Techniques for Lower Trapezius Transfer Using Achilles Allograft in Irreparable Posterosuperior Rotator Cuff Tears

Summary

Here, we describe a modified technique for lower trapezius tendon transfer using an Achilles allograft in the treatment of massive posterosuperior rotator cuff tears.

Abstract

The management of irreparable rotator cuff tears presents significant challenges, particularly in active individuals experiencing functional limitations, such as reduced forward elevation and deficits in both external and internal rotation. Traditional latissimus dorsi (LD) tendon transfer has shown effectiveness in reducing pain associated with posterosuperior cuff tears but often yields inconsistent functional outcomes. This is largely due to the LD's primary role as an internal rotator, which limits its capacity to restore normal shoulder biomechanics. To address these limitations, the lower trapezius (LT) tendon transfer, augmented with an Achilles allograft, has emerged as an alternative to enhance external rotation, leveraging the LT's line of pull, which closely resembles that of the infraspinatus muscle.

This protocol outlines a modified surgical technique for LT tendon transfer with Achilles allograft augmentation, detailing patient positioning, tendon harvest, graft preparation, arthroscopic passage, and fixation methods. The protocol emphasizes key anatomical landmarks to minimize neurovascular injury and enhance graft integration. Postoperative care includes a 3 month immobilization period followed by a structured rehabilitation program to facilitate functional recovery.

This procedure is indicated for a specific patient group requiring improved external rotation and is biomechanically advantageous over the LD transfer. Though additional studies are warranted to confirm its efficacy in broader patient populations, early clinical outcomes suggest that LT transfer with Achilles allograft could offer superior biomechanical alignment and improved external rotation.

Introduction

Irreparable rotator cuff tears in active individuals pose significant treatment challenges due to the resulting functional limitations, including diminished forward elevation and deficits in both external and internal rotation^1,2,3. While tendon transfers were initially developed to treat permanent nerve injuries, they have since been adapted for the management of irreparable rotator cuff tears^4,5.

The latissimus dorsi (LD) tendon transfer is traditionally used for reconstructing posterosup....

Protocol

This study was approved by the Ethics Committee of our institution and informed consent was obtained from all patients.

1. Patient positioning and surgical preparation (Figure 1)

1. Position the patient in the beach chair position with a 40-60° incline.
2. Position the patient close to the edge of the bed to optimize access to the medial border of the scapula¹⁴.
3. Drape a wide surgical field to ensure proper exposure of the shoulder and scapula region.
4. Apply an arm holder to provide a distal traction force to open t....

Results

The LT tendon transfer with Achilles allograft aims to restore external rotation and improve shoulder function in patients with irreparable rotator cuff tears^14,21. Representative outcomes include improvements in external rotation strength, range of motion, and pain relief post surgery, with objective measurements taken during clinical follow-up^27,28.

Patients generally demonst.......

Discussion

In this protocol, a few critical steps have been identified to optimize the effectiveness and safety of the lower LT tendon transfer. First, put the patient in the beach chair position with a head holder, fixing the head in slight neck flexion. Positioning the patient near the bed's edge allows optimal access to the medial border of the scapula, facilitating the necessary exposure for precise dissection and secure graft placement. A wide surgical field is draped to ensure complete visibility of the shoulder and scapular .......

Materials

Name	Company	Catalog Number	Comments
Flexigraft; Achilles allograft	LifeNet Health, Virginia Beach, VA		Fresh-frozen grafts, Tendon Length 160-260 mm
Footprint knotless PEEK suture anchors	Smith & Nephew, Andover, MA		4.5 mm anchor for lateral row fixation
TwinFix Ti suture anchors	Smith & Nephew, Andover, MA		5.0 mm anchor for medial row fixation
Ultrabraid sutures	Smith & Nephew, Andover, MA		braided sutures