Friday, November 8, 2013

Latissimus Dorsi Transfer for Massive Cuff Tears

Latissimus Dorsi Tendon Transfer for Treatment of Irreparable Posterosuperior Rotator Cuff Tears: Long-Term Results at a Minimum Follow-up of Ten Years

The purpose of this Level IV study was to evaluate the long-term outcome of transfer of the latissimus dorsi tendon to the greater tuberosity of the humerus for treatment of an irreparable rotator cuff tear in 57 shoulders with an average age of 57 years.

All shoulders had rupture of the supraspinatus and infraspinatus tendons associated with (1) at least stage-3 fatty infiltration of the supraspinatus and infraspinatus muscles and/or (2) an acromiohumeral distance of <7 mm on anteroposterior radiographs made with the arm in neutral rotation plus the inability to close the tendon defect intraoperatively because of excessive musculotendinous retraction. 

All shoulders had persistent pain and/or unacceptable function despite non-opertative treatment. Exclusion criteria were chronic, pain-free pseudoparalysis of anterior elevation, inability to stabilize the arm at 90° of abduction, and anterosuperior escape. Shoulders with an irreparable subscapularis tear were also excluded.

Minimal followup was ten years (mean 147 months).  46 shoulders were available at the time of final follow-up. The relative Constant score improved from 56% to 80%, and the pain score improved from 7 to 13 points (p < 0.0001 for all). Mean flexion increased from 118° to 132°  and external rotation increased from 18° to 33°. The authors rigorously evaluated the 14 of 46 shoulders that had an increase in the SSV of <30%, considered to be an unsatisfactory result. Shoulders with insufficiency of the subscapularis muscle and fatty infiltration of the teres minor muscle did less well.

One shoulder required superficial debridement and wound closure because of a wound dehiscence. Four shoulders had reoperations: 2 for postoperative stiffness, 1 for reconstruction of a traumatically avulsed latissimus dorsi tendon, and one for avulsion of the central portion of the deltoid muscle. Two patients had postoperative dysesthesia of the ulnar nerve, which resolved spontaneously within six months in both cases.

Comment: A number of options are to be considered in the management of irreparable cuff tears, ranging from stretching and strengthening exercisesthe smooth and move procedureCTA arthroplastyreverse total shoulder, and, as discussed in this article, a latissimus transfer. The choice depends on the active range of motion, condition of the joint surface, the stability of the joint, the status of the residual cuff and subscapularis, as well as the health and goals of the patient and the experience of the surgeon. 

Latissimus transfer is a big procedure requiring partial takedown of the deltoid, two incisions, and careful intraoperative and postoperative care. Comparison of the results with other methods is difficult due to the many important variables affecting comfort and function in these shoulders.

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