Graft Harvest and Preparation
  • A shoulder-specific positioning table is recommended.
  • Position the patient in the beach chair position.
  • The entire medial border of the scapula must be accessible, and prepping to the thoracic spinous processes is optimal to avoid interference from drapes.
Diagnostic Arthroscopy

Through a standard mid-glenoid posterior portal, access the glenohumeral joint, then progress to the subacromial space.

  • Identify and treat all relevant pathology; glenohumeral or acromioclavicular joint arthritis, subacromial impingement & biceps tears.
  • Prepare the greater tuberosity by removing soft tissue, exposing bone, and performing a microfracture to encourage graft healing.
  • Confirm the rotator cuff pathology and that a lower trapezius transfer is indicated.
  • Insert one HEALIX ADVANCE™ Anchor with DYNACORD™ Sutures at the articular margin of the posteromedial greater tuberosity. 
Diagnostic Arthroscopy
  • Mark the medial border of the upper/middle scapula and the scapular spine.
  • Make a horizontal incision 2-3 cm below the scapular spine. It should extend from 1 cm medial to 3 cm lateral to the medial scapular border.
Lower Trapezius Hat
  • Palpate the lower trapezius tendon insertion attached to the inferior portion of the scapular spine.
  • Identify and remove the overlying adipose.
  • Dissect the full length of the tendon from the scapular spine.
  • Careful mobilization of the tendon is required.

Note: The spinal accessory nerve is approximately 2 cm medial to the medial border of the scapula and care should be taken to ensure it remains intact.

  • Place a traction DYNACORD™ Suture through the lower trapezius tendon.
Achilles Tendon Allograft Preparation
  • Remove tissue from the inner package, place in a sterile basin, and cover with ambient or room temperature normal saline or isotonic solution of choice. Appropriate antibiotics of choice may be added.
  • Tissue should remain in solution until thawed.
  • Once thawed, remove calcaneus bone if present.
  • Place two #2 DYNACORD™ Sutures of different colors (Krakow configuration) in the thick, insertion end of the allograft.

Tip:  Mark the designated superior and inferior aspects of the allograft to help with identification in the subacromial space. 

Arthroscopic Allograft Passage
  • From the anterolateral portal, introduce a kelly clamp or suture manipulator towards the harvest site and between the posterior deltoid and remaining posterior rotator cuff.

Tip: In large arms, this may be performed in 2 steps introducing the clamp through a posterior portal

Note: Penetrate and open the infraspinatus and deltoid fascia.

  • Identify the clamp and place the DYNACORD™ Sutures from the allograft into the jaws of the clamp.
  • Retrieve the allograft into the subacromial space.
Allograft Intra-articular Attachment 1

A) Positioning of the Graft

  • Position the allograft onto the greater tuberosity rotator cuff footprint.
  • The graft should be lateral to the posteromedial anchor sutures.

B) Insert the Anteromedial HEALIX ADVANCE™ Self-Punching Anchor

  • Place a 7.0 mm cannula through an anterolateral portal and retrieve one limb of each DYNACORD™ Suture from the allograft.
  • Prepare the anterior greater tuberosity, taking care not to damage the biceps tendon if it is intact.
  • Pass the DYNACORD™ Sutures through the HEALIX ADVANCE™ Self-Punching Anchor and insert medially onto the anterior tuberosity.

C) Insert the Anterolateral HEALIX ADVANCE™ Self-Punching Anchor

  • Retrieve the remaining DYNACORD™ Sutures and deploy a second HEALIX ADVANCE™ Self-Punching Anchor anterolateral on the greater tuberosity.
Insert the Posterior HEALIX ADVANCE™ Self-Punching Anchor
  • Retrieve the sutures from the previously placed posterior HEALIX ADVANCE™ Anchor and pass the DYNACORD™ Sutures around the graft.
  • Insert the third HEALIX ADVANCE™ Self-Punching Anchor to the posterior tuberosity.

Note: This prevents anterior translation of the graft.

Note: If there is a repairable supraspinatus or infraspinatus tear, place medial row anchors (often easier before graft introduction) using HEALIX ADVANCE™ Anchors. Then pass the sutures through the tendon, tie medially, pass the sutures over the allograft and incorporate them into two HEALIX ADVANCE™ Self-Punching Anchors.

Lower Trapezius-Allograft Attachment 1

A) Split the allograft along the midportion

  • Place the arm in maximum external rotation, and approximately 30 degrees of abduction.
  • Split the end of allograft into superior and inferior portions.
Lower Trapezius-Allograft Attachment 2

B) Pass the upper portion of the graft through the lower trapezius muscle

  • Use a smaller clamp to penetrate through musculotendinous junction of the lower trapezius.
  • Retrieve the upper half of the split achilles tendon.
Lower Trapezius-Allograft Attachment 3

C) Secure the allograft to itself and the lower trapezius tendon

  • Once retrieved, pull laterally to double the allograft while tensioning the Lower Trapezius. Use multiple DYNACORD™ Sutures in a simple or figure of 8 configurations to secure the allograft to itself and the lower trapezius tendon.
  • The inferior portion of the allograft is pulled laterally, placed over the muscle and folded upper flap of the allograft and secured with multiple DYNACORD™ Sutures.
  • Excessive allograft is then trimmed.
  • Several cycles of shoulder internal and external rotations are performed to confirm a well-fixed construct.