35 Latissimus Dorsi Tendon Transfer
Abstract
Patients with irreparable rotator cuff tears remain a significant clinical challenge. The latissimus dorsi tendon transfer is a viable option for patients with irreparable posterosuperior rotator cuff tears. Ideally indicated patients are those considered to young for reverse shoulder arthroplasty and without evidence of advanced cuff tear arthropathy or fixed proximal humeral migration. A functional deltoid and intact subscapularis are required as well. The surgical technique has multiple options. We describe a single posterior incision technique facilitated by arm positioning. Care is taken to protect surrounding neurovascular structures. Final placement of the transferred tendon can be modified based on the presence of external rotation lag signs. Careful protection of the repair is required for 6-12 weeks with a graduated progressive rehabilitation program. Final recovery can take 8-9 months. The results of latissimus dorsi tendon transfer have been shown to be reliable for pain relief and inconsistent for functional recovery. The functional results are better in shoulders with an intact teres minor. Successful early results in patients following latissimus dorsi tendon transfer have been shown to be durable long term.
35.1 Goals of Procedure
The goals of the latissimus dorsi tendon transfer are to improve function and decrease pain for patients with shoulder dysfunction caused by irreparable posterosuperior rotator cuff tears. Latissimus dorsi tendon transfer achieves improved shoulder function in the setting of irreparable cuff tears by helping restore the force couples of the shoulder originally described by Burkhart. 1 Transfer of the latissimus dorsi tendon to the greater tuberosity imparts external rotation and head depressor moments to the proximal humerus allowing for improved balance between the anterior and posterior force couples.
35.2 Advantages
Surgical options for the treatment of symptomatic irreparable rotator cuff tears in younger more active patients are limited. Many older patients with irreparable rotator cuff tears having failed nonoperative management would be served well with a reverse shoulder arthroplasty or in some cases an arthroscopic debridement and biceps tenodesis or tenotomy. The latissimus dorsi tendon transfer provides a durable nonarthroplasty treatment option for younger patients with shoulder pain and dysfunction secondary to irreparable posterosuperior rotator cuff tears.
Improvements in range of motion, strength, and pain scores have been demonstrated at both short-term and long-term follow-up. 2 , 3 Gerber et al reported durable improvements in forward elevation, abduction, external rotation, pain scores, strength, and Constant scores for patients with a minimum of 10 years of postoperative follow-up after latissimus dorsi tendon transfer for irreparable rotator cuff tears. 3 Warner and Parsons described less favorable results particularly for patients undergoing latissimus dorsi tendon transfer in setting of a failed rotator cuff repair. 4 Although the published success rates and functional outcome improvements vary to some degree, the latissimus dorsi tendon transfer has a proven clinical track record for the management of irreparable rotator cuff tears in properly indicated patients. Of note, currently it remains controversial if this transfer has primarily a tenodesis effect or if active recruitment is consistently achievable. 5 Maintenance of at least partial teres minor function has been linked to better outcomes after latissimus dorsi tendon transfer. 6
35.3 Indications
The latissimus dorsi tendon transfer is indicated for younger (60 years and younger) and/or active patients with massive irreparable posterosuperior rotator cuff tears with continued pain and shoulder dysfunction despite nonoperative treatment. This procedure is also indicated for failed rotator cuff repair or failed debridement of irreparable rotator cuff tears. More refined indications for latissimus dorsi tendon transfer also include absence of significant glenohumeral arthritis, an intact subscapularis tendon, and maintenance of active overhead elevation. Additionally, significant patient compliance is needed to commit to the extended period of recovery and rehabilitation.
35.4 Contraindications
Latissimus dorsi tendon transfer is contraindicated for patients with advanced rotator cuff arthropathy defined as glenohumeral arthritis and/or advanced fixed proximal humeral migration. Success is predicated on the presence of healthy deltoid and periscapular muscles. Proximal humeral escape is an absolute contraindication to this procedure. Given the importance of the subscapularis for preserving the rotator cuff force couple, this tendon must be intact or repairable with minimal muscle atrophy. While the clinical results of latissimus dorsi tendon transfer are somewhat variable, there is evidence that patients with poor subscapularis function have decreased outcomes following latissimus dorsi tendon transfer. 2 , 3 It is also important to consider that patients with pseudoparalysis are less likely to demonstrate satisfactory improvement after latissimus dorsi tendon transfer. 7 Patients who are unable or unwilling to adhere to the required postoperative restrictions and prolonged rehabilitation protocol are poor candidates for this procedure. Furthermore, expectations to return to occupations with excessive overhead motion or heavy manual labor are not realistic given the modest gains in function realized following this procedure.
35.5 Preoperative Preparation/Positioning
35.5.1 Initial Evaluation
A complete history and physical examination is required prior to consideration of latissimus dorsi tendon transfer. The history will help further characterize the duration and severity of symptoms and reveal the patient’s expectations in regard to postoperative functional goals. Prior surgeries should be noted, especially those that may affect deltoid function such as open cuff repair. A careful review of occupational and recreational demands is warranted.
Inspection is initially performed to assess for muscle atrophy, integrity of the deltoid, and scapular posture. The physical examination should include a focused and complete assessment of range of motion and strength of the shoulder. The patient should have good passive range of motion (PROM) of the shoulder. Active range of motion (AROM) should assess elevation, external rotation in both adduction and abduction, and internal rotation with additional attention on scapular control. Strength testing in scapular plane elevation and external rotation is performed. Assessment of teres minor function is relevant given the known benefit of teres minor integrity on the clinical results of latissimus dorsi tendon transfer. 6 The presence of severe external rotation lag signs is important in potential latissimus dorsi tendon transfer candidates as these may influence the chosen insertion point of the tendon transfer. Subscapularis testing with belly-press or bear-hug test can be performed to determine the presence of subscapularis dysfunction. An upper quarter screen is important to rule out cervical radiculopathy.
35.5.2 Imaging
Preoperative imaging should include a full shoulder series: anteroposterior (AP), true AP, scapular Y, and axillary radiographs. The true AP and axillary views can be used to assess for glenohumeral joint space narrowing or other signs of arthritis. Severe or fixed proximal humeral head migration should be noted and caution is noted in cases with complete loss of the acromiohumeral interval with signs of chronic wear of the humeral head against the acromion. In the setting of a massive irreparable rotator cuff tear, an MRI, ultrasound, or CT arthrography of the shoulder can be used to assess for tear size, tendon retraction, and muscular fatty infiltration and atrophy.
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