Advertisement

Arthroscopic-Assisted Anterior Latissimus Dorsi Transfer for Irreparable Anterior Rotator Cuff Tear: A Technical Note

Open AccessPublished:January 05, 2021DOI:https://doi.org/10.1016/j.eats.2020.10.002

      Abstract

      Several reconstruction techniques for irreparable tears of the subscapularis tendon have been described with variable results regarding pain relief, functional recovery, and dynamic stabilization of the glenohumeral joint. Because of a more advantageous direction of movement compared with previously described transfer techniques such as transfer of the pectoralis major and pectoralis minor tendons, the anterior latissimus dorsi (LD) transfer has been proposed as a potentially beneficial treatment method. This Technical Note aims to introduce an alternative technique for the anterior LD transfer that combines the advantages of a proper muscle release and tendon reinforcement through an axillary incision with the arthroscopic intra-articular and periarticular work, including detachment of the LD tendon from its humeral insertion and reattachment at the lesser tuberosity.

      Technique Video

      (mp4, (77.7 MB)

      Right shoulder in a 49-year-old male patient in the beach-chair position. After a dorsal viewing portal has been established, diagnostic arthroscopy reveals an acute tear of the posterosuperior rotator cuff and an irreparable subscapularis (SSC) tendon tear. By use of anterior, anterolateral, and lateral portals, the remaining rotator interval is resected, and the torn rotator cuff is debrided and mobilized. After confirmation of the irreparability of the SSC tendon, an additional straight anteroinferior portal superior to the pectoralis major (PM) tendon is established under direct view with the arthroscope in the anterolateral portal. Through this portal, the latissimus dorsi (LD) tendon is released from its humeral insertion and tagged with a monofilament suture (e.g. No. 2 polydioxanone [PDS]). Thereafter, the shoulder is placed in maximal abduction and internal rotation, and the LD muscle is released through an axillary incision along the anterior border of the LD muscle. Once the muscle is sufficiently mobilized, the tendon is pulled out through the axillary incision and tagged twice with crisscross stitches, using 2 differently colored No. 2 FiberWire and TigerWire sutures. For the transfer of the LD tendon through the axillary incision back into the glenohumeral joint, the PDS suture is used to shuttle a ribbon of an abdominal bandage from the axillary incision through the lateral portal. By attaching the FiberWire and TigerWire to the ribbon, the tendon can safely be pulled back into the glenohumeral joint. Thereafter, the shoulder is adducted and placed in neutral position. With the arthroscope placed in the lateral portal, the transferred tendon is fixated to the lesser tubercle at the level of the SSC tendon insertion using 2 knotless anchors. Thereafter, the posterosuperior rotator cuff is reinserted into the footprint at the greater tubercle using a double-layer lasso-loop technique.

      Technique Video

      See video under supplementary data.

      Massive irreparable tears of the subscapularis (SSC) tendon remain a challenging problem, especially in young and active patients. Treatment depends on the condition of the glenohumeral joint and the patient's age, activity level, and symptoms. Although reverse shoulder arthroplasty is a valuable treatment option in the presence of combined irreparable rotator cuff (RC) tear and osteoarthritis,
      • Ernstbrunner L.
      • Andronic O.
      • Grubhofer F.
      • Camenzind R.S.
      • Wieser K.
      • Gerber C.
      Long-term results of reverse total shoulder arthroplasty for rotator cuff dysfunction: A systematic review of longitudinal outcomes.
      it should be avoided in young patients with intact cartilage in the glenohumeral joint. Various reconstruction techniques for the treatment of irreparable SSC tears have been described, including transfer of the pectoralis minor tendon,
      • Yamakado K.
      Arthroscopic-assisted pectoralis minor transfer for irreparable anterosuperior massive rotator cuff tear.
      upper trapezius transfer,
      • Goutallier D.
      • De Abreu L.
      • Postel J.M.
      • Le Guilloux P.
      • Radier C.
      • Zilber S.
      Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?.
      and pectoralis major (PM) transfer,
      • Ernstbrunner L.
      • Wieser K.
      • Catanzaro S.
      • et al.
      Long-term outcomes of pectoralis major transfer for the treatment of irreparable subscapularis tears: Results after a mean follow-up of 20 years.
      of which the latter is the most frequently performed procedure. However, although some authors showed good long-term outcomes after transfer of the PM tendon,
      • Ernstbrunner L.
      • Wieser K.
      • Catanzaro S.
      • et al.
      Long-term outcomes of pectoralis major transfer for the treatment of irreparable subscapularis tears: Results after a mean follow-up of 20 years.
      others reported unsatisfactory clinical results with weakness returning to the preoperative level and diminishing range of motion during long-term follow-up,
      • Moroder P.
      • Schulz E.
      • Mitterer M.
      • Plachel F.
      • Resch H.
      • Lederer S.
      Long-term outcome after pectoralis major transfer for irreparable anterosuperior rotator cuff tears.
      as well as persistent pain and a high failure rate.
      • Elhassan B.
      • Ozbaydar M.
      • Massimini D.
      • Diller D.
      • Higgins L.
      • Warner J.J.
      Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: Does it work?.
      Therefore, Elhassan et al.
      • Elhassan B.
      • Christensen T.J.
      • Wagner E.R.
      Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: An anatomic study.
      proposed the anterior latissimus dorsi transfer (ALDT) as an alternative treatment option for irreparable anterior RC tears. The working vector of the latissimus dorsi (LD) muscle is in the line of pull of the SSC muscle, which is at least a strong theoretical advantage. Usually, the ALDT is performed through an open deltopectoral approach,
      • Mun S.W.
      • Kim J.Y.
      • Yi S.H.
      • Baek C.H.
      Latissimus dorsi transfer for irreparable subscapularis tendon tears.
      thereby entailing the disadvantage of increased soft-tissue damage and difficulties in repairing concomitant posterior-superior RC lesions.
      This article aims to describe a technique for an arthroscopic-assisted ALDT, combining the advantages of the arthroscopic intra-articular and periarticular work, including detachment of the LD tendon from its humeral insertion and subsequent reattachment to the lesser tubercle, with a proper muscle release and tendon reinforcement through an axillary incision, which might be helpful for shoulder surgeons encountering the problem of irreparable SSC tendon tears.

      Surgical Technique

      The operative technique is shown in Video 1. Pearls and pitfalls of the procedure are listed in Table 1.
      Table 1Pearls and Pitfalls
      Pearls
       A hydraulic arm holder is used to support the arm during the surgical procedure.
       Diagnostic arthroscopy prior to tendon harvesting allows one to assess for additional posterosuperior rotator cuff tears and to verify irreparability of the anterior rotator cuff.
       Arthroscopic detachment of the LD tendon at its humeral insertion with subsequent PDS insertion into the tendon prior to the open dissection of the LD muscle allows for safe transfer and reinsertion of the tendon into the joint.
       Posterosuperior rotator cuff tears are easier to address compared with open techniques using a deltopectoral approach.
      Pitfalls
       Inaccurate portal placement makes access to the insertion of the LD tendon difficult.
       Insufficient visualization during arthroscopic release of the LD tendon from its humeral insertion endangers the axillary nerve and radial nerve.
       Care should be taken to detach the LD tendon exactly at its humeral insertion and to perform a proper muscle release to avoid over-tensioning and facilitate refixation to the lesser tubercle.
       Twisting of the LD tendon during reattachment to the lesser tubercle can be prevented by tagging the superior and inferior borders of the tendon with differently colored sutures.
      LD, latissimus dorsi; PDS, polydioxanone.

      Patient Positioning and Preparation

      Routinely, an interscalene nerve block and general anesthesia are administered. The patient is placed in the supine beach-chair position, and a hydraulic arm holder (Trimano Fortis Support Arm; Arthrex , Naples, FL) is applied ipsilateral to the operative limb, allowing for free range of motion of the operated shoulder. Widespread draping of the arm is performed to enable access to the shoulder as well as the axilla.

      Diagnostic Arthroscopy and Management of Concomitant Shoulder Pathologies

      In total, 5 arthroscopic portals are used (Fig 1). First, a standard posterior soft-point portal 2 cm medial and 2 cm inferior to the posterolateral corner of the acromion is established. Thereafter, standard anterior, anterolateral, and lateral portals are placed under direct view from the first portal. A general arthroscopic examination is performed to assess additional pathologies of the labrum, cartilage, long head of the biceps, and posterosuperior RC. After subacromial bursectomy and resection of the remaining rotator interval using an aggressive shaver blade (Aggressive Pro Line Shaver Blade; Karl Storz, Tuttlingen, Germany), the retracted tendons of the torn RC are debrided and mobilized (Fig 2).
      Figure thumbnail gr1
      Fig 1Right shoulder in a 49-year-old male patient in the beach-chair position. Five arthroscopic portals are used for the performed procedure: posterior portal (P), lateral portal (L), anterolateral portal (AL), anterior portal (A), and anteroinferior portal (AI).
      Figure thumbnail gr2
      Fig 2Right shoulder in a 49-year-old male patient in the beach-chair position. Intra-articular arthroscopic view from the lateral portal revealing a torn posterosuperior rotator cuff (red arrow) (A) and a torn and irreparable subscapularis tendon (blue arrow), which is retracted medially to the glenoid (B).

      Arthroscopic Tendon Release

      After confirmation of the irreparability of the SSC tendon, the coracoid process and the posterior surface of the conjoint tendon are exposed. With the camera in the anterolateral portal, an additional, straight, anteroinferior portal superior to or within the PM tendon is established under direct view, enabling good access to the LD tendon at its humeral insertion beneath the PM tendon (Fig 1). Now, the LD tendon is released from its humeral insertion and separated from the underlying teres major tendon using a 90° tipped radiofrequency device (Werewolf Coblation System; Smith & Nephew, London, England) (Fig 3A ). Care must be taken during the release to damage neither the axillary nerve, which passes just above the superior border of the LD tendon around the humerus, nor the radial nerve, as it passes obliquely over the inferior border of the LD tendon. Both nerves can be arthroscopically visualized if needed. Once the tendon is completely detached from the humerus and sufficiently mobilized, a monofilament suture (e.g. No. 2 polydioxanone) is passed through the tendon using a suture passer (Spectrum; ConMed, Utica, NY) and retrieved through the lateral or anterior portal (Fig 3B).
      Figure thumbnail gr3
      Fig 3Right shoulder in a 49-year-old male patient in the beach-chair position. Intra-articular arthroscopic view from the anterolateral viewing portal. (A) By use of a 90° tipped radiofrequency device inserted through the anteroinferior portal, the latissimus dorsi tendon (blue arrow) is released from its humeral insertion and separated from the underlying teres major tendon. (B) After release of the tendon, a polydioxanone suture (red arrow) is passed through the latissimus dorsi tendon (blue arrow) using a Spectrum suture retriever (ConMed) inserted through the anteroinferior portal.

      LD Muscle Dissection

      For the purpose of further LD muscle release and proper tendon reinforcement, the shoulder is placed in maximal abduction and internal rotation. A 5- to 8-cm incision (depending on the patient's anatomy) is made along the anterior border of the LD muscle. Thorough mobilization of the LD muscle is performed by excessive subcutaneous dissection and separation of fascial connections to the teres major muscle to increase excursion for the transfer (Fig 4A ). Care must be taken not to injure the thoracodorsal pedicle, which penetrates the LD muscle from its medial surface at an average distance of 13 cm caudal to its humeral insertion. Once the muscle is sufficiently mobilized, the tendon is pulled out through the axillary incision (Fig 4B) and tagged twice with crisscross stitches using a No. 2 FiberWire (Arthrex) and a No. 2 TigerWire suture (Arthrex) (Fig 4C). The use of differently colored sutures for tendon preparation is strongly recommended to avoid twisting during subsequent fixation of the tendon to the lesser tubercle. For the transfer of the LD tendon through the axillary incision back into the glenohumeral joint, the polydioxanone suture is used to shuttle a ribbon of an abdominal bandage from the axillary incision through the lateral portal. By attaching the FiberWire and TigerWire to the ribbon, the tendon can safely be pulled back into the glenohumeral joint (Fig 4D).
      Figure thumbnail gr4
      Fig 4Right shoulder in a 49-year-old male patient in the beach-chair position with the arm placed in maximal abduction and internal rotation. (A) The latissimus dorsi muscle (blue arrow) is mobilized through an axillary incision by excessive subcutaneous dissection and separation of the fascial connection to the teres major muscle. (B) Once the muscle is mobilized, the tendon (red arrow) is pulled out through the axillary incision. (C) The tendon is tagged twice with crisscross stitches, using 2 differently colored FiberWire and TigerWire sutures (red arrow). Thereafter, the previously placed polydioxanone suture is used to shuttle a ribbon of an abdominal bandage from the axillary incision through the lateral portal. (D) By attaching the FiberWire and TigerWire to the ribbon (yellow arrow), the tendon can now safely be retrieved back into the glenohumeral joint.

      Tendon Fixation

      For tendon-to-bone fixation, the shoulder is adducted and placed in neutral rotation. The arthroscope is placed in the lateral portal, and the footprint of the SSC tendon at the lesser tubercle is freed from scar tissue. After examination of the LD excursion to avoid over-tensioning, the TigerWire and FiberWire are separated and pulled through the anterior and anterolateral portals, respectively. By use of 2 knotless anchors (ReelX STT Knotless Anchor; Stryker, Kalamazoo, MI), the transferred LD tendon is reinserted into the lesser tubercle at the level of the SSC tendon insertion (Fig 5). Additional lesions of the posterosuperior RC can now be fixed to the footprint at the greater tubercle as customary.
      Figure thumbnail gr5
      Fig 5Right shoulder in a 49-year-old male patient in the beach-chair position. Intra-articular arthroscopic view from the lateral portal, showing the tagged latissimus dorsi tendon. (A) To avoid twisting of the tendon during reattachment, differently colored sutures at the superior border (blue arrow) and inferior border (red arrow) of the latissimus dorsi tendon are used. (B) The tendon is reattached at the footprint of the lesser tubercle with knotless anchors (yellow arrow) inserted through the anterior and anterolateral portals.

      Discussion

      Several operative techniques have been described for irreparable tears of the SSC tendon, of which the PM tendon transfer is the most frequently used.
      • Ernstbrunner L.
      • Wieser K.
      • Catanzaro S.
      • et al.
      Long-term outcomes of pectoralis major transfer for the treatment of irreparable subscapularis tears: Results after a mean follow-up of 20 years.
      ,
      • Elhassan B.
      • Ozbaydar M.
      • Massimini D.
      • Diller D.
      • Higgins L.
      • Warner J.J.
      Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: Does it work?.
      However, the PM muscle originates from the anterior chest wall; thus, the line of pull of the PM muscle forms a nearly 90° angle to the direction of movement of the SSC muscle fibers and tendon, which might explain unfavorable results in some patients after such procedures.
      • Elhassan B.
      • Ozbaydar M.
      • Massimini D.
      • Diller D.
      • Higgins L.
      • Warner J.J.
      Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: Does it work?.
      In contrast, the LD muscle originates from the posterior chest wall, thereby showing an almost similar direction of movement to that of the SSC muscle.
      • Elhassan B.
      • Christensen T.J.
      • Wagner E.R.
      Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: An anatomic study.
      Furthermore, the LD muscle acts as an internal rotator on the humerus and is therefore synergistic with the SSC muscle.
      • Kany J.
      • Guinand R.
      • Croutzet P.
      • Valenti P.
      • Werthel J.D.
      • Grimberg J.
      Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency.
      Therefore, the ALDT might be an advantageous treatment option for patients with an SSC deficiency compared with previously described transfer techniques such as the PM tendon or pectoralis minor tendon transfer. Elhassan et al.
      • Elhassan B.
      • Christensen T.J.
      • Wagner E.R.
      Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: An anatomic study.
      were the first authors to investigate the ALDT in a cadaveric study and showed its feasibility with a very low risk of nerve compression. Subsequently, Mun et al.
      • Mun S.W.
      • Kim J.Y.
      • Yi S.H.
      • Baek C.H.
      Latissimus dorsi transfer for irreparable subscapularis tendon tears.
      reported on 24 consecutive patients undergoing ALDT through a deltopectoral approach and found good clinical results and no neurovascular complications. However, although tagging of the tendon with sutures is usually not a problem through this kind of approach, a partial detachment of the proximal PM tendon was necessary to obtain appropriate access to the insertion of the LD tendon. Furthermore, repair of concomitant tears of the posterosuperior RC and thorough release of the LD muscle belly might be difficult to achieve, leading to potentially increased tension of the reinserted tendon at the lesser tuberosity.
      Other authors reported on an arthroscopically assisted technique for ALDT, which contains the advantages of decreased soft-tissue damage, increased visibility of concomitant intra-articular pathologies, and easier repair of posterosuperior RC tears. However, although they used an arthroscopic approach for reattachment of the LD tendon, release of the tendon from its humeral insertion was performed through an axillary incision. Thus, reinsertion of the LD tendon into the glenohumeral joint was performed blindly, using a grasping instrument or suture manipulator introduced through a proximal or distal anterolateral portal, which might endanger neurovascular structures.
      • Kany J.
      • Guinand R.
      • Croutzet P.
      • Valenti P.
      • Werthel J.D.
      • Grimberg J.
      Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency.
      ,
      • Elhassan B.T.
      • Wagner E.R.
      • Kany J.
      Latissimus dorsi transfer for irreparable subscapularis tear.
      The technique presented in this report combines the advantages of a proper muscle release and tendon reinforcement through a short open axillary approach but taking full advantage of an arthroscopic detachment of the LD tendon from its humeral insertion, as well as a more guided transfer back into the glenohumeral joint and reinsertion of the tagged LD tendon at the lesser tuberosity, thereby protecting neurovascular structures such as the axillary and radial nerves. It might therefore be helpful for shoulder surgeons encountering the problem of irreparable SSC tendon tears.

      Supplementary Data

      (mp4, (77.7 MB)

      Right shoulder in a 49-year-old male patient in the beach-chair position. After a dorsal viewing portal has been established, diagnostic arthroscopy reveals an acute tear of the posterosuperior rotator cuff and an irreparable subscapularis (SSC) tendon tear. By use of anterior, anterolateral, and lateral portals, the remaining rotator interval is resected, and the torn rotator cuff is debrided and mobilized. After confirmation of the irreparability of the SSC tendon, an additional straight anteroinferior portal superior to the pectoralis major (PM) tendon is established under direct view with the arthroscope in the anterolateral portal. Through this portal, the latissimus dorsi (LD) tendon is released from its humeral insertion and tagged with a monofilament suture (e.g. No. 2 polydioxanone [PDS]). Thereafter, the shoulder is placed in maximal abduction and internal rotation, and the LD muscle is released through an axillary incision along the anterior border of the LD muscle. Once the muscle is sufficiently mobilized, the tendon is pulled out through the axillary incision and tagged twice with crisscross stitches, using 2 differently colored No. 2 FiberWire and TigerWire sutures. For the transfer of the LD tendon through the axillary incision back into the glenohumeral joint, the PDS suture is used to shuttle a ribbon of an abdominal bandage from the axillary incision through the lateral portal. By attaching the FiberWire and TigerWire to the ribbon, the tendon can safely be pulled back into the glenohumeral joint. Thereafter, the shoulder is adducted and placed in neutral position. With the arthroscope placed in the lateral portal, the transferred tendon is fixated to the lesser tubercle at the level of the SSC tendon insertion using 2 knotless anchors. Thereafter, the posterosuperior rotator cuff is reinserted into the footprint at the greater tubercle using a double-layer lasso-loop technique.

      References

        • Ernstbrunner L.
        • Andronic O.
        • Grubhofer F.
        • Camenzind R.S.
        • Wieser K.
        • Gerber C.
        Long-term results of reverse total shoulder arthroplasty for rotator cuff dysfunction: A systematic review of longitudinal outcomes.
        J Shoulder Elbow Surg. 2019; 28: 774-781
        • Yamakado K.
        Arthroscopic-assisted pectoralis minor transfer for irreparable anterosuperior massive rotator cuff tear.
        Arthrosc Tech. 2018; 7: e193-e198
        • Goutallier D.
        • De Abreu L.
        • Postel J.M.
        • Le Guilloux P.
        • Radier C.
        • Zilber S.
        Is the trapezius transfer a useful treatment option for irreparable tears of the subscapularis?.
        Orthop Traumatol Surg Res. 2011; 97: 719-725
        • Ernstbrunner L.
        • Wieser K.
        • Catanzaro S.
        • et al.
        Long-term outcomes of pectoralis major transfer for the treatment of irreparable subscapularis tears: Results after a mean follow-up of 20 years.
        J Bone Joint Surg Am. 2019; 101: 2091-2100
        • Moroder P.
        • Schulz E.
        • Mitterer M.
        • Plachel F.
        • Resch H.
        • Lederer S.
        Long-term outcome after pectoralis major transfer for irreparable anterosuperior rotator cuff tears.
        J Bone Joint Surg Am. 2017; 99: 239-245
        • Elhassan B.
        • Ozbaydar M.
        • Massimini D.
        • Diller D.
        • Higgins L.
        • Warner J.J.
        Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: Does it work?.
        J Bone Joint Surg Br. 2008; 90: 1059-1065
        • Elhassan B.
        • Christensen T.J.
        • Wagner E.R.
        Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: An anatomic study.
        J Shoulder Elbow Surg. 2014; 23: 492-499
        • Mun S.W.
        • Kim J.Y.
        • Yi S.H.
        • Baek C.H.
        Latissimus dorsi transfer for irreparable subscapularis tendon tears.
        J Shoulder Elbow Surg. 2018; 27: 1057-1064
        • Kany J.
        • Guinand R.
        • Croutzet P.
        • Valenti P.
        • Werthel J.D.
        • Grimberg J.
        Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency.
        Eur J Orthop Surg Traumatol. 2016; 26: 329-334
        • Elhassan B.T.
        • Wagner E.R.
        • Kany J.
        Latissimus dorsi transfer for irreparable subscapularis tear.
        J Shoulder Elbow Surg. 2020; 29: 2128-2134