Editorial Commentary: Predictors of Best Outcomes After Latissimus Dorsi Transfer for Irreparable Rotator Cuff Tear.

The management of patients with massive posterosuperior rotator cuff tears without glenohumeral arthritis remains a challenge to arthroscopic surgeons. A wide variety of treatment options have been described, including latissimus dorsi tendon transfer (LDTT) and lower trapezius tendon transfer. These tendon transfers have been utilized to rebalance the glenohumeral force couple for patients with massive or irreparable posterosuperior rotator cuff tears. Proponents of the latissimus dorsi tendon transfer have touted several theoretical advantages, including improvement of the shoulder fulcrum, optimization of the deltoid function, improved humeral head depression, and restoration of shoulder motion. Currently accepted contra-indications to LDTT include glenohumeral arthritis, irreparable subscapularis tear, axillary nerve palsy and/or deltoid insufficiency. However, few studies have investigated the ideal patient selection for LDTT, particularly as it relates to clinically significant outcomes. Recent literature suggests a high rate of complications and re-tear following LDTT, and studies suggest that older age, previous surgery, true pseuoparalysis, lower low pre-operative acromiohumeral interval (AHI) or AHI reversibility negatively impact results. Ultimately, candidates for tendon transfer should be carefully stratified according to their modifiable and non-modifiable risk factors, and surgeons should understand how pre-operative patient characteristics may affect the treatment options available for this unique patient population. In the setting of supraspinatus and infraspinatus deficiency, we prefer to utilize the lower trapezius tendon transfer, given its more predictable handling characteristics, ease of harvest, and greater function consistency compared to LDTT.