Bassem T. Elhassan (2020) — Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears

Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

·J Shoulder Elbow Surg·2020·176 citations·Shoulder & Elbow

Retrospective case series of 41 patients with massive irreparable posterosuperior rotator cuff tears treated with arthroscopically assisted lower trapezius transfer (aaLTT) augmented by Achilles tendon allograft. Asks whether this minimally invasive technique reliably improves pain and function — including in patients with pseudoparalysis or prior failed repairs.

Study Snapshot

Design

Retrospective case series

Setting: Single academic referral center, Mayo Clinic

Objective

Whether aaLTT produces reliable pain relief and functional improvement with low complication rate in irreparable posterosuperior cuff tears.

Outcome(s)

VAS pain, range of motion, DASH, and SSV at final follow-up

Subjects

41 consecutive patients, mean age 52 years

Inclusion

Irreparable massive posterosuperior rotator cuff tear on MRI
Pain and functional limitation interfering with daily life
Normal lower trapezius function

Exclusion

Moderate to severe glenohumeral arthritis (Hamada grade 4–5)
Abnormal lower trapezius function

Follow-up

Mean 14 months (range 6–19 months)

Statistics

Fisher exact testStudent t-testDescriptive statisticsUnivariate analysis

Key Findings

90% of patients (37/41) achieved significant improvement in all outcomes at mean 14-month follow-up. VAS pain improved from 6 to 2, forward flexion from 67° to 133°, DASH from 49 to 18, and SSV from 55% to 80% (all P<.001). These are clinically meaningful gains across every domain measured.
Three predictors of failure were identified (P<.05):
–Hamada grade 3 arthropathy
–Symptom duration >2 years
–True pseudoparalysis (flexion and abduction <60° for ≥6 months, no improvement with lidocaine)
–Patients meeting any of these criteria should be counseled toward reverse shoulder arthroplasty rather than tendon transfer.
Unlike latissimus dorsi transfer, subscapularis tears, prior failed repair, fatty infiltration, and mild glenohumeral arthritis did NOT predict worse outcomes after aaLTT. This distinction is the key clinical reason to choose aaLTT over latissimus dorsi transfer when subscapularis function is compromised.
Hamada grading changed management directly: 2 of 4 patients with Hamada grade 2–3 failed and required conversion to reverse shoulder arthroplasty. The remaining 37 patients with Hamada grade 1 all remained joint-preserved. Screen radiographs carefully before offering this procedure.
Proximal humeral head migration improved radiographically in 28 of 33 shoulders with preoperative migration. Complete restoration of joint congruity occurred in 21 shoulders. No patient without preoperative migration developed new migration after surgery, suggesting the transfer restores the force couple effectively.
Complications were largely minor and self-limited (8 total: 3 seromas, 1 superficial infection, 4 transient brachial neuropraxias from the external rotation brace). Two patients (4.9%) sustained traumatic transfer rupture after falls at 5 and 8 months — revision aaLTT was successful in one; the other declined reoperation but achieved adequate pain relief.

Board PearlaaLTT succeeds in 90% of massive irreparable cuff tears regardless of subscapularis status, but Hamada grade 3 arthropathy and symptoms over 2 years predict failure.

Clinical Relevance

Latissimus dorsi transfer has historically been the default tendon transfer for massive irreparable posterosuperior cuff tears, but its outcomes worsen significantly with subscapularis insufficiency, prior failed repair, and pseudoparalysis — the very scenarios you encounter most in complex referral patients.

This paper establishes aaLTT as a reliable joint-preserving option for physiologically young patients with irreparable posterosuperior tears, achieving 90% success even when subscapularis function is poor or prior repairs have failed. When you see a patient with a massive irreparable posterosuperior tear and an intact or reparable subscapularis, latissimus dorsi transfer remains reasonable. When subscapularis function is compromised or prior repairs have failed, aaLTT is the stronger choice.

Before offering aaLTT, screen for the three failure predictors: Hamada grade 3 or higher on radiographs, symptoms lasting more than 2 years, and true pseudoparalysis confirmed by lidocaine injection. Patients with established arthropathy should go directly to reverse shoulder arthroplasty.

One nuance worth knowing: the 6-week immobilization in 40–60° of external rotation is non-negotiable for graft healing, and hand numbness from the brace is common but resolves once the brace is removed.

Emerging

Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

Elhassan, Wagner, et al.·J Shoulder Elbow Surg·2020·176 citations·Shoulder & Elbow

Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

Study Snapshot

Key Findings

Clinical Relevance

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Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

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Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

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Outcome of Arthroscopically Assisted Lower Trapezius Transfer to Reconstruct Massive Irreparable Posterior-Superior Rotator Cuff Tears

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Clinical Relevance

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