Surgical technique and anatomic study of latissimus dorsi and teres major transfers

Latissimus Dorsi Tendon Repair

Background:

Latissimus dorsi tendon ruptures are rare injuries that can occur in overhead or throwing motions and are almost always sports related.

Indications:

Latissimus dorsi tendon ruptures are largely treated nonoperatively, although surgical repair is indicated for the young active patient looking to return to a high level of sport and for those with complete avulsion injuries or mid-substance tendon tears.

Technique Description:

Depending on the degree of tendon retraction, anteroinferior or posteroinferior axillary incision is made. After the tendon is mobilized, sutures are placed in a Krackow fashion through the bulk of the tendon, and the tendon footprint is prepared by gently decorticating the surface of the humerus, just anterior and inferior to the teres major insertion point. Two Arthrex Pec Buttons are then loaded into the superior and inferior limbs of the suture tape and 2 unicortical holes are drilled into the footprint of the insertion site. The superior button is placed first and then tensioned to allow the latissimus dorsi to be pulled to the bone. Next, the second button is placed, though this is not tensioned until later at the time of the biceps tenodesis. Finally, the procedure is visualized and well inspected to ensure appropriate location of the tendon and securing hardware.

Results:

After an appropriate rehabilitation protocol is followed for up to 6 months postoperatively, acute repair of a ruptured latissimus dorsi tendon allows for near to complete restoration of patient functionality and strength, with return to full activity possible within 6 to 8 months.

Conclusion:

Surgical repair of a ruptured latissimus dorsi tendon is effective in restoring upper extremity strength and functionality and is associated with high patient satisfaction. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Soft Tissue Management in Shoulder Arthroplasty

Total shoulder arthroplasty is a rapidly growing field, with more procedures performed each year. An important aspect of shoulder arthroplasty surgery is the management of soft tissues. Good functional outcomes in shoulder arthroplasty are significantly dependent on the repair of the rotator cuff tendons and proper release of the shoulder capsule. The success of any shoulder arthroplasty is predicated upon the meticulous handling of these tissues. The surgeon's ability to execute appropriate soft tissue techniques will facilitate easier surgery by increasing exposure and lead to better outcomes for the patient.

Is workload associated with latissimus dorsi and teres major tears in professional baseball pitchers? An analysis of days of rest, innings pitched, and batters faced

BACKGROUND

Latissimus dorsi (LD) and teres major (TM) tears have become increasingly recognized injuries in professional baseball pitchers. The purpose of this study was to determine whether workload, as measured by the number of days of rest between outings, number of innings pitched, number of batters faced, and being a starting pitcher, is associated with an increased risk of sustaining an LD-TM tear in professional baseball pitchers.

METHODS

All professional baseball pitchers who sustained an LD-TM tear between 2011 and 2017 were identified using the Major League Baseball Health and Injury Tracking System. A separate player-usage data set was used to determine workload. We then compared workload variables between pitcher-games 2, 6, 12, and >12 weeks prior to a documented LD-TM tear and pitcher-games from a non-LD-TM tear control group. In a paired analysis, we compared the acute workload (2, 6, and 12 weeks) prior to injury and the injured pitchers' non-acute workload >12 weeks prior to injury.

RESULTS

A total of 224 unique LD-TM tears were documented in the Major League Baseball Health and Injury Tracking System database. In most periods, player-games with more innings pitched and more batters faced were associated with a higher incidence of subsequent LD-TM tears. The number of days of rest was not a significant predictor of an LD-TM tear in the acute workload setting, but pitchers who sustained an LD-TM injury averaged fewer days of rest over the previous ≥12 weeks than controls (P < .001). Pitchers who faced >30 batters per game showed a 1.57-fold increase in the percentage of pitchers with a subsequent LD-TM tear as compared with pitchers who faced ≤5 batters per game. Significantly more starting pitchers were in the case group that sustained LD-TM tears over multiple time points than in the control group.

CONCLUSION

Having a greater pitcher workload and being a starting pitcher were associated with an increased risk of sustaining LD-TM tears in professional baseball players. The average number of days of rest was only a risk factor for LD-TM tears over a 3-month or longer period.

Reverse Total Shoulder Arthroplasty with Concurrent Latissimus Dorsi Tendon Transfer

PURPOSE OF REVIEW

Reverse total shoulder arthroplasty (rTSA) has emerged as an effective treatment option for patients with rotator cuff arthropathy resulting from irreparable rotator cuff tears. However, patients with combined loss of abduction and external rotation may still experience functional deficits after rTSA. One option to address this has been the latissimus dorsi tendon transfer (LDTT), or modified L'Episcopo procedure. The purpose of this review is to describe the role of LDTT with rTSA and to critically evaluate the evidence on whether a supplemental LDTT ultimately improves patient function.

RECENT FINDINGS

Patients with an intact rotator cuff demonstrated a significant increase in active external rotation following rTSA compared to those with a deficient rotator cuff following rTSA. Compared to their pre-operative baseline assessments, patients who undergo rTSA with LDTT report significant improvements in active external rotation. However, a randomized trial comparing rTSA patients with and without LDTT failed to demonstrate a significant difference in active external rotation or patient-reported outcomes between groups. Observational studies have shown that patients experience significant improvements in active range of motion and various patient-reported outcome measures following rTSA with latissimus dorsi tendon transfer. When directly comparing rTSA with LDTT to rTSA alone, the current literature fails to demonstrate a statistically significant difference in active external rotation or patient-reported outcomes at short-term follow-up. Further randomized controlled trials are required to fully understand the potential benefits of added tendon transfer in the rTSA patient population.

Concept and simulation of an alternative design for an orthopaedic shoulder implant

For a first-time glenohumeral arthritis patient, total shoulder arthroplasty (TSA) is an option where the shoulder joint is replaced with an artificial humeral head that articulates against a cup attached to the glenoid. A patient with rotator cuff deficiency can undergo reverse total shoulder arthroplasty (RTSA) where the components are switched. Presented here is a concept design at simulation stage which offers a platform-based implant where either a system can be assembled and implanted for TSA or a reverse system for RTSA. Platform components and the glenoid baseplate have been designed as part of this concept stage. Modular components are also described as part of the concept, which can influence a patient's range of motion (ROM), as well as the effect of implant positioning within the patient. A 42 mm hemisphere is used as the articulating component providing a good balance between ROM, joint load and deltoid force. The most suitable material concluded for the concept design TSA was as follows: grade 5 Ti-6Al-4V for the humeral stem and baseplate and CoCrMo with cross-linked polyethylene (XLPE) for the metal-on-polymer bearing surface. Finite element analysis concluded that the concept prosthesis is able to withstand an impact force of six times bodyweight from a forward fall. A dynamic fatigue test concluded that the expected lifetime of the concept polymer bearing surface is 33 years.

Single incision latissimus dorsi surgical technique: a three button repair

Due to the infrequent occurrence of latissimus dorsi insertional avulsions or tendon ruptures, there is no clear evidence on the optimal surgical fixation strategy. A three suture unicortical button repair technique through a single incision offers an anatomic reconstruction of the broad insertional footprint with adequate exposure. This fixation strategy is the preferred technique by the senior author.

Anatomical study of the teres major muscle: description of an additional distal muscle slip

Background

Understanding muscle and tendon anatomy is of tremendous importance to achieve optimal surgical execution and results in tendon transfers around the shoulder. The aim of this study was to introduce and describe an additional distal muscle slip of the teres major (TM).

Methods

Sixteen fresh-frozen cadaver shoulders were dissected with the deltopectoral approach. The ventral latissimus dorsi (LD) tendon was harvested, and the shoulders were analyzed for the presence/absence of a distal teres major slip (dTMs) and its dimensions and relationship with the TM and LD tendons.

Results

The dTMs was identified in 12 shoulders (75%). It was always distal to the TM tendon and visible during the deltopectoral approach. There was a clear separation between the TM proximally and dTMs tendon distally. At the humeral insertion, both tendons had a common epimyseal sheet around the teres major and inserted continuously at the humerus. The mean width of the dTMs tendon at the insertion was 13 ± 4 mm (range, 7–22 mm). The total lengths of the dTMs tendon and LD tendon were 40 ± 7 mm (range, 25–57 mm) and 69 ± 7 mm (range, 57–79 mm), respectively (p < 0.001). The dTMs muscle showed direct adhesions in ten shoulders (83%) with the LD muscle.

Conclusions

This is the first macroscopic description of an additional distal slip of the teres major muscle. The dTMs has a separate (distal) but continuous (mediolateral) insertion at the humerus within a common epimyseal sheet around the TM. The dTMs tendon is visible during the deltopectoral approach and can therefore provide a lead structure, particularly in ventral LD transfers with the deltopectoral approach.

Latissimus Dorsi Tear in an Olympics-Level Tennis Player: Case Report and Review of Literature

Latissimus dorsi tears are extremely rare and are encountered primarily in high-level athletes. Noted initially in baseball pitchers, cases have been described in other sports too, with one report of a latissimus dorsi tear at the muscle-tendon junction in a tennis player. Anecdotal outcomes have been comparative after both non-operative and operative treatments. Although no clear indications for operative intervention exist, there is a general consensus that partial non-retracted tears can be managed with non-operative treatment, whereas complete tears warrant surgical repair. This case report describes a complete rupture with retraction of the latissimus dorsi tendon that occurred during a competitive match in an international level tennis player. Due to compelling sports participation reasons, this tear was managed with non-operative treatment. The player returned to competitive tennis within 6 weeks and won the Asian Games men's doubles tennis gold medal 53 days following his injury. He has had no subsequent shoulder-related symptoms despite his continuous participation in international level tennis for the past 18 months. We analyse the role of the latissimus dorsi in tennis and also review the available literature on this uncommon sports injury.

Surgically relevant anatomy of the axillary and radial nerves in relation to the latissimus dorsi tendon in variable shoulder positions: A cadaveric study

BACKGROUND

The purpose of this study was to define the relationship of the axillary and radial nerves, particularly how these are affected with changing arm position.

METHODS

Twenty cadaveric shoulders were dissected, identifying the axillary and radial nerves. Distances between the latissimus dorsi tendon and these nerves were recorded in different shoulder positions. Positions included adduction/neutral rotation, abduction/neutral rotation for the axillary nerve, adduction/internal rotation, adduction/neutral rotation, adduction/external rotation, and abduction/external rotation for the radial nerve.

RESULTS

Width of the latissimus tendon at its humeral insertion was 29.3 ± 5.7 mm. Mean distance from the latissimus insertion to the axillary nerve in adduction/neutral rotation was 24.2 ± 7.1 mm, the distance increased to 41.1 ± 9.8 mm in abduction/neutral rotation. Mean distance from the latissimus insertion to the radial nerve was 15.3 ± 5.5 mm with adduction/internal rotation, 25.8 ± 6.9 mm in adduction/neutral rotation, and 39.5 ± 6.8 mm in adduction/external rotation. Mean distance increased with abduction/external rotated 51.1 ± 7.4 mm.

CONCLUSIONS

Knowing the axillary and radial nerve locations relative to the latissimus dorsi tendon decreases the risk of iatrogenic nerve injury. Understanding the dynamic nature of these nerves related to different shoulder positions is critical to avoid complications.

Combined Fully Arthroscopic Transfer of Latissimus Dorsi and Teres Major for Treatment of Irreparable Posterosuperior Rotator Cuff Tears

Many treatment options have been proposed for treatment of irreparable posterosuperior rotator cuff tears. Among these options, latissimus dorsi tendon transfer can be considered a good alternative, especially in young patients before development of glenohumeral arthritic changes, aiming 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 technique was recently adapted from open to arthroscopically assisted with numerous advantages. We propose a combined fully arthroscopic technique for transfer of latissimus dorsi and teres major in which the tendons are fixed in a flat manner at the junction of supraspinatus and infraspinatus to decrease failure rate.

Performance and Return to Sport After Latissimus Dorsi and Teres Major Tears Among Professional Baseball Pitchers

BACKGROUND

Latissimus dorsi and teres major (LD/TM) tears are becoming an increasingly common cause of injury and disability among professional baseball pitchers.

PURPOSE/HYPOTHESIS

To determine performance and return to sport (RTS) among professional baseball pitchers after LD/TM tears treated operatively and nonoperatively and to compare the RTS rate and performance between pitchers who sustained an LD/TM tear and matched controls. The authors hypothesized a high RTS rate among professional baseball pitchers after LD/TM tears, with no significant difference in RTS rate or performance between cases and controls for operative and nonoperative treatment-specifically, in the primary performance outcome variables of WHIP ([walks + hits] / innings pitched), fielding independent pitching, and wins above replacement.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All professional baseball pitchers who sustained an LD/TM tear between 2011 and 2016 were identified with the Health and Injury Tracking System database of Major League Baseball. Demographic and performance data (before and after injury) were recorded for each player. Performance metrics were then compared between cases and matched controls by operative and nonoperative treatment.

RESULTS

Overall, 120 pitchers had a documented LD/TM tear; 42 (35%) were major league players. Most players (n = 107, 89.2%) were treated nonoperatively. Time to return to the same level of competition was 170 ± 169 days (mean ± SD) for pitchers treated nonoperatively and 406 ± 146 days for those treated operatively. The RTS rate among players treated nonoperatively and operatively was identical at 75%. Players treated nonoperatively had no change in fielding independent pitching or wins above replacement after injury but had a higher (ie, worse) WHIP after injury ( P = .039); they also performed significantly worse in several secondary performance metrics, including number of games played per year ( P < .001). Players treated operatively had no change in any measured performance metrics after surgery. No difference existed between cases and controls in the primary performance variables.

CONCLUSION

The majority of LD/TM tears are treated nonoperatively. The RTS rate is 75% for professional baseball pitchers after LD/TM tears treated operatively or nonoperatively. Players treated nonoperatively saw a decline in several performance metrics, while players treated operatively had no significant difference in performance after surgery.

Arthroscopic-assisted Latissimus Dorsi Tendon Transfer for the Management of Irreparable Rotator Cuff Tears in Middle-aged Physically Active Patients

Background

Latissimus dorsi (LD) tendon transfer is used as a treatment option for massive irreparable posterosuperior rotator cuff tears, and recently, an arthroscopic-assisted technique was introduced. This study was undertaken to evaluate the clinical and radiological outcomes of arthroscopic-assisted LD tendon transfer for the management of irreparable rotator cuff tears in active middle-aged patients.

Methods

The records of five patients (two males) with irreparable tears involving the supraspinatus and infraspinatus tendons managed by arthroscopic-assisted LD tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using the visual analogue scale (VAS) pain scale, American Shoulder and Elbow Surgeon’s (ASES) scores, the University of California Los Angeles (UCLA) scale, and ranges of motion. Postoperative integrities of transferred tendon were evaluated by magnetic resonance imaging in 4 patients and by ultrasound in one.

Results

Mean patient age was 55 years (range, 48–61 years), and mean follow-up period was 20 months (range, 12.0–27.2 months). Mean VAS score significantly improved from 6.6 ± 2.6 preoperatively to 1.8 ± 2.5 postoperatively (p=0.009), mean ASES score increased from 67.6 ± 9.2 to 84.6 ± 15.1, and mean UCLA score from 18.0 ± 1.4 to 28.8 ± 8.5 (all p<0.001). Postoperative imaging of the transferred LD tendon showed intact repair in 4 patients. The remaining patient experienced LD transfer rupture and a poor outcome.

Conclusions

Arthroscopic-assisted LD tendon transfer improved shoulder pain and function in patients with massive, irreparable rotator cuff tears, and may be an option for this condition, especially in physically active patients.

Latissimus Dorsi Tendon Rupture

Isolated injury to the latissimus dorsi is rare. Partial tendon tears may be successfully treated nonsurgically. Complete tendon ruptures require surgical repair. Tendon repair can be approached either through an anterior deltopectoral incision with a secondary small posterior axillary incision or through a long posterior axillary incision. Suture anchors can be used to repair the latissimus dorsi to the humeral attachment. Although the literature is limited to single-patient case series, most patients have returned to full athletic activity after surgical repair.

Approach to Latissimus Dorsi and Teres Minor Injuries in the Baseball Pitcher

PURPOSE OF REVIEW

Tears of the latissimus dorsi and teres major are uncommon but significant injuries, most frequently seen in high-level, overhead throwing athletes. Diagnosis can be challenging, as there are no pathognomonic signs, symptoms, or physical exam findings associated with latissimus dorsi/teres major tears, and the clinician must have a high suspicion for this injury. While many of these tears can be treated non-operatively, a subset of these benefits from surgical intervention. Rehabilitation following operative and non-operative treatments of these injuries is extensive, and timing of return to sport can be variable from 3 to 12 months.

RECENT FINDINGS

The literature surrounding latissimus dorsi/teres major injuries is sparse. Several small studies have shown good results in patients with mild to moderate tears that were treated non-operatively. Recent evidence has shown good results following operative repair of larger tears, with excellent return to sport rates. Furthermore, focused rehabilitation is imperative when treating patients with latissimus dorsi/teres major injuries to allow these athletes to return to sport. Latissimus dorsi/teres major tears are uncommon but significant injuries in the throwing athlete. Prompt diagnosis, proper treatment, and focused rehabilitation will allow these patients to return to sport in a safe and efficient manner.

Surgical Technique and Anatomical Considerations for the Modified L'Episcopo Tendon Transfer

BACKGROUND

Birth brachial plexus injury usually affects the upper trunks of the brachial plexus and can cause substantial loss of active shoulder external rotation and abduction. Due to the unbalanced rotational forces acting at the glenohumeral joint, the natural history of the condition involves progressive glenohumeral joint dysplasia with associated upper limb dysfunction. Surgical reconstruction methods have been described previously by Sever and L'Episcopo, and modified by Hoffer and Roper to release the adduction contracture and to restore external rotation and shoulder abduction.

METHODS

The authors describe their preferred technique for contracture release and tendon transfer to improve external rotation and shoulder abduction. Pertinent anatomy and highlights of surgical exposure are reviewed.

RESULTS

The senior author has utilized this technique with consistent clinical outcomes to improve shoulder function for patients with persisting nerve palsy associated with birth brachial plexus injury. A review of the literature supports utilization of this technique.

CONCLUSIONS

Transfer of the latissimus dorsi and teres major to the posterior rotator cuff for reanimation of shoulder abduction and external rotation deficits associated with birth brachial plexus injury is a safe and reliable technique. Careful patient selection and attention to surgical detail are critical for optimal outcomes.

Quantitative assessment of the growth dynamics of the teres major in human fetuses

PURPOSE

The main objective of the study was to examine the use of teres major (TM) as a flap in the pediatric surgeries from an anatomical perspective by: (1) revealing the growth dynamics of the developing TM; (2) assessing the possible interconnecting structures between TM and latissimus dorsi (LD); (3) exposing the innervation patterns of TM in human fetuses.

METHODS

Study was conducted on 50 fetuses (26 females and 24 males), on a mean gestational age of 22.86 ± 3.21 (range 18-30) weeks. All the measurements were collected with a digital caliper and a digital image analysis software. Additionally, structural relations between TM and LD were examined in detail and further classified.

RESULTS

No significant difference of side and sex was detected on TM measurements (p > 0.05). Linear functions for the surface area, width, length of the superior and inferior margins of TM were detected as follows: y = - 257.142 + 18.334 × age (weeks), y = - 5.497 + 0.545 × age (weeks), y = - 1.621 + 1.068 × age (weeks), and y = - 2.147 + 1.284 × age (weeks), respectively. As classified in five types, a number of 33 muscular or tendinous connections between TM and LD were detected. Musculo-tendinous slips from TM to triceps brachii (TB) were evident in four sides. Innervation of TM was observed to be providing by the lower subscapular nerve in all the cases.

CONCLUSION

First, linear functions, representing the developing fetal morphometry obtained by our study can be adapted for estimating the morphometric of this muscle in early childhood. Besides, acknowledging the diverse appointments of TM with the surrounding muscles such as LD and TB may facilitate the prevention of neurovascular structures and the application of surgical procedures during tendon transfers. In brief, our findings are highly potent to bring the attention of pediatric surgeons.

Novel Arthroscopic Tendon Transfers for Posterosuperior Rotator Cuff Tears: Latissimus Dorsi and Lower Trapezius Transfers

Background

Massive irreparable rotator cuff tears in both the primary and the revision setting are challenging problems. There remains controversy over the ideal treatment methods for these patients. In the case of an irreparable posterosuperior rotator cuff tear, tendon transfers^1-12 have emerged as a reliable option, with a durable outcome. The most commonly used tendon transfer options are the latissimus dorsi (LD)^1-6and the lower trapezius (LT)¹².

Description

The LD transfer is performed by first harvesting the LT tendon from the humeral shaft. It is critical to release the many adhesions to the muscle belly as well as to separate it from the teres major muscle. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor. The tendon is anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity. The LT transfer is performed by harvesting the LT muscle and tendon off its insertion on the medial aspect of the scapular spine. It should be mobilized to maximize excursion by releasing adhesions. An Achilles tendon allograft is anchored into the anterior aspect of the greater tuberosity arthroscopically. The Achilles tendon is then secured to the LT tendon.

Alternatives

In addition to tendon transfer, options include:Partial or complete attempted repair^13-17.Augmentation or bridging with allografts^18-23.Superior capsular reconstruction²⁴.Subacromial balloon²⁵.

Rationale

There remains a paucity of literature comparing tendon transfers with alternatives. However, when considering a tendon transfer, certain principles are critical in order to achieve an optimal outcome:The recipient and transferred tendons must have similar musculotendinous excursion.The recipient and transferred tendons should have similar lines of pull.One tendon (the transferred) should be designed to replace 1 function (of the recipient).The function of the transferred tendon and muscle should be expendable without substantial donor site morbidity.The strength of the transferred muscle must be at least grade 4.When deciding between the LT and LD transfer, certain considerations should be taken into account. The LD transfer has a proven history of successfully treating massive irreparable posterosuperior rotator cuff tears in studies with long-term follow-up^1-6. Alternatively, although the LT transfer has only recently gained popularity, it has the advantage of "in-phase" muscle function, since the trapezius naturally contracts during shoulder external rotation. Furthermore, its line of pull almost completely mimics the infraspinatus.

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.

Variants of latissimus dorsi with a perspective on tendon transfer surgery: an anatomic study

BACKGROUND

The latissimus dorsi (LD) is often used for tendon transfers to treat massive irreparable posterosuperior rotator cuff tears. The operation requires the LD tendon to be mobilized to reduce tension on the tendon. In that respect, any connection between the LD tendon and contiguous muscles may hamper tendon mobility and affect the surgical outcome. The goal of this study was to document the occurrence of connections between the LD and adjacent muscles and nerves.

METHODS

We studied the scapular region on 48 embalmed cadavers. The skin and superficial fascia were removed according to Cunningham's manual of dissection, and the muscle was exposed.

RESULTS

It was found that the LD and teres major (TM) muscles are connected by muscle fibers in 10% of the cadavers studied. Another vital discovery was that in some cadavers, the LD tendon was penetrated by a nerve.

CONCLUSION

Fascial connections between the LD and TM are well known, but these muscle links are comparatively unusual. From the results of this study, one should pay particular attention to muscle links between the LD and TM during dissection of the LD for transfer. It can also be suggested that during transfer surgery, the LD tendon should be cautiously examined for the possibility of a nerve penetrating it.

Surgical anatomy of the radial nerve in the deltopectoral approach for revision shoulder arthroplasty and periprosthetic fracture fixation: a cadaveric study

BACKGROUND

Radial nerve injury is a rare but clinically significant complication of revision shoulder arthroplasty and fixation of native and periprosthetic proximal humeral fractures. Understanding of the anatomic relationship between the radial nerve as it enters the humeral spiral groove and anterior shoulder landmarks in a deltopectoral approach is necessary to avoid iatrogenic radial nerve injury.

METHODS

Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosity/inferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Means, standard deviations, and ranges were determined for each distance.

RESULTS

The radial nerve entry into the proximal spiral groove averaged 133.1 mm (range, 110.3-153.0 mm) from the coracoid process, 101.9 mm (range, 76.5-124.3 mm) from the distal lesser tuberosity/inferior subscapularis insertion, 81.0 mm (range, 63.4-101.5 mm) from the superior latissimus insertion, and 39.6 mm (range, 25.5-55.4 mm) from the inferior latissimus insertion. The proximal spiral groove was distal to the inferior latissimus insertion in all specimens.

CONCLUSION

The risk of iatrogenic injury to the radial nerve at the spiral groove may be minimized through proper identification and protection or avoidance of circumferential fixation. However, if encircling fixation with cerclage cables is necessary, instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of radial nerve injury.

Teres major muscle - insertion footprint

Teres major muscle (TM) and latissimus dorsi muscle (LD) are frequently used in muscle transfers around the shoulder girdle. Some authors have suggested harvesting techniques in which the muscle is detached in continuity with a bone segment. Information on the bony attachment footprint of these muscles is lacking. The purpose of this study was to investigate the region of attachment of the TM to facilitate safe and complete harvesting with a bone segment where it is indicated, and to determine the relationship of the TM footprint with that of the LD. Twenty-eight upper extremities of 14 human cadavers (six female, eight male) were investigated during the students' dissection course in the winter term 2012. The attachment footprints were photographed and the images were processed with ImageJ Version 1.46r. The TM attachment footprint at the crest of the lesser tubercle had an average dimension of 187 ± 89 mm2 . It was 49.6 ± 7.9 mm long and 7.4 ± 2.5 mm wide. The bony attachment of the LD within the bicipital groove, just below the tendon of the long head of the biceps muscle, had an area of 94 ± 37 mm2 . It was 36.5 ± 8 mm long and 3.7 ± 1.2 mm wide. Both muscles were separated by 4.4 ± 1.7 mm and their attachments overlapped in the craniocaudal direction by 24.4 ± 12.4 mm. Earlier studies have investigated the dimensions of the muscles' tendons close to the attachment not the bony attachment itself. The dimension of the attachment of the TM was larger than that of the LD. The ratio between the footprint areas was approximately 2:1. This information should be considered by surgeons undertaking transfers, which include a bony segment of the muscle insertion.

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.

The neurovascular anatomy of the teres major muscle

BACKGROUND

Information in recent literature on the teres major muscle (TM) is limited and, at times, contradictory. Exact information on its neurovascular supply is clinically relevant for its use in a free or pedicled muscle transfer in reconstructive shoulder surgery. Therefore, the aim of this study was to analyze the TM topographically, especially its neurovascular supply and its macroscopic appearance.

MATERIALS AND METHODS

Thirty upper extremities of 15 human cadavers (7 female and 8 male cadavers) were investigated during the students' dissection course of our anatomic department in the winter term of 2012.

RESULTS

The lower subscapular nerve (LSN) innervated the TM in 86.6% of shoulders. In 13.3%, the thoracodorsal nerve (TDN) supplied the muscle. The LSN's branch was 49.8 ± 11.8 mm long. The TDN's branch was 83.5 ± 9.8 mm long. The entry of the neurovascular pedicle was located almost in the center part of the muscle. The arterial branch was 33.6 ± 7.3 mm long.

DISCUSSION

In general, the LSN innervates the TM. However, in 10% to 20% of shoulders, the TDN innervates this muscle. The branch of the TDN supplying the TM is longer than the branch of the LSN. In a muscle transfer, the vessels are the predictable limiting factor for translation because they are shorter than the nerve. The artery, nerve, and vein enter the muscle in a close relationship (<2 cm). It is useful to describe the entry point as an area of 2 cm in diameter around the middle of the TM.

Isolated latissimus dorsi transfer to restore shoulder external rotation in adults with brachial plexus injury

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

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.

Variant insertion of the teres major muscle

The teres major (TerMa) muscle has a clinical significance for tendon transfer procedures in patients with massive rotator cuff tears. Individually, it originates from the dorsum of the inferior angle of scapula and inserts into the medial lip of bicepital groove of the humerus. Functionally, TerMa in cooperation with latissimus dorsi (LD) adducts arm, medially rotates arm, and assists in arm extension. The variation of TerMa insertion is very rare. In the shoulder and axillary regions of a 33-year-old Thai male cadaver, the variant insertion of the right TerMa was found. The muscle fibers of TerMa are directly attached at the supero-medial border of LD tendon. Notably, there was no terminal tendon of TerMa. To explain an unusual movement of the arm, this rare variation of the TerMa insertion is necessary to be recognized. This case report is very important for surgeons to preoperatively consider using the terminal tendon of TerMa for tendon transfer in treating patients with irreparable cuff tears.

Teres major muscle tear in two professional ice hockey players: cases study and literature review

Ice hockey is a sport renowned for its numerous injuries; different studies report between 13.8 and 20 lesions per 1000 athlete exposures. Exactly 65.5% of these injuries occur during games, compared to 34.5% during training sessions. And 35.1% of all injuries involve the lower extremity and 29.7% the upper extremity (results drawn from games and training combined). Determining whether muscle injuries are extrinsic (contusions) or intrinsic (tears) is of utmost importance since the former generally require simple follow-up, whereas the latter necessitates further investigations, appropriate treatment and often prolonged absence from sports for the injured athlete. To our knowledge, no publication to date has reported isolated damage of the teres major muscle in Ice Hockey players. Seven cases were reported amongst baseball pitchers. Two cases presented after a waterskiing traction accident and a further case has been described in a tennis player. In the present study, we report two cases of isolated teres major tear in ice hockey players. These two athletes were both professional players competing at the highest level in the Swiss Ice Hockey League.

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.

Teres major muscle activation relates to clinical outcome in tendon transfer surgery

BACKGROUND

In massive rotator cuff tears a teres major (TMj) tendon transfer to the insertion of the supraspinatus (SSp) reverses its adduction moment arm into abduction which is supposed to be an adequate salvage procedure. Analysis of muscle function to find biomechanical ground of such success is scarce.

METHODS

We compared pre- and postoperative clinical outcome of TMj transfer, i.e. Range of Motion, pain, Constant Shoulder scores and arm force. TMj activation was evaluated in 14 patients suffering massive cuff tears using activation ratios to describe the desired 'in-phase' and undesired 'out-of-phase' contribution to the external arm moment. Additionally, we analyzed activation of the latissimus dorsi (LD) and the medial part of the deltoids (DE). The activation ratios were compared to controls and TMj activation ratios were related to clinical outcome.

FINDINGS

TMj tendon transfer improved arm function. Pre-operatively, we observed 'out-of-phase'abduction activation of TMj and LD. After transfer patients activated TMj according to its new anatomical position. 'Out-of-phase' LD abduction activation persisted. The clinical improvements coincided with changes in activation ratio of TMj.

INTERPRETATION

'Out-of-phase' TMj adductor activation is associated with compromised arm function in patients with irreparable cuff tears. After transfer, TMj is activated in correspondence with its new anatomical function, which was supportive for the improved arm function.

Management of massive and irreparable rotator cuff tears

Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including debridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.

Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm

Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70 degrees to 148 degrees (+78 degrees ) and external rotation from -18 degrees to 18 degrees (+36 degrees ). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.