Split Pectoralis Major and Teres Major Tendon Transfers for Reconstruction of Irreparable Tears of the Subscapularis

Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. In certain circumstances, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. A pectoralis major tendon transfer is an acceptable salvage option for irreparable subscapularis tendon ruptures. Although limited functional goals may be expected in most cases, the majority of patients obtain a good pain relief, which improves their function below chest level. Addition of the teres major component to the transfer may be beneficial in cases where both the upper and lower portion of the subscapularis muscle is irreparable. Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. Because unspecific complaints like pain and weakness without loss of function are in most cases the only subjective signs associated with subscapularis tears, diagnosis and treatment occurred often with delay (Fig. 1). In certain instances, such as chronic tears or subscapularis insufficiency after previous surgery, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. HISTORICAL PERSPECTIVE Isolated subscapularis tendon tear was first reported by Gerber and Krushell. The authors observed that clinical diagnosis remains a challenge and described the socalled lift-off sign as a very specific sign for subscapularis insufficiency. In a subsequent follow-up of his experience, Gerber reported on his results of repair of the subscapularis tendon. He observed that repairs performed for chronic subscapularis tears had a much poorer outcome than repairs performed in an acute setting. The anterosuperior cuff tear configuration, which represents a tear of the subscapularis in combination with the supraspinatus and sometimes the infraspinatus, was not recognized as a discreet entity before Warner et al presented their series. 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 Orthopaedic Surgery, 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