Dual-Vector Lower Trapezius Tendon Transfer With Quadriceps Tendon Allograft in Massive Rotator Cuff Tear: STAR (Superior Trapezius Anatomic Reconstruction) Procedure

Abstract

In the context of massive rotator cuff tear, attempted repair—partial/complete—remains the standard of care. However, outcomes vary, and retear rates are high. The lower trapezius tendon transfer for posterosuperior irreparable rotator cuff tears provides active external rotation and shoulder abduction. Superior capsule reconstruction is another option for enhancing range of motion and pain relief in severe cuff tears. Combining superior capsule reconstruction and lower trapezius tendon may offer improved motion and strength for irreparable posterosuperior rotator cuff tears. This Technical Note aims to describe a reproducible technique for combining both procedures in one surgery, using the same allograft tendon for both. The use of quadriceps tendon allograft offers the potential for combined lower trapezius transfer and superior capsule reconstruction, providing a viable option for irreparable posterosuperior rotator cuff tears.

In the setting of a massive rotator cuff tear (RCT), attempted repair—in part or full—remains the standard of care, although outcomes are variable, retear rates high, and durability questionable.1, 2, 3 Lower trapezius tendon transfer (LTT) can replicate the infraspinatus fibers better than latissimus dorsi transfer, and therefore it seems that lower trapezius (LT) is the best transfer option in cases of posterosuperior irreparable RCTs because it can provide strong external rotation and abduction arm movement.^4,5 Superior capsule reconstruction (SCR) represented a revolutionary strategy in the last decade. After the first description by Mihata et al.,⁶ several modifications of the original technique have been proposed, mainly aiming to ease the procedure, to reduce costs, and to improve fixation strength of the selected graft. However, the basics remained unchanged.^7,8 What is currently known is that SCR is a good option to obtain a full range of motion back, even in cases of pseudoparalysis.^9,10 In cases of irreparable RCTs, the LTT needs to be elongated, and this is commonly accomplished with an Achilles tendon allograft11, 12, 13, 14, 15, 16 or an autograft semitendinosus.¹⁷ Both techniques have their own advantages and disadvantages, with autografts generally thought to incorporate faster and have a lower risk of inflammatory response at the cost of increased donor-site morbidity.¹⁸

Quadriceps tendon grafts, first described by Marshall et al.,¹⁹ have been used in anterior cruciate ligament reconstruction since the 1980s, when they were popularized by Blauth.²⁰ The quadriceps tendon’s substantial cross-sectional area prevents synovial bathing, which has been shown to stimulate osteoclast activity, causing bone resorption through the inflow of cytokines.²¹ Although allografts tend to require longer times for biologic vascularization and integration,²² they do have advantages of a wider variety of sizes and avoid donor-site morbidity that can lead to infections or the need to rehabilitate the autograft harvest site.22, 23, 24

Grafts are shuttled into the shoulder between the deltoid and native infraspinatus and attached to the chosen site on the humeral head (i.e., infraspinatus insertion).¹¹ This can be achieved via an open approach (deltoid split or acromial osteotomy) or by more recently described arthroscopic techniques.^11,14,15

It goes without saying that combination of SCR and LTT might be the best option to obtain motion and strength back in cases of primary or revision irreparable posterosuperior RCTs. The aim of this Technical Note is to describe a reproducible and reliable technique to combine both options in one surgery, using the same allograft for both procedures.

Patient Evaluation, Imaging, and Indications

It is of utmost importance to conduct a proper evaluation of patients with irreparable massive RCTs for the indication of tendon transfers. Although it is a relatively complex surgical procedure that requires precise patient selection, tendon transfer can significantly improve quality of life.

For young and physically active patients with injuries classified according to Hamada et al. as stages 1 and 2 (without glenohumeral arthritis and static migration of the proximal humeral head), tendon transfer may be the only eligible treatment. The indication for the transfer of the LT tendon is a valuable option for patients with massive RCTs because it is a tendon that anatomically has a force vector more similar to the anatomy of the tendons in the posterosuperior region of the rotator cuff.^25,26

The selected patient is a 58-year-old physically active male basketball player who presented with a massive RCT, as observed on magnetic resonance imaging (Fig 1, Fig 2, Fig 3), associated with significant replacement of the muscle bellies and without glenohumeral arthritis. The patient had previously undergone rotator cuff repair 8 years previously. Therefore, the transfer of the LT tendon with a quadriceps allograft was indicated. Informed consent was obtained from the patient who participated in this case report.

Fig 1.

Magnetic resonance imaging of the right shoulder, sagittal view. Patient in horizontal supine position.

Fig 2.

Magnetic resonance imaging of the right shoulder, coronal view. Patient in horizontal supine position.

Fig 3.

Magnetic resonance imaging of the right shoulder, axial view. Patient in horizontal supine position.

Surgical Technique

Patient Positioning and Diagnostic Arthroscopy

Place the patient in the beach-chair position, perform proper asepsis, and apply sterile drapes, ensuring the full exposure of the scapula up to the medial border for harvesting the LT tendon (Fig 4 and Video 1). Mark anatomical structures for creating the arthroscopic portals. Create a visualization portal and perform an inspection with a 30° arthroscope through the standard posterior portal, confirming the absence of significant glenohumeral arthritis. Inspect the subscapularis tendon to ensure its integrity.

Fig 4.

Clinical image of the patient in beach chair positioning and demarcation of anatomical references of the right shoulder.

Soft-Tissue Releases and Greater Tuberosity Preparation

An extensive release and cleaning of the rotator interval should be performed, with anterior capsular release extending inferiorly to allow for recentering of the humeral head in cases of superior humeral head migration. The subacromial bursa is removed, and the rotator cuff is evaluated. The retracted posterosuperior rotator cuff is tested by pulling remaining portion to confirm irreparability (Video 1).

LT Tendon Harvest

Make the medial border of the scapula, scapula spine, and LT tendon insertion. A horizontal incision of approximately 8 cm should be made over the LT tendon insertion, and the subcutaneous tissue should be dissected until the tendon is identified. The LT tendon, an oblique tendon with horizontal-oriented fibers, is separated from the scapula spine, and extensive mobilization is necessary superiorly and medially along the upper border of the tendon to separate it from the middle trapezius (Fig 5). Care must be taken to avoid injury to the spinal accessory nerve, which is located approximately 3 to 4 cm medial to the scapula.

Fig 5.

Patient in beach chair position. Harvesting the lower trapezius tendon through a posterior approach over the spine of the scapula of the right shoulder.

The quadriceps graft is prepared and then divided into 2 halves (bands) (Fig 6 and Video 1). From the medial incision, the infraspinatus fascia should be incised to create a path for the transfer. A grasping clamp is passed from the anterolateral portal out the medial (harvest) incision, and sutures attached to the quadriceps tendon allograft are pulled through the anterolateral portal, transferring the graft into the joint without twisting. The graft is anchored to the anterior portion of the greater tuberosity using 2 suture anchors with nonabsorbable sutures attached to the tendon allograft. Another suture anchor is placed posteriorly to secure the graft further (Fig 7). The arm is positioned in maximal external rotation and 90° of abduction. The superior band of the allograft is sutured using the Pulvertaft weave, and a suture anchor is used to fix it to the scapular spine (Fig 8). The lower band is fixed to the LT tendon via the Pulvertaft weave. This combined procedure is named Superior Trapezius Anatomic Reconstruction (STAR). The final result of the surgery is depicted in Figures 9 and 10 and a schematic illustration is presented in Figure 11.

Fig 6.

Quadriceps allograft prepared for transfer.

Fig 7.

Quadriceps allograft after fixation in the greater tuberosity of the right shoulder (Patient in beach chair position).

Fig 8.

Anchor fixation of the upper band of the allograft (Right shoulder - Patient in beach chair position).

Fig 9.

Final result on the medial side after transfer and fixation of the allograft with anchors (Right shoulder - Patient in beach chair position).

Fig 10.

Final result after allograft transfer and fixation with anchors in view through a lateral arthroscopic portal of the right shoulder.

Fig 11.

Schematic illustration of the surgical procedure - STAR.

Discussion

The rationale behind combining SCR and LTT is determined by the concept that SCR restores the coronal force couple whereas LTT restores the sagittal force couple. This concept was validated in a recent cadaveric study by Omid et al.,²⁷ which showed that adding SCR to LTT adds static stabilization to a dynamic stabilizer. Therefore, SCR plus LTT may provide additional stability. Elhassan et al.²⁸ were the first to report outcomes after the LTT arthroscopic technique in 2016. They evaluated 33 patients (26 men, average age 53 years) at an average follow-up of 47 months, demonstrating statistically significant improvements in pain, subjective shoulder value, and Disabilities of the Arm, Shoulder, and Hand score. Valenti and Werthel¹⁷ published results in 2018 using a similar technique but with a semitendinosus tendon autograft instead of an Achilles allograft. Their study, including 14 patients, showed improvements in external rotation and abduction, disappearance of lag sign and Hornblower sign, and reduced pain.

The LTT is considered a more anatomical alternative tendon transfer for irreparable posterior-superior RCTs than the latissimus dorsi transfer. Recent cadaveric studies have highlighted the LT as an ideal transfer option because of its location cranial to the latissimus dorsi and medial to the infraspinatus fossa, with a line of pull nearly identical to the infraspinatus.²⁹ The LTT provides a more effective external rotation moment arm compared with the latissimus dorsi transfer, with excursion and tension forces similar to the infraspinatus.³⁰

Traditional grafts for LTT include Achilles tendon allograft and semitendinosus tendon autograft. Mabe and Hunter³¹ demonstrated that Achilles tendon and quadriceps allografts have similar biomechanical characteristics. The advantage of the quadriceps tendon lies in its ability to be used in two bands in the medial part, mimicking the SCR superior band and the LTT inferior band. Compared with the semitendinosus tendon autograft, the quadriceps tendon allograft does not require removal from the patient and avoids fixation with a bone tunnel, reducing the risk of elongation, eventual failure, or tunnel widening.³² The use of a quadriceps tendon allograft presents a viable option for LTT surgery, providing similar biomechanical results to the Achilles tendon allograft. This technique allows for a construction that combines LTT and SCR, offering a comprehensive solution for irreparable posterosuperior rotator cuff tears (Tables 1 and 2).

Table 1.

Advantages and Disadvantages of the Procedure

Advantages	Disadvantages
The lower trapezius tendon transfer (LTT) is considered a more anatomical alternative tendon transfer for irreparable posterior-superior rotator cuff tears than the latissimus dorsi transfer	Prolonged rehabilitation time considering fixation technique
Quadriceps tendon can be used in 2 bands in the medial part, mimicking the superior capsule reconstruction superior band and the LTT inferior band	Cost to acquire the allograft
Less-aggressive surgical approach than the transfer of the latissimus dorsi tendon.

Table 2.

Pearls and Pitfalls for the Procedure

Pearls	Pitfall
Use the sutures attached to the allograft as guides to prevent twisting of the tendon	Avoid excessive tension on the tendon at the anchors at both fixation points.
First, fix the anterior portion of the graft to the greater tuberosity.
Keep the arm in maximum external rotation and 90° of abduction when fixing the tendon

Disclosures

All authors (C.V.A., P.H.S.L., L.M.R., F.S.B., P.S.B., A.d.C.P., B.E.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Dual-vector lower trapezius tendon transfer with quadriceps tendon allograft in massive rotator cuff tear: STAR (Superior Trapezius Anatomic Reconstruction) procedure.