Novel Arthroscopic Tendon Transfers for Posterosuperior Rotator Cuff Tears: Latissimus Dorsi and Lower Trapezius Transfers

Lower trapezius tendon transfer vs. reverse shoulder arthroplasty for massive irreparable rotator cuff tears: an in-vivo scapulohumeral rhythm dynamic radiography study

BACKGROUND

Reverse shoulder arthroplasty (RSA) and arthroscopic-assisted lower trapezius tendon (aLTT) transfer are both treatment options for massive irreparable rotator cuff tears (MIRCTs) without glenohumeral arthritis; however, the indications for each remain controversial. Although RSA is an excellent reconstructive option, preserving the joint, recentering the humeral head, and restoring in-line active external rotation with an aLTT transfer may be preferred in certain patients to better restore more normal shoulder biomechanics. In-vivo kinematics, however, have been historically difficult to evaluate. Dynamic digital radiography (DDR) provides a novel way to examine shoulder function following surgical intervention by estimating the scapulohumeral rhythm (SHR)-the ratio of humerothoracic and scapulothoracic motion. The purpose of this study was to compare SHR between aLTT transfer and RSA in the setting of nonarthritic MIRCTs with the use of DDR. We hypothesized that aLTT transfer would restore SHR to values more typical of native shoulders compared to RSA.

METHODS

DDR > 6 months postoperatively was performed on 48 shoulders, comprised of 30 RSA and 18 aLTT transfer shoulders, secondary to nonarthritic MIRCT-the diagnosis for which was validated on radiographs and magnetic resonance imaging. Manual measurements of the angle between the humerus and the midline and the lateral border of the scapula and midline were taken by 2 readers at rest, 30°, 60°, and 90° of shoulder abduction. The ratio of these measurements formed the SHR. A paired subgroup analysis was performed on 7 RSA and 7 aLTT transfer shoulders with both preoperative and postoperative DDR to evaluate for precise changes in SHR. Data were compared using descriptive statistics, and inter-rater reliability of the manual measurements was assessed with intraclass correlations.

RESULTS

The aLTT transfer cohort had a higher median rest-90° range of motion SHR of 2.30, compared to 1.83 for the RSA cohort. Subgroup analysis of the RSA cohort demonstrated a nonsignificant improvement in median rest-90° range of motion SHR from 1.84 to 2.23 following surgical intervention. The aLTT transfer subgroup's median rest-90° SHR improved significantly from 2.20 to 2.46 following surgical intervention. The inter-rater reliability was 0.99.

CONCLUSIONS

aLTT transfer is associated with an increased SHR compared to RSA in patients with nonarthritic MIRCTs by establishing a higher glenohumeral contribution compared to scapulothoracic contribution. Further work is needed to understand scapular motion in multiple planes after these surgeries and correlate SHR changes with clinical outcomes.

Arthroscopic Pectoralis Minor Release and Infraclavicular Brachial Plexus Decompression for Neurogenic Thoracic Outlet Syndrome: A Novel Treatment for an Old Problem

Background

Neurogenic thoracic outlet syndrome (nTOS) of infraclavicular etiology is a complex condition involving the compression of the brachial plexus through the interscalene triangle and costoclavicular, infraclavicular, and pectoralis minor space. New insight into nTOS of infraclavicular etiology and its association with scapular dyskinesia has enabled minimally invasive treatments: endoscopic pectoralis minor release (PMR) and infraclavicular brachial plexus neurolysis. The purpose of this study was to analyze clinical outcomes of this technique compared with historically published outcomes for open first rib resection (FRR) and/or scalenectomy.

Methods

All patients who underwent endoscopic surgical decompression for nTOS of infraclavicular etiology were retrospectively reviewed at a single institution. Surgical treatment included endoscopic PMR, subclavius release, and neurolysis of the infraclavicular brachial plexus. Patient-reported outcomes were collected prospectively and compared with prior research on FRR and scalenectomy. A subgroup analysis was performed on patients with prior open FRR or anterior cervical discectomy and fusion (ACDF).

Results

Fifty-eight shoulders among 55 patients were included, with an average follow-up of 25.8 months (range: 12-52). Patients showed significant improvement in visual analog scale pain (7.0-2.1) and single alpha-numeric evaluation scores (37% to 84%). Overall, 90% of patients experienced good or excellent outcomes according to the Derkash classification. There were no major complications and only 2 minor ones (one wound infection and one case of adhesive capsulitis). Satisfaction and Derkash scores among patients undergoing endoscopic surgery were comparable with previously published studies on open FRR and scalenectomy, with lower rates of major complications and equivalent or improved clinical outcomes. Patients with prior ACDF or open FRR had worse postoperative American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder, and Hand; and Derkash scores than the subgroup with no prior intervention.

Conclusions

Endoscopic PMR and infraclavicular brachial plexus decompression is a viable and effective treatment option for nTOS of infraclavicular etiology driven by the pectoralis minor and associated scapular girdle dyskinesia. This cohort demonstrates improvements in clinical outcomes comparable with open scalenectomy and FRR with high patient satisfaction and no major neurologic, vascular, or thoracic complications.

Level of Evidence

Therapeutic Level IV-Case Series. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Fascia Lata Autograft for Irreparable Posterior-Superior Rotator Cuff Tears

Lower trapezius tendon transfer is a surgical procedure that has become increasingly popular in recent years. The biggest advantage of this method is that the pulling direction of the lower trapezius is the same as that of the infraspinatus. Thus, the transferred lower trapezius tendon can biomechanically mimic the functions of the posterior-superior rotator cuff. In this technical presentation, we described the surgical technique of an arthroscopic-assisted lower trapezius tendon transfer, which we augmented with autogenous fascia lata graft to reconstruct an irreparable rotator cuff tear.

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.

Early postoperative recovery comparisons of superior capsule reconstruction to tendon transfers

BACKGROUND

The management of massive posterosuperior rotator cuff tears is controversial, with no gold standard. Two recently developed techniques that have shown promising initial results include arthroscopic superior capsular reconstruction (SCR) and tendon transfers (latissimus or lower trapezius). However, there remains a scarcity of studies examining each procedure's early postoperative clinical outcomes individually or in comparison to each other. The purpose of this study is to compare the early postoperative recovery outcomes of tendon transfers (TTs) to SCR.

METHODS

Using the surgical outcomes system global database (Arthrex Inc.), we assessed the postoperative recovery outcomes for all patients who had outcomes recorded at least 6 months after SCR or TT. The time points analyzed included preoperative and postoperative (2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years). The outcomes analyzed included pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, VR-12 physical, and Single Assessment Numeric Evaluation (SANE).

RESULTS

Overall, 163 patients underwent SCR and 24 arthroscopically assisted TT. The mean age for SCR and TT was 60 and 56 years, respectively. Postoperative recovery curves demonstrate that both procedures produced improved outcomes at each postoperative time point compared to preoperative. The pain and functional outcomes measures, including VAS, ASES, SANE, and VR-12 physical, were comparable for TT and SCRs, with similar recovery curves between the 2 techniques. Ultimately at 2 years postoperatively, there were no significant differences between the 2 techniques.

CONCLUSIONS

Analysis of the early outcomes associated with arthroscopic treatment of massive posterosuperior rotator cuff tears demonstrated that the arthroscopically assisted tendon transfers and arthroscopic superior capsular reconstruction had similar pain and functional outcomes throughout the 2-year postoperative recovery period. Overall, the process of recovery appears equivalent between the 2 techniques. Future studies are needed to assess the outcomes of each technique and specific indications in an attempt to delineate an algorithm for the treatment of irreparable rotator cuff tears.

Middle Trapezius Tendon Transfer for Augmentation of In Situ Superior Capsular Reconstruction-Reinforced Partial Rotator Cuff Repair: Short-term Outcomes of a Prospective Cohort Study

BACKGROUND

Middle trapezius tendon (MTT) transfer has been described for dynamic reproduction of supraspinatus function. For management of irreparable rotator cuff (RC) tears, this procedure can be coupled with in situ (long head of the biceps tendon-based) superior capsular reconstruction (SCR) and partial RC repair.

PURPOSE

To investigate the functional outcomes of augmentation of in situ SCR-reinforced partial RC repair with MTT transfer for the management of irreparable posterosuperior RC tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Conducted between September 2014 and March 2022, this study included 24 patients with irreparable posterosuperior RC tears who were allocated into 2 groups: patients managed with 2-layer tendon construct (in situ SCR-reinforced partial RC repair) (group A; n = 15) and patients managed with 3-layer tendon construct (MTT transfer-augmented, in situ SCR-reinforced partial RC repair) (group B; n = 9). Outcome measures included 2-year postoperative pain, range of motion (ROM) in forward flexion and external rotation, and the American Shoulder and Elbow Surgeons (ASES) and the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores. For data comparison, independent and paired t tests were used for parametric quantitative variables, and Mann-Whitney and Wilcoxon signed-rank tests were used for nonparametric quantitative variables; Fisher exact and McNemar tests were used for qualitative variables.

RESULTS

The mean age of the patients was 58.40 ± 4.54 years in group A and 59.22 ± 4.46 years in group B; there were no between-group differences in baseline patient characteristics. Patients in both groups had significant preoperative to postoperative improvement on all outcome measures (P < .05 for all). Group B had a significantly higher magnitude of postoperative improvement compared with group A in forward flexion ROM (88.88° ± 29.34° vs 46.66° ± 20.93°; P = .001), external rotation ROM (32.22° ± 14.81° vs 16.0° ± 9.10°; P = .002), ASES score (71.07 ± 8.26 vs 57.87 ± 8.39; P = .001), and QuickDASH score (-70.20 ± 6.95 vs -58.34 ± 12.52; P = .007).

CONCLUSION

Augmentation of in situ SCR-reinforced partial RC repair with MTT transfer in a 3-layer tendon construct led to significantly greater improvement in postoperative ROM and functional scores compared with a 2-layer construct.

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.

Latissimus Dorsi Transfer Combined with Subacromial Balloon Spacer for Bidirectional Rotator Cuff Deficiency

Patients with massive, irreparable rotator cuff tears represent a challenge for treatment, particularly those with loss of external rotation and active elevation. In the cases of glenohumeral arthropathy, reverse shoulder arthroplasty combined with transfer of the latissimus dorsi and teres major tendons has improved active external rotation and overall patient outcomes. However, the reverse shoulder prosthesis could be better used as a second-line treatment in patients without arthropathy. Several joint-preserving surgical approaches have been described for irreparable cuff tears with no substantial differences in results. Although latissimus dorsi transfer has shown long-term clinical reliability and improved functional shoulder function in relatively young patients, isolated tendon transfer appears insufficient to restore range of motion in patients with a bidirectional deficit. The subacromial balloon spacer is an additional new treatment option. This surgical procedure describes an arthroscopic-assisted transfer of the latissimus dorsi tendon followed by the implantation of the subacromial balloon. This combination potentially addresses the bidirectional deficiency by restoring the shoulder external rotational coupling, improving the deltoid load, centering the humeral head, and protecting the transferred tendon from the subacromial compression stresses.

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.

Partial Rotator Cuff Repair Provides Improved Patient-Reported Outcome Measures Following Superior Capsule Reconstruction (SCR)

Purpose

To evaluate the role of concomitant partial rotator cuff repair (RCR) (i.e., infraspinatus) on patient-reported clinical outcomes following superior capsule reconstruction (SCR).

Methods

Postoperative recovery outcomes of SCR alone were compared with SCR with concomitant infraspinatus rotator cuff repair (SCR+RCR) at 3, 6, 12, and 24 months. Patients were included if they had an SCR surgery with or without a concomitant infraspinatus repair. Patients were excluded if they did not have a minimum of 6 months’ follow-up or if a preoperative baseline questionnaire was not performed. Outcome measures included pain visual analog scale, American Shoulder and Elbow Surgeons (ASES) Shoulder Function, ASES Shoulder Index, and Single Assessment Numeric Evaluation (SANE) score.

Results

Overall, 180 patients were evaluated, including 163 patients who underwent SCR alone and 17 patients who underwent concomitant infraspinatus repair (SCR+RCR). There was no difference in demographic data including age, sex, and body mass index. The postoperative recovery curves demonstrated SCR alone and SCR+RCR both provide significantly improved pain and functional scores at 2 years postoperatively (P < .001). When we compared the 2 groups, SCR+RCR provided significantly improved ASES Index (87.6 vs 78.2, P = .048) and ASES Function (25.5 vs 21.7, P = .02). There was no statistically significant difference in SANE scores (75.5 vs 64.2, P = .07) at 24 months’ follow-up.

Conclusions

SCR provides modest improvements in pain and function at 2 years postoperatively in patients with irreparable rotator cuff tears. Patients who underwent SCR and concomitant infraspinatus repair demonstrated significantly improved ASES Index and ASES Function scores and statistically nonsignificant improvement in SANE scores at 24 months postoperatively when compared with SCR alone.

Level of Evidence

III, retrospective cohort study.

A Biomechanical Analysis of Shoulder Muscle Excursions During Abduction, After the Treatment of Massive Irreparable Rotator Cuff Tears Using Superior Capsular Reconstruction (SCR), Bursal Acromial Reconstruction (BAR), and SCR with BAR

INTRODUCTION

Current understanding of the biomechanical effects of treatment options for irreparable rotator cuff (RC) tears is lacking. This study examines how shoulder muscle lengths and excursions are affected by superior capsular reconstruction (SCR), bursal acromial reconstruction (BAR), and SCR with BAR, following a complete supraspinatus tear.

METHOD

Six fresh-frozen cadaveric shoulders were examined. Deltoid and RC muscle lengths were measured at 0, 30, 45, 60, and 90° of shoulder abduction under six conditions: (1) intact, (2) partially torn supraspinatus, (3) completely torn supraspinatus, (4) SCR, (5) SCR with BAR, and (6) BAR. Muscle excursions from 0-90° of abduction were then calculated.

RESULTS

Subscapularis muscle lengths after SCR, BAR, and SCR with BAR were significantly greater (post-hoc Tukey HSD test; p < .01) compared to the other conditions. Supraspinatus, infraspinatus, teres minor, and deltoid lengths were not significantly different (ANOVA test; p > .01) between the conditions. All muscle excursions remained statistically similar between the conditions (ANOVA test; p > .01).

CONCLUSION

These findings demonstrate that the use of SCR, BAR, or SCR with BAR for a complete supraspinatus tear, may increase subscapularis muscle length while maintaining other shoulder muscle lengths. An increase in subscapularis length can allow for more effective subscapularis muscle strengthening and increased compensatory function in the long term. Additionally, all shoulder muscle excursions are preserved after partial or complete supraspinatus tears and after SCR, BAR, or SCR with BAR. Therefore, these surgical treatments can initially normalize shoulder muscle function during 0-90° of abduction, after an irreparable supraspinatus tear.

Muscle Tendon Transfers Around the Shoulder: Diagnosis, Treatment, Surgical Techniques, and Outcomes

➤

Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency.

➤

The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle.

➤

When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications.

➤

For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes.

➤

Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes.

➤

The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty.

➤

The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training.

Rotator cuff irreparability or failure of repair (re-tear): technical note on middle trapezius tendon transfer for reproduction of supraspinatus function

PURPOSE

Based on its close anatomic features and nearly-collinear force vector to those of supraspinatus muscle, the current article describes a technique of middle trapezius tendon transfer for reproduction of supraspinatus function in the context of rotator cuff irreparability/re-tear management.

METHODS

While seating the patient in beach-chair position, arthroscopic gleno-humeral examination and sub-acromial decompression are initially performed. Hamstring tendons are harvested and fashioned as flattened quadruple sheet. Through McKenzie approach, infraspinatus and subscapularis tendons are repaired. Then, medial half of middle trapezius insertion tendon is harvested from most medial 5-6 cm of the scapular spine. Through McKenzie approach, hamstring sheet is retrieved via a sub-trapezius/sub-acromial corridor from the scapular wound. Hamstring sheet is re-attached to cuff footprint by double row/suture bridge repair configuration. While retracting the scapula and placing gleno-humeral joint in 45O-abduction/45O-external rotation, hamstring sheet is re-attached to released middle trapezius tendon by non-absorbable sutures. Finally, tendon reconstruct is dynamically-tested in different positions of range of motion.

RESULTS

Transfer of medial portion of middle trapezius insertion tendon (lengthened by interposition hamstring tendon sheet) to cuff footprint was technically feasible. Dynamic testing showed smooth sub-acromial gliding motion of the tendon reconstruct.

CONCLUSION

For reproduction of supraspinatus function, hamstring tendon augmented-middle trapezius tendon transfer to cuff footprint heralds a number of technical and biomechanical advantages; thus offering a potential effective modality of cuff irreparability/re-tear management in relatively young patients of high functional demands. However, current description should be investigated in further biomechanical and clinical studies to validate its long-term outcomes.

Change in shoulder external rotation strength and motion after lower trapezius transfer to the infraspinatus in children with obstetric brachial plexus palsy

PURPOSE

Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP).

METHODS

This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4-12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device.

RESULTS

Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from -8° (range: -20-0°) to 37° (range: 15-50°) (p = 0.035), the modified Mallet score from 13 (range: 10-15) to 18 (range: 17-19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively.

CONCLUSION

Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement.

TRIAL REGISTRATION

18/07/31/5783, December 22, 2018.

Treatment Options for Massive Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.

RECENT FINDINGS

Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Complications of Superior Capsule Reconstruction for the Treatment of Functionally Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

The purpose of this systematic review is to characterize the complications associated with superior capsule reconstruction (SCR) for the treatment of functionally irreparable rotator cuff tears (FIRCTs).

METHODS

This systematic review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Two independent reviewers completed a search of PubMed, Embase, and Medline databases. Studies were deemed eligible for inclusion if they reported postoperative outcomes of arthroscopic SCR for FIRCTs and considered at least 1 postoperative complication. Statistical heterogeneity was quantified via the I² statistic. Due to marked heterogeneity, pooled proportions were not reported. All complications and patient-reported outcomes were described qualitatively.

RESULTS

Fourteen studies met the inclusion/exclusion criteria. The overall complication rate post-SCR ranged from 5.0% to 70.0% (I² = 84.9%). Image-verified graft retear ranged from 8% to 70%, I² = 79.4%), with higher rates reported when SCR was performed using allograft (19%-70%, I² 76.6%) compared to autograft (8%-29%, I² = 66.1%). Reoperation (0%-36%, I² = 73.4%), revision surgeries (0%-21%, I² = 81.2%), medical complications (0%-5%, I² = 0.0%), and infections (0%-5%, I² = 0.0%) were also calculated.

CONCLUSIONS

SCR carries a distinct complication profile when used for the treatment of FIRCTs. The overall rate of complications ranged from 5.0% to 70.0%. The most common complication is graft retear with higher ranges in allografts (19%-70%) compared to autografts (8%-29%). The majority of studies reported at least 1 reoperation (range, 0%-36%), most commonly for revision to reverse shoulder arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV or better investigations.

Clinical outcomes of latissimus dorsi tendon transfer and superior capsular reconstruction for irreparable rotator cuff tears: a systematic review

BACKGROUND

Functionally irreparable rotator cuff tears (FIRCTs) present an ongoing challenge to the orthopedic surgeon. The aim of this systematic review was to critically compare the outcomes of three latissimus dorsi tendon transfer (LDT) techniques and two superior capsular reconstruction (SCR) techniques in treatment of FIRCTs.

METHODS

A systematic review of studies evaluating the outcome of FIRCT treatment was performed via a search of four databases in April 2020. Each included study was reviewed in duplicate by two reviewers for evaluation of methodological quality. The treatments analyzed were arthroscopic LDT (aLDT), open LDT Gerber technique (oLDTG), open LDT L'Episcopo technique (oLDTL), SCR with allograft (SCR-Allo), and SCR with autograft (SCR-TFL). Demographics, range of motion, patient-reported outcome measures, radiographic acromiohumeral distance (AHD), treatment failures, and revisions were recorded.

RESULTS

Forty-six studies (1287 shoulders) met criteria for inclusion. Twenty-three studies involved open latissimus transfer, with 445 shoulders undergoing oLDTG with mean follow-up of 63.2 months and 60 patients undergoing oLDTL with mean follow-up of 51.8 months. Ten studies (n = 369, F/U 29.2mo) reported on aLDT. Seven studies (n = 253, F/U 16.9mo) concerned SCR-Allo, and six studies (n = 160, F/U 32.mo) reported on SCR-TFL. Range of motion and subjective outcome scores improved in all techniques with no differences across treatments. Both SCR methods provided greater improvement in AHD than open LDT methods (p < 0.01). The re-tear rates were lower in both oLDT groups compared to the SCR groups (p = 0.03). Clinical failure rates were higher in the SCR-Allo and oLDTG groups, while overall treatment failures were lowest in oLDTL compared to all four other groups.

CONCLUSION

SCR techniques were associated with improved short-term radiographic acromiohumeral distance, while the open LDT techniques had lower tendon re-tear and treatment failure rates. All techniques resulted in improved clinical outcomes and pain relief compared to preoperative levels with no differences across techniques.

LEVEL OF EVIDENCE IV

Systematic review of case series and cohort studies.

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.

Enhancement of External Rotation after Latissimus Dorsi Tendon Transfer (LDTT): A Cadaveric Study

Background and objectives: Massive rotator cuff tears compromise shoulder mobility function and cannot be directly repaired. Latissimus dorsi tendon transfer (LDTT) is a therapeutic alternative suitable for the treatment of rotator cuff tears that helps to restore external shoulder rotation. Cadaver models have been used for studying the effects of LDTT and procedural variations, but, to the best of our knowledge, none of them have been validated. The aim of our study was to validate a novel cadaver model while verifying the effects of LDTT on external rotation. Materials and Methods: Two groups were included in the study: a cadaver group and a control group made up of healthy volunteers, which were used for the validation of the cadaver model. Baseline external rotation measurements were performed with both groups, after which a massive rotator cuff tear was inflicted and repaired with LDTT in the cadaver group. Their postoperative external rotation was evaluated using three different tests. Results: No statistically significant differences were found between the baseline measurements of the two groups, and postoperative external rotation was significantly higher after LDTT in all cases but one. Conclusions: Cadaver models were validated, since they had a similar preoperative external rotation to healthy volunteers. Moreover, they allowed us to demonstrate the effect of LDTT on external shoulder rotation.

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.

Techniques for lower trapezius tendon transfer for the management of irreparable posterosuperior rotator cuff tears

Irreparable posterosuperior rotator cuff tears are a challenging treatment problem. Several tendon transfers have been described for the treatment of irreparable tears. Recently the lower trapezius (LT) tendon transfer has grown in popularity. This procedure has shown promise in biomechanical studies, improving the external rotation moment arm at the side. This transfer may be done in several ways, including an open approach with an acromial osteotomy, mini-open, and arthroscopic-assisted. The purpose of this paper is to review the current evidence and rationale for the use of the LT transfer and to describe the available techniques.

Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer

PURPOSE OF THE REVIEW

Functionally irreparable rotator cuff tears (FIRCTs) remain one of the most challenging pathologies treated in the shoulder. The lower trapezius transfer represents a very promising treatment option for posterosuperior FIRCT. This article reviews the role for the lower trapezius transfer in the treatment of patient with FIRCTs and highlights the tips and tricks to performing this arthroscopic-assisted procedure.

RECENT FINDINGS

The treatment of posterosuperior FIRCTs contemplates a wide array of surgical options, including partial repair, biceps tenodesis/tenotomy, superior capsule reconstruction, subacromial balloon, reverse shoulder arthroplasty, and open-/arthroscopic-assisted tendon transfers. Tendon transfers have emerged as very promising reconstructive options to rebalance the anterior-posterior force couple. Controversy remains regarding the relative indications of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT). Initially used with very good success in patients with brachial plexus injuries, the open LTT has shown excellent clinical and radiographic outcomes in a recent series of patients with FIRCTs. However, this technique should be reserved for patients with an intact or reparable subscapularis tendon and no advanced glenohumeral arthritis or humeral head femoralization. With advancements in surgical technique, the arthroscopic-assisted LTT has shown similar promising results. However, studies on arthroscopically assisted LTT are limited to short-term follow-up, and future comparative trials with large patient numbers and longer follow-up are needed to better understand the indications for this novel tendon transfer in the treatment of FIRCT. The arthroscopic-assisted LTT is a novel, promising option for the treatment of patients with functional irreparable posterosuperior rotator cuff tears. Careful attention to indications and technical pearls are paramount when performing this procedure to optimize postoperative clinical outcomes.

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

BACKGROUND

Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs.

METHODS

MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated.

RESULTS

Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation.

CONCLUSION

This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

Biomechanics of lower trapezius and latissimus dorsi transfers in rotator cuff-deficient shoulders

BACKGROUND

Irreparable posterosuperior rotator cuff tears cause pain and impaired shoulder function. Latissimus dorsi (LD) transfer has been proven to improve shoulder function, but lower trapezius (LT) transfer has recently been proposed as an alternative. This study aimed to compare the biomechanics of LD and LT transfers and how they are affected by different insertion sites.

METHODS

The Newcastle shoulder model was used to investigate the biomechanics of these 2 tendon transfers. Computed tomography data sets from 10 healthy subjects were used to customize the model, and virtual LD and LT transfers were performed on supraspinatus, infraspinatus, and teres minor insertion sites. Muscle moment arms and lengths were computed for abduction, forward flexion, and external rotation.

RESULTS

The LT yields greater abduction moment arms compared with the LD when it is transferred to the native supraspinatus and infraspinatus insertion sites. However, they become adductors when transferred to the native teres minor insertion. Both muscles show strong external rotation moment arms, except for the LT with a supraspinatus insertion. Resting muscle strains were 0.21 (±0.03), 0.12 (±0.02), and 0.06 (±0.03) for the LD and 0.70 (±0.15), 0.61 (±0.13), and 0.58 (±0.13) for the LT for the supraspinatus, infraspinatus, and teres minor insertions, respectively.

CONCLUSIONS

LT provided better abduction and external rotation moment arms when transferred to the infraspinatus insertion. LD performed better when transferred to the supraspinatus insertion. Overall, LT transfer showed a biomechanical advantage compared with LD transfer because of stronger abduction moment arms. However, significantly larger muscle strains after LT transfer necessitate a tendon allograft to prevent muscle overtensioning.

Significant improvement in patient self-assessed comfort and function at six weeks after the smooth and move procedure for shoulders with irreparable rotator cuff tears and retained active elevation

BACKGROUND

It has been documented that the smooth and move procedure-smoothing the proximal humeral surface while maintaining the coracoacromial arch-can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation. This study sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure.

METHODS

We conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).

RESULTS

In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID). The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus. In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).

CONCLUSIONS

In addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.