Lower trapezius transfer with semitendinosus tendon augmentation: Indication, technique, results

Abstract

Background: Lower trapezius transfer can restore external rotation in brachial plexus palsies. In some cuff tear arthropathies, there is lack of active external rotation with a preservation of forward elevation. We evaluated the clinical outcomes of a lower trapezius transfer extended with a semitendinosus tendon and fixed to the insertion of the infraspinatus via arthroscopy.

Methods: Between 2013 and 2016, we operated on 14 patients (8 men, 6 women; mean age of 62 years, range: 50-70) to reconstruct irreparable posterosuperior rotator cuff tear. A vertical incision of 6 cm following the medial border of the spine was made to harvest the lower trapezius in extension with the semitendinosus tendon. The extension band of the lower trapezius was fixed laterally via arthroscopy on the great tuberosity at the level of the insertion of the infraspinatus. The proximal stump of this extension band was then fixed medially into the muscle of the lower trapezius with the arm in maximum external rotation. Outcomes were evaluated with the Constant-Murley score, simple shoulder test (SST), and subjective shoulder value (SSV).

Results: Over a mean follow-up of 24 months (range: 12-36 months), the gain in external rotation with the arm at the side was 24° and 40° in 90° of abduction. The Constant-Murley score improved from 35 to 60 points, the SST from 3.5 to 7.5, the SSV from 30 to 60%, and the pain decreased from 7 to 2 (visual analogue scale, 0-10). Both the lag sign and hornblower sign were negative after this transfer. There were two cases of hematomas, and one was revised because of infection.

Conclusion: Lower trapezius transfer is a therapeutic option for irreparable posterosuperior cuff tears with a lack of active external rotation and a good subscapularis. Patients can expect improvements in pain and in active external rotation without any loss of active anterior elevation.

Keywords: Arthroscopy; Lack of active external rotation; Lower trapezius transfer; Rotator cuff tears; Shoulder.

Fig. 1

Mini-invasive vertical posterior approach (6 cm) with posterior and lateral portals for arthroscopic exploration of the shoulder and partial repair and fixation of the semitendinosus tendon

Fig. 2

Semitendinosus tendon doubled and reinforced with a distal and proximal Krackow suture and a nonabsorbable Orthocord #2 (DePuy Mitek, Raynham, MA, USA); length between 10 and 15 cm

Fig. 3

The semitendinosus is introduced at the level of the insertion of the infraspinatus into an anteroposterior bone tunnel and locked with a ZipTight device

Fig. 4

The semitendinosus tendon is first fixed by arthroscopy at the level of the insertion of the infraspinatus on the footprint (after shaving this area) with two or three anchors for good adaptation of the tendon to the bone

Fig. 5

In a massive posterosuperior cuff tear the semitendinosus graft is fixed to the footprint to reproduce the direction of the infraspinatus. SS supra spinatus, IS infraspinatus

Fig. 6

With the shoulder in 60° external rotation and 30° abduction, the medial stump of the graft is passed through the short tendon and sutured to itself with a nonabsorbable suture (Orthocord #2; DePuy Mitek, Raynham, MA, USA). A Krackow suture is placed in the trapezius and into the semitendinosus tendon to reinforce the repair

Fig. 7

Magnetic resonance image showing atrophy of the supraspinatus, infraspinatus, and teres minor and an excellent subscapularis; clinically the patient has a lag sign and a drop sign and forward elevation is complete

Fig. 8

No osteoarthritis with narrowing of the subacromial space

Fig. 9

Vertical mini-invasive posterior approach over the tubercle of the scapula to identify the lower trapezius with posterior and lateral portals for fixation by arthroscopy on the footprint

Fig. 10

Active external rotation on the left side, with the arm at the side at 30°; no lag sign

Fig. 11

Active external rotation in abduction (30°); no hornblower sign

Fig. 12

Complete forward elevation (170°)

Fig. 13

No limitation in medial rotation with the thumb at the level of L1