Sunday, September 8, 2013

Irreparable rotator cuff tears - is there a role for tendon transfers?

Tendon Transfers for Irreparable Rotator Cuff Tears

After analyzing 56 articles related to the use of the latissimus dorsi, the pectoralis major, and the trapezius, the authors of this review concluded that the indications for tendon transfers are "not clearly defined". Although the goal of transfers is to improve strength, mechanics and function by restoring the "glenohumeral force couple", they found that  "functional benefits are unpredictable".

What is clear is these tendon transfers are not minor surgery (see the figures in the article), carry a risk of failure and complications, and require substantial periods of immobilization in an orthosis followed by lengthy rehabilitation. 

While the authors found that these procedures can be associated with improved shoulder comfort, we note that improved comfort can also be realized after procedures the goal of which is simply to restore the smoothness and flexibility of the shoulder, even after prior failed repair attempts.  In the future, it will be important to determine if tendon transfers have any advantages over simpler, safer procedures in terms of their value (clinical improvement/(cost+risk))

In our practice we offer the 'smooth and move' procedure to patients who have  irreparable cuff tears and who have no arthritis and who do not have pseudoparalysis or anterosuperior esscape. The advantages of the smooth and move are (1) it is a short, safe procedure that is accomplished without detaching the deltoid, (2) it restores smoothness of the passage of the upper humerus beneath the coracoacromial arch without sacrificing the stability offered by the acromion and the coracoacromial ligament, (3) because it includes a gentle manipulation, it restores passive flexibility of the shoulder, (4) passive and active rehabilitative exercises and activities of daily living can be started immediately after surgery, and (5) it does not prevent any subsequent procedures (such as transfers, CTA arthroplasty or reverse total shoulder).

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