Latissimus Dorsi Tendon Reconstruction at the Myotendinous Junction With Acellular Dermal Allograft

Abstract

Background:

Limited available data have shown latissimus dorsi tendon reconstruction to be an effective treatment for tendon tears in specific subpopulations of elite overhead throwing athletes.

Indications:

Primary indication for latissimus dorsi tendon reconstruction is a symptomatic, full-thickness humeral avulsion with or without a concomitant teres major tendon tear. Surgical candidates are typically young, high-demand, elite or professional overhead throwing athletes. In this case, the patient is a 29-year-old male former minor league pitcher and current pitching coach with a full-thickness avulsion of the latissimus dorsi tendon.

Technique Description:

The patient was positioned left lateral decubitus with a dynamic limb positioner maintaining the arm in 90° abduction and maximal internal rotation. This technique used a single posterior axillary incision, which was performed and dissected down to the ruptured latissimus dorsi tendon. We circumferentially applied an acellular dermal allograft to augment the reconstruction at the myotendinous junction. Subsequently, the construct was prepared for transfer with a Krackow suture technique. Suture buttons were used to secure the reconstructed latissimus dorsi tendon to the anatomic footprint on the proximal humerus with a tension slide technique.

Results:

One case series showed return to the previous level of competition for all baseball pitchers who underwent a latissimus dorsi reconstruction with excellent improvement in visual analog scale pain, American Shoulder and Elbow Surgeons, and Kerlan-Jobe Orthopaedic Clinic scores. Another larger study demonstrated equal return to play rates for professional baseball pitchers with a latissimus dorsi tear treated either nonoperatively or operatively. However, those treated operatively had no decline in performance, whereas the nonoperative cohort saw decline in some statistics.

Conclusion:

Latissimus dorsi tendon reconstruction using an acellular dermal allograft at the myotendinous junction is a viable treatment option for elite overhead throwing athletes with full-thickness tendon avulsions. It allows for full return to play, particularly if the patient has failed nonoperative management.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Here, we present our technique of latissimus dorsi tendon reconstruction at the myotendinous junction with acellular dermal allograft. Our disclosures are listed here. We will review our patient's presentation, including the history and physical examination, followed by treatment indications, preoperative planning, and ultimately the details of our surgical technique for latissimus dorsi tendon reconstruction. We will then review potential complications of the procedure and best ways to avoid them. Finally, we will cover the rehabilitation protocol and some of the patient outcomes demonstrated in the literature.

A 29-year-old man with a prior history of a right-handed superior labral anterior posterior (SLAP) repair presented to our clinic with a chief complaint of chronic right shoulder pain located anteriorly and posteriorly. He was a former right-handed minor league pitcher who continues to throw at a high velocity for his sports performance company, but has been limited for the last 10 months due to pain. He had a poor response to nonoperative treatment strategies that included a home-based exercise program, cryotherapy, oral antiinflammatory treatment, and an intra-articular corticosteroid injection.

On physical examination, he had loss of normal posterior axillary contour that is exacerbated when he places his hands on his hips and forced downward pressure is applied. He had full active and passive range of motion with 5 of 5 rotator cuff strength in his supraspinatus, infraspinatus, and subscapularis. Significantly, he had a positive Neer and Hawkins examination with a notable painful arc. His O’Briens test was negative, as was SLAP testing. In addition, sensation was grossly intact to light touch in all peripheral nervous distributions. Our patient's axial magnetic resonance imaging (MRI) is depicted here showing a chronic high-grade tear of the latissimus dorsi with underlying mild atrophy as denoted by the orange star in the left T2 image. The white arrow in the left image shows where the humeral attachment is not well identified. A scarred portion of the latissimus dorsi tendon is retracted approximately 2 to 3 cm, as noted by the blue arrow in the T1 image on the right. This is a preoperative photograph taken in clinic demonstrating the loss of normal posterior axillary contour.

Operative treatment indications for latissimus dorsi reconstruction include a symptomatic, full-thickness tear of the latissimus dorsi tendon with avulsion in a young, high-demand patient who is typically an elite or professional overhead throwing athlete, such as a baseball pitcher. Avulsions can be the latissimus dorsi tendon alone, or the latissimus dorsi with a concomitant teres major tendon tear, as these tendons converge to insert on the humerus in the medial aspect of the bicipital sulcus. Nonoperative treatment is reserved for lower level and recreational athletes, patients with a partial tear, and those who are low demand, elderly, or poor surgical candidates due to other underlying medical conditions. In the case of our patient, given his failure to improve with conservative treatment, he elected to proceed with a latissimus dorsi tendon reconstruction. As such, we have counseled him at length about the benefits, risks, and alternatives. Consent was obtained, and the patient was scheduled for surgery.

To review the relevant anatomy of the case, this diagram depicts the proximal humerus. As you can see, the latissimus dorsi tendon and the teres major tendon both attach on the anteromedial aspect of the bicipital sulcus, inferior to the crest of the lesser tubercle, which is labeled with an arrowhead. The latissimus dorsi insertion is labeled number 2 and the teres major insertion is labeled number 3. The pectoralis major tendon attaches on the posterolateral aspect of the bicipital groove, labeled number 1 in the diagram.

To return to our patient, on the day of the procedure, he was appropriately identified, marked, and transported to the operating room. He was secured in the lateral decubitus position, prepped, and draped in typical sterile fashion using a beanbag and a dynamic limb positioner on the operative arm. The positioner was attached to the opposite side of the bed as the surgical team. Given the chronic nature of the injury and the MRI findings indicative of muscular atrophy, we ordered an acellular dermal allograft to have available should we need to augment the strength of the remaining tendon.

In contrary to a dual incision, our technique used a single posterior axillary-based incision, which measured approximately 10 cm. Importantly, the patient's arm was positioned in 90° abduction and maximal internal rotation across his body for the entirety of the case. This rotated the bicipital groove into the window of the posterior axillary incision and allowed better visualization of the anatomic footprint than the dual incision approach. After the incision, subcutaneous tissue was dissected, and care was exercised to preserve the posterior brachial cutaneous nerve. We also took care to identify and preserve the radial nerve and brachial artery as they course immediately anterior to the humeral attachment of the latissimus dorsi tendon. The isolated latissimus dorsi rupture was identified by locating the anatomic footprint on the proximal humerus. We then located the facial plane and the fibrous tract of scar tissue that had formed due to the chronic tear and followed this proximally until the retracted latissimus dorsi tendon was identified. A Penrose drain was placed around the tendon for mobilization and to free the tendon from these underlying scar and soft tissue adhesions. The tendon was deemed to have proper length and was able to be mobilized to the native footprint. Therefore, it was determined that a lengthening allograft, such as an Achilles tendon, was not necessary. However, given the atrophy to the limited residual stump of tendon, we elected to proceed with acellular dermal allograft augmentation to reinforce the tensile strength of the remaining tendon. As depicted in this figure, the graft was folded circumferentially around the myotendinous junction and secured to the tendon with suturetape. Once this construct was prepared, fibertapes were placed through the graft in a Krackow fashion. This suture construct is described by Neumann et al in their repair of chronic pectoralis major tendon rupture and allows for a tension slide technique. At this point, 1 retractor was placed anteriorly to protect the biceps, pectoralis major, radial nerve, and brachial artery. Additional retractors were placed posteriorly to mobilize the triceps and posterior brachial cutaneous nerve. A rasp and elevator were used to prepare the recipient site, and 2 unicortical drill holes were created approximately 1.5 cm apart. The buttons were then prepared and inserted, and 1 limb of the sutures was taken up through the graft to allow a tension slide technique. Axial traction on the suture delivered the tendon to its anatomic location. Returning to our previous diagram, we can see the anatomic location of the latissimus dorsi relative to the lesser tuberosity and teres major tendon, with our fixation site labeled in this image as number 2. Subsequently, the suture was tied with a knot pusher for stout repair and excellent stability throughout the arc of motion. The wound was copiously irrigated, and the operative site was closed in a layered fashion.

This is the postoperative x-ray which confirms proper placement of the surgical buttons in the anatomic footprint of the latissimus dorsi tendon, as indicated by the orange arrows in the diagram and x-ray. As you can see, the buttons are placed inferior to the lesser tuberosity on the medial aspect of the bicipital sulcus.

There are a number of potential complications that can occur with this procedure. Perhaps the most serious would be damage to the radial nerve as it courses anterior to the latissimus dorsi tendon insertion, so identification and protected retraction of the nerve is essential. Another serious complication would be damage to the brachial artery as it runs anterior to the latissimus dorsi tendon insertion, so again, identification and protected retraction during the case is important. It is not uncommon for patients to have a concomitant teres major tendon tear when the latissimus dorsi tendon is torn from the insertion. If this were the case in our patient, we would have secured the latissimus dorsi and teres major tendons complex to 3 suture buttons, rather than only 2. Another potential complication is failed allograft incorporation into the myotendinous junction. Therefore, proper Krackow technique with appropriate strength suture is critical. In addition, suture button loosening is a potential complication, but this risk can be mitigated with accurate sizing of the drill hole. Graft rejection or failure and lack of incorporation can occur, and some of this can be limited with proper patient selection and the use of acellular dermal allograft for augmentation. Infection or disease transmission is a risk with any allograft so sterile technique, in addition to preoperative antibiotic administration, as well as pulsatile irrigation before implantation should be performed. Finally, arthrofibrosis, given the open procedure can occur, therefore, it is important to focus on early range of motion as per the rehabilitation protocol.

There is variation within rehabilitation protocols depending on the location of the lesion, but, in this particular one, we used a 5-phase approach over the course of 12 months, broken down into a series of several weeks. Initially, the patient is restricted to strict immobilization in a sling with a 4-inch abduction pillow which places the shoulder in internal rotation. After 2 weeks, the patient can begin passive range of motion as tolerated, with progressive gentle pendulum exercises under the supervision of a physical therapist. After 6 weeks, the sling is discontinued and the patient can progress to active and passive range of motion as tolerated. Progressive light isometric and stretching exercises are also started at this time and advanced as tolerated. At 12 weeks, the patient will typically have full active and passive range of motion. At this time, light overhead activities and progressive throwing programs can be started. Ultimately, at 6 months, the patient is focused on advancing functional capacity and they may return to sport-specific activity when cleared by the surgeon.

As latissimus dorsi tendon tears are uncommon, and only a specific subpopulation of patients undergo surgery, there are limited data on postoperative results. However, we have experienced multiple cases where chronic neglected latissimus tendon injuries may require treatment, and many of these may be amenable to primary repair, with or without associated teres major injury. This is a retrospective case series on 11 patients who underwent latissimus dorsi tendon reconstruction. Eight of these patients were elite pitchers with 7 playing professionally and 1 collegiate athlete. Three patients were recreational athletes. The mean time from injury to repair was over a year, indicating most patients had attempted nonoperative management. They reported excellent postoperative outcomes at the first visit, with an average visual analog scale pain score of 0.7, an average ASES score of 100, and an average Kerlan-Jobe Orthopaedic Clinic score of 93. In addition, 7 of the professional pitchers included in the study, all returned to the same level of play as before the injury. This was a retrospective cohort of 120 professional baseball pitchers who sustained a latissimus dorsi tear. One hundred seven of these patients were treated nonoperatively, while 13 patients elected for operative reconstruction. Results showed that there was a 75% return to sport for both groups. Differences arose in time to return to play, and performance upon return. The nonoperative cohort returned to play on average 170 days after injury. However, as compared with their preinjury career, they played less games and had a statistically worse walks and hits per innings pitched, a common stat used to evaluate pitching performance. The operative group had a longer average return to play at 406 days, but they saw no significant change in any performance metric after surgery. These are our references. Thank you for your attention.