Latissimus Dorsi transfer for Rotator cuff tears

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Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: A Modified Technique to Improve Tendon Transfer Integrity

Surgical Technique

Mark Tauber, MD1, Mohamed Moursy, MD1, Rosemarie Forstner, MD1, Heiko Koller, MD1 and Herbert Resch, MD1

1 Departments of Traumatology and Sports Injuries (M.T., M.M., H.K., and H.R.) and Radiology (R.F.), Paracelsus Medical University, Muellner Hauptstrasse 48, 5020 Salzburg, Austria. E-mail address for M. Tauber: m.tauber@salk.at

Investigation performed at the Department of Traumatology and Sports Injuries and the Department of Radiology, Paracelsus Medical University, Salzburg, Austria The original scientific article in which the surgical technique was presented was published in JBJS Vol. 91-A, pp. 1924-31, August 2009  

 The Journal of Bone and Joint Surgery (American). 2010;92:226-239.
doi:10.2106/JBJS.J.00224

Conclusions:

  • This technique serves as a reliable salvage procedure for irreparable massive tears of the rotator cuff
  • Direct bone to bone transfixation of the graft with a small piece of bone, enables bone to bone healing and better functional results.

 

 

Comments

  1. admin says

    Other areas of interest in this topic:(for Postgraduates)
    1. How do you Stage tendon retraction according to the classification system of Patte, how to Stage fatty infiltration as determined with the
    system of Goutallier , and how to Stage muscle atrophy according to the classification system of Thomazeau et al.

    2.What are the contraindications for this procedure?

    3. Are there other tendon transfer options for management of massive cuff tears?

    4. What is the neurovascular bundle which is at risk during this procedure?

  2. bimal says

    i have only read bt this procedure…can some who has done/ seen this tell a bird’s eye view of how to go about it..

  3. admin says

    bimal, the entire procedure is described wonderfully with colour photographs in the JBJS supplement above.

  4. bimal says

    ya..but i would like to hear it from some one who has done it / or at least assisted a lot… those hands on tips..may b cuz i have never seen this tendon transfer..is it done in our part of the world?..

  5. Jayakumar says

    Yeah i would also like to hear it from some one who has done it

    coz i don’t have access to the journal (JBJS)

  6. Jayakumar says

    Patte classification of rotator cuff tears

    Segment 1: Subscapularis Tear
    Segment 2:Coracohumeral Ligmaent tear
    Segment 3; isolated supraspinatus tear
    Segment 4: Tear of entire supraspinatus and on half of infraspinatus
    Segment 5: Tear of supraspinatus and infra spinatus
    Segment 5 : Tear of subscapularis, supraspinatus and infraspinatus

    Fatty infiltration Classification Goutallier
    This five-stage grading system
    stage 0 completely normal muscle, without fatty streaks;
    stage 1 in which the muscle contains some fatty streaks;
    stage 2 in which the fatty infiltration is prominent, but with more muscle than fat;
    stage 3 in which there is as much fat as muscle
    stage 4 in which more fat than muscle is present.

  7. Jayakumar says

    CONTRAINDICATIONS FOR THE PROCEDURE
    1.Subscapularis tendon deficiency
    2.Teres minor deficiency
    3.Advanced glenohumeral osteoarthritis

  8. Jayakumar says

    TENDON TRANSFER OPTIONS FOR MASSIVE ROTATOR CUFF TEARS

    1.Split Pectoralis Major transfer for Reconstruction of an Irreparable Subscapularis Tear

    2.Latissimus Dorsi Transfer for Reconstruction of an Irreparable Posterior-Superior Rotator Cuff Tear

  9. Jayakumar says

    Classification of supraspinatus belly atrophy based on the occupation ratio of the supraspinatus (Herve Thomazeau)

    Ratio between 1 .OO and 0.60 (stage I), the muscle can be considered as normal or slightly atrophied.
    Values between 0.60 and 0.40 (stage 11) suggest moderate atrophy.
    Values below 0.40 (stage TIT) indicate serious or severe atrophy

    Reference:Atrophy of the supraspinatus belly
    Assessment by MRI in 55 patients with rotator cuff pathology
    Herve Thomazeau, Yann Rolland, Christophe Lucas, Jean-Marie Duval and
    Frantz Langlais

  10. admin says

    dear jayakumar,

    i am inspired by your persistent academic interest

  11. Dr Biju Pankappilly says

    Latissimus dorsi , the broadest muscle of the back is indeed a boon to those who have irrepairable massive cuff tears.By function its an internal rotator. LD transfers are widely in use for breast reconstructions and flap covers. The practical use of LD transfer in Erbs palsy has been well described by Hoffer with excellent results. Christian Gerber, the Swiss giant in his landmark paper in 1988 described the use of LD in massive irrepairable cuff tears. He used a double incision technique.
    People like habermeyer ,herzberg, L Episcopo have done a gud amount of work on LD transfer. The transfer can delay RSA in a young patient. One has to remember that LD transfer doesent provide strength.Its done basically to improve the pain by depressing the head owing to the tenodesis effect (remember that there is an upward migration of the humeral head owing to cuff deficiency leading to impingement and subsequent pain) and motion especially external rotation or forward flexion.
    The pain relief is dramatic. A well done procedure relives the patient off pain the next day of the surgery.
    About the procedure-Most of the surgeons perform the surgery using open techniques with double incisions. One for the harvest and the other one for fixation. The LD is detached from the humerus rerouted around the neck on to the head and fixed, converting it into an external rotator. One has to be careful of 4 things at the time of harvest-1) just proximal to the tendon insertion u have the axillary nerve with the vessels
    2) inferiorily u have the radial nerve
    3) its very difficult to find an interval between teres major and LD and sometimes they have a conjoined insertion. The tip is to find the interval bit lower down
    4- beware of the neurovasular pedicle to the LD. U cut it, the transfer fails.So its better to identify it prior to detaching the tendon from the bone and work around it.

    It can be performed also using arthroscopic techniques and the results are promising. The advantages are minimal trauma to the soft tissues. You are not damaging the deltoid which is the main prerequisite for RSA in the future if the need arises.
    In the immediate postop one can c the increase in humero-acromial distance due to the tenodesis effect , but the gap decreases as the years pass by. Its difficult to out line the reasons behind it. I assume it to be secondary to the loss of elasticity in the tendon, recurrent impingement on motion leading to the thinning of the tendon.
    It take almost one year for the patient to be happy . U got to educate the patient abt it. U are converting an internal rotator into an external rotator. The brain has to trained to fire inorder for the LD tO adapt to its new role. Physio is an integral part.
    Ld along with teres major
    I would say that the indications can be extended to active older population also so that we can delay the constrained implant in them atleast for 5- 10 years. After all u r not burning the bridge.
    The absolute contraindication to the transfer is the absence of the strong internal rotator- The subscapularis. The absence of teres minor is not a contraindication to the procedure. Its presence can be bonus.

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