Tears of the rotator cuff represent a leading reason for shoulder pain worldwide. Surgery is oftentimes considered for those individuals with a torn rotator cuff when symptoms do not improve despite medications, injections, and physical therapy. Luckily, many rotator cuff tears can be repaired arthroscopically. This is particularly true when cuff tears are repaired right after an injury. However, some cuff tears are so bad that they cannot be repaired surgically, or they have been repaired, but they never healed. Tendon transfers are one option to consider for bad rotator cuff tears that cannot be fixed.
Are you telling me that some cuff tears are not fixable?
You got it: we call them irreparable rotator cuff tears. It can be very frustrating for you as a patient -and for me as a surgeon- to realize that the damage is too extensive, and repairing the rotator cuff tear surgically will just not work: not even worth trying! Factors considered when attempting to determine if a tear is fixable or not include the presence of joint damage (secondary arthritis, also called cuff tear arthropathy), how large and chronic the tear is, how much tendon is actually left, and the condition of the muscle itself. Large, chronic, retracted tears oftentimes won’t even reach the area of bone where they are supposed to be reattached. Also, after tendons have been torn for a while, the corresponding muscles are not being used, and as a result they get weaker, smaller (they atrophy) and progressively replaced by fat (fatty infiltration). In these circumstances, even if the tendon were to reach the site of reattachment,… and heal,… the muscle would not have the power to make the surgery work.
I have a torn, unfixable rotator cuff tear…, now what?
The good news is that some individuals with a bad rotator cuff can cope with their somewhat imperfect shoulder. If you have a bad cuff tear that cannot be fixed, you may be able to function (although with some discomfort), and you may be able to avoid surgery all together. Remember that surgery for a chronic torn rotator cuff should only be considered when the resultant pain, weakness, or motion loss impairs your quality of life. Unfortunately, many of my patients with a torn unfixable rotator cuff tear are miserable: too painful to sleep at night, too difficult to put dishes away on a high shelf, too hard to even retrieve a parking ticket, play golf, enjoy life… If that is the way you feel, reconstructive shoulder surgery may be considered.
One option is to have your shoulder replaced. A few decades ago, a French surgeon by the name of Dr. Paul Grammont came up with the principles of a reverse shoulder replacement for patients with no rotator cuff left. Reverse shoulder arthroplasty has become one of the most successful procedures in modern shoulder surgery. However, it is not for everyone, and it has its fair share of potential issues: reaching behind the back may be close to impossible, restrictions are recommended to most patients (mostly not lifting heavy), and if complications happen, they can be hard to solve.
Another alternative is to consider a tendon transfer. Moving tendons to different locations so that they can compensate for tendons that are lost is not a new concept. Tendon transfers have been used for paralytic conditions for quite some time! What is new today is the use of one particular muscle-tendon unit, the lower portion of the trapezius, to compensate for an unfixable tear of the rotator cuff.
What is a tendon transfer?
Did you know that the human body has over 640 muscles? Even though every single muscle in your body is particularly important for specific tasks, the function of some muscles overlap to some extent. This is wonderful news because some muscles may be rerouted -and their tendons can be attached to a different spot in the skeleton- to compensate for the loss of function of another muscle. For example, in patients with paralysis of some of the nerves to the hand, lifting up the wrist and fingers may be impossible; however, rerouting tendons from one side of the forearm to the other allows patients to lift their wrist an fingers again,… magic!
If you like to work out at the gym, you may be familiar with some of the muscles around the shoulder region that have been considered for transfer in patients with bad tears of the rotator cuff. The pectoralis major has been considered when the main rotator cuff tendon in the front (the subscapularis) is torn. The latissimus dorsi has been considered when the tear involves the top and back of the cuff (supraspinatus-infraspinatus tears). One of my partners and a very good friend, Dr. Bassem Elhassan, came up with the idea of transferring the lower portion of the trapezius instead,… and it seems to work!
Transfer of the lower trapezius for irreparable cuff tears
Why the lower trapezius? So many reasons! The orientation of the muscle fibers of the lower trapezius is pretty much parallel to the orientation of the infraspinatus muscle. Surgery to transfer the lower trapezius is done through a relatively small skin incision, with the rest of the procedure being done arthroscopically. And more importantly, surgeons around the world are reporting good outcomes with this procedure. Do you want to know how is it done? Watch the video below.
What do I need to know as a patient if I am considering a lower trapezius transfer?
The first thing to know is that this is a new procedure, and should be discussed at length with your shoulder specialist to see if you are a candidate, and consider the pros and the cons of the surgical intervention. Your surgeon will likely try to repair your tendon tear first, at least as much as possible. The lower trapezius does not reach the shoulder joint fully without extending it with a tendon allograft (tendon from a cadaver donor used to make your trapezius tendon longer). After surgery, it is extremely important to keep the arm out in space (we call it external rotation), so you will need to use a somewhat cumbersome brace for at least six to eight weeks, maybe longer.
However, most of the procedure is performed arthroscopically, as an outpatient procedure, and many of our patients that have been considered candidates for the procedure have been satisfied to date.