TRANSFER OF LATISSIMUS DORSI FOR IRREPARABLE ROTATOR-CUFF TEARS

The Role of Tendon Transfers for Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

This review aims to describe the tendon transfer options for treating irreparable rotator cuff tears (RCTs). Options for transfer include latissimus dorsi and lower trapezius transfers for posterior-superior RCTs and pectoralis major and latissimus dorsi transfer for anterior-superior RCTs.

RECENT FINDINGS

While the latissimus dorsi tendon transfer has historically been performed for posterosuperior RCTs, the lower trapezius transfer is a more anatomic option and has demonstrated promising results in recent studies. Similarly, the pectoralis major transfer has historically been the tendon transfer of choice for anterosuperior RCTs. However, the latissimus dorsi tendon transfer has recently been shown to be a safe and anatomic tendon transfer for subscapularis insufficiency. The treatment of irreparable RCTs involves complex decision making. Tendon transfer procedures can restore the glenohumeral joint force couples, allowing restoration of near-normal shoulder kinematics. Benefits include reliable pain relief, increased function, and increased strength. Proper selection of donor tendon is crucial, and the principles of tendon transfer procedures must be adhered to for maximal benefit.

Three-dimensional shoulder motion after teres major or latissimus dorsi tendon transfer for posterosuperior rotator cuff tears

BACKGROUND

Teres major (TM) transfer and latissimus dorsi (LD) transfer are essential treatment options in patients with posterosuperior rotator cuff (RC) tears. The purpose of this study was to quantify shoulder kinematics before and after TM transfer and LD transfer in posterosuperior RC tear patients.

METHODS

In this prospective cohort study, we quantitatively measured shoulder movements using an electromagnetic tracking device (Flock of Birds) preoperatively and 1 year after either TM (n = 13) or LD (n = 9) tendon transfer. Additional outcome measures included the Constant score (CS), patient-reported pain, and quantitative range of motion. Scapular kinematics were evaluated during arm abduction.

RESULTS

By use of a quantitative assessment, forward flexion (from 87° to 106°, P = .007), abduction (from 86° to 106°, P = .010), and external rotation in abduction (from 52° to 70°, P = .019) improved. Both transfers reduced pain (from 50 to 10 mm, P < .001), and the CS improved (from 37 to 62 points, P < .001). No significant differences in postoperative improvement in pain and function were found between TM and LD tendon transfers. The TM transfer group showed increased scapular lateral rotation compared with the LD transfer group (13°; 95% confidence interval [CI], 4.8° to 21.7°; P = .003). We were unable to detect differences between TM transfer and LD transfer in the change in protraction (3.2°; 95% CI, -6.3° to 12.8°; P = .489) and posterior tilt (3.5°; 95% CI, -3.5° to 10.5°; P = .313).

CONCLUSION

Tendon transfer surgery resulted in an overall improvement in CS, pain relief, and quantitative range of motion in the treatment of an irreparable posterosuperior RC tear. Scapular lateral rotation gradually increased after TM transfer, reminiscent of RC function, whereas such an increase was not observed after LD transfer.

Superior Capsular Reconstruction

Superior capsular reconstruction (SCR) of the shoulder has recently gained popularity as an option for joint-preserving shoulder surgery for patients with an irreparable rotator cuff tear. In the absence of glenohumeral arthritis, rotator cuff tear irreparability should only be diagnosed for most patients after a careful diagnostic arthroscopy. Superior capsular reconstruction adds biological, passive, superior constraint to the glenohumeral joint, thereby optimizing the rotator cuff force couples and improving joint kinematics. At short-term follow-up, SCR has been shown to be effective for pain relief and restoration of active shoulder motion, even in the worst cases of shoulder dysfunction (true shoulder pseudoparalysis). The rapid early adoption and expansion of SCR is justified by its excellent anatomical, biomechanical, and short-term clinical results. The techniques for arthroscopic SCR using dermal allograft continue to improve; however, the operation remains technically demanding. Patients with risk factors for irreparability and who might benefit from reconstruction of the superior capsule should be counseled about the operation as an additional, joint-preserving procedure that can be done in conjunction with arthroscopic, partial rotator cuff repair. [Orthopedics. 2017; 40(5):271-280.].

Arthroscopic Subacromial Spacer Implantation in Patients With Massive Irreparable Rotator Cuff Tears: Clinical and Radiographic Results of 39 Retrospectives Cases

PURPOSE

To evaluate the clinical and radiographic outcome of a biodegradable subacromial spacer in the treatment of massive irreparable rotator cuff tear.

METHODS

Between January 2011 and December 2014, all shoulders with symptomatic massive irreparable rotator cuff tears treated at our institution with arthroscopic implantation of a biodegradable subacromial spacer followed for at least 1 year were included in our series. Patients with osteoarthritis ≥ grade 3 in the Hamada classification were excluded. Outcome measures included pre- and postoperative, range of motion, Constant score, acromiohumeral distance, and Hamada classification on anteroposterior and lateral radiographs.

RESULTS

Thirty-nine consecutive shoulders (37 patients) met the inclusion criteria. The mean age of patients was 69.8 (53-84) years. At the last follow-up (mean 32.8 ± 12.4 months), range of motion was significantly increased for all patients in anterior elevation (from 130° to 160°, P = .02), abduction (from 100° to 160°, P = .01), and external rotation (from 30° to 45°, P = .0001). The mean Constant score was also significantly (P < .001) improved from 44.8 (±15.2) preoperatively to 76.0 (±17.1) at the last follow-up. The mean acromiohumeral distance significantly (P = .002) decreased from 8.2 mm (±3.4) to 6.2 mm (±3.1) at the last follow-up. The Hamada score progressed of 1 radiographic stage in 4 shoulders (15%) and progressed of 3 stages in 2 (4%), whereas the other 32 shoulders remained stable. No intra- or postoperative complications were found except for 1 patient who required a revision for spacer migration.

CONCLUSIONS

Arthroscopic implantation of a subacromial spacer for irreparable rotator cuff tear leads to significant improvement in shoulder function at a minimum of 1 year postoperatively.

LEVEL OF EVIDENCE

Level IV, therapeutic case series; treatment study.

Current concepts in the management of irreparable rotator cuff tears

Irreparable rotator cuff tears can be painful and cause significant limitation of shoulder function. Treatment protocols have been proposed but there is no current gold standard for their management. This article summarizes the evidence for current practice in their treatment.

Latissimus Dorsi Transfer in Posterior Irreparable Rotator Cuff Tears

BACKGROUND

Massive rotator cuff tears pose a difficult and complex challenge even for the experienced surgeon; inability to repair these tears by conventional means designates them as irreparable, while management becomes quite taxing. Several operative options have been suggested for the management of such lesions with varying degrees of success, while it is imperative to match patient demands and expectations to the predicted outcome.

METHODS

Research articles are examined and key concepts are discussed, in order to provide an evidence based review of the available literature. The anatomy and pathomechanics along with the indications, contraindications and surgical techniques are reported.

RESULTS

Transfer of the Latissimus dorsi has been used with success to restore shoulder function in deficits of the posterior rotator cuff. Although it can be used in a variety of settings, the ideal patient for a Latissimus dorsi tendon transfer is a young and active individual, with no glenohumeral osteoarthritis that has a severe disability and weakness related to an irreparable posterior cuff tear.

CONCLUSION

Tendon transfers have proved to be a successful treatment option in salvaging this difficult problem, providing pain relief and restoring shoulder function. Despite the excellent functional outcomes and pain suppression following operation, a variety of factors may affect the outcome; thus making indications and preoperative assessment a valuable component.

Three-dimensional analysis of the shoulder motion in patients with massive irreparable cuff tears after latissimus dorsi tendon transfer (LDT)

INTRODUCTION

Latissimus dorsi tendon transfer (LDT) is a recent method for surgical treatment of massive, irreparable posterosuperior cuff tears (MIPCT). So far, there are no studies on the quantitative motion analysis of the shoulder and latissimus dorsi (LD) muscle activation after LDT. The changes in shoulder movements after LDT can be objectively assessed by the 3-D motion analysis. These changes may not be due to an increased activity of the LD muscle as external rotator.

MATERIALS AND METHODS

The shoulder kinematics of nine patients with MIPCT were recorded through a 3-D motion analysis system, before LTD (T0), and after 3 (T1) and 6 (T2) months post-LDT. Maximal shoulder flexion-extension, abduction-adduction, and horizontal abduction-adduction, and the internal and external circumduction of the shoulder joint were measured during upright standing posture. Surface EMG activity of the LD muscle was recorded during both internal rotation (IR) and external rotation (ER) tasks in three different postures.

RESULTS

A significant increase of shoulder movements was observed at T2 compared with T0 for almost all motor tasks. A significant effect of LDT was also found on LD-IR/ER ratio in posture 1 at T2 compared with T0 and T1. No significant effects were found for the LD-IR/ER ratio in the other postures.

CONCLUSIONS

Our study indicates that LDT is effective in shoulder motion recovery. Such improvement is not associated with a change in function of the LD muscle, which may be induced by a depression of the humeral head into the glenoid cavity instead.

Rotator cuff rehabilitation: current theories and practice

A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.

Recovery of active external rotation and elevation in young active men with irreparable posterosuperior rotator cuff tear using arthroscopically assisted latissimus dorsi transfer

BACKGROUND

Massive irreparable posterosuperior rotator cuff tears represent a serious functional disablement for young and active patients in their daily activities. Latissimus dorsi (LD) muscle-tendon transfer can restore elevation and external rotation where supraspinatus and infraspinatus function is lost.

MATERIALS AND METHODS

Between 2009 and 2013, 45 consecutive patients underwent arthroscopically assisted LD transfer for an irreparable posterosuperior rotator cuff tear. Thirty-three patients agreed to participate in this retrospective study. For 8 patients, we used a standard passage of the LD through the plane between the infraspinatus-teres minor and the deltoid muscles. For the remaining 25 patients, we transferred the LD tendon in front of the triceps muscle according to a personal described technique. The follow-up period was 35.7 months. Final follow-up included assessment by standard radiographs, bipolar surface electromyography, pain score by visual analog scale, Constant-Murley shoulder score, and Disabilities of the Arm, Shoulder, and Hand score. For quantitative strength evaluation measurements, a Biodex dynamometer was used.

RESULTS

Overall clinical outcomes improved at the final follow-up and were significantly age related. We found similar results for revision and primary patients with mean increase in Constant-Murley scores of 29.5 and 30.5 points, respectively. In our series, we recorded osteoarthritis progression in 33.3% of patients.

CONCLUSION

Arthroscopic LD tendon transfer for irreparable posterosuperior rotator cuff tears can achieve good clinical outcomes at a midterm follow-up, especially in active men 60 years of age or younger and in patients with low preoperative elevation (<80°) but an intact or reparable subscapularis tendon.

Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear

BACKGROUND

Management of massive irreparable posterior-superior rotator cuff tear can be very challenging. This study reports the outcome of the lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.

METHODS

Included were 33 patients with an average age of 53 years (range, 31-66 years). All patients had symptomatic massive irreparable rotator cuff tear that failed conservative or prior surgical treatment and underwent reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft. The tear was considered irreparable based on the magnetic resonance imaging finding of ≥2 full-thickness rotator cuff tears associated with shortening and retraction of the tendon to the level of the glenoid and a high grade of fatty infiltration of the muscles. This was confirmed at the time of the surgery.

RESULTS

At an average follow-up of 47 months, 32 patients had significant improvement in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder and Hand score and shoulder range of motion, including flexion, 120°; abduction, 90°; and external rotation 50°. One patient, with a body mass index of 36 kg/m(2), required débridement for an infection and then later underwent shoulder fusion. Patients with >60° of preoperative flexion had more significant gains in their range of motion. Shoulder external rotation improved in all patients regardless of the extent of the preoperative loss of motion.

CONCLUSIONS

Transfer of the lower trapezius prolonged with Achilles tendon allograft to reconstruct massive irreparable posterior-superior rotator cuff tear may lead to good outcome in most patients, specifically for those who have preoperative flexion of >60°.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers

Background:

Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis.

Conclusion:

Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

All-Arthroscopic Latissimus Dorsi Transfer

Massive irreparable rotator cuff tears are often associated with severe functional impairment and disabling pain. One viable treatment option is a latissimus dorsi tendon transfer. We propose an all-arthroscopic technique that we believe avoids insult to the deltoid musculature while reducing morbidity from open harvest of the tendon. The operation is performed with the patient in the lateral decubitus position, by use of a combination of viewing and working portals in the axilla. The initial viewing portal is placed along the anterior belly of the latissimus muscle in the axilla. The latissimus and teres major are identified, as is the thoracodorsal neurovascular pedicle. The tendons are carefully separated, and the inferior and superior borders of the latissimus are whipstitched using a suture passer, which helps facilitate subsequent mobilization of the muscle. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the supraspinatus footprint with suture anchors. Our preliminary data suggest that this surgical technique results in improvement in pain, range of motion, and function.

Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears

BACKGROUND

Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has been recently introduced for treatment of irreparable, posterosuperior massive rotator cuff tears. We sought to evaluate the functional outcomes of this technique and to check for possible outcome predictors.

METHODS

The study reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer after 36.4 ± 9 months of follow-up. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff tear after a failed arthroscopic rotator cuff repair. The Constant and Murley score (CMS) was used to assess patients' functionality preoperatively and at follow-up.

RESULTS

As a group, the CMS improved with surgery from 35.5 ± 6.1 to 69.5 ± 12.3 (P < .001). A lower preoperative CMS and a previous failed rotator cuff repair resulted in lower postoperative range of motion (P = .044 and P = .007, respectively) and CMS (P = .042 and P = .018, respectively). A previous rotator cuff repair resulted in lower satisfaction with surgery (P = .009). Gender and age did not affect the clinical outcomes.

CONCLUSIONS

Our results support the effectiveness of arthroscopic-assisted LDTT in the treatment of patients with an irreparable, posterosuperior massive rotator cuff tears in pain relief, functional recovery, and postoperative satisfaction. Patients with lower preoperative CMS and a history of failed rotator cuff repair have a greater likelihood of having a lower clinical result. However, the favorable values of summary postoperative scores do not exclude these patients as candidates for arthroscopic-assisted LDTT.

Secondary latissimus dorsi transfer after failed reverse total shoulder arthroplasty

BACKGROUND

Combined single-stage reverse total shoulder arthroplasty (RTSA) plus latissimus dorsi transfer (LDT) has been reported to be a reliable treatment for pseudoparalysis of elevation and external rotation caused by irreparable rotator cuff tears. Secondary LDT in patients with pseudoparalysis of external rotation after previous RTSA has not yet been studied.

METHODS

Ten patients were treated with LDT at a mean of 27 months (range, 4-134 months) after RTSA. Standard LDT was performed in 4 patients and a LDT plus teres major transfer according to L'Episcopo in 6 patients. All patients had preoperative and postoperative clinical evaluation, including the assessment of the Constant score and the subjective shoulder value.

RESULTS

RTSA increased the preoperative mean relative Constant score from 26% (range, 11%-67%) to 51% (range, 20%-100%; P = .05). At a mean of 49 months (range, 23-67 months) after additional LDT, the relative Constant score further increased to 58% (range, 34%-100%; P = .141), remaining significantly superior to the score before RTSA (P = .021). The mean subjective shoulder value was 15% (range, 0%-30%) before and 44% (range, 20%-70%) after RTSA (P = .273) and was 56% (range, 20%-90%) after LDT (P = .686), a significant overall improvement of the state of the shoulder compared with before RTSA (P = .042). Mean active flexion increased from 36° (range, 0°-130°) to 86° (range, 10°-140°) after RTSA (P = .024) and to 109° (range,70°-140°) after LDT (P = 0.017 compared with pre-LDT; P = .011 compared with pre-RTSA). Mean active external rotation decreased from 0° (range, -80° to 50)° to -18° (range, -50°to 10)° after RTSA (P = .079) and was improved to 2° (-40° to 40)° after LDT (P = .24 compared with pre-LDT; P=.865 compared with pre RTSA).

CONCLUSION

Secondary LDT significantly improves active mobility in patients with residual dysfunction after RTSA.

Biomechanical comparison between the trapezius transfer and latissimus transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

The purpose of this study was to characterize the biomechanical effects of the lower trapezius transfer and to compare it with the latissimus dorsi transfer in a cadaveric model of a massive posterosuperior rotator cuff tear.

METHODS

Eight cadaveric shoulders were tested at 0°, 30°, and 60° of shoulder abduction. Range of motion, humeral rotational position due to muscle loading, joint reaction forces, and kinematics were measured. All specimens were tested in 4 conditions: intact, massive posterosuperior cuff tear, lower trapezius transfer, and latissimus dorsi transfer. A repeated-measures analysis of variance was used for statistical analysis.

RESULTS

Internal rotation due to muscle loading increased with massive cuff tear compared with the intact condition (P < .05). The latissimus transfer corrected this change at 0° abduction, whereas the trapezius transfer corrected this at all abduction angles. The massive cuff tear decreased glenohumeral joint compression forces at all abduction angles; these forces were restored by the lower trapezius transfer (P < .05). At maximum humeral internal rotation and 0° of abduction, the humeral head apex shifted superiorly and laterally with massive cuff tear (P < .05); this shift was more closely restored to intact values by the trapezius transfer compared with the latissimus transfer (P < .05).

CONCLUSION

The lower trapezius transfer is superior to the latissimus transfer at restoring native glenohumeral kinematics and joint reaction forces in our cadaveric model. It may be a promising treatment option for patients with a massive irreparable rotator cuff tear.

Massive rotator cuff tears: pathomechanics, current treatment options, and clinical outcomes

Rotator cuff tear size has an important effect on clinical outcomes after repair. Management options for massive rotator cuff tears are numerous, and selection of the most appropriate treatment method for individual patients can be a challenge. An understanding of the pathomechanics, treatment, and clinical outcomes in patients with massive rotator cuff tears can serve as a guide for clinical decision-making. The purpose of this article was to review treatment options and clinical outcomes for the management of massive rotator cuff tears.

Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear

BACKGROUND AND PURPOSE

Irreparable rotator cuff tears are a common cause of pain in adult population, requiring in many cases a surgical treatment. Possible alternatives are debridement, partial repair, muscle transfers and joint replacement. We evaluated two groups of patients with irreparable rotator cuff tear treated surgically: one group received an arthroscopic-assisted latissimus dorsi tendon transfer (LDTT), and the other an arthroscopic rotator cuff partial repair. Aim of our study was to compare clinical results and quality of life in two groups of patients with massive irreparable rotator cuff tear: one receiving an arthroscopic LDTT and the other receiving an arthroscopic rotator cuff partial repair.

METHODS

Forty patients were assigned to two groups: 20 patients to group TT treated with LDTT and 20 patients to group PR treated with a partial repair. The average follow-up duration was 2.8 years (1-5, SD 3). Pre- and postoperative modified UCLA shoulder score, ROM, measurement of the strength and the rotator cuff quality of life (RC-QOL) were used to asses the outcome.

RESULTS

LDTT showed significative improvements when compared to partial repair in UCLA score results, strength and RC-QOL questionnaire. No differences were found between the groups in pain relief.

CONCLUSION

Both techniques are effective in reducing patients' symptoms. We believe that in younger, high-demanding patients with no or mild osteoarthritis, the LDTT represents a valid treatment option with better modified UCLA score improvement and strength at our follow-up.

Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears

PURPOSE

To evaluate, in a multicenter, prospective study, the clinical, magnetic resonance imaging (MRI), and radiologic results of arthroscopic-assisted latissimus dorsi (LD) tendon transfer for irreparable posterosuperior rotator cuff tears; and to assess the influence of perioperative data on clinical results.

METHODS

Fifty-five patients with irreparable tears of at least the supraspinatus and infraspinatus tendons were managed with arthroscopic-assisted LD tendon transfer and reviewed clinically, with standardized radiographs and MRI, after a mean of 29 months. Outcome measures included the Constant score and the Subjective Shoulder Value. The osteoarthritic stage and acromiohumeral distance were measured on standardized radiographs, and the transferred tendon aspect was evaluated on MRI.

RESULTS

Thirty patients had already undergone 1 or more previous surgical procedures. The mean Subjective Shoulder Value increased from 26% preoperatively to 71% postoperatively. The Constant score improved from 37 preoperatively to 65.4 postoperatively. The pain score increased from 1.7 preoperatively to 12.6 postoperatively; the activity score, from 6.4 to 13.8; active forward flexion, from 134° to 157°; active abduction, from 67° to 92.5°; active external rotation, from 29° to 41.5°; and abduction strength, from 1.4 kg to 4.8 kg. The only statistically significant factor negatively influencing the Constant score was previous surgery. Four patients had a ruptured LD tendon on MRI follow-up at 1 year. There was no statistical difference between preoperative and final follow-up acromiohumeral distance. There was no increase in osteoarthritic stage.

CONCLUSIONS

Arthroscopic-assisted LD tendon transfer improves shoulder pain and function in patients with irreparable posterosuperior cuff tears, with similar clinical and radiologic results compared with results of published series using open techniques. Patients with a history of surgery had lower Constant scores compared with non-previously operated patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Irreparable posterosuperior rotator cuff tears are treated in several ways. Transfer of the latissimus dorsi is an alternative with acceptable mid-term results, but long-term results have rarely been published.

METHODS

The cases of 108 consecutive patients with 115 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed clinically and radiographically. Ninety-three shoulders in eighty-six patients were included in the follow-up analysis. The mean duration of follow-up was 9.3 years (range, 6.6 to 11.7 years), and the mean age at the operation was fifty-six years (range, forty to seventy-two years). Outcome measures included the Constant-Murley score (Constant score), American Shoulder and Elbow Surgeons (ASES) index, and visual analog scale (VAS) for pain. The progress of cuff tear arthropathy was determined with radiographic evaluation according to the system described by Hamada et al.

RESULTS

The mean relative Constant score improved from 44% preoperatively to 71% at the time of follow-up (p < 0.0001, effect size = 0.6), excluding the clinical failures. Similarly, the mean ASES index improved from 30 to 70 (p < 0.0001, effect size = 0.7), and the mean VAS score decreased from 7.8 to 2.4 (p < 0.0001, effect size = 0.8). A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly (p < 0.05). The mean Hamada radiographic grade of cuff tear arthropathy increased from 1.7 (range, 0 to 2) preoperatively to 2.2 (range, 1 to 5) (p < 0.0001, effect size = 0.2). The rate of clinical failure of latissimus dorsi transfer was 10%, and the rate of shoulder prosthetic replacement after latissimus dorsi transfer was 4%.

CONCLUSIONS

Pain relief and improvement of shoulder function were maintained a mean of 9.3 years after latissimus dorsi transfer for irreparable posterosuperior cuff defects. The younger the patient, the better the outcome.

Trapezius muscle transfer for external shoulder rotation: anatomical study

OBJECTIVE:

To compare the viability of transferring the lower and transverse trapezius to the greater tuberosity using three different techniques.

METHODS:

Twelve shoulders from six cadavers were used. The primary outcome was to assess the suture viability of the trapezius muscle transfer to the greater tuberosity in the insertion topography of the infraspinatus, with the arm adducted during internal rotation (hand on the abdomen) and maximum scapular retraction. Three transfers were applied to each shoulder: the lower and transverse trapezius distal insertion (Group 1); lower trapezius alone (Group 2); and lower trapezius insertion and origin (Group 3). Accessory nerve integrity was assessed before and after transfers.

RESULTS:

Sutures were viable in 42% (5/12) and 58% (7/12) on Groups 1 and 3, respectively, with no statistically significant difference (Fisher's test, p=0.558); Group 3 exhibited frequent neurologic injury (11/12). Group 2 was the least successful; the tendon did not reach the greater tuberosity, and no sutures were viable.

CONCLUSION:

Groups 1 and 3 exhibited the best nongrafting suture viability to the greater tuberosity; however, Group 3 was associated to frequent spinal accessory nerve injury. Level of Evidence IV, Anatomical Study

Time-dependent changes after latissimus dorsi transfer: tenodesis or tendon transfer?

BACKGROUND

Transfer of the latissimus dorsi tendon to the posterosuperior part of the rotator cuff is an option in active patients with massive rotator cuff tears to restore shoulder elevation and external rotation. However, it is unknown whether this treatment prevents progression of cuff tear arthropathy.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether the observed improvement in shoulder function in the early postoperative period with latissimus dorsi tendon transfer for irreparable rotator cuff tears will be permanent or will deteriorate in the midterm period (at 1-5 years after surgery).

METHODS

During a 6-year period, we performed 11 latissimus dorsi tendon transfers in 11 patients for patients with massive, irreparable, chronic tears of the posterosuperior part of the rotator cuff (defined as > 5 cm supraspinatus and infraspinatus tendon tears with Goutallier Grade 3 to 4 fatty infiltration on MRI), for patients who were younger than 65 years of age, and had high functional demands and intact subscapularis function. No patients were lost to followup; minimum followup was 12 months (median, 33 months; range, 12-62 months). The mean patient age was 55 years (median, 53 years; range, 47-65 years). Shoulder forward elevation, external rotation, and Constant-Murley and American Shoulder and Elbow Surgeons scores were assessed. Pain was assessed by a 0- to 10-point visual analog scale. Acromiohumeral distance and cuff tear arthropathy (staged according to the Hamada classification) were evaluated on radiographs.

RESULTS

Shoulder forward elevation, external rotation, Constant-Murley scores, and American Shoulder and Elbow Surgeons scores improved at 6 months. However, although shoulder motion values and Constant-Murley scores remained unchanged between the 6-month and latest evaluations, American Shoulder and Elbow Surgeons scores decreased in this period (median, 71; range, 33-88 versus median, 68; range, 33-85; p = 0.009). Visual analog scale scores improved between the preoperative and 6-month evaluations but then worsened (representing worse pain) between the 6-month and latest evaluations (median, 2; range, 0-5 versus median, 2; range, 1-6; p = 0.034), but scores at latest followup were still lower than preoperative values (median, 7; range, 4-8; p = 0.003). Although acromiohumeral distance values were increased at 6 months (median, 8 mm; range, 6-10 mm; p = 0.023), the values at latest followup (median, 8 mm; range, 5-10 mm) were no different from the preoperative ones (mean, 7 mm; range, 6-9 mm; p > 0.05). According to Hamada classification, all patients were Grade 1 both pre- and postoperatively, except one who was Grade 3 at latest followup.

CONCLUSIONS

The latissimus dorsi tendon transfer may improve shoulder function in irreparable massive rotator cuff tears. However, because the tenodesis effect loses its strength with time, progression of the arthropathy should be expected over time. Nevertheless, latissimus dorsi tendon transfer may help to delay the need for reverse shoulder arthroplasty for these patients.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Clinic and electromyographic results of latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

Background

This study examines the clinical and electromyographic results of latissimus dorsi transfer (LDT) using a combined open and arthroscopic technique for the treatment of symptomatic irreparable posterosuperior rotator cuff tears.

Methods

Between 2006 and 2009, LDT was performed in 14 patients (mean age 59 years) with massive and symptomatic irreparable posterosuperior rotator cuff tear. The patients were examined preoperatively and postoperatively with mean follow-up of 52 months using the Constant score, and the integrity of the latissimus dorsi (LD) transfer was assessed by ultrasound in all cases and by MRI in ten cases. The functional activity of the LD transfer was compared to the non-operated side using surface electromyography.

Results

All patients demonstrated a significant improvement in the Constant score (p = 0.001), from a preoperative score of 33 points (range 10–55 points) to a postoperative score of 59 points (range 13–80 points). The subjective assessment score was good to excellent in 12 patients (85%), and 11 patients (78%) would be willing to undergo surgery again. Integrity of the transferred tissue was confirmed in 13 of the 14 cases using ultrasound and MRI. Surface electromyographic signal showed increased activation of the transferred latissimus dorsi when performing active movements of external rotation (p = 0.002) and abduction-elevation (p = 0.009).

Conclusions

Our results indicate that LDT significantly improves function and diminishes pain in patients with a massive posterosuperior rotator cuff tear. The combined open and arthroscopic technique preserves the deltoid muscle and controls the LD tendon reinsertion. Surface electromyographic signal confirms the active function of the transferred muscle.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-014-0083-6) contains supplementary material, which is available to authorized users.

Latissimus dorsi tendon transfer for massive, irreparable posterosuperior rotator cuff tears: surgical technique

Massive rotator cuff tears remain a complex and challenging problem for both the patient and the surgeon. Although significant advancements in surgical techniques as well as technology for arthroscopic and mini-open rotator cuff repairs have been made, many massive tears result in failed repair with continued progressive tendon retraction and degeneration. In cases when primary tendon to bone healing is impractical, latissimus dorsi tendon transfer provides promising and reproducible clinical results. Herein, we present a latissimus tendon transfer surgical technique, a procedure we have used as a salvage operation for failed arthroscopic/mini-open primary rotator cuff repair.

Electromyographic activity after latissimus dorsi transfer: testing of coactivation as a simple tool to assess latissimus dorsi motor learning

BACKGROUND

The purpose of this study was to investigate coactivation (CoA) testing as a clinical tool to monitor motor learning after latissimus dorsi tendon transfer.

METHODS

We evaluated 20 patients clinically with the American Shoulder and Elbow Surgeons (ASES) and University of California-Los Angeles (UCLA) outcomes scores, visual analog scale, active external rotation (aER), and isometric strength testing in abduction and external rotation. Measurements of aER were performed while the latissimus dorsi was activated in its new function of external rotation with concomitant activation (coactivation) of its native functions (adduction and extension). Bilateral surface electromyographic (EMG) activity was recorded during aER measurements and the strength testing procedure (EMG activity ratio: with/without CoA). Patients were divided into two groups (excellent/good vs fair/poor) according to the results of the ASES and UCLA scores.

RESULTS

The mean follow-up was 57.8 ± 25.2 months. Subdivided by clinical scores, the superior outcome group lost aER with CoA, whereas the inferior outcome group gained aER (UCLA score: -2.2° ± 7.4° vs +4.3° ± 4.1°; P = .031). Patients with inferior outcomes in the ASES score showed higher latissimus dorsi EMG activity ratios (P = .027), suggesting an inadequate motor learning process. Isometric strength testing revealed that the latissimus dorsi transfer had significantly greater activity compared with the contralateral side (external rotation, P = .008; abduction, P = .006) but did not have comparable strength (external rotation, P = .017; abduction, P = .009).

CONCLUSIONS

Patients with inferior clinical results were more likely to be dependent on CoA to gain external rotation. Therefore, CoA testing may be used as a tool to evaluate the status of postoperative motor learning after latissimus dorsi transfer.

Arthroscopic-Assisted Latissimus Dorsi Transfer for the Management of Irreparable Rotator Cuff Tears: Short-Term Results

BACKGROUND

Irreparable rotator cuff tears associated with shoulder functional impairment represent a challenge, especially in young and active patients. Latissimus dorsi muscle-tendon transfer is performed to replace the irreversibly lost contractile elements in patients with irreparable tears of the posterosuperior aspect of the rotator cuff.

METHODS

From 2008 to 2010, we enrolled twenty-seven patients (mean age, sixty years; range, forty-six to sixty-seven years) with irreparable, full-thickness rotator cuff tears involving at least two tendons who underwent arthroscopic-assisted latissimus dorsi muscle-tendon transfer. Outcome measures included the Constant and Murley score, shoulder range of motion in external rotation, and muscle strength in forward elevation. The mean duration of follow-up was twenty-seven months (range, twenty-four to thirty-six months).

RESULTS

There was a significant improvement (p < 0.05) in the mean Constant and Murley score, pain score, muscle strength in forward elevation, and range of motion in external rotation at the time of the last follow-up. There was no significant correlation between the mean preoperative range of motion, pain, and strength and the mean postoperative Constant and Murley score. There was no significant osteoarthritis progression and proximal migration of the humeral head after surgery in the time period studied.

CONCLUSIONS

Arthroscopic-assisted latissimus dorsi muscle-tendon transfer at short-term follow-up is an effective alternative to open surgery for the management of painful irreparable posterosuperior rotator cuff tears refractory to conservative management.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation?

HYPOTHESIS

The purpose of this study is to evaluate the muscle activity with surface electromyography (EMG) and the clinical outcome of the latissimus dorsi transfer. It remains unclear whether the clinical results of the latissimus dorsi transfer for massive posterosuperior rotator cuff tears are achieved either by active muscle contractions or by a passive tenodesis effect of the transfer.

METHODS

Eight patients were evaluated preoperatively and at 1 year (SD, 0.1) after the latissimus dorsi transfer. Clinical evaluation of outcomes included active range of motion, Constant score, and visual analog scale (VAS) for pain and activities of daily living (ADL). Muscle activity was recorded with EMG during directional isometric abduction and adduction tasks.

RESULTS

The external rotation in adduction improved from 23° to 51° (P = .03). The external rotation in abduction improved from 10° to 70° (P = .02). The mean Constant score improved from 39 to 62 postoperatively (P = .01). The VAS for pain at rest improved from 3.3 preoperatively to 0.1 (P = .02). The VAS for ADL improved from 4.9 to 2.3 (P = .05). The transferred latissimus dorsi remained active in all cases, as reflected by increased latissimus dorsi EMG activity during abduction tasks. In addition, the latissimus dorsi EMG activity shifted from preoperative antagonistic co-activation in adduction to synergistic activation in abduction.

CONCLUSION

The latissimus dorsi has synergistic muscle activity after transfer. Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. A specific gain was observed for external rotation in elevated arm positions, a motion essential for ADL tasks.

Humeral resurfacing arthroplasty in combination with latissimus dorsi tendon transfer in patients with rotator cuff tear arthropathy and preserved subscapularis muscle function: preliminary report and short-term results

PURPOSE

Humeral resurfacing arthroplasty represents an alternative option to hemiarthroplasty for treatment of cuff tear arthropathy (CTA), with the advantages as follows: suitability for relatively young and high-demand patients because of preservation of bone stock and no loss of length, less invasive surgery, shorter operation time, no risk of periprosthetic stem fractures, and revision surgery can be undertaken easily. In the current study, resurfacing arthroplasty in combination with latissimus dorsi tendon transfer for CTA was performed. Three hypotheses: first, humeral resurfacing arthroplasty in combination with latissimus dorsi tendon transfer would improve the overall functional outcome in patients with CTA. Second, this combination would improve humeral external rotation. Third, this combination would improve abduction and shoulder elevation.

METHODS

Study was conducted as an observational case series. Fourteen patients (nine ♀ and five ♂) having CTA were included. Follow-up was carried out at the end of the 28th month for all patients. Constant Score was used for follow-up evaluation. Dorso-axillary approach was used for latissimus dorsi tendon transfer and ventral deltopectoral approach for Copeland resurfacing. Tendons were fixed to the greater tuberosity with two anchors.

RESULTS

The absolute Constant Score significantly improved from 34 preoperatively to 69 postoperatively, relative Constant Score from 42 to 91%, elevation from 95° to 138°, abduction from 88° to 147°, and external rotation from 16° to 22° (not significant).

CONCLUSION

Humeral resurfacing arthroplasty in combination with latissimus dorsi tendon transfer in patients having CTA with preserved subscapularis function has satisfactory short-term functional clinical outcome.

LEVEL OF EVIDENCE

IV.

Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances

Latissimus dorsi tendon transfer is a method for surgical treatment of massive irreparable posterosuperior cuff tears. It partially restores active anteflexion, external rotation, and function of the shoulder but does not significantly increase strength of the shoulder. It is contraindicated in case of pseudoparalytic shoulder; associated irreparable subscapularis tear, deltoid palsy, and in case of associated osteoarthritis, as an isolated procedure. Results are inferior when performed as a secondary procedure compared with a primary procedure. However, latissimus dorsi tendon transfer is an attractive solution to improve shoulder mobility and function of young and non osteoarthritic patients whose previous surgical treatment of massive postero-superior irreparable rotator cuff tear failed. As a primary procedure, latissimus dorsi tendon transfer competes with debridement, biceps tenotomy, and partial cuff repair. In association with reverse shoulder arthroplasty, it restores active external rotation in osteoarthritic patients with active external rotation deficit. New arthroscopic assisted techniques might improve results in the future.

Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) allows correction of pseudoparesis of elevation caused by irreparable rotator cuff tear but does not address loss of active external rotation. Latissimus dorsi transfer (LDT) is an established procedure for correction of pseudoparesis of external rotation.

METHODS

Forty-one shoulders of 40 consecutive patients, who were a mean age of 70 years old (range 47-85 years), underwent RTSA combined with LDT for irreparable rotator cuff failure with severe shoulder dysfunction.

RESULTS

Nine orthopedic complications occurred in 7 of the 41 shoulders. Four shoulders were lost to follow-up, and 5 were excluded from the functional analysis. The mean follow-up of the eligible 32 shoulders with the prosthesis still in place was 53 months (range, 24-105 months). The age-related Constant score increased significantly from a preoperative mean of 45% (range, 16%-80%) to 89% (range, 25%-100%). The mean subjective shoulder value increased from 33% (range, 0%-70%) to 75% (range, 30%-100%). Active external rotation significantly improved from a mean of 4° (range, -30° to 40°) to 27° (range, -10° to 70°). A preoperative external rotation lag sign could be corrected in 25 of the 32 shoulders. For the 16 shoulders with at least 5 years of follow-up, the Constant scores were 47% (range, 16%-80%) preoperatively, 92% (range, 51%-100%) at 2 years, and 94% (range, 57%-100%) at the latest follow-up, and the respective subjective shoulder values were 32% (range, 0%-70%), 73% (range, 30%-100%), and 80% (range, 60%-100%).

CONCLUSION

If treated with RTSA combined with LDT, patients with pseudoparesis of elevation and pseudoparesis of external rotation can expect an excellent clinical outcome for a period beyond 5 years, provided that complications that require removal of the prosthesis can be prevented.

Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years

BACKGROUND

The role of reverse shoulder arthroplasty (RTSA) in the relatively young individual is currently unclear. Our study evaluates the midterm to long-term results of RTSA for patients aged younger than 65 years with pseudoparalysis secondary to massive irreparable rotator cuff tears, with or without arthritis.

METHODS

Between 1997 and 2006, 46 RTSAs (41 patients) were performed. Mean age was 60 years (range, 46-64 years). At the latest follow-up, 5 patients had died and 1 was lost, leaving 35 patients (40 shoulders) with a mean follow-up of 93 months (range, 60-171 months).

RESULTS

The mean relative Constant score increased from 34% to 74% (P < .0001) and the subjective shoulder value improved from 23% to 66% (P < .0001). Significant improvements were seen in active forward elevation (72° to 119°), pain scores, and strength (P < .001). One or more complications occurred in 15 shoulders (37.5%), with 6 failures (15%) resulting in removal or conversion to hemiarthroplasty (3 with infection, 3 with glenoid loosening). Ten shoulders (25%) underwent partial or total component exchange, conversion to hemiarthroplasty, or removal. Of the 15 patients who developed complications, 9 did not require prosthesis removal or conversion and functional outcome and subjective shoulder value were similar to those with no complications (P > .4).

CONCLUSION

RTSA in younger patients provides significant subjective improvement and substantial gain in overall function, which is maintained up to 10 years. Although the complication rate is high, most can be treated successfully without compromise to clinical outcome. However, it is imperative that the high complication rate is explained to patients, with the risks and benefits carefully considered.

Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears: Short-term clinical results

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.

Latissimus dorsi tendon transfer for irreparable tears of the rotator cuff: An anatomical study to assess the neurovascular hazards and ways of improving tendon excursion

Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon.

Variation in the insertion of the latissimus dorsi & its clinical importance

The latissimus dorsi is the larger, flat, dorso-lateral muscle on the trunk, posterior to the arm, and partly covered by the trapezius on its median dorsal region. Origin of the latissimus dorsi is from spinous processes of thoracic T7-T12, thoracolumbar fascia, iliac crest and inferior 3 or 4 ribs, inferior angle of scapula and insertion on floor of intertubercular groove of the humerus. We have studied 50 cadavers in the different medical colleges in which we found 2% case of anterior and posterior slip of the muscle fibers with their extension up to the pectoralis major and teres major respectively. Usually, latissimus dorsi involve in extension, adduction, transverse extension also known as horizontal abduction, flexion from an extended position, and internal rotation of the shoulder joint. It also has a synergistic role in extension and lateral flexion of the lumbar spine. The latissimus dorsi may be used for the tendon graft surgeries. Tight latissimus dorsi has been shown to be one cause of chronic shoulder pain and chronic back pain. Because the latissimus dorsi connects the spine to the humerus, tightness in this muscle can manifest as either sub-optimal glenohumeral joint function (which leads to chronic shoulder pain) or tendinitis in the tendinous fasciae connecting the latissimus dorsi to the thoracic and lumbar spine. Latissimus dorsi used for pedicle transplant rotator cuff repair reconstruction of breast, face, scalp and cranium defect. The extra slip of the latissimus dorsi may puzzle any transplant operations. We as anatomist discuss the clinical implication of the extra slip of latissimus dorsi.

Biomechanical effect of latissimus dorsi tendon transfer for irreparable massive cuff tear

BACKGROUND

The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear.

METHODS

Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis.

RESULTS

The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction.

CONCLUSION

Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles.

Transfer of teres minor with bone pedicle for irreparable posterior-superior rotator cuff tears

BACKGROUND

The objectives of this study are to evaluate the clinical and radiographic mid- to long-term outcomes of patients treated by teres minor with bone pedicle transfer for irreparable massive rotator cuff tear and to investigate the limitations of this procedure.

METHODS

Clinical outcomes were assessed by quantifying: the range of shoulder motion; a visual analog pain scale; the University of California, Los Angeles Shoulder Score (UCLA score); and the Disability of the Arm, Shoulder, and Hand (DASH) score. Radiographs were assessed for deterioration of the glenohumeral joint and upper migration of the humeral head.

RESULTS

Eighteen patients with mean age of 66.9 years and mean follow-up of 74.4 months were included. The technique resulted in significant decrease in shoulder pain. The mean UCLA score improved from 10.3 points initially to 24.1 points at time of final follow-up. However, the postoperative results were classified as poor in 11 shoulders. The mean postoperative DASH score was 27.6 points. The mean active forward elevation significantly improved from 75.9° initially to 121.6° at time of final follow-up. In radiographic assessment, osteoarthritis of the glenohumeral joint progressed in 15 shoulders, and the upper migration of humeral head progressed in 14 shoulders.

CONCLUSIONS

Aggravation of the glenohumeral joint and upper migration of the humeral head both progressed postoperatively at a high rate. Therefore, we conclude that this procedure should no longer be performed despite its relative simplicity.

Indications for reverse shoulder replacement: a systematic review

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.

Arthroscopically assisted latissimus dorsi transfer with a minimally invasive harvesting technique: surgical technique and anatomic study

Latissimus dorsi musculotendinous transfer has been described for the treatment of massive rotator cuff defects. The aim of this paper is to present the relevant surgical anatomy of an arthroscopically assisted technique associated with a modified harvesting of the tendon. For tendon harvesting, a skin incision of about 5-6 cm in length is made in the axillary crease orthogonal to the longitudinal axis of the upper arm. For the musculotendinous transfer, we propose to increase vector action of the latissimus dorsi by passing the transferred tendon ahead the triceps muscle under or over the Teres Major and fixing the transferred tendon behind the humeral head center of rotation in a more posterolateral position. In order to check the feasibility and safety of this new surgical technique, two fresh-frozen adult cadaveric hemithorax specimens with an intact upper extremity were dissected, and the relationships between the tendons and local neurologic structures were described during various steps of the latissimus dorsi transfer procedure.

Rotator cuff tears treated with a modified deltoid flap repair technique

BACKGROUND

Few options exist in the treatment of irreparable rotator cuff tears, especially in younger patients. The purpose of this study was to present our experience with deltoid flap repairs combined with acromion elevation osteotomy increasing the space for the flap.

METHODS

We retrospectively reviewed the outcome of 57 patients with a mean age of 60 years who had undergone the modified anterolateral deltoid flap technique for the treatment of large and massive rotator cuff tears. Follow-up was performed after a mean of 6 years.

RESULTS

At follow-up, 84% of patients considered the condition of their shoulder as better or much better compared with before surgery. The mean Constant score was 88% (range, 45-122). Before surgery, all shoulders were significantly painful. At latest follow-up, 91% of the patients had no or mild pain. Elevation of the arm above 90° was possible in 38 patients before surgery and in 53 patients at latest follow-up. Tears involving 3 tendons were associated with inferior results. Retears of the deltoid flap occurred in 8 patients (14%); 1 of them was successfully treated with a reverse total shoulder replacement, and 6 had a repair of the flap, with only 1 satisfactory outcome.

CONCLUSIONS

The modified deltoid flap yielded reliable pain relief and a high rate of patient satisfaction, as well as satisfactory function in the majority of the patients. Especially in younger patients, this technique might be considered a viable alternative for the treatment of irreparable rotator cuff tears.

Latissimus dorsi tendon transfer for massive irreparable rotator cuff tears: a systematic review

Tendon transfers have been proposed as a possible solution to restore pain-free functions, strength, and range of motion in patients with massive and irreparable cuff tears. The aim of this review is to establish the outcomes of (1) latissimus dorsi tendon transfer (LDT-T) surgery performed as a single procedure or in combination with other muscle-tendon transfer procedures, replacement, or both; (2) LDT-T in primary and revision surgery for massive irreparable rotator cuff tears; (3) the LDT-T procedure in relation to subscapularis and teres minor integrity; (4) the LDT-T procedure in relation to the reattachment position on the humeral head of the transferred tendon; (5) the LDT-T procedure performed as a single or a double incision; (6) arthroscopic, open, or combined approach: and (7) the LDT-T procedure in patients with preoperative osteoarthritis and a nonosteoarthritic condition with the evaluation of osteoarthritis progression. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Studies of levels of evidence I-IV were included. The LDT-T surgical procedure, outcomes, and complications were evaluated. Twenty-two studies describing 493 shoulders in 487 patients were included in our study. There were no prospective randomized, controlled studies. LDT-T is a promising strategy for the management of massive and irreparable rotator cuff tears, even though no agreement was found on several aspects and options of LDT-T. Randomized prospective control studies are still awaited on this subject.

Tendon fixation in arthroscopic latissimus dorsi transfer for irreparable posterosuperior cuff tears: an in vitro biomechanical comparison of interference screw and suture anchors

BACKGROUND

The fixation of the tendon to the bone remains a challenging problem in the latissimus dorsi tendon transfer for irreparable cuff tears and can lead to unsatisfactory results. A new arthroscopic method of tendon to bone fixation using an interference screw has been developed and the purpose of this study was to compare its biomechanical properties to the ones of a standard fixation technique with anchors.

METHODS

Six paired fresh frozen cadaveric human humeri were used. The freed latissimus dorsi tendon was randomly fixed to the humeral head with anchors or with interference screw after a tubularization procedure. Testing consisted to apply 200 cycles of tensile load on the latissimus dorsi tendon with maximal loads of 30 N and 60 N, followed by a load to failure test. The stiffness, displacements after cyclic loadings, ultimate load to failure, and site of failure were analysed.

FINDINGS

The stiffness was statistically higher for the tendons fixed with interference screws than for the ones fixed with anchors for both 30 N and 60 N loadings. Likewise, the relative bone/tendon displacements after cyclic loadings were lower with interference screws compared to anchors. Load to failure revealed no statistical difference between the two techniques.

INTERPRETATION

Compared to the standard anchor fixation, the interference screw fixation technique presents higher or similar biomechanical performance. These results should be completed by further biomechanical and clinical trials to confirm the interest of this new technique as an alternative in clinical use.

Open repair for massive rotator cuff tear with a modified transosseous-equivalent procedure: preliminary results at short-term follow-up

BACKGROUND

Many surgical procedures have been reported for rotator cuff tears. We adopted the modified transosseous-equivalent procedure, also termed "surface-holding repair with transosseous sutures," and demonstrated that this procedure has a biomechanical advantage regarding the concentration of stress on the tendon stump. This study aimed to evaluate the clinical and structural outcomes of this technique, which has been demonstrated by postoperative magnetic resonance imaging (MRI) to produce high intact rates.

METHODS

Twenty-nine massive rotator cuff tears involving at least two tendons were treated by open repair using this procedure. Twenty-four patients were evaluated at an average of 43.2 months (range 24-71) postoperatively (the follow-up rate was 83.8%). The pre- and postoperative clinical outcomes were examined using the scoring system of the Japanese Orthopedic Association (JOA score). In an A-P radiograph, the presence of osteoarthritis (OA) of the glenohumeral joint and upward migration of the humeral head were compared pre- and postoperatively. The repair integrity of the cuff tendon was evaluated by applying Sugaya's classification to the postoperative MRIs.

RESULTS

The JOA score improved from 42.8 points preoperatively to 89.3 points at final follow-up. Radiographic examination showed that OA progressed in 16.7% and upward migration of the humeral head progressed in 20.8%. Postoperative MRI scans revealed 14 shoulders with type 1 repair based on Sugaya's classification, 4 shoulders with type 2, 4 shoulders with type 3, 2 shoulders with type 4, and no shoulders with a type 5 repair.

CONCLUSIONS

Although osteoarthritis of the glenohumeral joint and upward migration of the humeral head had both progressed postoperatively in some cases, postoperative MRI scans revealed that 91.7% of the repairs resulted in a continuous rotator cuff. Therefore, this technique produces a high healing rate.

Results of latissimus dorsi tendon transfer in primary or salvage reconstruction of irreparable rotator cuff tears

INTRODUCTION

This study intends to evaluate latissimus dorsi tendon transfer outcomes inpatients with irreparable rotator cuff tears, irrespective of the fact that this procedure had been used primarily in 17 patients (Group I) or as a revision of a previously shoulder surgery in eight patients (Group II).

PATIENTS AND METHODS

Twenty-five patients (14 males and 11 females), mean age 55.8 years were treated using this procedure. Tears involved both supraspinatus and infraspinatus in 21 cases. The latissimus dorsi flap was harvested through an axillary approach and reattached on the greater tuberosity, using suture anchors. Outcome was assessed at a mean follow-up duration of 22 months (12 to 60 months) based on objective measures (Constant and Murley scores) as well as on subjective criteria (patient's satisfaction).

RESULTS

Active forward elevation (AFE) improvement as well as external rotation and absolute Constant score gains were all significant. This amelioration was more important in patients with a preoperative AFE below 80 grades and this without any significant difference between group I and II. Subjectively, 84% of the Group I patients were satisfied with their outcome versus 50% of patients in Group II.

DISCUSSION AND CONCLUSION

In patients with irreparable rotator cuff tears, clinical results of latissimus dorsi tendon transfer showed significant pain level reduction, and gains in active range of motion both in forward elevation and external rotation. We did not find a significant difference between primary or revision repairs.

LEVEL OF EVIDENCE

Level IV retrospective therapeutic study.

Reversed shoulder arthroplasty with modified L'Episcopo for combined loss of active elevation and external rotation

HYPOTHESIS

In patients with a rotator cuff-deficient shoulder, a combined loss of active elevation and external rotation (CLEER) can occur when both the infraspinatus and teres minor muscles are absent. A reverse shoulder arthroplasty (RSA) can restore active elevation in these patients but cannot restore active external rotation because there are no other external rotator cuff muscles. We hypothesized that a modified L'Episcopo procedure (latissimus dorsi [LD] and teres major [TM] transfer) with a simultaneous RSA would restore shoulder function and activities of daily living (ADLs).

MATERIALS AND METHODS

Seventeen consecutive patients (mean age, 71 years) with CLEER underwent this combined procedure through a single deltopectoral approach and were prospectively monitored for at least 12 months. All patients had severe cuff tear arthropathy and advanced atrophy or fatty infiltration of the infraspinatus/teres minor muscles on preoperative magnetic resonance imaging or computed tomography scans. The patients were immobilized in 30 degrees of abduction and external rotation for 6 weeks postoperatively before starting rehabilitation.

RESULTS

Mean active elevation increased from 74 degrees preoperatively to 149 degrees postoperatively (+75 degrees ), and external rotation increased from -21 degrees to 13 degrees (+34 degrees ). Patient satisfaction, subjective shoulder value, Constant-Murley scores and ADLs all improved significantly. DISCUSSION & CONCLUSIONS: In patients with CLEER, the association of RSA with LD/TM transfer restores active elevation and external rotation. The combined procedure, performed in the same session through a deltopectoral approach, is indicated in a selected subgroup of patients with a rotator cuff-deficient shoulder and an absent or atrophied infraspinatus/teres minor muscles. Our technique is easier to perform than the two-incision procedure and appears to avoid problems such as extensive scarring, adhesions and axillary nerve lesions. Transferring both the LD and TM, rather than the LD alone, results in better active external rotation.