True AP x-ray view of the right shoulder in this patient demonstrating moderate superior migration of the humeral head and narrowing of the acromiohumeral interval. There are no arthritic changes present
Magnetic resonance imaging demonstrating a full-thickness, retracted posterosuperior rotator cuff tear on coronal T2 image (a), with grade 1 atrophy of the supraspinatus, grade 2 atrophy of the infraspinatus, grade 4 atrophy of the teres minor with a normal subscapularis (b)
This patient is presenting with an acute exacerbation of a posterosuperior rotator cuff tear after a minor trauma. The patient’s history, physical exam, and imaging all corroborate this diagnosis. The tear likely propagated anteriorly during the acute exacerbation leaving the supraspinatus with less severe atrophy compared to the infraspinatus and teres minor. While tears and atrophy of the teres minor are rare on presentation, this warranted an electromyographic study (EMG) to evaluate for a neurologic etiology such as a C5 radiculopathy. The EMG was obtained and demonstrated normal testing of the C5 distribution, as well as no evidence of suprascapular nerve or axillary nerve deficit.
While repair of the supraspinatus would likely improve his forward elevation, the chronicity of the posterior component of the tear involving the infraspinatus and teres minor would likely lead these to be less amenable to repair, and less predictable with regard to improving his profound external rotation weakness. For young, active patients with large, irreparable posterosuperior rotator cuff tears with an intact, functional subscapularis, a latissimus dorsi transfer to the greater tuberosity remains a viable, though unpredictable, option for restoring external rotation.
The decision was made to pursue an open rotator cuff repair and latissimus dorsi transfer.
The patient was positioned in a sloppy lateral decubitus position after an interscalene regional block was performed. The first incision was carried out in Langer’s lines just medial to the lateral border of the acromion. Skin flaps were raised, and the raphe between the anterior and middle thirds of the deltoid was incised and released off the acromion with the coracoacromial ligament. The deltoid was split 2.5 cm laterally and a stay suture placed to prevent propagation of the split. An acromioplasty was then performed as well as a thorough subacromial bursectomy in standard fashion. The supraspinatus and infraspinatus tendons were able to be identified and were tagged with heavy-braided #2 suture. The greater tuberosity footprint was then prepared to a bleeding base to optimize the biologic environment for healing. A transosseous rotator cuff repair was then performed through four drill holes double-loaded with heavy-braided #2 suture.
The bed was then tilted away to optimize the positioning for the latissimus transfer. A hockey-stick incision was then made along the lateral border of the latissimus dorsi and then parallel to the humerus. The latissimus was then identified, mobilized from the adjacent teres major, and released off the humerus. A heavy-braided #2 Dyneema suture was then run in Krackow fashion through the tendon, and a separate differing color #2 Dyneema suture was placed in similar fashion on the adjacent edge of the tendon, creating four limbs. The latissimus was then bluntly mobilized down to its neurovascular pedicle and off the fascia. Through the original incision, the latissimus sutures were retrieved deep to the deltoid and superficial to the repaired infraspinatus. The tendon was mobilized to the level of the posterior greater tuberosity footprint. This was then repaired to the level of the posterior greater tuberosity with a similar transosseous technique through drill holes.
The wounds were irrigated, and the deltoid split closed with heavy-braided #2 suture incorporating the coracoacromial ligament into the repair. The subcutaneous tissue and skin were closed in standard fashion. The patient was placed into a sling with a derotation wedge to maintain the arm in mild abduction but also approximately 10° external rotation. He was then extubated and transferred to the postanesthesia care unit in stable condition. There were no intraoperative complications.
The patient was started with a guided physical therapy regimen beginning 1 week after surgery. He was maintained in a sling for 6 weeks to protect the repair. Phase 1 of therapy consisted of pendulums, passive external rotation limited to 30°, and passive forward elevation to 90° for weeks 1–6. Avoiding internal rotation behind the back or across the midline for the first 4 weeks is emphasized. At week 6, phase 2 of therapy began with active assisted range of motion as tolerated, pulleys, and isometric strengthening of the deltoid and periscapular musculature. Feedback to the patient is provided while doing isometric ER and IR to begin to try to “train” the latissimus to become an external rotators. Phase 3 began at 3 months postoperatively, to include active range of motion as tolerated and rotator cuff strengthening.
At most recent follow-up 8 months postoperatively, the patient demonstrated active forward elevation to 160°, and active external rotation to 45°, with 5/5 strength in forward elevation and 5/5 strength in external rotation (Fig. 11.3). He demonstrated a negative Hornblower’s sign and external rotation lag sign. The reconstruction completely eliminated his essentially pseudoparalytic state and restored external rotation power.
The patient postoperatively demonstrated excellent range of motion in both forward elevation (a) and external rotation (b) without pain
Massive posterosuperior rotator cuff tears in young patients present a difficult clinical problem. Repair of these tears in these patients is associated with poor outcomes, likely given irreversible changes to muscular function [1–3]. As an alternative to massive rotator cuff repair in this setting, some surgeons have elected for a latissimus dorsi tendon transfer to supplement for loss of function of the posterosuperior rotator cuff [4–9], with a goal of restoring active forward elevation and external rotation.