|Massive irreparable posterosuperior rotator cuff tear with intact subscapularis tendon and function|
|Chronic tendon tear with retraction to level of glenoid|
|Combined loss of active forward flexion and external rotation with positive external rotation lag sign and horn-blower sign|
|Proximal migration of humeral head with acromiohumeral interval <7 mm|
|Stage 3 or 4 fatty infiltration of posterosuperior rotator cuff musculature on CT or MRI|
|Best candidate for surgery is patient with active flexion to horizon and preserved passive flexion similar to contralateral side and with ability to hold arm up without assistance|
|Tear of subscapularis with positive liftoff and/or belly-press test|
|Stiffness with passive forward flexion <100°|
|Unable to hold arm up at maximal forward flexion|
|Unable to cooperate with postoperative rehabilitation protocol|
|Brachial plexus injury|
Setup and Acromial Osteotomy
Latissimus Dorsi Muscle and Tendon Harvest
Tendon Augmentation, Transfer, and Fixation
Acromial Osteotomy Reduction
|Acromial fracture from osteotomy|
|Damage to deltoid muscle|
|Postoperative axillary nerve palsy or intraoperative injury|
|Injury to neurovascular pedicle of latissimus dorsi|
|Avulsion of latissimus tendon from transferred position|
|Brachial plexus injury|
|Intensive postoperative rehabilitation required to retrain latissimus to function as shoulder flexor and external rotator|
|Patients with extensive arthritis of glenohumeral joint are not good candidates for latissimus dorsi transfer|
|Perform the acromial osteotomy at the middle aspect of the distal-lateral acromion to give at least 7-8 mm of bone for repair back to the acromion.|
|Use No. 5 braided sutures to tie back the acromial osteotomy to the drill hole.|
|Use the GraftJacket to reinforce and give more excursion to the transferred latissimus dorsi tendon.|
|Release the latissimus tendon at the base of its humeral insertion for maximal tendon strength.|
|Take the arm out of the arm holder and internally rotate it to help further delineate the latissimus dorsi insertion point for safe harvest.|
|Ensure sufficient tendon tensioning to maximize strength postoperatively.|
|Note that the arm must be in 30° of flexion, 30° of external rotation, and 30° of abduction to ensure proper tensioning of the repair and muscle transfer.|
|Use multiple suture anchors spaced out on the greater tuberosity to fix down the tendon transfer.|
|Repair the residual tendon back to the tuberosity if possible. Note that even partial repair in combination with the muscle transfer may help the ultimate function of the patient.|
|Acromial fracture may occur at the time of osteotomy and may require ORIF and plate fixation.|
|Damage to the deltoid during acromial osteotomy will impair the outcome.|
|Insufficient latissimus dorsi excursion makes fixation difficult.|
|Failure to sufficiently enlarge the tunnel beneath the deltoid makes transfer difficult and may result in postoperative adhesions.|
|Inadequate tendon fixation to the greater tuberosity due to poor bone quality increases the risk of avulsion.|
|The arm position for the tendon transfer is crucial for the success of the procedure.|
|The patient must be immobilized in an SCOI brace postoperatively for 6 wk to protect the muscle transfer.|
|1. Patient positioning||The lateral decubitus position is used, with the arm and hemithorax exposed for surgical access.|
The limb is placed in an arm holder. The arm holder is placed on the opposite side of the table.
|2. Acromial osteotomy||An incision is made over the lateral acromion; it should be centered.|
Transverse osteotomy is performed approximately 7-8 mm from the acromion edge.
The acromial osteotomy is tagged with 3-4 No. 5 braided sutures to help with mobilization and to perform repair back to the acromion at the end of the case.
The greater tuberosity is decorticated with a burr to a bleeding bone bed.
|3. Latissimus dorsi harvest||The arm is placed in an overhead or flexed position in the arm holder.|
The incision is made, centered over the latissimus dorsi muscle and extending into the axilla. The senior author (X.L.) prefers a curved incision into the axilla.
The interval between the latissimus dorsi and teres major muscle is spread, and the latissimus dorsi muscle is isolated with a Penrose drain.
The arm is removed from the arm holder and internally rotated to further help in the exposure of the latissimus dorsi insertion.
The latissimus tendon is released at the base of the humeral insertion.
The latissimus muscle belly is bluntly dissected and freed to increase excursion for the transfer and to identify the neurovascular pedicle coming into the muscle belly underneath.
|4. Tendon augmentation||The GraftJacket is cut to the appropriate size and shape around the tendon.|
Two No. 2 Ethibond stitches are run on each edge of the GraftJacket to the top.
The senior author prefers to extend the GraftJacket another 2-3 cm past the muscle belly to increase the excursion of the latissimus dorsi muscle for the transfer to the greater tuberosity.
|5. Tendon transfer||The arm is positioned at 30° of abduction, 30° of flexion, and 30° of external rotation with the arm holder.|
The latissimus dorsi tendon is transferred through a tunnel beneath the deltoid and pulled over the top of the greater tuberosity. Passage can be performed with the help of a large Kelly clamp.
|6. Tendon fixation||Three metal Healix anchors are inserted in stellate fashion into the tendon footprint on the greater tuberosity.|
Suture is passed across the GraftJacket with the latissimus tendon in a horizontal mattress fashion using a free needle or a 90° suture passer.
The latissimus dorsi tendon is secured to the greater tuberosity using a suture bridge– or double row–equivalent repair with SwiveLock anchors as lateral-row anchors.
In addition, a superior capsule reconstruction can be performed at this time to augment the tendon transfer.
|7. Acromial osteotomy reduction||Three to four drill holes are placed over the acromion, and the osteotomy fragment undergoes fixation back to the acromion with No. 5 braided FiberWire sutures.|
|8. Closure||The wound is closed with Monocryl sutures, and both the acromion incision and the latissimus dorsi transfer incision undergo Dermabond application.|
A drain can be placed in the latissimus dorsi harvest site to prevent hematoma formation.
- ICMJE author disclosure forms
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The authors report the following potential conflict of interest or source of funding: X.L. receives support from Journal of Medical Insight. Editorial board and equity in company. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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