Transplantation of teres maior muscle for infraspinatus

muscle in irreparable rotator cuff tears

tuigi Celli, MD, Claudia Rovesta, MD, Maria Carmen Marongiu, MD, and Stefano Manzieri, MD,
Moa’ena, lkdy

The authors suggest transfer of teres major muscle for a Between 1990 and 1992 the authors performed
detached and atrophic infraspinafus muscle in krepara6le observations on 5 cadavers to evaluate the use of the
rotator cuff fears. Original studies were done on cadavers. teres maior muscle as a transfer for the infraspinatus
In the period between November 1993 and June 1994, we (keeping the scapular insertion, transferring the muscle
used this technique on 6 patients. Those patients were eval- into the infraspinatus fossa, and reinserting the distal
uated with the Consfanf-Mudey fesf and improved from an tendon into the greater tuberosity after changing its ori-
entation).7
average of 40 poinfs lrn;n;rnurn 27 fo maximum 541 before
Our observations were in agreement with those of
surgery fo an average of 62 poktfs lmin;mum 47 fo maxi-
Combes and Mansat.
mum 78j affer surgery. Acfke exferna/ rofafion recovered
1. The teres maior muscle can be separated from the
35’ in abducfion and 24’ in addu&on. The teres major latissimus dorsi muscle in both its muscular and
transferred on great fuberosiv is able to restore confinu;v tendinous parts; therefore it is possible to perform
of the cuff and fo depress fhe head of the humerus. If is its isolated transfer.
important to re-educafe the transferred muscle because if 2. The length of the teres major allows its reinsertion
j&al/y contracts more in add&on and internal rotation into the greater tuberosity with the correct ten-
than ;n exferna/ rofafion. One patient was very safisfied sion.
and 5 patients were saf&ed after surgical freafmenf. [J 3. The length and thickness of the teres maior ten-
Shoulder Elbow Surg 1998;7:485-90.) don (approximately 3 cm) allow the repair of
massive cuff tears with no subacromial encum-
E xternal rotation of the shoulder is an essential move- brance (a problem that can arise in cases where
ment in the normal function, because it allows for transfer of the teres major is combined with the
exploration of surrounding space not only with the arm latissimus dorsPflO).
adducted but also in abduction over 60’. The infra- 4. The transfer of the teres maior can be performed
spinatus muscle has a dual function: it is an external without either stretching or angulation of the neu-
rotator and helps to keep the humeral head centered. rovascular pedicle.
When infraspinatus muscle activity has been lost Based on these anatomic studies, we decided to per-
because of peripheral nerve lesions or irreparable form the transfer of the teres maior muscle for the infra-
degenerative tendon lesions with muscle atrophy, it is spinatus in 6 patients. The purpose of this article is to
possible to restore its functions by means of a muscle present a preliminary report of our surgical experience
transfer, and the results that have been achieved.
In patients with upper obstetric palsy,‘9 the teres
major and latissimus dorsi have been used by chang- MATERIALS AND METHODS
ing the orientation of their distal tendon inser- Between November 1993 and June 1994, after having
tionllJ13J2J3 or by inserting the 2 tendons into the used the teres major transfer in 4 obstetric palsies, we per-
humeral greater tuberosity. 12,17~18 For massive rotator formed it in 6 patients with massive rotator cuff tears and
cuff tears Gerber et allo proposed the transfer of only irreparable infraspinatus damage. The transfer was indi-
the latissimus dorsi into the greater tuberosity to repair cated for cases in which the infraspinatus was irreversibly
the rotator cuff with a vascularized tendon, to recenter damaged, there was no major de enerative osteoarticular
the humeral head, and to restore external rotation. alteration present (arthropathy cu 7f tear), passive external
rotation was still present (40’ at least), and the supraspina-
tus was still functional or its function could be restored
From the Department of Surgery, Orthopaedic Clinic, University through a direct reconstruction or transfer.
of Modena. In cases of cuff tears the clinical picture was document-
Reprint requests: tuigi Celli, MD, Orthopaedic Clinic, targo del ed first with electromyographic analysis to exclude a
Pozzo 71,411OO Modena, Italy. peripheral nerve lesion and then with ultrasonographic
Copyright @ 1998 by Journa/ of Shoulder and Elbow Surgev and magnetic resonance imaging analysis. These assess-
Board of Trustees. ments allowed us to detect the size and extent of the lesion,
1058-2746/98/$5.00 + 0 32/l/88991 muscle atrophy with adipose degeneration, and fibrosis of

485
 486 Celli et al J Shoulder Elbow Surg
September/October 1998

Table I Patients with irreparable rotator cuff tears

Patient Constant-Muriey Score Constan&Murley Score

No. be Sex Side Cause (preoperative) Surgery (postoperative)

Degeneration TM for infraspinatus 58

; 2: i Degeneration TM for infraspinatus
Tr for supraspinatus
61 F Degeneration TM for infraspinatus :z
: z Degeneration i; TM for infraspinatus 59
5 ii iti R Trauma 27 TM for infraspinatus
Tr for supraspinatus 47
6 24 M R Trauma 54 TM for infraspinatus 78

TM, transfer of teres maior.

Tr, transfer of trapezius.

the infraspinatus muscle that hindered direct repair of the After surgery the patient is immobilized in a thoraco-
cuff and restoration of function. brachial plaster cast with the arm abducted to 60°, in 30
Among 6 patients with rotator cuff tears, 4 had a to 40’ external rotation. The plaster cast is replaced by a
degenerative tear (2 men and 2 women, average age 60 thoracobrachiai brace, allowing the atient to start a reha-
years), and 2 (men with an average age of 28 years) had bilitation program at 3 months that rallows a precise and
a traumatic tear, 1 of these combined with neurologic del- progressive schedule.
toid deficiency. In all these cases the right arm was affect-
ed. In the 2 patients who had severe irreparable supra- RESULTS
spinatus damage, we combined the teres maior transfer
with the trapezius transfer pro su raspinatus. All patients We evaluated the results of cuff tear repairs with the
had significant signs of pain and rimited use of the arm in Costant-Murley system (average follow-up period 14
everyday life and working activity. In those patients with months, maximum 18 months, minimum 11 months).
rotator cuff tear, the Constant-Murley rating system was We obtained an average significant improvement of
used (Table I).* 22 points, of which 6 were the result of pain relief. The
patient’s “disability” grade deriving from shoulder
Surgical technique
defect was quantified based on possible activity level
The patient is put under general anesthesia and is according to age and sex (Table I). According to this
placed in the lateral decubitus position with the trunk system 5 patients showed overall functional improve-
raised by approximately 30’. In the last 2 cases we used
ment, going from a total or severe disability to a slight
a beach chair position. After acromioplasty has been per-
formed and the irreparability of the infraspinatus tendon or moderate one.
has been assessed, the teres maior is isolated. The skin An average gain of active external rotation equal to
incision is curvilinear and convex at the top, at the level of 35” with arm abducted to 90° and equal to 24’ with
the posterior axilla pillar, and goes from the external mar- arm adducted was observed.
gin of the scapula to the upper third of the humerus. Our observations brought out a difference between
The teres maior is isolated from the scapular origin to passive external rotation and gain in active motion
the humeral insertion by separating it from the latissimus resulting from the transfer, with an average gap of 25’
dorsi. In this phase the axillary nerve in the quadrilateral in abduction and 36’ in adduction of the arm (Figures
space is isolated and protected. The arm is brought into
4 and 5).
maximum internal rotation to visualize the humeral inser-
To assess the cause of this difference, we performed
tion of the teres major; the tendon is then taken with the
periosteum of the insertion [Figure 1). This technical device clinical, ultrasonographic, roentgenogt!aphic, and elec-
allows us to take the whole tendon while leaving the latis- tromyographic analysis and evaluated the following:
simus dorsi insertion fibers intact. integrity of the transferred muscle, good coverage and
Once the neurovascular pedicle of teres ma’or has been recentering of the humeral head, and the presence of
isolated, tetanizing stimulations are performe cl to evaluate contractile activity in the transferred muscle, evaluated
the functioning of the transfer: contractility and shortening in external rotation with arm adducted and abducted to
in maximum contraction (Figure 2). Once the teres maior 9o”.
and its pedicle have been prepared, keeping the scapular In 3 patients affected by cuff tear we detected main-
insertion, the transfer is moved into the subacromial space
tained contractility of the teres maior by electromyog-
passing beneath the deltoid, keeping the transferred mus-
raphy during the movement phase (external rotation-
cle parallel to the infraspinatus. The tendon is anchored
into the greater tuberosity with transosseous sutures, com- internal rotation), in which the muscle is mostly active.
bined with a plastic reconstruction of the cuff (Figure 3). We also detected the presence of cocontraction of the
Sutures are tied with the arm abducted to 40’ in maximum teres maior and latissimus dorsi.
external rotation. The previously described assessments allow us to
J Shoulder Elbow Surg Celli et al 487
Volume 7, Number 5

Figure 1 Teres major muscle is prepared from scapular origin

and detached from humerai insertion. Tendon is taken together
with periosteum insertion.

Figure 2 Once vascular-nervous peduncle of teres maior has

state that the transferred teres major maintains a good been isolated, tetanizing stimulations are performed (A) to evalu-
covering of the humeral head, helps to depress and ate functional@ of transfer. B, Contractiliiy and shortening in max-
recenter the humeral head, and contracts and is active imum contraction.
in external rotation. According to our observations the
transferred muscle maintains its synergism with the latis-
simus dorsi and contracts in internal rotation as well.
with average values of 40’,11 x?‘,*’ and no improve-
DISCUSSION ment.20 More recently, Sahal* and Hoffer et al.12 pro-
The surgery described by L’Episcopo,l3 Zachary,22 posed transfer of the teres maior and latissimus dorsi
Green,” and Zancolli and Zancolli,23 consisting of the tendons to the rotator cuff into the insertion of the infra-
transfer of the latissimus dorsi and teres maior tendon spinatus or teres minor, and they obtained an improve-
into the humeral diaphysis, yields good results in terms ment in external rototion (64”) and abduction (45’).
of restoration of external rotation.113 In these cases In shoulder abduction the integrity of the posterior
improvement in strength of abduction is controversial, cuff, not only of the supraspinatus, is essential to main-
488 Celli et al J Shoulder Elbow Surg
September/October 1998

Figure 3 Teres ma)or muscle is transferred into infraspinatus fossa under deltoid muscle (A, B) and reinserted into greater tuberosity (C)
to close rotator cuff tear.

EXTRAROTATION WITH ARM ADDIJCTED

P.G. G.G. D.S. F.I. G.S, V.G

Figure 4 Extrarotation movement with arm adducted in patients with rotator cuff tears. Average active external rota-
tion gain is 24’, with average gap of 36O between passive and active motion.

tain the balance between the force couples on the ver- the infraspinatus, Gerber et aP,lO choose to use only the
tical and horizontal planes, thus ensuring the perma- latissimus dorsi to prevent subacromial encumbrance.
nent static and dynamic recentering of the humeral Our choice and that of Bellumore et al2 and Combes
head.3 and Mansat is to use teres maior.
A lesion in the posterior cuff brings out the problem The advantages offered by this transfer are the following.
of strength recovery in young patients who need func- 1. It is physiologically more like the infraspinatus
tional shoulders. For massive irreparable rotator cuff because it is a scapulohumeral muscle.
tears affecting the supraspinatus and infraspinatus, 2. It can be transferred into the infraspinatus fossa
some reconstructive techniques have been presented and its orientation superimposed on the infra-
that aim at restoring the muscular forces that are essen- spinatus.
tial for an improvement of abduction and external 3. Its tendon is long enough to be inserted into the
active rotation.1/415f14,15~16 greater tuberosity.
In cases of rotator cuff tears that would allow the use 4. The surgical operation does not present mator
of both latissimus dorsi and teres mator as transfers for technical difficulties in the beach chair position.
J .%ou/der Elbow Surg Celli et al 489
Volume 7, Number 5

EXTRAROTATION WITH ARM ABOLICTED

P.G, G.G. D S. F I. G.S. VG,

Figure 5 Extrarotation movement with arm abducted to 90’ in patients with rotator cuff tears, Average active exter-
nal rotation gain is 35’, with average gap of 2.5’ between passive and active motion.

In our experience the transferred muscles always acromial space because of bulk. We hare verified that
maintained viability. the isolated transfer of 1 of the 2 muscles allows the
The disadvantages and difficulties that this transfer opposite antagonistic activity of the other one and that
can present are the following. the transferred teres maior can act as an external rota-
1. It can be difficult to establish the correct tension tor. Therefore when the main aim is restoration of
in the transfer into the greater tuberosity. Tension active external rotation, it is not possible to transfer the
must be determined by assessing the presence of teres major while maintaining an opposite function in
satisfactory internal rotators and the passive the latissimus dorsi. For a better restoration of external
motion in internal and external rotation to prevent rotation and the maintenance of humeral head recen-
the loss of internal rotation. tering, we deem it useful to combine the transfer of the
2. The transfer of the teres major cannot completely teres major with transfer of the latissimus dorsi as exter-
replace supraspinatus function, especially re- nal rotators.
garding the superoinferior and anteroposterior
plane stability, that is essential for a dynamic
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