Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft

Arthroscopically assisted lower trapezius tendon transfer results in similar clinical and structural outcomes for patients ≤60 and ≥70 years old

BACKGROUND

Arthroscopically assisted lower trapezius tendon (aLTT) transfer has emerged as an effective surgical option for patients with posterior-superior irreparable rotator cuff tears (PSIRCTs) who primarily complain of external rotation weakness and lag signs, in the absence of arthritis. The purpose of this study is to compare the clinical and structural outcome among different age groups in aLTT transfer for PSIRCTs.

METHODS

We retrospectively reviewed patients who underwent aLTT transfer for PSIRCTs between May 2017 and September 2021. We included patients with PSIRCTs, minimal glenohumeral arthritis (Hamada grade ≤ 2), poor muscle quality (Goutallier grades ≥3), and a minimum follow-up of 2 years. Patients lacking a minimum of 2-year follow-up data and a postoperative magnetic resonance imaging (MRI) scan were excluded. For the purpose of the study, 3 groups were created: group Total including all ages, group A consisting of patients aged ≤60 years, and group B consisting of patients aged ≥70 years. We compared patient-reported outcome scores (visual analog scale [VAS], Constant score, University of California-Los Angeles [UCLA] shoulder score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Activities of Daily Living Requiring Active External Rotation [ADLER]), pre- and postoperative range of motion (ROM), acromiohumeral distance (AHD), Hamada grade, graft integrity on postoperative MRI, and complications among the groups.

RESULTS

Eighty-four patients underwent aLTT transfer (51 with Achilles tendon allografts and 33 with fascia lata autografts), with a mean follow-up of 43.7 ± 14.6 months. There was significant improvement in VAS, Constant, UCLA, ASES, and ADLER scores, and ROM in the entire cohort. When comparing group A (n = 23) and group B (n = 19), there were no significant differences in patient-reported outcomes, ROM, AHD, and Hamada grade. Additionally, we observed comparable clinical results, with similar rates of complications such as retear, postoperative stiff shoulder, and revision surgery between the groups.

CONCLUSION

The current study demonstrates that aLTT transfer for PSIRCTs with minimal glenohumeral arthritis yields similar results between group A and group B. Additionally, the 2 different age groups did not show significantly different clinical results when compared to the entire cohort. Our findings contribute to a more comprehensive understanding of the applicability of aLTT transfer across different age groups, emphasizing its potential as a viable treatment option for a broader patient population.

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.

Arthroscopic-Assisted Lower Trapezius Transfer Augmented by Peroneus Longus Autograft in Irreparable Posterior Superior Rotator Cuff Tears: Functional Outcomes at 24 Months of Follow-up

Background

Massive irreparable rotator cuff tears are a devastating problem, especially for the middle-aged active population. Tendon transfer seems to be a feasible treatment option for this age group. Biomechanical studies have shown that lower trapezius tendon transfer, rather than latissimus dorsi tendon transfer, could restore the kinematics of the shoulder.

Purpose

To evaluate the functional outcome, efficacy, and safety of arthroscopy-assisted lower trapezius transfer with peroneus longus augmentation for irreparable posterior superior rotator cuff tears.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 20 patients who had massive rotator cuff tears, symptomatic global shoulder pain, and the inability to move their upper limbs actively. The patients were examined by manual testing using a goniometer, and the study had a follow-up period of at least 24 months.

Results

The mean age of the patients was 53.4 ± 4.3 years (range, 40-60 years). Thirteen patients had associated biceps pathology. The mean American Shoulder and Elbow Surgeons score improved from 22.88 ± 7.25 preoperatively to 84.44 ± 4.54 postoperative (P < .001). The mean visual analog scale improved from 7.9 ± 1.33 preoperatively to 2.7 ± 1.3 postoperatively (P < .001). All patients regained a good functional range of shoulder motion at the end of the follow-up without major shoulder complications.

Conclusion

Arthroscopy-assisted lower trapezius transfer with peroneus longus augmentation for irreparable rotator cuff tear is advisable because it shows marked improvement in the functional outcome and range of motion without major complications.

Arthroscope-Assisted Lower Trapezius Tendon Transfer Using Achilles Tendon Allograft for Irreparable Rotator Cuff Tears Demonstrates Excellent Short-Term Outcomes in the Setting of Concomitant Subscapularis Repair

PURPOSE

The purpose of this study was to quantify the improvement patients undergoing scope-assisted lower trapezius tendon transfer (SALTT) for irreparable rotator cuff tears (IRCT) have and whether intra-operative subscapularis management affected these outcomes.

METHODS

From 2015 to 2023, patients undergoing primary SALTT for IRCT without osteoarthritis or brachial plexopathy with serial follow-up at 6- and minimum 12-months post-operatively were identified. Subjective Shoulder Value (SSV) scores, active forward elevation (aFE), external rotation (ER) lag, and cuff strength was recorded. Continuous variables were analyzed with one-way or repeated measures analysis of variance, and a multivariate linear regression was performed evaluating demographic, radiographic, and intra-operative variable effects on SSV and ER lag.

RESULTS

Seventy-six (mean age: 56.5±8.1 years; BMI: 29.0±4.3; 73% male) patients operated on by 4 surgeons (A: 66%; B: 15%; C: 13%; D: 4%) demonstrated significant improvement in baseline SSV scores (mean: 23.9±SD:13.1) to 6-month (mean: 73.5±10.6, 91% MCID achievement P<0.001) and final (mean: 43.5±29.5 months) follow up scores (mean: 79.9±16.5, 92% MCID achievement P<0.001; n=45/122:37% 2-year inclusion rate). Regression analysis for final SSV demonstrated age (beta: 0.8, P=0.017) to have a positive effect and subscapularis fatty infiltration (beta: -10.6, P<0.001) to have a negative effect. Active FE improved from 6-month (139±SD:23.8°) to final (146±23.0°, P=0.013) follow-up while ER lag (17±SD:17°) improved as well (6-month mean: 3±7.8°, P<0.001; final: 3±5.6°, P<0.001). Regression analysis demonstrated subscapularis fatty infiltration (beta:-11.6, P=0.003) had a negative effect on final aFE while infraspinatus fatty infiltration (beta:-1.2, P=0.048) and concomitant subscapularis repair (beta:-5.0, P=0.023) had a negative effect in final ER lag. Presence of subscapularis tears alone (beta:4.5, P=0.030) had a positive effect on ER lag. Overall, five (7%) patients underwent re-operations.

CONCLUSION

Patients with IRCT undergoing SALTT with or without subscapularis tears requiring repair achieve excellent short-term clinical outcomes while improving from an exam standpoint.

Short-term functional, imaging, and electrodiagnostic outcomes of arthroscopy-assisted lower trapezius transfer

BACKGROUND

The purpose of this study was to evaluate the short-term functional outcomes, structural healing, and neuromuscular activity after arthroscopy-assisted lower trapezius transfer for irreparable posterior superior rotator cuff tears.

METHODS

All patients who underwent arthroscopy-assisted lower trapezius tendon transfer for an irreparable posterior superior rotator cuff tear between 2017 and 2021 by 2 surgeons with a minimum of 2-year follow-up were identified. Functional outcome scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] score, visual analog scale [VAS] for pain), range of motion, shoulder strength, magnetic resonance imaging (MRI) to assess transfer healing, and needle electromyographic (EMG) examination to assess lower trapezius muscle activity were performed at a minimum of 2 years postoperatively. Contralateral nonoperative lower trapezius muscle activity was assessed by EMG. Grafts were defined as completely healed if anatomic graft healing occurred, partial healing if some graft was healed to the proximal humerus, and unhealed if no graft was attached to the proximal humerus on postoperative MRI.

RESULTS

Twenty-four eligible patients (25 shoulders) were identified through chart review. Mean age and follow-up were 54.9 ± 9.5 and 2.9 ± 1.7 years, respectively. Overall, 72% (18/25) clinical follow-up was obtained. All functional outcomes including ASES (preoperative, 48.8 ± 19.6; postoperative, 80.9 ± 15.4; P < .001), VAS pain (4.9 ± 2.3; 1.4 ± 1.5; P < .001), and active forward flexion (110° ± 53.2°; 141.7° ± 40.4°; P = .024) statistically significantly improved. Twelve shoulders (48%) presented for EMG follow-up. All 12 patients demonstrated EMG activity of the lower trapezius in forward elevation, external rotation at the side, and external rotation at 90° of abduction, which was symmetric to the contralateral shoulder. Fifteen shoulders (60%) were available for MRI follow-up. Thirteen patients (87%) demonstrated complete or partial healing of the allograft to the greater tuberosity, whereas 2 (13%) demonstrated a complete tear of the graft.

CONCLUSIONS

Arthroscopy-assisted lower trapezius transfer demonstrates improved functional outcomes 2 years postoperatively. Complete retear of the transfer is relatively uncommon (13%). The lower trapezius fired in phase in forward flexion, external rotation at the side, and external rotation in 90° of abduction in all patients who underwent EMG testing, which was consistent with the firing pattern of the contralateral normal lower trapezius muscle. These results may support the theory that active function of the muscle transfer itself, as opposed to a tenodesis effect, is a potential mechanism by which this procedure improves shoulder function as it consistently fires in phase.

Arthroscopic Lower Trapezius Tendon Transfer Effectively Relieves Pain and Improves Shoulder Function in Patients With Irreparable Infraspinatus Tears: Minimum 5-Year Follow-Up

PURPOSE

To evaluate the clinical outcomes of arthroscopically assisted lower trapezius tendon (aLTT) transfer using Achilles tendon allograft in patients with irreparable infraspinatus musculotendinous tears (IISMTTs).

METHODS

We conducted a retrospective analysis of patients who underwent aLTT transfer for IISMTTs. The inclusion criteria were minimal glenohumeral arthritis (Hamada grade ≤ 1), isolated infraspinatus musculotendinous tear with poor muscle quality (Goutallier grade ≥ 3), and intact remaining rotator cuff muscles. The exclusion criteria included less than 5-year follow-up, loss to follow-up, or insufficient data. Clinical outcomes were assessed using the visual analog scale (VAS) pain score, Constant score, American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Value (SSV), range of motion, tendon integrity, and arthritis progression.

RESULTS

A total of 20 patients were included, with a mean follow-up period of 7.4 years. Significant improvements were observed in all clinical scores: VAS pain score, 7.9 ± 1.2 to 1.1 ± 0.7; Constant score, 33.7 ± 5.9 to 67.6 ± 16.3; ASES score, 38.0 ± 6.0 to 68.8 ± 16.2; and SSV, 20.2 ± 7.8 to 67.5 ± 18.1 (all with P < .001). Significant range-of-motion improvements were observed forward elevation (100° ± 13° to 139° ± 30°), abduction (77° ± 20° to 119° ± 13°), and external rotation (24° ± 9° to 56° ± 12°). Regarding the minimal clinically important difference (MCID), determined using the 0.5 standard deviation distribution-based method, all 20 patients (100%) achieved the MCID for the VAS pain score; 17 patients (85%), for the Constant score; 17 patients (85%), for the ASES score; and all 20 patients (100%), for the SSV. In all patients, glenohumeral joint integrity was maintained without the development of arthritis. No retears were observed.

CONCLUSIONS

The aLTT transfer effectively alleviated pain and improved shoulder function in patients with IISMTTs at mid-term follow-up. Significant improvements in pain and external rotation were observed without any progression of glenohumeral arthritis, and no retears were reported.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Return to Work and Sports After Lower Trapezius Tendon Transfer for Posterosuperior Irreparable Rotator Cuff Tears

BACKGROUND

Lower trapezius tendon (LTT) transfer has demonstrated promising results for patients with posterosuperior irreparable rotator cuff tears (PSIRCTs). However, there has been no study evaluating return to work (RTW) and return to sports (RTS) after LTT transfer.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the rates of RTW and RTS and identify associated factors among patients who have undergone LTT transfer for PSIRCTs. It was hypothesized that LTT transfer would result in favorable functional outcomes and high rates of RTW and RTS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review was conducted on patients who underwent LTT transfer for symptomatic PSIRCTs with minimal glenohumeral arthritis. The clinical assessment included patient-reported outcome measures, testing of active range of motion, and a radiological evaluation of arthritis. Patients were surveyed on occupation, sports activity, RTW or RTS status, time to return, and degree of resumption of previous work and sports levels. Exclusion criteria included a follow-up period of <1 year, revision surgery, postoperative infections, loss to follow-up, and unavailability of data.

RESULTS

A total of 110 patients (mean age, 63.0 ± 6.9 years; mean follow-up, 35.3 ± 15.7 months) were included. Clinical scores and active range of motion significantly improved at the final follow-up, with no significant differences between the different work levels. For RTW, 93.6% (n = 103) returned to work (63.1% completely, 36.9% partially), with a mean time to return of 5.2 ± 1.7 months; 6.4% (n = 7) did not return. Patients with lighter work levels had higher return rates and quicker times to return than those with heavier work levels. For RTS, 90.7% (n = 86) returned to sports (70.5% completely, 29.5% partially), with a mean time to return of 5.7 ± 1.3 months. For patients who participated in shoulder sports, 89.9% returned, and 10.1% failed to return. Multivariable logistic regression showed significant associations of higher RTW rates with lighter work levels (odds ratio [OR], 2.72; P = .005) and lower retear rates (OR, 5.41; P = .021). A lower retear rate was also significantly associated with a higher RTS rate (OR, 7.66; P = .010).

CONCLUSION

LTT transfer for PSIRCTs yielded favorable functional outcomes with high rates of RTW and RTS. Patient-related factors, notably work level and retears, influenced successful RTW and RTS.

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.

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.