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Functional Results after Transfer of the Pectoralis Major Muscle in Subscapularis Tears: A literatute review

Gabriel da Cunha Mendes, Christiane Veratti Petrucci, Renan Lima Monteiro

Gabriel da Cunha Mendes, Christiane Veratti Petrucci, Renan Lima Monteiro, Irmandade da Santa Casa de Misericórdia, Rehabilitation Service, São Paulo, SP, Brazil
Renan Lima Monteiro, Federal University of Amapá, Macapá, AP, Brazil

Correspondence to: Gabriel da Cunha Mendes, Irmandade da Santa Casa de Misericórdia, Rehabilitation Service, Santa Casa de Misericórdia de São Paulo (SCMSP), Street Doutor Cesário Mota Junior, number 112, SP 01201-000, São Paulo, Brazil.
Email: gabrielcunha_2@hotmail.com
Telephone: +55-11-2176-1585
Fax: +55-11-2176-1585
Received: May 8/, 2014
Revised: July 4, 2014
Accepted: July 9, 2014
Published online: August 23, 2014
Published online: August 23, 2014

ABSTRACT

AIM: The aim of the study was to investigate through a literature review functional outcomes after transfer of the pectoralis major muscle in irreparable tears of the subscapularis muscle.

METHODS: A systematic search was performed in electronic databases (Science Direct and Pubmed), which were reviewed only for studies who described functional results after muscle transfer. During the, based on retrospective facts, were pre-selected 455 articles and five of them met all criteria and specifications set.

RESULTS: There was an increase in range of motion in elevation, abduction and improved function

CONCLUSION: The transfer of the pectoralis major muscle in irreparable tears of the subscapularis muscle seems to be an treatment option to improve function, however, more studies with better methodological quality with emphasis on functional outcomes are needed.

© 2014 The Authors. Published by ACT Publishing Group Ltd.

Key Words: Rotator cuff; Pectoralis muscle; Tendon transfer; Shoulder

da Cunha Mendes G, Petrucci CV, MonteiroRL. Functional Results after Transfer of the Pectoralis Major Muscle in Subscapularis Tears: A literatute review. International Journal of Orthopaedics 2014; 1(2): 43-46 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/827

Introduction

The irreparable rotator cuff injuries are those which there are rupture of two or more tendons and more than five centimeters in diameter often associated with retraction of the myotendinous unit and degenerative changes of the Rotator Cuff muscles, such as fatty infiltration and atrophy which surgical repair is considered difficult, with an uncertain prognosis[1,2,3]. The tears of the subscapularis muscle can result in an increase in external rotation, increase translation of the humeral head and a decrease in shoulder abduction[4,5].

Muscle transfer and reverse arthroplasty are two treatment options when an irreparable rotator cuff repair is impossible to be done. The reverse prosthesis is used when there is an extensive rotator cuff injury associated with osteoarthritis and muscle transfer is used when the joint is already intact. The most frequently muscles used in the literature are the deltoid, pectoralis major, long head of the triceps and the latissimus dorsi[2].

The transfer of the pectoralis major muscle was described in 1997 by Wirth and Rockwood for the irreparable injury of the subscapularis muscle[6]. The pectoralis major muscle has gained favor as a suitable muscle for transfer because it contracts in-phase with subscapularis, and because by virtue of this position it may oppose the extension force of the posterior deltoid with shoulder abduction, which for example makes bringing the hand to the mouth difficult[7].

Nevertheless there is an inconclusive functional results obtained after the transfer of the pectoralis major in irreparable lesions of the subscapularis muscle. Although there are reports that pain relief is found after repair, the same results are not found in increasing muscle strength and range of motion[4,8,9]. Later on, literature review on the functional outcomes after transfer of the subscapularis in irreparable rotator cuff tears will assist in developing a consensus, as well as assist rehabilitation professionals to plan objectives and supplement the functional outcomes after surgical treatment.

The aim of this study was to investigate through literature review the functional outcomes after transfer of the pectoralis major muscle in irreparable tears of the subscapularis. According to Konrad et al[10] the transfer of the pectoralis major muscle can restore normal kinematics of the glenohumeral joint, and based on these data, we believe that there is an increase in range of motion and improved function after transfer.

METHODS

We conducted a literature review based on literature search using key words in English language on SCIENCEDIRECT and PUBMED databases (Figure 1). According to the descriptors found in DeCS and MeSH for choosing the keywords to be used in searches, the crossed terms used were: "rotator cuff", "pectoralis muscle", "tendon transfer", "shoulder" (Table 1).

Articles published in English that showed the functional outcomes after transfer of the pectoralis major muscle in individuals with irreparable tears of the subscapularis muscle were included in this study. During data collection there was no restriction on the publication year of the studies, only articles describing the surgical procedure and cadaver studies were excluded.

RESULTS

Five studies met the inclusion and exclusion criteria and were included in this literature review[11-15]. All included studies were retrospective, published in the period from 2000 to 2011 and the surgical procedure performed from 1993 to 2006; they had a total of 123 patients (mean of 24.6 individuals per study) and a follow-up made during 29.9 months (Table 2). The indication for the transfer of the pectoralis major muscle was for patients with irreparable tears of the subscapularis muscle with or without anterosuperior shoulder instability. The studies concluded that the transfer of the pectoralis major muscle technique is a treatment option, resulting in function improvements and pain relief, but Jost et al[13], adds that the injury of subscapularis muscle associated with supraspinatus has lower levels of functionality.

The functional data are shown in table 3. Five studies were included in the analysis, from which the study performed by Lederer et al[15] compared two surgical techniques of transfer of the pectoralis major muscle, while group 1 underwent a bone graft, group 2 underwent a tenotomy.

The range of motion pre and postoperative for elevation was evaluated in four studies[11-14], with an average of 96.25 and 117.5 degrees, respectively. Only one study[18] assessed the movement of internal rotation. Three authors[11-13] reported the results of pre and postoperative abduction, with an average of 106.3 and 124.6 degrees, respectively. The movement of external rotation was evaluated in three studies[12-14], with a mean of 51.3 degrees preoperatively to 36 degrees postoperatively.

The strength of pre and postoperative abduction, measured by a dynamometer, was evaluated in two studies[12,13], with a mean of 1.3 and 2.8 kg, respectively. Only one study[13] evaluated pre and postoperative strength of internal rotation.

Functional assessment, measured by Constant and Murley scale was applied in four studies[11,12,13,15] the mean preoperative values were 49.5 and 79.5 postoperatively, which resulted in a difference of 30 points on the scale. (Table 3). Only one study[14] showed the pre and postoperative visual analog pain scale.



Conclusion

The transfer of the pectoralis major muscle has been considered a resource to restore function and provide pain relief in patients with irreparable tears of the rotator cuff involving the subscapularis tendon in the absence of osteoarthritis at the glenohumeral joint[2,7].

In general, the transfer of the pectoralis major led to a significant improvement of the elevation and abduction motion, but no improvement for external rotation (Table 3). On average, there was a gain of 21 degrees on elevation, 18 degrees on shoulder abduction and a decrease of 15 degrees on external rotation. Only two studies[12,13] evaluated the strength of abduction, in which there was an increase of 125%. One study[12] assessed the strength pre and postoperative of internal rotation with a 20% of improvement.

A study by Nelson et al[16] corroborates with the data found in our study, which has concluded, through a literature review, that the transfer of the pectoralis muscle can be an effective treatment for pain reduction and improvement of function, in cases when conservative treatment and attempts to anatomical restoration failed, however it does not present a systematic methodology, with no inclusion and exclusion criteria as well as how to select articles. Furthermore, Konrad et al[10] in a biomechanical cadaver study showed that the transfer of the pectoralis major muscle, specifically below the conjoint tendon in subscapularis muscle injuries, can restore normal kinematics of the glenohumeral joint.

However, patients should not expect normal function return or total improvement of pain[13] and according to Lederer et al[15], fatty degeneration of the muscle will persist even after the reinsertion of the tendon.

Another important factor for normal function return is postoperative rehabilitation. Raabet et al[17] suggested in their prospective randomized study that early continuous passive motion after rotator cuff repair has a beneficial effect on range of motion and pain relief. Furthermore, Li et al[18] found that the continuous passive motion in rabbits caused a fibroblast growth factor, leading to increased synthesis of type III collagen in tendon-bone interface in the earliest stages of repair after acute disruption of the tendon, thus contributing to the recovery of tendon-bone after a rotator cuff injury.

Arndt et al[19] through a prospective randomized study, which compared the clinical effects of early passive motion and immobilization in the postoperative repair of the rotator cuff, concluded that early passive motion should be performed, because the functional results were better than the group that maintained immobilized for a period.

Among the studies included in this review, four of them started early mobilization of external rotation after the transfer of the tendon of the pectoralis major muscle. Jost et al[13] and Resh et al[12] also added the elevation motion associated to internal rotation and passive mobilization in all planes, respectively. Furthermore, Graviilidis et al[11] performed the passive motion only on the third day postoperatively limited to 30 degrees of flexion and 80 degrees of internal rotation. In general, the active movement without restriction was initiated at the sixth week, while muscle strengthening began at the twelfth.

On the other hand, one analyzed study did not perform early passive mobilization, however, descriptively, resulted in no differences in range of shoulder elevation when compared to other studies[14].

This study has a number of weaknesses. As it is typical of any literature review, the weaknesses inherent in each individual study (retrospective design and short follow-up period) brings limitations for this review. The methodologies of the reviewed studies did not provide bias controls, since the articles were mainly descriptive in nature, not having a suitable method of functional assessment, as well as the best surgical technique and postoperative rehabilitation. Just like them, our study is simply an observational analysis of observational studies in most cases, but provides an overview of the available literature. Furthermore, despite the fact we have used a systematic methodology in wich we believe to be reproducible, it is possible that the terms of searches in some different databases would have provided additional studies that would have met our inclusion criteria.

The transfer of the pectoralis major muscle in irreparable tears of the subscapularis muscle seems to be an effective treatment option to improve function. However, more studies with better methodological quality with emphasis on functional outcomes are needed.

CONFLICT OF INTEREST

There are no conflicts of interest with regard to the present study.

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Peer reviewers: Jae-Hwa Kim, Professor, MD, PhD, Department of Orthopaedics, 59yatap-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-712, korea; Maurice Balke, Department of Sportstraumatology, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Köln, Germany; Javier Muñoz-Marín, Hospital MAZ, Av Academia General Militar, 74, Zaragoza, 50015, Spain; Riccardo Maria Lanzetti, MD, Orthopaedic Department, St.Andrea Hospital University of Rome, Italy.

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