Tuesday, June 16, 2015

Irreparable rotator cuff tears - the use of the latissimus dorsi transfer

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

These authors reviewed 86 patients with 93 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed at a mean of follow-up was 9.3 years (range, 6.6 to 11.7 years). The mean age at the operation was fifty-six years (range, forty to seventy-two years). 

Inclusion criteria included chronic irreparable supraspinatus and infraspinatus tears (inability to mobilize the tendon to the normal attachment site with 60 degrees or less of abduction). Contraindications included inflammatory arthritis, subscapularis deficiency, axillary nerve lesions, deltoid muscle atrophy, cuff tear arthropathy, and stiffness (passive elevation of 80 degrees or less).

The latissimus dorsi tendon was incised through an axillary incision and then passed through the space between the infraspinatus, teres minor and deltoid to be inserted on the greater tuberosity with the medial edge sewn to the upper rim of the subscapularis tendon. The shoulder was held in 90 degrees of abduction for 6 weeks. Physical therapy was continued for four months after surgery.

There were 10% had clinical failure. For the remaining shoulders, the Constant score improved from 44% preoperatively to 71%, the mean ASES index improved from 30 to 70 and the mean VAS score decreased from 7.8 to 2.4. A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly. Younger patients had better outcomes. 

Four shoulders developed axillary hematomas. One patient had a temporary radial nerve lesion and one a temporary axillary nerve lesion. Deltoid insufficient occurred in three cases. Two cases had problems with post-operative shoulder stiffness.

Comment: These authors present a substantial followup of patients having latissimus dorsi transfers. In our mind, however, the role of this procedure in the management of irreparable cuff tears remains unclear. Many patients with irreparable two tendon tears can realize improvement in comfort and active function with nonoperative management or with the simple smooth and move procedure as posted here and here. On the other hand, patients with refractory pseudoparalysis are increasingly being managed with reverse total shoulders


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