Latissimus Dorsi Transfer
The latissimus dorsi transfer is a salvage operation for the massively torn rotator cuff. The rotator cuff is a series of four muscles that attach via tendon to the humeral ball (Figure 1). Tearing of these tendons leads to weakness and pain. Most rotator cuff tears are repairable via surgery. When the rotator cuff tear is massive in nature and associated with severe atrophy of the muscle, a surgical repair is not possible. It is in this small subset of patients that a latissimus dorsi transfer may be indicated
Figure 1. Normal shoulder and rotator cuff anatomy
The hallmark symptoms of a massively torn rotator cuff are pain and weakness, particularly in forward shoulder elevation and external rotation. If an MRI or previous arthroscopy has demonstrated an irreparable tear, depending on age, your surgeon will discuss salvage operations such as tendon transfer (i.e. latissimus) or reverse shoulder replacement
Initial treatment for the irreparable rotator cuff should the following conservative treatment measures:
- Rest. Because the shoulder is not a weight bearing joint like the knee, simply modifying one’s activities can improve symptoms
- Medications. Tylenol or anti-inflammatories can help with symptoms
- Injections. Steroid injections or visco-supplementation (e.g. Synvisc) can provide temporary relief.
- Physical therapy. Range of motion exercises and strengthening of the deltoid can improve symptoms.
- Arthroscopy. A simple arthroscopy with tenotomy of the biceps tendon can relieve pain.
A candidate for a latissimus dorsi transfer typically has the following characteristics:
- Massive irreparable rotator cuff tear
- Preserved cartilage in the shoulder joint
- Typical age 50-65
- Intact subscapularis tendon
- Failed conservative management
The latissimus dorsi transfer is a large operation. It takes 3 hours to perform under general anesthesia with the patient on the side. Two incisions are needed, one in the back of the shoulder to harvest the latissimus tendon (Figure 2), and one in the front of the shoulder to sew the tendon in its new position as a substitute for the rotator cuff (Figure 3).
Figure 2. Schematic of latissimus dorsi muscle
Figure 3. Latissimus Dorsi transfer after completion
V. WHAT TO EXPECT
- An MRI of your shoulder will be ordered to aid in preoperative planning. These studies aid in assessing two important factors: rotator cuff tendons assessment of cartilage.
- You will need a consultation with your PMD and/or cardiologist prior to surgery to ensure that you are safe for anesthesia.
- If you have had previous surgery, an infection workup will be performed, even if there is no sign of active infection: This will likely include an aspiration of the shoulder, lab work, and other tests.
DAY OF SURGERY/HOSPITAL STAY
- Nothing to eat or drink past midnight the night before surgery
- Surgery lasts 2-3 hours depending on complexity.
- Surgery is performed under general anesthesia with a nerve block of the shoulder as well
- Your arm will be in a large sling postoperatively for 6 weeks with a large pillow under the arm to protect the repair
- You will start exercises the day following surgery to move the shoulder passively.
- You will have a button to push to control your pain after surgery
- You will have a small drain in your shoulder for 24-48 hours
- You will stay on prophylactic antibiotics for 24 hours
- You will likely have a Foley catheter in your bladder until the first day after the operation
- Hospital stay is generally 2 nights.
- Blood transfusion is rarely needed except in revision surgery
- You may need help at home to assist in daily living activities
- Post-op visits:
- 2 weeks: suture removal, check motion and ensure proper performance of home exercises
- 6 weeks: discontinue sling, start Physical Therapy
- 12 weeks: Start strengthening
- 24 weeks. Therapy generally complete
- Your arm will be in a sling 6 weeks with a large pillow for abduction of the arm.
- Sutures come out at 1-2 weeks postop. The wound should be kept dry until then. After sutures come out, normal showering can begin.
- Supervised physical therapy starts at week 6 and continues for three months. No strengthening until 12 weeks post surgery
- Final healing 6 months or more
- Significantly decreased pain
- 20-30 degrees of forward elevation gain
- Improvement in active external rotation
- Because the transfer the latissimus involves surgery around several important nerves, nerve damage is possible
- Other complications include: bleeding, infection, reoperation, damage to nerves and arteries, continued shoulder pain, stiffness, and weakness
VI. DO I NEED TO HAVE A LATISSIMUS DORSI TRANSFER?
This operation is an elective surgery. Prior to surgery, the patient must be certain that he/she has exhausted all conservative measures. The latissimus transfer is a large operation but it has a defined role in the properly selected patient with a massive rotator tear.