Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

Abstract

Background:

Latissimus dorsi transfer (LDT) and pectoralis major transfer (PMT) were developed to treat an irreparable subscapularis tendon tear (ISScT); however, the difference in their outcomes remains unclear.

Purpose:

To systematically review and compare the outcomes of LDT and PMT for ISScT.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed through a comprehensive search of Embase, PubMed, and the Cochrane Library. Studies of LDT or PMT were included according to the inclusion and exclusion criteria. The primary outcome was the Constant-Murley score (CMS) at the final follow-up. Secondary outcomes included the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder range of motion, and the belly-press and lift-off tests. Postoperative failure and complication rates were the safety outcome measures. Outcomes were summarized into the LDT and PMT groups, and results were compared statistically (P < .05).

Results:

Twelve studies were included in this review: 184 shoulders from 9 studies for the PMT group and 85 shoulders from 3 studies for the LDT group. For the PMT and LDT groups, the mean ages were 58.9 and 55.1 years, respectively, and the mean follow-up was 66.9 and 17.4 months, respectively. Overall, the LDT and PMT groups improved in the primary outcome (CMS) and secondary outcomes (SSV, VAS, ROM, and belly-press and lift-off tests), with low rates of failure and complication. When compared with the PMT group, the LDT group showed more significant improvements in CMS (35.2 vs 24.7; P < .001), active forward flexion (44.3° vs 14.7°; P < .001), abduction (35.0° vs 17.6°; P < .002), and positive belly-press test rate (45% vs 27%; P < .001). No statistically significant difference was seen between the groups in postoperative failure rate, complication rate, mean improvement of active internal rotation, VAS, or SSV.

Conclusion:

In general, LDT showed significantly better clinical outcomes postoperatively than did PMT. The available fair-quality evidence suggested that LDT might be a better choice for ISScT. Further evaluations on the relative benefits of the 2 surgical approaches are required, with more high-quality randomized controlled studies.

Keywords

irreparable subscapularis tendon tears latissimus dorsi transfer pectoralis major transfer tendon transfer

Isolated subscapularis tendon tear (SScT) is uncommon, with an incidence of 3% to 10%,^38,61 but tear of the SScT is involved in 29% to 50% of rotator cuff tears that include >2 tendons.^32,38,42 A complete SScT might retract anteromedially^22,77 and lead to severe muscle atrophy and fatty infiltration in chronic cases.^16,47,70 An SScT with advanced fatty infiltration (Goutallier stage 3 or 4) and tendon retraction (Patte stage 3) may be considered an irreparable SScT (ISScT).^24,38,57

The subscapularis is the largest, most powerful muscle of the rotator cuff, providing approximately 50% of the force.³⁵ Functionally, the subscapularis internally rotates the humerus, contributes to anterior stability of the shoulder, and plays a vital role in balancing force couples of the glenohumeral joint in the coronal and transverse planes.^3,4,27 ISScT disrupts the force couples and results in pain, loss of internal rotation force,^2,51 and anterosuperior migration of the humeral head.^5,6 Moreover, ISScT might lead to anterior instability or pseudoparalysis.^9,67

Currently, salvage options for ISScT include anterior capsule reconstruction,^36,62 tendon transfer,^5,34 and reverse shoulder arthroplasty.^10,64 In recent cadaveric studies, anterior capsule reconstruction has been developed for treating ISScT with the theoretical feasibility to restore the anteroinferior shoulder stability but with decreased range of motion (ROM) as a result.^36,54,62 Reverse shoulder arthroplasty has been proposed for older patients with shoulder instability and osteoarthritis^17,20 but it is not recommended for active or young patients without severe arthrosis.^10-12,34

Tendon transfer has been widely used to treat ISScT given its effects of pain relief, ROM recovery, and shoulder function improvement.^12,13,49,75 The tendons chosen for transfer in ISScT include the pectoralis major (PM),¹³ pectoralis minor,⁵⁶ upper trapezius,²³ latissimus dorsi (LD),⁴⁹ and teres major,³⁹ with PM transfer (PMT)⁷⁵ and LD transfer (LDT)^12,49 being the most common. The purposes of PMT and LDT are to restore internal rotation strength of the subscapularis, limit anterior humeral translation, and minimize the risk of subcoracoid impingement.⁵

Although PMT can effectively improve pain, its effects of restoring strength and active motion and reducing anterosuperior migration of the humeral head are unsatisfactory.^{13,18,50,53,60} In addition, the transferred PM is anterior to the chest wall, and it cannot exactly replicate the vector of the subscapularis posterior to the chest wall.⁵ LDT was originally performed to restore external rotation strength after a massive rotator cuff,⁴⁴ but it was recently performed for ISScT^34,49,73 because the LD had a similar pull line with the subscapularis muscle.⁷³

Although PMT and LDT in ISScT yield good clinical outcomes,^{14,16,19,40,49,70} it remains unknown which technique is better. This review aims to evaluate and compare the clinical outcomes, complications, and failure rates of PMT and LDT. We hypothesized that LDT and PMT could yield comparatively good outcomes for ISScT.

Methods

This systematic review was written according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).^48,74

Search Strategy

The first 2 authors (Z.L. and J.L.) performed an electronic search in 3 databases between their inception date and July 10, 2020: PubMed, Embase, and Cochrane Library. The reference lists of previous systematic reviews for correlational studies were also reviewed. The detailed search strategies were as follows: (subscapularis*), (latissimus* or pectoralis*), (tear* or deficiency*), transfer.

Eligibility Criteria

Studies were included and systematically reviewed if they met the following criteria: (1) PMT or LDT was used to treat the subscapularis tears. (2) The subscapularis was irreparable. (3) Studies had a minimum 12 months of postoperative follow-up. (4) Postoperative functional outcomes were assessed using 1 of the following measurements: Constant-Murley score (CMS), the subjective shoulder value (SSV), visual analog scale (VAS) score for pain, active shoulder ROM, and belly-press or lift-off test.

The exclusion criteria were as follows: (1) a tendon transfer that did not include PMT or LDT surgery; (2) in vitro, cadaveric, or animal studies; (3) studies with a duplicated patient population; (4) case reports, pilot studies, reviews, systematic reviews, commentaries, unpublished manuscripts, editorials, book chapters, lectures, meeting abstracts, conference proceedings, or dissertations; and (5) studies without enough information for data analysis.

Study Selection

Z.L. and J.L. independently evaluated all titles and abstracts for relative articles. If these data were inadequate, full texts were assessed so the authors could judge if studies met the inclusion criteria. All references of enrolled studies were checked to avoid deleting relevant studies that were initially not enrolled. If there was an objection concerning the inclusion of studies, studies were judged by the senior author (J.C.) to make the final decision.

Data Extraction

The following information was extracted: study type, level of evidence,⁷⁶ first author, publication year, number of patients, mean age, mean duration of follow-up, surgical technique, transferring approach, tendon portion, number of suture anchors, pre- and postoperative clinical shoulder functional scores, postoperative failure rates, definition of ISScT, criteria, and complications. CMS at the final follow-up was selected as the primary outcome. Secondary outcomes included SSV, VAS (0-10 [10 = severe pain]), active external rotation at side (ER₀; degrees), active forward flexion (FF; degrees), active abduction (ABD; degrees), and internal rotation behind the back (IR₀; degrees). Two methods—recording the thumb positions and the direct degrees of internal rotation—were used to assess IR₀ in the involved studies. We synthesized IR₀ data by converting positions and degrees into numbers according to CMS⁷² and a 3-dimensional motion analysis study⁴⁵ as follows:

Positions of thumb position: lateral aspect of the thigh = 0, behind the buttock = 2, sacroiliac joint = 4, level of the waist = 6, 12th thoracic vertebrae = 8, and interscapular level = 10.

Degrees of IR₀: 0°-39.9° = 0, 40°-79.9° = 2, 80°-105° = 4, and so forth.

The primary safety outcome measure was the postoperative failure rate. Complications were summarized separately as secondary safety outcomes.

Data Analysis

The descriptive and clinical outcome data were presented in the form of mean and standard deviation (SD). For studies citing range, sample size, and median, the Stela Pudar Hozo formula was used to estimate the mean and SD.^29,69 Point estimates were acquired by combining weighted means and relevant SDs among studies.¹ SD and weighted means were acquired from the relevant studies. For the studies reporting pre- and postoperative scores, the difference between the mean scores (mean difference) was calculated to present the degree of improvement.⁶⁸ For studies in which the SD was known at preoperation and final follow-up, a correlation of 0.5 was applied to estimate the dispersion.⁴³ The P value for a continuous variable was calculated using a t test, while the Fisher exact test was performed for the categorical variable. P < .05 was considered statistically significant. To further analyze the robustness of the complete results of the primary outcome, the sample size was calculated per CMS at final follow-up. By performing a 2-tailed t test with 80% power (1 –b) and a 0.05 level of significance using G*Power software Version 3.1, an estimated sample size of 54 participants per group was required.

Quality Assessment

Given the abundance of nonrandomized studies in the available literature, 2 independent reviewers (Z.L. and J.L.) critically appraised all the eligible studies using Methodological Index for Nonrandomized Studies (MINORS) to evaluate their quality.⁶⁶ If a consensus was not achieved, a senior reviewer (J.C.) made the final decision on the assessment. The MINORS instrument consists of 12 items: 4 for comparative studies and 8 for noncomparative studies. A score of 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate) was suggested for each item, resulting in an ideal maximum score of 16 for noncomparative studies and 24 for comparative studies. For nonrandomized studies, the methodologic quality was classified as follows: 0 to 5, very low quality; 6 to 10, low quality; 11 to 15, fair quality; and 16, good quality. The outcomes of the risk-of-bias and quality assessment offered context for the conclusions to be drawn from this review.

Results

Study Selection

After duplicates were deleted, our search strategy yielded 546 articles (Figure 1). After title and abstract screening, 33 studies were chosen for full-text review, and 21 were excluded per our eligibility criteria. Overall, 12 studies were included in the qualitative and quantitative analyses.

Description of Studies

Of the 12 studies, 9 are PMT studies: 7 case series,^{13,18,19,60,70,71,73} 1 retrospective study,⁴⁰ and 1 therapeutic case study.¹⁶ These 9 studies all used open surgery as the surgical approach. The 3 LDT studies were observational case series,^14,34,49 with 1 using open surgery⁴⁹ and the other 2 using either arthroscopically assisted surgery or arthroscopy alone.^14,34 Other study characteristics are presented in Tables 1 and 2 and Appendix Table A1 (available in the online version of this article).

Table 1

Study Details^a

		Level of Evidence,	Surgery	No. of	Mean		Sex		Dominant
First Author	Year	Study Type	Approach	Shoulders	Age, y	Follow-up, mo	Male	Female	Yes	No	Recurrent	Complication
PMT
Vidil⁷¹	2000	4, case series	Open	5	54	19	4	1	3	2	3	1 tear in the anterior portion of the supraspinatus associated with the PMT
Resch⁶⁰	2000	4, case series	Open	12	65	28	10	2	8	4	2	0
Galatz¹⁸	2003	4, case series	Open	14	67.5	17.5	11	3	10	4		1 transient musculocutaneous neurapraxia, 1 rerupture of transferred tendon
Wambacher⁷³	2007	4, case series	Open	23		19	19	6				Not reported
Elhassan¹³	2008	4, case series	Open	22	37^b	49	9	2	7	4		3 failures
					58^c	57	7	4	7	4		4 failures
Gavriilidis¹⁹	2010	4, case series	Open	15	61.92	37	10	5	10	5	4	2 hematomas, 1 cuff tear arthropathy
Lederer⁴⁰	2011	3, retrospective case-control	Open	54	63.0	35.0	40	13	41	?	27	7 reruptures
Valenti⁷⁰	2015	4, case series	Open	15	57.0	24.0	10	5	8	7	7	1 rerupture, 1 pseudoparalysis
Ernstbrunner¹⁶	2019	4, therapeutic	Open	24	52.4	236.4	20	2				2 reruptures
LDT
Kany³⁴	2016	4, case series	Arthroscopic and open	5	65		4	1				1 hematoma, 1 deep infection with ruptured transfer
Mun⁴⁹	2018	4, case series	Open	24	58	27.8	12	12	18	6	2	0
Elhassan¹⁴	2020	4, case series	Arthroscopic and open	56	53	13	39	17	30	26	10	3 seromas, 2 superficial infections, 1 axillary wound dehiscence, 5 ruptures

LDT, latissimus dorsi transfer; PMT, pectoralis major transfer.

Isolated irreparable tear of the subscapularis after a failed instability procedure.

Rupture of the tendon of subscapularis associated with a massive tear of the rotator cuff.

Table 2

Study Characteristics at Preoperation^a

	PMT		LDT
Outcome	Mean ± SD or % (No.)	No. of Shoulders	Mean ± SD or % (No.)	No. of Shoulders	P Value^b
Age, y	58.9 ± 8.62	161	55.1 ± 9.28	85	.0015
Follow-up, mo	66.9 ± 12.1	146	17.4 ± 8.63	80	<.001
Male	77.35 (140)	181	64.7 (55)	85	.0297
Dominant side	75.81 (94)	124	60 (48)	80	.0196
Revision surgery	42.57 (43)	101	15 (12)	80	<.001

LDT, latissimus dorsi transfer; PMT, pectoralis major transfer.

Between the PMT and LDT groups. All comparisons, P < .05.

Risk of Bias

The mean MINORS scores of the 9 observational case series in the PMT group was 11.4 (SD, 0.36; range, 11-15) (Appendix Table A2, available online), indicating fair quality of evidence. The mean score of the 3 observational studies in the LDT group was 13.7 (SD, 1.5; range, 11-16), indicating fair quality of evidence. There was no statistical difference between the MINOR scores of the 2 groups (P = .354).

Study Characteristics

The types of procedure (PMT or LDT) and surgical approach (open or arthroscopic) are shown in Table 1. The relative characteristics at preoperation are listed in Table 2. A total of 85 shoulders from 3 studies in the LDT group and 184 shoulders from 9 studies in the PMT group were analyzed. The indication, contraindication, tendon portion, surgical technique, suture method, and number of suture anchors of PMT and LDT are summarized in Appendix Table A1 (available online). The mean age of patients at the time of surgery was 58.9 ± 8.62 years for the PMT group and 55.1 ± 9.28 years for the LDT group (P = .0015). In addition, 77.35% of the patients in the PMT group and 64.7% in the LDT group were male (P = .0297). The PMT group had a more extended follow-up period than did the LDT group (66.9 vs 17.4 months; P < .001). More patients underwent revision surgery in the PMT group than the LDT group (42.57% vs 15%; P < .001). The dominant-side rate in the PMT group was higher than that in the LDT group (75.81% vs 60%; P = .0196).

Surgical Techniques

For PMT, the surgical approach was open surgery among the 9 studies. Portions of the PM were transferred using various transfer routes. Among the 9 studies, 3 utilized a clavicular portion of the PM,^19,60,71 while only 1 used the sternal head alone to transfer.¹³ The other 5 studies used the entire PM to perform the surgery.^{16,18,40,70,73} Regarding the routing of the transferred tendon in PMT, 6 studies passed it behind a conjoined tendon,^{18,19,40,60,70,73} while just 2 performed PMT with transfers superficial to conjoined tendon.^13,16 The LDT was performed using arthroscopy,³⁴ open surgery,⁴⁹ or both¹⁴ using the whole LD. In the 3 LDT studies, the transferred tendon was passed behind or laterally from conjoined tendon.

Indications and Contradictions

All of the studies in this review explicitly reported that patients were diagnosed with ISScT. Eight articles defined ISScT as Lafosse type V: SScT with advanced fatty infiltration (Goutallier stage 3 or 4) and tendon retraction (Patte stage 3) (Appendix Table A1).^{13,14,16,19,34,49,70,71} The other 4 studies stated that ISScT was attributed to severe muscle retraction and fatty infiltration.^18,40,60,73 Additional indications were utilized in some studies, such as other intact or reparable rotator cuff tears, intact deltoid function, pain and limitations in shoulder function (internal rotation), a chief symptom of weakness, normal function of the LD/PM, anterosuperior instability, anterior subluxation, and superior migration of the humeral head upon attempted elevation.

Contradictions varied from study to study. Generally, patients were excluded if they had eccentric arthritis with Hamada stage 4 or 5, irreparable posterosuperior cuff tear, concomitant infraspinatus tendon rupture, stiff shoulder, diagnosis other than anterosuperior instability, nerve injuries, pseudoparalysis, subsequently required additional bone grafting, total shoulder replacement, or short follow-up period.

Primary Outcome

CMS was reported in 6 studies^{16,19,40,60,70,71} involving 125 shoulders in the PMT group and 3 studies^14,34,49 involving 85 repairs in the LDT group. LDT and PMT showed improvement in CMS (P < .001) (Table 3). Although the mean preoperative value of CMS in the LDT group was considerably lower than that in the PMT group (33.99 vs 38.62; P < .001), the mean postoperative value in the LDT group was significantly higher than that in the PMT group (69.22 vs 63.36; P = .002).

Table 3

Clinical Outcomes at Preoperation and Final Follow-up^a

	PMT		LDT
Outcome	Mean ± SD	No. of Shoulders	Mean ± SD	No. of Shoulders	P Value^b
CMS
Preoperative	38.62 ± 16.24	125	33.99 ± 6.44	85	<.001
Postoperative	63.36 ± 15.98^c	125	69.22 ± 7.96^c	85	.002
Mean difference	24.74 ± 16.11		35.23 ± 7.24		<.001
VAS for pain
Preoperative	7.40 ± 1.20	36	6 ± 1.18	80	<.001
Postoperative	3.69 ± 2.31^c	36	2 ± 0.83^c	80	<.001
Mean difference	3.71 ± 1.76		4 ± 1.02		.3616
SSV
Preoperative	22 ± 20	15	25 ± 7.5	56	.3611
Postoperative	71 ± 25^c	15	70 ± 10^c	56	.8115
Mean difference	49 ± 22.64		45 ± 8.84		.29

CMS, Constant-Murley score; LDT, latissimus dorsi transfer; PMT, pectoralis major transfer; SSV, subjective shoulder value; VAS, visual analog scale.

Between the PMT and LDT groups. Bold indicates P < .05.

Between pre- and postoperative, P < .05.

For verification, we calculated the mean difference between pre- and postoperative CMS. The mean improvement of CMS in the LDT group was also significantly higher in comparison with that in the PMT group (35.23 vs 24.74; P < .001). An estimated sample size of 54 participants per group was required for CMS after calculation.

Secondary Outcomes

Functional Outcomes

Overall, both groups showed significant improvements in VAS and SSV scores (Table 3). The LDT group had lower VAS scores than did the PMT group preoperatively (6 vs 7.4; P < .001) and postoperatively (2 vs 3.69; P < .001). However, the 2 groups did not significantly differ in pain relief (4 vs 3.71, P = .3616) or improvement of SSV scores (P = .29).

Active ROM

Preoperative active ROM (ABD, FF, ER₀, and IR₀) in the PMT group was greater than in the LDT group (Table 4). Overall, both procedures resulted in considerable improvement in active ABD, FF, and IR₀ (P < .05); however, ER₀ was significantly reduced in the PMT group (9.21°; P < .05) after surgery. Except for the similar IR₀, the postoperative ABD, ER₀, and FF in the PMT group were still greater than those in the LDT group; however, the LDT group had a greater improvement in ABD (35° vs 17.62°; P < .002), ER₀ (−0.5° vs −9.21°; P = .0023), and FF (44.3° vs 14.74°; P < .001).

Table 4

Range of Motion at Preoperation and Final Follow-up^a

	PMT		LDT
Range of Motion	Mean ± SD, deg	No. of Shoulders	Mean ± SD, deg	No. of Shoulders	P Value^b
ER₀
Preoperative	68.10 ± 22.89	71	46.8 ± 10.85	80	<.001
Postoperative	58.89 ± 21.24^c	71	46.3 ± 11.76	80	<.001
Mean difference	−9.21 ± 22.07		−0.5 ± 11.31		.0023
ABD
Preoperative	103.59 ± 40.72	56	55 ± 10	56	<.001
Postoperative	121.21 ± 33.3^c	56	90 ± 15^c	56	<.001
Mean difference	17.62 ± 37.2		35 ± 12.75		<.002
IR₀
Preoperative	3.67 ± 2.27	125	1.2 ± 0.66	85	<.001
Postoperative	5.55 ± 1.88^c	125	3.41 ± 0.88^c	85	<.001
Mean difference	1.88 ± 2.08		2.21 ± 0.77		.1636
FF
Preoperative	117.42 ± 36.36	115	96.5 ± 20.85	80	<.001
Postoperative	132.16 ± 34.4^c	115	140.8 ± 16.75^c	80	.0388
Mean difference	14.74 ± 35.38		44.3 ± 18.8		<.001

ABD, abduction; ER₀, external rotation at the side (in adduction); FF, forward flexion; IR₀, internal rotation behind the back (in abduction); LDT, latissimus dorsi transfer; PMT, pectoralis major transfer.

Between the PMT and LDT groups. Bold indicates P < .05.

Between pre- and postoperative, P < .05.

Internal Rotation Strength

The postoperative rates of positive belly-press and lift-off tests in the LDT and PMT groups were significantly lower than were the preoperative rates (P < .001) (Table 5). The postoperative positive rate of belly-press test in the LDT group was significantly lower in comparison with that in the PMT group (42% vs 65%; P = .0011). However, no difference existed for the lift-off test between the groups (P = .5788).

Table 5

Belly-press and Lift-off Tests at Preoperation and Final Follow-up^a

	Positivity Rate, % (No.)
	LDT	PMT	P Value^b
Belly-press test
Preoperative	87 (74 of 85)	92 (116 of 126)	.2336
Postoperative	42 (36 of 85)^c	65 (82 of 126)^c	.0011
Mean difference	45	27	<.001
Lift-off test
Preoperative	86 (65 of 76)	84 (139 of 165)	>.99
Postoperative	49 (37 of 76)^c	45 (74 of 165)^c	.5788
Mean difference	37	39	>.99

LDT, latissimus dorsi transfer; PMT, pectoralis major transfer.

Between the PMT and LDT groups. Bold indicates P < .05.

Between pre- and postoperative, P < .05.

For verification, we calculated the mean difference of pre- and postoperative positive test rates for both methods. The mean difference for the belly-press test in the LDT group was also significantly higher than that in the PMT group (45% vs 27%; P < .001). However, the mean difference for the lift-off test was not different between the groups.

Complications and Failure Rates

Overall, the failure rates were 7.06% (6/86) in the LDT group and 12.9% (20/155) in the PMT group (Table 6). Total numbers for each group differ from those given earlier because some studies did not provide the data. The failure rates were not significantly different between the groups (P = .1954).

Table 6

Postoperative Failure and Complication Rate at Final Follow-up^a

	Rate, % (No.)
	PMT (n = 155)	LDT (n = 86)	P Value^b
Postoperative failure	12.9 (20)	7.06 (6)	.1954
Complications	15.48 (24)	15.11 (13)	.9395

Total numbers for each group differ from those given earlier because some studies did not provide the data. LDT, latissimus dorsi transfer; PMT, pectoralis major transfer.

Between the PMT and LDT groups.

As for other complications, the LDT group had 1 case of a hematoma, 1 case of deep infection, 3 seromas, 2 superficial infections, and 1 axillary wound dehiscence (Table 1). In the PMT group (excluding rerupture), there were 3 cases of hematoma, 1 case of recurrent anterior instability, 1 case of supraspinatus and infraspinatus rerupture, 1 case of mechanical conflict of the coracoid process with the humeral head, 1 case of deep venous thrombosis of the axillary vein, 3 secromas, 2 superficial infections, and 1 case of transient musculocutaneous nerve neurapraxia. No significant difference in complication rates was seen between the groups (15.48% vs 15.11%; P = .9395).

Discussion

This systematic review examined 12 studies involving 269 shoulders with ISScT treated using PMT or LDT, including 184 PMT cases from 9 studies^{13,16,18,19,40,60,70,71,73} and 85 LDT cases from 3 studies.^14,34,49 The LDT and PMT groups were improved postoperatively in the primary outcome (CMS) and secondary outcomes (VAS, SSV, ROM, belly-press test, and lift-off test), with low rates of failure and complication. When compared with the PMT group, the LDT group showed greater improvements in the primary outcome (CMS) and in some secondary outcomes, such as ABD, FF, ER₀, and belly-press test.

For shoulder internal rotation, the subscapularis generates much higher force (1030 N) than does the PM (462 N).⁷ The complete loss of subscapularis strength in ISScT would impair the force couple balance between internal and external rotators,⁶⁵ thus disrupting the lever fulcrum during shoulder elevation,⁴⁶ and might result in shoulder paralysis and arthropathy.^{9,16,19,65,67} In addition, the loss of the anterior buttress from an intact subscapularis could cause anterior shoulder subluxation.⁵⁸ Therefore, the aim of tendon transfer for ISScT is to rebuild the counteracting strength and anterior shoulder buttress.⁵ Studies have indicated that tendon transfer could effectively relieve pain and improve shoulder function in ISScT.^8,50,65 The PM and LD are the most used tendons for transfer in ISScT, given their anatomic feasibility, large muscle excursion, sufficient force for internal rotation, and reasonable pull line.^{5,12,25,34,63}

In 1997, Wirth and Rockwood⁷⁵ reported PMT for 7 patients with ISScT, in which 5 had satisfactory overall outcomes at a mean 5-year follow-up. In 2014, Elhassan et al¹² tested LDT for ISScT in their anatomic study. Later, whole LDT was utilized for ISScT via open⁴⁹ or arthroscopically assisted surgery.^63,14 PMT and LDT demonstrated satisfactory outcomes in ISScT after surgery in this review. As for the primary outcomes, the mean CMS improved from 38.62 ± 16.24 to 63.36 ± 15.98 (P < .05) in the PMT group and from 33.99 ± 6.44 to 69.22 ± 7.96 (P < .05) in the LDT group. Regarding ROM, the mean improvements of active FF, ABD, and IR₀ were 14.74°, 17.62°, and 1.88°, respectively, in the PMT group and 44.3°, 35°, and 2.21° in the LDT group, respectively. In the included literature, the belly-press test and the lift-off test were used to evaluate the strength of shoulder internal rotation. The positive rate of belly-press test improved in the PMT group (from 92% to 65%; P < .05) and the LDT group (from 87% to 42%; P < .05), while the lift-off test also improved in the PMT group (from 84% to 45%; P < .05) and the LDT group (from 86% to 49%; P < .05). The postoperative positive rates of the 2 tests being >40% indicated that neither PMT nor LDT could restore the internal rotation strength consistently.

When compared with the PM, the LD could generate more powerful strength for shoulder internal rotation, owing to a pull line similar to that of the subscapularis,⁴⁹ and could pull down the humeral head to counteract the lifting force of the deltoid,^12,14,33 which might be why LDT could lead to superior outcomes over PMT. In this review, the LDT group achieved greater improvement in CMS (35.23 vs 24.74; P < .001), active ABD (35° vs 17.62°; P < .002), active FF (44.3° vs 14.74°; P < .001), and positive belly-press test rate (45% vs 27%; P < .001) than did the PMT group. The transferred pectoralis has a different force vector from the subscapularis because the chest wall is located between them,^12-14 which causes the pull lines of the PM and the subscapularis to form almost a 90° angle, especially when the lesser tuberosity moves next to the glenoid in an internal rotation position.^34,37 Although patients had significant clinical improvement after PMT, patients and surgeons should not expect a return to normal function because of the salvage surgery.⁵ As compared with the PM, the LD originates from the posterior side of the chest wall, is closer to the subscapularis,^15,59 and could better imitate the orientation of the subscapularis muscle for providing internal rotation strength.^34,41 In that way, LDT keeps the rotational center of the shoulder, maintaining the leverage during shoulder elevation.

Although PMT was widely used for ISScT, no consensus has been reached regarding its surgical technique, such as the harvested portion of the PM and graft routing.⁶⁵ The whole PM,^{16,18,40,70,73} the sternal head,¹³ and the clavicular head^19,60,71 were harvested for PMT in different studies. Because its fiber orientation is similar to that of the subscapularis, the sternal head of the PM has been reported to successfully restore internal rotation strength of the subscapularis.^30,63 The graft routing in PMT was anterior (superficial)^13,16 or posterior (deep)^{18,19,40,60,70,73} to the conjoined tendon in the studies in this review. The routing deep to the conjoined tendon is thought to be beneficial for restoring the kinematics of glenohumeral joint^32,37 and the buttress effect on the humeral head to maintain the anterior instability.³⁰

LDT and PMT showed significant pain relief after surgery, which was explained as the graft interposition in the subcoracoid space and the effect of balancing force couple.^5,60,73 PMT articles stated that the complete CMS pain score significantly increased from 4.67 to 12.84 (P < .05),^16,19,60,70 while 2 other PMT studies noted that the VAS score considerably decreased after surgery (7.4 vs 3.69; P < .05).^13,18 Two LDT studies reported that the VAS score decreased after surgery (6 vs 2; P < .05).^14,49 Given the different methods of pain evaluation across studies, the pain relief effects of PMT and LDT were difficult to compare in this review.

Anterior shoulder subluxation and superior migration of the humeral head were reported in 1 LDT study¹⁴ and 3 PMT studies.^13,18,40 Two of the 3 PMT studies^18,40 cited improved outcomes of anterior shoulder subluxation, while 1 indicated inferior outcomes.¹³ Galatz et al¹⁸ performed subcoracoid PMT for anterosuperior subluxation and superior migration of the humeral head in 14 cases of massive rotator cuff tear, stating that 13 patients experienced improvement of humeral head containment. Anterior shoulder subluxation might result from a combination of rotator cuff deficiency, loss of the coracoacromial arch, and anterior deltoid compromise.^18,62 Improvement occurred because LD and PM provide an appropriate internal rotation vector to counter the anterior displacement of the humeral head.^5,18 Meanwhile, the anterior buttress effect of the subscapularis was restored via the transferred tendon, which limited the abnormal movement of the humeral head.⁵ However, the anterior humeral head subluxation might indicate inferior outcomes after tendon transfer.¹³ Elhassan et al¹³ indicated that 3 patients with preoperative anterior subluxation had no improvement in pain or CMS and showed recurrent anterior subluxation after PMT surgery. In addition, Elhassan et al¹⁴ found that the patients with preoperative anterior humeral head subluxation continued to have proximal migration of the humeral head in 26% of cases and anterior subluxation of the humeral head in 11% after LDT.

In this study, SScT with severe muscle retraction and fatty infiltration was considered an ISScT, which was mostly defined as type V in the Lafosse classification.^{12,14,16,19,33,49,70,71} Although the contradictions for PMT or LDT varied among studies, patients with arthropathy of Hamada stage 4 or 5, irreparable posterosuperior cuff tear, stiff shoulder, or pseudoparalysis were generally excluded. Postoperative failures after PMT or LDT include transferred tendon tear and serious postoperative complications, such as pseudoparalysis. Although Kany et al³³ reported that LDT has a high probability of tendon rupture (38%) when dealing with irreparable rotator cuff insufficiency, the postoperative failure rate of the LDT group (7.06%) was low for treating ISScT under our analysis. No significant difference in postoperative failure rates (12.9% vs 7.06%; P = .1954) and complication rates (15.48% vs 15.11%; P = .9395) was found between the PMT and LDT groups. PMT could lead to injury of the musculocutaneous nerve and brachial plexus, which might result from direct nerve damage or nerve entrapment in the subcoracoid space^31,60,75; however, according to the literature, the incidence of nerve injury after PMT was as low as 0% to 7%.^13,40,70 In contrast, LDT is unlikely to damage the nerve from the anatomic point of view.^12,28,55,63 The 3 clinical studies of the LDT involved in this study cited no case of nerve injury.^14,34,49

This study had several limitations. First, the available studies or data about LDT used for anterosuperior rotator cuff tear were limited (85 patients),^14,34,49 although the case number reached the minimal sample number (54 in each group). Second, the difference in mean follow-up between the LDT group (17.4 months) and the PMT group (66.9 months) might have influenced the comparison of outcomes. However, because most complications and failures happened within 12 months after surgery and most clinical outcomes peaked within 12 months after surgery in both groups,^{13,14,16,49,70} it is likely that the different follow-up periods might not have compromised the current conclusion. Third, high-quality comparative evidence was insufficient because most studies were level 4. The mean MINORS scores of these studies were 13.7 and 11.4 in the LDT and PMT groups, respectively, indicating fair quality of evidence. Future research is required in the form of standard-evaluation prospective multicenter randomized controlled studies. Fourth, some data from the LDT and PMT groups at preoperation, such as patients’ age, dominant side, sex, revision surgery rate, ABD, IR₀, and VAS score, were different, and this may have influenced the results of this study.

Conclusion

This systematic review demonstrated that the overall clinical outcomes of LDT and PMT were good for ISScT and that LDT might result in a superior outcome to PMT. More high-quality randomized controlled studies on the long-term outcomes of these 2 techniques are required to further assess them.

Supplemental Material

sj-pdf-1-ajs-10.1177_03635465211018216 – Supplemental material for Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211018216 for Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review by Zhiwen Luo, Jinrong Lin, Yaying Sun, Kesen Zhu, Chenghui Wang and Jiwu Chen in The American Journal of Sports Medicine

Supplemental Material

sj-pdf-2-ajs-10.1177_03635465211018216 – Supplemental material for Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review

Supplemental material, sj-pdf-2-ajs-10.1177_03635465211018216 for Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review by Zhiwen Luo, Jinrong Lin, Yaying Sun, Kesen Zhu, Chenghui Wang and Jiwu Chen in The American Journal of Sports Medicine

Footnotes

Submitted November 20, 2020; accepted February 1, 2021.

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by the project of the National Natural Science Foundation of China (grants 81772419 and 81972062). AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

An online CME course associated with this article is available for 1 AMA PRA Category 1 Credit™ at . In accordance with the standards of the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The American Orthopaedic Society for Sports Medicine that authors, editors, and planners disclose to the learners all financial relationships during the past 12 months with any commercial interest (A ‘commercial interest’ is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients). Any and all disclosures are provided in the online journal CME area which is provided to all participants before they actually take the CME activity. In accordance with AOSSM policy, authors, editors, and planners’ participation in this educational activity will be predicated upon timely submission and review of AOSSM disclosure. Noncompliance will result in an author/editor or planner to be stricken from participating in this CME activity.

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