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Transfer of the Pectoralis Major Muscle for the Treatment of Irreparable Rupture of the Subscapularis Tendon*

H. RESCH, M.D., P. POVACZ, M.D., E. RITTER, M.D. and W. MATSCHI, PH.D., SALZBURG, AUSTRIA

Investigation performed at General Hospital Salzburg, Salzburg

	Abstract

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Background: The clinical diagnosis of a tear of the subscapularis tendon is difficult, and the resulting delays frequently cause a major time-lapse before repair is attempted. Diagnostic delay often means that surgical repair is no longer possible. In twelve patients who had an irreparable tear of the subscapularis tendon, the superior one-half to two-thirds of the tendon of the pectoralis major muscle was used as a substitute for the subscapularis tendon. In order to adapt the orientation of the transferred muscle to that of the subscapularis, it was routed behind the conjoined tendon of the coracobrachialis muscle and the short head of the biceps to the lesser tuberosity.

Methods: The operations were performed between May 1993 and June 1997. The average age of the twelve patients was sixty-five years old (range, forty-nine to eighty-one years old). Eight patients had an isolated rupture of the subscapularis tendon, and four had a concomitant lesion in the form of either a partial or a complete rupture of the supraspinatus tendon. The dominant symptoms were anterior shoulder pain and weakness that had responded poorly to nonoperative therapy. Four patients also had signs of recurrent anterior instability.

Results: After an average follow-up interval of twenty-eight months (range, twenty-four to fifty-four months), nine of the twelve patients assessed the final result as excellent or good; three, as fair; and none, as poor. Pain was reduced, with the score improving from an average of 1.7 points (of a maximum of 15 points) preoperatively to an average of 9.6 points postoperatively. The patients' subjective functional evaluation improved from an average score of 20 points preoperatively to an average of 63 points postoperatively. The average functional rating with use of the Constant and Murley score increased from 26.9 to 67.1 percent of normal. All four preoperatively unstable shoulders were stable at the time of the latest follow-up.

Conclusions: This repair technique can be recommended as a reconstructive procedure for elderly patients who have an irreparable tear of the subscapularis tendon.

	Introduction

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The symptoms of a tear of the subscapularis tendon as described in the literature are anterior shoulder pain with dysfunction and weakness and a poor response to nonoperative therapy^6,9,10,15,19. Both the pain and the dysfunction may be caused by a loss of balance between the anterior and posterior elements of the rotator cuff, which changes the kinematic pattern of the shoulder^1,2. There is also agreement in the literature that the clinical diagnosis of a subscapularis tendon tear is difficult, often leading to a delay of months or even years before surgical repair is attempted^6,9.

Unlike an isolated rupture of the supraspinatus tendon, a rupture of the tendon of the subscapularis muscle can be followed by retraction of the tendon, which is unhindered by intact tendon tissue alongside of the rupture site. After a delay of several months or years, this retraction makes repair very difficult. Gerber et al. reported significantly better results in patients who had had only a short delay between the traumatic event and the repair compared with those who had had a considerable delay before the operation¹⁰. The average time between the injury and the operation in their series was fifteen months (range, one to fifty-six months)¹⁰.

Compared with tears of the supraspinatus and infraspinatus tendons, rupture of the subscapularis tendon is rare. Codman reported involvement of the subscapularis tendon in only 3.5 percent of 200 rotator cuff tears³. Deutsch et al. found major involvement of the subscapularis tendon in fourteen (4 percent) of 350 rotator cuff tears⁶, and Frankle and Cofield reported involvement of the subscapularis tendon in twenty-five (8 percent) of 301 full-thickness rotator cuff tears⁷. Hauser¹², Neviaser et al.¹⁵, and Wirth and Rockwood¹⁹ described subscapularis tendon tears following anterior traumatic dislocation of the shoulder. In the series of Neviaser et al., of thirty-one patients with a rotator cuff tear following dislocation of the shoulder, eight had a subscapularis tendon tear with consequent recurrent shoulder instability¹⁵. In the series of Wirth and Rockwood, of 221 patients who were operated on because of anterior instability, eighteen had a subscapularis tendon tear¹⁹. In 1991, Gerber and Krushell described sixteen patients with an isolated tear of the subscapularis tendon, which was clearly the result of trauma involving hyperextension of the arm or extreme external rotation of the adducted arm⁹. In 1997, Deutsch et al. reported on fourteen patients who had an isolated rupture of the subscapularis tendon⁶; eleven patients had the same mechanism of injury as described by Gerber and Krushell⁹.

The delay caused by difficulties in diagnosis leads to a situation in which mobilization of the retracted tendon is no longer possible or repair is not indicated because of the degree of atrophy in the muscle. On the other hand, persistent pain with shoulder dysfunction and, in some cases, pronounced anterior instability call for some form of surgical intervention. The irreparable subscapularis tendon can be replaced with the superior portion of the pectoralis major tendon. Wirth and Rockwood detached the superior half of the tendon of the pectoralis major from the humerus and transferred it superiorly to the humeral head¹⁹. However, with use of this procedure, the course of the subscapularis muscle is not followed and soft tissue is not interposed between the humeral head and the coracoid process.

The aim of the current study was to find a muscle-tendon unit to replace an irreparably torn subscapularis tendon and to evaluate the results following surgery.

	Materials and Methods

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Between May 1993 and June 1997, twelve patients who had a chronic, irreparable rupture of the tendon of the subscapularis muscle were operated on with use of a portion of the tendon of the pectoralis major muscle as a substitute. At the time of the intervention, the patients (ten men and two women) had an average age of sixty-five years (range, forty-nine to eighty-one years). The right shoulder was involved in seven patients and the left shoulder, in five. Eight patients had involvement of the dominant shoulder. Nine patients had sustained a definite injury. Three of them sustained the injury in a downhill-skiing accident, one was injured in a cross-country-skiing accident, two fell on a level surface, one fell from a ladder, one slipped on ice, and one had an accident at work. This last patient was the only one who was able to provide a precise description of the mechanism of injury (the adducted arm was subjected to abrupt external rotation). Three patients had no clear memory of a traumatic event. Four patients had a traumatic injury that caused anterior shoulder dislocation followed by recurrent anterior instability. Two patients had symptoms that were so severe they had very little functional use of the arm.

Eight of the twelve patients had been examined initially at an outside institution, where the correct diagnosis had been made for only one. Two patients had had a previous repair of the rotator cuff, which had failed to reveal the rupture of the subscapularis tendon. The average interval from the traumatic event or the onset of the symptoms to the surgical procedure was twenty-seven months (range, sixteen to sixty months).

When first seen in our department, all twelve patients reported disabling anterior shoulder pain radiating into the upper arm and down as far as the hand. The pain occurred during the night and during activities of daily living. All patients had pronounced dysfunction and weakness, and two of the four patients with shoulder instability had almost complete loss of arm function.

Active flexion of the involved shoulder was identical to that on the contralateral side in seven patients, and it was reduced by an average of 36 degrees in five. Active flexion in the twelve patients averaged 93 degrees (range, 30 to 170 degrees). In six patients active abduction was the same as that on the uninjured side, and in six it was reduced by an average of 38 degrees. Active abduction in the twelve patients averaged 85 degrees (range, 20 to 170 degrees). Ten patients had the same amount of active external rotation on both sides, and two had less active external rotation on the injured side. Measurements of passive external rotation were available for only eight patients; in five, it was an average of 10 degrees greater on the injured side than on the contralateral side. Evaluation of internal rotation showed that two patients were able to touch the lumbar spine; three, the sacrum; five, the buttock; and two, the thigh only.

The lift-off test as described by Gerber and Krushell⁹ could be used for the five patients who could touch their back. All five had a positive result—that is, they were incapable of maintaining the raised position of the hand behind the back. Eight patients were evaluated with the so-called belly-press test¹⁰, and all eight had a positive result—that is, when they exerted pressure on the stomach they were not able to maintain the elbow anterior to the midline of the trunk as viewed from the side; instead, the elbow dropped back behind the trunk (Figs. 1-A and 1-B). In our study, the test was performed with the examiner's hand inserted between the patient's hand and stomach to assess the pressure exerted on the stomach compared with that exerted by the hand on the uninjured side. All patients demonstrated a difference in the pressure exerted against the stomach compared with that exerted by the hand on the contralateral side. Eight of the twelve patients were able to perform strength tests with the arm in 90 degrees of abduction and 90 degrees of flexion; a spring balance was used to measure the force in the wrist in kilograms. The remaining four patients were not able to raise the arm actively to 90 degrees for testing. The spring balance also was used, for all twelve patients, to measure internal rotation strength against manual resistance with the upper arm adducted and the forearm in the neutral position.

View larger version (116K): [in this window] [in a new window]   FIG1-A: Figs. 1-A and 1-B: Photographs of a patient performing the belly-press test. Fig. 1-A: Positive result on the injured side. With the hand pressed against the belly, the patient cannot maintain the elbow anterior to the midline of the trunk as seen from the side.

View larger version (103K): [in this window] [in a new window]   FIG1-B: Fig. 1-B: Negative result on the contralateral side. The elbow remains in the frontal plane.

Intraoperative Findings
Eight patients were found to have an isolated rupture of the subscapularis tendon, with avulsion from the lesser tuberosity. In the remaining four patients, the rupture of the subscapularis tendon was combined with a rupture of the anterior half of the supraspinatus tendon (two patients) or with a complete tear of the supraspinatus tendon (two patients). All four patients demonstrated clinical signs of anterior instability; two had recurrent anterior dislocation and two, recurrent anterior subluxation. In eight patients, the subscapularis tendon tear was complete, whereas in four, tendinous fibers that were approximately five millimeters wide remained intact at the distal margin. In eight patients, the long head of the biceps had ruptured; in three, it was completely dislocated anteriorly; and in one, it was subluxated anteriorly.

Anatomical Study
Before the surgery was performed, the practicality of using a portion of the pectoralis major muscle to replace the subscapularis was studied in twenty shoulders from fourteen fresh cadavera. The assumption was that the portion of the pectoralis major muscle to be transferred should be routed behind the conjoined tendon of the coracobrachialis muscle and the short head of the biceps. This analysis focused on the neurovascular supply to the pectoralis major muscle, the distance to be bridged by the transferred muscle, the route behind the conjoined tendon, the course of the musculocutaneous nerve, the width of the tendon defect, and the width of the pectoralis major tendon. It has been shown that longitudinal dissection of the clavicular portion of the pectoralis major muscle does not disturb the neurovascular supply in either the dissected or the remaining part of the muscle because of its segmental supply¹³. In all twenty shoulders, a muscle transfer was performed, as will be described. In no shoulder was the muscle transfer impaired by the musculocutaneous nerve. In a previous study, the length of the musculocutaneous nerve from the tip of the coracoid process to the point of insertion in the muscle belly of the conjoined tendon was measured for another purpose in seventy-nine shoulders and the average distance was found to be 5.4 centimeters (range, two to 11.2 centimeters)¹⁶.

Operative Technique
All operations were performed with the patient under general anesthesia and in a beach-chair position. The deltopectoral approach was used to expose the conjoined tendon, the tendon of the pectoralis major, and the anterior surface of the humeral head. The scar-like or bursa-like tissue found in the area of the defect was removed. In all patients, an attempt was made to mobilize the subscapularis muscle, but this was impossible because of pronounced retraction and atrophy. In patients in whom the long head of the biceps was dislocated anteriorly, it was tenotomized and the distal portion was sutured to the intertubercular groove.

The tendon of the pectoralis major was exposed over its full length at the humerus, and the superior one-half to two-thirds of the tendon (depending on the size of the defect) was detached from the humerus (Fig. 2-A). The muscle fibers corresponding to the detached section of the tendon were split by blunt dissection over a length of approximately ten centimeters between the clavicular and sternal portions in order to take only the clavicular part for the transfer, working from the insertion medially. The muscle fibers of the sternal portion that radiate from dorsal into the proximal part of the tendon had to be transected. This left the clavicular portion of the pectoralis major muscle attached to the tendon with the exception of the transected muscle fibers just mentioned. The sternal portion remained intact.

View larger version (94K): [in this window] [in a new window]   FIG2-A: Figs. 2-A, 2-B, and 2-C: Surgical technique. Fig. 2-A: Schematic view of the detachment of the superior one-half to two-thirds of the pectoralis major tendon from the humerus.

The stay sutures attached to the tendon of the pectoralis major were grasped with curved forceps, the muscle was advanced behind the conjoined tendon but in front of the musculocutaneous nerve, and the tendon was attached to the lesser tuberosity with transosseous, nonabsorbable number-1 sutures. If there was a concomitant partial or complete rupture of the supraspinatus tendon, the tendon was attached not only to the lesser tuberosity but also to the anterior part of the greater tuberosity (Figs. 2-B and 2-C).

View larger version (130K): [in this window] [in a new window]   FIG2-B: Fig. 2-B Photograph made after blunt exploration, showing how a portion of the pectoralis major is passed between the pectoralis minor and the conjoined tendon and then behind the conjoined tendon to the lesser tuberosity, where it is attached with bone sutures. CP = coracoid process, CT = conjoined tendon, H = humeral head, and P = pectoralis major muscle (transferred portion).

View larger version (115K): [in this window] [in a new window]   FIG2-C: Fig. 2-C Schematic view of the course of the muscle.

At the end of the procedure, a final check was performed with the index finger palpating the musculocutaneous nerve and the space between the nerve and the muscle to confirm that there was no tension on the nerve. If such tension is found, the size of the muscle belly must be reduced.

Postoperative Management
The shoulder was immobilized in a sling for six weeks, and passive range-of-motion exercises for abduction, flexion, and internal rotation were begun on the first postoperative day. External rotation was permitted only as far as the neutral position. After six weeks, active range-of-motion exercises were begun in all planes including external rotation. After twelve weeks, full loading was permitted.

	Results

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Clinical Examination (Table III)
At an average of twenty-eight months (range, twenty-four to fifty-four months) postoperatively, four of the twelve patients reported complete relief of pain and eight, partial relief. The latter group included patients in whom complete coverage of the supraspinatus tendon defect had not been possible. On the 15-point visual analog scale of the scoring system of Constant and Murley⁴, the patients' pain-assessment scores improved from an average of 1.7 points (range, 0 to 5 points) preoperatively to an average of 9.6 points (range, 5 to 15 points) at the time of follow-up.

Of the five patients who had had a positive lift-off test preoperatively, three had a negative result at the time of follow-up—that is, they could maintain the hand in the raised position behind the back for at least a few seconds. Six patients had a positive result, and three patients could not be assessed. Six of the twelve patients had a positive result on the belly-press test, five had a negative result, and the result was unclear for one patient. None of the four patients who had had anterior instability preoperatively had had a redislocation at the time of follow-up, and three patients had lost the subjective feeling of instability. A seventy-six-year-old patient with pronounced preoperative instability complained of a feeling of uncertainty in flexion and abduction, and she avoided such movements as much as possible.

Strength-testing was performed at 90 degrees of abduction and flexion for all except one patient, for whom it was performed at 70 degrees because the patient was not able to raise the arm higher. Abduction strength improved from an average of 0.8 kilogram (range, zero to four kilograms) preoperatively to an average of two kilograms (range, one to four kilograms) at the time of follow-up, and flexion strength improved from an average of 0.6 kilogram (range, zero to two kilograms) to an average of two kilograms (range, zero to four kilograms). With the upper arm adducted and the elbow flexed to 90 degrees, the strength of internal rotation was tested from the neutral position. The result was an increase from an average of 4.5 kilograms (range, two to nine kilograms) preoperatively to an average of 5.6 kilograms (range, two to twelve kilograms) at the time of follow-up.

The Constant and Murley⁴ score improved from an average of 22.6 points (range, 2 to 47 points) preoperatively to an average of 54.4 points (range, 33 to 81 points) at the time of follow-up. The average change in the score adjusted for age and gender-matched normal values was from 26.9 percent (range, 3 to 51 percent) to 67.1 percent (range, 37 to 108 percent).

The postoperative subjective assessment was excellent according to five patients, good according to four, and fair according to three. No patient rated the result as poor. The overall subjective score for the involved shoulder, with use of the 100-point functional visual analog scale, changed from an average of 20 points (range, 0 to 40 points) preoperatively to an average of 63 points (range, 40 to 100 points) at the time of follow-up. This visual analog scale was used as a separate assessment from, and in addition to, the assessment with use of the Constant and Murley⁴ score.

Ultrasonography
The follow-up evaluation included dynamic ultrasonography for all patients. The study was performed with the arm in slight external rotation. Satisfactory images of the pectoralis major tendon were obtained for all patients and demonstrated that the transferred muscle was still attached to the lesser tuberosity.

Magnetic Resonance Imaging (Figs. 3-A, 3-B, and 3-C)
As part of the follow-up, magnetic resonance imaging was performed for seven patients, and good images of the musculotendinous section of the transferred portion of the pectoralis major muscle were obtained for six of them. The course of the transferred muscle to the lesser tuberosity could be identified, demonstrating that the repair was still intact. In six of these seven patients, an abnormal signal was generated by the subscapularis tissue (primarily due to fatty degeneration), whereas the transferred portion of the pectoralis major produced the same signal as the deltoid muscle. Transverse scans of four patients permitted good comparison with the preoperative images with regard to the distance from the coracoid process to the humeral head; in all four, placement of the substitute tissue had caused this distance to increase. The distance was measured at the level of the tip of the coracoid process. After correction of the measured distance with use of the measurement scale of the images, the average distance was 2.5 millimeters preoperatively and 4.5 millimeters postoperatively. The anterior translation of the humeral head that had been noted in two patients preoperatively was no longer present on the follow-up images.

View larger version (159K): [in this window] [in a new window]   FIG3-A: Figs. 3-A, 3-B, and 3-C: Magnetic resonance images of a chronically ruptured subscapularis tendon. Fig. 3-A: Preoperative image showing osseous impingement between the humeral head and the coracoid process. The subscapularis muscle has a greatly increased signal due to fatty degeneration (arrow).

View larger version (159K): [in this window] [in a new window]   FIG3-B: Fig. 3-B The distance between the humeral head and the coracoid process increased from approximately three millimeters preoperatively (Fig. 3-B) to five millimeters eight months postoperatively (Fig. 3-C); the increase was due to interposed pectoralis major tissue (arrowhead). The interposed tissue has the same signal intensity as the deltoid muscle.

View larger version (124K): [in this window] [in a new window]   FIG3-C: Fig. 3-C The distance between the humeral head and the coracoid process increased from approximately three millimeters preoperatively (Fig. 3-B) to five millimeters eight months postoperatively (Fig. 3-C); the increase was due to interposed pectoralis major tissue (arrowhead). The interposed tissue has the same signal intensity as the deltoid muscle.

Complications
No complications were encountered either intraoperatively or postoperatively. Dysfunction of the musculocutaneous nerve was not observed in any patient. No patient had sensory or motor changes or any cosmetic changes caused by the muscle transfer. In very thin patients, a slightly more prominent anterior bulging of the anterior part of the deltoid muscle was seen compared with the other side.

	Discussion

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Clinical diagnosis of an isolated rupture of the subscapularis tendon is difficult, and until recently there was no reliable clinical test for this lesion^6,9,11,14. Therefore, correct diagnosis often was delayed for months or even years^6,10. In the series of Gerber et al., the interval until repair of isolated ruptures of the subscapularis tendon averaged fifteen months (range, one to fifty-six months)¹⁰. Those authors reported consistently good results in patients who had had early repair and markedly less satisfactory results in those who had had a delayed procedure.

In our experience, a repair of the ruptured tendon after a delay of more than twelve months has been difficult to perform and usually has not led to a favorable result. In the present study, the length of time between the trauma or the onset of pain and the diagnosis averaged twenty-seven months.

Unlike a ruptured supraspinatus tendon that is associated with an intact infraspinatus tendon, a subscapularis tendon that is completely torn can retract unhindered by contact with intact tendon tissue. If the rupture remains untreated for several years, it may no longer be possible to use the subscapularis due to tendon retraction and irreparable changes in the muscle. However, because patients present with disabling pain, a dysfunctional shoulder, and a poor response to nonoperative therapy, sometimes combined with severe shoulder instability, surgical intervention is often indicated in spite of the usually older age of these patients.

The cause of the anterior shoulder pain, and its negligible response to nonoperative treatment, may be subcoracoid impingement⁸. In the current study, magnetic resonance imaging indicated a reduction in the distance between the humeral head and the coracoid process, accompanied by slight translation of the humeral head anteriorly compared with the position on the contralateral side, at least in the patients who had a concomitant lesion of the supraspinatus tendon. This translation appears to be caused by imbalance between the anterior and posterior muscles^1,2. As pointed out by Burkhart, who performed a fluoroscopic imaging study, a tear that involves most of the anterior or posterior aspect of the cuff causes unstable fulcrum kinematics¹. Replacement of the subscapularis tendon with a portion of the pectoralis major, following the course of the subscapularis muscle, interposes muscle between the coracoid process and the conjoined tendon on the one side and the humeral head on the other. There is evidence that the transferred portion of muscle acts as an internal rotator, since the electromyographic examinations of the transferred muscle fibers at the point of entry between the pectoralis minor tendon and the conjoined tendon showed almost symmetrical patterns of electrical activity. This assumption is also supported by the finding that, in almost all of our patients in whom magnetic resonance imaging was performed as part of the follow-up, the tissue of the transferred muscle produced the same signal as did other active muscles such as the deltoid, whereas the signal for the ruptured subscapularis muscle was usually different and indicated fatty degeneration.

The only position of the arm in which the subscapularis or the transferred muscle can be tested in isolation is that of maximum passive internal rotation as employed in the lift-off test^9,11. Unfortunately, this test could not be performed by all of our patients due to a limited range of movement. However, three patients who had not been able to maintain the raised position of the hand behind the back preoperatively were able to do so briefly at the time of follow-up. The belly-press test, which yielded reliable results with regard to subscapularis function in the series of Gerber et al.¹⁰ and in our study, was negative at the time of follow-up for five of our twelve patients; this also suggests involvement of the transferred muscle in internal rotation. Therefore, it can be assumed that the transferred muscle not only acts as a tether but also at least partially balances the infraspinatus-teres minor muscle complex and helps to restore the force couple in the transverse plane².

In our anatomical study, we found that transfer of the clavicular portion of the pectoralis major did not compromise the neurovascular supply to the muscle. Segmental ramification of the acromiothoracic artery and the pectoral nerve shortly after they pass beneath the clavicle, forming main branches for the clavicular, sternocostal, and abdominal portions of the pectoralis major, enables the muscle to be split from the periphery to well into the central area without jeopardizing the neurovascular supply. There is also room for the muscle under the coracoid process, owing to its convex shape. In all patients, there was enough space for passage of the transferred muscle. As the width of the subscapularis tendon is approximately half that of the pectoralis major tendon, it was enough to harvest just the superior half of the tendon in patients who had an isolated rupture of the subscapularis tendon. In those who had a concomitant partial or complete rupture of the supraspinatus tendon, the superior two-thirds of the pectoralis major tendon was harvested to allow at least partial coverage of the supraspinatus defect. However, two-thirds of the substitute tendon is not sufficient to provide full coverage of a combined subscapularis and complete supraspinatus defect; the whole tendon has to be used, which we chose not to do. The goal was to convert a dysfunctional torn cuff to a functional one by restoring the force couple in the transverse plane, with the assumption that a remaining defect would have no influence on the kinematic pattern of the glenohumeral joint². When two-thirds of the tendon was used, it was necessary to reduce the muscle belly to avoid putting tension upon the musculocutaneous nerve. The nerve must always be palpated with the index finger at the end of the procedure and, if there is too much tension on the nerve, the diameter of the muscle belly must be reduced.

The most striking finding of our study was the level of patient satisfaction, which derived primarily from relief of pain. Preoperatively, the patients had had severe pain for an average of twenty-seven months. Because almost all patients reported a reduction in pain just a few days postoperatively, we assume that this pain reduction was due primarily to the interposition of soft tissue between the coracoid process and the humeral head. The improved joint kinematics may also have contributed to the pain relief, though it does not seem likely that it did so in the first few days after the operation. Both of these variables may have helped to prevent subcoracoid impingement. It was not possible, however, to determine the exact degree to which soft-tissue interposition or improved kinematics contributed to this effect.

Reduced pain in turn meant improved function, especially in flexion, abduction, and internal rotation, and fewer problems with premature tiring. The 25-degree average reduction in external rotation resulting from the intervention was not considered a problem by the patients; because their function had been so poor preoperatively, they did not feel impaired by this restriction.

Patient satisfaction also was reflected in the patients' subjective evaluation of arm function with use of the visual analog scale. Their postoperative rating was 43 points higher than the rating before the operation. This change corresponds to the 40 percent increase in the Constant and Murley score⁴ at the time of follow-up compared with the preoperative score.

It is difficult to compare the clinical results with those reported in other studies in the literature^6,8,19, as the average age of the patients was much lower in the other studies (thirty-nine years in the series of Deutsch et al.⁶, fifty years in that of Gerber et al.⁸, and forty-nine years in that of Wirth and Rockwood¹⁹) and reconstruction of the subscapularis tendon was possible in most of the patients in those studies. In our patients, reconstruction of the subscapularis tendon was no longer possible, so our results must be interpreted in terms of a salvage operation for elderly patients.

Burkhart et al. emphasized the importance of the transverse-plane force couple for the balance of humeral head motion^1,2. When the anterior part of the rotator cuff is torn, the posterior part is no longer balanced, which may cause anterior instability. DePalma et al.⁵ and Symeonides¹⁷ stressed the buttress effect of the subscapularis muscle against anterior instability. Turkel et al. also mentioned the importance of the subscapularis muscle with regard to anterior stability of the shoulder with the arm in the adducted or slightly abducted position¹⁸. Neviaser et al. discussed eight patients who presented with anterior instability and concomitant rupture of the subscapularis tendon; stability was restored through repair of the subscapularis tendon¹⁵. Wirth and Rockwood reported on thirteen patients who were operated on because of anterior instability and an irreparable rupture of the subscapularis¹⁹. In most procedures, they, like us, used the superior portion of the pectoralis major as a replacement muscle, but, unlike us, they routed the substitute muscle not behind but in front of the conjoined tendon and reinserted it lateral to the bicipital groove. We believe that the route behind the conjoined tendon not only approximates the orientation of the subscapularis muscle but also restores a buttress effect on the humeral head as a result of the tissue interposed between the conjoined tendon and the humeral head. The fact that the interposed muscle belly rests on the conjoined tendon increases anterior stability. As none of our four patients with anterior instability were able to abduct the arm to more than 110 degrees, it cannot be said whether the buttress effect of the transferred muscle as described for the subscapularis¹⁸ would have been lost with increased abduction. However, the fact that all of our patients with instability had marked restriction of external rotation at the time of follow-up can be seen as a contributing stabilizing factor.

All four patients with recurrent anterior instability reported slight or no pain at the time of follow-up; three had subjective stability, and one had a feeling of uncertainty with the arm raised. The introduction of clinical tests (the lift-off test⁹ and the belly-press test¹⁰) as reliable tools for the diagnosis of lesions of the subscapularis tendon¹¹ should allow detection at an early stage, when direct suturing of the tendon is still possible. Of course, these clinical tests can only raise the suspicion of a torn subscapularis tendon, and the diagnosis must be confirmed by ultrasound or magnetic resonance imaging. Nevertheless, it is to be expected that some patients will continue to present with old, irreparable ruptures. The technique that we have described is a relatively simple and safe way of replacing the traumatized muscle. Even though function is not completely restored in most patients, the technique produces high levels of subjective satisfaction with regard to pain relief, function, and stability.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

General Hospital Salzburg, Unfallchirurgie, Müllner-Hauptstraße 48, A-5020 Salzburg, Austria. Please address requests for reprints to H. Resch.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Burkhart, S. S.: Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model. Clin. Orthop., 284: 144-152, 1992.

2. Burkhart, S. S.; Nottage, W. M.; Ogilvie-Harris, D. J.; Kohn, H. S.; and Pachelli, A.: Partial repair of irreparable rotator cuff tears. Arthroscopy, 10: 363-370, 1994.[Medline]

3. Codman, E. A.: The Shoulder. Rupture of the Supraspinatus Tendon and Other Lesions In or About the Subacromial Bursa. Ed. 2, pp. 262-312. Boston, Thomas Todd, 1934.

4. Constant, C. R., and Murley, A. H.: A clinical method of functional assessment of the shoulder. Clin. Orthop., 214: 160-164, 1987.[Medline]

5. DePalma, A. F.; Cooke, A. J.; and Prabhakar, M.: The role of the subscapularis in recurrent anterior dislocations of the shoulder. Clin. Orthop., 54: 35-49, 1967.[Medline]

6. Deutsch, A.; Altchek, D. W.; Veltri, D. M.; Potter, H. G.; and Warren, R. F.: Traumatic tears of the subscapularis tendon. Clinical diagnosis, magnetic resonance imaging findings, and operative treatment. Am. J. Sports Med., 25: 13-22, 1997.[Abstract/Free Full Text]

7. Frankle, M. A., and Cofield, R. H.: Rotator cuff tears including the subscapularis. In Proceedings of the Fifth International Conference on Surgery of the Shoulder. Paris, International Conference of Surgery of the Shoulder, 1992.

8. Gerber, C.; Terrier, F.; and Ganz, R.: The role of the coracoid process in the chronic impingement syndrome. J. Bone and Joint Surg., 67-B(5): 703-708, 1985.

9. Gerber, C., and Krushell, R. J.: Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J. Bone and Joint Surg., 73-B(3): 389-394, 1991.

10. Gerber, C.; Hersche, O.; and Farron, A.: Isolated rupture of the subscapularis tendon. Results of operative repair. J. Bone and Joint Surg., 78-A: 1015-1023, July 1996.[Abstract/Free Full Text]

11. Greis, P. E.; Kuhn, J. E.; Schultheis, J.; Hintermeister, R.; and Hawkins, R.: Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. Am. J. Sports Med., 24: 589-593, 1996.[Abstract/Free Full Text]

12. Hauser, E. D. W.: Avulsion of the tendon of the subscapularis muscle. J. Bone and Joint Surg., 36-A: 139-141, Jan. 1954.[Free Full Text]

13. Hoffman, G. W., and Elliott, L. F.: The anatomy of the pectoral nerves and its significance to the general and plastic surgeon. Ann. Surg., 205: 504-507, 1987.[Medline]

14. Mendoza Lopez, M.; Cardoner Parpal, J. C.; Samso Bardes, F.; and Coba Sotes, J.: Lesions of the subscapular tendon regarding two cases in arthroscopic surgery. Arthroscopy, 9: 671-674, 1993.[Medline]

15. Neviaser, R. J.; Neviaser, T. J.; and Neviaser, J. S.: Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient. J. Bone and Joint Surg., 70-A: 1308-1311, Oct. 1988.[Abstract/Free Full Text]

16. Resch, H.; Wykypiel, H. F.; Maurer, H.; and Wambacher, M.: The antero-inferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: an anatomic and clinical study. Arthroscopy, 12: 309-322, 1996.[Medline]

17. Symeonides, P. P.: The significance of the subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder. J. Bone and Joint Surg., 54-B(3): 476-483, 1972.

18. Turkel, S. J.; Panio, M. W.; Marshall, J. L.; and Girgis, F. G.: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J. Bone and Joint Surg., 63-A: 1208-1217, Oct. 1981.[Abstract/Free Full Text]

19. Wirth, M. A., and Rockwood, C. A., Jr.: Operative treatment of irreparable rupture of the subscapularis. J. Bone and Joint Surg., 79-A: 722-731, May 1997.[Abstract/Free Full Text]

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