Thread: Tendon Transfer
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Old 06-05-2010, 01:28 PM
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Default The role of latissimus transfer for irreparable rotator cuff tears

Thanks for your question. Patient selection for this option is important--and typically the best results correlate with "better" preoperative function.In that light, it's really important to understand the nature of your problem: do you have pain, but good function? Do you have poor function, but little pain? Do you have pain and no function (pseudoparalysis)?
What your expectation is, coupled with what different options can provide will help--in combination--to choose the most optimal treatment strategy for you.

Firstly, in physiologically young patients with pain, weakness, and loss of range of motion due to either a chronic tear of the rotator cuff that is no longer fixable, or due to a failed repair, latissimus muscle tendon transfer is an option that can improve function and decrease pain by "substituting" for the absence of the torn posterosuperior cuff. Classically this option is indicated for massive tears (at least 2 tendons--supra- and infraspinatus.) The transfer is most successful when it provides "active motor control," which requires postoperative rehabilitation that involves, in many cases, biofeedback to encourage firing of the latissimus during external rotation and forward elevation, even though this muscle was an "adductor and internal rotator."

Dr JP Warner, who was one of my partners while at the University of Pittsburgh and now heads the Shoulder section at Harvard, has shown the value of retraining the transfer by beginning motion with adduction---and then combing external rotation and forward elevation--to encourage coactivation. The latissimus transfer affords it benefit partly by restoring active muscle contraction, and partly by restoring a force couple to "depress" the humeral head and improve its centering in the socket. The xray attached below shows superior elevation in a case of a 2 tendon chronic tear, and after a successful tenon transfer, the acromiohumeral interval can improve. When this happens, not only can range of motion improve, but the pain above shoulder level may diminish due to the improvement in "space" between the acromium and the greater tuberosity.

However, it is very important to appreciate that when overhead range of motion is good and when strength and external rotation are acceptable, this particular option--when performed primarily to improve pain-- is a hard to predict. In other words, it may be best to adapt, given good motion, and try to "work around" the pain.

Prior to having this option (which requires that you have functioning deltoid and subscapularis muscles, little or no arthritis, at least shoulder level active elevtion, and no stiffness), it may be worth considering an arthroscopic attempt at a partial repair----which may also help improve the "course" of the suprascapular nerve--thus improving the pain that may be due to subtle suprscapular neuropathy. Indeed, an EMG study preoperatively may be of value to evaluate for this, acknowleging, however, that electrodiagnostic changes in the supra- and infraspinatus muscles might be secondary to the chronic tear and not "de facto" proof that the nerve is in any way tethered or entrapped.

Rehabilitation following latissimus transfer involves 6 weeks in an abduction splint, with passive motion only until 8 weeks. Full recovery can take as long as 12-18 months. If you have good motion and strength, but pain-----it is important to evaluate the joint for early arthritis---since its presence may potentially support an option that "resurfaces" the humeral head with an "extended articular surface" (see attached pic).

Happy to continue this dialogue!
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