- Email: [email protected]
High Clinical Failure Rate After Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears
High Clinical Failure Rate After Latissimus Dorsi Transfer for Revision Massive Rotator Cuff Tears Lukas N. Muench, M.D., Cameron Kia, M.D., Ariel A. Williams, M.D., Daniel M. Avery III, M.D., Mark P. Cote, D.P.T., Nicholas Reed, M.D., Robert A. Arciero, M.D., Rajiv Chandawarkar, M.D., and Augustus D. Mazzocca, M.S., M.D.
Purpose: To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. Methods: We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1 year were included in the study. The indications for inclusion were large (2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (D in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure. Results: A total of 22 patients (mean age, 53 6 years) were included in the study, with a mean follow-up time of 3.4 1.1 years. Over 63% of patients (n ¼ 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 21.9 preoperatively to 55.8 22.9 postoperatively, P ¼ .001), Simple Shoulder Test scores (from 3.5 3.1 preoperatively to 5.2 3.4 postoperatively, P ¼ .002), and pain scores (from 5.9 2.8 preoperatively to 4.6 4.3 postoperatively, P ¼ .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n ¼ 3) after a mean of 2.7 years, and the clinical failure rate was 41% (n ¼ 9) at final follow-up. An acromiohumeral interval of less than 7 mm (P ¼ .04) and high-grade fatty infiltration (grade 3 or greater, P ¼ .004) were significant preoperative risk factors for clinical failure. Conclusions: Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure. Level of Evidence: Level IV.
See commentary on page 95
R
otator cuff tears are a common clinical dilemma, with an incidence of over 54% in patients aged 60 years or older.1 The ideal treatment of large or massive rotator cuff tears is still not completely understood, with retear rates as high as 94% having been reported after primary repair.2 Failure of the tendon to
heal can result in pain, disability, and increased risk of osteoarthritis.3,4 Revision surgery for failed rotator cuff repair is fraught with intraoperative challenges; loss of elasticity, atrophy, and retraction of the remaining tendon have led several experts to abandon any attempt at revision
From the Department of Orthopaedic Surgery, UConn Health Center (L.N.M., C.K., M.P.C., R.A.A., A.D.M.), Farmington, Connecticut, U.S.A.; Department of Orthopaedic Sports Medicine, Technical University of Munich (L.N.M.), Munich, Germany; Department of Orthopaedic Surgery, University of Minnesota (A.A.W.), Minneapolis, Minnesota, U.S.A.; OrthoSports Associates (D.M.A.), Birmingham, Alabama, U.S.A.; Associates in Orthopedics and Sports Medicine (N.R.), Dalton, Georgia, U.S.A.; and The Ohio State University Wexner Medical Center (R.C.), Columbus, Ohio, U.S.A. This investigation was performed at the Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A. The authors report the following potential conflicts of interest or sources of funding: D.M.A. receives consulting fees from Dunamis Medical. M.P.C. receives personal fees from the Arthroscopy Association of North America
(Arthroscopy). R.A.A. receives research support from Arthrex and consulting fees from Biorez. A.D.M. is a paid consultant for and receives research support from Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received April 9, 2019; accepted July 24, 2019. Address correspondence to Cameron Kia, M.D., Department of Orthopaedic Surgery, UConn Health Center, 263 Farmington Ave, Farmington CT 06032, U.S.A. E-mail: [email protected] Ó 2019 by the Arthroscopy Association of North America 0749-8063/19460/$36.00 https://doi.org/10.1016/j.arthro.2019.07.034
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Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 36, No 1 (January), 2020: pp 88-94
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repair.3,5-8 Although reverse total shoulder arthroplasty is a viable option, early loosening and a high complication rate in young and active patients make the procedure less desirable.8,9 In the absence of glenohumeral arthritis, superior capsule reconstruction has been proposed for the treatment of massive, irreparable posterosuperior rotator cuff tears; however, this technique has been shown to be limited in restoring sufficient external rotation.10,11 To circumvent this problem, transfer of the latissimus dorsi tendon has been described for use in this patient population.12-15 First described by Gerber et al.,16 latissimus dorsi transfer has shown promising results for massive rotator cuff tears in several studies.4,9,17 However, open latissimus dorsi transfer comes with the inherent risk of wound complications, axillary or brachial nerve dysesthesia, or potential damage to the deltoid muscle.18 In addition, studies have suggested that patients undergoing tendon transfer as a salvage revision procedure have worse outcomes than when it is performed in the primary setting.18,19 These studies, however, were limited in their sample sizes and did not examine predictors of clinical failures.19,20 The purpose of this study was to evaluate the clinical success rate, along with preoperative factors for risk of failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. We hypothesized that latissimus dorsi transfer would result in a substantial improvement in clinical outcomes.
Methods This was a retrospective review of prospectively collected data from patients undergoing latissimus dorsi transfer for rotator cuff tears by a single shoulder fellowshipetrained surgeon (A.D.M.) between 2006 and 2013. Data were collected through a global shoulder outcome study, which was approved by the institutional review board (No. 13-151-1). The indications for study inclusion were patients aged 18 years or older with large (involvement of 2 tendons), retracted, chronic rotator cuff tears with either fatty infiltration or atrophy in whom prior surgical treatment and conservative management had failed. Patients were included regardless of smoking status, medical comorbidities, or socioeconomic factors. We excluded patients with glenohumeral arthritis (Hamada grade 3), less than 1 year of followup, or preoperative pseudoparalysis; those without preoperative clinical outcome scores; and those with no prior attempt at rotator cuff repair. A minimum followup period of 1 year was considered sufficient because previous studies reported clinical failure to occur at an average of 19 months after surgery.19 All alternative options were discussed with patients, including continued conservative treatment or attempted
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arthroscopic repair. Reverse total shoulder arthroplasty was recommended for patients older than 70 years. Diagnostic Imaging All patients underwent preoperative radiography (true anteroposterior view, axillary lateral view, and scapular Y view) and magnetic resonance imaging (MRI) of the involved shoulder. On radiographs, the acromiohumeral interval was measured as the distance between the humeral head and the undersurface of the acromion on the true anteroposterior view. On MRI, tendon retraction was quantified on coronal T2 fatsaturated images using the Patte classification system (A, minimal retraction; B, retraction to humeral head; or C, retraction to glenoid).21 Fatty infiltration was assessed on T1 sagittal oblique views and divided into 5 categories based on the presence of fatty streaks within the supraspinatus muscle belly using the Goutallier staging system, which was originally described using computed tomography but is now commonly applied to MRI.22 Muscle atrophy on sagittal oblique images was classified into 4 categories, with 0 representing none and 3 representing severe, according to the system of Tingart et al.23 Surgical Technique: Latissimus Dorsi Transfer To maximize the surgical technique of latissimus dorsi transfer, a team approach was taken to enhance speed, reproducibility, and outcomes. All surgical procedures in this study were performed by a single fellowshiptrained shoulder surgeon (A.D.M.). A single plastic surgeon (R.C.) assisted with the latissimus harvest, tunneling, and closure. Latissimus dorsi transfer was performed as originally described by Gerber et al.16 in 1988. In brief, the procedure was performed with the patient in the lateral decubitus position. A transverse incision was made along the inferior border of the scapula and taken down to the latissimus muscle. The latissimus was identified and mobilized, with care taken to protect the neurovascular pedicle. The rotator cuff was approached via a saber incision centered along the lateral edge of the acromion, parallel to the Langer lines. The dissection was then taken down to the deltopectoral fascia, and the anterior, middle, and posterior heads of the deltoid were identified. To preserve the deltoid’s attachment to the acromion as much as possible, a 2-mm lateral acromial osteotomy was made using a microsagittal saw and an osteotome to mobilize the middle head of the deltoid and expose the underlying rotator cuff defect.16 The latissimus tendon was then delivered into the subacromial space and proximal humerus via a tunnel through the plane between the external rotators and deltoid. The transferred tendon was fixed to a bony trough in the superior greater tuberosity with suture anchors. If possible, the remaining rotator cuff was repaired to the transferred tendon. The
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acromial osteotomy was repaired meticulously with high-strength No. 2 suture (FiberWire; Arthrex, Naples, FL) through bone tunnels. The anterior and posterior deltoid heads were repaired to the anterior and posterior attachment with No. 0 Ethibond (Ethicon, Somerville, NJ). The anterior deltoid raphe and posterior deltoid raphe were then closed with No. 0 Vicryl (Ethicon). Finally, the incision for the latissimus harvest was closed over a drain. Postoperatively, patients were placed in an Ortho Immobile abduction orthosis (Otto Bock, Austin, TX) in 60 of abduction and neutral external rotation for a minimum of 8 weeks. Subsequently, they were allowed to start passive range of motion without limitations until 12 weeks postoperatively, followed by activeassisted motion in all planes until 20 to 24 weeks. After that point, strengthening and active range-ofmotion exercises were initiated without limitation. Clinical Outcome Measures American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores were collected preoperatively and postoperatively. Single Assessment Numerical Evaluation scores were collected only postoperatively at follow-up visits.24 Pain scores were obtained from the ASES survey. Besides, preoperative and postoperative range of motion (forward elevation, abduction, and external rotation) was physically examined. Statistics An a priori power analysis was performed. Assuming a standard deviation of 20 points, a sample size of 13 would provide 80% power to detect a 17-point difference between preoperative and postoperative ASES scores at an a level of .05.25 Descriptive statistics were calculated as mean and standard deviation or frequency. Preoperative and postoperative ASES and SST scores, as well as the difference between preoperative and postoperative scores (D), were compared using a nonparametric equivalent to the paired t test where appropriate. For patients who underwent revision surgery after latissimus transfer, the final outcome scores obtained prior to revision were used for analysis. At latest follow-up, patients who had not required further revision surgery and whose ASES scores were improved from preoperative values by a clinically significant amount (defined as D in ASES score 17) were categorized as clinical successes.23 Patients who did not meet these criteria were categorized as clinical failures. Logistic regression was performed to create odds ratios (ORs) to evaluate the relation between clinical failure and the following variables: acromiohumeral interval, sex, diabetes, smoking status, age, body mass index, involvement of dominant arm, number of previous failed rotator cuff repairs, tear characteristics, and
Workers’ Compensation at the time of latissimus transfer. P < .05 was considered statistically significant. The distribution of ASES scores was examined graphically with a histogram and appeared to be slightly right skewed. Statistical tests of normality were also carried out, which were at the level of statistical significance (P ¼ .05). To ensure we had adequately examined the hypothesis of a positive change in clinical outcome scores from preoperatively to postoperatively, the signed rank test (nonparametric equivalent to the paired t test) was also run to compare the scores. This resulted in P ¼ .001, P ¼ .002, and P ¼ .002 for the ASES, SST, and pain scores, respectively.
Results Subjects In a single surgeon’s practice, 37 patients underwent latissimus dorsi transfer between November 2006 and March 2013. Of these patients, 8 were initially excluded because they had single-tendon tears and 2 were excluded for not having preoperative ASES or SST scores. In addition, we excluded 2 patients because they had not undergone prior rotator cuff repair surgery and 3 patients because they had less than 1 year of followup. Thus, the final study group comprised 22 latissimus transfer patients (Fig 1). The mean age of the included patients was 53 6 years, and the average follow-up period was 3.4 years (range, 1.1-7.1 years) (Table 1). Most patients were men and had undergone 2 or more previous rotator cuff repairs. Radiographic Analysis Although all patients had radiographs and MRI scans obtained prior to surgery, at the time of analysis, preoperative MRI scans were available for only 19 of 22 patients. All patients had at least grade 1 fatty infiltration or supraspinatus atrophy, with most patients having retraction of the cuff to the humeral head (Patte stage 2) (Table 2). The average preoperative acromiohumeral interval was 6.6 3.4 mm. Clinical Outcome Overall, significant improvement was noted in ASES scores (35.2 21.9 preoperatively vs 55.8 22.9 postoperatively; D, 20.1 23.1; P ¼ .001) (Fig 2) and SST scores (3.5 3.1 preoperatively vs 5.2 3.4 postoperatively; D, 2.1 2.7; P ¼ .002) (Fig 3). Pain scores improved postoperatively as well (5.9 2.8 preoperatively vs 4.6 4.3 postoperatively; D, 2.4 2.7; P ¼ .002). Postoperative Single Assessment Numerical Evaluation scores varied widely among all patients (mean, 43 38). Regarding range of motion, significant improvements were found in the degree of forward elevation (88 20 preoperatively vs 124 50 postoperatively,
LATISSIMUS TRANSFER FOR REVISION CUFF TEAR
Fig 1. Potential included in study.
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patients
P ¼ .005) and external rotation (21 14 preoperatively vs 46 26 postoperatively, P ¼ .004) at final follow-up. However, range of abduction motion did not improve significantly (82 18 preoperatively vs 92 48 postoperatively, P ¼ .323). Comparing patients with clinical success versus those with failure, we found no significant differences in preoperative-topostoperative improvements regarding forward elevation (D, 49 46 in success group vs 20 42 in failure group; P ¼ .092), abduction (D, e8 48 in success group vs e12 35 in failure group; P ¼ .857), or external rotation (D, 28 34 in success group vs 19 23 in failure group; P ¼ .607). Complications and Revisions The revision rate after latissimus transfer was 13.6% (3 patients), with 3 reverse total shoulder arthroplasties. Revisions occurred on average 2.7 years (range, 0.8-5.7 years) after tendon transfer. The complication rate was 27% (6 patients), which included
2 deep infections, 2 ulnar neuropathies at the elbow believed to be due to the sling, and 2 neuromas. Both neuromas were located in the area of the latissimus harvest site, causing significant pain. Electromyography in 1 patient showed suprascapular neuropathy, and excision was required. The other neuroma resolved without treatment. Clinical Failure Characteristics An ASES score D of less than 17 was defined as clinical failure.25 On the basis of this criterion, 41% of patients (n ¼ 9) reported clinical failure at follow-up. A preoperative acromiohumeral interval of less than 7 mm was a significant risk factor for failure (OR, 7.86; 95% confidence interval, 1.1-56.1; P ¼ .04) (Table 3). Clinical failure occurred in all patients with fatty infiltration of grade 3 or higher. In contrast, failure occurred in only 1 of 11 patients (9.1%) with grade 1 or 2 fatty infiltration; thus, preoperative high-grade fatty infiltration was a significant risk factor for failure (OR, 72;
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Table 1. Patient Demographic Characteristics (N ¼ 22) Data Sex, n (%) Male Female Age, mean SD, yr BMI, mean SD Involved side, n (%) Dominant Nondominant Smoking, n (%) Diabetes, n (%) No. of prior cuff repairs, n (%) 1 2
14 (64) 8 (36) 53 6 33.9 5.5 15 7 7 5
(68) (32) (32) (23)
8 (36) 14 (64)
BMI, body mass index; SD, standard deviation.
95% confidence interval, 3.8-1,349.5; P ¼ .004). Smoking, diabetes, sex, age, body mass index, number of previous failed rotator cuff repairs, involvement of dominant arm, or Workers’ Compensation at the time of surgery were not found to be significant risk factors for failure (Table 3).
Discussion This study found that despite an overall statistical improvement in outcomes, clinical failure was found in 41% of patients who underwent latissimus dorsi transfer as a salvage procedure after failed rotator cuff repair. Moreover, an acromiohumeral interval of 6 mm or less was a significant predictor of clinical failure and revision surgery. Salvage procedures for massive, irreparable rotator cuff tears in the young and active population are limited, without a clear understanding of which
Fig 2. Preoperative (Pre-Op) and postoperative (Post-Op) American Shoulder and Elbow Surgeons (ASES) scores. The asterisk indicates P < .05.
procedure is ideal.26,27 Warner and Parsons19 reported on latissimus dorsi transfer as a salvage procedure for rotator cuff repair. They compared the outcomes of patients who underwent latissimus dorsi transfer as a salvage procedure for previously failed prior rotator cuff repair versus patients who underwent primary tendon transfer without a prior repair attempt. Latissimus dorsi transfer as a salvage reconstruction procedure resulted in significantly worse outcomes with a late rupture rate of 44% compared with 17% for primary transfers at 19 months. It was later recommended to augment the latissimus dorsi transfer with a fascia lata autograft to prevent this late complication.28 Despite taking special precautions to optimize the surgical technique of latissimus dorsi transfer, the results found in our study were inferior to those reported by other authors in terms of outcome scores, complication rates, and pain scores.13,14,29 However, direct comparison to previous
Table 2. Preoperative Rotator Cuff Tear Characteristics (N ¼ 22) No. of tendons involved 2 3 Retraction Little to none Humeral head Glenoid Fatty infiltration Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Atrophy (supraspinatus) None Mild Moderate Severe
n
%
18 of 22 4 of 22
82 18
0 of 19 11 of 19 8 of 19
0 58 42
0 5 6 6 2
of of of of of
19 19 19 19 19
0 26 32 32 11
4 5 9 1
of of of of
19 19 19 19
21 26 47 6
Fig 3. Preoperative (Pre-Op) and postoperative (Post-Op) Simple Shoulder Test (SST) scores. The asterisks indicate P < .05.
LATISSIMUS TRANSFER FOR REVISION CUFF TEAR Table 3. Risk Factors for Clinical Failure at Final Postoperative Assessment Risk Factor AHI <7 mm Male sex Workers’ Compensation Smoking Diabetes Age BMI Dominant arm involved 2 previous failed cuff repairs Fatty infiltration grade 3 Retraction to glenoid level Supraspinatus atrophy grade 2
OR 7.86 1.13 4.4 0.15 0.95 1.1 0.93 6.9 1.67 72 2.9 3.0
95% CI 1.1-56.1 0.18-6.9 0.6-32.5 0.01-1.5 0.12-7.3 0.97-1.3 0.79-1.1 0.66-71.7 0.25-11.1 3.8-1,349.5 0.44-19.2 0.46-19.6
P Value .04* .90 .15 .11 .96 .11 .39 .11 .60 .004* .27 .25
AHI, acromiohumeral interval; BMI, body mass index; CI, confidence interval; OR, odds ratio. *Significant risk factor for clinical failure.
studies in the literature is difficult because they did not use the same outcome measure used in our study (ASES score); in addition, these studies only reported the final mean outcome score without establishing the percentage of patients who actually significantly benefited from the procedure.13,14,29 Although all cases included the assistance of a plastic surgeon with special expertise in latissimus flaps, we found a clinical failure rate of roughly 41%, along with a complication rate of 27%. Miniaci and MacLeod30 reported on 17 patients who underwent latissimus transfer for the treatment of failed repairs of massive rotator cuff tears and found that the patients’ average subjective functional rating on a visual analog scale was only 56.1 mm at a minimum of 2 years’ follow-up. Furthermore, the patients in our study underwent prior arthroscopic rotator cuff repairs, with some undergoing up to 4 previous surgical procedures before tendon transfer. Pagani et al.31 recently described an augmentation to the latissimus tendon transfer technique for patients with a decreased acromiohumeral interval and severe muscle atrophy. They recommended performing an acromial osteotomy to limit disruption of the deltoid tendon and an augmentation repair using a collagen matrix. Sidler-Maier et al.32 presented preliminary outcomes using a bursal sideeonly dermal augmentation in patients with massive posterosuperior tears. At a mean follow-up of 27 months, patients reported significant improvements in forward flexion and all but 1 of the 24 patients reported being “satisfied” with their operation. The authors did not find previous surgery, tendon retraction, or atrophy to have an effect on postoperative motion.32 Although reverse total shoulder arthroplasty is a viable salvage procedure, implant longevity and failure preclude the use of arthroplasty in this young and active population.33 Whereas latissimus dorsi tendon transfer is thought to restore external rotation and re-establish the anterior-posterior force couples on the humeral head,
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the orientation of the tenodesis places a nonphysiological vector across the shoulder joint.33 This may be a reason for the high progression of osteoarthritis that has been described after the procedure.13,34 Elhassan et al.35 described the use of a lower trapezius tendon transfer with an Achilles allograft augmentation in patients with irreparable rotator cuff tears. Their case series found that patients had significant improvements in pain and range of motion with limited postoperative complications. The better anatomic position of the lower trapezius transfer provides biomechanical advantages to the latissimus tendon transfer; however, further comparative studies are needed. Limitations There were several limitations to the study. Although data were collected prospectively, the chart review was performed retrospectively, which could create selection bias. The sample size was limited because only patients with previously failed rotator cuff repairs were included in the study. In addition, with reporting on the outcomes of only a single surgeon’s practice, external validity may be limited in terms of both patient population and surgical technique. Finally, several patients did not have a full 2-year follow-up period, and repeated MRI or ultrasound was not available to evaluate the status of the repaired tendon.
Conclusions Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure.
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7. Shamsudin A, Lam PH, Peters K, Rubenis I, Hackett L, Murrell GA. Revision versus primary arthroscopic rotator cuff repair: A 2-year analysis of outcomes in 360 patients. Am J Sports Med 2015;43:557-564. 8. Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006;88:1742-1747. 9. Ek ET, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: Results after five to fifteen years. J Shoulder Elbow Surg 2013;22:1199-1208. 10. Burkhart SS, Denard PJ, Adams CR, Brady PC, Hartzler RU. Arthroscopic superior capsular reconstruction for massive irreparable rotator cuff repair. Arthrosc Tech 2016;5:e1407-e1418. 11. Catapano M, de Sa D, Ekhtiari S, Lin A, Bedi A, Lesniak BP. Arthroscopic superior capsular reconstruction for massive, irreparable rotator cuff tears: A systematic review of modern literature. Arthroscopy 2019;35:1243-1253. 12. Tauber M, Moursy M, Forstner R, Koller H, Resch H. Latissimus dorsi tendon transfer for irreparable rotator cuff tears: A modified technique to improve tendon transfer integrity: Surgical technique. J Bone Joint Surg Am 2010;92:226-239 (suppl 1, pt 2). 13. Namdari S, Voleti P, Baldwin K, Glaser D, Huffman GR. Latissimus dorsi tendon transfer for irreparable rotator cuff tears: A systematic review. J Bone Joint Surg Am 2012;94:891-898. 14. Gerber C, Rahm SA, Catanzaro S, Farshad M, Moor BK. Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years. J Bone Joint Surg Am 2013;95:1920-1926. 15. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res 1992:152-160. 16. Gerber C, Vinh TS, Hertel R, Hess CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. A preliminary report. Clin Orthop Relat Res 1988;(232):51-61. 17. Piasecki DP, Verma NN, Nho SJ, et al. Outcomes after arthroscopic revision rotator cuff repair. Am J Sports Med 2010;38:40-46. 18. Gerber C, Maquiera G, Espinosa N. Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Bone Joint Surg Am 2006;88:113-120. 19. Warner JJ, Parsons IM IV. Latissimus dorsi tendon transfer: A comparative analysis of primary and salvage reconstruction of massive, irreparable rotator cuff tears. J Shoulder Elbow Surg 2001;10:514-521. 20. Valenti P, Kalouche I, Diaz LC, Kaouar A, Kilinc A. Results of latissimus dorsi tendon transfer in primary or salvage reconstruction of irreparable rotator cuff tears. Orthop Traumatol Surg Res 2010;96:133-138.
21. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res 1990;(254):81-86. 22. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res 1994;(304):78-83. 23. Tingart MJ, Apreleva M, Lehtinen JT, Capell B, Palmer WE, Warner JJ. Magnetic resonance imaging in quantitative analysis of rotator cuff muscle volume. Clin Orthop Relat Res 2003;(415):104-110. 24. Makhni EC, Steinhaus ME, Morrow ZS, et al. Outcomes assessment in rotator cuff pathology: What are we measuring? J Shoulder Elbow Surg 2015;24:2008-2015. 25. Tashjian RZ, Deloach J, Green A, Porucznik CA, Powell AP. Minimal clinically important differences in ASES and simple shoulder test scores after nonoperative treatment of rotator cuff disease. J Bone Joint Surg Am 2010;92:296-303. 26. Thon SG, O’Malley LK, O’Brien MJ, Savoie FH. Preliminary results with the use of a bioinductive collagen patch in the setting of large massive rotator cuff tears. Arthroscopy 2018;34:e5 (suppl). 27. Delaney RA, Lin A, Warner JJ. Nonarthroplasty options for the management of massive and irreparable rotator cuff tears. Clin Sports Med 2012;31:727-748. 28. Djurasovic M, Marra G, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am 2001;83:1849-1855. 29. El-Azab HM, Rott O, Irlenbusch U. Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. J Bone Joint Surg Am 2015;97:462-469. 30. Miniaci A, MacLeod M. Transfer of the latissimus dorsi muscle after failed repair of a massive tear of the rotator cuff. A two to five-year review. J Bone Joint Surg Am 1999;81:1120-1127. 31. Pagani NR, Cusano A, Li X. Latissimus dorsi tendon transfer with acromial osteotomy for massive irreparable rotator cuff tear. Arthroscopy 2018;7:e105-e112. 32. Sidler-Maier CC, Mutch JA, Sidler M, Leivadiotou D, Payandeh JB, Nam D. Augmented latissimus dorsi transfer: Initial results in patients with massive irreparable posterosuperior rotator cuff tears. Shoulder Elbow 2019;11: 59-67 (suppl). 33. Omid R, Heckmann N, Wang L, McGarry MH, Vangsness CT, Lee TQ. Biomechanical comparison between the trapezius transfer and latissimus transfer for irreparable posterosuperior rotator cuff tears. J Shoulder Elbow Surg 2015;24:1635-1643. 34. Aoki M, Okamura K, Fukushima S, Takahashi T, Ogino T. Transfer of latissimus dorsi for irreparable rotator-cuff tears. J Bone Joint Surg Br 1996;78:761-766. 35. Elhassan BT, Wagner ER, Werthel JD. Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear. J Shoulder Elbow Surg 2016;25:1346-1353.
Purpose: To evaluate the clinical success rate, along with risk factors for failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. Methods: We performed a retrospective chart review of prospectively collected data from an institutional shoulder outcome registry. All patients who underwent latissimus dorsi transfer for previously failed rotator cuff repair between 2006 and 2013 with a minimum follow-up period of 1 year were included in the study. The indications for inclusion were large (2 tendons), retracted, chronic rotator cuff tears with fatty infiltration or atrophy for which prior surgical repair had failed. Preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores were collected, along with postoperative Single Assessment Numerical Evaluation scores. Complications and clinical failures (D in ASES score <17) were recorded. Patient demographic and tear characteristics were evaluated as potential risk factors for failure. Results: A total of 22 patients (mean age, 53 6 years) were included in the study, with a mean follow-up time of 3.4 1.1 years. Over 63% of patients (n ¼ 14) reported undergoing 2 or more prior failed rotator cuff repairs. Patients undergoing latissimus dorsi transfer showed significant improvements in ASES scores (from 35.2 21.9 preoperatively to 55.8 22.9 postoperatively, P ¼ .001), Simple Shoulder Test scores (from 3.5 3.1 preoperatively to 5.2 3.4 postoperatively, P ¼ .002), and pain scores (from 5.9 2.8 preoperatively to 4.6 4.3 postoperatively, P ¼ .002) at final follow-up. The complication rate after latissimus transfer was 27%. The rate of revision to reverse total shoulder arthroplasty was 13.6% (n ¼ 3) after a mean of 2.7 years, and the clinical failure rate was 41% (n ¼ 9) at final follow-up. An acromiohumeral interval of less than 7 mm (P ¼ .04) and high-grade fatty infiltration (grade 3 or greater, P ¼ .004) were significant preoperative risk factors for clinical failure. Conclusions: Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure. Level of Evidence: Level IV.
See commentary on page 95
R
otator cuff tears are a common clinical dilemma, with an incidence of over 54% in patients aged 60 years or older.1 The ideal treatment of large or massive rotator cuff tears is still not completely understood, with retear rates as high as 94% having been reported after primary repair.2 Failure of the tendon to
heal can result in pain, disability, and increased risk of osteoarthritis.3,4 Revision surgery for failed rotator cuff repair is fraught with intraoperative challenges; loss of elasticity, atrophy, and retraction of the remaining tendon have led several experts to abandon any attempt at revision
From the Department of Orthopaedic Surgery, UConn Health Center (L.N.M., C.K., M.P.C., R.A.A., A.D.M.), Farmington, Connecticut, U.S.A.; Department of Orthopaedic Sports Medicine, Technical University of Munich (L.N.M.), Munich, Germany; Department of Orthopaedic Surgery, University of Minnesota (A.A.W.), Minneapolis, Minnesota, U.S.A.; OrthoSports Associates (D.M.A.), Birmingham, Alabama, U.S.A.; Associates in Orthopedics and Sports Medicine (N.R.), Dalton, Georgia, U.S.A.; and The Ohio State University Wexner Medical Center (R.C.), Columbus, Ohio, U.S.A. This investigation was performed at the Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A. The authors report the following potential conflicts of interest or sources of funding: D.M.A. receives consulting fees from Dunamis Medical. M.P.C. receives personal fees from the Arthroscopy Association of North America
(Arthroscopy). R.A.A. receives research support from Arthrex and consulting fees from Biorez. A.D.M. is a paid consultant for and receives research support from Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received April 9, 2019; accepted July 24, 2019. Address correspondence to Cameron Kia, M.D., Department of Orthopaedic Surgery, UConn Health Center, 263 Farmington Ave, Farmington CT 06032, U.S.A. E-mail: [email protected] Ó 2019 by the Arthroscopy Association of North America 0749-8063/19460/$36.00 https://doi.org/10.1016/j.arthro.2019.07.034
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repair.3,5-8 Although reverse total shoulder arthroplasty is a viable option, early loosening and a high complication rate in young and active patients make the procedure less desirable.8,9 In the absence of glenohumeral arthritis, superior capsule reconstruction has been proposed for the treatment of massive, irreparable posterosuperior rotator cuff tears; however, this technique has been shown to be limited in restoring sufficient external rotation.10,11 To circumvent this problem, transfer of the latissimus dorsi tendon has been described for use in this patient population.12-15 First described by Gerber et al.,16 latissimus dorsi transfer has shown promising results for massive rotator cuff tears in several studies.4,9,17 However, open latissimus dorsi transfer comes with the inherent risk of wound complications, axillary or brachial nerve dysesthesia, or potential damage to the deltoid muscle.18 In addition, studies have suggested that patients undergoing tendon transfer as a salvage revision procedure have worse outcomes than when it is performed in the primary setting.18,19 These studies, however, were limited in their sample sizes and did not examine predictors of clinical failures.19,20 The purpose of this study was to evaluate the clinical success rate, along with preoperative factors for risk of failure, in patients undergoing latissimus dorsi transfer for the treatment of massive, irreparable, previously failed rotator cuff tears. We hypothesized that latissimus dorsi transfer would result in a substantial improvement in clinical outcomes.
Methods This was a retrospective review of prospectively collected data from patients undergoing latissimus dorsi transfer for rotator cuff tears by a single shoulder fellowshipetrained surgeon (A.D.M.) between 2006 and 2013. Data were collected through a global shoulder outcome study, which was approved by the institutional review board (No. 13-151-1). The indications for study inclusion were patients aged 18 years or older with large (involvement of 2 tendons), retracted, chronic rotator cuff tears with either fatty infiltration or atrophy in whom prior surgical treatment and conservative management had failed. Patients were included regardless of smoking status, medical comorbidities, or socioeconomic factors. We excluded patients with glenohumeral arthritis (Hamada grade 3), less than 1 year of followup, or preoperative pseudoparalysis; those without preoperative clinical outcome scores; and those with no prior attempt at rotator cuff repair. A minimum followup period of 1 year was considered sufficient because previous studies reported clinical failure to occur at an average of 19 months after surgery.19 All alternative options were discussed with patients, including continued conservative treatment or attempted
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arthroscopic repair. Reverse total shoulder arthroplasty was recommended for patients older than 70 years. Diagnostic Imaging All patients underwent preoperative radiography (true anteroposterior view, axillary lateral view, and scapular Y view) and magnetic resonance imaging (MRI) of the involved shoulder. On radiographs, the acromiohumeral interval was measured as the distance between the humeral head and the undersurface of the acromion on the true anteroposterior view. On MRI, tendon retraction was quantified on coronal T2 fatsaturated images using the Patte classification system (A, minimal retraction; B, retraction to humeral head; or C, retraction to glenoid).21 Fatty infiltration was assessed on T1 sagittal oblique views and divided into 5 categories based on the presence of fatty streaks within the supraspinatus muscle belly using the Goutallier staging system, which was originally described using computed tomography but is now commonly applied to MRI.22 Muscle atrophy on sagittal oblique images was classified into 4 categories, with 0 representing none and 3 representing severe, according to the system of Tingart et al.23 Surgical Technique: Latissimus Dorsi Transfer To maximize the surgical technique of latissimus dorsi transfer, a team approach was taken to enhance speed, reproducibility, and outcomes. All surgical procedures in this study were performed by a single fellowshiptrained shoulder surgeon (A.D.M.). A single plastic surgeon (R.C.) assisted with the latissimus harvest, tunneling, and closure. Latissimus dorsi transfer was performed as originally described by Gerber et al.16 in 1988. In brief, the procedure was performed with the patient in the lateral decubitus position. A transverse incision was made along the inferior border of the scapula and taken down to the latissimus muscle. The latissimus was identified and mobilized, with care taken to protect the neurovascular pedicle. The rotator cuff was approached via a saber incision centered along the lateral edge of the acromion, parallel to the Langer lines. The dissection was then taken down to the deltopectoral fascia, and the anterior, middle, and posterior heads of the deltoid were identified. To preserve the deltoid’s attachment to the acromion as much as possible, a 2-mm lateral acromial osteotomy was made using a microsagittal saw and an osteotome to mobilize the middle head of the deltoid and expose the underlying rotator cuff defect.16 The latissimus tendon was then delivered into the subacromial space and proximal humerus via a tunnel through the plane between the external rotators and deltoid. The transferred tendon was fixed to a bony trough in the superior greater tuberosity with suture anchors. If possible, the remaining rotator cuff was repaired to the transferred tendon. The
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acromial osteotomy was repaired meticulously with high-strength No. 2 suture (FiberWire; Arthrex, Naples, FL) through bone tunnels. The anterior and posterior deltoid heads were repaired to the anterior and posterior attachment with No. 0 Ethibond (Ethicon, Somerville, NJ). The anterior deltoid raphe and posterior deltoid raphe were then closed with No. 0 Vicryl (Ethicon). Finally, the incision for the latissimus harvest was closed over a drain. Postoperatively, patients were placed in an Ortho Immobile abduction orthosis (Otto Bock, Austin, TX) in 60 of abduction and neutral external rotation for a minimum of 8 weeks. Subsequently, they were allowed to start passive range of motion without limitations until 12 weeks postoperatively, followed by activeassisted motion in all planes until 20 to 24 weeks. After that point, strengthening and active range-ofmotion exercises were initiated without limitation. Clinical Outcome Measures American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores were collected preoperatively and postoperatively. Single Assessment Numerical Evaluation scores were collected only postoperatively at follow-up visits.24 Pain scores were obtained from the ASES survey. Besides, preoperative and postoperative range of motion (forward elevation, abduction, and external rotation) was physically examined. Statistics An a priori power analysis was performed. Assuming a standard deviation of 20 points, a sample size of 13 would provide 80% power to detect a 17-point difference between preoperative and postoperative ASES scores at an a level of .05.25 Descriptive statistics were calculated as mean and standard deviation or frequency. Preoperative and postoperative ASES and SST scores, as well as the difference between preoperative and postoperative scores (D), were compared using a nonparametric equivalent to the paired t test where appropriate. For patients who underwent revision surgery after latissimus transfer, the final outcome scores obtained prior to revision were used for analysis. At latest follow-up, patients who had not required further revision surgery and whose ASES scores were improved from preoperative values by a clinically significant amount (defined as D in ASES score 17) were categorized as clinical successes.23 Patients who did not meet these criteria were categorized as clinical failures. Logistic regression was performed to create odds ratios (ORs) to evaluate the relation between clinical failure and the following variables: acromiohumeral interval, sex, diabetes, smoking status, age, body mass index, involvement of dominant arm, number of previous failed rotator cuff repairs, tear characteristics, and
Workers’ Compensation at the time of latissimus transfer. P < .05 was considered statistically significant. The distribution of ASES scores was examined graphically with a histogram and appeared to be slightly right skewed. Statistical tests of normality were also carried out, which were at the level of statistical significance (P ¼ .05). To ensure we had adequately examined the hypothesis of a positive change in clinical outcome scores from preoperatively to postoperatively, the signed rank test (nonparametric equivalent to the paired t test) was also run to compare the scores. This resulted in P ¼ .001, P ¼ .002, and P ¼ .002 for the ASES, SST, and pain scores, respectively.
Results Subjects In a single surgeon’s practice, 37 patients underwent latissimus dorsi transfer between November 2006 and March 2013. Of these patients, 8 were initially excluded because they had single-tendon tears and 2 were excluded for not having preoperative ASES or SST scores. In addition, we excluded 2 patients because they had not undergone prior rotator cuff repair surgery and 3 patients because they had less than 1 year of followup. Thus, the final study group comprised 22 latissimus transfer patients (Fig 1). The mean age of the included patients was 53 6 years, and the average follow-up period was 3.4 years (range, 1.1-7.1 years) (Table 1). Most patients were men and had undergone 2 or more previous rotator cuff repairs. Radiographic Analysis Although all patients had radiographs and MRI scans obtained prior to surgery, at the time of analysis, preoperative MRI scans were available for only 19 of 22 patients. All patients had at least grade 1 fatty infiltration or supraspinatus atrophy, with most patients having retraction of the cuff to the humeral head (Patte stage 2) (Table 2). The average preoperative acromiohumeral interval was 6.6 3.4 mm. Clinical Outcome Overall, significant improvement was noted in ASES scores (35.2 21.9 preoperatively vs 55.8 22.9 postoperatively; D, 20.1 23.1; P ¼ .001) (Fig 2) and SST scores (3.5 3.1 preoperatively vs 5.2 3.4 postoperatively; D, 2.1 2.7; P ¼ .002) (Fig 3). Pain scores improved postoperatively as well (5.9 2.8 preoperatively vs 4.6 4.3 postoperatively; D, 2.4 2.7; P ¼ .002). Postoperative Single Assessment Numerical Evaluation scores varied widely among all patients (mean, 43 38). Regarding range of motion, significant improvements were found in the degree of forward elevation (88 20 preoperatively vs 124 50 postoperatively,
LATISSIMUS TRANSFER FOR REVISION CUFF TEAR
Fig 1. Potential included in study.
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patients
P ¼ .005) and external rotation (21 14 preoperatively vs 46 26 postoperatively, P ¼ .004) at final follow-up. However, range of abduction motion did not improve significantly (82 18 preoperatively vs 92 48 postoperatively, P ¼ .323). Comparing patients with clinical success versus those with failure, we found no significant differences in preoperative-topostoperative improvements regarding forward elevation (D, 49 46 in success group vs 20 42 in failure group; P ¼ .092), abduction (D, e8 48 in success group vs e12 35 in failure group; P ¼ .857), or external rotation (D, 28 34 in success group vs 19 23 in failure group; P ¼ .607). Complications and Revisions The revision rate after latissimus transfer was 13.6% (3 patients), with 3 reverse total shoulder arthroplasties. Revisions occurred on average 2.7 years (range, 0.8-5.7 years) after tendon transfer. The complication rate was 27% (6 patients), which included
2 deep infections, 2 ulnar neuropathies at the elbow believed to be due to the sling, and 2 neuromas. Both neuromas were located in the area of the latissimus harvest site, causing significant pain. Electromyography in 1 patient showed suprascapular neuropathy, and excision was required. The other neuroma resolved without treatment. Clinical Failure Characteristics An ASES score D of less than 17 was defined as clinical failure.25 On the basis of this criterion, 41% of patients (n ¼ 9) reported clinical failure at follow-up. A preoperative acromiohumeral interval of less than 7 mm was a significant risk factor for failure (OR, 7.86; 95% confidence interval, 1.1-56.1; P ¼ .04) (Table 3). Clinical failure occurred in all patients with fatty infiltration of grade 3 or higher. In contrast, failure occurred in only 1 of 11 patients (9.1%) with grade 1 or 2 fatty infiltration; thus, preoperative high-grade fatty infiltration was a significant risk factor for failure (OR, 72;
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Table 1. Patient Demographic Characteristics (N ¼ 22) Data Sex, n (%) Male Female Age, mean SD, yr BMI, mean SD Involved side, n (%) Dominant Nondominant Smoking, n (%) Diabetes, n (%) No. of prior cuff repairs, n (%) 1 2
14 (64) 8 (36) 53 6 33.9 5.5 15 7 7 5
(68) (32) (32) (23)
8 (36) 14 (64)
BMI, body mass index; SD, standard deviation.
95% confidence interval, 3.8-1,349.5; P ¼ .004). Smoking, diabetes, sex, age, body mass index, number of previous failed rotator cuff repairs, involvement of dominant arm, or Workers’ Compensation at the time of surgery were not found to be significant risk factors for failure (Table 3).
Discussion This study found that despite an overall statistical improvement in outcomes, clinical failure was found in 41% of patients who underwent latissimus dorsi transfer as a salvage procedure after failed rotator cuff repair. Moreover, an acromiohumeral interval of 6 mm or less was a significant predictor of clinical failure and revision surgery. Salvage procedures for massive, irreparable rotator cuff tears in the young and active population are limited, without a clear understanding of which
Fig 2. Preoperative (Pre-Op) and postoperative (Post-Op) American Shoulder and Elbow Surgeons (ASES) scores. The asterisk indicates P < .05.
procedure is ideal.26,27 Warner and Parsons19 reported on latissimus dorsi transfer as a salvage procedure for rotator cuff repair. They compared the outcomes of patients who underwent latissimus dorsi transfer as a salvage procedure for previously failed prior rotator cuff repair versus patients who underwent primary tendon transfer without a prior repair attempt. Latissimus dorsi transfer as a salvage reconstruction procedure resulted in significantly worse outcomes with a late rupture rate of 44% compared with 17% for primary transfers at 19 months. It was later recommended to augment the latissimus dorsi transfer with a fascia lata autograft to prevent this late complication.28 Despite taking special precautions to optimize the surgical technique of latissimus dorsi transfer, the results found in our study were inferior to those reported by other authors in terms of outcome scores, complication rates, and pain scores.13,14,29 However, direct comparison to previous
Table 2. Preoperative Rotator Cuff Tear Characteristics (N ¼ 22) No. of tendons involved 2 3 Retraction Little to none Humeral head Glenoid Fatty infiltration Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Atrophy (supraspinatus) None Mild Moderate Severe
n
%
18 of 22 4 of 22
82 18
0 of 19 11 of 19 8 of 19
0 58 42
0 5 6 6 2
of of of of of
19 19 19 19 19
0 26 32 32 11
4 5 9 1
of of of of
19 19 19 19
21 26 47 6
Fig 3. Preoperative (Pre-Op) and postoperative (Post-Op) Simple Shoulder Test (SST) scores. The asterisks indicate P < .05.
LATISSIMUS TRANSFER FOR REVISION CUFF TEAR Table 3. Risk Factors for Clinical Failure at Final Postoperative Assessment Risk Factor AHI <7 mm Male sex Workers’ Compensation Smoking Diabetes Age BMI Dominant arm involved 2 previous failed cuff repairs Fatty infiltration grade 3 Retraction to glenoid level Supraspinatus atrophy grade 2
OR 7.86 1.13 4.4 0.15 0.95 1.1 0.93 6.9 1.67 72 2.9 3.0
95% CI 1.1-56.1 0.18-6.9 0.6-32.5 0.01-1.5 0.12-7.3 0.97-1.3 0.79-1.1 0.66-71.7 0.25-11.1 3.8-1,349.5 0.44-19.2 0.46-19.6
P Value .04* .90 .15 .11 .96 .11 .39 .11 .60 .004* .27 .25
AHI, acromiohumeral interval; BMI, body mass index; CI, confidence interval; OR, odds ratio. *Significant risk factor for clinical failure.
studies in the literature is difficult because they did not use the same outcome measure used in our study (ASES score); in addition, these studies only reported the final mean outcome score without establishing the percentage of patients who actually significantly benefited from the procedure.13,14,29 Although all cases included the assistance of a plastic surgeon with special expertise in latissimus flaps, we found a clinical failure rate of roughly 41%, along with a complication rate of 27%. Miniaci and MacLeod30 reported on 17 patients who underwent latissimus transfer for the treatment of failed repairs of massive rotator cuff tears and found that the patients’ average subjective functional rating on a visual analog scale was only 56.1 mm at a minimum of 2 years’ follow-up. Furthermore, the patients in our study underwent prior arthroscopic rotator cuff repairs, with some undergoing up to 4 previous surgical procedures before tendon transfer. Pagani et al.31 recently described an augmentation to the latissimus tendon transfer technique for patients with a decreased acromiohumeral interval and severe muscle atrophy. They recommended performing an acromial osteotomy to limit disruption of the deltoid tendon and an augmentation repair using a collagen matrix. Sidler-Maier et al.32 presented preliminary outcomes using a bursal sideeonly dermal augmentation in patients with massive posterosuperior tears. At a mean follow-up of 27 months, patients reported significant improvements in forward flexion and all but 1 of the 24 patients reported being “satisfied” with their operation. The authors did not find previous surgery, tendon retraction, or atrophy to have an effect on postoperative motion.32 Although reverse total shoulder arthroplasty is a viable salvage procedure, implant longevity and failure preclude the use of arthroplasty in this young and active population.33 Whereas latissimus dorsi tendon transfer is thought to restore external rotation and re-establish the anterior-posterior force couples on the humeral head,
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the orientation of the tenodesis places a nonphysiological vector across the shoulder joint.33 This may be a reason for the high progression of osteoarthritis that has been described after the procedure.13,34 Elhassan et al.35 described the use of a lower trapezius tendon transfer with an Achilles allograft augmentation in patients with irreparable rotator cuff tears. Their case series found that patients had significant improvements in pain and range of motion with limited postoperative complications. The better anatomic position of the lower trapezius transfer provides biomechanical advantages to the latissimus tendon transfer; however, further comparative studies are needed. Limitations There were several limitations to the study. Although data were collected prospectively, the chart review was performed retrospectively, which could create selection bias. The sample size was limited because only patients with previously failed rotator cuff repairs were included in the study. In addition, with reporting on the outcomes of only a single surgeon’s practice, external validity may be limited in terms of both patient population and surgical technique. Finally, several patients did not have a full 2-year follow-up period, and repeated MRI or ultrasound was not available to evaluate the status of the repaired tendon.
Conclusions Latissimus dorsi tendon transfer resulted in a clinical failure rate of 41% and complication rate of 27%, with an acromiohumeral interval of less than 7 mm and high-grade fatty infiltration being associated with postoperative failure.
References 1. Bartolozzi A, Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop Relat Res 1994;308:90-97. 2. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 2004;86:219-224. 3. Burkhart SS, Barth JR, Richards DP, Zlatkin MB, Larsen M. Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration. Arthroscopy 2007;23:347-354. 4. Miller BS, Downie BK, Kohen RB, et al. When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears. Am J Sports Med 2011;39:2064-2070. 5. Keener JD, Wei AS, Kim HM, et al. Revision arthroscopic rotator cuff repair: Repair integrity and clinical outcome. J Bone Joint Surg Am 2010;92:590-598. 6. Parnes N, DeFranco M, Wells JH, Higgins LD, Warner JJ. Complications after arthroscopic revision rotator cuff repair. Arthroscopy 2013;29:1479-1486.
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