Graft-Augmented Repair of Irreparable Massive Rotator Cuff Tears with Latissimus Dorsi Transfer to Treat Pseudoparesis

Abstract

Background: Irreparable massive rotator cuff tears are characterized by a poor prognosis with high failure rates following repair. Numerous strategies, such as partial repair, graft interposition, latissimus dorsi (LD) transfer, balloon arthroplasty, and superior capsular reconstruction, have been proposed. We have adopted a graft-augmented LD-transfer procedure, in which partial repair, graft interposition, and LD transfer are performed simultaneously.

Methods: Thirty-nine patients underwent the graft-augmented LD-transfer procedure using autologous fascia lata from 2007 to 2016. All patients underwent a 5-year assessment at a mean (and standard deviation) of 54.8 ± 3.5 months. Of 20 patients with a history of >10 years, 14 underwent a 10-year assessment at a mean of 112.6 ± 5.6 months. To characterize the therapeutic effects of the procedure, the patients were divided into 3 groups according to the tear pattern: superior-posterior tears (Group A), superior-anterior tears (Group B), and global tears (Group C).

Results: The overall mean Constant-Murley score improved from 33.8 ± 5.3 preoperatively to 63.1 ± 9.4 at the 5-year assessment (p < 0.001). The overall mean active anterior elevation (AE) improved from 57.3° ± 13.2° preoperatively to 131.3° ± 18.2° at 5 years (p < 0.001). Preoperatively, AE was significantly different between Groups A and C (p < 0.001) and between Groups B and C (p < 0.001), reflecting the difference in cuff tear patterns. Postoperatively, AE was significantly higher in Group A than in Groups B (p < 0.001) and C (p < 0.001). The present study also showed that AE was electromyographically synchronized to the contraction of the transferred LD. The transferred LD was kinetically more potent at a slower speed, but it was easier to exhaust, than the native rotator cuff. Osteoarthritis progression was radiographically found to occur during the first 5 years.

Conclusions: The graft-augmented LD-transfer procedure may be a treatment option for massive rotator cuff tears, especially for active patients who are <60 years old.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fig. 1

Figs. 1-A through 1-D Graft-augmented LD transfer with the window positions. Fig. 1-A Illustration showing a complete rupture of the SSP and ISP tendons with partial rupture of the SSC tendon, for which the present graft-augmented LD transfer is indicated. Fig. 1-B The glenohumeral joint, consisting of the glenoid (G) and humerus (H), was approached through the first window. Fig. 1-C A schematic demonstration of a 7-cm superolateral skin incision creating the first window (1), a 15-cm posterior skin incision along the lateral border of the LD creating the second window (2), and a 7-cm deltopectoral incision creating the third window (3). Fig. 1-D An intraoperative view demonstrating the first (1), second (2), and third (3) windows. A subdeltoid tunnel has been already created from the first to the third windows, through which a retractor is inserted (arrows).

Fig. 2

Figs. 2-A through 2-D Mobilization of the SSP and partial repair of the SSC tendons. Fig. 2-A The SSP tendon is mobilized through the first window (arrow). Fig. 2-B The SSC tendon is mobilized through the third window (3) and is connected to the first window (1) and is partially secured to the lesser tuberosity (LT) using suture anchors (arrowhead). The long head of the biceps tendon is incised and processed for subsequent tenodesis (arrow). Fig. 2-C The SSP tendon is prepared for graft-securing with number-2 nonabsorbable composite sutures (arrow). Fig. 2-D The SSC tendon is partially secured using suture anchors to the LT (arrow). Although the inferior portion of the SSC tear has been secured (arrow), the upper portion of the SSC tendon remains detached; however, it is later closed by suturing with the graft.

Fig. 3

Figs. 3-A through 3-D Enhancement of tissue strength and protection of the LD tendon with grafting. Fig. 3-A The graft was sized to the 3 free edges of the defect (SSP, ISP, and SSC) with sutures coming from anchors (A-SSP) inserted in the greater tuberosity. Fig. 3-B The graft is approaching the 3 free edges of the defect (SSP, ISP, and SSC). Fig. 3-C The graft is secured laterally to the GT with suture anchors (A-SSP), with the stump of the long head of the biceps tendon secured for tenodesis. Fig. 3-D Uncut sutures (A-SSP) are passed through the first window for subsequent securing of the transferred LD tendon.

Fig. 4

Figs. 4-A through 4-D Preparation of the LD through the second window. Fig. 4-A The thoracodorsal artery supplying the LD and the serratus anterior muscles appears after the release of the LD tendon from the humerus (arrow). Fig. 4-B Identification of the serratus branch (arrow) and measurement of its length. Fig. 4-C Ligation of the serratus branch (arrowhead) allowing elongation of the LD excursion (arrow). Fig. 4-D The elongated LD muscle reaching far beyond the humeral head.

Fig. 5

Figs. 5-A through 5-D Creation of the subdeltoid tunnel and pulling the LD through the tunnel. Fig. 5-A A subdeltoid tunnel is created from the second (2) to the third window (3) via the first window (1). Fig. 5-B The tendon stumps (arrow) are grasped by number-2 braided nonabsorbable sutures in a baseball suture manner and are pulled through the third window (3). Fig. 5-C The transferred LD is intermediately secured to the GT (arrowhead) with its tendon stump terminally secured to the LT (arrow). Fig. 5-D Tendon excursion of >10 cm is confirmed through the first window immediately before securing to the GT and the LT. The length of tendon excursion (arrowhead) is confirmed, while pulling number-2 braided nonabsorbable sutures (arrow).

Fig. 6

Figs. 6-A through 6-F MRI scans and radiographs of a 58-year-old man who was followed for 10 years after the graft-augmented LD-transfer procedure. Figs. 6-A and 6-B Preoperative oblique coronal T2-fat suppression MRI scan demonstrates a far-reaching retraction of the SSP tendon (Fig. 6-A) and an anteroposterior radiograph shows an almost diminished acromiohumeral interval (Fig. 6-B). Figs. 6-C and 6-D At the 5-year assessment, an oblique coronal T2-fat suppression MRI scan shows that the SSP tendon is very loose (arrow), suggesting rupture of the graft-SSP connection; however, the graft-LD composite (arrowhead) remained intact (Fig. 6-C), and an oblique sagittal T1-weighted MRI scan shows the intact graft (arrowhead) and LD (arrow) composite (Fig. 6-D). S = subscapularis, i = infraspinatus, and t = teres minor. Figs. 6-E and 6-F At the 10-year assessment, the T2-fat suppression MRI scan shows the ruptured graft-LD composite (arrow) (Fig. 6-E), and the radiograph shows the development of arthritis with irregular ossification (arrowhead) around the humeral head (Fig. 6-F).

Fig. 7

Figs. 7-A, 7-B, and 7-C Electromyographic changes during postoperative rehabilitation. Fig. 7-A Preoperative electromyographs show that the pectoralis major potential (green arrow) was unintendedly synchronized to that of the anterior deltoid (red arrow) as the patient attempted to elevate the arm. Fig. 7-B At 4 months postoperatively, the unintended pectoralis major potential (green arrow) is attenuated in magnitude and the potential of the transferred LD appeared (purple arrow). Fig. 7-C At 8 months postoperatively, the unintended pectoralis major potential (green arrow) had disappeared, and the potential of the transferred LD had increased in magnitude (purple arrow).

Fig. 8

Figs. 8-A through 8-E Radiographic analysis of glenohumeral-scapular movement in lateral elevation. Fig. 8-A Dynamic anteroposterior radiographs of both shoulders made at 10°, 45°, and 90° of lateral elevation and the maximum lateral elevation were used. The glenohumeral-scapular rhythm of the shoulders with LD transfer was compared with that of nontreated shoulders by calculating the β angle and α angle. (The β angle is the inclination of a line crossing the superior and inferior poles of the glenoid facet, and the α angle is the presumed glenohumeral angle, which is the lateral elevation angle minus the β angle.) Fig. 8-B Linear regression for the α angle of the contralateral, untreated shoulder demonstrates that the α angle at 0°of lateral elevation was −2.38°. Fig. 8-C Linear regression for the β angle of the contralateral, untreated shoulder demonstrates that the β angle at 0° of lateral elevation was +2.38°. Fig. 8-D The estimated increase of the α angle of the shoulder with LD transfer starts later than that of the contralateral shoulder. Fig. 8-E The estimated increase of the β angle of the shoulder with LD transfer starts earlier than that of the contralateral shoulder.