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E-mail address: yeosubaek@gmail.com
All the authors declare no conflict of interest.
INTRODUCTION:
Untreated subscapularis (SSC) tendon tears can lead to tendon retraction, muscle atrophy, and fatty degeneration, which often result in significant shoulder dysfunction—particularly impairing internal rotation and limiting daily activities.[1,2] As these tears progress, chronic degeneration may render them irreparable, making surgical management particularly challenging. Various surgical approaches have been proposed for irreparable SSC tears, including anterior capsular reconstruction (ACR), reverse total shoulder arthroplasty (RSA), and tendon transfers.[2-4] Anterior transfer of the latissimus dorsi (LD) tendon has emerged as a viable surgical option for managing irreparable SSC tears.[5-7] Owing to its anatomical trajectory and vector of pull, the LD tendon closely replicates the native biomechanics of the subscapularis, making it well-suited for restoring internal rotation and enhancing shoulder stability.[8] Nevertheless, isolated LD transfer has shown limitations in fully correcting superior migration of the humeral head and addressing persistent anterior glenohumeral instability for irreparable subscapularis tears.[6,7]
To better restore shoulder stability and depress the humeral head, a combined transfer using the latissimus dorsi and teres major (LDTM) tendons has been proposed.[9] This approach aims to enhance biomechanical strength and optimize internal rotation function.[10] Both biomechanical and clinical studies suggest that LDTM transfer provides superior outcomes compared to single tendon transfers, particularly in maintaining humeral head positioning.[10-12] Despite promising clinical results, previous techniques have relied on anchor-based fixation, which may be insufficient in osteoporotic bone and pose a risk of anchor pullout.[9,12] This current technical note describes a combined LDTM transfer augmented with an acellular dermal matrix (ADM) allograft and secured using a transosseous fixation method. This approach is designed to promote soft-tissue integration, reduce the risk of fixation failure—particularly in osteoporotic bone—and enhance overall functional outcomes. Ideal candidates are those who have failed nonoperative management and present with irreparable subscapularis tears (Lafosse[13] grade ≥ 4) with marked fatty degeneration (Goutallier[14] grade ≥ 3), and minimal or no glenohumeral arthritis (Hamada[15] stage < 3). Contraindications include advanced glenohumeral arthritis (Hamada[15] stage ≥ 3), significant neurological deficits, active infection, or systemic conditions that could adversely affect surgical outcomes.
TECHNIQUE DESCRIPTION:
Patient Positioning and Surgical Approach
The procedure is performed under general anesthesia with the patient positioned in the beach chair position. A skin incision is made from the coracoid process extending to the inferior border of the pectoralis major (PM) tendon. Through a standard deltopectoral approach, the subscapularis is evaluated. If the subscapularis tendon cannot be mobilized and reduced to its native footprint, a tendon transfer is indicated. If reducible, primary repair is performed instead, and the tendon transfer is omitted. Surgical dissection proceeds with careful release of the superior and inferior borders of the PM muscle. The PM is then retracted laterally with a Kolbel retractor, while the coracobrachialis and short head of the biceps are retracted medially to expose the intended insertion site for the LDTM tendon on the humerus.
Harvest and Preparation of the LDTM Tendon
The LDTM tendon is harvested as a single composite unit without separating the LD and TM. The harvested tendon is augmented with an ADM allograft (Surederm; Hans Biomed Co., Daejeon, Republic of Korea), trimmed to conform to the dimensions of the LDTM tendon. The ADM allograft is then secured to the tendon using three #2 non-absorbable sutures placed in a Krakow stitch configuration along the upper, middle, and lower lateral edges. Medial release of the harvested tendon is performed meticulously, with careful dissection to free adhesions and optimize tendon mobilization and excursion. During this step, meticulous hemostasis is maintained to prevent bleeding from the anterior humeral circumflex vessels located near the upper border of the LDTM tendons. Special care is taken to protect the radial nerve, which courses along the anteroinferior surface of the LDTM muscle, thereby minimizing the risk of iatrogenic injury.
Fixation of the LDTM Tendon
The prepared LDTM tendon is passed beneath the PM muscle and directed toward the lateral aspect of the greater tuberosity of the humerus, laterally to the bicipital groove. With the arm positioned in full internal rotation and 45° of abduction, the prepared LDTM tendon is placed approximately 2 cm distal to the lateral aspect of greater tuberosity, and the fixation sites are marked accordingly. To create the transosseous tunnels, three parallel tunnels are drilled at the upper, middle, and lower thirds of the marked fixation site. While an anterior cruciate ligament (ACL) guide may be used, it is not essential; the tunnels can also be created freehand using a 1.6-mm K-wire and drill bit, provided they remain parallel. Each corresponding suture from the LDTM tendon (upper, middle, and lower) is passed through its respective tunnel using a spinal needle loaded with a looped wire. Additional free looped sutures are also shuttled through each tunnel. For each tunnel, the free looped sutures are first threaded through the harvested LDTM tendon using a suture lasso passer and secured with sliding locking knots. Subsequently, the corresponding LDTM tendon sutures are passed through the LDTM tendon and tied with simple knots to further reinforce the fixation. Once all sutures are secured and trimmed, the humerus is taken through a full range of motion to confirm the absence of impingement or mechanical restriction.
Postoperative Rehabilitation
During the first four weeks following surgery, patients are instructed to wear an abduction brace with the arm maintained in internal rotation. Continuous passive range of motion exercises are performed throughout this period. After four weeks, the abduction brace is discontinued, and patients begin active-assisted range of motion exercises to progressively restore mobility. Strengthening exercises targeting all planes of shoulder movement are initiated at three months postoperatively. Patients are advised to avoid active physical labor and sports activities until six months after surgery to ensure optimal healing and functional recovery.
RESULTS:
Recent evidence supports the clinical efficacy of anterior LDTM transfer for the treatment of irreparable subscapularis and anterosuperior rotator cuff tears.[9] In a clinical series of 30 patients undergoing anterior LDTM transfer, statistically significant improvements were observed across multiple validated outcome measures.[9] The Constant score improved from 47.4 to 69.9, the American Shoulder and Elbow Surgeons (ASES) score from 44.9 to 79.2, the UCLA score from 20.0 to 28.7, and the Activities of Daily Living requiring Internal Rotation (ADLIR) score from 13.2 to 26.9 (all P < .001). Active range of motion also significantly increased, particularly in forward elevation and internal rotation at the back (P < .001). Eighty-three percent of patients returned to their preoperative level of occupational activity. Radiographic evaluation revealed no significant progression of cuff tear arthropathy at final follow-up (Hamada grade: 1.3 ± 0.5 to 1.5 ± 0.7; P = .155). Preoperative anterior glenohumeral subluxation was corrected in all cases. Reported complications included one transient axillary nerve palsy and two cases of partial, non-retracted tendon failure.
LDTM transfer has also demonstrated positive outcomes in cases of global irreparable rotator cuff tears involving the subscapularis, supraspinatus, and infraspinatus.[16] In a cohort of 23 patients followed for a mean of 28.2 ± 4.3 months, all clinical scores—including VAS, Constant, ASES, UCLA, and ADLIR—showed significant improvement postoperatively (P < .001).[16] Forward elevation improved to 129° ± 29°, abduction to 105° ± 13°, and internal rotation at the back to 5.9 ± 2.5 vertebral levels. Strength in forward elevation and internal rotation also increased significantly (P < .001). Complete reversal of pseudoparesis was observed in six patients, and reversal of pseudoparalysis in two of four. There was no significant change in acromiohumeral distance (AHD) or Hamada grade at final follow-up. Three patients experienced partial retears of the transferred tendon without complete rupture or retraction.
A comparative study further evaluated the outcomes of isolated LD transfer versus combined LDTM transfer in 53 patients with irreparable anterosuperior rotator cuff tears.[12] Patients were assigned to either LD transfer fixed to the lesser tuberosity (n = 23) or LDTM transfer fixed to the greater tuberosity (n = 30).[12] At the two-year follow-up, both groups showed significant improvement in pain and functional scores (P < .001). However, the LDTM group demonstrated superior internal rotation strength (P < .001), ADLIR scores (P = .017), and results in subscapularis-specific physical examination tests: belly-press (P = .027), bear-hug (P = .031), and lift-off (P = .032). There were no significant intergroup differences in AHD (P = .539) or Hamada grade (P = .974). Both groups exhibited improved anterior glenohumeral subluxation, with the LDTM group showing a significantly higher rate of restoration (P = .015).
Collectively, these findings support anterior LDTM transfer as an effective surgical option for irreparable subscapularis tear, providing enhanced internal rotation strength, improved functional outcomes, and better restoration of glenohumeral joint alignment. Compared to isolated LD transfer, the combining TM appears to confer additional biomechanical and clinical benefits, particularly in restoring internal rotation and stabilizing the humeral head.
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