36 Lower Trapezius Transfer

10.1055/b-0039-167685

36 Lower Trapezius Transfer

William R. Aibinder and Bassem T. Elhassan

Abstract

The lower trapezius tendon transfer aims to restore shoulder flexion and external rotation in patients with either paralysis or irreparable rotator cuff tears. This particular transfer utilizes a more direct line of pull to restore external rotation compared to the traditional latissimus dorsi transfer. The procedure can be performed via an open technique or an arthroscopically assisted technique. Appropriate tensioning of the tendon transfer in external rotation is crucial to a satisfactory outcome. Additionally, careful patient selection can prevent deleterious results, as compliance with a rehabilitation protocol is imperative.

36.1 Goals of Procedure

To eliminate pain and restore function, particularly shoulder flexion and external rotation, in patients with either massive rotator cuff tears not amenable to repair or shoulder paralysis, such as after brachial plexus injury.

36.2 Advantages

The lower trapezius transfer is a simple procedure. In restoration of shoulder function, the lower trapezius provides a more direct line of pull for external rotation compared to the traditional latissimus dorsi transfer. ¹ ^, ² Additionally, the lower trapezius muscle is able to the stabilize the humeral head, even in the absence of subscapularis or deltoid function. ² The lower trapezius tendon transfer can be performed as a single-tendon transfer or in combination with other tendon transfers to restore multiple planes of motion.

36.3 Indications

Paralytic shoulders that lack active external rotation.
Massive posterosuperior rotator cuff tears not amenable to repair or after failure of previous attempts at repair/reconstruction.

36.4 Contraindications

Paralysis of the trapezius muscle, such as after spinal accessory nerve transfer.
Active soft-tissue infections with or without associated open wounds.
Advanced degenerative joint disease affecting the glenohumeral articulation.
Inability to comply with the postoperative bracing and physical therapy protocol.

36.5 Preoperative Preparation/Positioning

Preoperative trapezius function must be assessed clinically by a shoulder shrug with evidence of muscle activation.
When approaching a massive posterosuperior rotator cuff, an Achilles tendon allograft should be available.
The patient is positioned laterally with the affected side up. A dynamic arm holder (SPIDER2; Smith & Nephew, Andover, MA) is utilized to position and stabilize the shoulder during the procedure and allow the assistant to retract.
The operative extremity, and posterior and anterior thorax are prepped and draped passed midline.

36.6 Operative Technique

Anatomic landmarks are drawn on the patient including the scapula and scapular spine to identify the direction and location of the trapezius muscle fibers ( Fig. 36.1 ). An incision is made 2 cm medial to the medial aspect of the scapular spine and extending distally approximately 5 to 7 cm. The lower and middle trapezius muscle bellies are then separated by identifying the triangular-shaped tendon insertion on the medial scapular spine of the lower trapezius and dissecting along the superior border. The spinal accessory nerve is identified and protected. It can usually be visualized two fingerbreadths medial to the medial border of the scapula on the undersurface of the muscle. Occasionally, a nerve stimulator is required. The insertion is detached and the tendon is secured with a no. 2 nonabsorbable suture (ORTHOCORD; DePuy Synthes, Warsaw, IN) in a Krackow technique ( Fig. 36.2 ). The tendon is then placed in the wound and the tendon transfer site is prepared.

**Fig. 36.1** A patient in the lateral decubitus position with the arm draped free and exposed passed midline. All anatomic landmarks are drawn including the humeral head, scapula, spinous processes, as well as the orientation and fibers of the trapezius muscle.

**Fig. 36.2** The triangular-shaped lower trapezius tendon following harvest, secured with a Krackow suture.

36.6.1 Paralytic Shoulder

In paralytic shoulders, the infraspinatus tendon is usually intact and its attachment is preserved. A vertical incision is placed just posterior to the lateral end of the acromion over the insertion of the infraspinatus. The posterior deltoid is detached. The infraspinatus tendon is identified and dissected to expose its full extent, which is usually 3 to 4 cm longer than the visible portion. A portion of the superficial muscle should be peeled back to allow visualization of the entire tendinous portion. A Krackow suture is placed in the visible infraspinatus tendon with a no. 2 nonabsorbable suture. A subcutaneous tunnel is created between the medial and lateral wounds and the suture in the lower trapezius tendon is pulled into the medial wound. To relieve tension, finger dissection may be needed to provide length to the tendon. Occasionally, the length is not sufficient to attach the tendons without tension. Therefore, an Achilles tendon allograft should be available. The broad proximal end is secured to the trapezius tendon with multiple sutures, while the distal end is prepared with a Krackow suture, which is used to pull the allograft into the lateral wound. The allograft is sized appropriately, and a free needle can be used to secure the distal end to the intact infraspinatus tendon. The transfer should be performed in maximal external rotation. The end of the Krackow suture in each tendon is then sewn into the other tendon to create a stout repair. TenoGlide (Integra LifeSciences Corporation, Plainsboro, NJ) is routinely placed around the repair to prevent adhesions and maximize the gliding of the tendon transfer.

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