Latissimus dorsi transfer with amodified single-incision Herzberg technique and description of its arthroscopic advancement

Abstract

Latissimus dorsi transfer aims to reduce pain and improve function for irreparable tears of the posterosuperior rotator cuff by restoring the transversal force couple to improve external rotation and delaying superior migration of the humeral head. Surgery is advocated in patients with unbearable shoulder pain and limited external rotation caused by an irreparable posterosuperior rotator cuff tear. Usually, alatissimus transfer is recommended in the presence of superior migration of the humeral head, higher grade fatty infiltration of the rotator cuff and arestriction of range of motion and strength for abduction and external rotation. Advantages of the arthroscopically assisted technique are the missing need of detaching the deltoid from its origin, smaller incisions and therapy of concomitant intraarticular lesions. Little pain and sufficient shoulder function in massive posterosuperior rotator cuff tears do not necessitate latissimus transfer. In the presence of subscapularis tears, osteoarthritis and deltoid dysfunction as well as shoulder stiffness tendon transfer are associated with inferior clinical outcomes. Surgery is performed in prone position. The incision is made about 5 cm caudal of the posterolateral corner of the acromion and extends over 6 cm at the inferior border of the deltoid muscle. After exploration and protection of the axillary and radial nerve the latissimus tendon is peeled off of the humerus. The medial part of the latissimus is then mobilized to gain length for the later transfer. Afterwards the footprint of the infraspinatus is visualized and debrided. Two or three suture anchors are placed into the posterosuperior aspect of the greater tuberosity. The sutures are stitched through the tendon in ahorizontal mattress stitch configuration and the tendon tied onto the bone. In arthroscopic advancement, the patient is placed in an upright beach-chair position with the arm attached to an arm holder. After debridement of the supraspinatus and infraspinatus footprint, arthroscopic preparation at the anterior border of the subscapularis tendon is performed. The latissimus tendon is visualized and detached with electrocautery. Afterwards the interval between posterior rotator cuff and deltoid muscle is prepared to allow the transfer of the latissimus tendon to the posterosuperior footprint. This marks the transition to the open approach, in which the arm is placed in aflexed and internally rotated position. Immobilization in ashoulder sling for 3weeks. Early passive range of motion (ROM: flexion30°, internal rotation60°, abduction0°, external rotation0°) was immediately allowed. After 3weeks, passive ROM was increased to90° of flexion, 60° of abduction, whereas external rotation was still restricted. After 7weeks, free passive ROM and after 8weeks active ROM (assisted) were allowed. In all, 67patients (mean age 63years) were examined 54months (± 28) after open transfer of the latissimus dorsi tendon. Constant score improved from 24 (± 6) points to 68 (± 17) points. Active flexion increased from 83° (± 47°) to 144° (± 35°), abduction from 69° (± 33°) to 134° (± 42°) and external rotation from 24° (± 18°) to 35° (± 21°). The VAS score decreased from 6.3 (± 1.1) to 1.8 (± 2). However, osteoarthritis worsened over time and the Hamada-Fukuda stage increased from1.4 to2.1 and the acromihumeral distance decreased from 7.9 (± 2.6) to 5.1 (± 2.2) at final follow-up.