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Lower Trapezius Transfer
Management of irreparable posterior and posterosuperior rotator cuff tears is very challenging, particularly in younger or higher demand patients. Suggested treatment options include partial rotator cuff repair, superior capsular reconstruction, and reverse shoulder arthroplasty. However, those procedures may not be optimal for patients who have significant external rotation strength deficits and minimal glenohumeral arthritis.
This procedure provides surgeons with additional treatment options and should be included in a surgeon’s armamentarium for the management of complex rotator cuff pathology.
It is a straightforward transfer that is arthroscopically assisted
The line of pull of the lower trapezius more closely mimics the infraspinatus tendon so there is better restoration of shoulder biomechanics
The trapezius muscle normally contracts during shoulder external rotation so post-operative training is easier
Partial subscapularis tear is not a contraindication
Arthroscopic Assisted Lower Trapezius Transfer For Massive Rotator Cuff Tear
Dr. Paul Favorito describes how to treat an irreparable rotator cuff tear with an arthroscopic assisted lower trapezius transfer & rotator cuff repair using HEALIX ADVANCE™ Anchors with DYNACORD™ Suture & HEALIX ADVANCE™ Self-Punching Knotless Anchors.
Surgical Technique Steps
- 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.
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.
Identify Scapular Landmarks for Lower Trapezius Transfer Harvest
- Mark the medial border of the upper/middle scapula and the scapular spine.
- Make a horizontal incision 2-3 cm below scapular spine. It should extend from 1 cm medial to 3 cm lateral to medial scapular border.
Lower Trapezius Harvest
- 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 approx. 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 sterile basin, and cover with ambient or room temperature normal saline or isotonic solution of choice. Antibiotics of choice may be added.
- Tissue should remain in solution until thawed.
- Once thawed, remove the calcaneus bone if needed.
- 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
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
- This prevents anterior translation of the graft.
- 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 into two HEALIX ADVANCE™ Self-Punching Anchors.
Lower Trapezius-Allograft Attachment
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.
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.
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 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.
Post Operative Protocol
- Brace x 8 weeks
- Active range of motion elbow, wrist & hand
- Shoulder passive forward flexion to 90˚, External rotation neutral
- Remove for showers, hygiene
- 8-12 weeks
- Restore passive range of motion
- Internal rotation to abdomen.
- No internal rotation stretching
- Active forward flexion and external rotation
- Active internal rotation
- Restore passive range of motion
- 12+ weeks
- Gentle internal rotation stretching
- Begin active feedback techniques to activate lower trapezius
Specifications - Ordering Information
HEALIX ADVANCE™ Self-Punching Anchors
|222423||4.9mm HEALIX ADVANCE SP PEEK Anchor|
|222425||5.5mm HEALIX ADVANCE SP PEEK Anchor|
|222427||6.5mm HEALIX ADVANCE SP PEEK Anchor|
|222422||4.9mm HEALIX ADVANCE SP Bio-Composite Anchor|
|222424||5.5mm HEALIX ADVANCE SP Bio-Composite Anchor|
|222426||6.5mm HEALIX ADVANCE SP Bio-Composite Anchor|
Clear Cannula System
|214116||Clear Cannula, Threaded 7mm X 75mm|
|214118||Clear Cannula, Threaded 8.5mm X 55mm|
|214120||Clear Cannula, Threaded 8.5mm X 75mm|
|214113||7mm X 75mm Reusable Obturator|
|214117||8.5mm X 55mm Reusable Obturator|
|214119||8.5mm X 75mm Reusable Obturator|
|222071||#2 DYNACORD Suture Pack Striped/Blue (with MO-7 needles)|
|222066||#2 DYNACORD Suture Pack Blue (with MO-7 needles)|
Achilles Tendon Allograft (Parametrics Medical)
|AT2000||Achilles Tendon w/bone – Lo-RAD|
|NAT2000||Achilles Tendon w/bone – No-RAD|
|ACH1001E||Achilles Tendon w/bone – Coll-e-Strong|
|AT2000N||Achilles Tendon w/out bone – Lo-RAD|
|NAT2000N||Achilles Tendon w/out bone – No-RAD|
|ACH1001EN||Achilles Tendon w/out bone – Coll-e-Strong|
HEALIX ADVANCE™ with DYNACORD™ Suture
|222028||4.5mm HEALIX ADVANCE PEEK Anchor with #2 DYNACORD Suture|
|222032||5.5mm HEALIX ADVANCE PEEK Anchor with #2 DYNACORD Suture|
|222036||6.5mm HEALIX ADVANCE PEEK Anchor with #2 DYNACORD Suture|
|222001||4.5mm HEALIX ADVANCE BR Anchor with #2 DYNACORD Suture|
|222004||5.5mm HEALIX ADVANCE BR Anchor with #2 DYNACORD Suture|
|222011||6.5mm HEALIX ADVANCE BR Anchor with #2 DYNACORD Suture|
- Elhassan BT, Sanchez-Sotelo J & Wagner ER. Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. JSES 2020; 29(10): 2135-2142.
Please refer to the instructions for use for a complete list of indications, contraindications, warnings and precautions. HEALIX ADVANCE Self Punching Anchors were developed in collaboration with Thomas Knapp, M.D., Santa Monica, CA
Parametrics Medical is the exclusive biologics provider for DePuy Synthes.
© DePuy Synthes 2022 . All rights reserved. 198421-211208 DSUS