Ortho-Plastic Reconstruction of Massive Rotator-Cuff Tears Using the Latissimus Dorsi Tendon

GOAL: Patients that fail initial repair of massive rotator-cuff tears pose a therapeutic challenge. Chronically debilitated, unemployed, they are in severe refractory pain that requires narcotic analgesia. Anatomically, "massive" tears involve 2-4 tendons, severe retraction into the glenoid. Widespread scarring and fatty infiltration make the rotator-cuff structurally incapable of supporting a highly-mobile joint. Resection results in a 3-4cm defect of the rotator-cuff. Healthy local tissues for secondary reconstruction are unavailable & alloplastic materials are not durable enough. Here, we describe latissimus tendon reconstruction of massive rotator-cuff defects using a multidisciplinary therapeutic approach (orthopedic, plastic surgeons, physical therapists, occupational therapists and orthoticians). METHODS & MATERIALS: Eighteen consecutive patients that failed previous rotator-cuff repair (average=2 prior unsuccessful surgeries [range:1-4]) were included. They underwent latissimus dorsi transfers using the multidisciplinary team approach (described above) at the University of Connecticut Health Center. Rationale for using the latissimus tendon was based on work by Gerber et al, and the reconstructive need: strong, well-vascularized, neurotized, viable, autologous tissue could repair the tissue-defect, durably withstand the wear-and-tear and improve function. IRB-approved analysis of standard objective pre- and post-operative parameters for shoulder outcome measures was performed on 12 patients with >/= 2-year followup. Scores on both, the American-Shoulder-&-Elbow Surgeons [ASES] shoulder scale, and Simple-Shoulder-Test [SSTs] were recorded preoperatively and at 3, 6, 12 months and 2-years postoperatively. Demographic data, operative-time, blood-loss, hospital-stay and donor-site morbidities, were also collected and data was statistically analyzed. RESULTS: There were no intraoperative complications. All patients tolerated the surgery well. Overall, ASES scores improved by 25.1 points or 90% (p=0.0004) with marked improvement after one year. Function as measured by SST scores improved significantly after one year by 3.5 points (p<0.01). Pain scores improved on average by 43% (p<0.01). Every patient demonstrated a dramatic improvement in pain relief: 50% patients were weaned off narcotics and overall analgesic use dropped sharply in all patients. Complications were minor and temporary (n=1 each) (wound infection & ulnar palsy {incorrect orthotic brace positioning}). CONCLUSION Ortho-plastic reconstruction of massive rotator-cuff tears with latissimus-dorsi tendon transfer offers patients a safe, multidisciplinary team approach, significant (and lasting) pain relief and functional improvement in an otherwise refractory condition. It also creates a new reconstructive opportunity for plastic surgeons.