Acute Repair of Latissimus Dorsi and Teres Major Tendon Tears

Abstract

Background:

Latissimus dorsi and teres major tendon tears are rare, typically occurring in high-level throwers but also from sudden shoulder extension or hyperabduction. While nonoperative management was previously preferred, recent literature favors operative repair, especially for complete, retracted tears.

Indications:

Recent literature suggests partial-thickness tears can be managed nonoperatively, allowing return to competitive play, while repair is recommended for higher-grade tears to restore full performance. This approach can also apply to young, active individuals seeking full shoulder function.

Technique Description:

Patient positioning is lateral decubitus with a bean bag, and an arm positioner aids exposure of the latissimus through arm abduction/internal rotation. A curvilinear incision is made over the tendon defect, avoiding the posterior armpit, angled toward the posteromedial humerus. Skin flaps are raised for muscle visualization, and the latissimus dorsi and teres major are mobilized, protecting the radial nerve/deep brachial artery and axillary nerve/posterior circumflex vessels, respectively. The humerus is palpated, and the bony footprint is exposed with blunt Hohmann retractors. Two to 3 unicortical buttons are placed 1 to 1.5 cm apart. No. 5 FiberWire and FiberTape are passed to facilitate a tension-slide technique. Sequential reduction is performed starting distally, reducing the tendon and tying each button. The wound is irrigated and closed in layers, and a waterproof dressing with a shoulder immobilizer is applied. Rehabilitation begins with 6 weeks of strict immobilization in a shoulder immobilizer, with pendulums and passive range of motion (ROM) exercises starting at 2 weeks. From 6 to 12 weeks, the sling is discontinued, and passive/active ROM exercises, light isometrics, and stretching are introduced. After 12 weeks, light overhead activities or throwing may begin, with full return to sport delayed until at least 6 months.

Results:

Recent studies show high return-to-sport rates (75%) for both nonoperative and operative treatments, with faster recovery nonoperatively. However, athletes treated surgically had no significant decline in performance, which was observed in those treated nonoperatively, suggesting limited healing of complete tears and compensation ability.

Discussion/Conclusion:

Repair of latissimus/teres major tears is a safe, dependable option to restore function and preoperative athletic activity, as well as minimize pain in professional or recreational athletes.

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

We present our study acute repair of latissimus dorsi and teres major tendon tears.

In this video, we will review the background, preoperative planning, patient positioning, and procedure of acute latissimus dorsi and teres major tendon repairs, along with potential complications, rehabilitation, and return to sports and patient outcomes in the literature.

Background

We present the case of a 38-year-old active man, 10 days after a fall while ice skating, in which he experienced a stretching sensation with an audible pop and immediate pain in his posterior shoulder. In the ensuing days, he noticed swelling, ecchymosis, and pain aggravated by dressing, stretching, and attempted push-ups/planks. He had no treatment to date, with no physical therapy, injections, or previous surgeries of the affected shoulder.

His examination was significant for ecchymosis over the latissimus with equivocal deformity. There was pain with resisted shoulder extension and abduction. Additionally, he had a symptomatic acromioclavicular joint and positive impingement testing on examination, but full shoulder range of motion and isolated rotator cuff strength.

Radiographs reveal no acute fractures or dislocations and no significant degenerative change of the glenohumeral or acromioclavicular joints. T2-weighted coronal, sagittal, and axial magnetic resonance imaging (MRI) cuts show a complete latissimus dorsi and teres major tear with 3 cm of retraction. Additionally, they demonstrate biceps tenosynovitis and a long head of the triceps strain.

Indications

Erickson et al ³ published an MRI classification system for these injuries to help guide treatment decisions. He found that partial-thickness tears could be managed with a trial of nonoperative management and get back to competitive throwing at the same or higher level of play. But if the patient has higher-grade tears, repair is indicated, as it is unlikely to allow the athlete to return to their previous level of performance. These authors extrapolate this treatment scheme for young, active individuals wanting to restore full shoulder function.

For preoperative planning, it is important to set expectations with the patient regarding rehabilitation and the time frame for return to sport. One should critically review the preoperative MRI to determine the precise tendons torn, in addition to the amount of retraction, given the proximity to neurovascular structures.

Technique Description

Patient positioning is lateral decubitus with a bean bag. A trimano or surgical arm positioner can be placed in front of the patient, just below the level of the shoulder, to aid exposure of the latissimus through arm abduction/internal rotation.

The typical incision is curvilinear, centered over the visual or palpable tendon defect proximally, avoiding the posterior aspect of the armpit, and angled toward the posteromedial humerus distally. This incision is extensile in either direction but should be preferentially erred distally, as humeral exposure is often more difficult.

The incision is carried down through the subcutaneous tissues with electrocautery. There are some small cutaneous nerves but no major cutaneous nerves to worry about.

Skin flaps are raised and mobilized to allow visualization of the musculature. Fascia overlies the muscles of the region, which may be traumatically disrupted from the injury. From posterior to anterior, identify and define the deltoid, teres major, and latissimus. The teres major muscle belly is seen within the center of the wound. It is important to recognize that the latissimus is more anterior than often believed and demarcated by a thinner, broader tendon.

In acute settings, one can follow the hematoma through the zone of injury to the humerus to ensure the proper plane.

The teres major is more central within the operative wound and is mobilized from the more posterior deltoid through a combination of blunt dissection and careful use of electrocautery with a tonsil. This interval comprises parts of the quadrangular space, and one must be cautious that the axillary nerve and posterior circumflex vessels are in close proximity. The latissimus is more anterior and has a thinner, broader tendon. Similarly, blunt dissection and the use of electrocautery with a tonsil are used for mobilization. The triangular interval is just distal to the insertion of the latissimus/teres major, so one must be cautious that the radial nerve and deep brachial artery are in close proximity distally. After the medial and lateral boundaries of the torn, retracted tendons are mobilized, there is often a combined fascia distally at the confluence of the deltoid, teres major, latissimus, and triceps that must be cut.

Blunt Hohmann retractors can be placed medially and laterally around the humerus to protect neurovascular structures and show the footprint for the latissimus and teres major. Two to 3 unicortical buttons are placed in a standard fashion using the pectoralis button kit, ensuring the spread of at least 1 to 1.5 cm. One should recognize that the latissimus rotates 90° as it attaches to the medial humerus, so this should be accounted for with placement of the distal button.

The buttons comprise No. 5 FiberWire and FiberTape (Arthrex). One limb of No. 5 FiberWire from each button is passed in a running locking fashion with 3 to 4 throws up and down the tendon; the other limb will serve as the “pull” suture for this tension-slide technique. This is repeated with 1 limb of FiberTape from each button but with a series of simple passes for 2 to 3 throws. For suture management, remove the needle from the stitches that were passed, and maintain the needle on the “pull” stitches.

Starting distally, a sequential reduction is performed by first pulling the No. 5 FiberWire “pull” suture to reduce the tendon. This is followed by the “pull” tape to remove the slack. Repeat for each successive proximal button and then tie.

Once the repair is complete, gentle range of motion (ROM) can be performed. The wound is then copiously irrigated. The fascia can be reapproximated if desired.

Buried 2-0 Monocryl (Ethicon) is used for deep dermal reapproximation and a running 3-0 Monocryl for subcuticular closure. Dermabond is preferred given the proximity to the axilla. A 4 × 4 gauze and overlying Tegaderm (3M Healthcare) are applied for a waterproof dressing.

Results

Several complications should be avoided during this procedure. Given the proximity to several neurovascular structures, understanding of the anatomy, careful placement of blunt retractors, and use of electrocautery can aid in safe dissection and surgery. Moreover, understanding the course of the latissimus dorsi tendon can aid in the restoration of appropriate anatomy. The tendon rotates 90° as it attaches to the medial humerus, so this should be accounted for with placement of the distal button. It can be helpful to use the biceps within the bicipital groove as a guide through a combination of palpation and retractor placement. The tension-slide technique helps ensure secure reduction of the repair. One should think of the No. 5 FiberWire as the main workhorse for this technique, with the FiberTapes as more of a backup, as the tapes do not slide as well. Given its proximity to the axilla, wound complications are possible but may be minimized through meticulous hemostasis, watertight closure, and use of surgical skin glue and a waterproof dressing.

The first 6 weeks of rehabilitation consist of strict immobilization in a shoulder immobilizer that helps place the shoulder in internal rotation, with gentle pendulums and passive ROM exercises initiated at 2 weeks. ⁴ From 6 to 12 weeks, the sling is discontinued, and passive and active ROM exercises are performed with light isometrics and stretching. After 12 weeks, light overhead activities and/or throwing programs may be initiated. General return to sport or full activity is delayed until at least 6 months postoperatively, depending on tissue integrity, repair quality, and anticipated at-risk physical demand.

Discussion/Conclusion

Latissimus and teres major tendon tears are relatively rare and almost exclusively encountered by professional and high-level recreational throwers but can also be seen with any sudden, forced extension or hyperabduction of the shoulder, as in this case.^1,6 The true incidence is unknown but represents 0.7% of Major League Baseball injuries, with 87% being accounted for by pitchers. Historically, there was a strong recommendation for nonoperative management with successful return to sport, but it is unclear if all of these were complete, retracted tears.^2,5 More recent literature has delved into comparisons of nonoperative and operative management.^2,4,6 Return to sport is high for both at 75% each, with athletes returning to sport much faster when managed nonoperatively, and each having a similar time buildup from activation to the same level of competition. However, athletes undergoing repair had no significant decline in primary performance metrics, while those treated nonoperatively pitched in fewer games, started and finished fewer games, and gave up more hits and home runs, suggesting the latissimus/teres major may have a limited intrinsic ability to heal, and the surrounding musculature has a limited ability to compensate for this deficit, which may lead to a permanent alteration in humeral internal rotation power and pitching effectiveness.

These are our references.

Thank you for your attention.