Mini invasive axillary approach and arthroscopic humeral head interference screw !xation for latissimus dorsi transfer in massive and irreparable posterosuperior rotator cuff tears.

Abstract: As the number of shoulder surgeries is increasing, the challenges of treating the massive and irreparable rotator cuff tears pose an operative challenge for the shoulder surgeons. The purpose of this study is to propose a new mini invasive axillary incision (5 cm) for harvesting latissimus dorsi (LD) tendon and arthroscopic-assisted interference screw fixation of the transfer on the humeral head for the treatment of massive and irreparable posterosuperior rotator cuff tears. We describe our technique. The incision is minimized with the help of ultrasound Doppler-guided identification of the LD pedicle preoperatively. This study also makes clear how to maintain the tension on the pedicle of the LD uniform before and after the fixation of the transfer. During our experience of 17 cases from November 2007 to July 2009, we had good-to-excellent results in patient satisfaction. The clinical outcomes were not indifferent from the other methods of fixation. Key Words: latissimus dorsi transfer, massive irreparable posterosuperior cuff tear, iterative cuff tear, interferrence screw latissimus dorsi fixation, arthroscopic latissimus dorsi fixation, mini invasive axillary approach (Tech Should Surg 2010;11: 8--14) T he incidence of the challenges for massive and irreparable rotator cuff tears is on the raise in the patients attending shoulder specialty centers for surgery. Some of these patients have already been operated by open or arthroscopic technique even before the age of 50 years. Gerber et al 1 is the first to publish the latissimus dorsi (LD) tendon transfer for the treatment of these massive irreparable rotator cuff tears. The LD flap is well known and widely used in other specialties such as breast reconstructions and paralytic shoulder owing to birth palsy in pediatric orthopedics. 2 Gerber 3 and Gerber et al 4 discussed in detail regarding the indications and contraindications for the LD transfer. He concluded that when posterosuperior rotator cuff tears were associated with subscapularis tears, the LD transfer is contraindicated. Other authors 5-10 also confirmed bad results in case of subscapularis tears, deltoid anterior deficit, proximal migration of the humeral head, preoperative poor function of the shoulder, and as a salvage procedure. Whereas the patient selection plays an important role in success of this transfer, it remains a viable and effective option for younger patients with massive and irreparable rotator cuff tears. Moreover, constantly great tuberosity is fragile owing to earlier surgery or lack of mechanical stimulus chronically by the absence of rotator cuff musculature. The technical difficulties of fixation of the LD transfer on to osteoporotic bone need to be studied in detail. Gerber et al 1 fixed the transfer to the subscapularis with transosseous sutures. Warner and Parson 6 fixed the transfer on to the greater tuberosity by transosseous sutures. Habermeyer et al, We hypothesized that the reasons for failures of this transfer were not only owing to invasive and open surgery (new deltoid injury), but also owing to lack of adequate strong and stable fixation of the LD tendon on to the greater tuberosity. From the experience of the anterior cruciate ligament (ACL) reconstruction of the knee and from the work of Boileau et al 14 in the tenodesis of long head of biceps into the humeral head, we describe a new mini invasive technique for harvesting the LD tendon, new technique of fixation by tubularization, and interference screw (IFS) fixation into a bone tunnel made in the humeral head. This fixation initially carried out by open procedure now switched to arthroscopically assisted procedure as our experience increased and it was more advantageous. This procedure is a viable alternative to the existing techniques in the hands of surgeon who is skilled in arthroscopic management of shoulder pathology. The specific biomechanical study conducted under the guidance of Jean Grimberg (personal communication) has concluded that the IFS fixation of the LD transfer on the humeral head is equal or slightly better than the multiple anchor fixation technique. Various studies OPERATIVE TECHNIQUE The patient is in lateral position with shoulder in 30 degrees abduction, slightly tilted toward the back, and a 3 kg traction. The operative position allows free wide access to the shoulder, entire scapula, and its apex as this transfer needs free movement of shoulder and arm. This position also allows easy shifting over from open axillary approach for LD tendon harvesting to shoulder arthroscopic fixation of the transfer. It is important at this point to mention that the LD muscle neurovascular pedicle enters from the medial and under surface of the muscle from about 10 cm from humeral insertion of the LD tendon and 2 cm from the lateral scapular border. The exac