The procedure is performed in a modified fashion from the original
description of Gerber et
al.5 with the
additional use of the teres major tendon. The patient is positioned in the
lateral decubitus position and stabilized with a sandbag, and the entire limb
and hemithorax are draped free in the sterile field. The operative extremity
is held in approximately 60° of abduction in a limb holder such as the
Spider limb positioner (Smith and Nephew, Andover, Massachusetts), which
permits stable positioning of the limb during the procedure
(Fig. 2).
A two-incision approach is utilized. First, the rotator cuff is approached
through a standard open incision. We use a vertical incision, starting at the
anterolateral edge of the acromion (Fig.
3). The anterior fascial raphe of the deltoid is identified and
split, with care taken not to extend the split in the raphe more than 5 cm
distal to the acromion to avoid injury to the axial nerve. The anterior
portion of the deltoid is released from the acromion with use of sharp
dissection. An acromioplasty is performed as necessary. The rotator cuff is
inspected (including an assessment of the integrity of the subscapularis), and
an attempt is made in all patients to mobilize a sufficient amount of
retracted rotator cuff tissue to perform a tension-free primary repair. Lysis
of adhesions, resection of the coracohumeral ligament, and a capsular release
may be necessary to free the retracted tendon tissue adequately. If it is
determined that a primary repair cannot be performed, then the latissimus
dorsi and teres major transfer is carried out.
Attention is then turned to the posterior aspect of the shoulder. A 15-cm
posterior incision is made, following the lateral border of the latissimus
dorsi, and is continued superiorly to the posterior border of the axilla
(Fig. 4-A). The posteroinferior
aspect of the latissimus dorsi muscle belly is identified and dissected free
in a proximal direction, with care taken to not injure the neurovascular
structures on the undersurface (Fig.
4-B).
After the incision and superficial exposure, great care is taken during the
dissection to ensure that the latissimus dorsi and teres major tendons are
safely dissected directly from the humerus in order to maximize tendon length.
The tendon of the latissimus dorsi is found and traced laterally. As
dissection is followed toward the humerus, the tendon of the teres major is
identified and the two tendons are followed to their insertions on the
anteromedial portion of the humerus (Fig.
5-A). At this point, it is important to internally rotate the arm
in the limb-holding device; maximal internal rotation of the humerus delivers
the latissimus dorsi and teres major tendons into the surgical field and
allows for a safe tenotomy directly from their insertion sites on the humerus.
With this maneuver, an average of 1.9 cm (range, 1.5 to 2.4 cm) of additional
latissimus dorsi and teres major tendon tissue can be visualized as compared
with that seen in neutral rotation. External rotation obscures the tendon
insertions. When these tendons are exposed from this posterior axillary
approach, a band of variable thickness is palpable just anterior to the
insertion of the latissimus dorsi tendon. This is the proximal aspect of the
intermuscular septum between the anterior and posterior compartments of the
arm, and a plane exists between this septum and the latissimus dorsi tendon.
It is a reassuring anatomic landmark as tenotomy of the latissimus dorsi
tendon from the bone posterior to the septum avoids injury to the radial
nerve.
When identifying the tendinous insertions on the humerus, knowledge of the
proximity of the radial and axillary nerves is important to avoid injury to
these structures (Figs. 5-B and
5-C). The radial nerve crosses the anterior aspect of the
latissimus dorsi and teres major tendons. At the level of the tendon
insertions on the humerus, the radial nerve is encased in fatty tissue and
courses medial to the proximal aspect of the medial intermuscular septum
between the anterior and posterior compartments of the arm. As the radial
nerve passes from proximal to distal over the anterior surface of the tendons,
it angles laterally and courses toward the spiral groove of the humerus. When
the arm is held in adduction and neutral rotation, the radial nerve lies an
average of 2.9 cm medial to the humerus at the superior border of the
latissimus dorsi tendon. At the inferior border of the latissimus dorsi
tendon, the nerve is an average of 2.7 cm medial to the humerus, a measurement
that is consistent with that found in other anatomic
studies10. At the
inferior border of the teres major tendon, which extends distal to the
latissimus dorsi tendon, the nerve is an average of 2.3 cm medial to the
humerus. The axillary nerve lies an average of 1.4 cm (range, 0.8 to 2.0 cm)
proximal to the upper edge of the teres major, which extends superior to the
latissimus dorsi tendon at this level.
In adults, the average width of the latissimus dorsi tendon at its
insertion site is 3.1 cm (range, 2.4 to 4.8 cm), and the average length of the
tendinous portion is 8.4 cm (range, 6.3 to 10.1 cm). The average width of the
teres major tendon at its insertion site is 4.0 cm (range, 3.3 to 5.0 cm), and
the average length is 3.9 cm (range, 3.3 to 4.6 cm). In some patients, the
tendons merge near their insertion sites to form a conjoined unit that can
only be separated with sharp dissection.
The tenotomy can be performed safely through a sharp incision made directly
at the tendinous insertion sites on the humerus; the tendons and muscle
bellies are then mobilized axially from the chest wall
(Fig. 6). The tendons are
tagged with nonabsorbable sutures to assist in their passage to the greater
tuberosity. While traction is applied to the tagging sutures, the anterior and
superior borders of the latissimus dorsi and teres major tendons and their
lateral muscle bellies are dissected free from the chest wall. This axial
dissection is carried out until the tendons have enough excursion to reach the
posterolateral border of the acromion; clinically, we have found that the
requisite free musculotendinous length of both the latissimus dorsi and teres
major after this mobilization is approximately 20 cm. In the course of
mobilizing the muscle bellies from the chest wall, the neurovascular pedicles
for both the teres major and the latissimus dorsi must be identified and
protected. The neurovascular pedicle to the latissimus dorsi, consisting of
the thoracodorsal artery and nerve, innervates the muscle on the
anteroinferior surface approximately 2 cm medial to the muscular
border11. In our
previous study9, we
found that the thoracodorsal neurovascular pedicle inserts on the anterior
part of the muscle belly of the latissimus dorsi at an average of 13.1 cm
(range, 11.0 to 15.3 cm) medial to its humeral insertion. The lower
subscapular neurovascular pedicle enters the anterior muscle belly of the
teres major at an average of 7.4 cm (range, 6.0 to 8.8 cm) medial to its
humeral insertion. Division of these structures will devitalize the tendon
transfer.
When the tendons are fully mobilized, preparation is made for tunneling the
musculotendinous units under the posterior portion of the deltoid and
superficial to the infraspinatus and teres minor. The plane between the
posterior part of the deltoid and the rotator cuff muscles is identified, and
the posterior part of the deltoid is gently retracted laterally. A curved
clamp is guided through the anterior incision, under the deltoid and into the
subacromial space, and out through the posterior incision, creating a tunnel
for tendon passage (Fig. 7-A).
Tunneling the musculotendinous units under the posterior part of the deltoid
places the transferred tendons in close proximity to the posterior branch of
the axillary nerve and its branches. The posterior branch of the axillary
nerve exits the quadrilateral space and travels with the deep fascia of the
deltoid until it inserts into the deltoid muscle. The superior lateral
brachial cutaneous nerve divides from the posterior branch of the axillary
nerve at the level where it inserts into the muscle at the posterior part of
the deltoid; the superior lateral brachial cutaneous nerve then travels in the
deep deltoid fascia medially until it hooks around the posteromedial edge of
the deltoid. The tendon transfer passes directly deep to the course of the
posterior branch of the axillary nerve and the superior lateral brachial
cutaneous nerve. Therefore, the plane between the deep deltoid fascia and the
posterior part of the rotator cuff must be carefully identified. Superficial
deviation into the deltoid fascia during tunneling or passage of the tendons
places the posterior branch of the axillary nerve and its divisions at risk.
Care should also be taken to avoid traction on the nerve when expanding the
tunnel inferolaterally toward the quadrilateral space.
After the tunnel has been established, the tagging sutures on the tendons
are grasped with the clamp and passed anteriorly
(Figs. 7-A and 7-B). The
tendons are then secured to the footprint of the rotator cuff on its lateral
edge with use of suture anchors. The remnant of the native rotator cuff is
repaired in a side-to-side manner to the transferred tendons, if the cuff
tissue is adequately mobile. Anteriorly, the leading edge of the latissimus
dorsi is sutured to the superior border of the subscapularis muscle
(Figs. 8-A and 8-B). Finally,
the shoulder is gently taken through a full range of motion to ascertain that
there is not excessive tension or laxity of the repair. A drain is placed
under the deltoid fascia, and the wound is closed after reattaching the
anterior portion of the deltoid through drill holes into the acromion. A
sterile dressing is applied, and the limb is placed in an abduction brace.
For the initial six weeks postoperatively, the limb is maintained in an
abduction sling and gentle pendulum exercises are allowed
(Fig. 9). Thereafter, passive
and active-assist supine forward elevation and rotation movements are started.
Care is taken to ensure that the patient avoids excessive scapulothoracic
compensatory motion (a shrug) when active-assist and active motion is
initiated. At twelve weeks postoperatively, the patient starts active supine
range-of-motion exercises and progresses with active motion and strengthening
under the direction of a qualified therapist.
CRITICAL CONCEPTSINDICATIONS:Latissimus dorsi transfer is indicated for the primary treatment of massive
irreparable rotator cuff tears involving the supraspinatus and infraspinatus,
or as a salvage procedure after failed operative treatment, in patients with
limited elevation and external rotation and an intact
subscapularis7-9,
12-15.
Tears are considered irreparable when the supraspinatus and infraspinatus
cannot be sufficiently mobilized to secure the tendons to the footprint of the
cuff; poor tissue quality of the rotator cuff tendons or adipose infiltration
of the cuff musculature from chronic injury or failed previous repairs often
precludes direct
repair2,3.We have found that latissimus dorsi and teres major transfers work best in
younger patients who have minimal glenohumeral arthritis and who are unable to
actively lift the arm above shoulder level due to a massive irreparable
rotator cuff tear. In this subset of patients, the procedure and subsequent
therapy can result in impressive increases in active range of motion such that
the patient is able to lift the arm above the head. We have found that
patients gain some strength in external rotation but still have poor
supraspinatus strength; thus, we advise patients that the procedure is
primarily aimed at increasing active motion rather than increasing
strength.Factors such as patient history, activity level, and expectations of
surgical outcome should be considered. All patients should undergo a course of
physical therapy, consisting of passive glenohumeral range-of-motion exercises
as well as rotator cuff and deltoid strengthening exercises, before surgery is
undertaken. Younger patients are best able to tolerate the extensive
rehabilitation that is necessary to maximize the results of this
procedure.Preoperative assessment should include magnetic resonance imaging studies
to evaluate the subscapularis, the supraspinatus and infraspinatus tears, and
the status of the latissimus dorsi muscle and tendon. The subscapularis should
be intact to consider the procedure. Some superior migration of the humeral
head is acceptable; however, cuff tear arthropathy is a contraindication to
the procedure.CONTRAINDICATIONS:Contraindications to this procedure are lack of motivation on the part of
the patient to undergo the procedure and participate in the associated
rehabilitation. Patients with an overall poor general fitness level, morbid
obesity, and extremes of age should not undergo this procedure. Female
patients with poor shoulder function and generalized muscle weakness prior to
surgery have a greater likelihood of having a poor clinical
result16.Patients with subscapularis tendon tears and deltoid dysfunction tend to
have less favorable
outcomes17.
Patients with glenohumeral arthritis and cuff tear arthropathy are better
served with a prosthesis. Patients with nonpainful, chronic pseudoparesis of
elevation who display anterosuperior subluxation with escape of the humeral
head from underneath the coracoacromial arch on attempted elevation and have
minimal active elevation may be more suitable as candidates for a constrained
shoulder
prosthesis11.PITFALLS:Patients should be carefully counseled regarding the expected outcome as
well as the demands of rehabilitation prior to undergoing the procedure. While
active motion gains can be impressive, patients usually only obtain grade four
of five strength in forward elevation above shoulder level.Technical pitfalls include failure to obtain sufficient length for the
musculotendinous transfer. In many patients, the attachment of the latissimus
dorsi to the inferior tip of the scapula must be released to improve length.
We do not recommend "lengthening" the transferred tendon with
allograft tissue. The tendon transfer should only be used in the setting of
massive superoposterior rotator cuff tears rather than irreparable tears of
the subscapularis. Damage to the adjacent neurovascular structures is possible
during tenotomy, axial dissection of the musculotendinous units, and tunneling
and passage of the tendons. Familiarity with the complex local anatomy around
the humeral tendinous insertions of the latissimus dorsi and teres major
facilitates tendon harvest. Knowledge of the location of the neurovascular
pedicle insertions into the latissimus dorsi and teres major muscles assists
in the axial dissection of the muscles from the chest wall. Finally, awareness
of the proximity of the posterior branch of the axillary nerve in relationship
to the transfer beneath the posterior deltoid allows for safer passage of the
tendons.AUTHOR UPDATE:Over the past two years, we have used the Spider limb positioner (Smith and
Nephew) during this procedure, as we have found that it helps us to maintain
maximal internal rotation during tenotomy and it holds the limb in gentle
external rotation and abduction when the tendons are fixed to the greater
tuberosity. Arthroscopic rotator cuff strategies, such as use of a massive
cuff stitch as well as margin convergence, have helped maximize the repair of
remnant rotator cuff tissue prior to the transfer. Finally, we now prefer
bioabsorbable suture anchors in a single or double-row configuration for
fixation of the transferred tendons.
CRITICAL CONCEPTS
INDICATIONS:
Latissimus dorsi transfer is indicated for the primary treatment of massive
irreparable rotator cuff tears involving the supraspinatus and infraspinatus,
or as a salvage procedure after failed operative treatment, in patients with
limited elevation and external rotation and an intact
subscapularis7-9,
12-15.
Tears are considered irreparable when the supraspinatus and infraspinatus
cannot be sufficiently mobilized to secure the tendons to the footprint of the
cuff; poor tissue quality of the rotator cuff tendons or adipose infiltration
of the cuff musculature from chronic injury or failed previous repairs often
precludes direct
repair2,3.We have found that latissimus dorsi and teres major transfers work best in
younger patients who have minimal glenohumeral arthritis and who are unable to
actively lift the arm above shoulder level due to a massive irreparable
rotator cuff tear. In this subset of patients, the procedure and subsequent
therapy can result in impressive increases in active range of motion such that
the patient is able to lift the arm above the head. We have found that
patients gain some strength in external rotation but still have poor
supraspinatus strength; thus, we advise patients that the procedure is
primarily aimed at increasing active motion rather than increasing
strength.Factors such as patient history, activity level, and expectations of
surgical outcome should be considered. All patients should undergo a course of
physical therapy, consisting of passive glenohumeral range-of-motion exercises
as well as rotator cuff and deltoid strengthening exercises, before surgery is
undertaken. Younger patients are best able to tolerate the extensive
rehabilitation that is necessary to maximize the results of this
procedure.Preoperative assessment should include magnetic resonance imaging studies
to evaluate the subscapularis, the supraspinatus and infraspinatus tears, and
the status of the latissimus dorsi muscle and tendon. The subscapularis should
be intact to consider the procedure. Some superior migration of the humeral
head is acceptable; however, cuff tear arthropathy is a contraindication to
the procedure.
Latissimus dorsi transfer is indicated for the primary treatment of massive
irreparable rotator cuff tears involving the supraspinatus and infraspinatus,
or as a salvage procedure after failed operative treatment, in patients with
limited elevation and external rotation and an intact
subscapularis7-9,
12-15.
Tears are considered irreparable when the supraspinatus and infraspinatus
cannot be sufficiently mobilized to secure the tendons to the footprint of the
cuff; poor tissue quality of the rotator cuff tendons or adipose infiltration
of the cuff musculature from chronic injury or failed previous repairs often
precludes direct
repair2,3.
We have found that latissimus dorsi and teres major transfers work best in
younger patients who have minimal glenohumeral arthritis and who are unable to
actively lift the arm above shoulder level due to a massive irreparable
rotator cuff tear. In this subset of patients, the procedure and subsequent
therapy can result in impressive increases in active range of motion such that
the patient is able to lift the arm above the head. We have found that
patients gain some strength in external rotation but still have poor
supraspinatus strength; thus, we advise patients that the procedure is
primarily aimed at increasing active motion rather than increasing
strength.
Factors such as patient history, activity level, and expectations of
surgical outcome should be considered. All patients should undergo a course of
physical therapy, consisting of passive glenohumeral range-of-motion exercises
as well as rotator cuff and deltoid strengthening exercises, before surgery is
undertaken. Younger patients are best able to tolerate the extensive
rehabilitation that is necessary to maximize the results of this
procedure.
Preoperative assessment should include magnetic resonance imaging studies
to evaluate the subscapularis, the supraspinatus and infraspinatus tears, and
the status of the latissimus dorsi muscle and tendon. The subscapularis should
be intact to consider the procedure. Some superior migration of the humeral
head is acceptable; however, cuff tear arthropathy is a contraindication to
the procedure.
CONTRAINDICATIONS:
Contraindications to this procedure are lack of motivation on the part of
the patient to undergo the procedure and participate in the associated
rehabilitation. Patients with an overall poor general fitness level, morbid
obesity, and extremes of age should not undergo this procedure. Female
patients with poor shoulder function and generalized muscle weakness prior to
surgery have a greater likelihood of having a poor clinical
result16.Patients with subscapularis tendon tears and deltoid dysfunction tend to
have less favorable
outcomes17.
Patients with glenohumeral arthritis and cuff tear arthropathy are better
served with a prosthesis. Patients with nonpainful, chronic pseudoparesis of
elevation who display anterosuperior subluxation with escape of the humeral
head from underneath the coracoacromial arch on attempted elevation and have
minimal active elevation may be more suitable as candidates for a constrained
shoulder
prosthesis11.
Contraindications to this procedure are lack of motivation on the part of
the patient to undergo the procedure and participate in the associated
rehabilitation. Patients with an overall poor general fitness level, morbid
obesity, and extremes of age should not undergo this procedure. Female
patients with poor shoulder function and generalized muscle weakness prior to
surgery have a greater likelihood of having a poor clinical
result16.
Patients with subscapularis tendon tears and deltoid dysfunction tend to
have less favorable
outcomes17.
Patients with glenohumeral arthritis and cuff tear arthropathy are better
served with a prosthesis. Patients with nonpainful, chronic pseudoparesis of
elevation who display anterosuperior subluxation with escape of the humeral
head from underneath the coracoacromial arch on attempted elevation and have
minimal active elevation may be more suitable as candidates for a constrained
shoulder
prosthesis11.
PITFALLS:
Patients should be carefully counseled regarding the expected outcome as
well as the demands of rehabilitation prior to undergoing the procedure. While
active motion gains can be impressive, patients usually only obtain grade four
of five strength in forward elevation above shoulder level.Technical pitfalls include failure to obtain sufficient length for the
musculotendinous transfer. In many patients, the attachment of the latissimus
dorsi to the inferior tip of the scapula must be released to improve length.
We do not recommend "lengthening" the transferred tendon with
allograft tissue. The tendon transfer should only be used in the setting of
massive superoposterior rotator cuff tears rather than irreparable tears of
the subscapularis. Damage to the adjacent neurovascular structures is possible
during tenotomy, axial dissection of the musculotendinous units, and tunneling
and passage of the tendons. Familiarity with the complex local anatomy around
the humeral tendinous insertions of the latissimus dorsi and teres major
facilitates tendon harvest. Knowledge of the location of the neurovascular
pedicle insertions into the latissimus dorsi and teres major muscles assists
in the axial dissection of the muscles from the chest wall. Finally, awareness
of the proximity of the posterior branch of the axillary nerve in relationship
to the transfer beneath the posterior deltoid allows for safer passage of the
tendons.
Patients should be carefully counseled regarding the expected outcome as
well as the demands of rehabilitation prior to undergoing the procedure. While
active motion gains can be impressive, patients usually only obtain grade four
of five strength in forward elevation above shoulder level.
Technical pitfalls include failure to obtain sufficient length for the
musculotendinous transfer. In many patients, the attachment of the latissimus
dorsi to the inferior tip of the scapula must be released to improve length.
We do not recommend "lengthening" the transferred tendon with
allograft tissue. The tendon transfer should only be used in the setting of
massive superoposterior rotator cuff tears rather than irreparable tears of
the subscapularis. Damage to the adjacent neurovascular structures is possible
during tenotomy, axial dissection of the musculotendinous units, and tunneling
and passage of the tendons. Familiarity with the complex local anatomy around
the humeral tendinous insertions of the latissimus dorsi and teres major
facilitates tendon harvest. Knowledge of the location of the neurovascular
pedicle insertions into the latissimus dorsi and teres major muscles assists
in the axial dissection of the muscles from the chest wall. Finally, awareness
of the proximity of the posterior branch of the axillary nerve in relationship
to the transfer beneath the posterior deltoid allows for safer passage of the
tendons.
AUTHOR UPDATE:
Over the past two years, we have used the Spider limb positioner (Smith and
Nephew) during this procedure, as we have found that it helps us to maintain
maximal internal rotation during tenotomy and it holds the limb in gentle
external rotation and abduction when the tendons are fixed to the greater
tuberosity. Arthroscopic rotator cuff strategies, such as use of a massive
cuff stitch as well as margin convergence, have helped maximize the repair of
remnant rotator cuff tissue prior to the transfer. Finally, we now prefer
bioabsorbable suture anchors in a single or double-row configuration for
fixation of the transferred tendons.