Chapter 11

Latissimus Dorsi Transfer

for Severe Rotator Cuff Tears

Case Presentation
The patient is a 45-year-old male with a history of hyperten-
sion who presented after he injured his right shoulder while
trying to throw a bag of garbage and felt a ripping sensation
in his shoulder. Prior to presentation, he had intermittent
anterolateral shoulder pain that was mild and worse with
overhead activity. The trauma dramatically worsened his
pain, and he also noticed significant weakness in the shoulder.
He denies a prior history of surgery or trauma to the ipsilat-
eral shoulder, and had yet to trial physical therapy.
Physical exam demonstrated a well-developed, well-
nourished male, 5 feet 8 inches tall weighing 245 pounds. The
cervical spine was mildly limited in its range of motion with

179
180 R.J. Thorsness and G.P. Nicholson

flexion to 25, extension to 20, and rotation to 30 right and

left, with a negative Spurlings sign. On the healthy, contralat-
eral left shoulder he demonstrated active forward elevation
to 170, and active external rotation to 60, and demonstrated
5/5 external rotation strength, and 5/5 belly press strength.
On the affected, right shoulder he demonstrated passive for-
ward elevation to 160, and passive external rotation 60, but
was unable to actively forward elevate. He had a remarkably
positive external rotation lag sign and positive Hornblowers
sign, with 3/5 external rotation strength. He had a negative
belly press test and 5/5 internal rotation strength. His AC
joint was nontender, as well as the remainder of the shoulder
girdle including the biceps tendon within the bicipital groove.
He possessed a normal, symmetric bicipital contour.
True AP, scapular Y, and axillary lateral radiographs were
obtained which demonstrated moderate superior migration
of the humeral head without evidence of glenohumeral
arthritis (Fig.11.1). There was no evidence of early rotator

Figure 11.1 True AP x-ray view of the right shoulder in this patient
demonstrating moderate superior migration of the humeral head
and narrowing of the acromiohumeral interval. There are no
arthritic changes present
 Chapter 11. Latissimus Dorsi Transfer forSevere 181

a b

Figure 11.2Magnetic resonance imaging demonstrating a full-

thickness, retracted posterosuperior rotator cuff tear on coronal T2
image (a), with grade 1 atrophy of the supraspinatus, grade 2 atro-
phy of the infraspinatus, grade 4 atrophy of the teres minor with a
normal subscapularis (b)

cuff arthropathy present. An MRI from an outside hospital

was reviewed which demonstrated a large, moderately
retracted posterosuperior tear of the rotator cuff involving
the supraspinatus, infraspinatus, and teres minor. On sagittal
T1 images, there was Goutallier grade 1 atrophy of the supra-
spinatus, grade 2 atrophy of the infraspinatus, and unexpect-
edly severe grade 4 atrophy of the teres minor with a normal,
intact subscapularis (Fig.11.2).

Diagnosis/Assessment
This patient is presenting with an acute exacerbation of a
posterosuperior rotator cuff tear after a minor trauma. The
patients history, physical exam, and imaging all corroborate
this diagnosis. The tear likely propagated anteriorly during
the acute exacerbation leaving the supraspinatus with less
severe atrophy compared to the infraspinatus and teres
minor. While tears and atrophy of the teres minor are rare on
presentation, this warranted an electromyographic study
(EMG) to evaluate for a neurologic etiology such as a C5
182 R.J. Thorsness and G.P. Nicholson

radiculopathy. The EMG was obtained and demonstrated

normal testing of the C5 distribution, as well as no evidence
of suprascapular nerve or axillary nerve deficit.
While repair of the supraspinatus would likely improve his
forward elevation, the chronicity of the posterior component
of the tear involving the infraspinatus and teres minor would
likely lead these to be less amenable to repair, and less pre-
dictable with regard to improving his profound external rota-
tion weakness. For young, active patients with large,
irreparable posterosuperior rotator cuff tears with an intact,
functional subscapularis, a latissimus dorsi transfer to the
greater tuberosity remains a viable, though unpredictable,
option for restoring external rotation.

Management
The decision was made to pursue an open rotator cuff repair
and latissimus dorsi transfer.
The patient was positioned in a sloppy lateral decubitus
position after an interscalene regional block was performed.
The first incision was carried out in Langers lines just medial
to the lateral border of the acromion. Skin flaps were raised,
and the raphe between the anterior and middle thirds of the
deltoid was incised and released off the acromion with the
coracoacromial ligament. The deltoid was split 2.5cm later-
ally and a stay suture placed to prevent propagation of the
split. An acromioplasty was then performed as well as a thor-
ough subacromial bursectomy in standard fashion. The supra-
spinatus and infraspinatus tendons were able to be identified
and were tagged with heavy-braided #2 suture. The greater
tuberosity footprint was then prepared to a bleeding base to
optimize the biologic environment for healing. A transosse-
ous rotator cuff repair was then performed through four drill
holes double-loaded with heavy-braided #2 suture.
The bed was then tilted away to optimize the positioning
for the latissimus transfer. A hockey-stick incision was then
made along the lateral border of the latissimus dorsi and then
 Chapter 11. Latissimus Dorsi Transfer forSevere 183

parallel to the humerus. The latissimus was then identified,

mobilized from the adjacent teres major, and released off the
humerus. A heavy-braided #2 Dyneema suture was then run
in Krackow fashion through the tendon, and a separate dif-
fering color #2 Dyneema suture was placed in similar fashion
on the adjacent edge of the tendon, creating four limbs. The
latissimus was then bluntly mobilized down to its neurovas-
cular pedicle and off the fascia. Through the original incision,
the latissimus sutures were retrieved deep to the deltoid and
superficial to the repaired infraspinatus. The tendon was
mobilized to the level of the posterior greater tuberosity foot-
print. This was then repaired to the level of the posterior
greater tuberosity with a similar transosseous technique
through drill holes.
The wounds were irrigated, and the deltoid split closed
with heavy-braided #2 suture incorporating the coracoacro-
mial ligament into the repair. The subcutaneous tissue and
skin were closed in standard fashion. The patient was placed
into a sling with a derotation wedge to maintain the arm in
mild abduction but also approximately 10 external rotation.
He was then extubated and transferred to the postanesthesia
care unit in stable condition. There were no intraoperative
complications.

Outcome
The patient was started with a guided physical therapy regi-
men beginning 1 week after surgery. He was maintained in a
sling for 6 weeks to protect the repair. Phase 1 of therapy
consisted of pendulums, passive external rotation limited to
30, and passive forward elevation to 90 for weeks 16.
Avoiding internal rotation behind the back or across the mid-
line for the first 4 weeks is emphasized. At week 6, phase 2 of
therapy began with active assisted range of motion as toler-
ated, pulleys, and isometric strengthening of the deltoid and
periscapular musculature. Feedback to the patient is pro-
vided while doing isometric ER and IR to begin to try to
184 R.J. Thorsness and G.P. Nicholson

a b

Figure 11.3The patient postoperatively demonstrated excellent

range of motion in both forward elevation (a) and external rotation
(b) without pain

train the latissimus to become an external rotators. Phase 3

began at 3 months postoperatively, to include active range of
motion as tolerated and rotator cuff strengthening.
At most recent follow-up 8 months postoperatively, the
patient demonstrated active forward elevation to 160, and
active external rotation to 45, with 5/5 strength in forward
elevation and 5/5 strength in external rotation (Fig.11.3). He
demonstrated a negative Hornblowers sign and external
rotation lag sign. The reconstruction completely eliminated
his essentially pseudoparalytic state and restored external
rotation power.

Literature Review
Massive posterosuperior rotator cuff tears in young patients
present a difficult clinical problem. Repair of these tears in
these patients is associated with poor outcomes, likely given
irreversible changes to muscular function [13]. As an alter-
native to massive rotator cuff repair in this setting, some
 Chapter 11. Latissimus Dorsi Transfer forSevere 185

surgeons have elected for a latissimus dorsi tendon transfer

to supplement for loss of function of the posterosuperior
rotator cuff [49], with a goal of restoring active forward
elevation and external rotation.
While reverse total shoulder arthroplasty remains a viable
treatment of massive irreparable rotator cuff tears in elderly,
lower demand patients, this is often not an ideal treatment
strategy for younger, more active patients given the risk of
component loosening and subsequent revision [1012].
Latissimus dorsi tendon transfer does remain a reasonable
option for these younger patients, but unfortunately the clini-
cal outcomes are mixed [57, 1320]. The ideal candidate is a
young, active patient with an irreparable posterosuperior
rotator cuff tear, with an intact and functional subscapularis,
without glenohumeral arthritis.
While latissimus transfer will often lead to significant
improvements in pain and function, it is imperative for sur-
geons to manage expectations with these patients as a return
to normal or near-normal function is unlikely. Patient should
be counseled that they can expect approximately 35 increase
in forward elevation, 10 increase in external rotation, and a
70% increase in abduction strength following the procedure
[20]. However, it is imperative to instruct patients that latis-
simus transfer does not preclude cuff tear arthropathy in
young patients, and they should expect continued progression
of glenohumeral arthritis with age. There are a variety of fac-
tors that may influence outcome including age, sex, surgical
technique, and concomitant transfer of the teres major, but
most studies are heterogeneous and likely underpowered to
detect the influence of these factors on outcome [20]. Further,
the literature lacks appropriate studies to evaluate compara-
tive outcomes in similar patients undergoing partial rotator
cuff repair, patch augmentation, or reverse total shoulder
arthroplasty, further highlighting the need for high-quality
studies of this procedure.
When indicating patients for a latissimus transfer, it is
imperative to understand the factors that are associated with
poor outcome. Surgeons should expect poor functional
186 R.J. Thorsness and G.P. Nicholson

results following latissimus transfer in patients undergoing

revision surgery, in patients with a torn or deficient subscapu-
laris, or those with advanced teres minor atrophy [20]. The
integrity of the subscapularis is paramount, as the subscapu-
laris is necessary to maintain a balanced, centered humeral
head following a latissimus transfer during forward elevation
and external rotation.

Clinical Pearls andPitfalls

The ideal candidate for a latissimus transfer is a young,
active patient with an irreparable posterosuperior rotator
cuff tear, with a functional subscapularis in the absence of
glenohumeral arthritis, and poor external rotational ability
and compromised motors of the posterior rotator cuff.
If the patient is lower demand, or elderly, then a reverse
total shoulder will provide a more predictable functional
outcome.
Latissimus transfer does not preclude cuff tear arthropa-
thy, and patients must be instructed that they should
expect progression of arthritic changes over time that may
necessitate a reverse total shoulder arthroplasty in the
future.