Musculotendinous transfer as a treatment option for irreparable posterosuperior rotator cuff tears: Teres major or latissimus dorsi?

Abstract

Irreparable posterior cuff tears can cause pain and lack of shoulder function. Surgical treatment includes musculotendinous transfers of either latissimus dorsi (LD) or teres major (TM). This study aimed to give a detailed description of the morphology of these two muscles with particular regard to their suitability for use in transfers. Sixty-two shoulders in 31 cadaveric specimens (mean age 50 years) were dissected. The mean length of the TM was 13.7 cm at its superior edge while the distance from the muscle origin to the greater tuberosity (GT) was 19.2 cm. The tendon of the TM had a length of 1.5 cm, a width of 3.4 cm, and a thickness of 1.3 mm. The mean length of the LD was 26.0 cm and the distance from its origin to the GT was 32.9 cm. The mean length of the LD tendon was 5.2 cm, its width 2.9 cm, and its thickness 1.0 mm. The increased length required to achieve transfer was 47% (of the original length) for TM and 33% for LD. Both TM and LD could reach the GT with ease, according to the potential muscle excursions. Tension of the neurovascular bundle is more probable with LD because it enters the muscle relatively closer to the tendon. Problems with regard to reattachment may be more likely to occur in a transfer of the TM because of its short tendon.

Latissimus dorsi tendon transfer for irreparable postero-superior cuff tears: current concepts, indications, and recent advances

“…Current concepts: anatomical and biomechanical rationale LD tendon is inserted on the distal part of the medial bicipital groove between the greater pectoralis and the teres major tendons. It is a very thin (1 mm) tendon, rather wide (3-5 cm) and its length is highly variable among patients, although usually around 5-7 cm [32,33] (4-12 cm in our experience) (Fig. 1).…”

Teres major tendon transfer for patients with massive irreparable posterosuperior rotator cuff tears

“…The line of action of the teres major transfer in relation to the glenoid is similar to that of infraspinatus, as compared with latissimus dorsi, which arises from the pelvic crest. 20,21,23 Secondly, teres major and its neurovascular pedicle are long enough for transfer onto the posterolateral aspect of the greater tuberosity regardless of the size of the rotator cuff tear. 12 However, during latissimus dorsi transfer the thoracodorsal nerve is at risk of neurotmesis if it is attached too anteriorly onto the humeral head.…”

“…Compared with latissimus dorsi, it is rather bulky and has a short tendon. 21 A relatively broad tunnel must be made under the deltoid and teres major has to be detached from the humeral periosteum to produce sufficient length, whereas latissimus dorsi is slim and its tendon is several centimetres long so it can be detached at some distance from the humeral periosteum.…”

“…18 As an alternative, Celli et al 12,19 described the transfer of teres major to the insertion of the supraspinatus tendon into the greater tuberosity of the humerus with similar successful results. Biomechanical and anatomical analysis demonstrated a favourable use of teres major based on the moment arm, 20 muscle length, 21 and muscle activation. 22,23 The clinical results of teres major transfer are supported only by a preliminary report describing the results in a small case series with short follow-up.…”

Latissimus Dorsi Transfer in Posterior Irreparable Rotator Cuff Tears

“…Variable means of fixation have been used by several authors such as transosseous sutures [23, 47], classic anchors [45, 81, 100] and interference screw [101]. A common mode of repair failure has been discussed by several authors [102, 103] and involves splitting of the transferred tendon by sutures mainly due to its reduced thickness [104]. A recent biomechanical study supports this finding by reporting that the weakest element was the tendon itself and not the anchor – suture construct [103]; while they conclude that interference screw fixation presents higher or similar biomechanical properties to anchor fixation whereas tubularization of the tendon which is performed in conjunction, may address the reduced thickness variable [103].…”