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Case Presentation
The patient is a 45-year-old male with a history of hyperten-
sion who presented after he injured his right shoulder while
trying to throw a bag of garbage and felt a ripping sensation
in his shoulder. Prior to presentation, he had intermittent
anterolateral shoulder pain that was mild and worse with
overhead activity. The trauma dramatically worsened his
pain, and he also noticed significant weakness in the shoulder.
He denies a prior history of surgery or trauma to the ipsilat-
eral shoulder, and had yet to trial physical therapy.
Physical exam demonstrated a well-developed, well-
nourished male, 5 feet 8 inches tall weighing 245 pounds. The
cervical spine was mildly limited in its range of motion with
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180 R.J. Thorsness and G.P. Nicholson
Figure 11.1 True AP x-ray view of the right shoulder in this patient
demonstrating moderate superior migration of the humeral head
and narrowing of the acromiohumeral interval. There are no
arthritic changes present
Chapter 11. Latissimus Dorsi Transfer forSevere 181
a b
Diagnosis/Assessment
This patient is presenting with an acute exacerbation of a
posterosuperior rotator cuff tear after a minor trauma. The
patients history, physical exam, and imaging all corroborate
this diagnosis. The tear likely propagated anteriorly during
the acute exacerbation leaving the supraspinatus with less
severe atrophy compared to the infraspinatus and teres
minor. While tears and atrophy of the teres minor are rare on
presentation, this warranted an electromyographic study
(EMG) to evaluate for a neurologic etiology such as a C5
182 R.J. Thorsness and G.P. Nicholson
Management
The decision was made to pursue an open rotator cuff repair
and latissimus dorsi transfer.
The patient was positioned in a sloppy lateral decubitus
position after an interscalene regional block was performed.
The first incision was carried out in Langers lines just medial
to the lateral border of the acromion. Skin flaps were raised,
and the raphe between the anterior and middle thirds of the
deltoid was incised and released off the acromion with the
coracoacromial ligament. The deltoid was split 2.5cm later-
ally and a stay suture placed to prevent propagation of the
split. An acromioplasty was then performed as well as a thor-
ough subacromial bursectomy in standard fashion. The supra-
spinatus and infraspinatus tendons were able to be identified
and were tagged with heavy-braided #2 suture. The greater
tuberosity footprint was then prepared to a bleeding base to
optimize the biologic environment for healing. A transosse-
ous rotator cuff repair was then performed through four drill
holes double-loaded with heavy-braided #2 suture.
The bed was then tilted away to optimize the positioning
for the latissimus transfer. A hockey-stick incision was then
made along the lateral border of the latissimus dorsi and then
Chapter 11. Latissimus Dorsi Transfer forSevere 183
Outcome
The patient was started with a guided physical therapy regi-
men beginning 1 week after surgery. He was maintained in a
sling for 6 weeks to protect the repair. Phase 1 of therapy
consisted of pendulums, passive external rotation limited to
30, and passive forward elevation to 90 for weeks 16.
Avoiding internal rotation behind the back or across the mid-
line for the first 4 weeks is emphasized. At week 6, phase 2 of
therapy began with active assisted range of motion as toler-
ated, pulleys, and isometric strengthening of the deltoid and
periscapular musculature. Feedback to the patient is pro-
vided while doing isometric ER and IR to begin to try to
184 R.J. Thorsness and G.P. Nicholson
a b
Literature Review
Massive posterosuperior rotator cuff tears in young patients
present a difficult clinical problem. Repair of these tears in
these patients is associated with poor outcomes, likely given
irreversible changes to muscular function [13]. As an alter-
native to massive rotator cuff repair in this setting, some
Chapter 11. Latissimus Dorsi Transfer forSevere 185