Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Autologous Semitendinosus Tendon and Long Head of Biceps Superior Capsule Reconstruction for Massive Irreparable Posterosuperior Rotator Cuff Tears

Abstract

We present a surgical technique combining arthroscopic-assisted lower trapezius tendon (LTT) transfer with autologous semitendinosus tendon and long head of biceps tendon (LHBT) superior capsule reconstruction (SCR) for massive irreparable posterosuperior rotator cuff tears. The patients are placed in the beach-chair position with the ipsilateral lower leg prepared simultaneously. After both tendons are harvested, 1 limb of a semitendinosus graft is fixed with the LTT via a Krakow suture. The LHBT is then fixed by an anchor 5 to 8 mm posterior to the bicipital groove and tenotomized distally. The transverse humeral ligament is released afterward to provide better visualization. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove, and drilled posteriorly until it exits at the infraspinatus footprint. Next, 4.5- and 8-mm cannulated drills are used sequentially to create a humeral tunnel. A shuttle suture passed through infraspinatus fascia in the back brings the EndoButton and looped semitendinosus graft from posterior to anterior of the humerus, until the EndoButton flips and is fixed inside the bicipital groove. The shoulder is placed in 45° abduction and 30° external rotation. The free limb of semitendinosus tendon is then sutured with LTT with the desired tension.

Fig 1

Patient position and arthroscopic portals, right shoulder, beach chair position. (A) All patients had general anesthesia with interscalene nerve block and were placed in the beach-chair position with a traction device. (B) The ipsilateral lower leg is prepared simultaneously. (C) Normally 3 arthroscopic portals are needed. (D). The semitendinosus tendon harvest site (arrowhead, the insertion of pes anserinus), right lower leg. Abbreviations: ALP, anterolateral portal; AP, anterior portal; LP, lateral portal; LTT, lower trapezius tendon; PP, posterior portal.

Fig 2

Harvest and preparation of lower trapezius tendon and semitendinosus tendon, right shoulder. (A) An 8-cm horizontal incision is made just below the spine of the scapula over the lower trapezius tendon insertion. The tendon part of LT was whipstitched with no. 2 Ethibond (arrow) to facilitate further manipulation. (B) The semitendinosus autograft was harvested with both ends sutured with no. 2 Ethibond. (C) One limb of semitendinosus graft was fixed with the tendon part of harvested LTT via a Krackow technique (arrowhead). Abbreviations: LTT, lower trapezius tendon; MSB, medial scapular border; USB, upper scapular border.

Fig 3

Superior capsule reconstruction with long head of biceps tendon, right shoulder, viewed from lateral portal. (A) The bicipital groove and LHGT are visualized. (B) A suture-based anchor is passed from anterolateral portal and inserted 5-8 mm posterior to the bicipital groove near the cartilage of humerus. (C) One lasso-loop is made by a suture manipulator and CleverHook. (D) The lateral part of the LHBT is rerouted posteriorly, proving a strong spacer effect. (E) THL is released. (F) The bicipital groove is cleared after LHBT tenotomy and THL release, providing better visualization for humeral tunnel drilling and graft passage. Abbreviations: BG, bicipital groove; LHBT, long head of the biceps tendon; THL, transverse humeral ligament.

Fig 4

Humeral tunnel drilling and graft passage, right shoulder, viewed from lateral portal. (A) A Beath pin is introduced from anterolateral portal, aiming at bicipital groove. (B) The pin is drilled posteriorly until it exits at the upper part of native infraspinatus tendon insertion point. (C) A 4.5-mm rigid cannulated drill is first used to ream from anterior to posterior to create a humeral tunnel. The length of the tunnel is measured. (D) An 8-mm rigid cannulated drill is used to ream from posterior to anterior until the desired length inside the humeral tunnel. (E) A grasper is inserted along the length of the infraspinatus muscle, and the shuttling suture is pulled out of the opening of the infraspinatus fascia. (F) The free limb of semitendinosus tendon not fixed with LTT is passed from the loop of a 20-mm EndoButton (arrowhead) and works in a double fashion. (G and H) The EndoButton is passed intra-articularly from posterior to anterior, until it exits the bicipital groove. Abbreviations: BG, bicipital groove; ISP, intraspinatus; LTT, lower trapezius tendon.

Fig 5

Tensioning of lower trapezius tendon and semitendinosus graft, right shoulder. (A) After the EndoButton is flipped and fixed at the bicipital groove, the tension of the ST graft is checked intra-articularly under arthroscopy. (B) The other limb of ST graft is fixed side by side with the LTT with Krakow suture (arrow). (C) Postoperative x-ray revealing EndoButton fixed inside bicipital groove. Abbreviations: LTT, lower trapezius tendon; ST, semitendinosus.

Fig 6

The final construct of the reconstruction.