Sunday, October 9, 2016

Treatment of massive irreparable cuff tears with lower trapezius transfer

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

These authors present 33 patients,average age of 53 years (range, 31-66 years), with symptomatic massive irreparable rotator cuff tear that failed conservative or prior surgical treatment who  underwent reconstruction with lower trapezius transfer prolonged by Achilles tendon allograft.

Patients aged older than 55 to 60 years and who could have been potentially good candidates for reverse shoulder arthroplasty were aware of this option but did not want it mainly because of the restrictions and potential complications associated with it.

Preoperatively patients showed variable degrees of loss of active shoulder function, with average shoulder flexion of 70° (range, 20°-120°) and abduction of 40° (range, 20°-70°).

Preoperative MRI showed massive rotator cuff tear (all patients had at least 2 full-thickness rotator cuff tears, involving at least the supraspinatus and infraspinatus) that was determined preoperatively to be irreparable based on the advanced fatty atrophy involving the torn muscles (Goutallier grade III-IV) and retraction of the torn tendon medial to the level of the glenoid.

The procedure involved an acromial osteotomy (below left) and extension of the trapezius with an Achilles tendon allow graft (below right).


 

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.

At an average follow-up of 47 months, 32 patients had significant improvement in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder and Hand score and shoulder range of motion, including flexion, 120°; abduction, 90°; and external rotation 50°. One patient, with a body mass index of 36 kg/m2, required d├ębridement for an infection and then later underwent shoulder fusion. Patients with >60° of preoperative flexion had more significant gains in their range of motion. Shoulder external rotation improved in all patients regardless of the extent of the preoperative loss of motion.

Comment: This is an extensive procedure that, in the hands of experienced surgeons, can improve shoulder function in a highly selected group of individuals with massive irreparable cuff tears. Theoretically this lower trapezius transfer may have better biomechanics than a latissimus transfer because line of pull of the lower trapezius more closely mimics that of the infraspinatus tendon. 

It will be of interest to see how the expanding indications for reverse total shoulder arthroplasty affect the future utilization of muscle transfers in the management of irreparable cuff tears.