When it comes to shoulder fractures, the most common fracture in adults is that of the top part of the humerus or the proximal humerus. This type of fracture at the top of the arm bone occurs when the ball, of the ball-and-socket shoulder joint, is broken. Most proximal humerus fractures are not out of position but about 15-20 percent of these type of fractures are displaced calling for an invasive treatment.
But in the case that there is a high-grade fatty infiltration which means that there is more than a 50% fatty muscle atrophy the treatment approach ought to be different. When the supraspinatus, infraspinatus and subscapularis is found to be completely torn, the tear can be categorized as irreparable.
Irreparable rotator cuff tears are basically characterized by a torn and retracted tendon associated with muscle atrophy and impaired mobility. Fixing the torn tendon directly is not possible because of the retracted tendon and poor healing potential. When the tendon is torn chronically the muscle becomes fibrotic and infiltrated with fat. Joint movement is impossible when this happens.
In these kinds of tears, a detailed MRI examination will reveal that there will not be any muscle attachment to the shoulder. The rotator cuff will show a Patte grade 3 retraction and Goutallier grade 4 fatty infiltration. The Patte classification describes the amount of supraspinatus tendon retraction in a complete tear of the rotator cuff of the shoulder and a Goutallier classification is used to grade the rotator cuff muscle fatty degeneration. A muscle transfer procedure is the most effective way to treat such cases.
In the muscle transfer procedure, the latissimus dorsi can be transferred to the supraspinatus position on the greater tuberosity and pectoralis major to the lesser tuberosity in such a way that the subscapularis is replaced. The latissimus dorsi is a large, flat muscle on the back that stretches to the sides, behind the arm, and is partly covered by the trapezius on the back near the midline. This area is the broadest section of the back. In some severely torn cases, the transfer of the pectoralis major muscle can improve function and alleviate pain.
Muscle transfer is a relatively rare procedure reserved for patients with weak shoulders which are not so weak as to appear almost paralyzed or with pseudo paralysis. The muscle transferred from the back of the shoulder can now substitute in function for the rotator cuff. This procedure will require an incision in the back of the shoulder as well as the top of the shoulder. After the surgery a special brace will help keep the arm in place during the recovery period which is anywhere close to 6 weeks.
Muscle transfer is a much discussed and quite favorable treatment option in the case of irreparable rotator cuff tears that are associated with severe functional impairment and chronic, disabling pain. Previously done studies on the resulting outcomes of this surgical procedure have evidently shown improved pain relief, higher mean Subjective Shoulder Value, increased flexion, abduction and external rotation as well as increased abduction strength. Significant improvements were also observed in terms of both function, strength and pain. But in the case of shoulders that had poor subscapularis function, the improvement observed was minimal.
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