massive irreparable rotator cuff tear - management with arthroscopic-assisted latissimus dorsi transfer

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

These authors reviewed 86 patients (aged 59.8 ± 5.9 years) who underwent an arthroscopic-assisted latissimus dorsi tendon transfer for treatment of irreparable, posterosuperior massive rotator cuff tears at 36.4 ± 9 months after surgery. Of these, 14 patients (16.3%) sustained an irreparable massive rotator cuff retear after a prior arthroscopic rotator cuff repair. 

The Constant scores improved. A lower preoperative Constant score and a previous failed rotator cuff repair resulted in lower postoperative range of motion, Constant score, and patient satisfaction.

Comment: This article can be compared to another recent publication that used a lower trapezius transfer for similar indications (see this link).

The management of a patient with an irreparable cuff tear needs to be highly individualized based on the patients health and expectations as well as the condition of the shoulder before shoulder surgery. We use a range of approaches including the smooth and move procedure, CTA arthroplasty, and reverse total shoulder arthroplasty. We have not found a role for tendon transfers in our practice, but will observe with interest the attempts of others to explore other approaches.

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Massive irreparable posterior-superior rotator cuff tear treated with a lower trapezius transfer

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

These authors report on 33 patients (average age of 53 years (range, 31-66 years)) having reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft for a symptomatic massive irreparable (≥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) rotator cuff tear that failed conservative or prior surgical treatment.

Postoperatively, patients were placed in a custom-made shoulder spica brace in 30° of abduction and 50° of external rotation for 8 weeks. The patient then began active assisted range of motion exercises in every direction except internal rotation for 4 weeks (from weeks 8-12), then full range of motion and gentle strengthening after that. Patients were allowed to return to unrestricted activities after 6 months.

The acromial osteotomy performed as a part of this procedure healed in 25 of 33 patients.

One patient, with a body mass index of 36 kg/m2, required débridement for an infection and then later underwent shoulder fusion. 

These patients were characterized preoperatively as " All patients were active and did repetitive lifting activities, such as weight lifting, light labor, or daily repetitive lifting of objects 10 pounds or greater. Thirteen patients reported heavy lifting activities, including construction workers, farmers, lifting heavy wood, boxes, or animals. The mechanism of injuries included slipping on ice in 6, falling from stairs in 4, car accident in 5, motorcycle accident in 4, sports injury (football, hockey) in 6, and repetitive heavy lifting (farmers) in 8. " The ability of patients to perform these functions after surgery is not provided.

At an average follow-up of 47 months, 32 patients were reported to have improved comfort and function. The range of flexion improved from 70° (range, 20°-120°) before surgery to 120° (range, 80°-150°), but the statistical significance of this change is not provided.

Comment: The management of a patient with an irreparable cuff tear needs to be highly individualized based on the patients health and expectations as well as the condition of the shoulder before shoulder surgery. We use a range of approaches including the smooth and move procedure, CTA arthroplasty, and reverse total shoulder arthroplasty. We have not found a role for tendon transfers in our practice, but will observe with interest the attempts of others to explore other approaches.

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Irreparable cuff tears - is an iliotibial-bone autograft useful?

Rotator cuff repair using an original iliotibial ligament with a bone block patch: preliminary results with a 24-month follow-up period.

These authors advocate managing massive shoulder rotator cuff tears not amenable to primary repair with a patching method that uses an autograft consisting of a section of the iliotibial band with an attached bone block so that the ligament part of the graft is sutured to the remaining rotator cuff and the bone end fixed to the greater tuberosity using a suture bridge. They state that this operative procedure is applicable when primary repair is not possible but repair of the subscapularis and infraspinatus muscles alone is possible

They report 5 patients with 2 years followup.

Patients were clinically improved. No mention is made of complications or the time necessary to perform the procedure.  Fusion of the bone graft with the greater tubercle of the humerus was confirmed on computed tomography in all patients. No retearing was observed on magnetic resonance imaging at the 24-month point, and the thickness of the ligament part of the graft was maintained.

Comment: This is clearly a big procedure, requiring surgery on the shoulder and the knee.

Below is a preoperative MRI

And here is a postoperative MRI at two years. While tissue apparently remains between the humeral head and the acromion, the muscle seems to have remained atrophic and the connection between the graft and the muscle appears slack.

it will be important to compare the results of this procedure with a more conservative surgical procedure in which no attempt is made to span the defect in the rotator cuff, the smooth and move. See this link 

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Rotator cuff tears - what to do if they are irreparable?

Long-term outcome of tuberoplasty for irreparable massive rotator cuff tears: is tuberoplasty really applicable?

These authors report on 16 patients who underwent arthroscopic tuberoplasty for symptomatic irreparable massive RCT without pseudoparalysis. Patients were a mean age of 64 years (range, 43-80 years) at the time of the operation, and the mean duration of follow-up was 98 months (range, 84-126 months).

At the last follow-up, the visual analog scale score for pain during motion had decreased to 2.3 from a preoperative mean of 6.9 (P < .001). The mean University of California at Los Angeles and Constant scores improved from 10.3 and 37.9 preoperatively to 27.2 and 59.2, respectively, at the last follow-up (P < .001 for both). 

The mean acromiohumeral interval changed from 5 mm preoperatively to 4 mm at the last follow-up. Only 1 patient underwent revision surgery.

The authors concluded that arthroscopic tuberoplasty is a good option for relieving pain and improving functionality in nonpseudoparalytic patients with painful irreparable massive RCT.

Comment: Currently there is enthusiasm for treating massive irreparable cuff tears with marginal convergence, superior capsular reconstructions, patch grafts, and reverse total shoulders. These authors demonstrate that some patients may be substantially improved with a simpler option that does not require prolonged periods of rehabilitation after surgery.

As Codman pointed out many years ago, the shoulder is a joint with two concentric spheres sharing a common center of rotation: (1) the humeral head articulating in the glenoid socket and (2) the proximal humeral convexity articulating within the coracoacromial arch. The radius of the second is equal to the radius of the first plus the thickness of the cuff and tuberosity. Here is an illustration from his book:

When the cuff is absent, the uncovered tuberosity extends beyond the extended curvature of the humeral surface, disrupting the normally smooth surface of the proximal humeral convexity. As the figure below from Steve Lippitt shows, smoothing of the tuberosity can restore the smoothness of the proximal humeral convexity that articulates with the undersurface of the (hopefully) intact coracoacromial arch.

Our favored procedure for the painful, stiff and crepitant irreparable cuff tear without pseudoparalysis is the smooth and move procedure, which includes tuberoplasty along with a bursectomy, lysis of adhesions, and a gentle manipulation under muscle relaxation.See this link and this link.

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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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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 exercises, the smooth and move procedure, CTA arthroplasty, reverse 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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Irreparable rotator cuff tears - is there a role for tendon transfers?

Tendon Transfers for Irreparable Rotator Cuff Tears

After analyzing 56 articles related to the use of the latissimus dorsi, the pectoralis major, and the trapezius, the authors of this review concluded that the indications for tendon transfers are "not clearly defined". Although the goal of transfers is to improve strength, mechanics and function by restoring the "glenohumeral force couple", they found that  "functional benefits are unpredictable".

What is clear is these tendon transfers are not minor surgery (see the figures in the article), carry a risk of failure and complications, and require substantial periods of immobilization in an orthosis followed by lengthy rehabilitation. 

While the authors found that these procedures can be associated with improved shoulder comfort, we note that improved comfort can also be realized after procedures the goal of which is simply to restore the smoothness and flexibility of the shoulder, even after prior failed repair attempts.  In the future, it will be important to determine if tendon transfers have any advantages over simpler, safer procedures in terms of their value (clinical improvement/(cost+risk))

In our practice we offer the 'smooth and move' procedure to patients who have  irreparable cuff tears and who have no arthritis and who do not have pseudoparalysis or anterosuperior esscape. The advantages of the smooth and move are (1) it is a short, safe procedure that is accomplished without detaching the deltoid, (2) it restores smoothness of the passage of the upper humerus beneath the coracoacromial arch without sacrificing the stability offered by the acromion and the coracoacromial ligament, (3) because it includes a gentle manipulation, it restores passive flexibility of the shoulder, (4) passive and active rehabilitative exercises and activities of daily living can be started immediately after surgery, and (5) it does not prevent any subsequent procedures (such as transfers, CTA arthroplasty or reverse total shoulder).

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