Advertisement

Editorial Commentary: Is It Time to Abandon the Latissimus Dorsi Tendon Transfer as a Salvage Procedure for Patients With Large Irreparable Rotator Cuff Tears That Failed Primary Repair?

      Abstract

      The management of large irreparable rotator cuff tears in the young and active patient population without arthritis presents a challenge for shoulder surgeons due to the limited number of treatment options available that provide predictable outcomes. Latissimus dorsi tendon transfer (LDTT) for the treatment of large, irreparable posterosuperior rotator cuff tears or as a salvage procedure for failed surgical (arthroscopic or open) repair was originally introduced in 1988. Multiple studies have reported both the short- and long-term outcomes after LDTT; however, the majority of these studies included patients without history of previous surgery or a mixed patient population. However, LDTT as a salvage procedure is not as predictable as a primary procedure in terms of pain relief and functional improvement. This is especially true in patients with severe fatty infiltration of the posterior cuff musculature and preoperative acromiohumeral distance <7 mm on static anteroposterior radiography. Conversely, we should not abandon the LDTT in young and active patients with large irreparable rotator cuff tear and intact or repairable subscapularis without arthritis as a primary procedure for treatment. There is plenty of clinical evidence that demonstrates good-to-excellent outcomes in this subset of patients. However, in the setting of one or multiple failed arthroscopic or open cuff repairs, limited range of motion, acromiohumeral distance <7 mm on static anteroposterior radiograph, and severe fatty infiltration of the posterior cuff musculature, I would caution against the use of LDTT as a salvage procedure due to the high failure rate and unreliable clinical results. Currently, there is no role in my own practice for LDTT as a salvage procedure in this patient population.
      The management of large irreparable rotator cuff tears in a young patient population presents a challenge for shoulder surgeons due to a limited number of treatment options that provide predictable outcomes. Primary repair results in high failure rates,
      • Chung S.W.
      • Kim J.Y.
      • Kim M.H.
      • Kim S.H.
      • Oh J.H.
      Arthroscopic repair of massive rotator cuff tears: Outcome and analysis of factors associated with healing failure or poor postoperative function.
      whereas reverse shoulder arthroplasty is not an ideal solution for these young and active patients due to concerns for long-term outcome and lack of revision options in the event of unexpected complications.
      • Vancolen S.Y.
      • Elsawi R.
      • Horner N.S.
      • Leroux T.
      • Alolabi B.
      • Khan M.
      Reverse total shoulder arthroplasty in the younger patient (</=65 years): A systematic review [published online September 3, 2019].
      In the absence of shoulder arthritis, superior capsule reconstruction with folded fascial lata autograft was first introduced in Japan and recently introduced in the United States using acellular dermal allograft tissue.
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • et al.
      Superior capsule reconstruction for reinforcement of arthroscopic rotator cuff repair improves cuff integrity.
      ,
      • Mihata T.
      • Lee T.Q.
      • Hasegawa A.
      • Kawakami T.
      • Fukunishi K.
      • Fujisawa Y.
      • et al.
      Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
      Good-to-excellent early- to mid-term clinical outcomes have been reported
      • Galvin J.W.
      • Kenney R.
      • Curry E.J.
      • et al.
      Superior capsular reconstruction for massive rotator cuff tears: A critical analysis review.
      ; however, data on long-term clinical outcomes are lacking, and a recent systematic review found graft re-tear rates of up to 36%.
      • Catapano M.
      • de Sa D.
      • Ekhtiari S.
      • Lin A.
      • Bedi A.
      • Lesniak B.P.
      Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature.
      Latissimus dorsi tendon transfer (LDTT) for the treatment of large, irreparable posterosuperior rotator cuff tears or as a salvage procedure for failed surgical (arthroscopic or open) repair was originally introduced by Gerber et al.
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      in 1988. Biomechanically, transferring the latissimus dorsi tendon to the posterosuperior humeral head changes the vector of force to exert an active external rotation moment arm while depressing the humeral head to allow the deltoid muscle to effectively elevate the arm.
      • Henseler J.F.
      • Nagels J.
      • Nelissen R.G.
      • de Groot J.H.
      Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation?.
      Multiple studies have reported both short- and long-term outcomes after LDTT; however, the majority of these studies included patients without a history of previous surgery or a mixed patient population.
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      ,
      • Castricini R.
      • De Benedetto M.
      • Familiari F.
      • et al.
      Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears.
      • Donaldson J.
      • Pandit A.
      • Noorani A.
      • Douglas T.
      • Falworth M.
      • Lambert S.
      Latissimus dorsi tendon transfers for rotator cuff deficiency.
      • El-Azab H.M.
      • Rott O.
      • Irlenbusch U.
      Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.
      • Ersen A.
      • Ozben H.
      • Demirhan M.
      • Atalar A.C.
      • Kapicioglu M.
      Time-dependent changes after latissimus dorsi transfer: Tenodesis or tendon transfer?.
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      • Grey S.G.
      Combined latissimus dorsi and teres major tendon transfers for external rotation deficiency in reverse shoulder arthroplasty.
      • Paribelli G.
      • Boschi S.
      • Randelli P.
      • Compagnoni R.
      • Leonardi F.
      • Cassarino A.M.
      Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear.
      In this study, “High Clinical Failure Following Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears,” the authors Muench, Kia, Williams, Avery, Cote, Reed, Arciero, Chandawarkar, and Mazzocca
      • Muench L.
      • Kia C.
      • Williams A.
      • et al.
      High clinical failure following latissimus dorsi transfer for revision massive rotator cuff tears.
      evaluated the clinical outcomes and preoperative risk factors for failure in patients after LDTT for a massive, irreparable, and previously failed rotator cuff repair. A retrospective chart review of prospectively collected data was performed using an institutional shoulder outcome registry. All patients who underwent LDTT with previously failed rotator cuff repair had a minimum of 1-year follow-up for clinical outcomes. A total of 22 patients (age 53 ± 6 years) and mean follow-up (3.4 ± 1.1 years) were evaluated with Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES), and Single Assessment Numerical Evaluation scores along with complication rates, overall clinical failure rates, and need for further revision surgeries.
      Overall, in this small cohort of patients, 16 (63%) had 2 or more failed rotator cuff repairs before the LDTT, and all of the patients in this study improved in their functional outcome scores (ASES, Simple Shoulder Test, Single Assessment Numerical Evaluation, and pain scores) at final follow-up. The overall complication rate after LDTT was 63% with a clinical failure rate of 41%, as defined as an improvement of the delta ASES<17 points. Furthermore, 3 patients (13.6%) required revision to a reverse shoulder arthroplasty between less than 1 year to almost 6 years after the LDTT. All of the patients with grade 3 or 4 fatty infiltration resulted in clinical failure and preoperative acromiohumeral distance of <7 mm was also a significant risk factor for failure.
      In orthopaedic shoulder surgery, we can all agree that in most cases, a primary surgery will result in a better outcome than revision surgery. For patients who present with primary massive irreparable posterosuperior rotator cuff tears, LDTT can be a reliable operation providing good-to-excellent outcomes with mid- to long-term follow-up.
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      ,
      • Donaldson J.
      • Pandit A.
      • Noorani A.
      • Douglas T.
      • Falworth M.
      • Lambert S.
      Latissimus dorsi tendon transfers for rotator cuff deficiency.
      ,
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      Gerber et al.
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      reported the longest follow-up in the literature on a cohort of patients (N = 56) after LDTT and found significant improvement in the Subjective Shoulder Value, relative Constant scores, pain scores, and mean flexion and external rotation between preoperative to final follow-up (mean of 147 months). However, the majority of the patients in Gerber et al.’s study underwent primary LDTT (82%) compared with 18% who had the LDTT as a savage procedure. Risk factors for poor outcome include fatty infiltration of the teres minor muscle belly, subscapularis muscle insufficiency, and critical shoulder angle >36°. The authors did find a trend toward less-favorable results after LDTT transfer as revision surgery; however, it was not statistically significant due to the limited number of patients in the revision group. In a small cohort of patients, Warner et al.
      • Warner J.J.
      • Parsons 4th, I.M.
      Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
      compared the outcomes of primary versus salvage LDTT for massive, irreparable rotator cuff tears and reported a much greater rupture rate of 44% in the salvage group compared with the primary group of 17% at 19 months postsurgery. Furthermore, patients who experience late rupture of the tendon transfer will have a compromised outcome and poor satisfaction. In a similar study, Valenti et al.
      • Valenti P.
      • Kalouche I.
      • Diaz L.C.
      • Kaouar A.
      • Kilinc A.
      Results of latissimus dorsi tendon transfer in primary or salvage reconstruction of irreparable rotator cuff tears.
      also found significantly better subjective outcomes in patients after primary LDTT (84%) compared with LDTT for failed cuff repair (50%). On the contrary, several other authors have reported that LDTT used as a salvage procedure provided reasonable results and patient satisfaction.
      • Miniaci A.
      • MacLeod M.
      Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review.
      ,
      • Pearsall 4th, A.W.
      • Madanagopal S.G.
      • Karas S.G.
      Transfer of the latissimus dorsi as a salvage procedure for failed debridement and attempted repair of massive rotator cuff tears.
      Miniaci and MacLeod
      • Miniaci A.
      • MacLeod M.
      Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review.
      reported significantly improved pain relief and function in 14 patients (82%) after LDTT for failed cuff repair. However, the overall improvement of the University of California at Los Angeles shoulder score in their group was only 16.4 points. The authors concluded that the relative improvement is “at best…considered fair. This reflects the fact that the patients were still moderately disabled.”
      The best way to gain insight into this article and how it may change practice was to interview the senior author, Augustus Mazzocca, M.D., M.S. I proposed several questions to Dr. Mazzocca regarding his study, including his current indications for LDTT, and any further insight that he has about LDTT as a salvage procedure for failed cuff repair. His direct comment was as follows, “We did everything in our power to maximize this surgical technique. We started seeing some failures and really worked hard to make it better. We practiced it in the bio skills cadaver lab multiple times. I had a plastic surgeon work with me to do a better dissection of the latissimus dorsi muscle. We studied videos, I spoke with Tony Romeo, Herbert Resch, J. P. Warner, and Christian Gerber to further our knowledge of the LDTT procedure. I had the patients adhere to strict postoperative protocol with their arm in a special abduction orthosis to maximize healing. In my hands, this procedure did not work well for providing pain relief or functional improvement. Prior to this study, my indications for LDTT was for pain control. Our patients did not achieve this goal. In speaking with some of these patients, it was so much surgery that they were burned out. I’m also sure that many of them went somewhere else after failing despite our efforts. Currently, there are no indications for me to do a LDTT unless I do it with a reverse shoulder arthroplasty.”
      I want to congratulate Dr. Mazzocca and his co-authors for publishing honest data that shows poor outcome and high failure rate after LDTT as a salvage option in patients with large irreparable cuff tears that had failed previous surgeries. This is a very difficult patient population to manage, especially if they are young, active, and still have high demand (job or life) for their shoulder. It takes up to 1 year to recover from arthroscopic or open rotator cuff surgery, and if they had multiple failed repairs, that means a significant amount of time was spent dealing with the frustrations related to failed surgeries due to the pain and disability. It is clear from the results of this study and others in the literature that LDTT as a salvage procedure is not as predictable in both pain relief and functional improvement as is for a primary procedure. This is especially true in patients with severe fatty infiltration of the posterior cuff musculature and preoperative acromiohumeral distance <7 mm on static anteroposterior radiography.
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      ,
      • Muench L.
      • Kia C.
      • Williams A.
      • et al.
      High clinical failure following latissimus dorsi transfer for revision massive rotator cuff tears.
      Furthermore, Hart et al.
      • Hart R.
      • Barta R.
      • Nahlik D.
      Latissimus dorsi transfer for the treatment of irreparable craniodorsal tears of the rotator cuff.
      best summarized the LDTT procedure: “The transfer itself is a demanding surgical procedure associated with several risks and it should therefore be performed by an experienced and competent surgeon with a deep knowledge of the shoulder girdle anatomy. When based on a correct indication, latissimus dorsi transfer with an uncomplicated postoperative therapy will result in improvement of shoulder function and pain relief, and it is therefore justified.” We should not abandon the LDTT in young and active patients with large irreparable rotator cuff tear and intact or repairable subscapularis without arthritis as a primary procedure for treatment. In the right hands, with the right indications, and in the right patient who is willing to commit to the extensive postoperative therapy, LDTT will provide good-to-excellent long-term outcomes of improved pain and function.
      • Gerber C.
      • Vinh T.S.
      • Hertel R.
      • Hess C.W.
      Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
      ,
      • Donaldson J.
      • Pandit A.
      • Noorani A.
      • Douglas T.
      • Falworth M.
      • Lambert S.
      Latissimus dorsi tendon transfers for rotator cuff deficiency.
      ,
      • El-Azab H.M.
      • Rott O.
      • Irlenbusch U.
      Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.
      ,
      • Gerber C.
      • Rahm S.A.
      • Catanzaro S.
      • Farshad M.
      • Moor B.K.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
      However, in the setting of one or multiple failed arthroscopic or open cuff repairs, limited range of motion, acromiohumeral distance <7 mm on static anteroposterior radiograph, and severe fatty infiltration of the posterior cuff musculature, currently there is no role in my own practice for LDTT as a salvage procedure in this patient population.

      Supplementary Data

      References

        • Chung S.W.
        • Kim J.Y.
        • Kim M.H.
        • Kim S.H.
        • Oh J.H.
        Arthroscopic repair of massive rotator cuff tears: Outcome and analysis of factors associated with healing failure or poor postoperative function.
        Am J Sports Med. 2013; 41: 1674-1683
        • Vancolen S.Y.
        • Elsawi R.
        • Horner N.S.
        • Leroux T.
        • Alolabi B.
        • Khan M.
        Reverse total shoulder arthroplasty in the younger patient (</=65 years): A systematic review [published online September 3, 2019].
        (J Shoulder Elbow Surg. doi:)
        • Mihata T.
        • Lee T.Q.
        • Hasegawa A.
        • et al.
        Superior capsule reconstruction for reinforcement of arthroscopic rotator cuff repair improves cuff integrity.
        Am J Sports Med. 2019; 47: 379-388
        • Mihata T.
        • Lee T.Q.
        • Hasegawa A.
        • Kawakami T.
        • Fukunishi K.
        • Fujisawa Y.
        • et al.
        Arthroscopic superior capsule reconstruction can eliminate pseudoparalysis in patients with irreparable rotator cuff tears.
        Am J Sports Med. 2018; 46: 2707-2716
        • Galvin J.W.
        • Kenney R.
        • Curry E.J.
        • et al.
        Superior capsular reconstruction for massive rotator cuff tears: A critical analysis review.
        JBJS Rev. 2019; 7: e1
        • Catapano M.
        • de Sa D.
        • Ekhtiari S.
        • Lin A.
        • Bedi A.
        • Lesniak B.P.
        Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature.
        Arthroscopy. 2019; 35: 1243-1253
        • Gerber C.
        • Vinh T.S.
        • Hertel R.
        • Hess C.W.
        Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report.
        Clin Orthop Relat Res. 1988; : 51-61
        • Henseler J.F.
        • Nagels J.
        • Nelissen R.G.
        • de Groot J.H.
        Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation?.
        J Shoulder Elbow Surg. 2014; 23: 553-560
        • Castricini R.
        • De Benedetto M.
        • Familiari F.
        • et al.
        Functional status and failed rotator cuff repair predict outcomes after arthroscopic-assisted latissimus dorsi transfer for irreparable massive rotator cuff tears.
        J Shoulder Elbow Surg. 2016; 25: 658-665
        • Donaldson J.
        • Pandit A.
        • Noorani A.
        • Douglas T.
        • Falworth M.
        • Lambert S.
        Latissimus dorsi tendon transfers for rotator cuff deficiency.
        Int J Shoulder Surg. 2011; 5: 95-100
        • El-Azab H.M.
        • Rott O.
        • Irlenbusch U.
        Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.
        J Bone Joint Surg Am. 2015; 97: 462-469
        • Ersen A.
        • Ozben H.
        • Demirhan M.
        • Atalar A.C.
        • Kapicioglu M.
        Time-dependent changes after latissimus dorsi transfer: Tenodesis or tendon transfer?.
        Clin Orthop Relat Res. 2014; 472: 3880-3888
        • Gerber C.
        • Rahm S.A.
        • Catanzaro S.
        • Farshad M.
        • Moor B.K.
        Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years.
        J Bone Joint Surg Am. 2013; 95: 1920-1926
        • Grey S.G.
        Combined latissimus dorsi and teres major tendon transfers for external rotation deficiency in reverse shoulder arthroplasty.
        Bull Hosp Jt Dis (2013). 2013; 71: 82-87
        • Paribelli G.
        • Boschi S.
        • Randelli P.
        • Compagnoni R.
        • Leonardi F.
        • Cassarino A.M.
        Clinical outcome of latissimus dorsi tendon transfer and partial cuff repair in irreparable postero-superior rotator cuff tear.
        Musculoskelet Surg. 2015; 99: 127-132
        • Muench L.
        • Kia C.
        • Williams A.
        • et al.
        High clinical failure following latissimus dorsi transfer for revision massive rotator cuff tears.
        Arthroscopy. 2020; 36: 88-94
        • Warner J.J.
        • Parsons 4th, I.M.
        Latissimus dorsi tendon transfer: a comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears.
        J Shoulder Elbow Surg. 2001; 10: 514-521
        • Valenti P.
        • Kalouche I.
        • Diaz L.C.
        • Kaouar A.
        • Kilinc A.
        Results of latissimus dorsi tendon transfer in primary or salvage reconstruction of irreparable rotator cuff tears.
        Orthop Traumatol Surg Res. 2010; 96: 133-138
        • Miniaci A.
        • MacLeod M.
        Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review.
        J Bone Joint Surg Am. 1999; 81: 1120-1127
        • Pearsall 4th, A.W.
        • Madanagopal S.G.
        • Karas S.G.
        Transfer of the latissimus dorsi as a salvage procedure for failed debridement and attempted repair of massive rotator cuff tears.
        Orthopedics. 2007; 30: 943-949
        • Hart R.
        • Barta R.
        • Nahlik D.
        Latissimus dorsi transfer for the treatment of irreparable craniodorsal tears of the rotator cuff.
        Acta Chir Orthop Traumatol Cech. 2010; 77 ([in Czech]): 215-221