of the aponeurotic band). If the goal
is to restore external rotation in abduc-
tion, the intubulated aponeurotic band
of the latissimus dorsi was then intro-
duced into a bony tunnel and fixed with
a locked cortical button.
The axillary incision was closed with
a drain for 24 h and a compressive ban-
dage was applied for 2 days on the ax-
illary wound to prevent hematoma for-
mation. The arm was then immobilized
at 30° abduction and in neutral rotation
for 6 weeks.
The patient then began passive and
active assisted range of motion exercises
in every direction after 6 weeks (from
weeks 6–12), then full active range of
motion and gentle strengthening was au-
thorized. Patients were allowed to return
to unrestricted activities after 6 months’
rest.
The review of the literature proved
a long time ago that latissimus dorsi trans-
fer is an effective and reliable procedure
to relieve pain and to increase forward
Fig. 3 8 a, b A 65-year-old woman with excellent forward elevation and no active external rotation with a hornblower’s sign.
c, d Arthrographic computed tomography scan confirms the reparable cuff tear of the supra-, infraspinatus, and teres minor.
This is an excellent indication for the L’Episcopo procedure
elevation, external rotation and strength
[18, 20, 29, 30, 42, 48, 52]. Thus, between
2011 and 2013 we prospectively com-
pared two groups of patients: Seventeen
had an isolated LDT transfer and four-
teen had a combined LDT with a partial
cuff repair. At the last follow-up, patients
with LDT plus partial cuff repair had a sig-
nificantly higher Constant score (64 ± 8
versus 58 ± 4 p < 0.03), range of motion
(33 ± 5 versus 29 ± 5 points p < 0.03), and
strength at 90° of abduction (2.5 kg ± 1 kg
versus 1.9 kg ± 0.9 kg p < 0.029). No sig-
nificant differences were found between
the two groups regarding pain scores,
shoulder subjective value (SSV), and ac-
tive external rotation. Predictive factors
of a good functional result are the follow-
ing: preoperative active forward flexion
>120° (2), preoperative active abduction
>120° (1.9), preoperative strength >2 kg
(1.9), and concomitant partial repair of
the remaining tendons (2.07). The only
factor which was found to be predictive
of a poor result was a preoperative SSV <
40 points (0.5). Arthroscopically assisted
LDT gives better results when it is com-
bined with partial cuff repair than when
it is performed isolated in the treatment
of massive irreparable rotator cuff tear.
Latissimus dorsi combined with the
teres major rerouted around the humerus
as the L’Episcopo procedure [3] can be
used to restore active external rotation
Fig. 4 9 Using a min-
imally invasive distal
deltopectoral approach,
we rerouted the latissimus
dorsi and teres major
around the humerus and
fixed it opposite of their in-
sertion in the posterolateral
metaphyseal bone
for patients with good active anterior el-
evation (. Figs. 3 and 4).
Lower trapezius transfer
Lower trapezius transfer has already
been used to restore external rotation
in brachial plexus lesions. The results
reported by Elhassam et al. [13] and
Bertelli [1] were promising in para-
lytic shoulder. Thus, some authors [14,
15] proposed it for massive irreparable
posterosuperior cuff tears with a lack
of active external rotation and com-
plete integrity of the subscapularis. The
advantages of this transfer to restore ex-
ternal rotation are the following: it is an
Der Orthopäde 2 · 2018 107
 Leitthema
Fig. 5 8 The lower trapezius (LT) has the same
vector of action and is an agonist of the in-
fraspinatus. Excursion is close to the infraspina-
tus (14.8 cm versus 8.6 cm) but less strength
than infraspinatus (2.7 versus 9.7 points)
agonist and there is a cocontraction with
external rotation of the arm; similar line
of pull; similar excursion and tension.
One drawback is less strength compared
to the infraspinatus (. Fig. 5).
Surgical technique
A 5 cm horizontal incision is made start-
ing 2 cm medial to the tubercule of the
spine and extended distally about 3 cm.
The inferior border of the lower trapez-
ius is released toward the insertion of
the short tendon on the tubercule of the
spine. The lower trapezius transfer is
identified and separated superiorly from
the middle trapezius. The nerve of the
trapezius is identified at this level be-
tween the middle and inferior part of the
trapezius and runs vertically 2 cm medi-
ally to the spinal border of the scapula.
To reach the insertion of the infraspina-
tus, the lower trapezius is extended with
an Achilles tendon allograft or a dou-
ble-stranded semitendinosus. A metallic
landmark positioned 2 cm from the end
of the fascia can be used to follow the ten-
don transfer on standard X-rays. A deep
subcutaneous tunnel is created between
the posterior deltoid and the atrophic in-
fraspinatus. The elongated tendon of the
lower trapezius can reach to the subacro-
mial space with the same direction of the
infraspinatus. Under arthroscopy, the al-
lograft or the semitendinous tendon is
fixed at the insertion of the infraspinatus
with anchors or introduced into a bony
tunnel and fixed with a locked endobut-
ton. With the arm in external rotation,
the graft is passed through the short ten-
108 Der Orthopäde 2 · 2018
don of the lower trapezius as described
by Pulvertaft. The arm is maintained for
6 weeks in a brace with 20° of external
rotation. Physiotherapy is started sec-
ondary, passively and actively for 3 to
6 months.
In 2016, Elhassam et al. [15] reported
the outcome of 33 lower trapezius trans-
fers extended with an Achilles tendon
allograft performed using an open tech-
nique to reconstruct massive irreparable
posterosuperior rotator cuff tears. At
an average follow-up of 47 months,
32 patients had significant improvement
in pain, subjective shoulder value, and
shoulder range of motion (flexion, 120°;
abduction, 90°; and external rotation
50°). One patient required debridement
for an infection and then later under-
went shoulder fusion. The outcomes in
external rotation are particularly good if
preoperative flexion is greater than 60°.
In 2016, we reported during the instruc-
tional course in the European society
of shoulder and elbow, a prospective
monocentric study of 10 cases to restore
active external rotation in posterosupe-
rior irreparable cuff tears. A minimally
invasive posterior approach was used to
harvest the lower trapezius, followed by
fixation on the footprint by arthroscopy.
At the 1-year follow-up, the external
rotation improved from –20 to 24° with
the arm at the body and –10 to 40°
with the arm in 90° abduction. The
Constant Murley score improved from
35 to 60 points, SST from 3.5 to 7.5, SSV
from 30 to 60%, and the pain decreased
from 7 to 2 (visual analogue scale 0/10).
In addition, 100% of the hornblower’s
sign was corrected.
Lower trapezius transfer is a thera-
peutic option for irreparable posterosu-
perior cuff tears with a lack of active
external rotation. It is indicated for ir-
reparable posterosuperior cuff tears in-
volving supraspinatus, infraspinatus, and
teres minor with a functional subscapu-
laris.
Tendon transfer to repair
irreparable anterosuperior cuff
tear
Pectoralis major transfer
When repair of the subscapularis is not
possible because of significant muscle re-
traction, muscle atrophy, or fatty infil-
tration, transfer of the pectoralis major
tendon can be performed.
Different techniques have been de-
scribed. The entire pectoralis major ten-
don [32], only the clavicular [50], or the
sternal head [31] can be harvested. It has
been reported that—from a biomechan-
ical point of view—the sternal head is
superior for restoring internal rotation.
Moreover, the tendon harvested can
be rerouted to the lesser tuberosity either
underneath or over the conjoint tendon.
It has been shown that rerouting under-
neath the conjoint tendon results in a bet-
ter biomechanical effect than a transfer
above the conjoint tendon. At the same
time, passive tension on the transferred
portion of the pectoralis major muscle
is accomplished [36]. Biomechanically,
the pectoralis major does not respect the
rules of tendon transfer: it comes from
the anterior chest to the humerus which is
posterior and the direction of this tendon
transfer is opposite of the subscapularis
even if it is rerouted under the conjoined
tendon.
Surgery is classically performed in an
open manner with an extended deltopec-
toral approach (12–15 cm) which allows
the anterosuperior cuff to be assessed
and pectoralis major tendon to be har-
vested. No acromioplasty and no section
of the coracoacromial ligament were per-
formed. The musculocutaneous and the
axillary nerves were systematically iden-
tified in order to prevent any damage
particularly when there are many adhe-
sions or in revision surgery. Dissection of
the clavicular and the sternal head is per-
formed easily through the interval sepa-
rating them. The sternal head is inserted
underneath the clavicular head. The clav-
icular tendinous fibers are superficial and
inserted inferiorly. The harvested tendon
was tagged with a nonabsorbable suture
and then passed posteriorly, under the

conjoined tendon, in front of the mus-
culocutaneous nerve.
The area of fixation onto the upper
part of the lesser tuberosity was decorti-
cated and the harvested pectoralis major
tendon was fixed transosseously to the
bone (with two 2.7 mm tunnels) or with
suture anchors. Patients were immobi-
lized in a sling with the arm at the side
in a neutral position for 6 weeks. Passive
external rotation over 30° was allowed
after 4 weeks and active physical therapy
after 6 weeks. Strengthening exercises
were delayed for 6 months.
A review of the literature did not find
any differences regarding the technique:
in a clinical series of 10 patients, Warner
et al. [52] only used the sternal portion of
the pectoralis major. All patients recov-
ered a stable shoulder with a pain relief
but the functional gain was limited. Af-
ter surgery, no patient had a negative lift-
off test. In a series of 12 patients, Resh
et al. [43] harvested the superior half
of the pectoralis major tendon from the
humerus (which includes parts of both
the sternal and the clavicular heads of the
muscle). They observed a significant in-
crease in the Constant score at an average
of 28 months. Four shoulders with pre-
operative anterior instability were stable
at the latest follow-up. After surgery, 3 of
5 patients had a negative lift-off test. Jost
et al. [32] released the whole pectoralis
major tendon from its humeral insertion.
Scores for pain, activities of daily liv-
ing, mobility and abduction strength im-
proved significantly. However, the lift-off
test remained positive in 23 of 30 shoul-
ders. Valenti et al. [49] reported 7 cases of
sternal band compared to 8 cases of clav-
icular band of the pectoralis major under
the coracoid process. These procedures
resulted in a decrease of pain, improved
strength and function of the shoulder,
but we did not find any difference with
regard to the technique.
Latisimus dorsi transfer (LDT)
LDT has been widely proposed for ir-
reparable posterosuperior cuff tear and
Elhassam et al. [11] recently reported
the anatomic feasibility was studied for
anterosuperior irreparable cuff tear. El-
hassan et al. [14] showed in a cadaveric
Hier steht eine Anzeige.
K
study that the potential risk of nerve com-
pression in this technique, including the
axillary, radial, and musculocutaneous
nerves, is very low. The risk of axillary
nerve compressionis higherwiththe teres
major. Latissimus dorsi—an internal ro-
tator—originates from the posterior side
of the chest wall with a similar direc-
tion compared to the subscapularis. An
arthroscopically assisted latissimus dorsi
and preliminary results of 5 cases were
recently reported by Kany et al. [33].
Surgical technique
An anterior minimally invasive axillary
approach allows the latissimus dorsi to
be harvested. With a standard posterior
portal and two anterior portals, the lesser
tubercle is prepared. Sometimes after re-
lease of the remaining subscapularis, it is
possible to partially reinsert it with a me-
dialization; then the LD functions as a
cuff augmentation. Fixation can be done
using two anchors or the aponeurotic
band can be tubularized and introduce
into a bony tunnel at the middle por-
tion of the lesser tubercle and fixed with
a locked cortical button.
Pectoralis minor transfer
This transfer described in 1997 by Wirth
and Rockwood [53] relies on tendon-to-
bone healing, and a modification of this
transfer relying on bone-to-bone healing
was more recently described by Paladini
et al. [41]. This technique involves har-
vesting the pectoralis minor with a bone
chip from the coracoid process and gives
very good results in terms of elevation
and internal rotation without excessively
limiting external rotation. This is a bet-
ter vector of action compared to trans-
fer of pectoralis major, with an adequate
tendon excursion. We extend the short
tendon inserted to the medial edge of the
coracoid with a small bone from the cora-
coid process and fixed it with a little me-
dialization on the less tuberosity to avoid
excessive muscle tension after the transfer
is in place and limitation of the external
rotation. Paladini et al. reported 27 pec-
toralis minor transfers [41]. There were
no cases of musculocutaneous nerve or
brachial plexus injury or graft failure. Ac-
tive forward flexion improved from 127
 Leitthema
Postero
superior tear
Lower
Episcopo LDT+/ -
trapezius
No ER Partial repair
No active
Good AAE AAE limited
ER
Fig. 6 8 Treatment algorithm for patients with a symptomatic irreparable rotator cuff tear. ER external rotation, LDT Latis-
sius dorsi transfer, AAE active anterior elevation, ASCR arthroscopic superior capsule reconstruction, Laf Lafosse classification,
P Minor pectoralis minor, P Major pectoralis major
to 177°; external rotation with the arm
at the side declined by 11°. The Simple
Shoulder Test score improved by 5 points
and the Constant score by 41 points, al-
though the strength subscore did not rise
significantly. The authors concluded that
this transfer can reach the less tuberosity
and is anatomically feasible, safe in term
of the proximity of the musculocutaneous
nerve, and brachial plexus can improve
shoulder function and provide pain relief
in patients with Lafosse grade III sub-
scapularis tears, likely through a tenode-
sis effect.
The open technique transfer of the
pectoralis minor is an invasive procedure
which involves extensive dissection, and
recently Cartaya et al. [6] reported a less
invasive arthroscopically assisted tech-
nique of a pectoralis minor transfer. The
proximity of the brachial plexus under
the pectoralis minor and the musculo-
cutaneous nerve close to the tip of the
coracoid process leads to difficulties with
this anterior arthroscopic approach. The
atraumatic dissection of the pectoralis
minor with bone chips harvested from
the coracoid process and the strong fix-
ation with a special device on the lesser
tuberosity allow a reliable arthroscopic
technique to be performed.
Pectoralis minor transfer is indi-
cated in irreparable tears of the upper
two-thirds of the subscapularis ten-
don (Lafosse grade III; [37]), with
110 Der Orthopäde 2 · 2018
Younger patients
superior tear
Partial P Minor
ASCR
repair Laf III
grade III fatty degeneration, and ir-
reparable supraspinatus tears. Lafossse
grade IV and V are contraindications
for this procedure.
Balloon
Since 2012, several authors have de-
scribed the implantation of a biodegrad-
able subacromial spacer into the subacro-
mial space in symptomatic irreparable
cuff tears [45–47]. The goal of this
spacer is to maintain the position of the
humeral head when the cuff is torn to
facilitate deltoid action. Deranlot et al.
[9] reported 39 consecutive shoulders
(37 patients). They excluded patients
with glenohumeral arthritis (Hamada
>3) or with subscapularis tears. At
the last follow-up (mean 33 months),
forward elevation was significantly in-
creased for all patients (from 130 to
160) and external rotation (from 30 to
45). The mean Constant score was also
significantly improved from 44.8 pre-
operatively to 76.0 postoperatively. No
intra- or postoperative complications
were found except for 1 patient who
required revision for spacer migration.
At the last follow-up, the mean acromio-
humeral distance significantly decreased
from 8.2 to 6.2 mm. The authors con-
cluded that arthroscopic implantation of
a subacromial spacer for irreparable ro-
tator cuff tear is a safe and reproducible
Older patients
Antero Conservative
treatment
Debridement
LDT P Major Biceps
Laf IV /V Laf IV tenotomy
Balloon
Partial
repair
procedure which leads to significant
improvement in shoulder function at
a minimum of 1 year after surgery.
Capsular superior
reconstruction
In 2013, Mihata et al. [40] considered that
patients with posterosuperior irreparable
rotator cuff tears and superior migration
of the humeral head have a defect of
the superior capsule, which is located on
the inferior surface of the supraspina-
tus and infraspinatus tendons. There-
fore, they arthroscopically reconstructed
this capsule with a fascia lata to stabilize
the glenohumeral joint. The graft is in-
serted medial to the superior tubercle of
the glenoid and laterally to the greater
tuberosity. Side-to-side sutures between
the graft and infraspinatus tendon and
between the graft and the soft tissue of the
rotator interval or subscapularis tendon is
performed to improve the function of the
anterior cable. In a total of 24 shoulders
(23 consecutive patients; mean age 65.1
years) with irreparable rotator cuff tears
underwent arthroscopic superior capsu-
lar reconstruction (ASCR) using fascia
lata. Average follow-up after surgery was
34.1 months (range 24–51 months). With
a mean follow-up of 34 months, forward
elevation increased significantly from 84
to 148 and external rotation increased
from 26 to 40. The acromiohumeral
distance increased from 4.6 to 8.7 mm
postoperatively There were no cases of
progression of osteoarthritis. The Ameri-
can Shoulder and Elbow Surgeons (ASES)
score improved from 23.5 to 92.9 points.
No graft tears or no retears of the repaired
rotator cuff tendon were observed during
the follow-up period in 20 of 24 shoul-
ders (83.3%) in the MRI. The authors
concluded that ACSR technique is a reli-
able and useful alternative treatment for
irreparable rotator cuff tears. To decrease
the morbidity of the donor site, recent
papers reported the use of a synthetic
patch (Arthrex Inc, Naples, FL, USA) or
dermal allograft [25].
Conclusion
In symptomatic irreparable rotator cuff
tear, there is no clear surgical guideline
to treat this population and no proce-
dure has scientifically proved superiority.
However, there are many clinical situa-
tions and many available therapeutic op-
tions (. Fig. 6). The medical treatment
should be tried systematically particu-
larly in older patients with a low de-
mand, and surgical options are indicated
in physiotherapy failure. Pseudoparalytic
shoulder defined as an escape superiorly
and anteriorly of the humeral head un-
der the skin with a forward elevation
less than 80° is a contraindication of sur-
gical technique preserving the joint: In
these cases, reverse shoulder arthroplasty
is recommended. If the lack of active el-
evation is combined with a lag sign and
hornblower’s sign, tendon transfer of the
latissimus dorsi and teres major around
the humerus associated with a reverse
shoulder arthroplasty can restore active
external rotation and forward elevation.
Corresponding address
P. Valenti, MD
Paris Shoulder Unit, Clinique Bizet
21 rue Georges Bizet, 75116 Paris, France
philippe.valenti@wanadoo.fr
Compliance with ethical
guidelines
Conflict of interest. P. Valenti declares that he has no
competing interests.
This article does not contain any studies with human
participants or animals performed by any of the au-
thors.
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Fachnachrichten
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