When the preoperative clinical or imaging findings led to suspect that the cuff tear was irreparable, the patient was placed in the lateral decubitus position on the operating table with 20° anti-Trendelenburg inclination (Fig. 2). This position allows the musculotendinous unit of the latissimus dorsi to be exposed and transferred to the greater tuberosity if the cuff lesion is irreparable.

The subacromial space is exposed through an anterolateral or superolateral approach. The deltoid was detached from the anterolateral border of the acromion using cutting current diathermy and split up vertically for approximately 5 cm in the middle part of the exposed portion. After horizontal acromioplasty, the rotator cuff was inspected to assess tear size and tissue degeneration. If the subscapularis tendon cannot be repaired, then the latissimus dorsi transfer should not be done without performing also a pectoralis muscle transfer. If the biceps tendon shows any signs of wear, the tendon can be tenodesed in the bicipital groove to prevent pain postoperatively. The greater tuberosity is debrided of soft tissue and osseous prominences. Skin incision was temporarily closed with clamps and the second incision was done to expose the latissimus dorsi muscle (Fig. 3). Posterior skin incision along the anterior border of the latissimus dorsi to the posterior axillary fold, curving proximally to be perpendicular to the humeral shaft is performed. Careful attention is made to avoid crossing a skin crease without changing the direction of the incision and so to avoid scar contracture at the skin crease. Deltoid, long head of triceps, and latissimus dorsi are identified.

The latissimus dorsi is easily recognized as the large muscle crossing, with an oblique direction, the distal portion of the scapula. There is no large muscle inferior to the latissimus dorsi and, if one is found, then the surgeon may have mistaken the teres major for the latissimus dorsi muscle. Latissimus dorsi is followed laterally toward the humeral insertion and progressively dissected from the teres major. The neurovascular bundle, running on the undersurface of the muscle, is identified and carefully preserved. By blunt dissection, proceeding along the dorsal surface of the muscle, the tendon of the latissimus dorsi is palpated with the finger and exposed as far as its insertion on the humerus, while placing the arm in adduction and internal rotation. The axillary nerve is superior to the teres major tendon. The brachial plexus is deep and anterior. The radial nerve, lying deep to the tendon, is rarely exposed, but its presence is taken into consideration to avoid neural damage. The tendon is detached as close as possible to the bone surface, using scissors under direct vision of the anatomical structures (Fig. 4). If the latissimus dorsi tendon does not seem long enough or broad enough to cover the greater tuberosity after it has been dissected free from the humerus, teres major tendon transferring has to be considered, too. Teres major must be attached to the greater tuberosity separately because the length and tension relationship of each muscle is different and the tendon length of the teres major is shorter than the latissimus dorsi one. While retracting the detached tendon medially and distally, the dissection of the undersurface of the muscle is completed, avoiding tearing and stretching of the neurovascular bundle. It is identified and mobilized with scissors to allow complete excursion of the tendon out of the wound and above the acromion. The tendon is prepared by weaving a No 2 Fiber wire or equivalent suture with locking Krackow technique along each of its edges so that two suture strands can be used for attachment to the superior aspect of the subscapularis tendon (Fig. 5). The undersurface of the posterior portion of the deltoid is separated from the triceps tendon by blunt dissection and a clamp is inserted deeply to the deltoid with a craniocaudal direction to grasp the sutures in the latissimus dorsi and bring them above the humeral head (Fig. 6). Often the tunnel needs to be enlarged inferiorly to accommodate the large muscle belly and to avoid excessive tension on the tendon or the neurovascular bundle. The tendon of the latissimus dorsi is advanced as far as possible toward the greater tuberosity by both pulling the sutures and pushing upward the muscle belly with the hands.

A bone trough is created in the region of the greater tuberosity, where the latissimus dorsi tendon is anchored with nonabsorbable transosseous sutures (Fig. 7a, b). On the basis of electromyographic studies, Codsi et al. [24] believe that the latissimus dorsi acts primarily as a passive humeral head depressor. Therefore, they repair the latissimus tendon over the top of the humeral head. The residual free margins of the latissimus dorsi tendon may be sutured to the subscapularis tendon. Postacchini et al. [17], in very few patients, sutured the latissimus dorsi tendon to the long biceps tendon, after anchoring the distal portion of the latter to the bicipital groove. The medial edge of the tendon is secured to the edge of the remaining portions of the supraspinatus and infraspinatus tendons. If the teres major tendon is transferred as well, it can be secured more laterally and posteriorly on the humeral head than the latissimus dorsi tendon. If the tendon does not have at least 2 cm² of coverage over the humerus, the healing potential will be compromised and the surgeon should consider using a graft to augment the tendon. In these cases, Codsi et al. [24] use a fascia lata graft. The humeral head could be completely covered with tendon tissue in many cases.

The deltoid is reattached with transosseous sutures to the acromion and the deltopectoral fascia is closed. A drain is placed in the latissimus dorsi muscle bed if needed, and the skin is closed without closing the deep fascia. A brace is applied to hold the arm in neutral rotation and 20° of abduction.

The shoulder is immobilized 35 days after surgery. Passive elevation in neutral rotation is done twice a day for the first 4 weeks. A rehabilitation program of active motion in flexion, abduction, and external rotation was initiated 6 weeks after operation and continued for 8 weeks. Afterward, strengthening exercises started and usually continued for 4–8 weeks.

We report our experience with the transfer of the latissimus dorsi muscle in patients with irreparable rotator cuff tears who had no previous surgery for cuff defect.

We were able to follow 41 patients who underwent a primary transfer of latissimus dorsi musculotendinous unit for an irreparable posterosuperior rotator cuff tear. There were 28 men and 13 women, aged 46–69 years (mean, 59). The right, dominant shoulder was involved in 34 cases and the left, nondominant shoulder, in 7. All patients had shoulder pain lasting 6–24 months at the time of surgery. The active range of motion was limited in all cases, though to a variable extent.

Seven patients had a positive Lift-off, Bear and Napoleon tests, indicating a tear of the subscapularis tendon.

In no patient did plain radiographs show evidence of cuff arthropathy. The acromiohumeral interval was less than 7 mm in 28 cases. Diagnosis of cuff tear was made by magnetic resonance imaging (MRI) in all cases. MR scans showed a massive lesion in all patients, with a varying degree of degeneration of the cuff muscles, as evaluated by the Goutallier and Fuchs grading system [25, 26].