Achilles tendon allograft versus fascia lata autograft as the interpositional graft in arthroscopically assisted lower trapezius tendon transfer for irreparable posterosuperior rotator cuff tear

Abstract

Background: Although arthroscopically assisted lower trapezius tendon transfer (aLTT) is an effective treatment option for posterosuperior irreparable rotator cuff tear (PSIRCT), interpositional grafts should be used because of the length limitations of the LTT. This study compared the radiologic and clinical results of an Achilles tendon allograft (ATA) versus a fascia lata autograft (FLA) as the interpositional graft.

Methods: This study included 64 and 26 patients treated with aLTT using an ATA or FLA, respectively. Clinical outcomes were compared using the visual analog scale score, University of California Los Angeles shoulder score, American Shoulder and Elbow Surgeons score, Constant shoulder score, activities of daily living that require active external rotation score, and range of motion. Arthritic changes of the glenohumeral joint were evaluated by acromiohumeral distance (AHD) and Hamada grade. Extent of arthritis was evaluated by magnetic resonance imaging.

Results: Both groups showed significant improvement after the surgery in intra-group analysis, and no significant difference in clinical outcomes were observed between the two groups. AHD and Hamada grades were also comparable. The rate of graft retear was higher in the ATA group than in the FLA group, but without statistical significance.

Conclusions: aLTT may lead to significant improvement in clinical and radiologic outcomes in PSIRCT, regardless of whether an ATA or FLA is used as the interpositional graft. The retear rate of the interpositional bridging graft was not associated with graft status. However, measures to promote graft healing should be considered. Level of evidence: III.

Keywords: Achilles tendon allograft; Fascia lata autograft; Interpositional graft; Lower trapezius tendon transfer; Irreparable rotator cuff tear.

Fig. 1.

Preoperative clinical photographs and magnetic resonance images. The patient exhibited preoperative loss of external rotation of the left shoulder at the side (A) and 90˚ of abduction (B). Preoperative anteroposterior simple radiograph of the left shoulder showed little or no advanced arthritis in the glenohumeral joint (Hamada classification grade I or II) (C). Preoperative T1-weighted coronal image of the left shoulder demonstrated supraspinatus (SSP) tendon tear (asterisk) to the level of the glenoid (D). Preoperative T1-weighted oblique image of the right shoulder demonstrated severe fatty infiltration of the SSP and infraspinatus (ISP) tendon (E).

Fig. 2.

Flowchart showing patient selection for the study. aLTT: arthroscopically assisted lower trapezius tendon, PSIRCT: posterosuperior irreparable rotator cuff tear, SSC: subscapularis, MRI: magnetic resonance image, ATA: Achilles tendon allograft, FLA: fascia lata autograft.

Fig. 3.

(A) Arthroscopic preparation of the greater tuberosity and harvesting of the lower trapezius tendon. Arthroscopic images from the lateral portal of the left shoulder showed a posterosuperior irreparable rotator cuff tear. (B) The harvested lower trapezius tendon was prepared using the Krakow method with no. 2 nonabsorbable suture material along the muscular portion of the inferior margin.

Fig. 4.

Achilles tendon allograft harvest. Achilles tendon allograft was prepared using Krakow sutures at the tendon–bone junction.

Fig. 5.

Fascia lata autograft harvest. (A) Exposure of the fascia lata, and (B) folding of the harvested fascia lata autograft two or three times to obtain an adequate graft thickness and length. One side of the fascia lata autograft was prepared using Krakow sutures. The other side of the fascia lata autograft was tagged with other sutures.

Fig. 6.

Arthroscopic image and intraoperative photograph of interpositional graft fixation. The interpositional bridging graft was attached to the supraspinatus footprint using a double-row suture-bridge technique (A: Achilles tendon allograft, B: fascia lata autograft). The interpositional bridging graft was attached along the inferior margin of the lower trapezius muscle using the Krakow method. Asterisk: subscapularis tendon.

Fig. 7.

Postoperative magnetic resonance image of the transferred tendon with the Achilles tendon allograft. Axial (A) and coronal (B) images showed that the transferred tendon was intact (asterisks). Axial (C) and coronal (D) images showed retear of the transferred tendon (arrows).