Hi, my name is Joe Eichinger, and I'm going to talk about lower trapezius tendon transfer. I don't have any relevant disclosures. We'll start with a case example. 55-year-old male. He's a machinist with right shoulder pain and weakness, particularly over in motion. He has a history of two prior attempted rotator cuff surgeries done at an outside hospital. Subjective shoulder value of only 30%. He's quite miserable at this point, and presents requesting a reverse total shoulder, as he was told that this is his only option at this point. He has some retained active forward elevation. He does have weakness and a 10-degree lag sign with external rotation. He does have preserved internal rotation and subscapularis function. His x-rays show only minimal proximal humeral migration and minimal degenerative changes. Looking at his CT arthrogram, it appears that he does not have a significantly retracted rotator cuff tear, and he appears to have what appears to be some preserved rotator cuff that does not look severe on the CT arthrogram, with the exception of the anterior infraspinatus and the supraspinatus. Looking at the sagittal imaging, you can see that he does not have a significant amount of fatty infiltration, but he does have a complete tear of the supraspinatus, a partial tear of the infraspinatus, and minimal glenohumeral osteoarthritis. So in this situation, what are my options? He has relatively well-preserved function, but he has weakness and pain that makes it difficult for him to do his job. Should I do a reverse? Can he still work as a machinist doing demanding labor with a reverse? Is there anything else that we can consider for this gentleman? Should it be patches, grafts, SCR, or tendon transfers? Lots of options. What works? So do tendon transfers work? Well the original posterior superior cuff tendon transfer treatment was the latissimus transfer, and as shown in this systematic review, reasonably good results were obtained in this difficult subset of patients. And about 80% of those who underwent surgery were satisfied with the results. It wasn't perfect, but it certainly worked well for a number of these individuals. The risk factors for poor outcomes, of course, revision surgery, subscap insufficiency, and Terry's minor atrophy. There's a new kid on the block, well it's not so new anymore, but the lower trapezius tendon transfer has seemed to supplant the latissimus, and why is that? Well it may be that the Terry's minor may work a little bit better for restoring external rotation in the posterior superior cuff tear, especially the young patient. And while the latissimus dorsi does have some success in showing some pain relief, it has less consistent restoration of motion. And I think for posterior superior cuff tears, biomechanically, you may have some superiority in the lower trapezius in restoring external rotation. The other factor is that the latissimus does require a larger incision and greater dissection. So in terms of the biomechanics, you can see on the right is the black arrow marks the force vector of the lower trapezius, excuse me, of the latissimus, which works for suppression of the humeral head and some external rotation. But on the left, you can see the lower trapezius force pull is essentially just coming and mimicking the infraspinatus, which may have some advantages. So Bossom, as I mentioned, came up with this operation and he reported on his initial results back in 2016 on 33 patients, and these were individuals that were doing heavy lifting activities, including construction workers, farmers, lifting heavy wood boxes and animals. Of course, he used an Achilles tendon allograft to extend the lower trapezius to the shoulder and really had pretty good results with this. In 2016, I went and visited Bossom, this was back when I had a little less gray hair, and learned how to do this surgery from him. At that time, he was using a vertical incision for harvesting the lower trapezius, and then a chromial osteotomy to access the superior cuff and greater tuberosity. So let's go back to our patient. Here you can see, looking from a posterior portal, the rotator cuff, while it's there, it just has no mobility despite a capsular release, and it just will not reach back over to the greater tuberosity. So obviously, despite the findings on the CT arthrogram, you can see this gentleman has an irreparable posterior superior rotator cuff tear. So we went ahead and did the original surgery, this is an open procedure where we harvested the lower trapezius. You can see it here through a more vertical incision. I did this in a lateral decubitus. And here is the repair of the Achilles onto the greater tuberosity through the chromial osteotomy. You can see incredible exposure with this. And as you can see with this video, the patient did quite well with his outcome and had excellent restoration of his range of motion and function. And this is his one-year post-op. How long did it take you to recover? So the chromial osteotomy and digging into Bossom's original study showed that only 25 out of 33 healed radiographically and there was no difference in outcome. So certainly there was a concern for that. I eventually did end up having an acromial osteotomy, non-union, and this was in an individual who had a tremor and I don't think he was able to be compliant with restriction of motion as a result and pulled off the acromial osteotomy. And this resulted in the requirement for an iliac crest bone graft reconstruction. It was after this surgery that I had committed to doing this all arthroscopically to avoid this sort of an issue. Bossom later did publish his technique on doing this arthroscopically and then published his results as well, showing similar results to the open procedure with patients doing quite well with this in a difficult situation. So what are my pearls for doing this for an arthroscopic lower trapezius tendon transfer? I have made some changes over time as I've adapted this. You can use the beach chair or the lateral position since I primarily do rotator cuff in the beach chair position. The beach chair is what I prefer. You do need to make sure that the scapula is fully exposed. I try to actually get the exposure all the way over to the thoracic spine so there's no difficulty. And instead of using an incision longitudinally parallel to the thoracic spine, I use one parallel with the scapular spine now. And of course, you dock the graft to the subscapularis or the intact supraspinatus. And I think that that has improved my results and the function of the patients. And then I simply do a double row construct. We're all familiar with that. And that is really the second part of the fixation of this. And as a part of that, I do perform a partial rotator cuff repair if possible. So here's an example of an arthroscopic procedure, a similar situation, a chronic irreparable rotator cuff tear. It's an individual who's had not had surgery before, a chronic cuff tear. You can see here. Actually, he had had surgery once before. You can see the metal anchor there. He still had a biceps in place. So I went ahead and did a biceps tenodesis. Arthroscopically, I placed one medial row anchor to repair the biceps and incorporate this into my overall repair. So you can see that. And then finally, I placed a second more posterior medial row anchor. And I like using tape-based suture constructs for these types of repairs, not only for tendon transfers, but also for rotator cuff surgery. Here, you can see what's left of the infraspinatus. You can see there's quite a bit of tissue deficiency. So I went ahead and passed the sutures through that portion of the cuff. And I also passed sutures from the anterior anchor anteriorly. So I got a partial repair. Then I did running, locking sutures through my graft. And then I harvested the lower trapezius. And I find this right off of the scapular spine. And I want to free it up and mobilize it so I have excursion of the graft itself enough so I can pull it out of the incision. And then I go ahead and bring my graft up. And I shuttle in the four sutures that have been placed. I paint the top of the graft blue so I can keep its orientation. And two of the sutures, primarily the medial sutures, so I can differentiate the order in which I want to pass them. So the two anterior go through the residual supraspinatus or infraspinatus anteriorly with a bird beak suture passer. And I passed, in this case, I passed all four. If I need to, I'll use a suture anchor for the other pair of sutures if it's tissue deficient anteriorly. And here I am grasping the final anterior suture. So all four sutures are now passed. And then I pull the graft in posteriorly over the top of the previous sutures, which are now docked in the nebias or portal. And the graft comes over those sutures. And I guide it in so it's oriented properly underneath the residual supraspinatus and subscapularis. I tuck that portion of the graft in. And then I simply perform a double row construct over the existing, whatever's left of the rotator cuff and the lower trapezius. So I start first with the anterior anchor. Again, a double row construct and then a posterior anchor. So it's pretty simple. If you can do a double row arthroscopic rotator cuff repair, you can do a lower trapezius tendon transfer. Once it's fixed, we bring the arm into abduction external rotation. I split the lower trapezius and then typically feed one limb of the graft through the lower trapezius and then suture the two together using non-reversible suture. You have to be careful not to fold this over too many times as it can become bulky and can bother the patient. And then it's just a series of sutures to repair the tendon to the lower trapezius. I remove the excess graft and then close the incision. So in summary, tendon transfers remain a viable option for irreparable rotator cuff tears in young patients. You can also consider using this for brachial plexus birth palsies in younger patients and for patients that have an intact cuff but superscapular nerve injuries that are permanent. The lower trapezius tendon transfer may offer mechanical advantages over the original latissimus teres major transfer. Patient selection does remain critical. They have to have an intact subscapularis or one that is highly repairable. You need to have the absence of substantial osteoarthritis, an absence of fixed proximal migration. It has to be a motivated patient. And they need to have relatively preserved motion to 90 degrees of forward elevation with just minimal assistance from the examiner. Thank you and good luck.

lower trapezius tendon transfer

irreparable rotator cuff tears

young patients

surgical procedure

tendon transfers