Editorial Commentary: Is It Time to Abandon the Latissimus Dorsi Tendon Transfer as a Salvage Procedure for Patients With Large Irreparable Rotator Cuff Tears That Failed Primary Repair?

Abstract

The management of large irreparable rotator cuff tears in the young and active patient population without arthritis presents a challenge for shoulder surgeons due to the limited number of treatment options available that provide predictable outcomes. Latissimus dorsi tendon transfer (LDTT) for the treatment of large, irreparable posterosuperior rotator cuff tears or as a salvage procedure for failed surgical (arthroscopic or open) repair was originally introduced in 1988. Multiple studies have reported both the short-and long-term outcomes after LDTT; however, the majority of these studies included patients without history of previous surgery or a mixed patient population. However, LDTT as a salvage procedure is not as predictable as a primary procedure in terms of pain relief and functional improvement. This is especially true in patients with severe fatty infiltration of the posterior cuff musculature and preoperative acromiohumeral distance <7 mm on static anteroposterior radiography. Conversely, we should not abandon the LDTT in young and active patients with large irreparable rotator cuff tear and intact or repairable subscapularis without arthritis as a primary procedure for treatment. There is plenty of clinical evidence that demonstrates good-to-excellent outcomes in this subset of patients. However, in the setting of one or multiple failed arthroscopic or open cuff repairs, limited range of motion, acromiohumeral distance <7 mm on static anteroposterior radiograph, and severe fatty infiltration of the posterior cuff musculature, I would caution against the use of LDTT as a salvage procedure due to the high failure rate and unreliable clinical results. Currently, there is no role in my own practice for LDTT as a salvage procedure in this patient population.

Superior Capsular Reconstruction Versus Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: Minimum 5-year Outcomes

“…In the LDTT group, 59% of patients had a workers' compensation claim and all patients had 1 prior rotator cuff repair, both of which are known risk factors for inferior outcomes. 16,24,39 Additionally, the mean follow-up was 7.0 years in the present study, potentially allowing for outcome deterioration as demonstrated by Gerber et al 12 in their 10-year LDTT outcome study.…”

“…Despite these promising results, unsatisfactory outcomes have been demonstrated when LDTT is performed in the revision setting. 24,30 In a retrospective analysis of 22 patients undergoing LDTT in the setting of prior failed rotator cuff repair, Muench et al 30 reported a postoperative ASES score of 55.8 and a clinical failure rate of 41% at a mean follow-up of 3.4 years. Importantly, all LDTT procedures in our series were performed in the revision setting and 59% were workers’ compensation cases.…”

Latissimus Dorsi Transfer Combined with Subacromial Balloon Spacer for Bidirectional Rotator Cuff Deficiency

“… 9 Among the various joint preservation surgical approaches described for MIRCTs, 4 , 6 many studies have demonstrated the clinical reliability of LDTT, 4 particularly as a primary procedure. 11 , 12 In a long-term follow-up cohort of 108 patients, the rate of clinical failure of LDTT was 10%, and the conversion to RSA was 4%. Pain relief and improved shoulder function were consistent after 9 years, particularly in younger patients.…”

How the Biomechanical Complexity of Tendon Transfers in Shoulder Surgery is Still Robbing us of Sleep in 2021

“…However, we should not abandon tendon transfers as a primary procedure for young and active patients with large irreparable rotator cuff tears and intact or repairable subscapularis in the absence of severe osteoarthritis. 22 In the current literature, there is plenty of clinical evidence demonstrating high satisfaction rates in this challenging patient cohort. In contrast, when facing patients with multiple previously failed arthroscopic or open rotator cuff repairs or limited preoperative range of motion, high failure rates and unreliable clinical results may be observed.…”