Latissimus dorsi transfer for primary treatment of irreparable rotator cuff tears

Transfer of the musculotendinous unit of the latissimus dorsi was performed in seven patients (5 men and 2 women, with a mean age of 57 years) with irreparable rotator cuff tear who had had no previous surgery for cuff repair. Preoperatively, the mean active shoulder motion was 86° in flexion, 74° in abduction and 22° in external rotation. One patient had a positive lift-off test. The average preoperative Constant and Murley score was 44%. Diagnosis of irreparability of the cuff leasion was made preoperatively only in one case. In the remaining patients, the preoperative data only led to suspect that the tear was irreparable. At surgery, all patients had an irreparable tear of the superoinferior portion of the cuff and one patient also had a tear of the subscapularis tendon. In all cases the latissimus dorsi tendon was inserted to the greater tuberosity and, in four cases, to the subscapularis tendon; in three patients it was sutured to the bicipital tendon. Postoperatively all patients had relief of shoulder pain. The mean improvement in active flexion, abduction and external rotation was, respectively, 39°, 29° and 10°: At the latest follow-up, the average Constant and Murley score was 64%. The results of surgery were rated as excellent in three cases, good in two, fair in one and poor in one. All patients but one returned to preoperative work. Transfer of the latissimus dorsi muscle is an effective procedure for patients in middle or early elderly age who have an irreparable tear of the supraspinatus and infraspinatus tendons. Received: 18 December 2001/Accepted: 4 January 2002     

Latissimus dorsi tendon transfers for rotator cuff deficiency

Purpose:

Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency.

Materials and Methods:

At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation.

Results:

Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05).

Conclusion:

Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term.

Level of Evidence:

Level 4.     

Delayed Breast Reconstruction with Latissimus Dorsi Flap

Background  The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion. Methods  The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site. Results  The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30–63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site. Conclusion  The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.     

Hot-Knife Dissection of the Latissimus Dorsi Muscle for Dynamic Cardiomyoplasty

Abstract: The overall purpose of circulatory assistance utilizing skeletal muscle is the most efficient application of muscle power. From the histological viewpoint, hot-knife dissection of the latissimus dorsi muscle (LDM) is presented to preserve muscle tissue. The shaw hemostatic scalpel could be used similarly to standard surgical blades, and its hemostatic performance was efficient in sealing collateral vessels from the thoracic wall. Muscular and nervous twitching was never observed throughout dissecting the LDM. Histological findings revealed that muscle fibers could be preserved by hot-knife dissection rather than by electrocautery. This technique may reduce the inconvenience of the operators, and, therefore, shorten the operation time in dynamic cardiomyoplasty and other experiments.     

Biomechanical Fixation in Arthroscopic Rotator Cuff Repair

Rotator cuff repair remains a challenging and rapidly evolving field. Several recent studies have shown that arthroscopic repair yields functional results similar to those of mini-open and open procedures, with all of the benefits of minimally invasive surgery. However, the “best” repair construct remains relatively unknown, with wide variations in surgeon preference and conflicting evidence in the literature. The most recent developments in basic science, suture and suture anchor technology, and innovative prospects for arthroscopic rotator cuff repair are reviewed.     

Canine Latissimus Dorsi Muscle: An Apparatus for Isometric Force Measurements

Abstract: This paper describes a device used to measure the isometric forces generated during electrical stimulation of the canine latissimus dorsi muscle in vivo with a preserved neurovascular supply. This device uses 2 strain gauge force sensors linked to a movable alignment frame to which the muscle is attached. The muscle length is controlled by the application of known weights to the system. The device has a frequency of response of 17.5 Hz and compliance of -0.1 mm N^-1, and its experimental performance was tested in the anesthetized mongrel dog.     

Effects of Stimulated Free Latissimus Dorsi Muscle Graft on LVEDV and LVSW: A New Dynamic Cardiomyoplasty Technique

Abstract: The effectiveness of dynamic cardiomyoplasty (DCMP) remains controversial. We hypothesized that effectiveness of DCMP using the latissimus dorsi muscle graft (LDMG) depends on the wrapping method. We analyzed pressure-volume relations (PVR), the left ventricular stroke work (LVSW), and the left ventricular end diastolic volume (LVEDV) changes during nonstimulation and stimulation of the LDMG to evaluate the effect of a new wrapping method of DCMP on the LVSW and the LVEDV changes. The new wrapping technique was evaluated in an acute animal experimental model. In 12 mongrel dogs, we performed continuous measurement of the dimensional and pressure dates of the left ventricle (LV) after the DCMP. The measurement was performed 15 min after wrapping during 5 periods. The duration of one measurement period was 15 s. The animals were divided into 2 groups according to the wrapping method. The heart was wrapped with the LDMG using 2 different methods. For Method 1, Carpentier's method, the heart was wrapped primarily with the distal part of the LDMG, the lateral segment. The vasculoneural pedicle of the latissimus dorsi muscle (LDM) was preserved. For Method 2, the LDM was separated, and the vasculoneural pedicle was cut. The medial sternotomy was performed. The thoracodorsal artery of LDMG was anastomosed to the right internal mammary artery, and the thoracodorsal vein was anastomosed to the right atrial appendage. The heart was wrapped primarily with the proximal part of the “free LDMG,” the transverse segment. Based on the PVR loops, the changes of the LVSW and the LVEDV in both experimental groups were analyzed. The paired t-test was used for statistical analysis. Using Method 1, the LVSW and the LVEDV showed no significant changes during stimulation (stim) of the LDMG, compared with non-stimulation (nonstim) (LVSW: nonstim, 970 ± 168 erg × 10³; stim, 1,181 ± 203 erg ± 10³; p = 0.126 and LVEDV: nonstim, 36.6 ± 6.7 ml; stim, 37.2 ± 6.8 ml; p = 0.36). Using Method 2, the LVSW was increased, and the LVEDV was decreased during stimulation of the free LDMG, compared with nonstimulation (LVSW: nonstim, 694 ±117 erg ± 10³; stim, 846 ± 104 erg ± 10³; p < 0.001 and LVEDV: nonstim, 47.7 ± 2.8 ml; stim, 46.8 ± 2.7 ml; p < 0.001). The stimulated free LDMG wrapping of the heart seems to be a more effective wrapping method for DCMP, and it results in an increase of the LVSW and a decrease of the LVEDV, compared with the original Carpentier's rnethod.     

背阔肌双极移位重建产瘫儿童屈肘肌功能

目的：介绍和评价背阔肌双极移位重建臂丛神经产伤后屈肘肌功能障碍的手术方法和结果。方法：从1992年6月-2002年6月，本科共收治分娩性臂丛神经损伤病人36例，其中采取背阔肌双极移位治疗臂丛神经产伤后屈肘肌功能障碍10例，男4例，女6例，手术时平均年龄为7(5—12)岁，2例息儿在术后1年因肩关节连枷而行肩关节固定术。结果：本组10例病人术后平均随访3(1．5—6)年，肘关节屈曲肌力达到4级以上，手触嘴的功能均恢复，无神经血管束损伤等手术并发症。结论：臂丛神经产伤引起的屈肘肌功能障碍严重影响患儿的生活和学习能力，需要手术治疗。本组选择的背阔肌双极移位，具有操作相对简便、符合生物力学、并发症少和结果确实的优点，因此是一种值得推荐的手术方法。     

关节镜辅助下背阔肌肌腱转位治疗不可修复肩袖撕裂

目的:探讨关节镜辅助下背阔肌肌腱转位术在不可修复肩袖撕裂(irreparable rotator cuff tears,IRCT)治疗中的临床疗效。方法:自2015年5月至2018年5月,采用关节镜辅助下背阔肌肌腱转位术修复治疗的23例不可修复肩袖撕裂患者,21例获得最终随访,其中男8例,女13例;年龄48～82(64.3±9.1)岁;病程6～36(14.0±6.4)个月。分别于术前和末次随访时分别采用美国肩肘外科协会评分(American Rotator and Elbow Surgeons Score,ASES),ConstantMurley评分进行临床疗效评价。结果:21例患者获得随访,时间36～54(39.4±4.4)个月。1例术后腋下切口红肿渗出,换药3周愈合,渗出物培养阴性;2例末次随访时MRI提示转移肌腱部分撕裂,但患肩疼痛及活动仍优于术前。ASES由术前的(41.0±9.6)分提高至末次随访时的(75.6±14.0)分(t=10.50,P<0.01);Constant-Murley评分由术前的(49.8±7.1)分提高至末次随访时的(67.5±11.6)分(t=1...     

Latissimus Dorsi Free Flap Salvage of Recurrent Chronic Osteomyelitis with Simultaneous Elbow Interposition Arthroplasty

Chronic osteomyelitis is difficult to resolve and usually requires radical debridement, filling of dead space, and a well-vascularized tissue to cover the involved bone. In the tibia, this is frequently accomplished with free vascularized muscle transfer and success rates over 90% for cases of limited involvement but lower success for diffuse involvement. Elbow joints, with advanced arthritis but ineligible for total joint replacement, have been treated with interposition arthroplasty and varying degrees of success limited primarily by instability. A 46-year-old male presented with diffuse osteomyelitis of all three bones at the elbow joint and advanced articular destruction from septic arthritis. He had undergone more than ten previous surgeries without resolution of the osteomyelitis or restoration of elbow function over a 2-year period. Radical debridement followed by a latissimus dorsi free muscle flap interposed to the dead space and layered onto the bones as an interposition membrane was able to solve both of his problems. At 3 years postoperatively, there is no evidence of recurrent osteomyelitis, and the patient declares satisfaction with the daily functional performance of his elbow joint.     

Multistage Latissimus Dorsi Flap with Implant for Complex Post-Mastectomy Reconstruction: An Old but Still Current Technique

IntroductionThe latissimus dorsi (LD) flap has been used for reconstructing mastectomy defects since the early 1900s. Although its popularity has declined over the last decades, it still retains an important role in breast reconstruction. We present our recent experience with the multistage LD flap and implant for extremely complex post-mastectomy defects.Patients and MethodsBetween 2011 and 2020, 42 consecutive patients underwent post-mastectomy LD reconstruction with an expander (STAGE 1). Some of them received prior fat-grafting of the mammary region (STAGE 0). All patients were scheduled for an expander-definitive implant change (STAGE 2). Some of them completed the program with fat-grafting, nipple and areola reconstruction, and other refinements (STAGE 3 or 4).ResultsTwo patients underwent fat-grafting at STAGE 0. Mean age at STAGE 1 was 46.7 years, mean BMI was 23.6, 14.4% of the patients were smokers, and 21.4% had comorbidities. Immediate reconstructions were performed in 35.7% and delayed in 64.3%. Mean surgical time at STAGE 1 was 194.7 min for delayed reconstructions and 242.3 min for immediate ones. Mean hospital stay for STAGE 1 procedures was 3.8 days; all other STAGES were performed as ambulatory surgery. No flap necrosis was observed and only 1 patient required a surgical revision for bleeding. Dorsal seroma occurred in 45.2% of cases.ConclusionsThe multistage LD flap with implant is a useful and safe tool within the reconstructive armamentarium for post-mastectomy defects. It combines multiple simple procedures and does not require specific skills and surgical training (level of evidence 4).     

Effect of Adaptive Pulse Train Duration on Latissimus Dorsi Blood Flow

Abstract: Blood flow, intramuscular pressure, and stroke work of the trained latissimus dorsi muscle (LD) were measured during electrical stimulation at contraction rates between 20 and 160/min using pulse trains of 2 to 6 pulses in length. Epimysial electrodes and intramuscular pressure sensors were implanted in the LD of 5 dogs. The muscle remained in situ. After 12 weeks of a progressive training protocol, LD blood flow (BF) was measured using an ultrasonic flow probe and work (SW) was determined from the measured force and shortening. For pulse trains of 2 or 3 pulses, BF increased with rate, and SW was maintained at all rates. For 4 pulses, BF and SW decreased when the contraction rate exceeded 120/min. SW decreased above 100/min and 80/min for 5 and 6 pulses, respectively. An upper rate limit dependent upon the pulse train duration exists above which BF and SW decline. Exceeding these upper rate limits should be avoided in cardiomyoplasty. Excessive stimulation rates could be detrimental to the muscle by creating a metabolic insufficiency or ischemia. The cardiac assistance benefit is compromised as SW declines during high contraction rates of long pulse train duration.     

Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

ObjectiveTo investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest.MethodsThe function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery. The entire treatment period was divided into two stages, during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II.During stage I, the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively; the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch; and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months.In stage II, the chest scars were excised, and breast tissues were repositioned; the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery.ResultsFrom October 2010 to October 2019, 21 patients (on 24 sides) underwent reconstructive procedures for extensive scar contractures on the anterior chest. All flaps survived, and their donor sites were sutured directly. During a follow-up of 3 months to 8 years, the flaps became soft and exhibited color similar to that of the adjacent tissues. The limited neck and shoulder movements improved, and postoperatively, all female patients were satisfied with the shape of their breasts. Additionally, neither apparent weakening on the adduction, internal rotation, or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed.ConclusionPre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.     

Arthroscopic Transosseous Reinsertion of the Rotator Cuff

Abstract Objective: Arthroscopic reinsertion of the supraspinatus and infraspinatus tendons by means of imitation of an open trans osseous reinsertion technique. Indications: Tears in the tendon cuffs of the supraspinatus and infraspinatus muscles. Patients < 75 years of age. Contraindications: Retracted tendons that cannot be sufficiently mobilized to provide a tension-free reinsertion. Tears of the tendon cuff of the subscapsularis muscle. Surgical Technique: The free edges of the tendons are sparingly resected. The tendon attachment site on the greater tuberosity is freed of soft tissue and decorticated using an arthroscopic bone burr. A full-radius burr is used to drill insertion sites for the sutures in the tuberosity. A hollow needle is inserted percutaneously to puncture the free edges of the tendon for a single reinsertion suture. The hollow needle is then fed through the greater tuberosity to the lateral portal. The suture is guided through the needle and advanced via a working cannula. If the tear is > 2 cm in width, a mattress suture should be placed via another channel in the bone. This is to provide plane contact of the tendon to the reinsertion site. Postoperative Management: Restriction of movement using a shoulder bandage for 6 weeks after the operation. Results: In the 75 patients treated using a single suture, there was an improvement compared to the related Constant Score from 55.8% before the operation to 80.4% at the follow-up examination, after an average of 26.8 months. The average age in this group was 58.2 years (range 35–75 years). In the 21 patients treated with a mattress suture, there was an improvement compared to the related Constant score from 59% before the operation to 83% at 14.3 months after the operation. The average age in this group was 58 years (range 35–75 years). The following is a reprint from Operat Orthop Traumatol 2006;18:1–18 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Oper Orthop Traumatol 2006;18:1–18 DOI 10.1007/s00064-006-1159-1     

Experimental In Situ Conditioning of the Latissimus Dorsi Muscle for Circulatory Assist by Multichannel Stimulation

Abstract: This study was undertaken to survey the changes in force and fatigue of the latissimus dorsi muscle during transformation into a fatigue–resistant muscle by indirect or nervous multichannel stimulation. In sheep, a silicone chamber connected to a pressure–transducing system was implanted under the left latissimus dorsi muscle. Muscle conditioning was performed by multichannel (carousel) stimulation of the thoracodorsal nerve. The program was started with active periods of 10 min/h producing 10 tetanic contractions/min. It was increased until 70 contractions/min could be performed during 24 h. The changes of muscle force and fatigue were monitored by the silicone balloon system. After a mean period of 22 weeks, fatigue resistance was reached. The fatigueresistant muscle was able to produce a pressure of about 100 mm Hg in the balloon. After finishing the conditioning procedure, muscle forces and the fatigue resistance of the conditioned muscle were evaluated. The conditioned muscle showed only a minimal decrease of force during 20 min. Under a preload of 20 N, it exhibited a maximum tetanic tension of 95 N.     

背阔肌肌皮瓣联合假体在乳腺癌术后二期乳房再造中的应用

目的探讨背阔肌肌皮瓣联合假体植入在乳腺癌术后二期乳房再造术中的临床应用。方法 2009年至2013年,共8例乳腺癌术后年轻患者接受二期乳房再造手术。术前以排水法测定健侧乳房体积,根据患者健侧乳房形状、大小及背部组织情况,设计胸背部供区皮瓣,术中测量移植皮瓣的容积,然后根据健侧乳房和移植皮瓣的容积差,选择大小合适的乳房假体,将假体埋植于背阔肌-胸大肌后间隙,利用背阔肌肌皮瓣移植联合乳房硅胶假体进行二期乳房再造。结果本组患者术后随访6个月至4年,再造乳房外形较佳,效果满意,供区无明显并发症。结论对于年轻有生育要求的乳腺癌术后乳房缺失患者,健侧乳房较大,利用背阔肌肌皮瓣联合假体进行乳房再造,可取得良好的手术效果。     

Treatment options for irreparable postero-superior cuff tears in young patients

Rotator cuff tears (RCTs) occur more commonly with advanced age, with most rotator cuff abnormalities in patients less than 30 years old being painful tendinoses or partial-thickness RCTs. Irreparable postero-superior cuff tears has been reported as frequent as 7% to 10% in the general population, and the incidence of irreparable RCTs in young patients is still unknown. Several surgical procedures have been proposed for young patients with irreparable postero-superior RCTs, such as rotator cuff debridement, partial rotator cuff repair, biceps tenotomy/tenodesis, rotator cuff grafting, latissimus dorsi tendon transfer, and reverse shoulder arthroplasty. After being thoroughly investigated in open surgery, arthroscopic techniques for latissimus dorsi tendon transfer have been recently described. They have been shown to be an adequate option to open surgery for managing irreparable postero-superior RCTs refractory to conservative management.