Muscle Tendon Transfers

Latissimus Dorsi Tendon Transfer for Rotator Cuff Repair

What is Latissimus Dorsi Tendon Transfer (LDTT)?

Latissimus dorsi tendon transfer is a surgical procedure performed to reconstruct the irreparable rotator cuff tears in your shoulder. The procedure typically involves detaching the latissimus dorsi tendon from its original location and transferring it to the shoulder to repair the rotator cuff.

Irreparable rotator cuff tears are a challenging problem for patients and surgeons alike. LDTT can be an effective option for patients with massive posterosuperior rotator cuff tears and is increasingly being used in cases where the subscapularis tendon is unharmed. 

The latissimus dorsi muscle is well suited to transfer for several reasons including its large surface area, strength, and good vascularization (formation of blood vessels).

Anatomy

A rotator cuff is a group of four muscles and tendons that hold the shoulder joint in place and let you move shoulder and arm. The subscapularis muscle is one of the four muscles that make up the rotator cuff and is the largest, most powerful of all the muscles. 

The latissimus dorsi tendon, also called the “lat,” is a large, wide, flat muscle spanning the width of your back, behind the arms. It connects the upper arm bone to the spine and the hip, stabilizes your back and helps control the movement of your shoulders.

Latissimus dorsi tendon is the most commonly transferred tendon to the shoulder area. 

Indications for LDTT

• Severe pain in the shoulder joint combined with a popping sensation
• Immediate weakness in the upper arm and reduced mobility of the arm 
• Muscle atrophy (wasting or loss of muscle tissue in the shoulder joint) 
• Irreversible rotator cuff tears with the subscapularis tendon intact 
• Joint replacement surgery (to improve external rotation and elevation mobility)

Preparation

Prior to the surgery, your surgeon will conduct a physical examination of the affected area and perform certain imaging tests before instructing you to:

• Stop taking any medications
• Fast after midnight on the day of surgery
• Arrange a drive home after surgery
• Arrange help with tasks at home 

The Procedure of LDTT

The procedure is performed as an open surgery or with arthroscopic assistance under general anesthesia. 

During the LDTT:

• You will be positioned on your side. 
• Your arm will be placed in a flexed position using an arm holder.
• Two incisions are made - one in the front and one in the back of your shoulder. 
• The latissimus dorsi tendon is accessed and mobilized via the back incision.
• In the back, one end of the latissimus dorsi tendon is detached from the bone.
• With the help of a needle, a suture is passed across the freed end of the tendon. 
• In the front, a flap is created in the deltoid muscle that covers the shoulder joint. 
• Using a grasping tool, the freed end of the tendon is brought under the deltoid muscle. 
• The transferred tendon is then connected to the remaining rotator cuff with sutures.
• The sutures are tightened to pull the latissimus dorsi tendon against the shoulder bone.
• The tendon and the sutures are further secured to the bone with strong suture anchors. 
• The flap in the deltoid muscle and the incisions are then closed in the front and back.

After-Care and Rehabilitation

After the surgery, you will wear a sling or brace for 4 to 6 weeks to help keep your arm and shoulder immobilized. However, limited internal rotation and adduction (lowering the arm to one’s side) may be allowed.

Additionally, a three-phase rehabilitation program including specific shoulder exercises may be recommended for a successful outcome. 

Benefits of LDTT 

The procedure is a popular option, as it ensures the following:

• Reduced pain and weakness in the shoulder
• Improved mobility and function of the shoulder
• Long term results with fewer incidences of a revision procedure

Complications 

As with any surgery, LDTT comes with a few complications such as:

• Failure of the tendon transfer
• Rupture of the transferred attachment
• Shoulder weakness, stiffness or infection 
• Decreased active forward elevation
• Need for revision procedures 

Contraindications

LDTT cannot be an option in cases of:

• Progressive chondropathy
• Clinically overt osteoarthritis 
• Concomitant irreparable subscapularis tear 

What is Lower Trapezius Tendon Transfer?

Lower trapezius tendon transfer is a surgical procedure to treat massive, irreparable, posterosuperior rotator cuff tears of the shoulder.

Lower trapezius tendon transfer with incorporation of an Achilles tendon allograft has emerged as an effective way to restore function and provide pain relief in patients with massive rotator cuff tears. A reparable subscapularis tear or an intact subscapularis is a necessary prerequisite for a successful outcome.

The reconstructive procedure generally involves harvesting of the lower trapezius tendon, preparation of the Achilles tendon allograft, and transfer of the lower trapezius tendon to your shoulder. 

Anatomy

The trapezius muscle is a wide, flat and triangular muscle lying just beneath the skin covering the upper back of the shoulders and neck. It includes three parts: the upper trapezius, middle trapezius, and the lower trapezius. 

Lower trapezius tendon is the last part of the trapezius muscle that is attached to your shoulder blade (scapula). It helps in rotating the shoulder and twisting the arm.

A rotator cuff is a group of muscles and tendons that holds the shoulder joint in place and allows movement of the arm and shoulder.

Indications and Contraindications for the Procedure

Indications for the surgery include:

• Young and active patient with irreparable posterior-superior rotator cuff tears
• Persistent pain and shoulder dysfunction with limitations in elevation and external rotation
• Failed conservative treatment
• Motivated patient who is amenable to intensive physical therapy and postoperative immobilization along with full passive range of motion

The surgery is contraindicated in patients with:

• Deltoid deficiency
• Glenohumeral arthritis
• Chronic subscapularis deficiency
• Inability to comply with aggressive rehabilitation protocol
• Physiologically advanced age

Preparation for Surgery

As part of the preparation, your surgeon will:

• Review your medical history to ascertain about disease conditions, previous surgeries, etc.
• Perform a detailed physical examination to check for shoulder motion, external rotation, and subscapularis and scapular strength
• Order appropriate imaging, such as X-ray, CT scan, or MRI to confirm the best method of treatment for your massive rotator cuff tear

Procedure

The procedure can be performed by either open or arthroscopic-assisted techniques. Your surgeon will decide on the best suitable option based on your condition. The procedure is usually performed under general anesthesia and involves the following:

• You are preferably placed in a beach chair position.
• The extremity involved is secured in an arm holder.
• An incision is made below your scapular spine (flat bone in the back of your shoulder).
• Lower trapezius (LT) is exposed by dissecting the subcutaneous tissue under the skin.
• The lowest edge of the LT muscle is mobilized and separated from the underlying tissue.
• The tendon at the edge of the LT muscle is traced and detached from the scapular spine. 
• LT tendon is then prepared with nonabsorbable sutures to ready for the transfer.
• The LT tendon is augmented by weaving it with a ready to use Achilles tendon allograft.
• The torn rotator cuff is removed arthroscopically to create room for the transfer. 
• Any healthy rotator cuff is either partially repaired or secured to the tendon transfer. 
• Sutures attached to the Achilles tendon allograft are passed into the joint. 
• The graft is moved back and forth to ensure adequate opening of the passageway.
• The graft along with the LT tendon is passed below the deltoid (the muscle that covers your shoulder) with adequate tension to secure the tendon.
• The incision is closed in a layered fashion with absorbable sutures.

After Care

As you recover from the procedure, you must protect the reconstruction while the tendon heals. Therefore, you are required to wear a sling and keep your shoulder immobilized. Further, you should strictly avoid using your arm for the first 4 to 6 weeks.   Recovery from lower trapezius tendon transfer is a slow process and you must ensure you follow the prescribed rehabilitation protocol for strengthening muscles and improving range of motion. Strict adherence to prescribed medications, diet, incision site care, and follow-up instructions are strongly advised for a successful recovery.

Risks and Complications of Lower Trapezius Tendon Transfer

Lower trapezius tendon transfer is a relatively safe procedure; however, as with any surgery, there may be some risks and complications, such as:

• Problems related to anesthesia
• Infection
• Damage to nerves and blood vessels
• Persistent pain
• Need for further surgery 

Benefits of Arthroscopic Lower Trapezius Tendon Transfer

Some of the benefits of performing the surgery using minimally invasive methods (arthroscopy) versus open technique include:

• Less postoperative pain
• Less infection risk
• Faster recovery
• Minimal scars
• Small surgical cuts
• Less blood loss
• Improved strength and range of motion