The patient is placed in the lateral decubitus position, and the drapes are
placed to expose the spine, shoulder, and arm to the level of the elbow
(Fig. 1). If an assistant is
not available to hold the arm, a mechanical arm holder can be used to allow
for abduction and rotation of the shoulder during the procedure.
A superior approach to the shoulder is used to expose the rotator cuff
tear. The incision is made just lateral to the acromion from anterior to
posterior. The anterior portion of the deltoid muscle is taken off the
anterior aspect of the acromion from the acromioclavicular joint to the edge
of the acromion. The deltoid muscle is split at the midpoint between the
anterior and posterior edges of the acromion. A stay suture is placed in the
deltoid, 5 cm distal to the acromion, to prevent it from splitting distal to
the axillary nerve. A complete bursectomy is performed, and the edges of the
rotator cuff are defined, débrided, and mobilized
(Fig. 2). If the infraspinatus
and supraspinatus tendons cannot be repaired at this point in the procedure,
then the decision is made to proceed with the latissimus dorsi transfer. If
the subscapularis tendon cannot be repaired, then the latissimus dorsi
transfer should not be done without also performing a pectoralis muscle
transfer. If the biceps tendon shows any signs of wear, the tendon can be
tenodesed in the bicipital groove to prevent pain postoperatively. The new
insertion site of the latissimus dorsi is prepared before the tendon is
harvested. The greater tuberosity is débrided of soft tissue and
osseous prominences. A large cutting needle is used to pass three #2 FiberWire
(Arthrex, Naples, Florida) or equivalent sutures through the greater
tuberosity for later use in attachment of the transfer.
CRITICAL CONCEPTSINDICATIONS:Irreparable supraspinatus and infraspinatus tendon tears associated with
loss of shoulder elevation and external rotation. A relative indication is a
tenuous repair or incomplete repair of the posterosuperior aspect of the
rotator cuff.CONTRAINDICATIONS:Superior escape of the humeral head outside the coracoacromial archGlenohumeral arthritisAcetabularization of the inferior aspect of the acromion caused by superior
migration of the humeral headIrreparable deltoid detachmentPseudoparalysis or inability to hold the arm at shoulder heightAxillary nerve injuryRELATIVE CONTRAINDICATIONS:Irreparable subscapularis tendon tearsPatients who are unwilling to make the investment in a time-intensive
postoperative physical therapy programPatients with general muscle deconditioningObese patients with heavy armsActive elevation of <80°PITFALLS:The surgeon should minimize handling of the latissimus dorsi tendon before
placing the locking sutures because the tendon can fray easily. There are few
fibers that are perpendicular to the length of the tendon, which makes it easy
to pull the tendon apart into many thin unusable fibers. Poor placement of
retractors or incomplete visualization of the latissimus dorsi tendon
attachment on the humerus can prevent the harvest of the entire tendon,
necessitating the use of tendon graft augmentation so that the latissimus
dorsi tendon can be attached to the humerus without excessive tension on the
repair.AUTHOR UPDATE:We currently use nonabsorbable suture such as #2 FiberWire instead of
Dacron tape or Ethibond for the repair of the latissimus dorsi tendon to the
humeral head because this suture is three times stronger.
CRITICAL CONCEPTS
INDICATIONS:
Irreparable supraspinatus and infraspinatus tendon tears associated with
loss of shoulder elevation and external rotation. A relative indication is a
tenuous repair or incomplete repair of the posterosuperior aspect of the
rotator cuff.
CONTRAINDICATIONS:
Superior escape of the humeral head outside the coracoacromial archGlenohumeral arthritisAcetabularization of the inferior aspect of the acromion caused by superior
migration of the humeral headIrreparable deltoid detachmentPseudoparalysis or inability to hold the arm at shoulder heightAxillary nerve injury
Superior escape of the humeral head outside the coracoacromial arch
Glenohumeral arthritis
Acetabularization of the inferior aspect of the acromion caused by superior
migration of the humeral head
Irreparable deltoid detachment
Pseudoparalysis or inability to hold the arm at shoulder height
Axillary nerve injury
RELATIVE CONTRAINDICATIONS:
Irreparable subscapularis tendon tearsPatients who are unwilling to make the investment in a time-intensive
postoperative physical therapy programPatients with general muscle deconditioningObese patients with heavy armsActive elevation of <80°
Irreparable subscapularis tendon tears
Patients who are unwilling to make the investment in a time-intensive
postoperative physical therapy program
Patients with general muscle deconditioning
Obese patients with heavy arms
Active elevation of <80°
PITFALLS:
The surgeon should minimize handling of the latissimus dorsi tendon before
placing the locking sutures because the tendon can fray easily. There are few
fibers that are perpendicular to the length of the tendon, which makes it easy
to pull the tendon apart into many thin unusable fibers. Poor placement of
retractors or incomplete visualization of the latissimus dorsi tendon
attachment on the humerus can prevent the harvest of the entire tendon,
necessitating the use of tendon graft augmentation so that the latissimus
dorsi tendon can be attached to the humerus without excessive tension on the
repair.
AUTHOR UPDATE:
We currently use nonabsorbable suture such as #2 FiberWire instead of
Dacron tape or Ethibond for the repair of the latissimus dorsi tendon to the
humeral head because this suture is three times stronger.
The incision over the latissimus dorsi muscle is made slightly posterior to
the axilla and is extended distally approximately 15 cm. It can be extended
superiorly toward the shoulder if more exposure is needed. Careful attention
is made to avoid crossing a skin crease without changing the direction of the
incision to avoid scar contracture at the skin crease. The incision is made
down to the muscle fascia, and then skin flaps are elevated to define the
inferior and superior borders of the latissimus dorsi muscle
(Fig. 3). In order to avoid
confusing the latissimus dorsi muscle with the teres major, the inferior
border of the muscle must be clearly defined. There is no large muscle
inferior to the latissimus dorsi and, if one is found, then the surgeon may
have mistaken the teres major for the latissimus dorsi muscle. After the
muscle belly is found, the dissection is continued toward the shoulder to
identify the tendon. Self-retaining retractors such as a Kolbel or a blunt
Gelpi retainer may help with visualization, especially in patients with large
deltoid and teres major muscles. Once the latissimus dorsi tendon has been
identified, it is dissected free of all soft tissue up to its insertion site
on the humerus. In this position, all of the important neurovascular
structures are deep and anterior to the tendon
(Fig. 4). The axillary nerve is
superior to the teres major tendon. The brachial plexus is deep and anterior,
and the radial nerve is distal to the latissimus dorsi tendon. Therefore, the
surgeon should stay on top of (dorsal to) the tendon until the dissection
reaches the humeral attachment site. These neurovascular structures are at
greatest risk of being damaged during dissection of the tendon edges away from
the surrounding tissue. Frequent adjustment of retractors and the use of long
right-angle retractors may be necessary as the dissection gets closer to the
humerus. To maximize the tendon length and to obviate the need for a tendon
graft, the latissimus dorsi tendon should be released as close to the
insertion site as possible. The humerus should be internally rotated during
the release to maximize the tendon length. The surgeon should be aware that
the superior edges of the teres major and latissimus dorsi often merge
together, and careful attention must be directed to the axillary nerve as it
courses superior to the teres major tendon. If the latissimus dorsi tendon
does not seem long enough or broad enough to cover the greater tuberosity
after it has been dissected free from the humerus, we consider transferring
the teres major tendon to the humeral head as well. This tendon is released
from the humerus with the same technique that is used to release the
latissimus dorsi tendon. It must be attached to the humeral head separately
because the length/tension relationship of each muscle is different and the
tendon length of the teres major is shorter than the tendon of the latissimus
dorsi muscle.
The tendon is prepared by weaving a #2 FiberWire or equivalent suture with
a locking Krackow technique along each of its edges so that two suture strands
can be used for attachment to the superior aspect of the subscapularis tendon
(Figs. 5-A and 5-B). With use
of these sutures to grip the tendon, the muscle belly is dissected free from
the underlying adhesions. The neurovascular pedicle is identified and
mobilized with scissors to allow for complete excursion of the tendon out of
the wound and above the acromion. Then the tunnel under the deltoid and over
the teres major and teres minor is developed with blunt dissection. A clamp
can be placed from the superior incision through the tunnel, and the
latissimus dorsi tendon is pulled into the superior incision
(Fig. 6). Often the tunnel
needs to be enlarged inferiorly to accommodate the large muscle belly and to
avoid excessive tension on the tendon or the neurovascular bundle
(Fig. 7).
Next, the arm is secured in the arm holder in neutral rotation. The tendon
is brought to the humeral head to a position that covers most of the rotator
cuff defect without excessive tension. Some surgeons believe that the tendon
should be attached only to the greater tuberosity to act solely as an external
rotator. On the basis of electromyographic studies that we have performed for
patients who have had the transfer, we believe that the latissimus dorsi acts
primarily as a passive humeral head depressor. Therefore, we repair the
latissimus tendon over the top of the humeral head. If the tendon does not
have at least 2 cm2 of coverage over the humerus, the healing
potential will be compromised and the surgeon should consider using a graft to
augment the tendon. We use a fascia lata graft for this purpose. The tendon is
secured with the two nonabsorbable sutures that are passed through the
subscapularis tendon edge and the lesser tuberosity if possible (Figs.
8,
9-A, and 9-B). Then the medial
edge of the tendon is secured to the edge of the remaining portions of the
supraspinatus and infraspinatus tendons. The three nonabsorbable sutures that
were passed earlier in the procedure are then secured to the lateral edge of
the latissimus dorsi tendon. If the teres major tendon is transferred as well,
it can be secured more laterally and posteriorly on the humeral head than the
latissimus dorsi tendon. The arm is then taken through a range of motion to
assess the integrity of the repair.
The deltoid muscle is reattached to the acromion with nonabsorbable sutures
passed through bone. A drain is placed in the latissimus dorsi muscle bed if
needed, and the skin is closed without closing the deep fascia. Before the
patient emerges from anesthesia, a brace is applied to hold the arm in neutral
rotation and 20° of abduction.
The patient wears the brace for four weeks and then is allowed to take off
the brace for showers and dressing as long as the arm is kept in neutral
rotation. Passive elevation in neutral rotation is done twice a day for the
first four weeks. After four weeks, the brace is removed and passive motion is
allowed in all planes. Active motion is allowed after seven weeks in
conjunction with a physical therapy program that focuses on retraining the
latissimus dorsi muscle to function as an external rotator during elevation
instead of as an internal rotator during adduction. The patient is taught to
place a pillow under the arm to support it in 30° of abduction. Active
external rotation of the arm while it is adducted against the pillow trains
the latissimus dorsi muscle to act as an external rotator. In physical
therapy, we use biofeedback electrodes, placed over the latissimus dorsi, to
tell the patient when the muscle is contracting appropriately during arm
elevation. Other methods, such as squeezing a large ball with both hands, and
then raising the ball overhead, can help to train the latissimus dorsi muscle
to contract during arm elevation as well.