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    A New Option for Irreparable Rotator Cuff Tears

    After a fall at work, a 51-year-old male can no longer perform his job functions, which include lifting heavy loads. He’s diagnosed with a massive rotator cuff tear, but when the surgical repair fails, what options are available? The authors offer him a lower trapezius tendon transfer with Achilles allograft reconstruction.

    Authors

    Brian Lee, MD, and Surena Namdari, MD, MSc

    Disclosures

    The authors have no conflicts of interest related to this case presentation.

    Case Presentation

    A 51-year-old male presented 3 months following a fall at work. He said that at the time of the injury, he felt he had sustained a shoulder dislocation that self-reduced.

    The patient works for a package delivery service, and is required to lift heavy loads (50 to 70 pounds) to chest level. Since the injury, he has had difficulty with reaching, lifting, pulling, and pushing, and he has been unable to raise his arm overhead. He has had substantial difficulty sleeping at night.

    He was seen by a workman’s compensation physician and sent for 12 weeks of physical therapy. He did not experience much improvement and continued to feel 10/10 pain. He noted that he had a history of pre-existing shoulder pain that was unrelated to a specific injury.

    Physical Examination, Left Upper Extremity

    • Active range of motion
      • Forward elevation: 170° to the right, 40° to the left (scapular assist)
      • Abduction: 160° to the right, 30° to the left (scapular assist)
      • External rotation at the side: 70° to the right, 20° to the left
    • Passive range of motion
      • Forward flexion: 170° to the right, 150° to the left
      • External rotation with arm at the side: 70° to the right, 70° to the left
      • Internal rotation with arm at the side: T5 to the right, S1 to the left
    • Strength
      • Forward flexion: 5/5 to the right, 3/5 to the left
      • Thumb-down abduction: 5/5 to the right, 3/5 to the left
      • External rotation: 5/5 to the right, 3/5 to the left
    • Rotator cuff signs: Postive Neer’s test, positive Hawkin’s test, positive pain with resisted external rotation, negative belly press test
    • Lag signs: External rotation at side negative, external rotation at 90° positive

    Neurovascular Examination, Left Upper Extremity

    • Sensation intact to light touch in axillary, radial, ulnar, and median nerve distributions
    • 2+ radial pulse
    • Radial, ulnar, median, axillary, anterior interosseous and posterior interosseous nerves intact to motor testing

    Differential Diagnosis

    • Rotator cuff tear
    • Cuff tear arthropathy
    • Biceps tendonitis
    • Fracture

    Imaging

    • Radiographs of the left shoulder (Figures 1a-c)
      • Mild proximal humeral migration
    • MRI of the left shoulder (Figures 2a-g)
      • Massive rotator cuff tear that spared the subscapularis
      • Retraction of the tendon edge to the level of the glenoid
      • Muscle bellies appear to be with grade 2 fatty atrophy in the supraspinatus and grade 1 fatty atrophy in the infraspinatus
      • Posterior “sag” to the humeral head with respect to the glenoid on the axillary view

             

    Figures 1a-c. Preoperative radiographs demonstrating mild proximal humeral migration, no evidence of glenohumeral arthrosis.

             

    Figures 2a-c. Coronal MRI sequence exhibits a full-thickness, retracted tear of supraspinatus tendon with retraction medial to the glenoid. Proximal migration of the humerus is again seen.

        

    Figures 2d-e. Coronal MRI sequence demonstrates full-thickness tearing of the infraspinatus tendon with retraction. The teres minor is intact.

        

    Figures 2f-g. Axial and sagittal MRI sequence demonstrating an intact subscapularis tendon with biceps located within the bicipital groove. Fatty atrophy of the supraspinatus tendon is exhibited.

    Diagnosis

    • Massive rotator cuff tear in the left shoulder

    Treatment

    The patient underwent an attempted rotator cuff repair. However, the tendon was found to be irreparable.




    Figures 3a-d. Intraoperative arthroscopy images. The supraspinatus tendon is seen torn and retracted medial to the glenoid. Figure 3c (third image) demonstrates posterior interval slide release with exposure of the scapular spine. Traction stitches were also placed in the tendon to facilitate tendon mobilization, as seen in Figure 3d (bottom image).

    A partial repair was then attempted, but the suture material pulled out of the infraspinatus during knot tying. As a result, a debridement and biceps tenotomy was performed.

    The patient then underwent 12 weeks of physical therapy. He unfortunately had no significant functional improvement and remained with a painful pseudoparalytic shoulder; he was unable to work.

    Surgical Options

    At this point, the surgical options included:

    • Allograft patch bridge reconstruction of rotator cuff defect
    • Latissimus dorsi tendon transfer
    • Lower trapezius tendon transfer with allograft
    • Reverse shoulder arthroplasty
    • Shoulder arthrodesis

    After consultation with the patient, the authors performed a left shoulder lower trapezius tendon transfer with Achilles allograft reconstruction.

    History of Technique

    • The technique has been described by Dr. Basem El-Hassan, from the Mayo Clinic, for restoration of motion in the paralytic shoulder. [1-3]
    • The technique has been modified and utilized by Dr. Leesa Galatz, from Washington University in St. Louis, for the treatment of rotator cuff pathology. [4]

    Advantages

    • Restores force couples of rotator cuff in irreparable tear
    • Pull of lower trapezius is more in line with physiologic pull of rotator cuff than the latissimus dorsi
    • Avoids reverse total shoulder arthroplasty in a patient who is physiologically young and active and does not have arthritis

    Disadvantages

    • Limited clinical data in the literature
    • Results of tendon transfers have been shown to be less predictable when compared with arthroplasty
    • Allograft must be used to obtain adequate tendon excursion
    • Long recovery (approximately 1 year)

    Type of implant: Achilles tendon allograft, suture anchors

    Procedure

    • Lateral positioning, beanbag
    • Incision 1 cm medial to the medial spine of the scapula
    • Dissection through the skin and subcutaneous tissue to the fascia, which is incised
    • Lower border of the trapezius identified, with care taken to avoid injury to the accessory nerve (Figure 4)
    • Insertion of the lower trapezius tendon on the scapular spine identified and then released sharply
    • Achilles tendon transfixed to the native trapezius tendon with a heavy, braided, nonabsorable suture (Figure 5a-c)
    • Saber approach to the humerus 2 cm lateral to the posterolateral aspect of the acromion
    • Deltoid split longitudinally
    • Debride greater tuberosity to bleeding bone bed with burr or curette, taking care to avoid compromising subchondral bone
    • Cobb elevator utilized to identify and develop an unrestricted, subdeltoid path between posterior incision and lateral incision
    • Two suture anchors placed in the medial aspect of the tuberosity, one limb from each anchor passed retrograde to posterior incision
    • Hemostats placed on the shortened limbs to avoid unloading of the suture anchor
    • Using a free needle and starting approximately 1 cm from the edge of the tendon, each limb passed through Achilles tendon in a Krackow fashion, from distal to proximal, and tied to one-another
    • Tendon then shuttled from posterior to lateral incision by pulling on the shortened limbs of anchors
    • With arm placed in abduction and external rotation, free suture limbs of each anchor used to reduce the tendon to the bone
    • Sutures tied; second suture from each anchor can be offloaded or utilized to augment the repair
    • Free sutures limbs from knots then secured with one or two lateral row suture anchors
    • Patient’s arm brought to the side to ensure adequate tension remains on the graft
    • Wounds irrigated, then closed in a layered fashion
    • Arm placed in a gunslinger brace in 30° abduction and 30° external rotation prior to reversal of anesthesia and extubation

    Figure 4. The lower border of the trapezius tendon is identified.



    Figures 5a-c. In Figure 5a (top), the appropriate length of Achilles tendon allograft is marked and resected. In Figures 5b-c (middle and bottom), the allograft Achilles tendon is transfixed to the native trapezius tendon in Krackow fashion using a heavy, braided non-absorbable suture.

    Postoperative Management

    The patient tolerated the procedure well, without complications. He was discharged home in a gunslinger brace, where he was allowed to perform elbow, wrist, and hand motion in a supine position.

    Initial 2-week postoperative visit

    • Tolerating gunslinger brace
    • Axillary nerve motor/sensation intact
    • Initiated passive flexion in supine position

    6-week postoperative visit

    • Tolerating gunslinger brace, compliant
    • Passive flexion 100°, external rotation 30°
    • Start formal physical therapy, wean brace with regular sling
    • Allowed passive range of motion, active-assisted range of motion
    • Initiate active range of motion at 8 to 10 weeks
    • No cross-body adduction, no internal rotation behind the back
    • No strengthening

    12-weeks postoperative visit

    Improving in physical therapy, able to actively flex shoulder 150° in supine position (previously unable to do this), externally rotates to 50° actively with arm at side, сan hold arm in 150° flexion when passively raised and while in seated position

    18-week postoperative visit

    Continues to improve in physical therapy, able to actively flex shoulder 170° in supine position and 90° in seated position

    6-month postoperative visit

    Can raise arm actively to 130° and strength is improving

    Author Information

    Brian Lee, MD, and Surena Namdari, MD, MSc, are from The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

    Shoulder Reconstruction Section Editor, Rothman Institute Grand Rounds

    Luke S. Austin, MD

    References

    1. Elhassan B, Bishop A, Shin A: Trapezius transfer to restore external rotation in a patient with a brachial plexus injury. J Bone Joint Surg 2009;91:939-944.
    2. Elhassan B. Lower trapezius transfer for shoulder external rotation in patients with paralytic shoulder. J Hand Surg 2014;39:556-562. 
    3. Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg 2013;21:492-501. 
    4. Donegan RP, Jobin CM, Chamberlain AM, Namdari S, Tang CT, Galatz LM. Lower Trapezius Tendon Transfer for Irreparable Posterior-Superior Rotator Cuff Tears. Poster presented at the annual meeting of the American Academy of Orthopaedic Surgeons, March 2014.