Open Latissimus Dorsi Transfer for Irreparable Subscapularis Tendon Tear

In cases of irreparable subscapularis (SSC) tendon tear in young and active patients, tendon transfers stand as the only surgical option. With a posterior-inferior-medial line of action and a synergistic action with the SSC muscle, the latissimus dorsi (LD) muscle appears to be the most adequate option.

Indications include symptomatic and irreparable Lafosse type-IV or type-V SSC lesions in young and active patients with preserved glenohumeral joint.

With the patient in the supine position under general anesthesia, a deltopectoral approach is used and extended distally so that the pectoralis major (PM) and long head of the biceps (LHB) tendons can be fully exposed and mobilized. The LD tendon is then exposed, freed from its humeral insertion to be prepared in a Krackow fashion, and extensively released from surrounding fasciomuscular adhesions to be freely mobilized proximally. The lesser tuberosity is prepared with a rongeur so that the LD tendon can be secured to cancellous bone on the former SSC insertion site with two rows of anchors. The rotator interval is then closed to prevent any extension of the existing tear to the superior aspect of the rotator cuff. Finally, the LHB is fixed to conjoint tendon in physiologic tension, and the surgical wound is closed.

With failure and revision rates ranging from 0% to 20%, this transfer seems as safe and reliable as other transfers. Unspecific complications were observed by different teams, but no cases of nerve compressions were reported. Conversely, significantly better functional outcomes are reported when using the LD muscle then when using the PM muscle as donor.

With a rather straightforward surgical technique, the open LD transfer seems to provide satisfactory short- to mid-term outcomes in cases of irreparable and symptomatic SSC tendon tear. Long-term results have yet to be determined, particularly regarding the prevention of glenohumeral osteoarthritis.