Subacute Latissimus Dorsi Tendon Repair via a Single Posterior Incision

Abstract

Background:

This is a rare case of the surgical treatment of a subacute presentation of a latissimus dorsi tendon rupture via a posterior single-incision approach.

Indications:

The patient had extensive conservative, nonoperative treatment that failed, and ultimately a surgical intervention was required to return to his activities of daily living.

Technique Description:

The patient is positioned in a lateral decubitus position. A 10-cm incision is created along the posterior axillary fold. Sharp and blunt dissection is utilized to carefully mobilize the chronic tendon rupture. The tendon is captured with 2 suture tapes utilizing a locking Krackow whipstitch. The tendon footprint is identified between the pectoralis major and teres major. The insertion point is prepared with a Cobb to debride the soft tissue and decorticate the bone bed to optimize healing. Two endobuttons are loaded with the suture tapes and then passed through unicortical holes drilled in the tendon bed. Care is taken to ensure the 90° external rotation of the tendon is achieved. A tendon-slide technique is used to reduce the tendon to the humerus. Afterward, a free needle is used to pass 1 limb of the suture through the tendon before tying an additional knot for added fixation.

Results:

The patient was able to resume his activities of daily living without pain at the 4-month mark.

Conclusions:

After the failure of extensive nonoperative management, surgical treatment of a subacute complete rupture of the latissimus dorsi tendon via a single, posterior incision is an effective method of returning a patient to their painless activities of daily living.

Patient Consent Disclosure Statement:

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.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a presentation reviewing a subacute latissimus dorsi tendon rupture treated via a single-incision approach.

We have no relevant disclosures.

Background

The patient is a 51-year-old right hand–dominant truck driver who injured his left shoulder while attempting to negotiate uneven monkey bars during a Spartan race 2 months prior to presentation. While he never felt a “pop,” he noted sharp pain and posterior axillary bruising afterward.

Prior to presenting, the patient had received care at an outside facility. They placed him in a sling, trialed him on nonsteroidal anti-inflammatory drugs, and attempted a subacromial corticosteroid injection.

Now 2 months out from injury, the patient had no ecchymosis, but asymmetry was noted in the posterior axilla. The patient was tender to palpation over the retracted latissimus dorsi tendon and weak and painful with resisted extension.

Radiographs were negative for acute osseous abnormalities, but an ultrasound performed at the outside facility demonstrated nearly 5 cm of retraction of the latissimus dorsi.

The diagnosis here is a subacute latissimus dorsi tendon rupture. The latissimus dorsi is a large fan-shaped muscle that originates from the iliac crest, thoracolumbar fascia, inferior thoracic (T7-12), and lumbar spinous processes. The tendon insertion externally rotates 90° before attaching to the medial aspect and floor of the intertubercular groove.^1,7

This insertion is medial to the pectoralis major insertion and lateral and proximal to the teres major insertion, leading to the memory tool “miss between two majors.”

These injuries are rare, ³ but case reports and small case series have documented them occurring in elite baseball pitchers, cross-fit athletes, and those participating in water-skiing sports, rock climbing, tennis, and even golf. ¹ This injury occurs with resisted extension and/or adduction of the arm.

With the appropriate history obtained, the accurate diagnosis is determined through the physical examination finding of asymmetry in the posterior axillary folds. If the injury is acute, ecchymosis can be seen along the proximal arm and posterior axilla. Occasionally, the patient will have tenderness to palpation over a palpable tendon or demonstrate weakness with adduction and internal rotation. An ultrasound or magnetic resonance imaging can be obtained for confirmation of the diagnosis and preoperative planning.

Nonoperative treatment is historically the most conservative approach. This includes a period of rest followed by gentle range of motion. Anti-inflammatories, injections, and physical therapy can help mobilize a patient while alleviating pain. Afterward, a gradual return to normal activities is permitted.^9,11,12 Nonoperative treatment has a high success rate, with professional baseball players returning to sport between 75% and 100% of the time.^5,9,12

Alternatively, operative intervention can be performed via 2 surgical options: the single and 2 incision approaches. ⁷ The single-incision technique tends to be more cosmetic, as it is placed in the posterior axillary fold. But the more crucial reason to consider this approach is that is extensile, which is critical in the scenario of a delayed repair. The downside of this technique is that it can be difficult to visualize the latissimus dorsi footprint. ¹¹

The 2-incision approach is another option. ⁴ While this technique offers much improved visualization of the latissimus footprint, it may be difficult to find the latissimus if it is more than 5 cm retracted.^2,4

Indications

Operative treatment tends to be reserved for complete, retracted tendon avulsions and is more commonly performed in competitive athletes. Given the rare nature of this injury, there are limited data available to compare technique outcomes. Both cortical button and suture anchor fixation techniques have been described.^5,6,7,11

Given the patient's age, activity level, and subacute presentation, the patient was advised to pursue a course of nonoperative management, with physical therapy and appropriate modalities.

However, the patient returned to the clinic 4 months out from injury, having physical therapy, anti-inflammatories, and activity modifications that failed. He was consented for repair with the surgical indication of persistent pain and weakness, which prevented his activities of daily living.

Technique Description

The patient is situated in a lateral decubitus position with a beanbag and an axillary roll. The operative extremity is secured in a dynamic limb positioner, which is attached anterior to the patient. By maintaining the arm in abduction, flexion, and internal rotation, the positioner provides crucial access to the posterior axillary fold. Here, a 10-cm incision is drawn from the latissimus insertion on the humerus to the posterior chest wall.

The incision is made through the skin, and a combination of sharp and electrocautery dissection is performed through the subcutaneous tissue. While acute latissimus ruptures can be readily identified after incising the fascia, our patient is 4 months out from injury. The latissimus here is heavily scarred into the thick fascia, the teres major, and surrounding soft tissue. Much of the case was spent carefully liberating the latissimus dorsi tendon from the soft tissues around it before bluntly encouraging full excursion of the tendon back to the humerus.

Care was taken at all times to avoid neurovascular injury during the dissection. The axillary nerve lies just superior to the latissimus while the radial nerve is found anterior and medial. The radial nerve is retracted with the pectoralis major anteriorly while the posterior brachial cutaneous nerve is taken posteriorly with the triceps.

As attention is turned to the humeral insertion, the positioner is used to fully abduct and internally rotate the arm for optimal exposure. Dissection is performed down to the intertubercular groove, which is palpable with finger dissection.

The native footprint is then prepared with a Cobb elevator to provide favorable biology for healing.

Two unicortical holes are drilled in the footprint of the tendon. These should be 1 to 2 cm apart and ideally at a 30° to 45° angle.

It is now time to prepare the tendon. Two fibertapes are sutured in locking Krackow fashion through the tendon, leaving 4 suture limbs emerging from the distal end of the tendon. We elect to use tape over suture as it has been demonstrated to significantly improve pull-out strength. ⁸ These sutures are then loaded in a standard fashion through 2 cortical buttons.

One last excursion check, and it is time to insert the buttons. Immediately prior to its insertion onto the humerus, the latissimus dorsi externally rotates 90°. Keep this in mind when choosing which button should go in each hole. The inserter is placed, and the button is flipped. These steps are repeated with the second button. Afterward, the tendon is advanced to the humerus with a tension slide technique.

Once satisfied the tendon is reduced to its native footprint, a free needle is utilized to shuttle 1 limb from each suture button back through the tendon in a ripstop onlay technique. The sutures are then tied on top of the tendon to complete the fixation.

The wound is copiously irrigated, and 1 g of vancomycin powder is used in the deep tissue as antibiotic prophylaxis. Following this, a layered closure is performed.

The key to success with the single-incision approach lies in the utilization of the dynamic arm positioner and by being aware of the nearby neurovascular structures. With the positioner, it is important to get the arm abducted and internally rotated to visualize the latissimus footprint. As mentioned during the dissection portion of the video, the proximity of the posterior brachial cutaneous, radial, and axillary nerves requires the surgeon to be ever vigilant. ¹⁰

The patient was placed in a sling with an abduction pillow for 6 weeks. He was encouraged to begin gentle pendulums and other passive range of motion exercises at 2 weeks. At the 6-week mark, the patient was allowed to begin active range of motion exercises, with the goal of achieving full range of motion between 10 and 12 weeks out from surgery. After obtaining full range of motion, gradual strengthening exercises were initiated.

Results and Discussion

The management of latissimus dorsi tendon injuries typically results in a good outcome. In 2009, Schickendantz et al ¹² published an article in AJSM describing the course of 10 professional baseball players with latissimus dorsi and teres major injuries. All patients with isolated latissimus dorsi tendon injuries were able to return to full velocity in 3 months, although 1 of the 5 had a recurrence of injury.

Similarly, the 2011 article by Nagda et al ⁹ described the outcome of 16 professional baseball players who were treated nonoperatively. While 94% were able to return to the same level of play or higher, they did describe a 16% recurrence of injury.

The 2019 AJSM article by Erickson et al ⁵ looked at professional baseball players with latissimus dorsi and teres major injuries from 2011 through 2016. They reported a 75% rate of return to sport for both nonoperatively and surgically managed groups but did notice some key differences in outcome. While there was a large amount of variance, leading to a high standard of deviation, the nonoperative group was able to return at a faster rate. However, the nonoperative group had significantly worse performance outcomes, such as in WHIP (which is a stat that combines walks and hits over innings pitched). There was no such performance decrease in the operatively treated group.

Our patient did very well postoperatively. He was back to all of his activities of daily living by 4 months out and no longer complained of pain. His strength was quickly returning and his SANE (Single Assessment Numeric Evaluation) score improved from 50 to 85 postoperatively.