Does the Body Mass Index Affect the Clinical Outcomes Following Arthroscopically Assisted Posterior Latissimus Dorsi Tendon Transfer for Irreparable Posterosuperior Rotator Cuff Tears ? : A 5-Year Follow-Up Study
Dr. Bensaka Mohammed*
Residence Jnane Pasteur, Boulevard Abdelmoumen, Casablanca, Morocco.
*Corresponding author
Dr. Bensaka Mohammed, Residence Jnane Pasteur, Boulevard Abdelmoumen, Casablanca, Morocco.
DOI: 10.55920/JCRMHS.2025.11.001492
Abstract
Purpose: Arthroscopically assisted posterior latissimus dorsi (LD) tendon transfer has shown promise in patients with posterior superior rotator cuff tears (PSRCTs). Body mass index (BMI), a modifiable patient factor, may influence outcomes in rotator cuff surgeries. However, its impact on outcomes following arthroscopically assisted LD transfer remains underexplored. This study aims to assess the relationship between BMI and clinical outcomes in patients undergoing LD transfer for PSRCTs.
Methods: A retrospective review of patients who underwent arthroscopically assisted posterior latissimus dorsi transfer with a minimum of 5 years of follow-up was conducted. Clinical outcomes, including pain (VAS), patient reported outcome measures (PROMs), and range of motion (ROM), were assessed preoperatively and at final follow-up. Patients were divided into two groups based on BMI (≥26.2 and <26.2). Also, univariable and multivariable regression models were used to evaluate associations between BMI and clinical outcomes.
Results: A total of 57 patients were included, with a mean follow-up of 76.7 ± 7.2 months (range, 69–92), and a mean age of 63.2 ± 8.6 years (range, 43–80). The average BMI was 26.2. Significant improvements were observed in all clinical measures, including pain, PROMs including Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), Activities of Daily Living External Rotation (ADLER) score, and the American Shoulder and Elbow Surgeons (ASES) score, and ROM, all P<.001. No significant differences were found in clinical outcomes between the above-average and below-average BMI groups. Furthermore, BMI was not significantly correlated with the magnitude of clinical improvement.
Conclusion: Arthroscopically assisted posterior LD tendon transfer for PSRCTs leads to substantial improvements in pain, function, and ROM. No significant differences were observed between above-average and below-average BMI groups, and BMI was not correlated with clinical improvements. These findings suggest that BMI may not influence the effectiveness of posterior LD transfer
Study Design: Retrospective case series; Level of evidence: IV.
Keywords: Irreparable Rotator Cuff Tear; Latissimus Dorsi Transfer; Tendon Transfer; Body Mass Index; Posterior Superior Rotator Cuff Tear
Introduction
Latissimus dorsi (LD) transfer has emerged as a valuable surgical option for managing irreparable posterosuperior rotator cuff tears (PSRCTs), demonstrating favorable clinical outcomes.1-6 With the evolution of surgical techniques—from traditional open procedures to arthroscopically assisted and fully arthroscopic approaches—LD transfer now offers several advantages, including reduced soft tissue injury, a minimally invasive approach, and enhanced visualization of intra-articular and subacromial structures.2,6,7 These advancements have contributed to improved postoperative recovery and functional restoration.
Despite these technical refinements, the success of tendon transfer procedures remains multifactorial, influenced by both patient characteristics and intraoperative variables. Previous studies on rotator cuff repair have identified several predictors of clinical outcomes, such as patient age, tear size and chronicity, tendon retraction, fatty infiltration, bone mineral density, and systemic conditions.8-13 These factors can significantly affect both tendon healing and the extent of functional improvement.14 Among the modifiable patient-related factors, body mass index (BMI) has received growing attention due to its systemic and biomechanical implications. Obesity contributes to a chronic pro-inflammatory state, impairs collagen remodeling, and increases mechanical stress on the shoulder joint—all factors that may compromise tendon integration and postoperative healing.14 Obesity has also been linked to longer operative times, increased perioperative risks, and greater challenges during rehabilitation following rotator cuff repair.8,9,11,15 Nevertheless, some studies have found no clear association between BMI and surgical outcomes.16-20 While the impact of BMI on conventional rotator cuff repair has been relatively well studied, its influence on tendon transfer procedures—particularly arthroscopically assisted posterior LD transfer—remains largely unexplored.
The current study aims to investigate the relationship between BMI and clinical outcomes following arthroscopically assisted posterior LD transfer in patients with PSRCTs. It is hypothesized that BMI is not associated with postoperative clinical results.
Methods and Materials
Patient Selection: The medical records of patients who underwent arthroscopically assisted posterior LD transfer for PSRCTs between June 2014 and September 2018 were retrospectively reviewed. Inclusion criteria included patients with irreparable tears of both the supraspinatus and infraspinatus intraoperatively, severe fatty infiltration of these muscles (Goutallier21 grade ≥3) in preoperative magnetic resonance imaging (MRI), no advanced glenohumeral arthritis (Hamada22 grade <3), either an intact subscapularis or a repairable tear (Lafosse23 grade ≤3), and minimum of 5-years follow-up. Exclusion criteria were patients who had undergone combined procedures involving superior capsule reconstruction (SCR) using the long head of the biceps tendon (LHB), those lost to follow-up, and those with incomplete medical records. [Fig.1]
Surgical Procedure: A single surgeon (J.K.) performed all procedures using a standardized arthroscopically assisted posterior LD transfer technique, as previously described in the literature.24,25 Each surgery began with a diagnostic arthroscopy to evaluate the condition of the shoulder. If any LHB pathology was identified, it was addressed with either tenotomy or tenodesis. When present, subscapularis tears were treated with arthroscopic repair. The supraspinatus and infraspinatus were assessed for reparability; if neither could be reduced to the native footprint, tendon transfer was indicated.
The LD tendon was harvested through a mini-open incision along its anterior border while the arm was placed in flexion, internal rotation, and abduction. Careful dissection was performed to isolate the LD tendon and avoid injury to surrounding neurovascular structures, particularly the radial nerve and the anterior humeral circumflex vessels. Blunt dissection was employed to mobilize the thoracodorsal neurovascular bundle safely. The LD tendon was completely detached from its humeral insertion and then prepared using #2 free sutures in a running locked configuration.
Under arthroscopic visualization, the harvested tendon was passed between the external rotators and deltoid muscles and delivered to the posterolateral aspect of greater tuberosity. The supraspinatus and infraspinatus footprint was prepared using a shaver and burr to promote bone-to-tendon healing and ensure secure fixation. The LD tendon was anchored with two knotless anchors (Quattro® Link Knotless SP anchors; Zimmer Biomet, Warsaw, IN, USA), each preloaded with the prepared sutures of LD tendon. Final fixation was tested using a probe to ensure stability
Postoperative Rehabilitation: Postoperative rehabilitation followed a protocol outlined in the existing literature. 24,25 For the first four weeks, patients were instructed to wear a sling and perform passive range of motion (ROM) exercises to manage pain and prevent stiffness. From weeks 4 to 8, patients incorporated active-assisted ROM exercises and light isometric strengthening. At 8 weeks, active ROM exercises and strengthening of the shoulder muscles, particularly the rotator cuff and scapular stabilizers, were initiated. By 12 weeks, patients progressed to more intensive strengthening and functional exercises, with a gradual return to sports and daily activities beginning at 16 weeks.
Clinical Assessment: Demographic data, including age, sex, BMI, smoking status, and history of prior shoulder surgeries, were collected. Pain was assessed using the Visual Analog Scale (VAS). Shoulder function was evaluated through patient-reported outcome measures (PROMs), including the Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), Activities of Daily Living External Rotation (ADLER) score, and the American Shoulder and Elbow Surgeons (ASES) score. ROM was measured using a standardized goniometer, assessing forward elevation, abduction, external rotation at the side, and internal rotation behind the back. Radiologic evaluations were assessed preoperatively and at final follow-up, including two-view shoulder radiographs (true anterior-posterior and scapular Y views) and preoperative magnetic resonance imaging (MRI). Preoperative fatty infiltration was graded using the Goutallier21 classification based on sagittal T1-weighted MRI images. Arthritis progression was evaluated using the Hamada22 classification. At the end of the follow-up period, transferred tendon integrity was assessed both radiologically through sonography and physically by observing muscle activation and palpating the transferred LD muscle during external rotation at 90° abduction.
Statistics: Statistical analyses were performed using SPSS for Windows, version 11.0 (IBM, Armonk, NY, USA). Continuous variables were compared between preoperative and final postoperative clinical parameters using paired t-tests for normally distributed data or Mann-Whitney U tests for non-normally distributed data. Categorical variables were analyzed using Chi-square tests or Fisher's exact tests. To compare clinical outcomes between patients with above-average and below-average BMI, patients were stratified by BMI, and outcome measures were analyzed using independent t-tests for continuous variables and Chi-square tests for categorical variables. Additionally, both univariable and multivariable linear regression analyses were performed to identify factors independently associated with BMI. Statistical significance was defined as p < 0.05 for all analyses.
Results
Of the 62 patients who underwent arthroscopically assisted LD transfer for PSRCTs, 3 were excluded due to loss of data and follow-up, and 2 were excluded due to concomitant SCR using the LHB. A total of 57 patients were included in the final analysis. The mean follow-up duration was 76.7 ± 7.2 months (range: 69–92), and the mean age was 63.2 ± 8.6 years (range: 43–80). The average BMI was 26.2, and 8.8% of patients were smokers. [Table I] The VAS score showed a significant reduction in pain (p < 0.001). All PROMs, including SST, SSV, ADLER, and ASES scores, demonstrated significant improvements (p < 0.001). ROM also showed significant improvement in all directions, including forward elevation, abduction, external rotation at the side, and internal rotation at the back. [Table II]
Patients were divided into two groups based on BMI: above-average (≥26.2) and below-average (<26.2). Both groups showed significant improvements across all clinical outcome measures. However, there were no significant differences between the two groups in terms of VAS scores, PROMs, ROM, or radiologic assessments. [Table III] In the univariable regression analysis, sex (male average BMI: 27.9 ± 4.7; female average BMI: 24.7 ± 3.9) was a significant predictor of BMI (p = 0.008), with male patients showing a higher association with increased BMI. This association remained significant in the multivariable regression model (p = 0.008). In contrast, other variables—including age, smoking status, and changes in clinical outcome measures—were not significantly associated with BMI, indicating that BMI was not an independent factor influencing these variables in the regression analysis. [Table IV] Five patients (2 with above-average BMI and 3 with below-average BMI) experienced retears, and 3 patients (1 with above-average BMI and 2 with below-average BMI) showed progression of arthritis and underwent conversion to reverse shoulder arthroplasty. Retears and progression of arthritis were not associated with BMI.
Discussion
This study focuses the relationship between BMI and clinical outcomes following arthroscopically assisted posterior LD transfer in patients with PSRCTs. Significant improvements were observed postoperatively in pain levels, PROMs, and ROM. Patients were stratified into two groups based on BMI, and both cohorts demonstrated statistically significant improvements across all clinical parameters. However, no significant differences were identified in clinical outcomes between the higher and lower BMI groups. Furthermore, BMI was not significantly correlated with the magnitude of clinical improvement, suggesting that BMI may not independent factor that influences the effectiveness of posterior LD transfer.
The effect of BMI on rotator cuff surgery outcomes remains controversial. Some studies suggest that elevated BMI negatively impacts tendon healing due to systemic inflammation, increased mechanical load, and impaired collagen metabolism.8-12 For instance, Zhao et al.8 identified BMI as a risk factor for retears, and Erşen et al.11 reported that both higher BMI and older age were independent risk factors for poor healing after rotator cuff surgeries. Several reports have associated obesity with inferior functional scores and higher complication rates. 9,15,26 However, other studies have found no significant association between BMI and clinical outcomes.16-20 Longo et al.14 emphasized the role of surgical technique, rehabilitation, and individual factors as potentially more influential. Ahmad et al.27 highlighted factors like tear size, tendon quality, and repair tension as stronger predictors of outcomes. Likewise, other studies also reported no significant differences in pain or function between obese and non-obese patients after rotator cuff repair.17-19 Consistent with these findings, the present study found no significant differences in clinical outcomes between above- and below-average BMI groups. BMI was also not correlated with changes in postoperative pain, function, or ROM, suggesting that BMI may not be a determining factor in surgical success.
Consistent with previous reports in the literature,2,7,25,28,29 the current study demonstrated that arthroscopically assisted posterior LD transfer yields promising postoperative outcomes. Yet, the determinants of clinical outcomes following posterior LD transfer remain poorly defined, with limited consensus on which factors most significantly influence success. Muench et al.30 and Gerber et al.31 found that advanced fatty degeneration of teres minor and muscle insufficiency of subscapularis were strongly associated with decreased postoperative function in posterior LD transfer. Ironically, age has not been considered a significant modifier factor in posterior LD transfer outcomes. In a cohort study of 153 patients undergoing tendon transfer for irreparable rotator cuff tears, Kany et al.32 found that both younger (≤55 years) and older (≥75 years) patients experienced significant improvements, with no significant difference in clinical outcome. These findings suggest that age alone may not be a limiting factor in postoperative recovery. Besides preoperative patient factors, Kany et al.29 reported that posterior fixation onto the infraspinatus footprint was associated with the lowest tendon rupture rates. Despite the findings of these aforementioned studies, the role of BMI in LD transfer outcomes has received relatively little attention. The present study addresses this gap by demonstrating that BMI was not significantly associated with changes in pain, PROM, or ROM. Both above- and below-average BMI groups showed significant clinical improvements with no difference between the groups, indicating that BMI may not be an independent determinant of surgical success. Rather, factors such as surgical technique, sex, tendon quality, and tailored rehabilitation protocols may play more prominent roles in shaping patient outcomes.
Several limitations should be considered when interpreting the results of this study. First, the relatively small sample size (n = 57) may limit the generalizability of the findings to broader patient populations. Second, the mean follow-up duration of 76.7 months, while moderately long, may not fully capture the long-term durability of clinical improvements following tendon transfer surgery. Third, although BMI was the primary variable of interest, other potentially influential factors—such as comorbidities, baseline shoulder muscle strength, and psychological status—were not comprehensively evaluated. These variables may also impact postoperative outcomes and warrant further investigation. Lastly, the retrospective design introduces inherent limitations, including potential selection bias and limited capacity to establish causality.
Conclusion
Arthroscopically assisted posterior LD transfer for PSRCTs results in significant improvements in pain, PROMs, and ROM. No significant differences were observed between above- and below-average BMI groups, and BMI was not correlated with clinical improvements. These findings suggest that BMI may not influence the effectiveness of posterior LD transfer.
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