Latissimus dorsi transfer is an operation to reroute the latissimus dorsi muscle and tendon from the back to the top of the shoulder, replacing the function of an irreparable posterosuperior rotator cuff tear. It restores active external rotation.
An incision is made in the posterior axillary fold. The latissimus dorsi tendon is detached from its insertion on the humerus. The tendon is rerouted around the humerus and reattached to the greater tuberosity (the normal rotator cuff insertion site) using suture anchors. The muscle then functions as an external rotator instead of an internal rotator. The operation takes two to two and a half hours.
Latissimus dorsi transfer is considered for younger, active patients (under 65) with massive, irreparable posterosuperior rotator cuff tears causing loss of active external rotation, who are too young for reverse shoulder replacement. The key indication is a functional deltoid with an intact subscapularis.
Physiotherapy (anterior deltoid rehabilitation), subacromial injection, superior capsular reconstruction (SCR), partial rotator cuff repair, and reverse shoulder replacement.
MRI confirming irreparable posterosuperior cuff tear with intact subscapularis. CT to assess arthropathy. Functional assessment of external rotation deficit. EMG may be used to confirm latissimus function.
Restoration of active external rotation and improvement in overhead function. Approximately 70–80% of carefully selected patients report significant functional improvement. Pain relief is good.
Six to twelve months for full recovery.
The transferred muscle does not fully replicate normal rotator cuff function.
Soreness in the posterior axillary fold.
The transferred tendon may not heal to its new attachment. Risk approximately 10–15%.
Thoracodorsal nerve (motor nerve to latissimus) must be preserved during mobilisation.
Wound infection.
Despite transfer, the shoulder may develop cuff tear arthropathy over time.
During the re-routing of the tendon.
General anaesthesia. Lateral decubitus position.
Sling and abduction pillow for six weeks. No active internal rotation (which would stress the transfer) for six weeks. Passive external rotation exercises from two weeks. Active external rotation from six weeks. Strengthening from three months. Full recovery six to twelve months. The brain must learn to use the latissimus for external rotation — a process called 'motor re-education' that takes dedicated practice.
Reviews at two weeks, six weeks, three months, and six months.
The latissimus dorsi normally performs internal rotation. After transfer to the rotator cuff footprint, it must perform external rotation. Through repetitive exercises, the brain creates new neural pathways. Initially, the patient activates the muscle by thinking about its original function (pulling the arm toward the body), then gradually the new movement becomes automatic.
Reverse replacement is a joint replacement with lifelong activity restrictions and a finite lifespan. Latissimus transfer preserves the native joint, allows higher activity levels, and can delay or avoid the need for replacement. It is best suited for younger, active patients.