Thank you very much for the privilege of presenting at the ANNA meeting. On behalf of the Scholder Center here at Bell University Medical Center in Dallas, we've put together a very nice debate talking about how to handle the irreparable subscapularis tear. And I'm going to start by way of teaching you how to stack the deck with the peck. By way of disclosure, my disclosure slides are on the Academy's website for the AOS, and nothing is germane to this talk. So when we're talking about the irreparable subscapularis tear, we really need to define the problem. Irreparable means cannot heal. The real question is not, cannot the subscapularis be repaired, but can the subscapularis actually heal? We see people stand at podiums and say, well, I can repair any tendon. Well, that's fine, but the question is, can it actually heal to the bone? Most subscapularis tears, with enough fatty infiltration that there's more fat than muscle, which would be Goutelier grade three and four tears, likely are considered irreparable and unlikely to heal. And those are the tears that we're going to speak about when we're talking about stacking the deck with the peck. So what to do? The treatment options for the irreparable subscapularis can range from non-operative treatment all the way through to arthroplasty. But what we're going to talk about here is a technique that is applicable to any subscapularis tear in pretty much any clinical situation. And that is the pectoralis major tendon transfer. We owe a debt of gratitude to Professor Herbert Resch from Austria, who more than 20 years ago first described the technique of transferring the pectoralis tendon to the lestatuberosity to account for the irreparable subscapularis. In his technique originally described in the Journal of Bone and Joint Surgery, he transferred both the sternal heads and the clavicular heads. He did this in a subcoracoid fashion behind the conjoined tendon of the short head of the biceps and the coracobrachialis. Well, over the last 20 years, this has now been a technique that has been adopted and changed and adapted for many clinical situations by legendary shoulder surgeons around the world. Professor Christian Gerber, Professor Giuseppe Porcellini, our own Lisa Gallitz and Tony Romeo, again Herbert Resch and Professor Gerber have all described not only the technique of using part of the pectoralis, all of the pectoralis, the pectoralis minor, transferring behind the conjoined tendon, transferring in front of the conjoined tendon, transferring in an arthroscopic assisted manner, transferring for just isolated tendon tears and even for tendon tears with arthroplasty such that this really becomes a full deck of cards that you can use in your stack. The anatomy of the pectoralis is really quite simple. As you can see from this slide from Dr. Gallitz's original paper, the subscapularis inserts on a lesser tuberosity very similar to the external auricle of the ear. The pectoralis major inserts on the lateral lip of the bicipital groove and it has a fan-shaped insertion. Amr Almiraghi from Canada first described this fan-shaped insertion of the sternal head diving under the clavicular head to perform a very broad insertion onto the bone itself. So therefore, most surgeons who are comfortable with delto-pectoral anatomy between the deltoid and the pectoralis can perform this transfer. The surgical technique is really relatively straightforward. As we'll see here, this is a right shoulder and we're performing this particular transfer for an irreparable subscapularis in the face of an arthroplasty. As we can see, the elevator is demonstrating the insertion on the lateral lip of the bicipital groove. Inferiorly, we can dissect where the sternal head dives underneath the clavicular head and expose with a right angle clamp the entire pectoralis. If you prefer to take the entire tendon as I'm doing here, it's easy to sharply dissect this off the lateral lip of the bicipital groove, place a clamp on the edge of the tendon itself and then evert the tendon edge. Again, there are no neurovascular structures in this particular region because the insertional points of the medial and lateral pectoral nerves to the pectoralis minor and pectoralis major are actually far medial to where you're at working. So once you place a clamp on the lateral edge of the tendon, we can use both cautery and blunt dissection to dissect the muscle belly. The pectoralis major has a clavicular head and also a sternal head. There are also abdominal attachments that, as you can see here, dive in deep to the rectus fascia. By using a clamp, we can dissect all the way around the inferior sternal head, superiorly the clavicular head, expose the entire pectoralis and then suture this in a transosseous fashion to the lesser tuberosity. This is no different from doing this with an arthroscopic repair of the subscapularis or an open repair of the subscapularis. We perform this in a dual row technique with transosseous sutures laterally and transosseous sutures medially. So in summary, why I like this transfer, it's familiar anatomy. Every surgeon can understand the anatomy of the pectoralis. It just takes a moment to dissect inferiorly, dissect superiorly, externally rotate the arm, expose the tendon insertion. It's technically easy because the pectoralis is sitting right in the front of the shoulder to subcutaneous muscle. It burdens no bridges. You don't have to take one muscle down to transfer another muscle. The peer-reviewed outcomes for either partial or complete transfers, subcoracoid or supercoracoid open or arthroscopic are all very, very acceptable in terms of dealing with irreparable subscapularis. So I submit to you, why mess with success? Thank you.

irreparable subscapularis tears

pectoralis major tendon transfer

surgical technique

shoulder surgery

Herbert Resch