TECHNICAL NOTE • SHOULDER - ARTHROSCOPY Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency Jean Kany 1 • Re ´gis Guinand 1 • Pierre Croutzet 1 • Philippe Valenti 2 • Jean David Werthel 3 • Jean Grimberg 3 Received: 30 November 2015 / Accepted: 17 February 2016 Ó Springer-Verlag France 2016 Abstract Few salvage procedures have been described in case of irreparable subscapularis tear and with variable outcomes. Latissimus dorsi transfer has been widely pro- posed as a transfer for irreparable posterio-superior rotator cuff tear with good outcomes. The anatomic feasibility of the latissimus dorsi to reconstruct the antero-superior irreparable rotator cuff tear has been suggested, but no clinical study has ever been published. We hypothesized that it was possible to use an arthroscopic-assisted latis- simus dorsi transfer to reconstruct the subscapularis func- tion. Five patients were enrolled. A 5–7-cm axillary incision was performed to release the latissimus dorsi tendon from its humeral insertion, the teres major muscle and the apex of the scapula. Afterwards, under arthroscopic control, a 7-mm-diameter tunnel was drilled at the anterior and superior part of the humeral head with an oblique inferior and posterior direction. The tubularized latissimus dorsi tendon was introduced into the tunnel and fixed with a ZipLoop on the posterior humeral cortex. The authors show overall good experience with this technique. Level of evidence Level IV-a, case series. Keywords Latissimus Á Transfer Á Arthroscopy Á Irreparable Á Subscapularis Á Transfer Introduction Massive subscapularis (Sscp) tear leads to horizontal imbalance of the shoulder with pain and decrease of active internal rotation [1]. An associated supraspinatus (SS) tear leads to vertical imbalance with an antero-superior escape of the humeral head (HH) and to a decrease of active forward flexion [2]. There are only few Sscp reconstruction techniques that can reduce pain, recover internal rotation and stabilize this HH antero-superior escape. Reverse shoulder arthroplasty has been reported, but is not recom- mended in young and active patient without arthrosis. Pectoralis major (PM) transfer has been commonly pro- posed (clavicular or sternocostal part) with a route above or below the conjoined tendon with variable outcomes on pain and sometimes unsatisfactory active mobility recover and unsatisfactory stabilization of the HH with a persistent antero-superior escape [2–8]. To explain these disap- pointing PM transfer results, we hypothesized that this transfer did not respect one of the principles of a tendon transfer: a direction similar to the replaced tendon. Indeed, the PM originates anteriorly from the chest wall while the Sscp originates from the subscapularis scapula fossa pos- teriorly from the chest wall. Conversely, the LD originates from the posterior side of the chest wall with a similar direction compared to the Sscp. LD transfer has been widely proposed for irreparable posterio-superior rotator cuff treatment with good results either with an open or with an arthroscopic technique [9–12]. LD is an internal rotator and therefore synergistic with the Sscp. The anatomic feasibility of the latissimus dorsi to reconstruct the antero- superior irreparable rotator cuff tear has been suggested [13], but to our knowledge, no clinical study has been published so far. The purpose of this study was to describe a novel technique—arthroscopic-assisted LD transfer for Electronic supplementary material The online version of this article (doi:10.1007/s00590-016-1753-3) contains supplementary material, which is available to authorized users. & Jean Kany [email protected]1 Clinique de l’Union, 31240 Saint Jean, France 2 Clinique Jouvenet, Paris, France 3 LIRCOS, Paris, France 123 Eur J Orthop Surg Traumatol DOI 10.1007/s00590-016-1753-3
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TECHNICAL NOTE • SHOULDER - ARTHROSCOPY
Arthroscopic-assisted latissimus dorsi transfer for subscapularisdeficiency
Jean Kany1 • Regis Guinand1 • Pierre Croutzet1 • Philippe Valenti2 •
Jean David Werthel3 • Jean Grimberg3
Received: 30 November 2015 / Accepted: 17 February 2016
� Springer-Verlag France 2016
Abstract Few salvage procedures have been described in
case of irreparable subscapularis tear and with variable
outcomes. Latissimus dorsi transfer has been widely pro-
posed as a transfer for irreparable posterio-superior rotator
cuff tear with good outcomes. The anatomic feasibility of
the latissimus dorsi to reconstruct the antero-superior
irreparable rotator cuff tear has been suggested, but no
clinical study has ever been published. We hypothesized
that it was possible to use an arthroscopic-assisted latis-
simus dorsi transfer to reconstruct the subscapularis func-
tion. Five patients were enrolled. A 5–7-cm axillary
incision was performed to release the latissimus dorsi
tendon from its humeral insertion, the teres major muscle
and the apex of the scapula. Afterwards, under arthroscopic
control, a 7-mm-diameter tunnel was drilled at the anterior
and superior part of the humeral head with an oblique
inferior and posterior direction. The tubularized latissimus
dorsi tendon was introduced into the tunnel and fixed with
a ZipLoop on the posterior humeral cortex. The authors
show overall good experience with this technique.
Level of evidence Level IV-a, case series.
Keywords Latissimus � Transfer � Arthroscopy �Irreparable � Subscapularis � Transfer
Introduction
Massive subscapularis (Sscp) tear leads to horizontal
imbalance of the shoulder with pain and decrease of active
internal rotation [1]. An associated supraspinatus (SS) tear
leads to vertical imbalance with an antero-superior escape
of the humeral head (HH) and to a decrease of active
forward flexion [2]. There are only few Sscp reconstruction
techniques that can reduce pain, recover internal rotation
and stabilize this HH antero-superior escape. Reverse
shoulder arthroplasty has been reported, but is not recom-
mended in young and active patient without arthrosis.
Pectoralis major (PM) transfer has been commonly pro-
posed (clavicular or sternocostal part) with a route above or
below the conjoined tendon with variable outcomes on pain
and sometimes unsatisfactory active mobility recover and
unsatisfactory stabilization of the HH with a persistent
antero-superior escape [2–8]. To explain these disap-
pointing PM transfer results, we hypothesized that this
transfer did not respect one of the principles of a tendon
transfer: a direction similar to the replaced tendon. Indeed,
the PM originates anteriorly from the chest wall while the
Sscp originates from the subscapularis scapula fossa pos-
teriorly from the chest wall. Conversely, the LD originates
from the posterior side of the chest wall with a similar
direction compared to the Sscp. LD transfer has been
widely proposed for irreparable posterio-superior rotator
cuff treatment with good results either with an open or with
an arthroscopic technique [9–12]. LD is an internal rotator
and therefore synergistic with the Sscp. The anatomic
feasibility of the latissimus dorsi to reconstruct the antero-
superior irreparable rotator cuff tear has been suggested
[13], but to our knowledge, no clinical study has been
published so far. The purpose of this study was to describe
a novel technique—arthroscopic-assisted LD transfer for
Electronic supplementary material The online version of thisarticle (doi:10.1007/s00590-016-1753-3) contains supplementarymaterial, which is available to authorized users.