Tuesday, March 15, 2016

Massive irreparable posterior-superior rotator cuff tear treated with a lower trapezius transfer

Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear.

These authors report on 33 patients (average age of 53 years (range, 31-66 years)) having reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft for a symptomatic massive irreparable (≥2 full-thickness rotator cuff tears associated with shortening and retraction of the tendon to the level of the glenoid and a high grade of fatty infiltration of the muscles) rotator cuff tear that failed conservative or prior surgical treatment.

Postoperatively, patients were placed in a custom-made shoulder spica brace in 30° of abduction and 50° of external rotation for 8 weeks. The patient then began active assisted range of motion exercises in every direction except internal rotation for 4 weeks (from weeks 8-12), then full range of motion and gentle strengthening after that. Patients were allowed to return to unrestricted activities after 6 months.

The acromial osteotomy performed as a part of this procedure healed in 25 of 33 patients.

One patient, with a body mass index of 36 kg/m2, required dĂ©bridement for an infection and then later underwent shoulder fusion. 

These patients were characterized preoperatively as " All patients were active and did repetitive lifting activities, such as weight lifting, light labor, or daily repetitive lifting of objects 10 pounds or greater. Thirteen patients reported heavy lifting activities, including construction workers, farmers, lifting heavy wood, boxes, or animals. The mechanism of injuries included slipping on ice in 6, falling from stairs in 4, car accident in 5, motorcycle accident in 4, sports injury (football, hockey) in 6, and repetitive heavy lifting (farmers) in 8. " The ability of patients to perform these functions after surgery is not provided.

At an average follow-up of 47 months, 32 patients were reported to have improved comfort and function. The range of flexion improved from 70° (range, 20°-120°) before surgery to 120° (range, 80°-150°), but the statistical significance of this change is not provided.

Comment: The management of a patient with an irreparable cuff tear needs to be highly individualized based on the patients health and expectations as well as the condition of the shoulder before shoulder surgery. We use a range of approaches including the smooth and move procedure, CTA arthroplasty, and reverse total shoulder arthroplasty. We have not found a role for tendon transfers in our practice, but will observe with interest the attempts of others to explore other approaches.