The conditions necessary to practice this intervention are:
- the absence of a pseudo-paralytic shoulder
- (normal active mobility if necessary after a long rehabilitation phase sometimes beyond 6 months or a year after failure to repair the cap),
- the isolated deficit of active external rotation is not a contra-indication if the anterior elevation and abduction are present,
- subscapularis functional or repairable tendon,
- the long biceps broken or not seeming to explain all the pains,
- no major osteoarthritis in the shoulder,
- a voluntary patient with a chronic painful shoulder causing a severe gene in daily life.
Principe de l’intervention
(les schémas sont tirés du livres « tendon transfer for irreparable cuf tear » chez Springer GECO series, Dr Philippe Valenti auteur principal et Dr Jean Kany co-auteur)<
The objective is to transfer the tendon of the latissimus dorsi to the major tubercle after releasing it from its attachments on the humerus, the scapula and the thoracic wall, in order to compensate for the non-repairable rupture of the posterior superior cap ( infra and supraspinous tendons).
The absence of active external rotation will be taken into account for the fixation site of the dorsal tendon in order to recover it (in part).
Stages of the intervention
(The diagrams are taken from the books ‘tendon transfer for irreparable cuff tear’ at Springer GECO series, Dr. Philippe Valenti senior author and Dr. Jean Kany co-author)
The position of the patient can be either in lateral decubitus’ on the side) or in beach chair (half-seated). Two separate approaches are needed:
– one at the level of the thorax and the axillary fossa making it possible to collect and release the muscle and tendon backbone
– the other at the level of the cap back to recover the tendon and fix it. This approach is currently replaced by arthroscopy
|Release of the muscle and then the tendon (and its fascia) of the large dorsal including the large round and vasculonerveux elements including the axillary nerve. The anterior serrated muscle is visible deep in contact with the ribs.|
|Legends: LD: latissimus dorsi (latissimus dorsi), TM: teres major (large round) ALD: latissimus aponeurosis dorsiT: triceps, D: deltoid, SA: anterior serratus (anterior serratus) RN: radial nerve, AN: axillary nerve|
The tendon of the long dorsal once completely released will be reinforced with wires and will be passed under the posterior deltoid (DP) in the direction of the cap using a clamp.
LD: latissimus dorsi (latissimus dorsi), TM: teres major (large round)
T: triceps, DP: posterior deltoid
Once the tendon is recovered at the level of the cap it can be applied in all its surface in order to try to fill the tendinous substance loss
(initial version of the open-air technique that we do not use)
The tendon is then united to the stump of the cap and the humerus at the level of the major tubercle.
Depending on the clinical examination of the patient before the operation, the positioning of the fixation may vary:
If one wishes to favor the anterior elevation without pain, the fixation will be at the top see forward of the major tuber;
IS + SS I: infraspinatus and supraspinatus insertions or insertions of infraspinatus and supraspinatus.
on the other hand, if we want to favor the deficient external rotation (bugle sign), then the fixation will be more at the level of the insertion of the infra-spinous alone which is an external rotator.
(IS I: Infra-spinatus insertion or insertion of infraspinatus
LD: Latissimus dorsi (dorsal dorsal)
Another possibility of fixation is to tubulate (transform into a tube) the tendon suturing on itself and incarcerate in a blind tunnel (without exit on the other side of the bone).
An interference screw comes to press on the walls of the tunnel.
The technique we are currently using is an evolution of previous versions above, fixation is provided by a metal button (‘endobouton’) placed on the anterior cortex of the humerus at the bottom of the bicipital gutter.
This fixation process was developed by Dr. Jean Kany because it corresponds to the most solid fixation (the walls of the tunnel are very fragile because located in a humeral head generally fragile).