Studies have shown that the trees minor plays an important role after total (TSA) and reverse (RSA) shoulder arthroplasty, as well as in maintenance of function in the setting of infraspinatus wasting. In this regard, teres minor hypertrophy has been described as a compensatory change in response to this infraspinatus wasting, and has been suggested that this compensatory hypertrophy may mitigate the loss of infraspinatus function in the patient with a large rotator cuff tear. The purpose of this study was to determine the prevalence of teres minor hypertrophy in a cohort of patients undergoing rotator cuff repair, and to determine its prognostic effect, if any, on outcomes after surgical repair. Over a 3 year period, all rotator cuff repairs performed in a single practice by 3 ASES member surgeons were collected. Inclusion criteria included both preoperative and postoperative validated outcomes measures (minimum 2 year), and preoperative Magnetic Resonance Imaging (MRI) scanning. 144 patients met all criteria. MRIs were evaluated for rotator cuff tear tendon involvement, tear size, and Goutallier changes of each muscle. In addition, occupational ratios were determined for the supraspinatus, infraspinatus, and teres minor muscles. Patients were divided into 2 groups, based upon whether they had teres minor hypertrophy or not, based on a previously established definition. A 2 way ANOVA was used to determine the effect of teres minor hypertrophy(tear size by hypertrophy) and Goutallier. Teres minor hypertrophy was a relatively common finding in this cohort of rotator cuff patients, with 51% of all shoulders demonstrating hypertrophy. Interestingly, in patients without an infraspinatus tear, teres minor hypertrophy was still present in 19/40 (48%) of patients. Teres minor hypertrophy had a significant, negative effect ASES scores after rotator cuff repair in patients with and without infraspinatus tearing, infraspinatus atrophy, and fatty infiltrative changes (P<0.05). In general, the presence of teres minor hypertrophy showed 10–15% less improvement (Figure 1) than when no hypertrophy was present, and this was consistent across all tear sizes, independent of Goutallier changes. Teres minor hypertrophy is a common finding in the setting of rotator cuff tearing, including in the absence of infraspinatus tearing. Contrary to previous publications, the presence of teres minor hypertrophy in patients with rotator cuff repair does not appear to be protective as a compensatory mechanism. While further study is necessary to determine the mechanism or implication of teres minor hypertrophy in setting of rotator cuff repair, our results show it is not a positive of outcomes following rotator cuff repair

Introduction. Supraspinatus and infraspinatus tears (Massive Rotator Cuff Tear- MRCT) cause compensatory activation of the teres minor (TM) and subscapularis (SubS) to maintain humeral head alignment. This study measures force changes in TM and SubS using a dynamic shoulder testing setup. We hypothesize that combining superior capsule reconstruction (SCR) and lower trapezius tendon (LTT) transfer will correct rotator cuff forces. Methods. Eight fresh-frozen human shoulder specimens from donors aged 55-75 (mean = 63.75 years), balanced for gender, averaging 219.5 lbs, were used. Rotator cuff and deltoid tendons were connected to force sensors through a pulley system, with the deltoid linked to a servohydraulic motor for dynamic force measurement. The system allowed unrestricted humeral abduction from 0 to 90 degrees. Results. Teres Minor (TM):. -. Control: 7.43 N (SD = 1.66). -. SS tear: 5.46 N (SD = 1.45). -. MRCT: 3.94 N (SD = 1.43). -. LTT post-MRCT: 5.85 N (SD = 1.13). -. SCR post-MRCT: 4.68 N (SD = 0.71). -. Combined LTT+SCR: 6.43 N (SD = 1.24). -. TM force reduction: 26.51% post-SS tear, 46.97% from intact to MRCT, 63.20% increase with LTT+SCR. Subscapularis (SubS):. -. Control: -0.73 N (SD = 0.43). -. SS tear: -0.46 N (SD = 0.36), 36.99% increase. -. MRCT: 0.96 N (SD = 0.47), 31.51% increase. -. LTT post-MRCT: -0.32 N (SD = 0.47), 66.67% reduction. -. SCR post-MRCT: -0.28 N (SD = 0.16), 70.83% reduction. -. Combined LTT+SCR: -0.66 N (SD = 0.32), 31.25% reduction. Non-parametric Friedman's ANOVA showed overall statistical significance for TM (P = 1.083×10. -6. ) and SubS (P = 4.77×10. -4. ). Conclusion. The cadaveric model assesses rotator cuff compensations, showing significant TM force reductions following rotator cuff tears and improvements with LTT and SCR, particularly when combined. SubS exhibited negative force during normal abduction but compensated during MRCT, returning to normal values post-LTT and SCR

Purpose of the study: Data concerning the teres minor in the context of rotator cuff tears is scarce despite the fact that this muscle plays a crucial role in the event of an infraspinaus tear. The purpose of this study was to analyse the computed tomography and magnetic resonance images of the teres minor muscle in rotator cuff tears.

Material and method: The aspect of the teres minor muscle was studied in 1624 shoulders with rotator cuff tears. The axial and sagittal CT or MRI aspect was noted as normal, hypertrophic, atrophic or absent (Walch classification). We searched for correlations with the tendon torn, tear mechanism (trauma, degeneration, mixed), gender, dominance, time to imaging, age at imaging, and fatty infiltration of the supraspinatus, infraspinatus and subscapularis.

Results: The teres minor was noted normal in 90.9% of the shoulder, hypertrophic in 5.2%, atrophic in 3.2% and absent in 0.2%. The type of cuff tear had a significant impact (p< 0.0005). Regarding the aspect of the teres minor muscle, the highest percentages were as follows: normal for isolated supraspinatus tears, hypertrophic for supraspinatus and subscapularis tears, atrophic for posterosuperior (supraspinatus, infraspinatus ± teres minor) tears and absent for massive tears involving the supraspinatus, the infraspinatus ± the subscapularis (p< 0.0005). The correlation was statistically significant between the aspect of the teres minor and the grade of fatty infiltration of the infraspinatus (p< 0.0005) and the subscapularis (p< 0.0005).

Discussion: The aspect of an atrophic or absent teres minor, which correlates with the trumpet sign in massive tears, was only found in 3.5% of the tears. There would thus be few indications for latissimus dorsi transfer to restore active external rotation.

Abstract

Aims

We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes.

Sub-Acromial Decompression (SAD) for impingement has a failure rate of 5–20%. We used MRI to see whether SAD failure is associated with muscle wasting or fatty degeneration in the rotator cuff. Fifty one patients with impingement were assessed using MRI pre- and post-op. Following arthroscopic SAD, seven patients with cuff tears were excluded. This study reviews the pre-op and 6 month post-op MRIs of the remaining 44 patients (25 males; 19 females) and also 17 additional MRIs obtained at three years post-op. MRI assessment was performed by an experienced radiologist using Zanetti’s muscle bulk assessment with values expressed as standard deviations from an age matched mean and Goutallier’s fatty degeneration assessment graded 0 to 4. There was a wide range of pre-op muscle bulk values (SupraSpinatus minus;2.4 to +3.4; SubScapularis minus;2.1 to +4.8; and InfraSpinatus/ Teres Minor minus;1.1 to +5.7). Comparing post-op with pre-op there was a gradual trend towards a reduced muscle bulk for each muscle after surgery but to a limited extent only (< 0.5SD). Pre-op fatty degeneration of SS and IS was grade 2 in about a half with a mild increase with time post-op (SS pre=50%, 6/12 and 3 years=59%; IS pre=45%, 6/12=43% and 3 years=59%). There was a similar age distribution for grades 1 and 2. Only three of the patients were a clinical failure at 6 months but this increased to five of the 17 patients scanned at 3 years. Predicting these failures was not possible based on the pre-op MRI data. The high initial success of SAD was not accompanied by an overall increase in muscle bulk or quality of the muscle at 6 months. The progressive loss of muscle bulk and quality over 3 years was accompanied by an increased clinical failure rate

Purpose. While treating fracture sequelae (FS) with unconstrained prostheses has been shown to give inferior or unpredictable outcomes, the literature is still scant regarding their treatment with reverse shoulder arthroplasty (RSA). This study was performed to determine the suitability of RSA as a solution for FS with severe tuberosity malunion/nonunion and rotator cuff dysfunction, and to identify any useful preoperative prognostic factors. Method. Between 1997 and 2007, RSA was performed in 26 cases for FS of type 4 according to the classification of Boileau et al., previously treated either operatively or nonoperatively. Prior treatment with hemiarthroplasty was an exclusion criteria, as was follow-up of less than two years, leaving 20 patients who had undergone an average of one surgery prior to the index RSA (range, 1–3) and were followed up for a mean of 4.8 years. Preoperatively, the mean global fatty degeneration index (GFDI) was 1.8 (range, 0.7–2.9), and almost half the patients had an atrophic or ruptured teres minor. The mean age at surgery was 70 years (range, 50–91). Clinical evaluation was performed by two independent observers with the help of the Constant score (CS) and Subjective Shoulder Value (SSV). Results. Three patients (15%) had five complications, all of which were treated with reoperation. No infections and only one case of instability occurred. Overall, 82% were satisfied or very satisfied, and the mean relative CS improved by 45% (from 35% to 80%). The best range-of-motion gains were made in active anterior elevation, which improved by 53 (from 62 to 115), although gains were generally variable. Teres minor and subscapularis insufficiency was observed in many patients. Worse clinical outcomes were associated with these preoperative variables: prior surgical treatment, medical comorbidity, a lack of active external rotation, and a GFDI of 2.0 or more. However, the numbers available did not produce statistically significant correlations. Radiographic humeral-component loosening was seen in one patient (5%), and either the humeral or the glenoid component was considered at-risk in three patients (15%), although no revisions were performed for loosening. Conclusion. These results show that in the medium term, RSA is a very good treatment option for elderly patients with severe FS and rotator cuff dysfunction. They are better than previously published results of RSA performed for FS but not as good as those of RSA for CTA. High satisfaction rates may be related to the severity of preoperative disability and good patient education. The association of prior surgical treatment with worse results may be related to the negative effect of surgery on the rotator cuff and anterior deltoid. Much can be learned from the reported complications, and outcomes will probably improve with improved prosthetic design and surgical techniques, as well as with better surgeon and patient awareness of the surgical pitfalls and variable clinical gains, especially in rotation

Lateralizing the center of rotation in reverse shoulder arthroplasty has been the subject of renewed interest due to complications associated with medialized center of rotation implants. Benefits of lateralization include: increased joint stability, decreased incidence of scapular notching, increased range of motion, and cosmetic appeal. However, lateralization may be associated with increased risk of glenoid loosening, which may result from the increased shear forces and the bending stresses that manifest at the bone-implant interface. To address glenoid loosening in reverse implants with lateralized joint centers, recent studies have focused on testing and improving implant fixation. However, these studies use loads derived from literature specific to subjects with normal anatomy. The aim of this study is to characterize how joint center lateralization affects the loading in reverse shoulder arthroplasty. Using an established computational shoulder model that describes the geometry of a commercial reverse prosthesis (DELTA® III, DePuy), motion in abduction, scapular plane elevation, and forward flexion was simulated. The simulations were run for five progressively lateralized centers of rotation: −5, 0, +5, +10, and +15 mm (Figure 1). The model was modified to simulate a full thickness rotator cuff tear, where all cuff musculature except Teres Minor were excluded, to reflect the clinical indication for reverse shoulder arthroplasty on cuff tear arthropathy patients. To analyze the joint contact forces, the resultant glenohumeral force was decomposed into compression, anterior-posterior shear, and superior-inferior shear on the glenoid. Joint center lateralization was found to affect the glenohumeral joint contact forces and glenoid loads increased by up to 18% when the center was lateralized from −5 mm to +15 mm. Compressive forces were found to be more sensitive to lateralization in abduction, while changes in shear forces were more affected in forward flexion and scapular plane abduction. On average, the superior shear component showed the largest increases due to lateralization (up to a 21% increase), while the anterior-posterior shear component showed larger changes than those of compression, except in the most lateralized center position (Figure 2). The higher joint loads in the lateralized joint centers reflect a shortening of the Deltoid muscle moment arms (Figure 3), since the muscle needs to exert more force to provide the desired motions. The additional shear forces generated by the lateralization may increase the risk of the ‘rocking-horse’ effect. Together with the lateralized joint center, this creates an additional bending stress at the bone-implant interface that puts the implant at further risk of loosening (Figure 1). Current studies on implant fixation tend to use loads in compression and superior shear that exceed the forces seen in this study but have not investigated anterior-posterior shear loads. Our data support that loading in anterior-posterior direction can be significant. Using inappropriate loads to design fixation may result in excessive loss of bone stock and/or unforeseen implant loosening. The implication is that future studies may be performed using this more relevant data set to navigate the tradeoff between fixation and bone conservation

Aims

The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts.

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

Abstract

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Residual muscle weakness in obstetric brachial plexus palsy results in soft-tissue contractures which limit the functional range of movement and lead to progressive glenoid dysplasia and joint instability. We describe the results of surgical treatment in 98 patients (mean age 2.5 years, 0.5 to 9.0) for the correction of active abduction of the shoulder. The patients underwent transfer of the latissimus dorsi and teres major muscles, release of contractures of subscapularis pectoralis major and minor, and axillary nerve decompression and neurolysis (the modified Quad procedure). The transferred muscles were sutured to the teres minor muscle, not to a point of bony insertion. The mean pre-operative active abduction was 45° (20° to 90°). At a mean follow-up of 4.8 years (2.0 to 8.7), the mean active abduction was 162° (100° to 180°) while 77 (78.6%) of the patients had active abduction of 160° or more. No decline in abduction was noted among the 29 patients (29.6%) followed up for six years or more. This procedure involving release of the contracted internal rotators of the shoulder combined with decompression and neurolysis of the axillary nerve greatly improves active abduction in young patients with muscle imbalance secondary to obstetric brachial plexus palsy.

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001).

In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.

Cite this article: Bone Joint J 2013;95-B:523–9.

Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha’s technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique.

The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6° (0 to 45) to 34° (5 to 90) at the last review. The mean forward flexion increased from 12° (0 to 85) to 30° (5 to 90).

Abduction (41°) and especially forward flexion (43°) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42° of abduction and 56° of forward flexion. Active abduction (28°) and forward flexion (19°) were much less in completely flail shoulders (n = 34).

Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished.

The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.