With Michael Amini, we're going to move on to lower trap transfer. The envy of following Joe Boud. All right, so my disclosures in the Academy website. So by the end of this, you'll understand when to do a lower trapezius transfer and importantly how to do a lower trapezius because I think it can be intimidating if you haven't done one before. Latissimus dorsi used to be the workhorse for tendon transfers for posterior super cuff. You need to retrain it to work with forward elevation and external rotation when it normally does adduction and internal rotation. Only 50% of people actually do that and that's highly associated with their outcome. So the line of pull of the infraspinatus, right, we want to give a posterior anterior cuff. If they have a subscap, you give them an infra, they can be balanced. The latissimus dorsi is quite off axis and here's what it looks like in one of my last cases that I did. No, I'm kidding. If you go look at the back of the shoulder, infra, latissimus, it then becomes very obvious the lower trap is right there. It's in line, it's in phase, it already works how it's supposed to work upon activation of external rotation and elevation. So although it seems intimidating, I'm going to convince you that in the words of Patches O'Houlihan, if you can fix a rotator cuff, you can do a lower trapezius. Technically speaking, there's not a very big leap and this is the one step that's going to be novel for you. So I've never operated on this part of the shoulder until I started doing this. It seems like it ought to be easy and it's not. It's not necessarily complicated or risky. The nerve is about two centimeters medial to the medial border of the scapula, so spinal accessory nerve. But the lower trap and the subcutissue are very adherent. The tissue planes don't give themselves up to you. So although Bassamel Hassan talks about going under, I actually like to come right down on the scapular spine and then peel off everything underneath of it. So that takes your lower trap off and it also takes your infraspinatus fascia off, which you need to do anyways to actually shuttle the graft into the shoulder. So dual purpose and then you can see the two fascial layers and actually identify the tendon. I find that much easier than trying to dissect through the subcutissue to find it. Once you're done, the rest of this is off to the races. So shuttle the suture of the graft on the back table, shuttle it into the shoulder. So here's a patient. There is zero chance you can convince me that you can repair that. That's the supraspinatus. Infraspinatus is behind there. If you follow the acromion back, you'll find the scapular spine right there. It's vascularized, so don't do this with your shaver. Do this with your wand. I've already cleaned this up. And then right behind there, you find that dark abyss. You ask your circulator to find the largest, longest curved Kelly clamp in the hospital. When they come back, you tell them to go find one longer. You need an 11 to 14 inch curved Kelly clamp. I missed it. So you shuttle the curved Kelly clamp to your open incision, pull the sutures of the graft into the shoulder, and all you have to do at this point is drop a few knotless anchors. So the arthroscopic part of this is actually very easy. It's just a cuff. Externally rotate the arm, split the graft, and pull it through the lower trapezius. So here it is. There's the Achilles side. I'm sorry, the calcaneal side is already fixed to the humerus. Gastrocnemius side, you split it in half. You can shuttle one or both of your new limbs through your musculotendinous junction. What you'll see here is the tip of the lower trapezius. It looks tiny. This muscle is massive, right? So you're seeing the tip of the iceberg. The traction stitch I have there is not just traction. What you really can't tell in this image, I have a tied to the end of it, but I run a crack out up and down one side, and then up and down the other side. So I have a closed V to help minimize the risk of pulling that graft through the musculotendinous junction. I think that really improves the weak mechanical link at time zero. I think biologically the weak link is getting an allograft to heal to the humerus, but mechanically at time zero, I think this is the weak link. And then all you have to do is pull the two together, sew it up, and you're done. Cut the extra graft. This is one of my earlier ones. I would have brought this over a little bit more laterally, a little bit more anterior now. This is kind of on the posterolateral humerus. I would bring it a little forward. Significant improvements in function, but really specifically external rotation. But this population's tough. If you're doing joint preservation on a massive superior cuff tear, 10 to 20% progression to OA is still notable, but not bad. Worse functions if you have worse pre-op functions. This is a really important point. Reverse, predictably reverses pseudoparalysis, and high pre-op function is a risk for dissatisfaction with the reverse. Tendon transfers and every soft tissue joint preservation surgery is the exact opposite. Best outcomes with best pre-op function. In the words of one of my gray-haired mentors, tendon transfers work the best when you need them to do the least. This guy right here is a poster child for what you want to do, for who you want to do a lower trap for. Good elevation, 60-year-old, muscular guy, mechanic, painful, weak, and really, really bad external rotation. You can see right here he does it mostly almost by dipping his shoulder backwards. He's really only got about 10 degrees of active external rotation here. He's the absolute poster child for what you want to do this for. Indications are everything. Don't push it in early arthritics. Inferior results when it's a revision surgery in women, which is true for every joint preservation we do. Follow the principles of tendon transfer. One function, one transfer. Check for ER stiffness. I've been burned by that a few times. A joint that doesn't have excursion still won't have excursion, and do a partial repair. Hopefully by now I've convinced you that you, too, can do a lower trapezius transfer.

orthopedic surgeon

Michael Amini

lower trapezius transfer procedure

tendon transfer

posterior super cuff