LDTM Transfer Achieves 91% Return-to-Work Rate for Subscapularis Tears

Restoring Anterior Stability in Irreparable Subscapularis Pathology

Irreparable subscapularis tears present a complex management challenge for clinicians, as these injuries significantly compromise anterior shoulder stability and internal rotation, the essential ability to rotate the arm toward the body [1, 2]. While arthroscopic repair is often the primary treatment for smaller tears, chronic cases involving high-grade fatty infiltration, the replacement of muscle fibers with fat cells that indicates irreversible muscle degeneration, or significant tendon retraction frequently necessitate alternative surgical strategies [3, 4]. Tendon transfers, including the use of the pectoralis major or latissimus dorsi, aim to restore force coupling and joint kinematics in high-functioning patients [5, 1]. Although various reconstructive techniques and debridement protocols have been utilized to manage massive rotator cuff pathology, the optimal approach for restoring vocational productivity remains a subject of ongoing debate [6, 7, 2]. A new study now provides detailed evidence regarding the functional recovery and occupational outcomes associated with a specific dual-tendon transfer technique.

Patient Selection and Surgical Indications

The researchers conducted a retrospective case series providing Level 4 evidence to evaluate the efficacy of anterior latissimus dorsi and teres major (LDTM) tendon transfer. From an initial cohort of 215 patients, 189 individuals met the criteria for inclusion after the researchers applied specific exclusions. This final study population consisted of 126 male and 63 female patients, with a mean age of 64.4 ± 6.7 years. To ensure the findings reflected the outcomes of the tendon transfer itself rather than confounding skeletal issues, the authors excluded any patients who had undergone prior bone surgery, as well as those with incomplete follow-up or those lost to follow-up during the 43.4 ± 17.1 month study period. Clinical eligibility for the procedure was strictly defined to target patients with severe, chronic pathology. Inclusion required the presence of irreparable subscapularis tears characterized by medial tendon retraction and advanced muscle degeneration. Specifically, patients had to exhibit grade 3 or 4 fatty infiltration according to the Goutallier classification, a system used to quantify the amount of fat within a muscle belly relative to the remaining muscle fibers. This degree of infiltration typically suggests that the muscle can no longer generate sufficient tension, making primary repair futile. Furthermore, the study focused on soft tissue reconstruction by including only those without advanced glenohumeral arthritis (degenerative joint disease of the shoulder), ensuring that the primary clinical challenge was the loss of the anterior rotator cuff's functional integrity rather than end-stage joint destruction that might otherwise necessitate arthroplasty.

Quantifying Functional Recovery and Pain Relief

The researchers evaluated clinical outcomes and return-to-work rates after anterior latissimus dorsi and teres major (LDTM) transfer for irreparable subscapularis tears over a mean follow-up duration of 43.4 ± 17.1 months. To quantify the impact of the procedure on patient quality of life and physical function, the study utilized several standardized clinical assessment tools. These included the visual analog scale (VAS), which measures subjective pain intensity on a scale of 0 to 10; the American Shoulder and Elbow Surgeons (ASES) form, a validated tool for assessing shoulder function and pain; the Constant score, which combines subjective symptoms with objective clinical parameters; and the Single Assessment Numeric Evaluation (SANE), a patient-reported percentage of how they perceive their current shoulder function compared to a healthy state. Analysis of the patient-reported data revealed substantial improvements in pain and functional capacity across all metrics. Visual analog scale (VAS) scores improved from 4.9 ± 1.1 preoperatively to 1.9 ± 1.2 postoperatively, indicating a clinically significant reduction in chronic shoulder pain. Similarly, the American Shoulder and Elbow Surgeons (ASES) scores improved from 49.4 ± 10.0 to 72.9 ± 14.0, reflecting an enhanced ability to perform activities of daily living and reduced disability following the tendon transfer. Objective and subjective functional recovery were further evidenced by gains in the remaining metrics. Constant scores improved from 49.1 ± 6.0 to 65.8 ± 9.9, while the Single Assessment Numeric Evaluation (SANE) scores improved from 48.7 ± 9.4 to 73.8 ± 13.9. Beyond these scoring systems, the researchers noted that range of motion and strength showed significant improvement across the cohort, suggesting that the LDTM transfer successfully restored mechanical leverage and stability to the glenohumeral joint for patients who previously lacked functional internal rotation. For the practicing clinician, these data suggest that LDTM transfer can effectively substitute for the lost subscapularis, providing the necessary anterior restraint to prevent the humeral head from shifting abnormally during movement.

Predictors of Occupational Reintegration

The primary clinical objective for many active patients undergoing latissimus dorsi and teres major (LDTM) transfer is the resumption of professional activities. In this cohort, the procedure demonstrated a high rate of vocational recovery, as overall, 91.0% of patients returned to work. When analyzing the quality of this reintegration, the researchers found that 58.2% of patients achieved complete return to their prior occupational duties, while 32.8% achieved partial return. The recovery timeline was relatively consistent across the study population, with a mean time to return to work of 5.4 ± 1.5 months across all employment levels. The physical demands of a patient's profession played a significant role in the speed of their recovery. The study found that lighter work groups achieved earlier and higher return-to-work rates than those in heavy labor categories. However, the underlying functional recovery appeared robust regardless of job type; no significant differences in clinical outcomes were observed among different work intensity groups. This indicates that while a patient in a sedentary role might return to the office sooner, a manual laborer can eventually expect similar levels of pain relief and functional gain from the transfer. To determine which variables most accurately forecast a successful vocational outcome, the researchers employed multivariable logistic regression (a statistical technique used to identify which specific factors independently predict a certain result while controlling for other variables). The analysis showed that tendon integrity and occupational work intensity were the strongest predictors of successful return to work. To ensure the structural success of the procedure, tendon integrity was evaluated postoperatively via magnetic resonance imaging (MRI). For the practicing clinician, these findings emphasize that both the biological healing of the graft and the baseline physical requirements of the patient's job are the most critical factors when counseling patients on their postoperative employment expectations, suggesting that postoperative imaging may be a useful tool for determining when a patient is physically ready to resume demanding labor.

References

1. Cartucho A. Tendon transfers for massive rotator cuff tears. EFORT Open Reviews. 2022. doi:10.1530/eor-22-0023

2. Aznar IDR, Lafuente JLÁ, Hachem A, et al. Tendon transfers for the management of irreparable subscapularis tears. The Bone & Joint Journal. 2024. doi:10.1302/0301-620x.106b9.bjj-2024-0165.r1

3. Kuan F, Shih C, Su W, et al. Definition of irreparable rotator cuff tear: a scoping review of prospective surgical therapeutic trials to evaluate current practice. BMC Musculoskeletal Disorders. 2023. doi:10.1186/s12891-023-07067-5

4. Powell SN, Lilley BM, Peebles AM, et al. Impact of fatty infiltration of the rotator cuff on reverse total shoulder arthroplasty outcomes: a systematic review. JSES Reviews Reports and Techniques. 2022. doi:10.1016/j.xrrt.2021.12.001

5. Luo Z, Lin J, Sun Y, Zhu K, Wang C, Chen J. Outcome Comparison of Latissimus Dorsi Transfer and Pectoralis Major Transfer for Irreparable Subscapularis Tendon Tear: A Systematic Review. The American Journal of Sports Medicine. 2021. doi:10.1177/03635465211018216

6. Davies A, Singh P, Reilly P, Sabharwal S, Malhas A. Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2022. doi:10.1186/s13018-022-03411-y

7. Soderlund M, Boren M, O’Reilly A, Juan AS, Mahylis JM. Arthroscopic debridement for management of massive, irreparable rotator cuff tears: a systematic review of outcomes. JSES Reviews Reports and Techniques. 2021. doi:10.1016/j.xrrt.2021.08.012