Improved Yet Varied Clinical Outcomes Observed With Comparison of Arthroscopic Superior Capsular Reconstruction Versus Arthroscopy-Assisted Lower Trapezius Transfer for Patients With Irreparable Rotator Cuff Tears

Lower Trapezius Tendon Transfer Improves Range of Motion, Functional Outcomes, and Pain for Irreparable Rotator Cuff Tears: A Systematic Review

PURPOSE

To analyze the available literature on lower trapezius tendon transfer (LTT) for functionally irreparable rotator cuff tears (FIRCT) and summarize the outcomes for this procedure.

METHODS

A systematic review was conducted on April 4, 2024 following PRISMA guidelines in MEDLINE, CINAHL, Embase, and SPORTDiscus databases to identify clinical outcomes studies on LTT for FIRCT. Peer-reviewed publications with a level of evidence IV or higher were included. Data related to clinical outcomes and complications were recorded. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

The initial search yielded 1,066 studies, resulting in 15 studies for inclusion, including 393 total patients. Mean follow-up ranged from 3 to 58.2 months. All studies reported significant improvements in patient-reported outcomes and range of motion following LTT for FIRCT. Postoperative American Shoulder and Elbow Surgeons (ASES) scores ranged from 54.8 to 84.8, with absolute improvements of 21.7 to 48.6 points, while Visual Analog Scale (VAS) pain scores improved by 1.7 to 5.4 points. Postoperative external rotation ranged from 35° to 101.7°, with mean improvements of 11° to 32.5°, while forward flexion improved by 7.9° to 66° to a range of 120° to 165.7°. Complications were reported in 12 studies, with LTT retear (range, 0-19%) and infection (0-13%) being the most common. Reoperations occurred in 10 studies, most frequently conversion to shoulder arthroplasty (0-20%).

CONCLUSION

Lower trapezius tendon transfer is a reliable option for functionally irreparable rotator cuff tears, offering significant improvements in clinical and functional outcomes. It is particularly effective in restoring external rotation, with complication and reoperation rates comparable to alternative surgical procedures.

Accelerating Efficiency in Arthroscopically Assisted Lower Trapezius Transfer: How Can We Shorten the Learning Curve?

INTRODUCTION

Arthroscopic lower trapezius tendon transfer (aLTT) is an effective strategy to treat massive rotator cuff tears by dynamically restoring the posterior aspect of the rotator cuff force couple and improving range of motion, strength, pain, and stability. aLTT is technically challenging with higher complication rates, and its learning curve has yet to be defined. We aimed to establish a learning curve for aLTT through trends in surgical time, postoperative outcomes, and complications. We hypothesized that increased surgeon experience would be associated with decreased surgical time, improved outcomes, and reduced complication rates.

METHODS

All patients who underwent primary aLTT at our institution between October 2018 and November 2022 were identified and included. Perioperative data, including diagnosis, operative time, complications, revisions, postoperative functional data, and patient-reported outcomes, were recorded and analyzed. A shoulder and elbow fellowship-trained surgeon's learning curve was determined using linear regression and cumulative sum (CUSUM) analyses. The CUSUM analysis evaluated objective differences in surgical time over the surgeon's course of practice and elucidated the completion of the learning curve.

RESULTS

Thirty-nine patients were included, with an average follow-up of 29 months. Mean surgical time was 163 minutes, with a linear decrease in surgical time throughout the study. CUSUM analysis of surgical times demonstrated a learning curve of 14 patients. When comparing the first 14 patients to the remaining 25, no difference was found in range of motion, American Shoulder and Elbow Surgeon score, and subjective shoulder value score, whereas visual analog scale pain scores at the final follow-up decreased in the proficiency phase.

CONCLUSION

This study found a notable linear decrease in surgical time and the number of cases completed without associated detriment to postoperative outcomes. At least 14 cases were required to exit the "learning phase." Further work is needed to find superior metrics to assess proficiency.

LEVEL OF EVIDENCE

4, case series.

Editorial Commentary: Treatment of Large and Massive Rotator Cuff Tear Must Be Based on Individual Patient Indications: Bridging Repair Allows Low-Tension Repair of Irreparable Tears

Treatment options for large and massive rotator cuff tears, in the setting of failed conservative treatment, include debridement, isolated biceps tenotomy or tenodesis, primary repair, partial repair, subacromial spacer, superior capsular reconstruction, biologic tuberoplasty, bridging reconstruction, tendon transfers, reverse shoulder arthroplasty, and others. Each performs well under optimal indications. Bridging reconstruction performs best in the setting of an irreparable tear of the superior-posterior rotator cuff, with an intact or reparable subscapularis, particularly if the patient has reasonably preserved function/range of motion preoperatively. Advantages of bridging reconstruction include lower-tension repair, which may be superior to partial primary repair with incomplete footprint coverage in the case of irreparable tears.

Lower Trapezius Tendon Transfer Restores Deltoid Function and Shoulder Stability More Effectively Than Superior Capsular Reconstruction in Massive Rotator Cuff Tears

Purpose

To compare the biomechanical effectiveness of superior capsular reconstruction (SCR) and lower trapezius tendon transfer (LTT) to restore the native shoulder kinematics in managing massive rotator cuff tears (MRCTs) using a dynamic shoulder testing system in a cadaver model.

Methods

Eight fresh-frozen cadaveric hemithoraces were tested using a custom-made dynamic shoulder testing system. The conditions tested are intact, supraspinatus tear, MRCT (supraspinatus and infraspinatus tear), LTT with Achilles allograft, SCR combined with LTT, and SCR alone. Measurements included cumulative deltoid force, humeral head translation (HHT), and subacromial peak pressure during humeral abduction at various angles.

Results

Significant reductions in cumulative deltoid force were observed from intact to MRCT conditions (P = .023). LTT alone significantly improved deltoid force compared to its combination with SCR (P = .017) and outperformed SCR alone (P = .023). The intact condition showed increasing subacromial peak pressure with higher abduction angles, peaking at 541 kPa at 90°. MRCT exhibited the highest HHT and peak pressure, indicating significant instability. LTT reduced HHT and peak pressure compared to MRCT, indicating partial restoration of stability. The combined LTT + SCR condition demonstrated HHT values close to the intact condition and lower peak pressures, indicating substantial restoration of glenohumeral stability.

Conclusions

Simulated active unconstrained humeral abduction in the scapular plane using an entire hemithorax model suggests that LTT can restore dynamic stability and deltoid function in MRCTs, while SCR offers static stability without restoring deltoid function. Combining LTT and SCR may result in lower subacromial peak pressures on the undersurface of the acromion than either procedure alone.

Clinical Relevance

This study will contribute to understanding shoulder kinetics concerning current surgical techniques and suggest a dynamic concept of shoulder biomechanics testing.

Arthroscopic superior capsular reconstruction with acellular human dermal allograft for irreparable rotator cuff tears: outcomes, complications, and reoperations at 2-year minimum follow-up

Background

Management of posterosuperior irreparable rotator cuff tears (IRCTs) remains challenging without clear consensus among shoulder surgeons. Arthroscopic superior capsular reconstruction (SCR) with dermal allograft has been proposed as a promising treatment option. However, current investigations are limited to short term studies and recent data has suggested variable clinical outcomes. Therefore, the purpose of this investigation was to report intermediate-term clinical outcomes in patients who underwent arthroscopic SCR with a dermal allograft for IRCTs.

Methods

Over a 4-year period (2016-2020), all patients who underwent an arthroscopic dermal allograft SCR with a minimum 2-year follow-up period were identified. SCR with dermal allograft was performed for patients with an IRCT utilizing a 3-mm acellular dermal allograft. Collected clinical outcomes included range of motion, strength, Numeric Rating Scale for pain, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Single-Assessment Numeric Evaluation score, complications, and reoperations.

Results

The final cohort included 41 dermal allograft SCR performed in 40 patients (1 bilateral) with a majority male cohort (n = 29; 72%), a mean age of 67 ± 7 years, body mass index of 28.4 ± 5.0, and follow-up of 5.3 ± 1.4 years. Clinically, there was a significant improvement in preoperative and postoperative Numeric Rating Scale pain scores from 5.0 to 1.8 (P < .001), but no differences in preoperative and postoperative forward flexion (P = .268), abduction (P = .822), external rotation (P = .323), or internal rotation (P = .995). The final postoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and Single-Assessment Numeric Evaluation scores were 66 ± 28 and 59 ± 30, respectively. There were 8 (19.5%) complications, which consisted primarily of symptomatic graft failure in 6 (14.6%) shoulders and progression of rotator cuff arthropathy in 2 (4.9%) shoulders. Reoperations occurred in 6 (14.3%) shoulders: 4 (9.8%) were conversion to reverse total shoulder arthroplasty and 2 (4.9%) were arthroscopic revision dermal allograft SCR with partial repair and reattachment of the torn graft.

Conclusion

At a cohort mean of 5 years after arthroscopic SCR with dermal allograft for IRCTs, patients experienced sustained pain relief but no significant improvement in shoulder function. Additionally, 20% sustained a postoperative complication with a 14% reoperation rate. These findings should be considered when counseling patients about the challenges of managing IRCTs and the possible outcomes of utilizing dermal allograft SCR as a surgical modality.

Combined Superior Capsular Reconstruction Using Fascia Lata Autograft and Lower Trapezius Transfer Using Achilles Tendon Allograft Are Associated With Improved Surgical Outcomes in Patients With Chronic Posterosuperior Irreparable Massive Rotator Cuff Tears

PURPOSE

To evaluate the minimum 12-month clinical and radiologic outcomes of combined superior capsular reconstruction (SCR) and lower trapezius transfer (LTT) for posterosuperior irreparable massive rotator cuff tears (IMRCTs).

METHODS

Patients with posterosuperior IMRCTs and severe fatty infiltration (Goutallier grade ≥3) of the infraspinatus who underwent combined SCR and LTT were retrospectively reviewed. A double-folded fascia lata autograft with 1 layer of polypropylene mesh inside was used for SCR, and an Achilles tendon allograft was used to connect the tendon of the lower trapezius to the greater tuberosity. A thorough preoperative assessment with clinical history, physical examination, and imaging studies was critical for identifying tear patterns that were reparable or irreparable and to guide further treatment. American Shoulder and Elbow Surgeons (ASES), visual analog scale (VAS), Constant, Single Assessment Numeric Evaluation (SANE) scores, and range of motion were collected at a minimum 12-month follow-up postoperatively. Radiologic evaluation included graft integrity and the acromiohumeral distance at the final follow-up. Postoperative magnetic resonance imaging was used to assess graft integrity. The minimal clinically important difference was calculated as one-half of the standard deviation of the score change between the preoperative baseline and the latest follow-up.

RESULTS

Fifteen patients were included in this study, with a mean follow-up period of 20.6 months (range, 12.2-31.2 months). Significant improvements in clinical and radiologic outcomes were found after surgery. The VAS score decreased from 4.1 to 0.7 (P = .001). The ASES, Constant, and SANE scores improved from 54.5 to 83.7 (P = .001), from 61.1 to 76.7 (P = .001), and from 48.7 to 74.0 (P = .001), respectively. External rotation improved from 26.0° to 45.7° (P = .009). Postoperative magnetic resonance imaging scans were obtained at a mean final follow-up of 14.2 months (range, 11.9-23.2). The acromiohumeral distance improved significantly from 4.9 mm to 8.1 mm after surgery (P = .003). In 2 patients (13.3%), both fascia lata and Achilles tendon graft tears developed during follow-up. The minimal clinically important difference was obtained in 80.0%, 66.7%, 53.3%, and 46.7% of patients for the ASES score, VAS score, Constant score, and SANE score, respectively.

CONCLUSIONS

SCR-LTT contributes to significant pain relief and functional improvements with a graft healing rate of 86.7% at a minimum 12-month follow-up in patients with posterosuperior IMRCTs and high-grade fatty infiltration of the infraspinatus.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

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.

Superior Capsular Reconstruction Using an Acellular Dermal Xenograft or Allograft Improves Shoulder Function but Is Associated with a High Graft Failure Rate

Objectives: The purpose of the present study was to evaluate clinical and functional outcomes, graft integrity rate and progression of osteoarthritis after superior capsular reconstruction (SCR) at short-term follow-up. Methods: Consecutive patients that underwent SCR using an acellular dermal xeno- or allograft between May 2018 and June 2020 for the treatment of irreparable posterosuperior rotator cuff tears were included. Shoulder function (American Shoulder and Elbow Surgeons [ASES] score), pain (Visual Analog Scale [VAS] for pain) and active shoulder range of motion (ROM) were evaluated preoperatively and after a minimum of 24 months postoperatively. Isometric strength was measured at follow-up and compared to the contralateral side. Magnetic resonance imaging was performed to evaluate graft integrity and osteoarthritis progression (shoulder osteoarthritis severity [SOAS] score). Results: Twenty-two patients that underwent SCR using a xeno- (n = 9) or allograft (n = 13) were evaluated 33.1 ± 7.2 months postoperatively. Four patients in the xenograft group underwent revision surgery due to pain and range of motion limitations and were excluded from further analysis (revision rate: 18.2%). Shoulder function (ASES score: 41.6 ± 18.8 to 72.9 ± 18.6, p < 0.001), pain levels (VAS for pain: 5.8 ± 2.5 to 1.8 ± 2.0, p < 0.001) and active flexion (p < 0.001) as well as abduction ROM (p < 0.001) improved significantly from pre- to postoperatively. Active external rotation ROM did not improve significantly (p = 0.924). Isometric flexion (p < 0.001), abduction (p < 0.001) and external rotation strength (p = 0.015) were significantly lower in the operated shoulder compared to the non-operated shoulder. Ten shoulders demonstrated a graft tear at the glenoid (n = 8, 44.4%) or humerus (n = 2, 11.1%). Graft lysis was observed in seven shoulders (38.9%). The graft was intact in one shoulder (5.6%), which was an allograft. A significant progression of shoulder osteoarthritis was observed at follow-up (SOAS score: 42.4 ± 10.1 to 54.6 ± 8.4, p < 0.001). Conclusions: At short-term follow-up, SCR using an acellular dermal xeno- or allograft resulted in improved shoulder function and pain with limitations in active external rotation ROM and isometric strength. Graft failure rates were high and osteoarthritis progressed significantly. Level of Evidence: Retrospective cohort study, Level III.

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.

Editorial Commentary: Lower Trapezius Transfer May Be Indicated for Surgical Management of Massive Irreparable Rotator Cuff Tears in Younger, Non-Arthritic Patients

Although shoulder rotator cuff repair fixation constructs and suture anchor design have evolved, repair of massive or functionally irreparable tears historically has relied on tendon mobilization and compression, optimizing footprint biology, and attempting a tension-free repair. However, despite these efforts, rates of failure of complete healing may be high, ranging from 20% to 94%. This has led to a search for alternative approaches, including bridging grafts, subacromial balloons, superior capsular reconstructions, biologic tuberoplasties, bursal acromial grafts, and, ultimately, renewed interest in tendon transfers. The latissimus dorsi transfer was traditionally a preferred tendon-transfer technique for posterosuperior massive cuff tears, but inconsistent outcomes have resulted in declining popularity. Recently, the lower trapezius transfer (LTT) has gained acceptance for the treatment of posterosuperior tears, particularly with external rotation weakness and lag signs. The LTT is biomechanically superior to the latissimus dorsi transfer, offering a more native vector of pull and in-phase activation. LTT could be indicated for younger patients with massive cuff tears. However, LTT is relatively contraindicated in patients with cuff tear arthropathy; combined loss of elevation and external rotation; irreparable subscapularis tear; teres minor involvement; and/or those of advanced age or unable to comply with rigid rehabilitation guidelines.

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.

Editorial Commentary: Superior Capsular Reconstruction Is the Treatment of Choice for Massive, Irreparable Rotator Cuff Tears With Pseudoparalysis

The ideal treatment approach to massive, irreparable rotator cuff tears remains a hot topic of debate. In addition to joint-preserving methods including partial repair and subacromial spacer, techniques such as superior capsular reconstruction and tendon transfers are viable alternatives. These techniques are effective in providing pain relief and-to an extent-functionality during short-term follow-up; however, superior capsular reconstruction (SCR) appears to be the treatment of choice to address the pseudoparalysis.The relatively lower success rates of pseudoparalysis treatment in tendon transfers may be related to (1) the disturbance of the rotator cable, (2) the fact that a single transferred tendon alone may not be good enough to restore the impaired force-coupling mechanism required for overhead motion, and (3) to oppose the forces generated by the deltoid. On the other hand, the SCR graft functions both as a soft tissue augment that restores glenohumeral kinematics by re-establishing the force transmission between the remaining anterior and posterior portions of rotator cuff and as a static depressor of the humeral head during shoulder motion. With adequate graft quality, compatibility (i.e., fascia lata autograft), and thickness (minimum 5 mm), SCR may reliably maintain these functions. Tendon transfers are best reserved for the limited subgroup of patients where active external rotation loss is the primary concern. For the majority of patients with irreparable cuff tears, SCR remains the treatment of choice, particularly for patients with pseudoparalysis.