Thank you very much to Dr. Dickens and Dr. Denard for the opportunity to present on tendon transfers for the functionally irreparable rotator cuff tear. My name is Joaquin Sanchez-Otello and I serve as division chair for shoulder and elbow surgery at Mayo Clinic. These are my disclosures. These are the x-rays and MRI of a patient in his mid-50s that presented to me with a combination of pain and loss of function secondary to weakness in standard rotation. Based on the MRI on your right, severe fat infiltration of the supraspinatus and the infraspinatus. This is the video of his physical examination and as you can see he has profound weakness in active standard rotation. However, surprisingly he has very good active elevation. When looking at him from posteriorly you can appreciate how his active elevation is well preserved whereas his active standard rotation is very limited secondary to profound atrophy of the infraspinatus. As such, his main complaint is pain and lack of function mostly because of weakness of the posterior rotator cuff. Some surgeons question if there is a role for tendon transfers in any patient with a functionally irreparable rotator cuff tear and I would argue that for patients like the one I just showed you nothing other than a tendon transfer will help this type of patient. In general, my indications for tendon transfers for patients with a functionally irreparable cuff tear include those who have no or mild symptomatic arthritis presenting with the main complaint of substantial weakness in eastern rotation or internal rotation which typically equates to fat infiltration grade 3 or 4. We must apply the general principles of tendon transfers to the shoulder. We want a joint that has no stiffness and we want to select a tendon to transfer that has adequate strength, amplitude, line of pull and synergism and ideally we will select one tendon per function lost. There are multiple studies including this one performed in my institution that have analysed which are the transfers that can be considered to optimise function for patients with a functionally irreparable rotator cuff tear. Classically, latissimus dorsi transfer was recommended for the management of functionally irreparable posterior superior cuff tears whereas the pectoralis major transfer was recommended for anterosuperior tears. Classically, we recommend transfer of the lower trapezius for posterior superior tears and an anterior transfer of the latissimus dorsi for functionally irreparable anterosuperior tears. Let's talk first about the lower trapezius transfer. The benefits of using the lower trapezius to restore the function of the lost posterior superior cuff include similar line of pull, synergism and ease of harvest. In addition, this muscle is not a scapulohumeral muscle which is another benefit. What are the minuses? Well, this is an indirect transfer, it requires some type of interposed tissue because the lateral end of the tendon will not reach the greater tuberosity and some people wonder if by removing the lower trapezius we will generate secondary scapular dyskinesis. This is the way the operation is performed. We create a posterior skin incision to harvest the tendon of the lower trapezius and then use some type of tissue extension, in our practice typically an Achilles tendon allograft which is fixed arthroscopically with standard lateral cuff techniques using also the sutures that have been used for a partial repair whenever possible to augment the fixation and then after placing the arm in abduction and standard rotation the allograft Achilles is sutured to the transfer tendon. I think most surgeons are interested in understanding how to harvest the lower trapezius which may sound intimidating but it's actually not very difficult to do. It's important to position the patient in the beach chair position with the whole posterior aspect of the scapula available for exposure and the skin incision is horizontal, it measures about six to eight centimeters and is placed on the lower part of the medial half of the spine of the scapula. The inferior edge of the trapezius can be identified and dissected free from the underlying infraspinatus and once that plane has been recreated it is not very difficult to follow the excursion of the tendon laterally to the attachment on the spine of the scapula. Once the lateral aspect of a tendon has been detached of part of the spine of the scapula and Alice clamp may be used to control the flap and we will create a somewhat artificial division between the middle trapezius and the lower trapezius. Once we continue our dissection on the deeper portion of the dissection if we feel that we have reached the medial aspect of the lower scapula we have to be careful about not to injure the pedicle which is approximately two centimeters medial to the medial edge of the scapula whereas dissection on the subcutaneous area is easy to perform and will provide adequate excursion as you can see in this video. Next we prepare an Achilles tendon allograft in the back table. On the narrower end we're going to place two color-coded non-absorbable sutures that will be used for fixation and in order to understand the orientation it is also useful to color some of the grafts so that it can be easily recognized arthroscopically. In this particular patient a partial calf repair has already been performed and we are now passing the sutures that are leading the narrower portion of the Achilles allograft into the surgical field. We will retrieve those sutures through an accessory portal and we will guide the transfer of the Achilles allograft under direct vision so that it passes very easily at the space underneath the deltoid and over any remaining infraspinatus and teres minor. In terms of fixation of the graft we prefer to fix it close to the occipital groove with two anchors one more lateral and one more medial and if we have done a partial calf repair the sutures that were used for the partial calf repair will be also incorporated in another lateral anchor which will effectively create a double row calf repair but also will compress the Achilles allograft to the tuberosity hopefully optimizing healing. And then once the arthroscopic portion of the procedure has been finalized and all the suture has been cut we're going to stop the arthroscopic portion and place the arm in abduction and external rotation using any type of arthroscopic arm holder and then overlap the tendon of lower trapezius which we harvested before with the allograft. This can be done with a simple side-to-side apposition and multiple suture fixation or it can be done using a pulverized technique. Once the attachment of the graft to the lower trapezius has been finalized the patient will be placed in an immobilizer in external rotation for approximately six to eight weeks and then start physical therapy. We reported on the outcome of the arthroscopically assisted lower trapezius transfer in a total of 41 shoulders of which almost two-thirds presented with a prior failed calf repair and 80% had prior surgery. It's important to note that before surgery 70% of the patients or more have an external rotation lag sign and 24% has pseudo-paralysis. We avoided doing the operation in patients with advanced arthritis and as such 90% of the patients were in the HAMADA 0 or 1 stage and interestingly the teres minor was also affected in about 20% of the patients with substantial fatty infiltration. Finally 60% of the patients had an associated subescapularis there. We found that 90% of the patients reported improvement in pain and patient reported outcomes including improvements in elevation from 70 degrees to 130 degrees and external rotation in many patients minus 50 or minus 20 all the way to 10 to 70. Better outcomes were recorded with patients that had less symptom duration before surgery. If they had flexion before surgery over 60 degrees and of course those who had no arthritis and there were complications in four shoulders to have a transfer tear and two were converted to a reverse shoulder arthroplasty. This is an example of one of my patients four months after a lower trapezius transfer for a factually irreparable post-surgery catheter and you can see how he has restored very good strength in active external rotation not only demonstrated by his motion but also by his resisted strength testing and the same thing is true sometimes for strengthening abduction although that is not always the case in my experience. What about the irreparable subescapularis there? In those cases we propose the use of an anterior latissimus dorsi transfer. Why? Because it has the similar line of pull of the subescapularis is also easy to expose and it has similar function it will function as a head depressor it will restrain again anterior translation and it provides at least in my mechanical studies good internal rotation in abduction. So you can see an illustration here of how close the latissimus dorsi is to the lesser tuberosity and how easy to some extent it is to transfer it proximally and just by changing slightly the location and the line of pull typically patients improve substantially. Dr. Elhassan, Wagner and Kani have reported on a total of 56 shoulders that underwent an anterior latissimus dorsi transfer for a functionally irreparable anterosuperior catheter. 14 cases opened 42 arthroscopic prior surgery in 82% of the patients and with a somewhat short follow-up of just over a year patients in generally improved in pain motion and severe disorder value 80% of the time although as you can see in the numbers this operation does not reliably restore complete strength of subescapularis since there wasn't complete reversal of lift-off or velcro test in all of the patients. So again for patients presenting with a functionally irreparable rotator catheter there is no question that tendon transfers do play a role in some patients. If you want to read more about this we have this current concept review in GBGS American that will summarize everything I talked about and more but in general when I see a patient that presents with a functionally irreparable catheter the first thing I look at is cartilage degeneration and if that is severe in my hands that patient is a candidate for a reversal of helplasty and sometimes you have to do tendon transfers in the setting of reverse as well. If a patient has no cartilage degeneration, AMADA 0 or 1 and is low demand many of those patients will present with pseudoparalysis and for me in the low demand end of the patient that's also a reversal of helplasty indication. However if the patient has no pseudoparalysis I think it is very wise to consider these patients that present mostly with pain for a debridement maybe a vicious procedure and a partial rotator catheter repair if possible. In the patient that is high demand though reverse helplasty in general is not recommended so if they have a post superior catheter we recommend currently a lower tap issues transfer. If they have an under superior catheter we recommend a transfer of the latissimodosity to the lesser tuberosity and occasionally we have considered combined transfers posteriorly and anteriorly realizing that when all these procedures fail they will go to the common final pathway of reversal of helplasty. We also published this topical collection of articles by many experts in the field reviewing different options including patch, balloon, SCR, mantendon transfers and reverse and I would invite the listeners to read them if they have interest in this topic. Thank you very much for listening and have a great rest of the course.

tendon transfers

functionally irreparable rotator cuff tears

pain and weakness

fat infiltration

surgical techniques