The latissimus dorsi tendon transfer is a surgical procedure used to restore shoulder function in patients with large, irreparable tears of the rotator cuff—particularly those involving the posterosuperior portion (upper and back side) of the shoulder. When the rotator cuff is too damaged to repair directly, surgeons may repurpose nearby muscles and tendons to take over its function. The latissimus dorsi, a strong back muscle typically involved in pulling movements, can be redirected to help restore shoulder motion.
Who Needs This Procedure?
This procedure is usually considered for people who:
- Have chronic, massive rotator cuff tears that cannot be repaired using standard techniques
- Experience significant pain and loss of function, especially when lifting the arm or rotating it outward
- Have already tried physical therapy and possibly previous rotator cuff repairs that failed
- Are not suitable candidates for reverse shoulder replacement, often due to age or activity level
Patients typically report symptoms like shoulder weakness, difficulty raising the arm, and pain during daily activities. Some may also exhibit signs such as the “hornblower sign,” which indicates a deficiency in one of the smaller shoulder muscles (teres minor).
How the Surgery Works
Basic Concept
The latissimus dorsi muscle is normally used for pulling actions (like when doing a pull-up). In this surgery, the tendon of this muscle is detached from its usual attachment on the upper arm and rerouted to the shoulder’s outer area (greater tuberosity of the humerus). Once reattached, this tendon helps perform functions the rotator cuff can no longer do—like rotating the arm outward and lifting it.
Surgical Technique
There are two main approaches to harvesting and attaching the latissimus tendon:
- Conventional Technique: The tendon is sharply detached from the bone and secured to the shoulder with strong stitches through drilled holes in the bone.
- Modified Technique (Bone Chip Fixation): A small piece of bone is taken along with the tendon. This piece allows a bone-to-bone connection, which tends to be more stable and heal better.
Surgeons often prefer the modified method because it provides better integrity and durability at the new tendon site.
Once the tendon is moved, it is carefully tunneled under the skin to its new position and fixed with strong non-absorbable sutures into the upper arm bone.
Recovery After Surgery
After surgery, the arm is typically immobilized in a sling for several weeks to protect the new tendon attachment. Physical therapy is started gradually, first with passive movements, then advancing to active exercises over the course of several months.
The full recovery process often spans several months and focuses on regaining shoulder mobility and strength without damaging the transferred tendon.
Benefits of the Procedure
Most patients experience:
- Improved Shoulder Motion: Especially in lifting the arm and rotating it outward
- Significant Pain Relief: As the muscle starts compensating for the damaged rotator cuff
- Better Shoulder Function in Daily Life: Like reaching overhead or behind the back
These benefits are generally sustained over time, especially when the tendon heals properly and the patient has good function in the other muscles around the shoulder.
Things That Can Affect Outcomes
Certain factors may impact the success of a latissimus dorsi tendon transfer:
- Condition of Surrounding Muscles: If the subscapularis (front shoulder muscle) or teres minor (back shoulder muscle) is damaged or weak, the outcome may be worse
- Pre-existing Muscle Degeneration: Muscles that are significantly atrophied or filled with fat may not recover well
- Previous Surgeries: Patients who had a failed rotator cuff repair before this procedure may not do as well
- Age and General Muscle Health: Older patients or those with weaker muscles may have slower recovery
Imaging and Monitoring
Magnetic resonance imaging (MRI) is often used after the surgery to check if the tendon has healed properly. One of the innovations from the modified technique is that the tendon is attached with a piece of bone, making it easier for the tendon to integrate securely with the shoulder bone. In clinical experience, this technique has led to fewer cases of tendon rupture post-surgery.
Potential Risks and Complications
As with any surgery, there are risks. These may include:
- Failure of the tendon to heal or rupture of the repair
- Continued weakness or limited motion
- Infection or nerve irritation (rare)
- Development of shoulder arthritis over time
However, when performed in the right patient and with careful technique, this surgery has a good track record of success and durability.
How It Compares to Other Treatments
This tendon transfer is typically considered in younger or more active patients who are not ideal candidates for shoulder replacement. Unlike reverse total shoulder replacement, which involves prosthetic implants, the tendon transfer uses the patient’s own tissue to restore function. It’s a biologic, joint-preserving procedure aimed at maintaining natural shoulder anatomy.
Another option for similar rotator cuff injuries is superior capsular reconstruction (SCR). While SCR focuses on using a patch to stabilize the joint, latissimus dorsi transfer aims to restore movement by actively replacing the function of damaged tendons. Each has its pros and cons, but both aim to reduce pain and improve function.
Conclusion
Latissimus dorsi tendon transfer is a reliable and effective surgical solution for patients with irreparable rotator cuff tears. It harnesses the strength of a nearby back muscle to restore lost shoulder function and relieve pain. Advances in technique—like incorporating a piece of bone with the tendon—have made this procedure more successful and durable. When performed in carefully selected patients, this surgery offers renewed mobility and improved quality of life.
