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Isolated Loss of Active External Rotation: a Distinct Entity and Results of L'episcopo Tendon Transfer

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Isolated Loss of Active External Rotation: a Distinct Entity and Results of L'episcopo Tendon Transfer J Shoulder Elbow Surg (2018) 27, 499–509 www.elsevier.com/locate/ymse Isolated loss of active external rotation: a distinct entity and results of L’Episcopo tendon transfer Pascal Boileau,MDa,*, Mohammed Baba,MDb, Walter B. McClelland Jr, MDc, Charles-Édouard Thélu,MDd, Christophe Trojani, MD, PhDa, Nicolas Bronsard, MD, PhDa aInstitut Universitaire Locomoteur et Sport (iULS), Hôpital Pasteur 2, University of Nice Sophia Antipolis (UNSA), Nice, France bSydney Adventist Hospital, Wahroonga, NSW, Australia cPeachtree Orthopaedic Clinic, Atlanta, GA, USA dHôpital Privé Métropole, Lille, France Background: The purpose of this study was to characterize a subgroup of cuff-deficient patients with iso- lated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L’Episcopo procedure to restore horizontal muscle balance. Methods: During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L’Episcopo tendon transfer was per- formed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months). Results: Preoperatively, despite maintained active elevation (average of 161°), ILER patients com- plained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L’Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear ar- thropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery. Conclusions: ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In prop- erly selected cases (Hamada stage 1 or 2), the modified L’Episcopo transfer is effective at restoring anterior- posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohu- meral joint. This study was approved by the local ethics committee: No. 2016-19. All participants signed an informed consent form for treatment and gave consent to participate in the study. *Reprint requests: Pascal Boileau, MD, iULS (University Institute of Locomotion and Sports), Pasteur 2 Hospital, University of Nice Sophia Antipolis, 30 Avenue de la Voie Romaine, F-06000 Nice, France. E-mail address: [email protected] (P. Boileau). 1058-2746/$ - see front matter © 2017 The Author(s). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). https://doi.org/10.1016/j.jse.2017.07.008 500 P. Boileau et al. Level of evidence: Level IV; Case Series; Treatment Study © 2017 The Author(s). This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). Keywords: Massive irreparable rotator cuff tears; posterosuperior cuff tears; isolated loss of active external rotation (ILER); teres minor muscle; tendon transfer; L’Episcopo procedure The prevalence of massive irreparable rotator cuff tears characterize the clinical and imaging presentation of this sub- (MIRCTs) reported in the literature has ranged from 10% to group of cuff-deficient patients with ILER and to evaluate 40%.1,21,32,37 Most MIRCTs are chronic and often asymptom- outcomes of the modified L’Episcopo procedure in this pop- atic, occurring in elderly, less active patients. This pathologic ulation. We hypothesized that the tendon transfer would process relates to a progressive and degenerative “tendon wear” provide efficient and durable functional improvement in pa- under the acromial arch.4,22,28,40 In these patients, in whom the tients with ILER. cuff tendon degeneration process is slow and progressive, the cuff-deficient shoulder often remains functional with normal Materials and methods or nearly normal active elevation and external rotation 4,23,40 (ER). Some cuff-deficient shoulders may become non- Study design functional and symptomatic, either traumatically or atraumatically, resulting in pain, weakness, and loss of We performed a retrospective cohort study, collecting prospective- 4,40 motion. In such circumstances, patients may lose active ly comprehensive preoperative and postoperative data, of all ILER forward elevation (AFE) or active ER (AER), temporarily or patients who were operated on. All surgical ILER patients were invited permanently.3,4 to return for clinical, radiographic, and follow-up examination at 6 In 2003, we saw for the first time at our institution a patient months, 1 year, 2 years, and yearly. Patients were called back for with a massive irreparable posterosuperior rotator cuff tear maximum follow-up and evaluated with minimum 2-year follow- who had permanently lost AER but with preserved AFE. This up. The average follow-up was 52 months (range, 24-104 months). 67-year-old woman complained that as she elevated her shoul- der, her forearm would fall into progressive internal rotation Patient selection (IR), the dropping sign. On clinical examination, she had pres- ence of the Hornblower,35 ER lag,19 drop,28 and dropping Inclusion criteria included patients who presented with ILER in the signs.35 This resulted in difficulty with simple activities of daily context of MIRCT, surgical treatment with a modified L’Episcopo living (ADLs), such as eating, drinking, combing her hair, tendon transfer, and minimum 2-year clinical and radiologic follow-up. applying makeup, holding a phone to her ear, or shaking some- We excluded patients with acute post-traumatic posterosupe- one’s hand. Imaging studies revealed severe fatty infiltration rior cuff tear that could be repaired; patients with massive posterosuperior cuff with conserved AFE and AER who under- (Goutallier grade 3 and grade 4)16 of supraspinatus and in- went a rotator cuff débridement or partial rotator cuff repair; patients fraspinatus with a completely atrophic teres minor (Tm). with cuff-deficient shoulder and definitive pseudoparalysis who un- The treatment of MIRCTs is still controversial and depends derwent an RSA; patients with cuff-deficient shoulder and combined on the symptoms presented by the patient; conservative therapy, loss of active elevation and ER who underwent an RSA in combi- arthroscopic débridement with or without partial cuff repair, nation with a modified latissimus dorsi (LD) or LD/teres major (TM) tendon transfers, and reverse shoulder arthroplasty (RSA) have transfer3,4; patients with loss of passive ER related to shoulder stiff- all been proposed.1,4,12,14,21,32,37 An RSA was not indicated in ness (after fracture sequelae with greater tuberosity migration or our patient because AFE was conserved (ie, the vertical muscle adhesive capsulitis); and patients with isolated Tm atrophy (related balance of the shoulder was maintained).2,5 We hypoth- to neurologic insult, such as traumatic paralysis, compression, or 7,8,13,39 esized that a tendon transfer, which could re-establish the lost systemic neurologic disorder). horizontal muscle balance of the shoulder, would result in im- proved AER and restore shoulder function.3,4 This led us to Surgical technique propose a modified L’Episcopo procedure, which success- fully restored AER in our patient without compromising The procedure was carried out with the patient in the beach chair AFE.3,26 position under general anesthetic with interscalene block. The arm In 2007, we introduced the concept of isolated loss of ER was draped free. Using a standard deltopectoral approach, the lo- cation and irreparability of the cuff tear were confirmed. The (ILER) to define the subset of patients with definitive hori- coracoacromial ligament was preserved, and no acromioplasty was zontal muscle imbalance and have proposed a modified performed as this could have led to vertical imbalance of the shoul- 3 L’Episcopo procedure as a surgical solution for these patients. der with anterosuperior escape of the humeral head and secondary Here we describe the largest series of MIRCT patients pre- pseudoparalysis. The axillary nerve and radial nerves were identified senting with ILER and the results obtained after modified and protected. When present, the biceps tendon was managed with L’Episcopo transfer. The purposes of the study were to soft tissue tenodesis at the proximal aspect of the bicipital groove. ILER 501 Figure 1 Modified L’Episcopo procedure. Latissimus dorsi (LD) and teres major (TM) are detached from the anteromedial side of the humerus and transferred on the posterolateral side. The superior 25%-50% of the pectoralis major tendon was re- of progressive stretching and strengthening in ER. Physiotherapy leased at its musculotendinous junction, leaving roughly 15- was continued for 6-12 months postoperatively, depending on the 20 mm of tendon attached to the humerus for later pectoralis repair. patient’s progress. Both LD and TM tendons (often a conjoint tendon) were detached from the humerus and sutured together. In 5 patients, the tendons Clinical assessment were detached with some bone chips. The combined tendons were tagged using 3 or 4 heavy, nonabsorbable sutures with Mason- Clinical assessment of rotator cuff function included the dropping Allen configuration. sign, described by Neer, to assess function of the infraspinatus,28,35 The 2 tendons were released bluntly to gain length while avoid- and both the drop sign31 and the Hornblower sign35 to evaluate the ing damage to the neurovascular structures, the most proximate of Tm.
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