Background: 

Transfer of the anterior latissimus dorsi and teres major (LDTM) tendons has demonstrated favorable outcomes in patients with irreparable anterosuperior rotator cuff tears1. The objective of this procedure is to restore internal rotation strength, enhance active range of motion, and provide pain relief while preserving the glenohumeral joint.

Description: 

The incision extended from the coracoid to the inferior border of the pectoralis major tendon, following the deltopectoral interval located laterally to the coracoid. While preserving the pectoralis major tendon, the latissimus dorsi (LD) and teres major (TM) tendons are identified and detached from the humerus without separating the tendons. The LDTM tendons are grasped, and nonabsorbable sutures are placed in a continuous running-locking suture fashion. Traction is applied to the sutures while bluntly releasing the adhesions surrounding the LDTM muscles in order to enable further mobilization and excursion. With the patient’s arm positioned in full internal rotation and at 45° of abduction for physiological tensioning, the LDTM tendons are attached 2 cm distal to the lateral edge of the greater tuberosity and lateral to the biceps groove with use of 1 medial anchor and 3 lateral anchors.

Alternatives: 

Arthroscopic partial repair, superior capsular reconstruction, pectoralis major tendon transfer, and isolated LD tendon transfer are potential alternative treatments. In cases in which these options are not feasible or have been unsuccessful, reverse total shoulder arthroplasty can be considered as a treatment option.

Rationale: 

Arthroscopic partial repair can provide pain relief, but its effectiveness in improving range of motion and muscle strength is limited2,3. Additionally, there is a high risk of retear, with reported rates as high as 52%4. Superior capsular reconstruction is considered a viable treatment, but it is not recommended in cases involving irreparable subscapularis tears5–7. Pectoralis major transfer may lead to less favorable clinical outcomes in cases in which an irreparable subscapularis tear and an irreparable supraspinatus tear are simultaneously present8–10. In cases of irreparable anterosuperior rotator cuff tears, the transfer of the LD tendon alone may not fully restore the superior migration and anterior subluxation of the humeral head.11. Reverse total shoulder arthroplasty may be another option in these cases, but it does not preserve the glenohumeral joint.

Expected Outcomes: 

The procedure involves stabilizing the superior translation of the humeral head by rebalancing the force couple, as the TM tendon exhibits scapulohumeral kinematics similar to the subscapularis tendon. Additionally, the procedure effectively reduces anterior glenohumeral subluxation through the combined effect of the posterior line of pull from the combined LDTM tendons and the scapulohumeral kinematics of the teres minor tendon. Also, by fixing the transferred LDTM tendons just distal to the greater tuberosity, the vector becomes less vertical, thereby preventing axillary nerve impingement and achieving appropriate tendon tensioning. The use of this procedure is supported by a study of 30 patients who were followed for a minimum of 2 years1. Significant improvements were observed in various scoring systems, including the pain VAS (visual analogue scale), Constant, ASES (American Shoulder and Elbow Surgeons), UCLA (University of California-Los Angeles), SANE (Single Assessment Numeric Evaluation), and ADLIR (Activities of Daily Living requiring active Internal Rotation) scores. Importantly, there was no significant progression of cuff tear arthropathy observed during the final follow-up. Additionally, preoperative anterior glenohumeral subluxation (15 of 30 patients) was restored in all patients after LDTM tendon transfer.

Important Tips:  Careful attention should be paid to the anterior humeral circumflex vessels to prevent bleeding. The radial nerve, passing through the anteroinferior surface of the LDTM tendons, should be carefully identified and protected to avoid iatrogenic injury. To maintain physiologic tension, the patient’s arm should be positioned in full internal rotation and 45° of abduction. To avoid axillary nerve impingement, the LDTM tendons should be fixed just distal to the greater tuberosity and lateral to the biceps groove. Acronyms and Abbreviations:  SCR = superior capsular reconstruction LDTM = latissimus dorsi combined with teres major ASRCTs = anterosuperior rotator cuff tears A/S = arthroscopic ROM = range of motion TM = teres major Tm = teres minor LD = latissimus dorsi SSC = subscapularis SSP = supraspinatus PM = Pectoralis major Pm = Pectoralis minor RSA = reverse total shoulder arthroplasty ASES = American Shoulder and Elbow Surgeons UCLA = University of California-Los Angeles ADLIR = Activities of Daily Living requiring active Internal Rotation GT = greater tuberosity ACR = anterior capsular reconstruction FF = forward flexion ER = external rotation IR = internal rotation AHD = acromiohumeral distance MRI = magnetic resonance imaging ISP = infraspinatus PEEK = polyetheretherketone POD = postoperative day EMG = electromyography SD = standard deviation BMI = body mass index DM = diabetes mellitus HTN = hypertension VAS = visual analogue scale SANE = Single Assessment Numeric Evaluation aROM =active range of motion