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Contents : Department of Rehabilitation Services Physical Therapy Standard of Care: Latissimus Dorsi Tendon Transfer Case Type / Diagnosis: Massive posterosuperior rotator cuff tears (PSRCT) involving the supraspinatus and infraspinatus are not common as less than one third of rotator cuff tears may be classified as massive and only 5% are classified as irreparable. 7 22 However in general individuals who do have a massive PSRCT often present with a painful and dysfunctional shoulder. Treatment options are limited particularly in young patients that are not suitable candidates for inverse arthroplasty. In the case of a massive posterior superior rotator cuff tear (PSRCT) a latissimus dorsi tendon transfer (LDTT) may be done to enhance function and reduce pain. The surgical authors recommend this type of procedure to about 25% of patients with posterosuperior irreparable rotator cuff tears. This type of surgery is most commonly recommended for patients who are under the age of 60 are without significant glenohumeral arthritis and still have some rotator cuff function with at least some anti-gravity forward flexion strength. Indications for this type of surgery include a massive full thickness PSRCT which is usually defined as a tear with a diameter of at least 5 cm. 14 Certain inclusion criteria should be met before this procedure is considered an option. Candidates must have failed to respond to conservative treatment including the use of nonsteroidal anti-inflammatory drugs (NSAID s) and concerted efforts at physical therapy for a duration of at least six months in the presence of an external rotation lag of at least 15 degrees. 5 Finally patients must report a subjective limitation in overhead shoulder function. The latissimus dorsi muscle is well suited to transfer for several reasons including its large surface area strength and good vascularization. 2 All of these factors are important when considering how this muscle will recover following surgery particularly the muscle s vascularity because an adequate supply of nutrients is essential for the healing processes to occur. Further considerations are that there is adequate excursion and that the muscle transfer is ideally in phase with the motion that is absent. Furthermore it is generally accepted that all transferred muscles lose one grade of muscle strength as the result of the transfer so the recovery of full strength is not possible. The typical anatomical origin of the latissimus dorsi is on the spine of T7 the spinous processes and supraspinous ligaments of all the lower thoracic lumbar and sacral vertebrae the lumbar fascia posterior third of the iliac crest last four ribs and the inferior angle of the scapula. It inserts on the floor of the bicipital groove of the humerus and is innervated by the thoracodorsal nerve. Primary actions of the latissimus dorsi muscle are to extend adduct and internally rotate at the glenohumeral joint. 3 1 Standard of Care: Latissimus Dorsi Tendon Transfer Copyright 2007 The Brigham and Women's Hospital Inc. Department of Rehabilitation Services. All rights reserved. Gerber et al 6 first introduced LDTTs for the repair of PSRCT in 1988 and found it to be an alternative treatment for massive rotator cuff tears. They reported that the morbidity caused by removing the latissimus dorsi is minimal with this type of surgery. The procedure aims to regain control of external rotation by stabilizing the humeral head. Warner 22 adds that some surgeons will only perform this type of procedure if the subscapularis muscle is still intact. If this muscle is not intact than there is a disruption of the anteroposterior force couple of the rotator cuff and this type of surgery is unable to compensate for such a loss. Furthermore the subscapularis is important in centering the humeral head in both coronal and axial planes. Werner et al 23 explored the biomechanical role of the subscapularis in a cadaveric model for the treatment of PSRCT with latissimus dorsi transfer. It was found that translation and rotation of the humeral head are significantly altered without the subscapularis thus explaining why post-operative results are found to be inferior in patients without an intact subscapularis. In addition to the criteria previously described the surgical authors recommend that candidates for LDTT surgery should also have a supple or easily pliable glenohumeral joint. A stiff shoulder is contraindicated as it will result in additional soft tissue limitations that will affect the success of postoperative rehabilitation and overall recovery. Other factors that may be identified preoperatively that are associated with more limited outcomes include poor tendon quality severe fatty degeneration previous attempt at rotator cuff repair and deltoid detachment. 21 Therefore it is imperative that surgeons identify the integrity of these structures before operating as they have been directly linked to both succes

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