Abstract
Background:
Latissimus dorsi tendon ruptures are rare injuries that can occur in overhead or throwing motions and are almost always sports related.
Indications:
Latissimus dorsi tendon ruptures are largely treated nonoperatively, although surgical repair is indicated for the young active patient looking to return to a high level of sport and for those with complete avulsion injuries or mid-substance tendon tears.
Technique Description:
Depending on the degree of tendon retraction, anteroinferior or posteroinferior axillary incision is made. After the tendon is mobilized, sutures are placed in a Krackow fashion through the bulk of the tendon, and the tendon footprint is prepared by gently decorticating the surface of the humerus, just anterior and inferior to the teres major insertion point. Two Arthrex Pec Buttons are then loaded into the superior and inferior limbs of the suture tape and 2 unicortical holes are drilled into the footprint of the insertion site. The superior button is placed first and then tensioned to allow the latissimus dorsi to be pulled to the bone. Next, the second button is placed, though this is not tensioned until later at the time of the biceps tenodesis. Finally, the procedure is visualized and well inspected to ensure appropriate location of the tendon and securing hardware.
Results:
After an appropriate rehabilitation protocol is followed for up to 6 months postoperatively, acute repair of a ruptured latissimus dorsi tendon allows for near to complete restoration of patient functionality and strength, with return to full activity possible within 6 to 8 months.
Conclusion:
Surgical repair of a ruptured latissimus dorsi tendon is effective in restoring upper extremity strength and functionality and is associated with high patient satisfaction.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
Latissimus dorsi tendon repair, as presented by John Belk, Drs Jonathan Bravman, Rachel Frank, Adam Seidl, and Eric McCarty.
The authors have no disclosures that are relevant to this topic.
And to give a quick overview of this presentation, we will talk briefly about the anatomy and function of the latissimus dorsi muscle, the diagnosis of a complete latissimus tear, operative versus nonoperative treatment depending on the severity of the injury, we will quickly go over a few of the surgical techniques used to repair a torn latissimus, and then we will dive into our specific case with the narrated surgical technique video. We will then wrap up with postoperative rehabilitation and any final thoughts on this procedure.
The latissimus dorsi has truly 4 origins: It primarily originates from the low thoracic spine around T7 all the way down to L5. And secondary origin points are the iliac crest, the thoracolumbar aponeurosis, and the inferior angle of the scapula. And the one and only insertion point of the latissimus is the bicipital groove, right along the proximal shaft of the humerus. And acute ruptures of a latissimus tendon, despite how rare they are, almost always occur right at that insertion point at the bicipital groove.
In a cadaveric study of 12 specimens, the mean width of the tendon itself was 3.1 cm and the mean length was 8.4 cm. So in a big picture, the latissimus tendon is fairly comparable in size to the pectoralis major tendon as well as the teres major tendon.
The primary function of the latissimus occurs at the glenohumeral joint, but it really works synergistically with the teres major and pectoralis major to adduct and medially rotate the humerus. It also aids in respiration and plays a huge role for throwing and overhead athletes.
And you know as we previously mentioned, latissimus ruptures are very rare. But when they do occur, they occur most commonly in movements that involve resisted contraction with the arm in hyperabduction or external rotation. These injuries are typically sports related and are almost always demonstrated in some kind of overhead or throwing motion.
Latissimus ruptures are typically associated with significant bruising, loss of muscle contour, strength deficits, and possible nerve disruption, though neuropathy is not as common as it is with other tendon ruptures. But one thing to be cognizant of is despite a torn tendon, patients may still present with full, unrestricted range of motion, which can be somewhat misleading if the physician is not looking for the right symptoms that may accompany a tear.
As indicated by the black circle, you can see an obvious loss of muscle contour due to a ruptured latissimus tendon.
Patients often present with a history of posterolateral shoulder and upper arm pain. The acute injury is often accompanied by a sudden popping sensation followed by tenderness to palpation over the tendon insertion.
X-rays are used to exclude any bony avulsions, and magnetic resonance imaging (MRI) can help differentiate between complete, partial, and intramuscular tears.
Due to the athletic population, the primary complaint from patients is functional limitation, including primarily pain and strength deficits.
Nonoperative management is usually reserved for patients with partial ruptures, patients with tears at the musculotendinous junction, or for lower demand patients. Nonoperative management usually includes early activity modification, rest, ice, and non-steroidal anti-inflammatories, while operative management has been indicated for either complete or partial tendon avulsion from the bone. And this is the treatment of choice for high-level athletes and is likely to show improvement in functionality regardless of tear location.
So nonoperative management: The real question here is who should proceed with nonoperative treatment. And this is reserved for those without complete tears, so anyone with a partial tear who still has considerable function, strength, and motion, these are the patients who can explore nonoperative treatment. And multiple studies have shown that patients with partial tears who still have this function intact actually do really well with conservative treatment and have high rates of return to preinjury activity levels.
So for high-level athletes, which really makes up most of the population or patients who are experiencing a latissimus tear, we should assume that operative management is the appropriate line of treatment, especially those with a complete tear. Open repair has been shown to relieve posterior shoulder pain and restore upper limb functionality as well as increase strength.
There are really 2 primary techniques used in open repair of ruptured latissimus tendons, including the suture anchor technique and the unicortical button technique, with the unicortical button technique pictured here to the right.
The structures most at risk are the short head of the biceps tendon, which sits directly medial to the insertion of the pectoralis major tendon, the pectoralis major tendon itself, the radial nerve, and the teres major.
In addition, surgeons should be cautious of the cephalic vein, which sits directly superficial and medial to the tendon insertion.
For this case, we will discuss a 46-year-old active man with acute right posterior shoulder pain following a water skiing incident. He reported feeling a popping sensation with immediate pain and deformity and was unable to use his right upper extremity due to pain. His goal is to return to full function without restriction.
Upon examination, he has tenderness to palpation over the musculotendinous junction as it inserts into the humerus, an obvious deformity at the posterior axillary fold that is indicative of a latissimus tendon rupture, a moderate protrusion over the inferolateral scapular border, and his range of motion is normal but has obvious weakness with pulling movements.
So upon MRI review, you can see the near complete tear of the latissimus tendon off the bicipital groove, which appears to be retracted somewhere between 3 and 4 cm.
Based on these results, the patient is indicated for open repair of the latissimus tendon.
The patient is placed in the modified beach chair configuration with his right arm held in about 90° of abduction and 90° of external rotation and positioned at the edge of the table to ensure exposure along the lateral scapular area.
Next, by palpation, the tendon was assumed to be retracted to the lateral chest wall.
An initial 4-cm anteroinferior axillary incision is made in the axillary fold, and the dissection is carried down through the skin and subcutaneous tissue. The short head of the biceps is retracted medially and the pectoralis major is retracted superiorly with the Hohmann retractor. The remaining tendon appears to be the teres major with some remnants of the lat, but there really is no clear identification of the retracted lat tendon. So because of this, a separate 5-cm posteroinferior axillary incision is made from superiorly to inferiorly. A small amount of the tendon is eventually identified, which is freed up from any adhesions and debrided. After the tendon is mobilized, two #2 FiberTapes are utilized in a Krackow fashion with the sutures coming off the tendon edge. These sutures are eventually pulled up through the initial anterior incision, and the tendon footprint is prepared by gently decorticating the surface of the humerus, just anterior and inferior to the teres major insertion point. Two Pec Buttons (Arthrex; Naples, FL) are then loaded into the superior and inferior limbs of the suture tape and two 3.7 mm unicortical holes are drilled into the footprint of the insertion site. The superior button is placed first and then tensioned to allow the latissimus dorsi to be pulled to the bone. Next, the second button is placed, although this is not tensioned until later at the time of the biceps tenodesis. As far as biceps tenodesis goes in the context of an acute lat repair, this can be performed according to surgeon preference and depending on the status of the tendon itself. Finally, the procedure is visualized and well inspected to ensure appropriate location of the tendon and securing hardware.
And so the postoperative rehabilitation protocol is really important to ensure proper healing of the repaired tendon. And the primary goals here of the rehabilitation are to protect the tendon insertion site and reach full shoulder range of motion. In the first 1 to 6 weeks of rehabilitation, the patient will concentrate on healing and passive range of motion where abduction should not exceed 90° in those first 6 weeks. This should be followed by resistance training beginning at 6 to 12 weeks postoperatively. And then return to sport should be really at a minimum of 6 months.
So in summary, nonoperative management should be considered for lower demand, older patients who would be accepting of potential cosmetic deformities, but this is not really recommended for athletes or patients with complete ruptures. If proceeding with open repair, the unicortical button technique has been shown to be very reliable in producing the predictable and desired postoperative outcomes that patients and surgeons both look for.
And on this final image, you can see the clear differences between the appearance of the initial injury and 8 months postoperatively. This patient in particular experienced great improvements in motion and strength and reported being fully functional at his 8-month check-up.
Our references are shown here, and thank you very much for your attention today.
Footnotes
Submitted July 7, 2022; accepted August 22, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.