The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes

Tendon transfers in the setting of shoulder arthroplasty

Background

Tendon transfers in conjunction with reverse total shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Methods

The authors reviewed the literature on tendon transfers in the setting of reverse total shoulder arthroplasty. Procedures to restore various shoulder functions were described including surgical anatomy, techniques, pearls and pitfalls, and photos.

Results

Subscapularis insufficiency can be reconstructed with a pectoralis major transfer or latissimus dorsi transfer, with the latter having better clinical outcomes and a more anatomic line of pull. Posterosuperior rotator cuff deficiency can be reconstructed with a latissimus transfer (L'Episcopo transfer) or lower trapezius transfer, with the latter proving superior in biomechanical and short-term studies. Deltoid deficiency can be reconstructed with a pedicled upper pectoralis major transfer. Massive proximal humerus bone loss can be reconstructed with an allograft-prosthetic composite, and any of the aforementioned transfers can be utilized in this setting as well.

Conclusion

Tendon transfers in conjunction with reverse shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

A Biological Spacer to Treat Irreparable Rotator Cuff Tears: A Biomechanical Study Utilizing a Secured Versus Unsecured Tensor Fascia Lata Graft

BACKGROUND

Designed to help treat pain and loss of function after rotator cuff repair, allograft spacer procedures utilize a graft to act as a spacer in the subacromial space, decreasing pain from impingement of the greater tuberosity on the acromion at the extremes of overhead motion.

PURPOSE

To evaluate the biomechanical characteristics of secured versus unsecured tensor fascia lata allografts used in an allograft spacer procedure.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 8 fresh-frozen cadaveric shoulder specimens were used. There were 4 conditions tested: (1) intact rotator cuff, (2) stage III rotator cuff tear (complete supraspinatus tendon and superior one-half of the infraspinatus tendon), (3) unsecured tensor fascia lata graft, and (4) secured tensor fascia lata graft. Both superior and posterior translation of the humeral head were calculated in each condition. A 4-cm × 5-cm × 6-mm tensor fascia lata graft was used in the subacromial space to act as a spacer. Grafts were secured at the lateral edge of the native rotator cuff footprint with 2 knotless anchors.

RESULTS

With unbalanced loading, both secured and unsecured grafts varied in their ability to limit superior and posterior translation at various rotation angles back to levels seen with intact rotator cuffs at 0° and 20° of abduction. During balanced loading, both unsecured and secured grafts limited superior and posterior translation more than those seen in the rotator cuff-deficient condition (P < .01) and similar to those seen in the intact condition (P > .05). The secured and unsecured grafts allowed similar amounts of translation at every position with both unbalanced and balanced loading (P > .05). Finally, total graft motion was <7 mm in all positions.

CONCLUSION

Unsecured tensor fascia lata grafts were biomechanically equivalent to secured grafts when used during allograft spacer procedures.

CLINICAL RELEVANCE

While both grafts were successful at limiting superior and posterior translation of the humeral head during early range of motion, the unsecured graft represents a cheaper, easier option to utilize during allograft spacer procedures.

Evaluation of spin in systematic reviews on the use of tendon transfer for massive irreparable rotator cuff tears

PURPOSE

To identify, describe and account for the incidence of spin in systematic reviews and meta-analyses of tendon transfer for the treatment of massive, irreparable rotator cuff tears. The secondary objective was to characterize the studies in which spin was identified and to determine whether identifiable patterns exist among studies with spin.

METHODS

This study was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Each abstract was assessed for the presence of the 15 most common types of spin derived from a previously established methodology. General data that were extracted included study title, authors, publication year, journal, level of evidence, study design, funding source, reported adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, preregistration of the study protocol, and methodologic quality per A Measurement Tool to Assess Systematic Reviews Version 2 (AMSTAR 2).

RESULTS

The search yielded 53 articles, of which 13 were included in the final analysis. Articles were excluded if they were not published in a peer reviewed journal, not written in English, utilized cadaveric or nonhuman models, or lacked an abstract with accessible full text. 53.8% (7/13) of the included studies contained at least 1 type of spin in the abstract. Type 5 spin ("The conclusion claims beneficial effect of the experimental treatment despite a high risk of bias in primary studies") was the most common, appearing in 23.1% (3/13) of included abstracts. Nine of the spin categories did not appear in any of the included abstracts. A lower AMSTAR 2 score was significantly associated with the presence of spin in the abstract (P < .006).

CONCLUSION

Spin is highly prevalent in the abstracts of systematic reviews and meta-analyses concerning tendon transfer for massive rotator cuff tears. A lower overall AMSTAR 2 rating was associated with a higher incidence of spin. Future studies should continue to explore the prevalence of spin in orthopedic literature and identify any factors that may contribute to its presence.

Improved Clinical Outcomes After Partial Repair and In Situ Biceps Tenodesis for the Treatment of Massive Irreparable Rotator Cuff Tears

PURPOSE

To present the short-term outcomes of arthroscopic in situ biceps tenodesis combined with partial rotator cuff repair in patients with massive irreparable rotator cuff tears (MIRCTs) and minimal arthritis.

METHODS

A retrospective review was conducted using prospectively maintained institutional databases to identify patients who had undergone a partial rotator cuff repair with in situ biceps tenodesis between March 2017 and December 2022. Patients were included if they (1) were diagnosed pre- or intraoperatively with MIRCT and (2) had complete preoperative and minimum 1-year postoperative patient-reported outcome measures.

RESULTS

Thirty-nine patients met the eligibility criteria and were included for analysis. The mean age of the study participants was 65 ± 7 years (range, 46-76) with 76.9% (n = 30) being male. The average follow-up was 21 ± 12 months (range, 12-58). Patients experienced significant improvement in visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES) score, and subjective assessment numeric evaluation (SANE) score (P < .001 for all comparisons). The pre- to postoperative improvement was 3.1 ± 2.3 for VAS, 27.5 ± 20.6 for ASES, and 31.3 ± 24.8 for SANE. Postoperatively, the average scores for VAS, ASES, and SANE were 1.3 ± 1.5, 79.5 ± 17.0, and 69.6 ± 20.1, respectively. Twenty-six patients (66.7%) achieved the minimal clinically important difference (MCID) for VAS, 33 patients (84.6%) achieved the MCID for ASES, and 30 patients (76.9%) achieved the MCID for SANE.

CONCLUSIONS

Partial rotator cuff repair with in situ biceps tenodesis is an effective treatment for MIRCT, leading to significant improvements in patient-reported outcome and range-of-motion measures compared to preoperative conditions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation.

RESULTS

Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%).

CONCLUSIONS

Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears

PURPOSE OF REVIEW

Functionally irreparable posterosuperior rotator cuff tears (FIRCT) represent a substantial source of morbidity for many patients. Several surgical options can be considered for the salvage of FICRTs. Transfer of the tendon of the lower trapezius to the greater tuberosity, originally described for surgical management of the paralytic shoulder, has emerged as an attractive option, particularly for patients with external rotation lag and those looking for strength restoration. The purpose of this publication is to review the indications, surgical technique, and reported outcomes of this procedure.

RECENT FINDINGS

Lower trapezius transfer (LTT) to the greater tuberosity in patients with irreparable posterosuperior rotator cuff tears has been reported to be associated with satisfactory outcomes and low reoperation rates. It seems to be particularly effective in improving external rotation motion and strength, even when the teres minor is involved. In patients with a reparable infraspinatus, minimal fatty infiltration, and an intact teres minor, the outcome of LTT may be similar to that of superior capsule reconstruction (SCR), but LTT is more beneficial otherwise. The hospital cost of LTT has been reported to be less than the cost of SCR and equivalent to the cost of reverse arthroplasty. When reverse arthroplasty has been performed after a failed LTT, the outcome and complication rates do not seem to increase. LTT provides satisfactory outcomes for many patients with a posterosuperior FIRCT, particularly when they present preoperatively with an external rotation lag sign, involvement of the teres minor, or a desire to improve strength.

Lower Trapezius Transfer Improves Clinical Outcomes With a Rate of Complications and Reoperations Comparable to Other Surgical Alternatives in Patients with Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To analyze the clinical outcomes of lower trapezius transfer (LTT) for patients with functionally irreparable rotator cuff tears (FIRCT) and summarize the available literature regarding complications and reoperations.

METHODS

After registration in the International prospective register of systematic reviews (PROSPERO [CRD42022359277]), a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Inclusion criteria were English, full-length, peer-reviewed publications with a level of evidence IV or higher reporting on clinical outcomes of LTT for FIRCT. Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus via Elsevier databases were searched. Clinical data, complications and revisions were systematically recorded.

RESULTS

Seven studies with 159 patients were identified. The mean age range was 52 to 63 years, 70.4% of the patients included were male, and the mean follow-up time ranged between 14 and 47 months. At final follow-up, LTT lead to improvements in range of motion, with reported forward elevation (FE) and external rotation (ER) mean gains of 10° to 66° and 11° to 63°, respectively. ER lag was present before surgery in 78 patients and was reversed after LTT in all shoulders. Patient-reported outcomes were improved at final follow-up, including the American Shoulder and Elbow Society score, Shoulder Subjective Value and Visual Analogue Scale. The overall complication rate was 17.6%, and the most reported complication was posterior harvest site seroma/hematoma (6.3%). The most common reoperation was conversion to reverse shoulder arthroplasty (5%) with an overall reoperation rate of 7.5%.

CONCLUSIONS

Lower trapezius transfer improves clinical outcomes in patients with irreparable rotator cuff tears with a rate of complications and reoperations comparable to other surgical alternatives in this group of patients. Increases in forward flexion and ER are to be expected, as well as a reversal of ER lag sign when present before surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

Changes in in vivo three dimensional shoulder kinematics following latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: A systematic review with meta-analysis

BACKGROUND

Latissimus dorsi transfer is a surgical procedure that can be used for treating posterosuperior rotator cuff tears. The procedure leads to improved shoulder function via alterations in the force vector couple around the shoulder. However, there is still no consensus on the biomechanical changes resulting from latissimus dorsi transfer.

METHODS

We performed a systematic review of the literature on 3D motion analysis studies evaluating the effects of latissimus dorsi transfer on shoulder kinematics. The available data on segment and joint range of motion was extracted and subject to meta-analysis when consistent across the studies.

FINDINGS

Our meta-analysis of pre- and post-operative studies revealed a significant improvement in forward flexion and abduction following latissimus dorsi transfer. When comparing the latissimus transferred shoulder with an uninjured contralateral side the meta-analysis found no significant difference in flexion range of motion, while abduction and external rotation was significantly higher in the uninjured shoulders. The overall risk of bias was moderate to high. High heterogeneity was found in the reporting of data, which limited our ability to perform a meta-analysis across the studies for all interest outcomes.

INTERPRETATIONS

Our findings suggest that latissimus dorsi transfer for posterosuperior rotator cuff tears effectively improves shoulder flexion and abduction. External rotation is also expected to improve but at inferior levels as compared to the unaffected side. However, the heterogeneity of the reported data on 3D motion analysis studies highlights the need for better standardization in research and reporting as to conclude the impact of different joints.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer Using a Fasciae Lata Autograft in Treatment of Posterior Superior Irreparable Rotator Cuff Tears in Lateral Decubitus Position

The optimal treatment for patients with posterior superior irreparable rotator cuff tears (PSIRCTs) is still a topic of ongoing debate. Lower trapezius tendon transfer is one of the effective surgical treatments for PSIRCTs in younger patients and elderly patients with high activity levels without arthritis. In this report, we describe an arthroscopic-assisted technique for lower trapezius transfer using a fascia lata autograft for patient with PSIRCTs in lateral decubitus position.

Outcomes of lower trapezius transfer with hamstring tendons for irreparable rotator cuff tears

Background

The aim of this study was to evaluate the results of the transfer of the lower trapezius with a graft from hamstring tendons in the treatment of irreparable rotator cuff tears . Level IV; Case Series; Treatment Study.

Methods

Ten patients diagnosed with irreparable tears of the supraspinatus and infraspinatus tendons, were evaluated retrospectively -preoperatively, 6 and 12 months postoperatively. They underwent transfer of the prolonged lower trapezius with an autologous graft of the knee flexor tendons.

Results

The Shoulder Subjective Value increased from 47 (preoperative) to 71 (1 year after surgery), American Shoulder and Elbow Surgeons Score increased from 26.63 to 75.24. Pain improved from 7.9 to 2.5 on the Visual Analogue Scale. The mean lateral rotation improved from 31° to 51°, flexion from 84° to 122°, and abduction from 76° to 101°. These results have not changed significantly between 6 and 12 months.

Discussion

The transfer of the lower trapezius with autologous grafts from the hamstring tendons showed good results in patients under 65 years of age with irreparable rotator cuff tears . Longer follow-up and a greater number of cases are necessary to confirm the efficacy of the transfer.

Arthroscopic Lower Trapezius Tendon Transfer for a Patient with Axillary Nerve Injury and Concomitant Rotator Cuff Tear: A Case Report and Technical Notes

Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics

BACKGROUND

Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement.

PURPOSE/HYPOTHESIS

The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators.

RESULTS

Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ-19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning.

CONCLUSION

LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning.

CLINICAL RELEVANCE

Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.

Massive and Irreparable Rotator Cuff Tears: A Review of Current Definitions and Concepts

Background

While massive and irreparable rotator cuff tears (MIRCTs) have been abundantly studied, inconsistent definitions in the literature and theories about pain and dysfunction related to them can be difficult to navigate when considering an individual patient.

Purpose

To review the current literature for definitions and critical concepts that drive decision-making for MIRCTs.

Study Design

Narrative review.

Methods

A search of the PubMed database was performed to conduct a comprehensive literature review on MIRCTs. A total of 97 studies were included.

Results

Recent literature reflects added attention to clarifying the definitions of "massive, "irreparable," and "pseudoparalysis." In addition, numerous recent studies have added to the understanding of what generates pain and dysfunction from this condition and have reported on new techniques for addressing them.

Conclusion

The current literature provides a nuanced set of definitions and conceptual foundations on MIRCTs. These can be used to better define these complex conditions in patients when comparing current surgical techniques to address MIRCTs, as well as when interpreting the results of new techniques. While the number of effective treatment options has increased, high-quality and comparative evidence on treatments for MIRCTs is lacking.

Lower trapezius tendon transfer for irreparable rotator cuff injuries: a scoping review

Background

Rotator cuff tears are a common source of shoulder pain and dysfunction. An irreparable rotator cuff tear poses a particular treatment challenge. There have been few studies reporting the outcomes of lower trapezius tendon (LTT) transfer for irreparable rotator cuff injuries. Therefore, the purpose of this review is to summarize the postoperative functional outcomes and complications of patients undergoing a LTT transfer for massive irreparable rotator cuff injuries.

Methods

A scoping review was performed using the Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar databases with the search terms "trapezius" AND "transfer." Of 362 studies included for initial screening, 37 full-text citations were reviewed, with 5 studies meeting all the inclusion criteria to be included in the review. Two reviewers extracted data on study design, patient demographics, surgical technique, functional outcomes, range of motion (ROM), and complications for each study according to the predefined criteria.

Results

Improvements in the preoperative to postoperative functional status, identified using the Disabilities of the Arm, Shoulder, and Hand (50.34 to 18), The American Shoulder and Elbow Surgeons Score (48.56 to 80.24), Visual Analog Scale (5.8 to 1.89), Single Assessment Numeric Evaluation (34.22 to 69.86), and Subjective Shoulder Value (52.24 to 77.66), were evident across all 5 studies. Preoperative to postoperative increases in ROM were seen for flexion (85 to 135), external rotation (18 to 52), and abduction (50 to 98). The overall complication rate was 18%, with seroma formation (8%) as the most common postoperative complication.

Discussion/Conclusion

Our analysis showed that LTT transfer improved postoperative function, ROM, and pain for patients with irreparable rotator cuff tears with an overall complication rate of 18%. Future controlled studies are required to directly compare LTT transfer to other tendon transfers and other surgical techniques for irreparable rotator cuff tears.

Biomechanical comparison of lower trapezius and latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears using a dynamic shoulder model

BACKGROUND

In the setting of irreparable posterosuperior rotator cuff tears (PSRCTs), lower trapezius transfer (LTT) may be anatomically better positioned for restoring the muscular force couple compared with latissimus dorsi transfer (LDT). The purpose of the study was to evaluate the effect of LTT and LDT on glenohumeral kinematics using a dynamic shoulder model.

METHODS

Ten fresh-frozen cadaveric shoulders (mean age: 56.5 ± 17.2 years) were tested using a dynamic shoulder simulator. The maximum abduction angle (MAA), superior humeral head migration (SHM), and cumulative deltoid forces (CDFs) were compared across 4 conditions: (1) native; (2) irreparable PSRCT; (3) LTT using an Achilles tendon allograft; and (4) LDT. MAA and SHM were measured using 3-dimensional motion tracking. CDF was recorded in real time throughout the dynamic abduction motion by load cells connected to actuators.

RESULTS

Compared to the native state, the PSRCT resulted in a significant decrease (Δ-24.1°; P < .001) in MAA, with a subsequent significant increase after LTT (Δ13.1°; P < .001) and LDT (Δ8.9°; P < .001). LTT achieved a significantly greater MAA than LDT (Δ4.2°; P = .004). Regarding SHM, both LTT (Δ-9.4 mm; P < .001) and LDT (Δ-5.0 mm; P = .008) demonstrated a significant decrease compared with the PSRCT state. LTT also achieved significantly less SHM compared with the LDT (Δ-4.4 mm; P = .011). Further, only the LTT resulted in a significant decrease in CDF compared with the PSRCT state (Δ-21.3 N; P = .048), whereas LTT and LDT showed similar CDF (Δ-11.3 N; P = .346). However, no technique was able to restore the MAA, SHM, and CDF of the native shoulder (P < .001, respectively).

CONCLUSION

LTT and LDT both achieved a significant increase in MAA along with significantly less SHM compared with the PSRCT state. Although LTT required significantly less compensatory deltoid forces compared with the PSRCT state, this was not observed for the LDT. Further, the LTT prevented loss of abduction motion and SHM more sufficiently. In the challenging treatment of irreparable PSRCTs, LTT may restore native glenohumeral kinematics more sufficiently, potentially leading to improved postoperative functional outcomes.

Management of Failed Rotator Cuff Repairs: A Review

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

The clinical outcomes of infraspinatus rotational transfer for irreparable posterosuperior rotator cuff tears: a preliminary report

Background

This study aimed to examine the preliminary clinical results of the infraspinatus rotational transfer procedure for irreparable posterosuperior rotator cuff tears.

Methods

This study included 34 patients (mean age, 68.4 years). Their mean tear width and length measurements were 50.9 mm and 50.6 mm, respectively. The functional outcomes, including physician-determined and patient-reported scores, were evaluated before and at 1 year after surgery. The structural outcomes determined using the magnetic resonance imaging examination results were also assessed.

Results

The clinical scores significantly improved after surgery compared with the scores before surgery: the Constant-Murley score (53.3±21.1 to 76.8±10.5), University of California at Los Angeles Shoulder score (15.6±3.6 to 27.8±6.7), American Shoulder and Elbow Surgeons Shoulder score (51.8±18.3 to 89.1±13.5), and WORC score (925.0±436.8 to 480.3±373.2) (all p<0.001). Postoperative re-tears were noted in two patients (5.9%).

Conclusions

One year postoperatively, the patient’s clinical scores significantly improved, with a re-tear rate of 5.9%.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Autologous Semitendinosus Tendon and Long Head of Biceps Superior Capsule Reconstruction for Massive Irreparable Posterosuperior Rotator Cuff Tears

We present a surgical technique combining arthroscopic-assisted lower trapezius tendon (LTT) transfer with autologous semitendinosus tendon and long head of biceps tendon (LHBT) superior capsule reconstruction (SCR) for massive irreparable posterosuperior rotator cuff tears. The patients are placed in the beach-chair position with the ipsilateral lower leg prepared simultaneously. After both tendons are harvested, 1 limb of a semitendinosus graft is fixed with the LTT via a Krakow suture. The LHBT is then fixed by an anchor 5 to 8 mm posterior to the bicipital groove and tenotomized distally. The transverse humeral ligament is released afterward to provide better visualization. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove, and drilled posteriorly until it exits at the infraspinatus footprint. Next, 4.5- and 8-mm cannulated drills are used sequentially to create a humeral tunnel. A shuttle suture passed through infraspinatus fascia in the back brings the EndoButton and looped semitendinosus graft from posterior to anterior of the humerus, until the EndoButton flips and is fixed inside the bicipital groove. The shoulder is placed in 45° abduction and 30° external rotation. The free limb of semitendinosus tendon is then sutured with LTT with the desired tension.

Tendon transfers for massive rotator cuff tears

Massive rotator cuff tears (MRCTs) present a particular challenge due to high rates of retear that can range from 18 to 94%, failure of healing after repair, and potential for irreparability.

Management of MRCTs must take into consideration the patient's characteristics, clinical examamination and expectation, number and quality of muscle tendons units involved.

Conservative treatment, arthroscopic long head of the biceps tenotomy, cuff debridement, partial repair, and superior capsule reconstruction are viable solutions to treat selected patients.

The goal of tendon transfers is to achieve stable kinematic by restoring rotational strength and force coupling of the shoulder joint.

The ideal candidate is a young, motivated patient with small degenerative changes of the glenohumeral joint, a massive irreparable cuff tear, significant atrophy, fatty infiltration, and functional deficit.

Patients with posterosuperior massive tears have impaired shoulder function with external rotation weakness and eventually lag sign If the teres minor is affected.

Latissimus dorsi transfer is the most used with results lasting for long follow-up and lower Trapezius transfer is becoming a surgical option. For anterosuperior tears, there is still controversial if pectoralis major is the best option when compared to latissimus dorsi although this last has a similar vector force with the supraspinatus tendon.

Complications associated with tendon transfers include neurovascular injury, infection, and rupture of the transferred tendon.

Does subscapularis integrity influence outcome following latissimus dorsi tendon transfer for irreparable cuff tears? A comparative series of 48 patients

Background

Latissimus dorsi tendon transfer (LDTT) remains a surgical option for massive irreparable rotator cuff tears. Despite a lack of comparative studies, subscapularis insufficiency has been reported as a contraindication. This study investigated the clinical outcome at a minimum 2-years post-surgery, in patients undergoing LDTT with varied subscapularis integrity.

Methods

This retrospective study included 48 patients, of which 22 underwent LDTT with an intact subscapularis (age 56.9 years, review time 79.6 months, males 68.2%) and 26 with partial (16 patients) or full-thickness (10 patients) subscapularis tearing (age 57.4 years, review time 73.3 months, males 73.1%) between 2004 and 2018. Pre-operative imaging ascertained subscapularis status. Outcomes included the Upper Extremity Functional Index (UEFI), Global Rating of Change (GRC) and patient satisfaction.

Results

No significant group differences were observed in age (p = 0.617) or review time (p = 0.555), nor the UEFI (intact 69.6, not intact 67.0, p = 0.265) or GRC (intact 3.6, not intact 2.9, p = 0.265). High levels of patient satisfaction were observed in both groups for pain relief, improving the ability to undertake daily and recreational activities, and overall satisfaction (intact 95.5-100.0%, not intact 92.3-96.2%).

Conclusion

LDTT resulted in encouraging clinical scores and high satisfaction levels, irrespective of the degree of untreated, underlying subscapularis integrity.

Level of evidence

Therapeutic Level III.

Superior Capsule Reconstruction and Lower Trapezius Transfer for Irreparable Posterior-Superior Rotator Cuff Tear: A Case Report

CASE

A 49-year-old right-hand-dominant male weightlifter was referred with persistent left shoulder pain, weakness, and range of motion limitations after failed arthroscopic rotator cuff repair and subsequent arthroscopic debridement for a massive posterior-superior supraspinatus and infraspinatus tear. The patient underwent a superior capsular reconstruction (SCR) with lower trapezius (LT) transfer to re-establish rotator cuff function.

CONCLUSION

LT transfer in addition to SCR may be a promising modality to treat massive, irreparable posterior-superior rotator cuff tears in young adults. LT transfer can optimize external rotation, whereas SCR may more adequately address pain and forward elevation.

Tendon transfers for irreparable rotator cuff tears

Symptomatic irreparable rotator cuff tears pose a challenge for shoulder surgeons. Whilst reverse polarity shoulder arthroplasty is an effective option for older symptomatic patients who have exhausted conservative management, the optimal treatment for younger patients remains controversial. In this article we outline the main tendon transfer options, including anatomical considerations, indications, contraindications, surgical technique, complications and a review of the evidence. Tendon transfers provide an alternative joint-preserving surgical option, but the evidence so far is limited, with a clear need for well-designed comparative studies to confirm their effectiveness.

Prevention and Treatment of Nerve Injuries in Shoulder Arthroplasty

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Nerve injuries during shoulder arthroplasty have traditionally been considered rare events, but recent electrodiagnostic studies have shown that intraoperative nerve trauma is relatively common.

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The brachial plexus and axillary and suprascapular nerves are the most commonly injured neurologic structures, with the radial and musculocutaneous nerves being less common sites of injury.

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Specific measures taken during the surgical approach, component implantation, and revision surgery may help to prevent direct nerve injury. Intraoperative positioning maneuvers and arm lengthening warrant consideration to minimize indirect injuries.

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Suspected nerve injuries should be investigated with electromyography preferably at 6 weeks and no later than 3 months postoperatively, allowing for primary reconstruction within 3 to 6 months of injury when indicated. Primary reconstructive options include neurolysis, direct nerve repair, nerve grafting, and nerve transfers.

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Secondary reconstruction is preferred for injuries presenting >12 months after surgery. Secondary reconstructive options with favorable outcomes include tendon transfers and free functioning muscle transfers.

Arthroscopic Humeral Bone Tunnel-Based Tendon Grafting and Trapezius Transfer for Irreparable Posterior Superior Rotator Cuff Tear

Irreparable posterior rotator cuff tears pose challenges to orthopaedic surgeons, especially when the medial remaining rotator cuff is not reusable. Trapezius transfer is biomechanically favorable due to the similar vector of the transferred muscle to the native posterior superior rotator cuff. Regarding combined tendon grafting in trapezius transfer, onto-surface tendon attachment to the humerus was reported in most previous reports. For better tendon-humeral head connection, we introduce an humeral bone tunnel-based tendon grafting technique. In this technique, we use the hamstring tendons and the anterior half of the peroneus tendon to make 3 grafts. The most critical steps of this technique are the proper creation of the humeral tunnels and graft implantation. We consider the introduction of this technique will shed light in the field of trapezius transfer for Irreparable posterior rotator cuff tears.

Short-Term Outcomes of Lower Trapezius Tendon Transfer With Achilles Allograft for Irreparable Posterosuperior Rotator Cuff Tears

Purpose

To evaluate functional outcomes, return to work, and reoperations associated with lower trapezius tendon transfer (LTT) for irreparable rotator cuff tears.

Methods

This is a retrospective study performed by a single surgeon with minimum 1-year follow-up. LTT was performed using an open (n = 9; 60%) or arthroscopically assisted (n = 6, 40%) technique. Outcomes included failure rate, range of motion, satisfaction, return to work, and pre- and postoperative functional scores, as well as American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, and the Simple Shoulder Test.

Results

Fifteen patients were included. LTT was performed using an open or arthroscopically assisted technique. Mean age was 52 (range 31-62 years), 13 (92.9%) were manual laborers, and 9 (60%) had a worker’s compensation claim. Three patients (20%) underwent conversion to reverse shoulder arthroplasty. Of the remaining 12 patients, there were significant improvements in American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and Simple Shoulder Test at 24.1 ± 9.6 (range 12-38.5) months. Active forward elevation, abduction, and external rotation were all significantly improved. Postoperative satisfaction ratings indicated 67% of the revision-free cohort was “very satisfied” and 33% was “somewhat satisfied” with their outcome. Seven (50%) returned to full duty, 4 (28.6%) returned to modified duty, and 3 (21.4%) were unable to return to work. Two patients (open techniques) underwent a superficial wound debridement for seroma and wound breakdown.

Conclusions

LTT results in successful clinical outcomes with a high rate of return to work in a challenging patient population. However, only 67% of patients rated themselves as “very satisfied,” and 20% of patients were revised to reverse shoulder arthroplasty before 1 year. Limited preoperative active forward elevation (<90°) appears to predict poor functional results and risk for reoperation.

Level of Evidence

Level IV, therapeutic case series.

Short-term outcomes of arthroscopic partial repair vs. latissimus dorsi tendon transfer in patients with massive and partially repairable rotator cuff tears

BACKGROUND

There is limited evidence on clinical outcomes of arthroscopic partial repair (APR) and latissimus dorsi tendon transfer (LDTT) for posterosuperior massive rotator cuff tears (mRCTs). We aimed to compare clinical outcomes of APR and LDTT for partially repairable posterosuperior mRCTs and to determine whether outcomes differ among tears that involve the teres minor.

METHODS

We retrieved the records of 112 consecutive patients with mRCTs deemed partially repairable due to fatty infiltration (FI) stage ≥3 in one or more rotator cuff muscles. Of the tears, 12 involved the subscapularis, 32 were managed conservatively, 14 were treated by reverse shoulder arthroplasty, and 7 were treated by stand-alone biceps tenotomy. Of the remaining 47 shoulders, 26 underwent APR and 21 underwent LDTT. At a minimum of 12 months, we recorded complications, active forward elevation, external rotation, the Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), and Simple Shoulder Test (SST) score.

RESULTS

No significant differences between the APR and LDTT groups were found in terms of follow-up (23.4 ± 3.5 months vs. 22.1 ± 4.1 months, P = .242), Constant-Murley score (64.8 ± 13.7 vs. 58.9 ± 20.0, P = .622), ASES score (78.3 ± 19.3 vs. 74.4 ± 14.5, P = .128), active forward elevation (158.1° ± 19.4° vs. 142.8° ± 49.1°, P = .698), or external rotation (33.3° ± 17.4° vs. 32.2° ± 20.9°, P = .752). By contrast, the APR group had a higher SSV (73.3 ± 17.5 vs. 59.5 ± 20.0, P = .010), and SST score (8.3 ± 2.4 vs. 6.4 ± 3.0, P = .024). Univariable analysis revealed that advanced FI of the teres minor compromised Constant-Murley scores (β = -25.8, P = .001) and tended to compromise ASES scores (β = -15.2, P = .062). Multivariable analysis corroborated that advanced FI of the teres minor compromised Constant-Murley scores (β = -26.9, P = .001) and tended to compromise ASES scores (β = -16.5, P = .058).

CONCLUSION

Both APR and LDTT granted similar early clinical outcomes for partially repairable posterosuperior mRCTs, regardless whether the teres minor was intact or torn. Advanced FI of the teres minor was the only independent factor associated with outcomes, as it significantly compromised Constant-Murley scores and tended to compromise ASES scores.

Arthroscopic Side-to-Side Repair of Massive Rotator Cuff Tears Maintains Adequate Functional Improvement at 12 to 14 Years' Follow-up

BACKGROUND

Rotator cuff tears are common shoulder injuries that often cause pain and loss of function. Nonanatomic side-to-side techniques facilitate repair by minimizing tensions within tendons to improve healing and optimize the thickness of sutured tissues.

PURPOSE/HYPOTHESIS

The purpose was to evaluate long-term clinical and radiographic outcomes of arthroscopic side-to-side repair of massive rotator cuff tears (mRCTs). The hypothesis was that, at a minimum follow-up of 12 years, arthroscopic side-to-side repair maintains clinically important improvements.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors reviewed records of all patients who underwent arthroscopic repair of mRCTs over 2 consecutive years. A total of 30 adult patients met the eligibility criteria and underwent side-to-side repair. Patients were evaluated clinically using the Constant score (CS) and ultrasound to assess retears at 3 timepoints after surgery: 2 to 4 years, 5 to 7 years, and 12 to 14 years.

RESULTS

At first follow-up (3.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 13 retears (43%). At second follow-up (6.2 ± 0.5 years), all 30 patients had clinical and ultrasound assessment, which revealed 2 new retears (total 50%). At final follow-up (13.0 ± 0.7 years), only 21 patients had clinical assessment (1 died and 8 could not be reached), and only 19 patients had ultrasound assessment, which revealed 6 new retears (total 79%). Both absolute CS and age-/sex-adjusted CS improved significantly from baseline values at first follow-up (73.5 and 96.6, respectively), and remained stable at second follow-up (69.0 and 91.9, respectively), and final follow-up (64.4 and 87.0, respectively). Compared to shoulders with intact repairs, those with retears tended to have lower absolute CS at all follow-up visits, although differences were not statistically significant.

CONCLUSION

Patients with mRCTs maintain satisfactory clinical scores at 12 to 14 years after arthroscopic side-to-side repair despite a high incidence of retears. Repair is a safe and effective treatment for mRCTs, providing a less invasive and less complex alternative to reverse shoulder arthroplasty and tendon transfer procedures.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Massive Irreparable Posterosuperior Rotator Cuff Tears Using an Achilles Tendon-Bone Allograft

The lower trapezius tendon (LTT) transfer has been described for the management of irreparable posterosuperior rotator cuff tears. Here we describe our technique of an arthroscopic-assisted LTT transfer using an Achilles tendon-bone allograft. This technique allows for augmentation of the tendon transfer using an Achilles tendon allograft while also keeping the calcaneal bone insertion, which allows for added bony fixation into the humerus and also minimizing the risk of the "killer turn" phenomenon at the aperture of fixation.