Abstract
Massive irreparable rotator cuff tears, particularly those involving the posterosuperior cuff, pose significant functional challenges. Arthroscopy-assisted lower trapezius transfer has emerged as the preferred treatment for patients with these tears, especially in the absence of glenohumeral arthritis. Although traditional techniques often use Achilles tendon allografts, limitations in cost and availability in developing countries necessitate the development of innovative alternatives. This article describes a surgical technique that uses a doubled peroneus longus autograft. We detail the surgical steps, technical nuances, and potential advantages of this approach.
Technique Video
Massive irreparable rotator cuff tears involving the posterosuperior cuff can lead to significant disability because of the loss of abduction strength and external rotation. Lower trapezius transfer (LTT), which mimics the biomechanical line of pull of the infraspinatus and teres minor, has become an effective option for restoring function in such cases.
Historically, the procedure relies on allografts, such as Achilles tendon allograft, to act as interposition grafts. However, in developing countries, the cost and availability constraints of allografts often limit their widespread use. Autografts such as fascia lata autograft have been explored.1,2 However, these options may lack the tensile strength needed to withstand mechanical loads over time. A technique with a single-strand peroneus longus (PL) autograft has been described.3 PL autograft is readily available, with minimal donor-site morbidity. When doubled, PL autograft offers superior strength. This article provides a step-by-step description of the surgical technique of LTT with doubled PL autograft as an interposition graft.
Surgical Technique
Patient Positioning and Setup
The patient is placed under general anesthesia and positioned in the beach-chair position. The affected arm is secured in an arm-holding device, ensuring adequate access to the scapula (Fig 1).
Fig 1.
Patient positioning and surface marking for lower trapezius harvest. (A) The patient is placed in the beach-chair position with the affected right arm supported on an arm-holding device. The surgical field is prepared and draped in such a way that the entire scapular region is exposed, allowing access to the insertion of the lower trapezius tendon on the scapular spine. (B) The soft spot just inferior to the superomedial angle of the scapula is palpated. An oblique incision line is marked just below this to facilitate the exposure and harvest of the lower trapezius tendon.
Diagnostic Arthroscopy and Preparation of Rotator Cuff Footprint
A standard posterior portal is established, and diagnostic arthroscopy is performed. The condition of the subscapularis is noted. If there is a subscapularis tear, it is repaired to the footprint on the lesser tuberosity. The absence of glenohumeral arthritis is confirmed. The presence of a massive posterosuperior cuff tear is documented. The arthroscope is redirected to the subacromial space. Thorough release of the medial, anterior, and posterior attachments of the rotator cuff is performed. The irreparability of the rotator cuff is confirmed after adequate release of the cuff. The supraspinatus and infraspinatus footprints on the greater tuberosity are prepared.
Harvesting of PL Autograft
Incision and Exposure
A 1-cm vertical skin incision is made 3 fingerbreadths above the tip of the lateral malleolus (which we refer to as the “3-finger technique”—placing the harvest above the superior peroneal retinaculum and the fibro-osseous tunnel) and in line with the PL just posterior to the lateral malleolus; care is taken to avoid the sural nerve. The fascia is incised, and the PL and brevis tendons (i.e., the “2 brothers”) are exposed. These tendons are then pulled out just above the common peroneal tunnel (Fig 2 A and B).
Fig 2.
Harvest and preparation of peroneus longus tendon graft. (A) Surface marking for incision to harvest the peroneus longus tendon on the right knee. The 3-finger technique is performed, and an incision is made approximately 3 fingerbreadths above the tip of the lateral malleolus on the lateral aspect of the leg. This provides optimal access to the peroneus longus and brevis tendons without damaging the peroneal retinaculum. The patient was positioned in Beach Chair position with the knee flexed at 30° during the procedure. (B) Intraoperative image showing the pulled-out peroneus longus and brevis tendons (gray arrow). (C) Prepared peroneus longus tendon after doubling. The tendon is folded, and the 2 free ends are sutured together using No. 2 FiberWire (orange arrow). The looped end is prepared with a separate FiberWire for each strand (red arrow) of the loop; the strands of tendon at the looped end are then interlinked with an absorbable suture. Two FiberWire limbs from the loop are used for subsequent anchoring with knotless anchors behind the bicipital groove on the supraspinatus footprint. The looped end (gray arrow) is marked with a blue surgical marker to aid in visualization within the subacromial space during graft passage. (D) The final length of the prepared graft after doubling is approximately 12.5 cm.
Tendon Harvesting
The distal part of the PL is sutured to the peroneus brevis (soft-tissue tenodesis). Above the tenodesis site, the PL is whipstitched with No. 2-0 FiberWire (Arthrex, Naples, FL) and blunt dissection is performed in the subcutaneous plane with scissors. PL tenotomy is performed just above the tenodesis site. PL harvest is conducted with a closed tendon stripper proximally up to a point 3 fingerbreadths distal to the head of the fibula (protecting the common peroneal nerve). After harvest, closure of the deep fascia was ensured to avoid peroneal herniation.
Graft Preparation and Doubling
The graft is prepared and doubled, resulting in a length of 12 to 14 cm. After doubling, the free PL strands are prepared with whipstitches performed using a single No. 2-0 FiberWire, which will be used for lower trapezius Pulvertaft stitching. The looped end of the PL graft is whipstitched for about 3 cm using a separate FiberWire for each of the 2 strands. In addition, inter-strand stitches are placed with absorbable sutures—thereby making the looped end of the PL graft flat for humeral footprint placement with 2 pairs of FiberWire strands—to be fixed with 2 knotless anchors (Fig 3 C and D).
Fig 3.
Preparation of lower trapezius tendon and graft passage into subacromial space. The patient is positioned in beach chair position with the affected right arm on arm holder (A) Clinical image showing the incision site for the exposure of the lower trapezius tendon, located just inferior to the scapular spine. The incision provides direct access to the insertion of the lower trapezius tendon. (B) Intraoperative image showing the removal of the adipose tissue pad near the insertion of the lower trapezius onto the scapular spine. This step is essential for clear visualization and identification of the tendon. (C) The lower trapezius tendon has been dissected and mobilized. A whipstitch using FiberWire has been applied to the free end of the tendon for secure traction. The correct identification of the lower trapezius can be confirmed by visually observing the excursion. (D) An arthroscopic grasper is inserted through the lateral portal and directed through the subacromial space and is then advanced in the plane between the infraspinatus and deltoid under arthroscopic visualization, exiting at the site of the open incision where the lower trapezius tendon was harvested. This grasper is used to pull the prepared peroneus longus graft from the open incision into the subacromial space, advancing it in the plane between the deltoid and infraspinatus muscles.
Lower Trapezius Transfer
Exposure and Release of Lower Trapezius
A 3-cm-long horizontal incision is made 1 cm below the superomedial aspect of the scapula (Fig 3A). The lower trapezius tendon is identified and released from the scapular spine at the insertion site after removal of the superficial fat (Fig 3B). The end of the lower trapezius tendon is prepared with whipstitches using a No. 2-0 FiberWire (Fig 3C). Confirmation of LTT can be made by evaluating for tendon excursion. Care is taken not to dissect medial to the scapula’s medial border to avoid the risk of injury to the spinal accessory nerve.
Graft Passage
The arthroscope is reinserted into the subacromial space. A suture grasper is passed in the interval between the infraspinatus and deltoid from the subacromial space, exiting at the level of the lower trapezius (Fig 3D). The prepared doubled PL tendon is shuttled in this space and brought to the footprint. This shuttling is performed so that the looped end of the doubled graft is at the rotator cuff footprint and the free strands of the doubled graft are available to be stitched with the lower trapezius tendon.
Graft Fixation
The PL graft is fixed using 2 knotless lateral-row anchors centered over the supraspinatus footprint posterior to the bicipital groove (Fig 4 A-C). The PL graft is also sutured with the remaining posterior cuff tissue using FiberWire (Fig 4D). This enables the flattened, thick PL graft to cover the entire infraspinatus footprint and entire supraspinatus footprint, balancing the force couple to improve external rotation and functional elevation.
Fig 4.
Arthroscopic graft fixation and partial rotator cuff repair (with the patient in beach chair position and the operated right arm on arm holder). (A) Arthroscopic view from anterolateral portal. The prepared graft (black arrow) is introduced into the subacromial space through the lateral portal using a suture grasper. The blue-marked looped end of the graft aids in easy identification within the subacromial space. (B) Viewing from the anterolateral portal, the surgeon inserts the first knotless anchor (black arrow) just posterior to the bicipital groove at the supraspinatus footprint for fixation of the graft (green arrow). (C) An arthroscopic image shows the insertion of a second knotless anchor (black arrow) into the supraspinatus footprint, again positioned just behind the bicipital groove, to further secure the graft. The viewing portal remains the anterolateral portal. (D) Viewing from the posterior portal, the surgeon partially repairs the remaining native rotator cuff to the graft. Bites are taken from the remaining cuff tissue (green arrow) using a retrograde suture-passing device (black arrow). Sutures are then passed through the graft and tied, achieving a side-to-side repair of the native tissue to the graft.
Attachment to Lower Trapezius
Multiple cycles of internal and external rotation of the shoulder are performed to eliminate creep. The arm is placed in a position of 60° of abduction and maximal external rotation, and the peroneus graft is woven in Pulvertaft fashion and sutured to the lower trapezius tendon using No. 2-0 FiberWire. Three-layer tenodesis—Pulvertaft weaving and strand-to-strand stitching of the doubled PL graft and strands to the trapezius stitching is performed. Smooth sliding of the PL interposition graft is evaluated, and the procedure is completed after washing and layered wound closure. Pearls and pitfalls of this technique are presented in Table 1, and advantages and disadvantages are listed in Table 2. A demonstration of this technique is shown in Video 1.
Table 1.
Pearls and Pitfalls
| Procedure | Pitfalls | Pearls |
|---|---|---|
| Beach-chair positioning of patient | The entire scapula including its medial border should be exposed to access the lower trapezius tendon. | Orientation is easy for lower trapezius transfer in the beach-chair position when compared with the lateral position. |
| PL graft harvest | Care should be taken to avoid injury to the common peroneal nerve during PL graft harvest. | The PL graft is thick and easy to harvest, with lower donor-site morbidity. |
| Lower trapezius harvest | Dissection should be limited to the lateral side of the medial border of the scapula to avoid injury to the spinal accessory nerve. | The lower trapezius is a superficial tendon. Dissection below the superomedial angle of scapula, close to the fat pad, will help the surgeon identify the tendon. |
| Graft tensioning and fixation | Appropriate graft tensioning and arm position during fixation are needed to achieve good external rotation. | The Pulvertaft technique for graft fixation with 3-layer tenodesis of the graft will help the surgeon achieve robust fixation. |
PL, peroneus longus.
Table 2.
Advantages and Disadvantages of Arthroscopy-Assisted Lower Trapezius Transfer With Doubled PL as Interposition Graft
| Advantages |
| The use of PL autograft is cost-effective and lowers the chance of the spread of infection when compared with allograft options. |
| Doubling the PL increases the strength and thickness of the autograft. |
| Partial repair of the remaining rotator cuff to the PL enables coverage of the entire rotator cuff footprint. |
| Disadvantages |
| Donor-site morbidity, though minimal, is present when compared with allograft-based techniques. |
| When the harvested graft is shorter, this technique can be difficult to execute. |
| In some chronic cases, partial repair of the rotator cuff is not possible. |
PL, peroneus longus.
Rehabilitation Protocol
The arm is placed in an abduction–external rotation splint at 30° of abduction and 40° of external rotation for 6 weeks to facilitate graft healing. Elbow and wrist mobilization exercises are started immediately. After 4 weeks, pendulum shoulder exercises, passive shoulder flexion and extension, and abduction are initiated. Rotation to a neutral position is allowed. After 6 weeks, active range-of-motion exercises and a gradual increase in internal rotation are commenced, and the splint is removed.
Discussion
Biomechanical studies support the use of the lower trapezius over the latissimus dorsi for tendon transfers in irreparable cuff tears.4,5 Unlike the latissimus dorsi, which creates an adduction force and requires greater deltoid compensation for abduction, the lower trapezius more closely replicates the line of pull of the infraspinatus. Studies show that LTT restores both the abduction and external rotation moment arms when attached to the infraspinatus and supraspinatus footprints.6
Whereas Achilles tendon allografts are commonly used for bridging,7,8 they pose cost and availability challenges in developing countries. This has led to the use of autografts such as fascia lata and semitendinosus autograft. The use of PL autograft remains sparsely documented, despite its established success in knee ligament reconstructions.9 The PL autograft offers several advantages: It is thick and durable and has low donor-site morbidity. Harvesting the PL tendon appears to result in minimal donor-site morbidity, with no significant impact on ankle function.10 The doubled construct significantly enhances tensile strength, reducing the risk of graft failure under mechanical loads. We fix the graft to the supraspinatus footprint, similar to Elhassan et al.,11 who reported favorable outcomes even in patients with subscapularis tears.
Arthroscopy-assisted LTT using a doubled PL autograft is a robust and cost-effective option for the management of irreparable posterosuperior rotator cuff tears. This innovative approach addresses the limitations of traditional allografts and provides a feasible alternative for patients in resource-limited settings.
Disclosures
All authors (K.K., S.R., G.C.) 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
Steps involved in arthroscopy-assisted lower trapezius transfer for a massive irreparable supraspinatus-infraspinatus tear, along with a partial subscapularis tear after subscapularis repair. The doubled peroneus longus is used as an interposition graft for the lower trapezius transfer. The procedure is performed with the patient in the beach-chair position. The right shoulder is being operated. The peroneus longus graft is harvested from the ipsilateral leg.
References
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Associated Data
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Supplementary Materials
Steps involved in arthroscopy-assisted lower trapezius transfer for a massive irreparable supraspinatus-infraspinatus tear, along with a partial subscapularis tear after subscapularis repair. The doubled peroneus longus is used as an interposition graft for the lower trapezius transfer. The procedure is performed with the patient in the beach-chair position. The right shoulder is being operated. The peroneus longus graft is harvested from the ipsilateral leg.