Refractory pain
Significant dysfunction and disability
Posterosuperior, massive rotator cuff tear or failed prior repair that is no longer amenable to repair or has a high likelihood of failure with repair
Minimal radiographic evidence of osteoarthritis or anteroposterior instability
Fatty degeneration > stage 2 of supraspinatus and/or infraspinatus muscles
Table 7.2
Contraindications to latissimus dorsi tendon transfer
Anterosuperior rotator cuff tears |
Subscapularis insufficiency |
Static or dynamic anterior or posterior instability |
Advanced osteoarthritis |
Inflammatory arthritis |
Axillary nerve injury |
Deltoid insufficiency |
Comorbid conditions negatively impacting postoperative rehabilitation potential |
Function and range of motion of the shoulder are essential to daily activities and often represent significant disability when absent. The degree of weakness and dysfunction is essential in the decision-making process (Fig. 7.1). With a massive posterosuperior tear, there will be a lag between passive and active external rotation. Evaluation of forward elevation is an essential component to determine shoulder function. With mild to moderate weakness, a latissimus dorsi tendon transfer is expected to provide sufficient power to elevate the arm against gravity above shoulder level. With severe weakness or pseudoparalysis, a latissimus dorsi tendon transfer is less predictable. In most patients with pseudoparalysis, it will not reliably provide effective overhead motion.
Fig. 7.1
Clinical photo of a patient with a massive rotator cuff tear and minimal (a) forward elevation and (b) external rotation (Figure taken with permission from Pearle et al. [18])
In addition to a careful and thorough physical examination, radiographic evaluation is essential. Standard radiographs including a true anteroposterior with the arm in neutral rotation are essential. Radiographs should be evaluated for the presence of osteophytes and joint space narrowing. The axillary radiograph should be evaluated to assess whether there are any anteroposterior instability, posterior subluxation, and evidence of arthritis. Superior humeral head migration, as seen with massive rotator cuff tears and cuff arthropathy, reduces the efficiency of the deltoid as a shoulder abductor and increases impingement. Superior humeral migration with an acromiohumeral distance of less than 5 cm is also a relative contraindication to a latissimus dorsi tendon transfer. Advanced osteoarthritis and any inflammatory arthritic conditions are contraindications to latissimus dorsi tendon transfers. These patients are often better served with a joint arthroplasty such as a reverse total shoulder. An overall guideline is that patients aged 60 or older are probably better suited to a reverse total shoulder arthroplasty, whereas patients aged 40 to early 50s may be a candidate for latissimus transfer, pending the results of other studies. Advanced imaging such as MRI is necessary to assess the whether the rotator cuff can be primarily repaired. This is most reliably determined by evaluating muscle fatty infiltration within the muscle as described by Goutallier [19].
Strict contraindications include static or dynamic anteroposterior instability. Many studies, as discussed in the outcomes section, have been performed looking at the outcomes of patients with and without subscapularis function after latissimus dorsi tendon transfers. Subscapularis insufficiency leads to lower postoperative outcomes and is considered a contraindication to latissimus transfers. After a thorough discussion of patient history, activity level, and expectations of surgical outcome, decision to proceed with a latissimus dorsi tendon transfer should be made based on indications, pain, and disability refractory to conservative treatment.
Technique
The surgical procedure is a modification of the original description of the latissimus dorsi tendon transfer by Gerber et al. [5] and has been previously reported by Pearle et al. [14, 18]. Regional anesthesia is performed prior to patient positioning. The patient is positioned in the lateral decubitus with sufficient access to the entire scapula and latissimus dorsi muscle belly. The entire limb and hemithorax are prepped and draped. A complete examination under anesthesia is performed with special focus on the stability of the joint as well as passive range of motion. The arm is positioned using the Spider limb positioner (Smith and Nephew, Andover, MA) which allows maintenance of limb position throughout the procedure (Fig. 7.2). The bony landmarks of the shoulder including the anterior and posterior acromion, acromioclavicular joint, coracoid process, and clavicle are palpated and appropriately marked.
Fig. 7.2
Patient in the lateral decubitus position with the arm in abduction in an extremity holder. The extremity holder allows for easy manipulation of the arm, with specific respect to internal and external rotation (Figure taken with permission from Pearle et al. [18])
A two-incision technique is then performed. The rotator cuff is approached (Fig. 7.3) through a standard vertical incision starting at the anterolateral edge of the acromion. The anterior raphe of the deltoid is identified and divided up to 5 cm distal to the acromion where care is taken to avoid injuring the anterior branch of the axillary nerve. The anterior aspect of the deltoid is detached sharply from the acromion and an acromioplasty is performed when needed. A complete inspection of the rotator cuff tissue is performed with every effort made to mobilize all retracted cuff tissue, lyse adhesions, resect the coracohumeral ligament, release the capsule, and attempt any possible tension-free repairs. Care is taken to preserve the coracoacromial ligament. Upon confirmation that no appropriate repair can be performed, attention is turned toward the latissimus dorsi tendon transfer. Of note, a combination latissimus dorsi and teres major transfer can be performed. When both tendons are transferred, there is usually insufficient excursion to reach the superior aspect of the greater tuberosity. Instead, the tendons can be reattached to the posterolateral aspect of the proximal humeral, around the teres minor insertion site. Therefore, this technique is typically reserved for patients in which external rotation weakness is their predominate complaint, and forward flexion remains fairly strong (which is a rare combination). The technique outlined here will discuss only isolated latissimus dorsi tendon transfers.
Fig. 7.3
The anterior incision is vertical and begins at the anterolateral edge of the acromion. The anterior deltoid raphe is split up to 5 cm distal to the acromion. The axillary nerve crosses more than 5 cm distal to the acromion (Figure taken with permission from Pearle et al. [18])
A posterior incision is used to harvest the latissimus dorsi tendon. A 15 cm incision over the lateral border of the latissimus dorsi and extending superiorly to the posterior border of the axilla is made (Fig. 7.4a). The latissimus dorsi muscle belly is identified posteroinferiorly and dissected in a proximal direction. The thoracodorsal nerve and vessels run on the undersurface of the latissimus dorsi muscle belly and must be protected throughout (Fig. 7.4b) to prevent postoperative denervation of the transferred muscle.
Fig. 7.4
Intraoperative photo of a patient in the lateral decubitus position with the arm in an extremity holder. (a) A 15 cm posterior incision is made along the border of the latissimus dorsi and is continued superiorly at the posterior axillary border. The muscle belly is dissected in a proximal direction. The interval between the teres major (arrowhead) and latissimus dorsi (arrow) is identified. (b) After the latissimus dorsi tendon (arrow) has been released. The thoracodorsal nerve and vessels (arrowhead) are identified. The teres major tendon (asterisk) remains attached in this specimen (Figure taken with permission from Pearle et al. [18])
The next component of the procedure is critical to allow appropriate tendon transfer length as well as to avoid the neurovascular structures that are at risk with this procedure. The tendon of the latissimus dorsi muscle is found and traced laterally toward the humerus. As dissection is carried laterally, the tendon of the teres major is identified and the two tendons can be followed to their insertions on the anteromedial portion of the humerus (Fig. 7.5). The teres major has a very short tendon, and its insertion remains muscular until just before its insertion into the humeral. In comparison, the latissimus dorsi tendon is long and flat and may be adherent to the undersurface of the teres major muscle. The latissimus dorsi is the most anterior tendon in the posterior axillary fold. During dissection of the tendinous insertions, it is imperative to maximally internally rotate the arm in the limb positioner to allow for a safe tenotomy that maximizes tendon length and places the radial nerve at less risk.
Fig. 7.5
Intraoperative photo of the right arm with the posterior incision exposed. The tendons of the teres major and latissimus dorsi (arrow) are identified and followed to their insertions on the anteromedial aspect of the humerus (arrowhead). The arm must be maximally internally rotated in the extremity holder to allow for a safe tenotomy directly from the humeral insertion (Figure taken with permission from Pearle et al. [18])
The anatomy of the latissimus dorsi and teres major tendons at their insertions has been well studied. In adults, the latissimus average width at insertion is 3.1 cm (2.4–4.8), average length is 8.4 cm (6.3–10.1), and the average distance from the humeral insertion to the thoracodorsal nerve is 13.1 cm (11.0–15.3) [14]. The latissimus and teres major tendons may either insert as separate tendons or may join and insert as a conjoint tendon which requires sharp dissection to separate [14]. Other important neurovascular structures including the radial nerve and axillary nerve must be appreciated during dissection. The radial nerve passes over the anterior surface of the tendons and, with the arm in neutral rotation and adduction, is 2.9 cm (2.0–4.0) medial to the humerus at the superior border of the latissimus tendon [14]. The axillary nerve is 1.4 cm (0.8–2.0) proximal to the superior edge of the teres major [14].
With the arm in maximal internal rotation, the latissimus tendon insertion can be sharply tenotomized safely from the humerus under direct visualization. Maximal internal rotation provides an additional 1.9 cm (1.5–2.4) of tendon tissue as compared to neutral rotation [18]. The posterior approach to the tendons for harvest provides visualization of a band of variable thickness just anterior to the tendon insertion. This band is the proximal aspect of the intermuscular septum and, when encountered, provides an additional landmark to ensure radial nerve protection.
The latissimus dorsi tendon and muscle are then mobilized from the chest wall (Fig. 7.6). The tendon is tagged with nonabsorbable sutures which provide traction to safely dissect the muscle from the chest wall. This axial dissection is performed until there is enough tendon excursion to reach the posterolateral border of the acromion. The average free musculotendinous length after mobilization is approximately 20 cm [18]. Of course, it is imperative during immobilization to ensure the safety and continuity of the neurovascular pedicle to the latissimus dorsi muscle to ensure appropriate function postoperatively.
