in Tendon Transfers

Fig. 10.1

AP radiograph demonstrating no significant superior migration of the humeral head

MRI Arthrogram demonstrated a massive tear of the postero-superior rotator cuff, with retraction to the glenoid (Figs. 10.2 and 10.3), but an intact subscapularis tendon (Fig. 10.4).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig2_HTML.png — Fig. 10.2

MRI Arthrogram: T2 FS Coronal slice demonstrating complete supraspinatus tear with retraction to the glenoid

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig3_HTML.png — Fig. 10.3

MRI Arthrogram: T1 FS Sagittal slice demonstrating extent of postero-superior cuff defect

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig4_HTML.png — Fig. 10.4

MRI Arthrogram: T1 FS Axial slice demonstrating intact subscapularis

10.7.5 Clinical Summary

57 year old fit and active patient with a delayed presentation of a massive retracted postero-superior cuff tear.
Pain, weakness and restricted active range of motion in elevation and external rotation.
No stiffness on passive mobilisation.
Positive Lag- and Hornblower sign. Clinically and radiologically intact subscapularis.
No progression of cuff-tear arthropathy on radiographs

10.7.6 Intra-Operative

Diagnostic scope: confirmation of irreparability of tear (Fig. 10.5).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig5_HTML.png — Fig. 10.5

Arthroscopic view from lateral portal demonstrating a massive retracted and irreparable postero-superior rotator cuff tear

Posterior space preparation for tendon passage: Axillary nerve identified emerging from the quadrilateral space and protected (Fig. 10.6).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig6_HTML.png — Fig. 10.6

Preparation of the posterior space, with exposure and protection of the axillary nerve in the quadrilateral space

Anterior compartment preparation and Latissimus Dorsi tendon harvest (Fig. 10.7).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig7_HTML.png — Fig. 10.7

Detachment of the latissimus dorsi tendon from its insertion on the anterior humerus

Graft fixation, following shuttling of the donor tendon through the previously prepared posterior space, using knotless suture anchors and combined with repair to residual posterior cuff (Fig. 10.8).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig8_HTML.png — Fig. 10.8

Fixation of the transferred latissimus dorsi tendon to the greater tuberosity

10.8 Case Study 2: All-Arthroscopic Latissimus Dorsi Transfer for Subscapularis Deficiency

10.8.1 Patient

53 year old male,
Right hand dominant construction-site foreman

10.8.2 History

Fall directly onto right shoulder from 2 m height 4 years previously
Arthroscopy some months later—irreparable complete subscapularis tear seen
Ongoing mechanical pain and weakness since
VAS pain score 5/10 day/6/10 night
SSV 80%

10.8.3 Examination (Right/Left)

Active (passive) RoM: Forward flexion: 180/180, Abduction: 180/180, Ext. rotation: 70/70, Int. rotation: LS/T12
Power: ER 5/5, Jobe 5/5, Palm-up 5/5, Belly press 4/5, Bear-hug 3/5, lift-off NA
IR lag-sign +, ER lag-sign −, Hornblower −
Constant score: 74/100 (Pain 5/15, Activity 15/20, Motion 32/40, Power 22/25)

10.8.4 Imaging

Plain radiographs were largely unremarkable, without any features of arthritic change, cuff arthropathy or superior humeral head migration (Fig. 10.9).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig9_HTML.jpg — Fig. 10.9

AP radiograph demonstrating no superior migration of the humeral head or features of arthritis or arthropathy of the glenohumeral joint

MRI Arthrogram demonstrated a complete tear of the subscapularis tendon, with retraction beyond the glenoid rim (Fig. 10.10) and fatty infiltration of the muscle belly (Fig. 10.11). The postero-superior rotator cuff was seen to be intact (Fig. 10.12).

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig10_HTML.png — Fig. 10.10

MRI Arthrogram: T1 FS Axial slice demonstrating complete retracted subscapularis tear

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig11_HTML.png — Fig. 10.11

MRI Arthrogram: T1 sagittal slice demonstrating fatty infiltration of the subscapularis muscle belly

../images/437034_1_En_10_Chapter/437034_1_En_10_Fig12_HTML.png — Fig. 10.12

MRI Arthrogram: T2 coronal slice demonstrating intact postero-superior cuff

10.8.5 Clinical Summary

53 year old fit and active patient, presenting with a previously diagnosed 4 year old irreparable isolated subscapularis tear.
Mechanical pain and weakness
No stiffness.
Positive internal rotation lag-sign. Clinically and radiologically intact postero-superior cuff.
No anterior glenoid wear, or escape, on imaging.