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Novel Arthroscopic Tendon Transfer Techniques for Posterosuperior Rotator Cuff Tears

Key findings

  • Latissimus dorsi (LD) and lower trapezius (LT) tendon transfers are now considered reliable options for treatment of irreparable rotator cuff tears
  • In short-term studies, results of arthroscopic LD transfers have been similar to those of the open techniques, though pain seems to be less with the arthroscopic method (there are no published studies of arthroscopic LT transfers)
  • Surgeons at Mass General published a comprehensive report on how they perform arthroscopic LD and LT tendon transfers
  • Currently, the choice between LD and LT tendon transfer is based on surgeon preference

The ideal treatment for massive irreparable rotator cuff tears is still controversial. In the case of an irreparable posterosuperior rotator cuff tear, though, tendon transfers have proven to have durable outcomes and can now be considered a reliable option. The most commonly used procedures are the latissimus dorsi (LD) and lower trapezius (LT) transfers.

In JBJS Essential Surgical Techniques, Jon J.P. Warner, MD, chief of the Shoulder Service at Massachusetts General Hospital, and colleagues detail how they perform arthroscopic-assisted LD and LT transfers for posterosuperior rotator cuff tears.

The first step in the LD transfer is to harvest the LD tendon from the humeral shaft. The tendon is then transferred intra-articularly, in an interval between the deltoid and the teres minor, and anchored arthroscopically after preparation of the anterolateral aspect of the tuberosity.

LT transfer is performed by harvesting the LT muscle and tendon from its insertion on the medial aspect of the scapular spine. An Achilles tendon allograft is anchored arthroscopically into the anterior aspect of the greater tuberosity and then secured to the LT tendon.

The authors present comprehensive guidance about the novel procedures, including indications, contraindications, preoperative evaluation and planning, negative prognostic factors, patient setup, tendon harvest (with videos), arthroscopic-assisted transfer, closure and postoperative protocols.

Dr. Warner's group found no published peer-reviewed reports on the results of arthroscopic LT transfers, but several short-term studies have shown that outcomes with arthroscopic LD transfers are similar to those of the open techniques.

The surgeons note that the choice between LD and LT tendon transfer for irreparable posterosuperior rotator cuff tears is currently based on surgeon preference because no studies have compared the two using either open or arthroscopic techniques.

However, a biomechanical study has suggested that for a patient whose main functional deficit is external rotation, particularly with the arm at the side, LT transfer would be better than LD transfer. Conversely, a patient whose main deficit is external rotation with the arm at 90° of abduction would benefit more from LD transfer.

Another biomechanical study of a massive rotator cuff model showed that LT transfer was better than LD transfer with regard to restoring glenohumeral kinematics and joint reaction forces in 0°, 30° and 60° of abduction.

A further consideration, the authors note, is that the LD technique has a proven history of success in studies with long-term follow-up. On the other hand, the newer LT transfer has the advantage of in-phase muscle function, since the trapezius naturally contracts during shoulder external rotation.

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At the AAOS Annual Meeting 2018, Jon J.P. Warner, MD, chief of the Shoulder Service at Massachusetts General Hospital, described how he used virtual planning to perform shoulder replacement surgery in a patient with a severe glenoid socket deformity.