Arthroscopically Assisted Latissimus Dorsi Tendon Transfer in Beach-Chair Position

Abstract

Irreparable rotator cuff tears remain a surgical problem. The open technique of latissimus dorsi (LD) tendon transfer to “replace” the irreparable rotator cuff is already well known. The aim of this article is to present a modified arthroscopically assisted LD tendon transfer technique. This technique was adopted to operate on patients in the beach-chair position with several improvements in tendon harvesting and fixation. It can be divided into 6 steps, and only 1 step—LD muscle and tendon release—is performed open. The advantages of the arthroscopic procedure are sparing of the deltoid muscle, the possibility of repairing the subscapularis tendon, and the ability to visualize structures at risk while performing tendon harvesting (radial nerve) and passing into the subacromial space (axillary nerve). It is performed in a similar manner to standard rotator cuff surgery—the beach-chair position does not need any modification, and no sophisticated equipment for either the open or arthroscopic part of the procedure is necessary. Nevertheless, this is a challenging procedure and should only be attempted after training, as well as extensive practice.

Irreparable rotator cuff tears remain a surgical problem, and many controversies remain regarding their treatment. Irreparability can be described as the inability to achieve direct tendon-to-bone repair or as a lack of healing potential that could be predicted by rotator cuff muscular fatty infiltration or atrophy. Christian Gerber described the open technique, and in 1992 presented the results of latissimus dorsi tendon (LDT) transfer—an “extrinsic” shoulder tendon to replace the irreparable rotator cuff.1 The first arthroscopically assisted LDT transfer technique was published by Gervasi et al.² in 2007. The aim of this article is to present a new modified arthroscopic technique adopted to operate on patients in the beach-chair position with several improvements in tendon harvesting and fixation.

Technique

The patient is operated on in the beach-chair position. The shoulder is draped in the same fashion as for conventional shoulder surgery, leaving 8 to 10 cm of free space below the axillary fold for the open part of the procedure. Routine arthroscopy portals are used, comprising the posterior, anterosuperior, posterolateral (PL), and anterolateral (AL) portals, with an additional suprapectoral portal for arthroscopic LDT harvesting and superior G portal for suprascapular nerve release.³ Simple arm traction (3 to 4 kg with a non-elastic tape) is used to slightly distract the subacromial space as in regular rotator cuff repair, and an additional suspension band is placed around the elbow to maintain the arm in overhead abduction during the open part of the surgical procedure. The operation can be divided into 6 steps, 5 of which are arthroscopic and 1 (the fifth step) is open.

Step 1: Joint Inspection

The arthroscope is placed in a standard posterior portal. Joint inspection is started to assess the glenohumeral joint. Long head of the biceps tenotomy is performed if any pathology is found. In case of a subscapularis tendon tear, repair is performed using 1 anchor for a grade 1 or 2 tear and 2 anchors for a grade 3 or 4 tear, according to the classification of Lafosse et al.⁴ If the subscapularis is not repairable, the procedure is discontinued. Depending on the type of subscapularis rupture, a repair is performed during this step or later, when the arthroscope is placed in the lateral portals.

Step 2: Tendon Release and Partial Cuff Repair

The arthroscope is switched to the PL portal. Circumferential rotator cuff release is performed with special attention to the coracohumeral ligament, followed by suprascapular nerve decompression in a standard way.³ At this moment, after complete mobilization and final assessment of the cuff tendons, the definitive decision of whether to perform latissimus dorsi (LD) transfer is made. If the decision is positive, the surgeon performs a partial rotator cuff repair and proceeds to step 3.

Step 3: Creating Space for Transfer Passage Into Subacromial Space

The arthroscope is in the AL portal (Fig 1). Space between the deltoid and posterior cuff—infraspinatus together with teres minor—is created using a shaver from the PL portal. It is important to divide the soft tissue connecting the deltoid and teres minor muscles. Dissection should be continued medial to the glenoid to spare the posterior branch of the axillary nerve (the anterior branch runs more laterally). The arthroscope is then switched from the AL portal to the PL portal, and instruments are introduced from the posterior portal. Following an inferomedial direction, the surgeon is able to dissect the vertical fibers of the long head of the triceps under the glenoid. More medially and inferiorly, after the dissection of some fat tissue in this area, the horizontal fibers of the posterosuperior part of the teres major (TM) muscle are found on the posterior side, opposite the triceps fibers. A standard urinary catheter inserted from the posterior portal is left in this location, and its balloon is inflated for future LDT passage.

Fig 1.

Creation of space for transfer passage into subacromial space. Posterolateral view, with shaver in posterior portal (right shoulder with patient in beach-chair position). The dotted line shows the future dissection plane. (Del, deltoid muscle; pAx, posterior branch of axillary nerve; pLTr, posterior part of long head of triceps tendon; Tm, teres minor muscle.)

Step 4: Arthroscopic LDT Harvesting

The surgeon switches the arthroscope to the anterosuperior portal, looking distally, following the long head of the biceps tendon in its groove (Fig 2). Shaving is performed through the AL portal, until the superior border of the pectoralis major tendon (PM) is clearly visible. Medial to the PM insertion, the circumflex vessels (“3 sisters”) are identified, marking the inferior border of the subscapularis tendon. Just underneath, the superior border of the LDT is visible. At this moment, the suprapectoral portal, just above the PM, is established, and a 1-cm release of the superior part of the PM tendon is performed. This allows the surgeon to bluntly prepare some space between 3 structures: the conjoined tendon anteriorly, the PM laterally, and the LDT posteriorly. Shaving is performed inferiorly to the circumflex vessels (3 sisters) until complete exposure of the LDT fibers, running medial to lateral, is achieved. The radial nerve, found inferiorly and crossing the borders of the LDT and TM tendon 3 to 4 cm medial to their humeral insertion, is a limit for dissection. Tendon dissection is continued as far medially as the arthroscope and shaver length allow. Release with an electrode is performed medially to laterally at the superior and inferior borders. Then, distal release from the humerus at the crista tuberculi minoris is performed with an electrode or osteotome with bone chips. The tendon is reflected medially for easier grasping later.

Fig 2.

Arthroscopic latissimus dorsi tendon harvesting. Anterior view from anterosuperior portal, looking inferiorly in plane of humerus (right shoulder with patient in beach-chair position). An electrode is in the suprapectoral portal. The superior part of the latissimus dorsi tendon insertion has just been released, with the inferior part still attached. (Con, conjoined tendon; PecM, pectoralis major tendon; pLDT, partially released latissimus dorsi tendon; Rn, radial nerve; TBL, biceps longus tendon; 3S, 3 sisters [anterior circumflex vessels]; TM, teres major muscle.)

Step 5: Open Dissection of LDT and LD Muscle

The arm is removed from traction and fully abducted—a traction band is suspended in the overhead position using a solid anesthesiology frame around the patient's head for fixation (Fig 3). A 4- to 6-cm straight vertical incision is performed in the middle of the posterior half and distally to the axillary fold. The subcutaneous tissue is divided until the “white tissue” of the LDT is found and followed anteriorly to the LD border. Then, dissection is continued superiorly until the previously arthroscopically released tendon is visible. If the tendon has been properly liberated during arthroscopy, it will “pop out” easily without the need for dissection at its humeral insertion. The tendon edges are then grasped with 2 clamps, which facilitate the placement of 2 pairs of Krackow stitches along the medial and lateral border. This is achieved using 2 different-colored sutures taken from 2 Healix (DePuy Synthes, Warsaw, IN) or Corkscrew FTII (Arthrex, Naples, FL) anchors. The LD muscle is released proximally until it is possible to reach the posterior part of the acromion with the LDT end. Care must be taken during anterior muscle belly release because of the neurovascular bundle insertion—about 6 to 8 cm proximal to the musculotendinous junction. The interval between the TM posterosuperior border and the posterior border of the deltoid is then bluntly opened, and the Foley catheter balloon is extracted. Sutures from the LD are attached to the catheter that serves as a shuttle relay. The LDT is then passed into the subacromial space with the catheter pulled out through the posterior portal. It is important to control the sutures to avoid twisting the tendon. Because the tendon is already in the subacromial space in the proper orientation, the sutures are kept under tension by clamping above the posterior portal. The axillary incision is closed in a standard manner over a suction drain. The arm is released from the overhead position and is left in a position of flexion with 3 to 4 kg of traction.

Fig 3.

Open dissection of latissimus dorsi tendon and muscle (right shoulder with patient in beach-chair position). The arm is fully abducted. The posterior border of the deltoid is pulled up with a retractor. (AF, axillary fold; B, balloon of Foley catheter; LD, latissimus dorsi with 2 Krackow stitches; TM, teres major.)

Step 6: Arthroscopic Fixation of LDT

The arthroscope is in the AL portal. The hematoma is washed out (Fig 4, Fig 5). The top of the greater tuberosity has already been debrided until a bleeding surface has been achieved. The medial LDT suture first and the lateral LDT suture second are brought into the anterior portal, and LD excursion is checked. The first anchor is positioned just posterior to or into the biceps groove in proximity to the humeral head cartilage (medial row). The remaining suture in the anchor and the medial suture from the LD are withdrawn together through the anterior portal. The LD suture is then passed through the anchor suture with a round-edge “naked” needle. The anchor suture is then used as a shuttle relay to pull the LD suture back into the anchor. The lateral anchor is inserted 2 to 3 cm laterally into the greater tuberosity surface (lateral row), and the lateral LD suture is managed in the same way. Knots are tied with the patient's arm kept in maximum external rotation. The remaining medial anchor suture is left for additional supraspinatus remnant repair. Gentle acromioplasty with coracoacromial ligament preservation and acromioclavicular joint resection in case of massive arthrosis are performed in a standard manner. Video 1 shows the described procedure from posterior dissection through subacromial LDT fixation.

Fig 4.

Latissimus dorsi tendon (LD) pulled into posterior portal (P). Subacromial view from posterolateral portal (right shoulder with patient in beach-chair position). (Del, deltoid muscle; INF, remnant of infraspinatus.)

Fig 5.

Final view from anterolateral portal (right shoulder with patient in beach-chair position). The latissimus dorsi tendon is fixed onto the top of the greater tuberosity (GT). The rotator cuff remnants (RC) are approximated to the medial edge of the transfer to close the joint space. (LDT, transferred latissimus dorsi tendon.)

Postoperative Protocol and Rehabilitation

The arm is immobilized using an abduction pillow in neutral rotation for 8 weeks. Self-assisted passive exercises in the supine position are started after 3 weeks. After 8 weeks, slow active rehabilitation is supervised by the physiotherapist. The first goal is to restore range of motion—passive flexion and gentle water exercises are recommended. After 4 months, if overhead flexion is possible, slow strengthening exercises are started.

Discussion

LDT transfer remains controversial. The results depend on many factors, but the integrity of the deltoid and subscapularis muscles seems to be especially important. According to Warner and Parsons,⁵ the adjusted Constant score reached only 43% in deltoid-deficit patients, as compared with 69% in the deltoid-intact group. In a study by Gerber,¹ the patients with subscapularis insufficiency had a Constant score of 49%, as compared with 85% in the subscapularis-intact group. An arthroscopic technique permits the surgeon to avoid this problem—it preserves the deltoid and allows subscapularis repair. Another advantage is proper visualization of the axillary nerve branches that allows the surgeon to control LDT passage into the subacromial space. Exact catheter placement permits avoidance of both nerve injury and blind massive preparation between the deltoid and TM. Another advantage of the arthroscopic technique is harvesting of the LDT in flexion and slight adduction: In this position, the axillary and radial nerves are at the safest distance from the tendon insertion.⁶ Moreover, visualization of the radial nerve in the arthroscopically harvested LDT is easier than in the open manner. Table 1 describes all the key factors of our technique, showing both the advantages and disadvantages. This technique differs from recently published techniques7, 8 in that it is performed with the patient in the beach-chair position and LDT dissection is performed fully arthroscopically, not “semi-blindly” as in open procedures. Although our technique does not allow entirely arthroscopic LDT transfer, we believe the technique is a step forward toward achieving this goal.

Table 1.

Key Factors Showing Advantages and Disadvantages of Technique

	Advantages	Disadvantages
Position	Beach chair; no need for any modification during surgery	None
Equipment	No specific tools other than surgeon's preferred tools for open and arthroscopic repair	None
Technical pitfalls of arthroscopy	Partial cuff repair and SSN release Creating space for transfer passage—visualization of posteriori branch of axillary nerve, staying medially to this branch LDT cut off from bone allows possibility to visualize and stay away from radial nerve and to maintain maximum possible tendon length (even to harvest tendon with bone chips) Graft fixation allows sparing of deltoid	Excellent arthroscopic skills and topographic anatomy knowledge are crucial (important to localize axillary and radial nerves, 3 sisters, conjoined tendon, and pectoralis major tendon)
Open part of technique	Relatively small incision in potentially contaminated area; no need for massive semi-blind dissection	None
Length of surgical procedure		Time-consuming surgery, especially initially (>180 min); operative time and open part of technique could become risk factors for infection

LDT, latissimus dorsi tendon; SSN, suprascapular nerve.

In a recent study by Tauber et al.,⁹ LD harvesting with bone chips showed better results because of a lower rate of late LDT rupture. In the last few cases, LDT harvesting was performed with bone chips under direct arthroscopic visualization. Late tendon rupture developed in 2 patients in our group, and we hope to limit this number in the future by achieving better fixation. This technique has been performed at our institutions since 2009 in more than 50 cases, and early results will be published soon. We believe that this technique is reproducible and yields promising early results. It can be performed in a similar manner to standard rotator cuff surgery—the beach-chair position does not need any modification, which is very comfortable for both the surgeon and anesthesiologist, and no sophisticated equipment is necessary. Nevertheless, the procedure is lengthy and a thorough knowledge of the structures at risk is very important, so the technique should be considered an advanced arthroscopic technique with a long learning curve.

Supplementary Data

Video 1

Posterior release (step 3) through subacromial latissimus dorsi tendon fixation (step 6). A right shoulder is shown, with the patient in the beach-chair position. The arthroscope is in the anterolateral portal initially and is later switched to the posterolateral and anterosuperior portals during dissection. Finally, fixation of the latissimus dorsi tendon is performed, viewing from the lateral portals.