Trapezius transfer for anterosuperior rotator cuff tendon tears
In massive irreparable rotator cuff tears, we would like to recover lost muscular function by replacing torn tendon and atrophic muscle with a muscular active transfer inserted on the tuberosities with the same direction and strength vector of the original muscle.
For this reason, since 1989, after using levator scapulae muscle, we have been using part of the upper and middle portion of trapezius muscle passed under the acromion and reinserted on the great tuberosity to replace the supraspinatus muscle, in irreparable massive cuff tears. In 1994 we started to consider this superior transfer not only as a “replacement” of supraspinatus but also as an “active stabiliser pulling up” the upper edge of subscapular muscle.
TECHNIQUE OF TRAPEZIUS TRANSFER:
Our trapezius transfer technique differs from the Yamanaka and Mikasa technique, because we don’t perform trasversal osteotomy of the acromion and we detach only a part of the middle portion of trapezius muscle inserted in the lateral and anterior part of the acromion.
The principal stages of this procedure are:
- In beach chair position, skin incision of about 8-10 cm is made from the lateral and posterior margin of the acromion to the middle level of the scapular spina.
- U incision of the insertion of trapezius on the acromion (anteriorly reaching A.C. joint, posteriorly leaving insertion on the acromial corner) is performed.
- Tendineal insertion with periostium is removed from the upper acromial surface
- Deltoid muscle is split for 2-3 cm along the anterior corner of the acromion to reach great tuberosity
- It is useful to bevel the posterior prominent portion of the clavicle allowing the transfer in a wide new passage under the acromion-clavicular arch
- Transfer is sutured, with the arm on the side, on the great tuberosity with transosseous stitches and on the superior edge of Subscapularis muscle (sometimes the transfer is directly inserted on the Subscapularis edge to pull it up)
- shoulder is immobilised for 3 weeks in soft bandage (Dessault) 30° of abduction and flexion, 0° of extrarotation.
Between 1989 to 2003 we operated on 43 patients with Antero-superior irreparable cuff tear. Patients operated on before 1994 (12) showed a global improvement but limited recovery of abduction and flexion (averaged 25°-30°).
After 1994, we started to tense and stabilize anterior structures and we observed a modest improvement of abduction and flexion (averaged out 45°), without pain but with an important deficit in strength.
The use of trapezius offer greater advantages than other superior transfers
- it has synergic contraction with deltoid muscles
- it has similar direction with supraspinatus
- it is performed in beach chair position easily
On the basis of our experience, we think that the main indications to perform trapezius transfer are;
- in antero-superior lesions, reinserting and upper tensioning the superior edge Subscapularis muscle
- in reoperation with an absent supraspinatus and not good tissue in the upper part of the Subscapularis (also as an alternative to cuff substitute or scaffolds).
The trapezius transfer remains a salvage operation indicated mainly in painful anterosuperior lesions with Subscapularis muscle traslating down, but not atrophic, also in old patients.