synonyms: lat transfer, Latissimus dorsi tendon transfer
Latissimus dorsi transfer CPT
Latissimus dorsi transfer Anatomy
Latissimus dorsi transfer Indications
- Massive RTC tear involving the supraspinatus and infraspinatus with severe muscle atrophy and severe external rotation weakness.
Latissimus dorsi transfer Contraindications
- Ability to primarily repair the RTC.
- Glenohumeral arthritis.
- Latissmus dorsi weakness or paralysis.
- Deltoid deficiency. (relative)
Latissimus dorsi transfer Alternatives
Latissimus dorsi transfer Planning / Special Considerations
- Latissimus dorsi transfer improves external rotation strength is best used in younger patients who have active elevation. Improvements in elevation are less predictable.
Latissimus dorsi transfer Technique
- Sign operative site.
- Pre-operative antibiotics, +/- regional block.
- Consider placing body portion of external rotation spica cast before anesthesia.
- General endotracheal anesthesia
- Lateral decubitous position. All bony prominences well padded, axillary role.
- Examination under anesthesia.
- Prep and drape in standard sterile fashion.
- 6-8cm incision along Langers lines just medial to the posterior axillary crease.
- Raise deep skin flaps.
- Isolate the Latismus Dorsi proximally at the muscle belly and trace it distally to its insertion on the medial side or the humeral shaft.
- Sharply release the tendon from its insertion.
- Place two #2 Orthocord sutures along each edge of the tendon using Krackow or similar stich.
- Mobilize the the Latismus Dorsireleasing any fascial attachments. There is generally a dense fascial connection at the inferior angle of the scapula which requires release.
- Tendon should easily reach the humeral head without tension or tethering of the skin.
- Define posterior edge of the deltoid and mobilize sufficiently to pass Latismus Dorsi tendon.
- The tendon is then secured to the infraspinatus footprint on the greater tuberosity through drill holes augmented with suture anchors as needed. This can be done through the posterior incision by mobilization of the posterior deltoid or through seperate lateral incision.
- Any remaining RTC should be repaired and augmented with the Latismus Dorsitendon to make as much of a anatomic RTC as possible.
- Close in layers.
Latissimus dorsi transfer Complications
- Traumatic rupture of transfer Latissimus dorsi tendon: up to 44%
- Radial nerve palsy
- Limited funcitonal outcome
Latissimus dorsi transfer Follow-up care
- Post-op: Immmoilize in external rotation for 3-5 weeks, consider external rotation spica casting.
- 7-10 Days: Wound check, continue external rotation immobilization. Active elbow/wrist/hand ROM.
- 6 Weeks: start physical therapy for shoulder motion and latissimus retraining. Wean out of sling
- 3 Months: continue PT, activity limitations
- 6 Months: gradually resume activites
- 1Yr: assess outcomes.
Latissimus dorsi transfer Outcomes
- Pain relief and improvement of shoulder function maintained 9.3 years after Latissimus dorsi transfer for irreparable posterosuperior cuff defects. Younger patients do better. (Hossam Mahmoud El-Azab, J Bone Joint Surg Am, 2015 Mar 18; 97 (6): 462 -469)
- Constant score improved from 55% to 73%; Pain score improved from 6 to 12 points (of a possible 15 points). Flexion=123°, abduction=119°, ER=29°. Results limited if subcrapularis was not intact. (Gerber C, JBJS 2006;88:113).
- 64% satisfied patients, 36% unsatisfied (Iannotti JP, JBJS 2006;88A:342).
- For revision of failed RTC repair: AFE=105°, AER=40°, ER strength=3.9, Constant score = 52%, Subjective = 13% excellent, 38% good, 31% fair, 19% poor. (Warner JJ, JSES 2001;10:514)
- For Birth palsy: (Pearl ML, JBJS 2006;88Am:564).
Latissimus dorsi transfer Review References
- Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res. 1992 Feb;275:152-60
- Pearl ML, in Advanced Reconstruction: Shoulder. AAOS 2007.
- Iannotti JP, JBJS 2006;88A:342