All-Arthroscopic Latissimus Dorsi Transfer

Full arthroscopic vs. arthroscopically assisted posterosuperior latissimus dorsi tendon transfer for shoulders with failed and irreparable rotator cuff repair: matched case-control study

PURPOSE

To compare clinical outcomes and complication rates of full arthroscopic latissimus dorsi tendon transfer (LDTT) vs. arthroscopically assisted LDTT, for the treatment of irreparable posterosuperior massive rotator cuff tears (mRCTs) in shoulders that had failed rotator cuff repair (RCR).

METHODS

We evaluated a continuous series of 191 patients who underwent LDTT over 4 consecutive years. A total of 107 patients did not have previous shoulder surgery, leaving 84 patients who had prior surgical procedures. All procedures performed over the first 2 years were arthroscopically assisted (n = 48), whereas all procedures performed over the last 2 years were full arthroscopic (n = 36). We noted all complications, as well as clinical scores and range of motion at ≥24 months. To enable direct comparison between the 2 techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up.

RESULTS

Compared with the 48 patients who underwent arthroscopically assisted LDTT, the 36 patients who underwent full arthroscopic LDTT had comparable complications (13% vs. 11%) and conversions to RSA (8.3% vs. 5.6%). Propensity score matching resulted in 2 groups, each comprising 31 patients, which had similar outcomes in terms of clinical scores (except mobility component of Constant score, which was better following fully arthroscopic LDTT; P = .037) and range of motion at a minimum follow-up of 2 years.

CONCLUSION

At a minimum follow-up of 24 months, for the treatment of irreparable posterosuperior mRCTs in shoulders that had surgical antecedents, full arthroscopic LDTT had significantly better mobility component of the Constant score than arthroscopically assisted LDTT, although there were no significant differences in the other clinical or functional outcomes. Arthroscopically assisted LDTT and full arthroscopic LDTT had comparable rates of complications (8.3% vs. 13%) and conversion to RSA (5.6% vs. 8.3%).

Modified Arthroscopic Latissimus Dorsi Transfer at the Infraspinatus Footprint With Anterior Extracortical Fixation

Massive irreparable cuff tears may represent as many as 20% to 40% of total cases of operated rotator cuff tears and can be a challenging clinical problem. Many treatment options have been proposed for their treatment. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before they develop glenohumeral arthritic changes. This technique aims at rebalancing the shoulder with a functioning subscapularis muscle and restoring both active external rotation and elevation with the aid of a properly functioning deltoid muscle. The modified arthroscopic latissimus dorsi transfer at the infraspinatus footprint with anterior extracortical fixation rebalances the pair of forces acting on the shoulder, stabilizing it in the transverse plane, minimizing the risk of latissimus dorsi transferred rupture and associated complications.

Matched Cohort Study Comparing Arthroscopic-Assisted Versus Full-Arthroscopic Latissimus Dorsi Tendon Transfer for Irreparable Massive Rotator Cuff Tears

Background

Latissimus dorsi tendon transfer (LDTT) is increasingly performed with arthroscopic assistance, requiring an open axillary incision, which could increase risks of infection, hematoma, and lymphoedema. Technological advancements now enable LDTT to be fully arthroscopic, but its benefits and safety have not yet been confirmed.

Purpose

To compare the clinical outcomes and complication rates of arthroscopic-assisted versus full-arthroscopic LDTT for irreparable posterosuperior massive rotator cuff tears in shoulders with no surgical antecedents.

Study Design

Cohort study; Level of evidence, 3.

Methods

The study included 90 patients who had undergone LDTT over 4 consecutive years by the same surgeon and did not have prior surgery. During the first 2 study years, all procedures were arthroscopically assisted (n = 52), while during the last 2 years, all procedures were fully arthroscopic (n = 38). Procedure duration and all complications were recorded, as well as clinical scores and range of motion at minimum 24-month follow-up. To enable direct comparison between the techniques, propensity score matching was used to obtain 2 groups with equivalent age, sex, and follow-up.

Results

From the initial cohort of 52 patients who underwent arthroscopic-assisted LDTT, 8 had complications (15.4%), of which 3 (5.7%) required conversion to reverse shoulder arthroplasty and 2 (3.8%) required drainage or lavage. From the initial cohort of 38 patients who had full-arthroscopic LDTT, 5 had complications (13.2%), of which 2 (5.2%) required conversion to reverse shoulder arthroplasty but no patients (0%) required other procedures. Propensity score matching resulted in 2 groups, each comprising 31 patients, with similar outcomes in terms of clinical scores and range of motion. The procedure time was about 18 minutes shorter for full-arthroscopic LDTT, which had different complications (2 axillary nerve pareses) as compared with arthroscopic-assisted LDTT (1 hematoma and 2 infections).

Conclusion

Equivalent outcomes at minimum 24-month follow-up were found for arthroscopic-assisted and full-arthroscopic LDTT in terms of complications rates (15.4% and 13.2%, respectively), conversion to reverse shoulder arthroplasty (5.7% and 5.2%), clinical scores, and range of motion.

Technical Guide and Tips to Posterior Arthroscopic Latissimus Dorsi Transfer for Irreparable Posterosuperior Rotator Cuff Tears

Latissimus dorsi (LD) transfer is a reliable treatment option for irreparable posterosuperior (PS) rotator cuff tears in young and active patients that need to recover the range of motion for their daily living activities. The technique starts with an arthroscopic assessment of the tear. The next step is the mini-open stage for muscle release from the subcutaneous layer of the skin, the teres major (TM), the triceps, and the lateral border and inferior angle of the scapula. Later, the scope is used to prepare the footprint (arthroscopy) and for the release and the harvest of the tendon (endoscopy), taking care not to detach the TM and not to damage the radial nerve. A grasper is used to push the LD to its correct path medial to the triceps. After that the same instrument is placed from the anterolateral and the anterior arthroscopic portals toward the mini-open incision to catch the sutures previously loaded on the LD tendon with Krackow stitches. The LD is transferred to the greater tuberosity and is attached with one medial and one lateral knotless anchors. A third point of fixation enables a partial RC repair and ensures a surface of bone to tendon healing.

Mid-term results of arthroscopically assisted latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

With progress in arthroscopic surgery, latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears (RCTs) has become a reliable all-arthroscopic or arthroscopically assisted procedure. The mid-term results of arthroscopically assisted latissimus dorsi transfer (aLDT) are scarce in the literature. The purpose of this study was to report our clinical and radiographic mid-term results of aLDT for irreparable posterosuperior RCTs.

METHODS

Thirty-one consecutive patients with a mean age of 55.5 years (range, 38-73 years) at the time of aLDT were evaluated after a mean of 3.5 years (range, 2-5 years). All patients had irreparable, full-thickness tears of at least the complete supraspinatus, with or without infraspinatus tendons, and 12 patients (39%) had undergone previous rotator cuff repair (RCR). A concomitant upper-third subscapularis repair was needed at the time of aLDT in 7 patients (23%). Mid-term results were assessed clinically and radiographically (including magnetic resonance imaging).

RESULTS

At final follow-up, 4 patients with failure (13%) had undergone revision to reverse total shoulder arthroplasty (RTSA) essentially for untreatable pain. Patients with revision to RTSA had significantly higher preoperative pain levels (Constant pain score, 6 points vs. 11 points; P = .032) and lower Constant activity scores (2 points vs. 5 points, P = .017) than the remaining 27 patients. Patients with failed previous RCRs had significantly inferior results compared with patients without previous repair (mean Subjective Shoulder Value, 67% vs. 88%; P = .035). For the 27 patients without revision, the mean relative Constant score improved from 63% to 76% (P = .032), the Constant pain score, from 10.5 to 12.7 points (P = .012), and the Subjective Shoulder Value, from 43% to 77% (P < .001). Significant progression of glenohumeral arthropathy by 2 or more grades according to the Hamada classification was observed in 13 of the 27 patients (48%), but there was no significant difference in clinical outcomes between the patients with arthropathy (n = 13) and those without it (n = 14, P = .923).

CONCLUSIONS

The mid-term results of aLDT for irreparable posterosuperior RCTs were associated with significant improvements in objective and subjective outcome measures. The failure rate leading to conversion to RTSA was relatively high in this cohort. The failures were associated with unusually intense pain in low-demand individuals and/or revision of failed RCR. Long-term results of aLDT are needed to evaluate the effect of this procedure on the progression of osteoarthritis.

Biomechanical analysis of arthroscopically assisted latissimus dorsi transfer fixation for irreparable posterosuperior rotator cuff tears-Knotless versus knotted anchors

We compared the construct stability of traditional knotted techniques with modern knotless anchor systems used in arthroscopically assisted latissimus dorsi transfers (aLDTs) for irreparable posterosuperior rotator cuff tears. Eighteen cadaveric shoulders were age- and gender-matched to the following three groups: knotted group (two knotted anchors); knotless group (two knotless anchors); and triple anchor group (two knotless anchors; one all-suture anchor at the apex of the humeral head). All tendons were cyclically loaded in line of the aLDT over 400 cycles followed by a load to failure test. Outcome measures were the ultimate load to failure, elongation, construct stiffness, and failure modes. The triple anchor group revealed the highest ultimate load to failure (431 ± 78 N) compared with the knotted (326 ± 52 N; p = .022) and knotless (353 ± 105 N; p = .129) groups. Total elongation and construct stiffness were not significantly different comparing all three groups. The failure modes were: anchor pull-out in all specimen of the knotted group; three (50%) anchor pull-out and three suture pull-out in the knotless group (p = .046); four (67%) anchor pull-out, one (17%) suture pull-out and one tendon pull-out in the triple anchor group. Biomechanical analyses of knotless fixation techniques for aLDTs show similar construct stability and elongation compared with the traditional, knotted techniques. Bone fixation seems to be improved with the knotless anchor systems. In our practice, we continue to use the knotless fixation technique for aLDT and in the situation of weak, osteoporotic bone, we add a third (all-suture) anchor to improve construct stability.

Tendon transfers for irreparable rotator cuff tears

Symptomatic irreparable rotator cuff tears pose a challenge for shoulder surgeons. Whilst reverse polarity shoulder arthroplasty is an effective option for older symptomatic patients who have exhausted conservative management, the optimal treatment for younger patients remains controversial. In this article we outline the main tendon transfer options, including anatomical considerations, indications, contraindications, surgical technique, complications and a review of the evidence. Tendon transfers provide an alternative joint-preserving surgical option, but the evidence so far is limited, with a clear need for well-designed comparative studies to confirm their effectiveness.

Prevention and Treatment of Nerve Injuries in Shoulder Arthroplasty

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Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common.

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The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury.

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Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries.

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Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers.

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Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

Enhancement of External Rotation after Latissimus Dorsi Tendon Transfer (LDTT): A Cadaveric Study

Background and objectives: Massive rotator cuff tears compromise shoulder mobility function and cannot be directly repaired. Latissimus dorsi tendon transfer (LDTT) is a therapeutic alternative suitable for the treatment of rotator cuff tears that helps to restore external shoulder rotation. Cadaver models have been used for studying the effects of LDTT and procedural variations, but, to the best of our knowledge, none of them have been validated. The aim of our study was to validate a novel cadaver model while verifying the effects of LDTT on external rotation. Materials and Methods: Two groups were included in the study: a cadaver group and a control group made up of healthy volunteers, which were used for the validation of the cadaver model. Baseline external rotation measurements were performed with both groups, after which a massive rotator cuff tear was inflicted and repaired with LDTT in the cadaver group. Their postoperative external rotation was evaluated using three different tests. Results: No statistically significant differences were found between the baseline measurements of the two groups, and postoperative external rotation was significantly higher after LDTT in all cases but one. Conclusions: Cadaver models were validated, since they had a similar preoperative external rotation to healthy volunteers. Moreover, they allowed us to demonstrate the effect of LDTT on external shoulder rotation.

Latissimus dorsi tendon transfers: a historical journey

Several latissimus dorsi tendon transfer techniques for shoulder problems have been previously described and developed. These techniques involve the transfer in obstetric palsy, transfer in irreparable posterosuperior rotator cuff tears and subscapularis tears, and transfer in reverse shoulder arthroplasty. We detail the differences in planning and surgery and the need for different approaches. This historical and technical description provided in this study will benefit surgeons wishing to use the procedure.

Surgical Management of Massive Irreparable Cuff Tears: Latissimus Dorsi Transfer for Posterosuperior Tears

PURPOSE OF REVIEW

This review aims to describe the role of the latissimus dorsi transfer (LDT) for patients with irreparable posterosuperior rotator cuff tears (RCTs).

RECENT FINDINGS

Historically, the LDT has been performed as an open (double-incision) procedure for neurologically intact, relatively young patients with irreparable posterosuperior RCTs with disabling loss of active external rotation with or without impaired active elevation. The transferred tendon reconstitutes the posterior rotator cuff and force couple, respectively and thus has the potential to function effectively as an external rotator and humeral head depressor. Long-term results of the open technique have demonstrated in the majority of patients substantial and durable improvements in shoulder function and pain relief at the 10-year benchmark. With the advancements of arthroscopic surgery, the LDT was expanded to an arthroscopically assisted procedure with promising short-term results. In addition to adequate technical performance, the success of the procedure depends on preoperative factors, such as exclusion of glenohumeral osteoarthritis and acromial acetabularization; intact or reparable subscapularis tendon; intact (or hypertrophic) teres minor muscle; adequate preoperative activity of the latissimus dorsi; and normal or mild impairment of overhead function. The LDT (open or arthroscopically assisted) is a reliable treatment option for patients with massive, irreparable posterosuperior RCTs with disabling loss of active external rotation, with or without diminished overhead function and without advanced glenohumeral osteoarthritis. Precise patient selection is of tremendous importance in the success of the LDT.

Tendon transfers in rotator-cuff surgery

Indications and techniques for tendon transfer in irreparable rotator-cuff tear have greatly progressed and are no longer restricted to external rotation deficit. The present article first reviews the various types of tear and corresponding tendon transfers and the biomechanics of the pseudoparalytic shoulder. The indication of choice for tendon transfer is iterative tear following failure of isolated long biceps tenotomy or partial repair. Latissimus dorsi, inferior trapezius and pectoralis major transfer are the 3 types to be used after failure of primary surgery. Latissimus dorsi transfer is indicated for partial loss of active limb elevation or isolated loss of internal rotation. Inferior trapezius transfer is best indicated for isolated active external rotation deficit. In pseudoparalytic shoulder with total loss of active elevation or combined loss of elevation and active external rotation, isolated transfer is insufficiently powerful to restore active range of motion and should be associated to reverse arthroplasty. We describe the various transfer techniques and report their results.

Comparison of arthroscopically assisted transfer of the latissimus dorsi with or without partial cuff repair for irreparable postero-superior rotator cuff tear

PURPOSE

To evaluate the effect of an additional partial repair in combination with an arthroscopically assisted transfer of the latissimus dorsi (LDT) in massive postero-superior irreparable cuff tear.

MATERIALS AND METHODS

Thirty-one patients (mean age 59.2 years) scheduled for arthroscopically assisted LDT either isolated or in combination with a partial cuff repair for a massive posterior-superior cuff tear were prospectively included between January 2011 and December 2013 at our institution. Seventeen had an isolated transfer (Group A) and 14 had a transfer combined with a partial cuff repair (Group B). Outcome measures included visual analogue scale (VAS), range of motion, strength, constant score, and subjective shoulder value (SSV). Potential predictive factors were analyzed.

RESULTS

At the last follow-up (mean 22 months), patients in Group B had a significantly higher constant score (64 ± 8 versus 58 ± 4 in Group A), range of motion (33 ± 5 versus 29 ± 5 points in Group A), and strength at 90° of abduction (2.5 kg ± 1 in Group B versus 1.9 kg ± 0.9 in Group A). No significant differences were found between both groups regarding pain scores, SSV, and active external rotation. Thirty-seven variables were analyzed and the only factor which was found to be predictive of a bad result was a preoperative SSV < 40 pts. (RR 0.5).

CONCLUSION

Arthroscopically assisted LDT gives better results when combined with a partial repair of the cuff than when it is performed isolated in the treatment of massive irreparable postero-superior rotator cuff tear.

LEVEL OF EVIDENCE

Treatment study, Level II.

Qualitative and Quantitative Anatomy of the Proximal Humerus Muscle Attachments and the Axillary Nerve: A Cadaveric Study

PURPOSE

To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve.

METHODS

Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured.

RESULTS

Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm).

CONCLUSIONS

The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm.

CLINICAL RELEVANCE

Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.

Clinical and Radiographic Outcomes With Assessment of the Learning Curve in Arthroscopically Assisted Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears

PURPOSE

To evaluate the clinical results of an arthroscopy-assisted latissimus dorsi tendon transfer (aLD) for irreparable posterosuperior cuff tears as a primary surgery. The secondary aim of this study was to quantify the learning curve using the log-linear model. We hypothesized that aLD significantly improved shoulder function and that there was consistent reduction of the operative time in support of a learning-curve effect.

METHODS

After the arthroscopic partial repair was completed, the latissimus dorsi tendon was harvested via axillary mini-open incision and fixed with a knotless anchor arthroscopically. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) scoring system, active range of motion, and the visual analog scale (VAS) for pain. The operative time was recorded to quantify the learning curve using a log-linear model.

RESULTS

Thirty patients with a mean age of 67.4 years who underwent aLD were included. At a mean of 34 months after an aLD, the mean UCLA score increased from 15.7 preoperatively to 28.8 postoperatively (P < .001). The mean active forward elevation increased from 105° preoperatively to 149° postoperatively (P < .001). The mean active external rotation increased from 22° preoperatively to 32° postoperatively (P < .001). The VAS improved from 58 mm to 18 mm (P < .001). In all but 2 cases (93%), the preoperative osteoarthritis grade was maintained. The mean operative time was 145 minutes. A significant linear correlation was observed between the operative time and cumulative volume of cases after performing a logarithmic transformation. The learning rate was calculated as 84%.

CONCLUSIONS

Arthroscopy-assisted latissimus dorsi tendon transfer is a technically demanding procedure; however, it can lead to significant improvements in overall shoulder pain and function. This study also confirmed a learning-curve effect for the aLD. The learning rate was 84%, indicating the existence of a long learning period.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.