split pectoralis major and teres major tendon transfers ... · split pectoralis major and teres...

Split Pectoralis Major and Teres Major TendonTransfers for Reconstruction of IrreparableTears of the SubscapularisAriane Gerber, MDShoulder, Elbow and Hand ServiceClinic for Trauma and Reconstructive SurgeryCharite, Virchow KlinikumHumboldt UniversityBerlin, Germany

Philippe Clavert, MD, Peter J. Millett, MD, MSc, Thomas F. Holovacs, MD, andJon J. P. Warner, MDThe Harvard Shoulder ServicePartner’s Department of Orthopaedic SurgeryMassachusetts General HospitalHarvard Medical SchoolBoston, Massachusetts

� ABSTRACTIsolated ruptures of the subscapularis and anterosuperiorrotator cuff lesions are encountered more rarely than su-praspinatus or anteroposterior rotator cuff tears. In cer-tain circumstances, reconstruction of the tendon may notbe possible due to fatty degeneration and atrophy of thesubscapularis muscle or poor tendon quality. Tendontransfer may represent the only surgical option for treat-ment. A pectoralis major tendon transfer is an acceptablesalvage option for irreparable subscapularis tendon rup-tures. Although limited functional goals may be expectedin most cases, the majority of patients obtain a good painrelief, which improves their function below chest level.Addition of the teres major component to the transfermay be beneficial in cases where both the upper andlower portion of the subscapularis muscle is irreparable.

Isolated ruptures of the subscapularis and anterosu-perior rotator cuff lesions are encountered more rarelythan supraspinatus or anteroposterior rotator cuff tears.1

Because unspecific complaints like pain and weaknesswithout loss of function are in most cases the only sub-

jective signs associated with subscapularis tears, diagno-sis and treatment occurred often with delay (Fig. 1). Incertain instances, such as chronic tears or subscapularisinsufficiency after previous surgery, reconstruction ofthe tendon may not be possible due to fatty degenerationand atrophy of the subscapularis muscle or poor tendonquality. Tendon transfer may represent the only surgicaloption for treatment.

� HISTORICAL PERSPECTIVEIsolated subscapularis tendon tear was first reported byGerber and Krushell.2 The authors observed that clinicaldiagnosis remains a challenge and described the so-called lift-off sign as a very specific sign for subscapu-laris insufficiency. In a subsequent follow-up of his ex-perience, Gerber reported on his results of repair of thesubscapularis tendon.3 He observed that repairs per-formed for chronic subscapularis tears had a muchpoorer outcome than repairs performed in an acutesetting.

The anterosuperior cuff tear configuration, whichrepresents a tear of the subscapularis in combination withthe supraspinatus and sometimes the infraspinatus, wasnot recognized as a discreet entity before Warner et alpresented their series.4 They observed, as did Gerber,that tears involving the subscapularis often had a delayed

Address correspondence and reprint requests to Dr. Jon J. P. Warner,The Harvard Shoulder Service, Partner’s Department of OrthopaedicSurgery, Massachusetts General Hospital, Harvard Medical School,Boston, MA 02114 (e-mail: [email protected]).

Techniques in Shoulder & Elbow Surgery 5(1):5–12, 2004 © 2004 Lippincott Williams & Wilkins, Philadelphia

� T E C H N I Q U E �

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diagnosis, which resulted in late presentation of the pa-tient for shoulder surgery. As this tear configuration oc-curs usually in younger and active patients, treatment inthe chronic situation after delayed diagnosis is challeng-ing, because recovery of function and strength is essen-tial to this high demanding group of patients.

Few studies have dealt with the management of ir-reparable subscapularis tendon tears. In 1997 Wirth et alreported good to excellent results with pectoralis majortransfer.5

In the original descriptions of the technique of pec-toralis major tendon transfer, the upper portion of thepectoralis major tendon was transferred.5 Others, likeResch, have described a technique in which the upper

portion of the pectoralis major is rerouted underneath theconjoined tendon.6,7 In their opinion, this would give amore favorable line of action for the transfer comparedwith the traditional pectoralis major transfer. However,major concerns with this approach are transfer close tothe musculocutaneous nerve, especially in the setting offailed prior surgery with extensive scarring, and the acuteangle of the tendon transfer around the conjoined tendon.Although the complication rate with this tendon does notseem to be higher than with the conventional transfer,short-term results do not seem to be better than those ofWirth and Rockwood.8

To improve the line of action of the transferred pec-toralis major without jeopardizing the musculoskeletal

FIGURE 2. Lift-off test. This test ispositive when the patient is unable tomaintain the raised position of the handbehind the back.

FIGURE 1. Unspecific subjective com-plaints and compensated shoulderfunction usually lead to a delay in diag-nosis of a subscapularis tear.

Gerber et al

6 Techniques in Shoulder and Elbow Surgery

nerve, the senior one of us (Dr Warner) modified theoriginal pectoralis tendon transfer by rerouting its sternalhead underneath the clavicular head before fixation tothe lesser tuberosity (split pectoralis major transfer, SPMtransfer).9

Recently, the anatomic and biomechanical basis of anew tendon transfer combining the split pectoralis majortendon and the teres major tendon (SPM–TM transfer)has been proposed by one of us (Dr Gerber). The ratio-nale of this combined tendon transfer is to replace theupper and lower portion of the subscapularis muscle withthe split pectoralis major and teres major, respectively.Surgical feasibility has been tested in 20 fresh cadavershoulders (unpublished data); in all cases the teres majorcould be mobilized and fixed to the lesser tuberositywithout jeopardizing its main neurovascular pedicle orthe axillary nerve. Furthermore, a 3-dimensional forcevector analysis showed that the orientation of the trans-ferred teres major is similar to the lower portion of thesubscapularis (unpublished data).

� CLINICAL EXAMINATIONAND IMAGING

History and clinical examination are essential to estab-lish the diagnosis of a subscapularis tear. The lift-off test(Fig. 2) and the belly-press test (Fig. 3) have both beenshown to be reliable clinical tests for subscapularis in-sufficiency.2,3 Increased passive external rotation is an-other very specific test for subscapularis (Fig. 1). Fur-thermore, apprehension in abduction is a reliable clinicalsign for a complete irreparable subscapularis tear.1

Advanced fatty degeneration and atrophy are themain features of irreparable rotator cuff tears10,11 and canbe determined and quantified by CT-scan and MRI.Therefore, preoperative assessment with CT-scan ormagnetic resonance imaging is essential to define musclequality and to design surgical treatment.12,13 This is best

done on the sagital oblique images obtained 2 cm medialto the coracoid process and on the axial views (Fig. 4).

Plain radiographs that demonstrate static anteriorsubluxation on the axillary view may also indicate anirreparable subscapularis tendon tear.14

FIGURE 3. Belly-press test. The pa-tient exerts an internal rotation force onhis belly, with the elbow forward andanterior to the midline of the trunk. Inthe case of a subscapularis rupture, thepatient is unable to keep his hand onhis stomach, with the elbow forward.

FIGURE 4. MRI showing a subscapularis rupture associ-ated with advanced fatty degeneration of the subscapu-laris muscle (parasagital plane medial from the coracoid).

Reconstruction of Irreparable Tears of the Subscapularis

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� INDICATION/CONTRAINDICATIONIndications for reconstruction of irreparable subscapu-laris tears by way of tendon transfer are not yet clearlyestablished. All considerations must be placed in the con-text of the patients’ disability and their expectations forpain relief and functional recovery.

Many factors, like location of the tear (isolated sub-scapularis tears, anterosuperior tears), quality of the ten-don tissue to repair, associated degenerative changes ofthe glenohumeral joint (cuff tear atropathy), number andnature of previous surgeries, and age and compliance ofthe patient, have to be considered prior to surgery.

Regardless of which subtype of pectoralis major ten-don is used for reconstruction, best functional outcomeseems to occur in the younger compliant individual witha symptomatic chronic isolated subscapularis rupture,which is not due to failed previous surgery.5,6 In morecomplex situations, like irreparable anterosuperior tears,subscapularis insufficiency after instability surgery, orarthropathy, outcome is less predictable in regard tofunction. However, it has been our experience that atleast pain relief can be expected after tendon transferwhen treating those conditions. In massive rotator cufftears involving the anterosuperior and posterior parts ofthe cuff and associated with pseudoparalysis, tendontransfer surgery does not seem to be of any benefit andalternative options should be considered. Although ten-don transfer for subscapularis rupture is not contraindi-cated in elderly patients, concomitant medical and socialproblems may bear on recovery and postoperative com-pliance with therapy.

Indication for the split pectoralis major and the com-bined split pectoralis major and teres major transfer isbased on our growing clinical experience. Whereas weuse the isolated spilt pectoralis major transfer to recon-struct irreparable tears of the cranial portion of the sub-

scapularis, it has been our impression that adding theteres major to reconstruct the lower portion of the sub-scapularis in case of loss of the complete subscapularisassociated with anterior subluxation improves clinicaloutcome.

� SURGICAL TECHNIQUEAnesthesia and PositioningSurgery is performed under a combined local regionaland general anesthesia in most cases, allowing for opti-mal pain management and relaxation after extubation.

The patient is placed in the beach chair position usinga beach chair device or a long beanbag that is contouredaround the head and thorax of the patient to allow freeaccess to the shoulder. The use of an arm holder is veryhelpful during the procedure, supporting the arm in thedesired position during dissection and tendon transfer(Fig. 5).

Approach and Subscapularis MobilizationAn extended deltopectoral approach is required to ex-pose the lower border of the pectoralis major and thelatissimus dorsi tendon. Identification of the anteriorstructures can be very difficult in revision surgery andrequires meticulous dissection. First, all adhesions be-tween the humeral head and the deltoid are released. The

FIGURE 5. Beach chair setup with an articulated armholder.

FIGURE 6. Subscapularis rupture. The lower portion ofthe subscapularis is often intact or can be repaired.

Gerber et al


interval between the conjoined tendon and the pectoralismajor is developed. The lesser tuberosity is usually cov-ered by scar tissue that is not the subcapularis tendon,which is retracted medially, deep to the conjoined ten-don. The scar tissue is detached from the lesser tuberos-ity, and a humeral head retractor is used to displace thehumeral head posteriorly facilitating dissection. The bi-ceps tendon, if still intact, is invariably medially dislo-cated and degenerated and is tenotomized. Braided num-ber-2 sutures are passed through the retracted edge of thesubscapularis tendon. The circumflex vessels and the ax-illary nerve are identified. The vessels are controlledwith suture ligature, and a vessel loop is placed aroundthe nerve. A retractor is then placed between the nerveand the underlying subscapularis muscle. The tendon ofthe subscapularis is mobilized. It is imperative that allnecessary steps for subscapularis mobilization be per-formed before the tendon is considered to be irreparable.This includes inferior dissection and mobilization afteridentification and protection of the axillary nerve. In allcases, an attempt should be made to mobilize the sub-scapularis so that even if the inferior portion is the only

remaining component that can be repaired, it is repaired.This may improve stability of the humeral head, and thusmay increase efficiency of the transfer (Fig. 6).

Tendon TransferSPM Transfer. The pectoralis major tendon is identi-fied at its humeral insertion. The plane between the ster-nal and the clavicular head can be found easily at thehumeral insertion and is developed. The tendon of thesternal head, which inserts to the humerus underneath theclavicular head, is carefully dissected and sharply re-leased from the bone humerus (Fig. 7). Number-2,braided, nonabsorbable sutures are placed through theend of the pectoralis tendon using modified Mason-Allenstitches. The sternal head of the pectoralis major muscleis dissected medially so that it can be oriented laterallyand cranially. Medial dissection should not exceed 10 cmto avoid denervation of the sternal part. After dissectionit is pulled underneath the clavicular portion of themuscle (Fig. 8). If the lower portion of the subscapularis

FIGURE 7. The sternal portion of the pectoralis major isdetached from the humerus.

FIGURE 8. The sternal head of the pectoralis tendon istransferred underneath the clavicular portion of themuscle.


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is still intact or has been repaired, the transferred tendonis fixed to the lesser tuberosity. This is performed usingtransosseous sutures or anchors. To complete the repair,the leading edge of the transferred pectoralis major issutured to the leading edge of the supraspinatus to closethe rotator interval. Adequate tensioning of the transferrequires surgical experience. As a rule the transfer shouldalready be tight in neutral rotation, but still allowing 30°of passive external rotation. Depending on the length ofthe transfer, fixation of the tendon laterally from thebicipital groove may be necessary to achieve adequatetension.Combined SPM–TM Transfer. In the presence of acomplete irreparable subscapularis tear, the teres major isadded to the split pectoralis major transfer. Dissection ofthe teres major tendon is performed prior to fixation ofthe SPM transfer.

The technique of dissection was developed by one ofus (Dr Gerber) after careful cadaveric dissections (un-published data). With the arm in maximal external rota-tion, the tendon of the latissimus dorsi is exposed. Theupper and the lower border are dissected before the ten-don is released from the humerus. To allow refixation of

the latissimus tendon at the end of the procedure, a 1cmlarge cuff of tendon is left at the humeral shaft. Therelease tendon is reflected medially after 3 number-2braided non-absorbable sutures have been placed in thetendon (Fig. 9). The plane between the latissimus dorsiand the teres major tendons is well defined laterally,close to their humeral insertion. Medially the plane be-comes less clear and dissection must be meticulous toavoid any damage to the short tendon of the teres majormuscle. After exposure of the upper and lower border ofthe teres major muscle, the tendon is elevated subperi-osteally from the humeral shaft and 3 sets of number-2braided non-absorbable sutures are placed through thetendon in a modified Mason-Allen configuration (Fig.10). The teres major tendon is then mobilized by releas-ing adhesions to the latissimus dorsi. Dissection at theupper border of the teres major should be performedcarefully to avoid any damage to the axillary nerve andthe posterior circumflex vessel. Furthermore, medial dis-section between latissimus dorsi and teres major shouldnot exceed 7 cm from the humeral end of the teres majortendon to save the main pedicle of the transfer. Usuallyadhesions limiting cranial mobilization are found be-tween the lower edge of the teres major and the latissi-mus dorsi and must be released. Before doing so, thesurgeon should be aware of the exact location of the

FIGURE 9. The latissimus dorsi tendon is detached fromthe humerus to expose the teres major tendon.

FIGURE 10. The teres major tendon is detached from theproximal humerus. All adhesions to the latissimus dorsiare released.

Gerber et al


radial nerve and the deep brachial artery. Finally thetendon is transferred to the lower portion of the lessertuberosity. The latissimus is repaired to the humeral shaft(Fig. 11).

After both the SPM and the TM has been transferred,both tendons are fixed to the lesser tuberosity, usingtransosseous sutures or anchors (Fig. 12). The TM isfixed first, using the criteria defined above for tension-ing. Then the SPM is fixed to the upper lesser tuberosity,adjusting tension accordingly. Finally the rotator intervalbetween the leading edges of the supraspinatus and SPMand the interval between the leading edges of the SPMand TM are sutured to improve stability of the fixation.

At the end of the procedure, passive motion is mea-sured, especially for external rotation, to guide postop-erative rehabilitation.

� POSTOPERATIVE MANAGEMENTThe shoulder is immobilized in a sling for 6 weeks. Strictpassive range of motion is mandatory for the first 6weeks following surgery. After 6 weeks the sling is re-moved and gentle active-assisted motion is initiated. Ingeneral, the postoperative therapy program goes much

slower than in the cases of a primary rotator cuff repair.Strengthening is started not earlier than the third postop-erative month. Return to work or sports is not expectedbefore the sixth month after. As for the latissimus dorsitransfer, completion of rehabilitation requires 12 to 18months.

� RESULTS AND COMPLICATIONSOur experience with the STM transfer and the combinedSPM–TM transfer is based on the follow-up of 20 pa-tients. All patients had an irreparable subscapularis rup-ture after previous surgery. A SPM transfer was per-formed in 11 patients, whereas 9 patients underwent acombined SPM–TM transfer. In all cases the procedurewas carried out without complications.

In the SPM group the mean ASES score at an aver-age follow-up of 38 months improved from 42 to 61points and 9 of 11 patients had significant pain relief.Two patients had persistent pain, which was attributed toa rupture of the transfer and had to be reoperated.

In the combined SPM–TM group, the mean ASES

FIGURE 11. Both tendons are transferred to the lessertuberosity.

FIGURE 12. Reconstruction of the upper part of the sub-scapularis with the pectoralis major and the lower partwith the teres major.


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score increased from 34 to 55 points, and 7 of 9 patientshad significant pain relief. One patient had persistentinstability 1 year after transfer and underwent fusion asthe seventh and last procedure. At the time of surgery thepectoralis major component of the transfer was found tobe ruptured.

In both groups functional gains were limited and thesubscapularis tests remained positive. A fair comparisonwith already published reports on pectoralis major trans-fer for irreparable subscapularis insufficiency is difficult,because all of our patients already had surgery prior totransfer (1–6 procedures) and many of them had not anisolated subscapularis tear, but a anterosuperior tear.

� CONCLUSIONA split pectoralis major muscle transfer is an acceptablesalvage option for irreparable subscapularis tendon rup-tures. Although limited functional goals may be expectedin most cases, the majority of patients obtain a good painrelief, which improves their function below chest level.Addition of the teres major component to the transfermay be beneficial in cases where both the upper andlower portion of the subscapularis muscle is irreparable.Encouraging results in a negative selection of patientsjustify further investigation. Three-dimensional vectoranalysis of the pectoralis major transfer and its subtypesis ongoing and may help in optimizing transfer surgeryfor irreparable subscapularis tears.

� REFERENCES

1. Warner JJ. Management of massive irreparable rotator cufftears: the role of tendon transfer. Instr Course Lect. 2001;50:63–71.

2. Gerber C, Hersche O, Farron A. Isolated rupture of thesubscapularis tendon. J Bone Joint Surg Am. 1996;78-7:1015–1023.

3. Gerber C, Krushell RJ. Isolated rupture of the tendon of thesubscapularis muscle. Clinical features in 16 cases. J BoneJoint Surg Br. 1991;73-3:389–394.

4. Warner JJ, Higgins L, Parsons I, et al. Diagnosis and treat-ment of anterosuperior rotator cuff tears. J Shoulder ElbowSurg. 2001;10-1:37–46.

5. Wirth MA, Rockwood CA Jr. Operative treatment of ir-reparable rupture of the subscapularis. J Bone Joint SurgAm. 1997;79-5:722–731.

6. Resch H, Povacz P, Ritter E, et al. Transfer of the pecto-ralis major muscle for the treatment of irreparable ruptureof the subscapularis tendon. J Bone Joint Surg Am.2000;82-3:372–382.

7. Galatz LM, Connor PM, Calfee RP, et al. Pectoralis majortransfer for anterior-superior subluxation in massive rotatorcuff insufficiency. J Shoulder Elbow Surg. 2003;12-1:1–5.

8. Gerber C, Hersche O. Tendon transfers for the treatment ofirreparable rotator cuff defects. Orthopaedic Clinics ofNorth America. 1997;28-2:195–203.

9. Warner J. Management of massive irreparable rotator cufftears: the role of tendon transfers. Instructional course lec-tures. J Bone Joint Surg Am. 2000;(in press).

10. Goutallier D, Postel JM, Lavau L, et al. Impact of fattydegeneration of the supraspinatus and infraspinatusmuscles on the prognosis of surgical repair of the rotatorcuff. Rev Chir Orthop Reparatrice Appar Mot. 1999;85-7:668–676.

11. Gerber C, Fuchs B, Hodler J. The results of repair of mas-sive tears of the rotator cuff. J Bone Joint Surg Am.2000;82-4:505–515.

12. Goutallier D, Postel JM, Bernageau J, et al. Fatty muscledegeneration in cuff ruptures. Pre- and postoperativeevaluation by CT scan. Clin Orthop. 1994;304:78–83.

13. Fuchs B, Weishaupt D, Zanetti M, et al. Fatty degenerationof the muscles of the rotator cuff: assessment by computedtomography versus magnetic resonance imaging. J Shoul-der Elbow Surg. 1999;8-6:599–605.

14. Gerber C, Nyffeler RW. Classification of glenohumeraljoint instability. Clin Orthop. 2002;400:65–76.

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split pectoralis major and teres major tendon transfers ... · split pectoralis major and teres...

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