Arthroscopically Assisted Lower Trapezius Transfer Using Peroneus Longus Autograft for Irreparable Posterosuperior Rotator Cuff Tears.

IF 1 Q3 SURGERY
JBJS Essential Surgical Techniques Pub Date : 2025-03-18 eCollection Date: 2025-01-01 DOI:10.2106/JBJS.ST.23.00047
Silvampatti Ramasamy Sundararajan, Rajagopalakrishnan Ramakanth, Bandlapally Sreenivasa Guptha Sujith, Terence Dsouza, Karthikeyan Pratheeban, Shanmuganathan Rajasekaran
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In the present video article, we describe the surgical technique for successful arthroscopic (\"scopy\")-assisted lower trapezius transfer (SALTT) with use of an easily accessible peroneus longus autograft.</p><p><strong>Description: </strong>The patient is positioned in a beach-chair position with the ipsilateral half of the posterior shoulder girdle included in the draping for surgical access. Joint was viewed through the standard posterior and posterolateral portals, while anterolateral and anterosuperior portals were utilized as the working portals. Subacromial and superior capsular adhesions are released, and a partial cuff repair is performed. A 3 to 4-cm vertical incision is made along the scapular spine. The superior and inferior borders of the lower trapezius are delineated and completely detached from where they insert at the scapular spine. A 3-cm vertical incision is made at the posterior border of the lateral malleolus. The fascia is incised. 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引用次数: 0

Abstract

Background: Massive retracted rotator cuff tears are disabling in physically active patients. In patients with persistent pain in whom nonoperative treatment has failed, multiple surgical treatment options are available. Lower trapezius tendon transfer is a promising surgical procedure that can decrease pain, improve external rotation strength, and recreate more normal glenohumeral kinematics. In the present video article, we describe the surgical technique for successful arthroscopic ("scopy")-assisted lower trapezius transfer (SALTT) with use of an easily accessible peroneus longus autograft.

Description: The patient is positioned in a beach-chair position with the ipsilateral half of the posterior shoulder girdle included in the draping for surgical access. Joint was viewed through the standard posterior and posterolateral portals, while anterolateral and anterosuperior portals were utilized as the working portals. Subacromial and superior capsular adhesions are released, and a partial cuff repair is performed. A 3 to 4-cm vertical incision is made along the scapular spine. The superior and inferior borders of the lower trapezius are delineated and completely detached from where they insert at the scapular spine. A 3-cm vertical incision is made at the posterior border of the lateral malleolus. The fascia is incised. The peroneus longus is identified and detached with the foot in maximum dorsiflexion and eversion and is harvested with use of a closed tendon stripper. Whip stiches are placed at 1 end of the autograft. With use of a large grasping clamp, starting from the anterolateral portal and aiming toward the medial scapular incision, the autograft is shuttled and the stitched end of the autograft is fixed to the humeral head with a knotless anchor. With the shoulder in maximum external rotation and 0° of abduction, tenodesis of the autograft is performed to the lower trapezius tendon with a Pulvertaft technique. The shoulder is then immobilized in 40° to 60° of external rotation in a custom brace for 6 to 8 weeks. Passive and gradual active-assisted shoulder exercises should begin at 6 to 8 weeks postoperatively.

Alternatives: Surgical alternatives for irreparable tears include partial rotator cuff repair with biceps superior capsular reconstruction, superior capsular reconstruction with fascia lata graft, subacromial balloon spacer, and reverse shoulder arthroplasty. Tendon transfers are preferred in younger patients.

Rationale: The lower trapezius has adequate tension, a similar line of pull as the infraspinatus, and enough tension to replace the function of the infraspinatus1. Biomechanical studies have shown that the maximum external rotation moment arm generated with use of a lower trapezius transfer with the arm at the side is superior to that with either latissimus dorsi or teres major transfer2, and lower trapezius transfer is technically less cumbersome than other tendon transfer techniques.

Expected outcomes: Expected outcomes following the presently described procedure include significant improvements in pain and function. Elhassan et al.3 reported the outcomes of lower trapezius tendon transfer utilizing an allograft in 33 patients with an average age of 53 years (range, 31 to 66 years). At an average follow-up of 47 months, 32 patients had significant improvements in pain, SSV, and DASH score. One patient required debridement for an infection and later underwent shoulder arthrodesis. In a separate study, Elhassan et al.4 reported on 41 patients who underwent arthroscopically assisted lower trapezius transfer. Of these, 37 (90%) patients showed significant improvements in the VAS pain scale, SSV, and DASH scores. Two other patients with preoperative cuff arthropathy underwent reverse shoulder arthroplasty for persistent pain. The remaining 2 patients experienced a traumatic rupture, at 5 and 8 months postoperatively. Valenti and Werthel5 performed arthroscopically assisted lower trapezius transfer using hamstring graft in 14 patients with a mean age of 62 years (range, 50 to 70 years). Over a mean follow-up of 24 months (range, 12 to 36 months), the gain in external rotation was 24° with the arm at the side and 40° in 90° of abduction. Both the lag sign and hornblower sign were negative after this transfer. Two patients developed a hematoma, and a third patient underwent revision because of infection.

Important tips: Proper case selection is necessary for optimal results.Ensure adequate release from the scapular spine to avoid difficult lower trapezius tendon harvesting and suboptimal lower trapezius tendon excursion.Utilize a combination of suture anchors to overcome insufficient graft fixation to the greater tuberosity as a result of poor bone stock.Make an adequate window beneath the infraspinatus fascia and utilize special long curved forceps to avoid difficult peroneus graft passage.Perform multiple cycles of rotation before fixation to avoid insufficient graft tensioning and graft excursion prior to lower trapezius attachment.

Acronyms and abbreviations: SSV = Shoulder Subjective ValueVAS = visual analog scaleDASH = Disabilities of the Arm, Shoulder and HandSST = Simple Shoulder TestERMA = external rotation moment armADL =activities of daily livingMRI= magnetic resonance imagingPEEK= polyetheretherketonePLT= peroneus longus tendon.

关节镜下应用自体腓骨长肌移植治疗不可修复的后上肩袖撕裂下斜方肌转移。
背景:在体力活动的患者中,大量的肩袖撕裂是致残的。对于非手术治疗失败的持续性疼痛患者,有多种手术治疗选择。下斜方肌腱转移是一种很有前途的手术方法,可以减轻疼痛,提高外旋强度,并重建更正常的盂肱运动。在这篇视频文章中,我们描述了关节镜(“镜下”)辅助下斜方肌转移(SALTT)的手术技术,并使用了容易接近的腓骨长肌自体移植物。描述:患者采用沙滩椅位,后肩带的同侧一半包括在手术切口内。通过标准的后门静脉和后外侧门静脉观察关节,使用前外侧和前上门静脉作为工作门静脉。解除肩峰下和上囊粘连,进行部分袖带修复。沿肩胛骨做一个3 - 4厘米的垂直切口。下斜方肌的上下边界已经画出来并完全脱离肩胛骨处。在外踝后缘处做一个3厘米的垂直切口。切开筋膜。腓骨长肌在足部最大背屈和外翻时被识别并分离,并使用封闭肌腱剥离器切除。鞭状缝线放置在自体移植物的一端。使用大钳钳,从门静脉前外侧开始,瞄准肩胛骨内侧切口,穿梭自体移植物,用无结锚钉将缝合后的自体移植物端固定在肱骨头。当肩关节处于最大的外旋和0°外展时,采用粉塔夫脱技术将自体移植物肌腱固定到下斜方肌腱。然后使用定制支架将肩部固定在40°至60°的外旋范围内6至8周。被动和渐进式主动辅助肩部锻炼应在术后6 - 8周开始。替代方案:不可修复撕裂的手术方案包括部分肩袖修复二头肌上囊重建术、上囊重建术及阔筋膜移植物、肩峰下球囊垫片和逆行肩关节置换术。年轻患者首选肌腱转移。理由:下斜方肌有足够的张力,与冈下肌有相似的牵拉线,并且有足够的张力取代冈下肌的功能1。生物力学研究表明,使用侧侧下斜方肌转移所产生的最大外旋力矩臂优于背阔肌或大圆肌转移2,并且下斜方肌转移在技术上比其他肌腱转移技术更简单。预期结果:目前描述的手术的预期结果包括疼痛和功能的显著改善。Elhassan等人3报道了33例平均年龄53岁(31 - 66岁)的患者采用同种异体移植进行下斜方肌腱移植的结果。在平均47个月的随访中,32例患者在疼痛、SSV和DASH评分方面有显著改善。一名患者因感染需要清创,后来接受了肩关节融合术。在另一项研究中,Elhassan等报道了41例接受关节镜辅助下斜方肌转移的患者。其中,37例(90%)患者在VAS疼痛量表、SSV和DASH评分上有显著改善。另外两例术前有袖带关节病的患者因持续疼痛接受了反向肩关节置换术。其余2例患者分别在术后5个月和8个月发生外伤性破裂。Valenti和Werthel5对14例平均年龄为62岁(范围50 - 70岁)的患者进行了关节镜辅助下斜方肌移植物移植。平均随访24个月(12至36个月),臂侧外展时外旋增加24°,臂外展90°时外旋增加40°。移植后的lag sign和hornblower sign均为阴性。两名患者出现血肿,第三名患者因感染接受了翻修。重要提示:正确的病例选择是获得最佳结果的必要条件。确保肩胛骨有足够的释放,以避免困难的下斜方肌腱收获和次优的下斜方肌腱偏移。利用缝合锚钉的组合来克服由于骨质不良而导致的大结节移植物固定不足的问题。在冈下筋膜下开一个适当的窗,并使用特殊的长弯曲钳,以避免难于通过腓骨移植物。 在固定前进行多次旋转,以避免下斜方肌附着前移植物张力不足和移植物偏移。首字母缩写:SSV =肩部主观价值evas =视觉模拟量表edash =手臂、肩膀和手的残疾sst =简单肩部TestERMA =外旋力矩armADL =日常生活活动mri =磁共振成像peek =聚醚醚酮plt =腓骨长肌腱
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来源期刊
CiteScore
2.30
自引率
0.00%
发文量
22
期刊介绍: JBJS Essential Surgical Techniques (JBJS EST) is the premier journal describing how to perform orthopaedic surgical procedures, verified by evidence-based outcomes, vetted by peer review, while utilizing online delivery, imagery and video to optimize the educational experience, thereby enhancing patient care.
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