A 58-year-old man with shoulder pain
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A 58-year-old man presented with left shoulder pain. His pain was six out of 10 in severity at its best, but 10 out of 10 at night and with activity. He reported he developed opioid dependence as a result of chronic pain and dysfunction of the shoulder. He reported an extensive history with regard to the left shoulder, which began 18 years prior to presentation.
When he was 40 years old, the patient had a motorcycle crash that resulted in a traumatic rotator cuff tear. The tear was repaired and resulted in good function for 17 years. However, 1 year prior to presentation, he sustained a traumatic retear of his repaired rotator cuff while he was boxing for exercise.
At that time, he underwent a revision rotator cuff repair at another center after which he had an interval of improvement for a few months, followed by an abrupt decline in progress with therapy and recurrence of pain. He performed 4 months of additional physical therapy and was dissatisfied with his progress.
On examination, the patient’s prior shoulder surgical incisions were well healed without evidence of infection. He had mild atrophy visible in the supraspinatus and infraspinatus fossae. He had mild tenderness to palpation of the proximal biceps tendon with a positive Speed’s test.
There was severe pain with passive range of motion, a positive Neer impingement test and positive empty can test with pain and weakness.
There was a positive drop arm sign test and positive Jobe test. Belly press, cross body, O’Brien’s tests and the Hornblower’s sign were negative.
He had 2/5 strength with resisted external rotation with 30° external rotation lag. His active range of motion was 140° forward elevation compared with 160° contralaterally, 70° external rotation with the arm abducted compared with 80° contralaterally, and 10° external rotation with the arm adducted compared with 50° contralaterally.
Passive motion, although painful, was symmetric to the contralateral side. The patient was neurovascularly intact to the radial, ulnar, median, musculocutaneous, axillary, long thoracic, spinal accessory, anterior interosseous and posterior interosseous nerves.
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Recurrent rotator cuff tear
Preoperative radiographs demonstrated proximal humeral migration without significant glenohumeral arthritic disease or acetabularization (Figure 1). Preoperative MRI of the shoulder revealed a recurrent retracted full-thickness tear of the supraspinatus and infraspinatus. The supraspinatus and infraspinatus were retracted medial to the glenoid margin, and there was low-grade fatty infiltration throughout the rotator cuff (Figure 2).
Treatment plan
We discussed with the patient that, given the multiple recurrent tears and retraction of the supraspinatus and infraspinatus tendons to the glenoid, his current tear was most likely irreparable. We discussed options including debridement, superior capsular reconstruction (SCR), reverse total shoulder arthroplasty (TSA), lower trapezius tendon transfer, partial repair and interpositional “bridging” grafts. The patient was relatively young and still interested in remaining physically active. He elected to undergo attempted arthroscopic revision rotator cuff repair, biceps tenodesis and possible lower trapezius tendon transfer if his recurrent posterosuperior (PS) rotator cuff tear was found to be irreparable.
The patient was positioned in the beach chair position with generous draping to include the medial border of the scapula in the sterile field (Figure 3). Diagnostic arthroscopy re-demonstrated the massive rotator cuff tear with retraction (Figure 4). The decision was then made to perform the lower trapezius tendon transfer as the infraspinatus and supraspinatus were intraoperatively confirmed to be irreparable, despite significant efforts at mobilization of the tear. A horizontal incision along the medial border of the scapula was created (Figure 5). After dissection through the fascial plane, the lower trapezius tendon was identified at the inferior portion of the scapular spine and bluntly mobilized. An Achilles tendon allograft was then prepared on the back table and shuttled into the shoulder joint deep to the posterior deltoid and along the course of the intended lower trapezius vector of action (Figure 6). The graft was brought down to the infraspinatus footprint with two single-loaded suture anchors and secured with two additional lateral-row anchors, completing a double-row repair (Figure 7). The arm was taken into 45° abduction and 45° external rotation and the medial portion of the graft was secured to the lower trapezius tendon using a Pulver Taft weave (Figure 8). A concomitant arthroscopic biceps tenodesis was performed.
The patient was placed into a gunslinger brace for 6 weeks and subsequently began a formal course of physical therapy for range of motion and muscle retraining. At 4 months after surgery, the patient had an improved pain level of 3/10. His forward elevation improved to 170° from 140° preoperatively. He was able to demonstrate 30° of active external rotation compared with 10° preoperatively. Final radiographs demonstrated restoration of the humeral head alignment without residual proximal migration (Figure 9).
Discussion
Irreparable rotator cuff tears pose significant treatment challenges, particularly in young, active patients. Reverse TSA is an excellent option for elderly patients or patients with end-stage rotator cuff tear arthropathy. However, young patients with some retained preoperative function are at risk for poor outcomes when reverse TSA is performed for a massive rotator cuff tear in the absence of arthritis. There are a number of alternative treatment options.
Joint preservation options for massive irreparable rotator cuff tears exist on a spectrum. In all cases, nonoperative treatment strategies should be discussed with the patient. Typically, nonoperative treatments are reserved for asymptomatic, low-demand patients or patients who are poor surgical candidates due to severe medical comorbidities. The most conservative operative treatment is arthroscopic debridement. Arthroscopic debridement has been shown in some studies to improve patient-reported outcomes and pain scores, but improvements are variable and typically short-lasting.
The next option on the continuum of treatment is partial rotator cuff repair. Stephen S. Burkhart, MD, and colleagues reported a 90° increase in forward elevation with high patient satisfaction after partial repair. Its success hinges on the ability to restore a force couple between the infraspinatus and subscapularis.
When this is not possible, surgeons can consider nonanatomic procedures, including SCR and subacromial balloon spacers, although the balloon spacer is currently not FDA approved. Research into vascularized dermal tissue transfers is ongoing and has potential to bring viable dermis to the superior capsule rather than allograft, autograft or synthetic material. The common goal of these procedures is to prevent proximal migration of the humeral head during deltoid muscle activity. Although these can be a good option for carefully selected patients, they do not address loss of external rotation strength or restore an active force couple.
The final joint preservation option for massive irreparable rotator cuff tears is the tendon transfer. Tendon transfers have theoretical advantages over arthroplasty, debridement, partial repair and SCR because tendon transfers can restore the rotator cuff force couple with an active substitute. For anterosuperior rotator cuff deficiency, pectoralis major and latissimus dorsi tendon transfers have been described to replicate the pull of the subscapularis. For PS rotator cuff deficiency, latissimus dorsi and lower trapezius tendon transfers have been described, in addition to several other transfers. In biomechanical studies, a latissimus dorsi tendon transfer has also been combined with SCR to add both a dynamic and static component to the reconstruction.
In this case, a PS tendon transfer was indicated and we elected to use a lower trapezius tendon transfer. The fibers of the lower trapezius run parallel to the infraspinatus, making it an appealing option to restore the infraspinatus force vector. In a biomechanical study, Reza Omid, MD, demonstrated that a lower trapezius tendon transfer centers the humeral head and restores force couple better than a latissimus tendon transfer. Clinically, the lower trapezius tendon transfer has shown early promise in the treatment of irreparable PS rotator cuff tears. Bassem T. Elhassan, MD, and colleagues followed 32 patients for a mean of 47 months. Patients had mean external rotation of 50° and mean forward elevation of 120° at final follow-up with improvement in patient-reported outcome measures.
In summary, lower trapezius tendon transfer has the potential to restore rotator cuff force couple and improve active external rotation in young, active patients with irreparable PS rotator cuff tears. Patients should be aware that postoperative rehabilitation is extensive and requires 6 to 9 months for a full recovery. With the many treatment options available, management of these patients should involve careful patient selection and shared decision-making.
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- For more information:
- Michael A. Stone, MD, can be reached at Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048; email: michael.stone@cshs.org.
- Nicholas A. Trasolini, MD, and Caroline Vonck, MD, can be reached at Los Angeles County+USC Medical Center, 2051 Marengo St., Los Angeles, CA 90033. Trasolini’s email: trasolinimd@gmail.com. Vonck’s email: caroline.vonck@med.usc.edu.
- Edited by Joshua D. Johnson, MD, and Nicholas A. Trasolini, MD. Johnson is a chief resident in the department of orthopedic surgery at Mayo Clinic in Rochester, Minnesota. He will be a musculoskeletal oncology fellow at MD Anderson following residency. Trasolini is the administrative chief resident in the department of orthopedic surgery at Keck Medical Center of the University of Southern California and will be a sports medicine fellow at Rush University Medical Center following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
Disclosures: Stone, Trasolini and Vonck report no relevant financial disclosures.
Editor's Note: This article was updated on May 29, 2020, to correct the orientation of Figures 5, 6 and 8.
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