Arthroscopic lat dorsi transfer www.shoulderdoc.co.uk

1. LennardFunk
CharlieTalbot JuliaWalton

2. Indicationfortendontransfer
• MRCT withWeakness
• Functionalstrengthloss+/-pain

3. Clinically
• Pain
• Weakness
• Functionloss
▫ IncludingADLs

4. Pre-requisitesofTransfer
• Intactdeltoid
• IntactSubscapularis-maintainforce-couple
• Goodbone-fixation
• Compliantpatient(youngactive)

5. Pre-Habilitation
• shouldertherapist
• OptimiseDeltoid&function
• Activitymodifications
• Re-assessbeforesurgery

6. Biomechanics
▫ GerberJSES2008
▫ 3differentinsertionsites
▫ Ant/post/inf GT
▫ PosteriormostmechanicallyadvantageoustoER

7. Principlesofthetechnique
• Open:
• HarvestTendon
• Mobilisetendon
• Arthroscopy:
• Preparesurfaces
• Developtrack
• Transfertendon
• Fixation

8. Position

12. Portals
viewing
Anchor
insertion
Working
Suture
Retrieval

14. PosteriorRelease

15. HumerusPrep

16. Sutureretrieval

17. TendonRetrieval

18. TendonRetrieval

19. TendonFixation

20. FinalFixation

21. PostSurgery
ERbrace-comfortonly
painmanagement
limitNSAIDs
coldcompression
Woundcare
Earlyrehab.

22. Stage1PostSurgery
(approx0-3weeks)
• Painmanagement
• Woundmonitoring
• ClosedactiveassistedROMwithinsafezones
• Notforgettingthekineticchain

23. Stage1Exerciseideas
Shoulderdoc

24. Stage1Exerciseideas
-earlykineticchain
ShoulderdocShoulderdoc

25. Stage1Avoid…
• Horizontaladduction/internalrotation
• Earlyresistedexternalrotation
• Pain!

26. Stage2(approx3-6Weeks)
• Reduceslingsupport–weanfromERwedge
• ContinuetoincreaseactiveassistedROMclosedchain
(Proprioceptivevalue) Qualityofmovement
• Facilitatinghandoverelbow
• BegingentleisometricERinneutral
Thelatdorsi’snewrole
Shoulderdoc

27. Exerciseideas
•
Shoulderdoc

28. Stage3(approx6-12Weeks)
• ContinuewithactiveROMreinforcinghandoverelbow
• Tips…
• Breakthemovementdown
• Startwitheccentricallyloweringarmtoaid
re-education
(Donaldsonetal2011)

29. Stage3(approx6-12Weeks)
• CommenceopenchainROMleadingtoresistance
work
• Continuetointegratekineticchainandgeneral
conditioningasable
Goalspecificrehab.

30. Stage3Exercise

31. Stage3ExerciseIdeas

32. Stage4(3Months+)
• Progressfunction- load/endurance
• unconstrainedROM
• Fitness&conditioning
• Returntowork

33. Stage4(3Months+)

34. Results
RCTnotappropriate/feasible
Evidencecohorts/largecaseseries

35. Results-Arthroscopic
FrenchMULTICENTERPROSPECTIVESTUDY
• J.Grimberg,J.Kany,Ph.Valenti,J.Garret,LD.
Duranthon,VKChang
• (Paris,SaintJean,Lyon,Hawaï)
• SECECmeeting,Lyon2011

36. RESULTS
• 49Patients(27DrJK,11DrPhV,11DrJG)
• Meanageatsurgery:59,4(31-73)
• 23primarysurgeries,26secondarysurgeries(1to
6previoussurgicalprocedures)
• Meanfollowup:21,2months(12-42)
• Nolosttofollow-up.

37. CLINICALRESULTS
• CONSTANTSCORE

38. CLINICALRESULTS
• 39/49=79,5%satisfiedorverysatisfied
• Complications:2hematomas,oneuninfectedfattissue
necrosis

39. MRI:oneyearpostop
• 44patients:89,8%ofpatientscontrolled
• 41intacttendons:93%ofcontrolledpatients
• 3tendon-bonesecondarypulloutprobablylinkedto
boneweakness

40. MRI
LDmuscle
LDtendon
Deltoidmuscle

41. PREDICTINGFACTORS
• NOINFLUENCEONCLINICALRESULTS
• Age>or<65
• Sex
• Manual/Light/Sedentarywork
• Preopactiveanteflexion>or<90°
• Zoneoftendonfixation:superiororposterior
• PEJORATIVEFACTORS
• Worker’scompensation
• Preoperativesurgery

42. Summary
• SetREALISTICExpectations
• pre-opspecialistrehab.
• PatientMUSTbecommitted
• CommunicationVITAL
• goodgraftfixation
• Open/arthroscopic(?)

43. lenfunk@shoulderdoc.co.uk