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When he attempts to press his abdomen with his right palm, his right elbow drops back
56%
876/1575
There is increased passive internal rotation of the right shoulder compared to the left
6%
95/1575
There is pain/weakness when the right arm is elevator to 90 degrees in the scapular plane
10%
164/1575
When asked to hold his right arm in 90 degrees of abduction and external rotation, the arm falls into internal rotation
14%
228/1575
There is obvious deformity and ecchymosis in the area of the right axillary fold
12%
191/1575
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This young laborer is presenting with a massive posterosuperior rotator cuff tear with retraction and significant muscle fatty infiltration, characteristics that make him a good candidate for a latissimus dorsi (innervated by the thoracodorsal nerve) tendon transfer. This tendon transfer has been reported to relieve pain and improve function when the subscapularis is intact. The physical examination of his eight elbow dropping back during attempted belly press would indicate a dysfunctional subscapularis. The optimal patient for latissimus dorsi tendon transfer is a younger adult patient with an irreparable posterosuperior rotator cuff tear, lack of advanced glenohumeral arthritis, and an intact subscapularis function to stabilize the humeral head after the latissimus tendon transfer. The relative contraindications to the latissmus dorsi tendon transfer include subscapularis deficiency, deltoid deficiency, pseudoparalysis of the shoulder and advanced glenohumeral arthritis. While superior capsular reconstruction is another potential option for younger, more active patients, long term results are currently being elucidated. For the older patient with an irreparable cuff tear, reverse shoulder arthroplasty may be indicated. Iannotti et al. investigated the clinical results of latissimus dorsi transfers in the setting of irreparable posterosuperior cuff tears 2 years after surgery. They reported that patients with good clinical results had a significantly better preoperative function in active forward flexion and external rotation compared with patients with poor results. They concluded that preoperative shoulder function and general shoulder strength influence the clinical outcomes of latissimus dorsi transfers. Gerber et al. investigated outcomes after latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. They reported that in patients with a negative preoperative lift-off test (intact subscapularis), significant improvements were observed in terms of and pain, motion, and strength, whereas no improvement in these parameters was observed when the preoperative lift-off test was positive. They concluded that this tendon transfer significantly improves chronically painful, dysfunctional shoulders with irreparable rotator cuff tears, especially when the subscapularis is intact. Figure A demonstrates an MRI with a massive rotator cuff tear with retraction and fatty infiltration of the muscle belly. Illustration A is a depiction of the latissimus dorsi tendon transfer. Incorrect Answers: Answer 2: Increased passive external rotation (not internal rotation) would be suggestive of a subscapularis tear. Answer 3: This is the drop sign, which assesses the integrity of the supraspinatus. Answer 4: This indicates a positive Hornblower's sign, which would be suggestive of a teres minor tear. Answer 5: This likely represents a pectoralis major rupture and not a subscapularis tear.
4.8
(4)
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