Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

Aims

Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients.

Aims

There is little information in the literature about the use of dual-mobility (DM) bearings in preventing re-dislocation in revision total hip arthroplasty (THA). The aim of this study was to compare the use of DM bearings, standard bearings, and constrained liners in revision THA for recurrent dislocation, and to identify risk factors for re-dislocation.

Aims

Multiple secondary surgical procedures of the shoulder, such as soft-tissue releases, tendon transfers, and osteotomies, are described in brachial plexus birth palsy (BPBP) patients. The long-term functional outcomes of these procedures described in the literature are inconclusive. We aimed to analyze the literature looking for a consensus on treatment options.

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.

Aims

To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures.

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

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Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation.

Aims

The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus.

Latissimus dorsi anterior to major transfers have been advocated in the setting of loss of external rotation and elevation in conjunction with reverse shoulder replacement. Reverse shoulder replacement is a prosthesis specifically designed for shoulders with poor rotator cuff function. In the vast majority of cases, some teres minor function at the minimum is maintained in shoulders destined for a reverse shoulder replacement. However, in certain circumstances there is complete loss of any external rotation, and a muscle transfer can be performed in order to restore some external rotation function. A reverse shoulder replacement in the absence of any rotator cuff function goes into obligate internal rotation with elevation. A minimum of external rotation strength is necessary in order to maintain the arm in normal rotation. The first tip is patient selection. Physical examination of active external rotation, external rotation strength and forward elevation should be just performed. A latissimus transfer is indicated in patients who cannot maintain their arm in neutral to at least a few degrees of external rotation. A lag sign is another physical examination finding which can indicate complete loss of rotator cuff function. The latissimus dorsi transfer is performed by first identifying and releasing the latissimus from its insertion on the anterior humerus. The arthroplasty is performed. The passage for the latissimus muscle is developed carefully and being mindful of the axillary nerve in particular. The latissimus is directed inferior to the nerve and around the medial and posterior aspect of the proximal humerus. Different ways of securing the transfer to the humerus have been described including bone tunnels and anchors. Often it is easier to place the anchors and/or the bone tunnels prior to inserting the humeral prosthesis. The latissimus is secured in the new position, enabling it to participate in external rotation. The value of this is difficult to clearly establish. Most studies are evidence level IV and there are no good comparative studies in a controlled patient population. This is a good option for shoulders with no active external rotation, but they may increase overall complication rate. Complications include dislocation, infection, and transient nerve palsy

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.

Aim. A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI. Method. We performed a retrospective review of all patients undergoing gastrocnemius muscle transfer with split thickness skin grafting as part of their treatment for knee PJI at a tertiary referral centre between 1994 and 2015. Data recorded included patient characteristics, orthopaedic procedure, microbiology result and antimicrobial management. Outcome measures included flap failure, infection recurrence, amputation, functional outcome (Oxford knee score; OKS) and mortality. Results. In total, 115 consecutive patients (39% female) with a mean age of 74.4 years (range 44–100) were followed up for an average of 5.5 years (range 119 days – 19.7 years). There were no reported cases of flap failure. Gastrocnemius flaps were most commonly performed at the time of the first stage of a two-stage revision (41%), or during debridement and implant retention (DAIR) (27%). 10% were performed at the second stage of a two-stage procedure and 4% were performed during a single stage revision. Of 96 positive deep specimen cultures, 43 (45%) showed mixed growth and 47 (49%) grew coagulase-negative staphylococcus (with or without other microorganisms). The infection recurrence rate was 32%. Limb salvage was achieved in 88% of cases. 12% of patients required life-long suppressive antibiotic therapy. 55 knees were followed up for five years or more, with a survival (not deceased, not amputated) of 64%. 37 knees were followed up for 10 years or more, with a survival of 32%. In living patients who did not have an amputation, the mean OKS was 25.8 (n=36; range 7–47). Conclusion. This study represents the largest series to date of infected knee prostheses treated with gastrocnemius flap coverage. A multidisciplinary approach to complex PJI surgery is recommended, involving infectious disease physicians and the orthoplastic team. We also recommend a low threshold for requesting plastic surgery input. In our experience, this technique is safe, with no flap failure, and has enabled limb salvage for the majority (88%) of patients with infected knee prostheses and insufficient soft tissue envelope

Aim. Simultaneous use of Ilizarov techniques with transfer of free muscle flaps is not current standard practice. This may be due to concerns about duration of surgery, clearance of infection, potential flap failure or coordination of surgical teams. We investigated this combined technique in a consecutive series of complex tibial infections. Method. A single centre, consecutive series of 45 patients (mean age 48 years; range 19–85) were treated with a single stage operation to apply an Ilizarov frame for bone reconstruction and a free muscle flap for soft-tissue cover. All patients had a segmental bone defect in the tibia, after excision of infected bone and soft-tissue defects which could not be closed directly or with local flaps. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap type, follow-up duration, time to union and complications. Results. 26 patients had osteomyelitis and 19 had infected non-union. Staphylococci were cultured in 25 cases and 17 had polymicrobial infections. Ilizarov monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, and bone transport in 8. 8/45 had an additional ankle fusion, 7/45 had an angular deformity corrected at the same time and 24 also had local antibiotic carriers inserted. Median time in frame was 5 months (3–14). 38 gracilis, 7 latissimus dorsi and 1 rectus abdominus flaps were used. One flap failed within 48 hours and was revised (flap failure rate 2.17%). There were no later flap complications. Flaps were not affected by distraction or bone transport. Mean follow-up was 23 months (10–89). 44/45 (97.8%) achieved bony union. Recurrence of infection occurred in 3 patients (6.7%). Secondary surgery was required to secure union with good alignment in 8 patients (17.8%; docking site surgery in 6, IM nailing in 2) and in 3 patients for infection recurrence. All were infection free at final follow-up. Conclusions. Simultaneous Ilizarov reconstruction with free muscle flap transfer is safe and effective in treating segmental infected tibial defects, and is not associated with an increased flap failure rate. It shortens overall time spent in treatment, with fewer operations per patient. However, initial theatre time is long and a committed multidisciplinary team is required to achieve good results

Hip abductor deficiency (HAD) associated with hip arthroplasty can be a chronic, painful condition that can lead to abnormalities in gait and instability of the hip. HAD is often confused with trochanteric bursitis and patients are often delayed in diagnosis after protracted courses of therapy and steroid injection. A high index of suspicion is subsequently warranted. Risk factors for HAD include female gender, older age, and surgical approach. The Hardinge approach is most commonly associated with HAD because of failure of repair at the time of index surgery or subsequent late degenerative or traumatic rupture. Injury to the superior gluteal nerve at exposure can also result in HAD and is more commonly associated with anterolateral approaches. Multiple surgeries, chronic infection, and chronic inflammation from osteolysis or metal debris are also risk factors especially as they can result in bone stock deficiency and direct injury to muscle. Increased offset and/or leg length can also contribute to HAD, especially when both are present. Physical exam demonstrates abductor weakness with walking and single leg stance. There is often a palpable defect over the greater trochanter and palpation in that area usually elicits significant focal pain. Note may be made of multiple incisions. Increased leg length may be seen. Radiographs may demonstrate avulsion of the greater trochanter or significant osteolysis. Significant polyethylene wear or a metal-on-metal implant should be considered as risk factors, as well as the presence of increased offset and/or leg length. Ultrasound or MRI are helpful in confirming the diagnosis but false negatives and positive results are possible. Treatment is difficult, especially since most patients have failed conservative management before diagnosis of HAD is made. Surgical options include allograft and mesh reconstruction as well as autologous muscle transfers. Modest to good results have been reported, but reproducibility is challenging. In the case of increased offset and leg length, revision of the components to reduce offset and leg length may be considered. In the case of significant instability, abductor repair may require constrained or multi-polar liners to augment the surgical repair. HAD is a chronic problem that is difficult to diagnose and treat. Detailed informed consent appropriately setting patient expectations with a comprehensive surgical plan is required if surgery is to be considered. Be judicious when offering this surgery

Abductor deficiency after THA can result from proximal femoral bone loss, trochanteric avulsion, muscle destruction associated with infection, pseudotumor, ALTR to metal debris, or other causes. Constrained acetabular components are indicated to control instability after THA with deficient abductors. However, the added implant constraint also results in greater stresses at the modular liner-locking mechanism of the constrained component and bone-implant fixation interface, which can contribute to mechanical failure of the constrained implant or mechanical loosening. Use of large heads has been effective in reducing the rate of dislocation after primary THA. However, relatively large (36mm) heads were not found to be effective in controlling dislocation in patients with abductor deficiency. Dual mobility implants which can provide considerably larger head diameters than 36mm may offer an advantage in improving stability in patients with abductor deficiency. However the utility of these devices in controlling instability after THA with deficient abductors has not been established. Whiteside has described a transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter for treatment of absent abductors after THA. Transposition of the tensor muscle requires raising an anterior soft tissue flap to the lever of the interval between the tensor muscle and sartorius, which is the same interval used in an anterior approach to the hip. The muscle is transected distally and transposed posteriorly to attach to the proximal femur. This can result in soft tissue redundancy between the posterior tensor muscle and anterior gluteus maximus. This interval is separated and the anterior gluteus maximus also attached to the proximal femur. The transposed tensor muscle provides muscle coverage over the greater trochanter, which may be beneficial in controlling lateral hip pain. In our practice, 11 patients were treated with Whiteside's tensor muscle transfer. Six patients had absent abductors, one had an avulsed greater trochanter, and four intact but weak abductors. One patient had a muscle transposition alone, one had an ORIF of the greater trochanter and muscle transposition, two had a muscle transposition and head/liner exchange, three had a muscle transposition and cup revision, two had a femoral revision and liner exchange with muscle transposition, and two had a muscle transposition with both component revision. None of the patients had constrained components. The mean pre-operative abductor strength was 2.2 (0/5 in four patients 3/5 in four patients, and 4/5 in three patients). Pre-operative lateral hip pain was none or mild in two patients, moderate in three, and severe in six patients. Mean post-operative abductor strength was 3.2 (2/5 in four patients, 3/5 in three, 4/5 in two, 5/5 in two patients). Post-operative lateral hip pain was none in five and mild in six patients. One patient sustained a dislocation four weeks after surgery which was treated with open reduction. All of the other hips have remained stable. Treatment of patients with hip instability and abductor deficiency has generally required use of a constrained acetabular component. In our experience, transfer of the tensor muscle and anterior gluteus maximus to the greater trochanter can improve abductor strength by one grade and also reduce lateral hip pain. The combination of a large head and tensor muscle transposition may be a viable alternative to use of a fully constrained component in patients with deficient abductors after THA. However, the need for implant constraint should also be individualised and based on factors such as the viability of the transposed muscle, patient compliance with post-operative activity restrictions, femoral head/neck ratio, and cup position

Avulsion of the abductor muscles of the hip may cause severe limp and pain. Limited literature is available on treatment approaches for this problem, and each has shortcomings. This study describes a muscle transfer technique to treat complete irreparable avulsion of the hip abductor muscles and tendons. Ten adult cadaver specimens were dissected to determine nerve and blood supply point of entry in the gluteus maximus and tensor fascia lata (TFL) and evaluate the feasibility and safety of transferring these muscles to substitute for the gluteus medius and minimus. In this technique, the anterior portion of the gluteus maximus and the entire TFL are mobilised and transferred to the greater trochanter such that the muscle fiber direction of the transferred muscles closely matches that of the gluteus medius and minimus. Five patients (five hips) were treated for primary irreparable disruption of the hip abductor muscles using this technique between January 2008 and April 2011. All patients had severe or moderate pain, severe abductor limp, and positive Trendelenburg sign. Patients were evaluated for pain and function at a mean of 28 months (range, 18–60 months) after surgery. All patients could actively abduct 3 months post-operatively. At 1 year post-operatively, three patients had no hip pain, two had mild pain that did not limit their activity, three had no limp, and one had mild limp. One patient fell, fractured his greater trochanter, and has persistent limp and abduction weakness. The anterior portion of the gluteus maximus and the TFL can be transferred to the greater trochanter to substitute for abductor deficiency. In this small series, the surgical procedure was reproducible and effective; further studies with more patients and longer follow-up are needed to confirm this

Background. Infected total knee arthroplasties present in a variety of different clinical settings. With severe local compromise and draining sinus tract around the knee, after adequate debridement, the resultant patellectomy with need for free muscle transfer and split thickness skin graft for closure, usually results in loss of quadriceps function. This necessitates the need for drop lock brace. No good mechanisms are available for reconstruction of large anterior defects in total infected total knees where this occurs. Questions. Can proximal placement of the knee joint with longer tibial segments aid in closure in patients with large anterior skin defects, and can this placement aid in quadriceps reconstruction to alleviate the need for drop lock braces while ambulating?. Methodology. 10 patients with 2 year follow-up with stage III-C-3 McPherson infected total knees presented with large soft tissue defects over the anterior aspect of the knee with sinus tract and scarring from multiple surgeries. The patients underwent a one stage treatment of the infected total joint. 4 required a free muscle flap and split thickness skin graft. Patellectomy with some quadriceps resection was required in the debridement process. Distal femur and proximal tibial replacements were performed with proximal placement of the knee joint. The patients were analyzed for extension control in gait and soft tissue closure over the operational knee joint. The quadraceps mechanism was over attached to the proximal tibial component. Results. Of 10 with 2 year follow up, none recurred with infection. There was no erosion of the soft tissue over the knee joint commonly seen in free flaps directly over the joint in these type of resection –replacements. 50% of the patients had enough extensor use to walk with a cane or walker as opposed to needing a drop lock knee brace. Discussion. Proximal placement of the knee joints in patients with large anterior soft tissue defects may lessen need for free flaps and provide for extension to lock hinges. Conclusion. Proximal placement of the total knee in case of infected total knees with large anterior soft tissue defect, provides for more quadriceps function and soft tissue coverage and lessened the need for free flaps

Abductor deficiency commonly contributes to total hip dislocation. Successful treatment of the deficiency can improve function, decrease pain, and decrease reliance on implants to cure recurrent dislocation. The defining physical exam findings are dependence on ambulatory assistive devices, severe limp, positive Trendelenberg sign, and inability to abduct against gravity. Three techniques have been described for chronic abductor discontinuity in which the abductors have retracted or are absent and cannot reach the greater trochanter: Vastus lateralis muscle shift, Achilles tendon allograft, and gluteus maximus muscle transfer. None of the techniques were specifically performed for dislocation. The vastus lateralis shift transfers the entire muscle proximally maintaining the neurovascular bundle. The procedure requires an incision from the hip to the knee, isolation of the neurovascular bundle, and elevation of the muscle from the femur. The authors admitted that the technique is demanding and not easily applicable to many surgeons. Repair with an Achilles allograft requires an identifiable contractile abductor mass. The allograft is looped through the abductors to bridge the gap to the trochanter. Two variations of a gluteus muscle transfer for abductor deficiency after total hip have been described. A portion of the gluteus maximus with its distal fascial portion are transferred to the greater trochanter. As far as dislocation is concerned an advantage of this technique is the use of the posterior maximus flap to fill a posterior and superior capsular defect not addressed with the other techniques. In addition the technique is easy to perform in almost all cases

Reverse total shoulder arthroplasty (RTSA) was designed to treat the cuff-deficient shoulder with arthritis and irreparable rotator cuff tears of the supraspinatus and infraspinatus tendons. The results of RTSA in this patient population have been very good and reliable in the majority of cases. However, it has also been reported that patients whose rotator cuff tear involves the supraspinatus, infraspinatus and teres minor and who demonstrate a ‘horn-blower's sign’ do very poorly if a muscle transfer is not performed to improve external rotation in these shoulders in abduction. The loss of the teres minor in these patients results in grave difficulty for the patient attempting to perform their activities of daily living even if they can obtain reasonable good forward flexion. The muscle transfer that is most commonly used for these select patients is a latissmus dorsi tendon transfer in conjunction with RTSA. The purpose of this talk is to review the pathology of this problem and review the technique for its surgical treatment

Objectives

Our objective was to predict the knee extension strength and post-operative function in quadriceps resection for soft-tissue sarcoma of the thigh.