Wow, that's a great surgical demonstration by Dr. Krishnan. I'm going to show you how the cool kids do it. I'm going to present to you an alternative method using latissimus tendon transfer for irreparable subscapularis tendenter. The latissimus dorsi muscle originates over the lateral border of the scapula, intercostals, and iliac crest. It inserts just inferiorly to the lesser tuberosity. It's innervated by the thoracodorsal nerve off the posterior cord, and its function is synergistic to the subscapularis tendon with adduction and internal rotation. The utilization of lat dorsi for treatment of irreparable subscapularis tendon have been proposed by Dr. Al-Hassan. It has been found to have similar excursion and tension as the subscapularis tendon. It has a similar biomechanic line of pull, and it has a low risk of neurologic complications after transfer. Clinically, recent studies have shown that the patients have good overall range of motion and clinical function after the latissimus dorsi transfer. And on specific clinical exams, there is reliable restoration of the belly press test and liftoff test. Here's a cadaver demonstration of latissimus tendon transfer for irreparable subscapularis repair. We're in the delta pectoral approach, visualizing the insertion of the pectoralis muscle. After releasing the top of the pectoralis, we can now place a retractor over the neurovascular safe zone over the lateral humerus. Now we can fully expose the latissimus insertion site. Here you can now sharply dissect the latissimus off the humeral shaft. We can mobilize this tendon posteriorly and inferiorly. This allows us to see the teres major muscle underneath at the floor. Then we tag this tendon and mobilize the tendon anteriorly and superiorly with a sponge stick. As you can see here, the radial nerve is anterior medial over the medial muscle belly of the lat dorsi. The axillary nerve is superior. Here is the lesser tuberosity and the articular surface. The irreparable subscapularis tendon is now medial and indeed does not come over to the tuberosity. Now we can pull the latissimus with easy excursion to the lesser tuberosity. With internal rotational arm, you can now fix it with the fixation technique of choice. Here to note, the pectoralis muscle travels superior medial to inferior lateral while the latissimus travels inferior medial to superior lateral with a 90 degree difference in the biomechanical direction of pull. So I would prefer the latissimus over the pectoralis because it anatomically replicates the subscapularis biomechanic direction of pull. It's a synergistic muscle and you do not have to worry about passing posterior to the conjoint tendon. There is a low risk of nerve injury and it is clinically promising. The disadvantages are that all surgeons are familiar with the pectoralis major, it is technically easy to identify and it has a long track record. Well you could do it one of these various ways to pass the pectoralis or you could do it the simple direct way with the latissimus. Let's keep it simple. Thank you.

latissimus tendon transfer

subscapularis tendon

surgical procedure

cadaver demonstration

clinical outcomes