Advancements in Shoulder Arthroscopy: Large to Irreparable Rotator Cuff tears
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Advancements in Shoulder
Arthroscopy: Large to
Irreparable Rotator Cuff tears
Detroit, MI
July 30, 2021
Shariff K. Bishai, D.O., M.S., FAOAO
Associated Orthopedists of Detroit, PC
Sports Medicine, Shoulder Surgery and Hip Arthroscopy
Assistant Professor, Michigan State University College of Osteopathic Medicine
Assistant Professor, Oakland University William Beaumont School of Medicine
Professor, Detroit Medical Center Sports Medicine Fellowship
Past-President, American Osteopathic Academy of Orthopedics Sports Section
Past-President, Detroit Academy of Orthopaedic Surgery
Shariff K. Bishai, DO, PC © 2021
Disclosures
u Paid Consultant
u DePuy Synthes, J&J
u Zimmer Biomet
u Stryker
u Arthrex
u Smith & Nephew
u Trice Medical
u BD
u Pacira
u RTI
u Xiros NA
u Anika Therapeutics
• Editoral Boards/Journal Reviewer
u Surgeon Advisory Boards • Journal of Shoulder and Elbow Surgeons (JSES), Reviewer
• Journal of Orthopaedic Experience and Innovation (JOEI), Editorial
u Mitek Sports Medicine Board
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Shoulder Pain
Ø United States:
u 4-6 Million People Per Year Seek
Medical Attention
u 1.5 Million Visits Per Year to
Orthopaedic Surgeons
Lehman RC: Shoulder pain in the competitive tennis player. Clin Sports Med. 7: 309-327, 1988.
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Anatomy
Ø Layer 1: Superficial fibers overlie the
cuff, an extension of the CHL
Ø Layer 2 and 3: Fibers of the rotator
cuff
Ø Layer 4: Deep extension of CHL
Ø Layer 5: Joint capsule (Superior
capsule)
Clark JM, Harryman DT II. JBJS 1992
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Layer 5 – Superior Capsular Reconstruction
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Tear Patterns
Ø Partial Thickness Tears
u PASTA Lesion
u PAINT Lesion
Ø Full Thickness Tears
u Small: Less than 1 cm
u Medium: 1-3 cm
u Large 3-5 cm
u Massive: Greater than 5 cm
u Irreparable
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Tear Patterns
Ø Partial Thickness Tears
u PASTA Lesion
u PAINT Lesion
Ø Full Thickness Tears
u Small: Less than 1 cm
u Medium: 1-3 cm
u Large 3-5 cm
u Massive: Greater than 5 cm
u Irreparable
Shariff K. Bishai, DO, PC © 2021
Rotator Cuff Disease
Defining the Tear
Ø Understanding the Footprint
u Average maximum length of 23
mm (range: 18 to 33 mm)
u Average maximum width of 16
mm (range: 12 to 21 mm)
Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR. The Instertional Footprint of the Rotator Cuff: An Anatomic Study. Arthroscopy
2006: 22 (6)603-609.
Shariff K. Bishai, DO, PC © 2021
Massive Rotator Cuff Tears: “Menu”
Ø Conservative
Ø Debride + tenotomy + rehab
Ø Partial repair
Ø Repair +/- ECM
augmentation/scaffold/biologics
Ø ECM interposition (bridging)
Ø Superior capsule reconstruction
Ø Subacromial spacer
Ø Latissimus/lower trap transfer
Ø Reverse Total Shoulder Arthroplasty
Shariff K. Bishai, DO, PC © 2021
Predictors of Rotator
Cuff Repair Success
Ø 33 Patients with MRI at 2 years
after repair
Ø Goutallier Grade 2 to 3 with 15 mm and no
fatty infiltration
uImaging
Goutallier D, CORR 1994; 304: 78
Shariff K. Bishai, DO, PC © 2021Predictors of Rotator Cuff Repair Success
Peter Chalmers et al
• Predictions based on
>2,500 patients and
algorithm built on multiple
studies
Shariff K. Bishai, DO, PC © 2021Does Age Affect Outcome?
Ø 49 pts arthroscopic double row repair evaluated
by US & clinical exam (6 mo-36 mo)
Ø 25 tears healed on follow up (51%)
u 67% if single-tendon
u 36% if multiple tendon
Ø All VAS, Active FF, ASES, & Simple Shoulder
test scores improved 2010, American Journal of Sports Medicine
Ø 55.1 vs 63.3 yo; younger more likely to heal
Ø Multivariant analysis found only age at time of
surgery and number of years at post-operative
follow-up correlated with cuff healing
Shariff K. Bishai, DO, PC © 2021Does Age Affect Outcome?
Ø 120 pts, 87 underwent post-op MRI
Ø 67% healed
Ø Incidence of retear increased with
age >60, size of initial tear, as well
as increased fatty degeneration
u Despite structural failures, mean 25 month
follow up showed excellent pain relief and
ability to perform ADLs
2011, American Journal of Sports Medicine
Shariff K. Bishai, DO, PC © 2021Does Smoking Affect
Outcome?
Ø 95Smokers (current & Hx 40ppd)
vs 129 Non-smokers
u UCLA scores
ü Pre-op 15.9 vs 17.6,
ü Post-op 25.0 vs 32.0
Ø Non-Smokers more likely to have
good to excellent results
Shariff K. Bishai, DO, PC © 2021Does Osteoperosis Affect
Outcome?
Ø 408 pts RCR, 272pts had CT arthrogram
or US used to verify cuff integrity
Ø BMD - DEXA scan at last pre-operative
visit
Ø Failure rate 22.8% (62/272)
u Multivariant analysis showed only BMD, fatty
infiltration of infra, and retraction size showed
significant relationship to cuff healing 2011, American Journal of Sports Medicine
Ø Odds ratio of cuff failure in patients with
osteoporosis vs normal were 1.56 and
0.22 respectively
Shariff K. Bishai, DO, PC © 2021Does Diabetes Affect
Outcome?
Ø 2462 patient (57 diabetics), 1o RCRs, median f/u
5.6yrs
u Adhesive Capsulitis: Diabetics 15.8% vs Non-
Diabetics 4.4%
u Cuff Re-Tear: Diabetics 26.3% vs Non-Diabetics
15.6%
u Any one complication: Diabetics 35.1% vs Non-
Diabetics 22.7%
ü Complications: Infection, Adhesive capsulitis, Re-
Tear, or Re-operation
Ø Diabetics diagnosed with A1c preoperatively
u Increasing A1c was NOT found to be associated
with higher risk of frozen shoulder, retear, or
reoperation 2020, Journal of Shoulder and Elbow Surgery,
Shariff K. Bishai, DO, PC © 2021 Retrospective reviewDoes Doxycycline Affect
Outcome?
Ø Rat Model, repair of supraspinatus
u Doxy-mediated inhibition of MMP-13
activity reduces excessive degradation or
remodeling of healing after RCR
Ø Benefit: Doxycycline has broad
spectrum antimicrobial activity against
Gram-positives & Gram-negatives,
including C. acnes
u Start before surgery or within 5 days Load to failure rate between
groups
2010, American Journal of Sports Medicine
Shariff K. Bishai, DO, PC © 2021Does Vitamin D
Affect Outcome?
Ø Rat Model, Vit-D deficient diet and UV light restriction
Ø Supraspinatus detached and repaired with bone tunnels suture fixation
Ø CT used to assess bone density and new bone formation at tuberosity
Ø Biomechanical testing demonstrated a significant decrease in load to failure
in experimental group compared to control at 2 weeks
u At 4 weeks no difference in load to failure between groups
u Histology showed less bone formation and less collagen fiber
organization in Vit-D deficient group
2013, American Journal of Sports
Medicine
Shariff K. Bishai, DO, PC © 2021Does Lipid Status Affect
Outcome? Cohort study, retrospective review
Ø 30,638 pts, between 40-85yo, 1o arthroscopic repairs
only, LDL/Cholesterol levels collected within 6
months of surgery
Ø Rate of revision increased in patients with moderate
to high total cholesterol levels
Ø Hyperlipidemia in patients without statin had higher
rates of revision
Ø Revision rate increased in patients with moderate &
high LDL levels
Ø High cholesterol environments cause lipids to
accumulate within extracellular matrix of tendon
which adversely affect stiffness and modulus
2017, American Journal of Sports Medicine
Shariff K. Bishai, DO, PC © 2021Level IV, Case Series
Ø Smoking history, diabetes mellitus, hyperlipidemia, vitamin D deficiency, & osteoporosis
Ø 41,467 patients (41,844 shoulders), primary arthroscopic RCR
u 3072 patients (3463 shoulders) underwent revision RCR (8.38%)
Ø ↑ age & male sex (odds ratio [OR] 1.10) were significantly predictive of revision RCR
Ø Smoking most strongly predicted revision RCR (OR 1.36,P2018, JBJS
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Shariff K. Bishai, DO, PC © 2021Ø 64pts, 2005-2008 PRGF injected into tendon
initially and then spread over top
Ø No significant differences in UCLA scores
between groups
Ø No differences at 1yr in patient satisfaction
Ø MR-Arthrogram
u 40% healed, 30% partial healing, 30% Lack
of healing
u No difference between PRGF and control
groups
2013, Level 1, Arthroscopy
Shariff K. Bishai, DO, PC © 2021Ø 48pts, PRP group had 3 PRP gels applied between torn
tendon and greater tuberosity
Ø Outcome measured via MRI or CTA at minimum 9
months post op
Ø Re-tear rate
u PRP group 20%, Conventional group 55.6%
u PRP group increase in cross-sectional area of
supraspinatus
u No difference in clinical outcomes, better structural
outcomes might suggest improved clinical outcomes
in longer term follow-up 2013, American Journal of Sports Medicine
Shariff K. Bishai, DO, PC © 2021DEBRIDE AND PARTIAL REPAIR
Shariff K. Bishai, DO, PC © 2021Massive Rotator Cuff Tears: “Menu”
Ø Debride + tenotomy + rehab
u Improves pain
u No consistent improvement of strength
or motion
Ø Partial repair
u Margin convergence can restore
balanced force couples
u No consistent improvement
u As high as 52% retear rates
Kim et al. Am J Sports Med 2012 Apr;40(4):786-93. doi:
10.1177/0363546511434546. Epub 2012 Feb 3.
Berth et al. J Orthop Traumatol . 2010 Mar;11(1):13-20. doi: 10.1007/s10195-
ü Kim et al: 42.4% (MRI) 010-0084-0. Epub 2010 Mar 3.
ü Berth et al: 52% (US) Shariff K. Bishai, DO, PC © 2021SUPERIOR CAPSULAR
RECONSTRUCTION
Shariff K. Bishai, DO, PC © 2021The Superior Capsule
Ø Passive constraint for the
glenohumeral joint to
superior humeral head
translation
Ø Rotator cuff is a dynamic
stabilizer to the joint
Ø Resists superior migration
of the humeral head with
deltoid contraction
Shariff K. Bishai, DO, PC © 2021Superior Capsular Reconstruction
(SCR) Rationale JSES 2014
Ø Superior capsule : 4-9 mm thick, and covers 30-60% of the greater tuberosity
Ø Absent superior capsule, humeral translation increases in all planes
Ø SCR can reverse superior translation and decrease subacromial contact pressures
Shariff K. Bishai, DO, PC © 2021Indications for SCR
Ø Intolerable pain and/or
unacceptable dysfunction
with irreparable rotator cuff
tear(s)
Ø Hamada Grade 1 or 2
Ø Intact or repairable
subscapulris
Shariff K. Bishai, DO, PC © 2021Contraindications for SCR
Ø Rotator cuff tears with
moderate to severe rotator
cuff arthropathy
Ø Hamada Grade ≥ 3
Ø Glenohumeral osteoarthritis
Ø Irreparable subscapularis
Shariff K. Bishai, DO, PC © 2021Rotator Cuff Disease
Irreparable Tears
Ø Superior Capsular Reconstruction
u Mihata described using Tensor Fascia
Lata
ü In the US, dermal allograft used
u Pushes humeral head down to allow
prevention of superior migration and
to provide fulcrum for motion
Shariff K. Bishai, DO, PC © 2021SCR: Reversing Superior Translation
Mihata T. Am J Sports Med. 2016 Jun;44(6):1423-30. doi: 10.1177/0363546516631751. Epub 2016 Mar 4.
Biomechanical Role of Capsular Continuity in Superior Capsule Reconstruction for Irreparable Tears of the Supraspinatus Tendon.
J Shoulder Elbow Surg. 2014 May;23(5):642-8. doi: 10.1016/j.jse.2013.09.025. Epub 2013 Dec 31.
Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
Shariff K. Bishai, DO, PC © 2021SCR: Reduces Subacromial Contact
Pressure
Mihata T, Am J Sports Med. 2016 Jun;44(6):1423-30. doi: 10.1177/0363546516631751. Epub 2016 Mar 4.
Biomechanical Role of Capsular Continuity in Superior Capsule Reconstruction for Irreparable Tears of the Supraspinatus Tendon.
J Shoulder Elbow Surg. 2014 May;23(5):642-8. doi: 10.1016/j.jse.2013.09.025. Epub 2013 Dec 31.
Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
Shariff K. Bishai, DO, PC © 2021Importance of Posterior Rotator Cuff
Continuity with SCR
Technique Superior Migration Subacromial Contact Compression force ROM
Pressure
SCR alone No effect decreased No effect No effect
SCR + posterior s/s reversed decreased No effect No effect
sutures
SCR+ posterior and No addl effect No addl effect No addl effect No addl effect
anterior s/s sutures
Mihata T, Am J Sports Med. 2016 Jun;44(6):1423-30. doi: 10.1177/0363546516631751. Epub 2016 Mar 4.
Biomechanical Role of Capsular Continuity in Superior Capsule Reconstruction for Irreparable Tears of the Supraspinatus Tendon.
J Shoulder Elbow Surg. 2014 May;23(5):642-8. doi: 10.1016/j.jse.2013.09.025. Epub 2013 Dec 31.
Role of the superior shoulder capsule in passive stability of the glenohumeral joint.
Shariff K. Bishai, DO, PC © 2021Effect of Graft Thickness
2016
Ø < 4 mm graft reduced subacromial contact pressure
u Superior migration not improved
Ø 8 mm graft attached at 15 – 45o abduction reversed superior
migration and decreased subacromial contact pressure
Arthroscopy. 2016 Mar;32(3):418-26. doi: 10.1016/j.arthro.2015.08.024. Epub 2015 Oct 30.
Shariff K. Bishai, DO, PC © 2021Biomechanics of Different Grafts
Ø Decreased subacromial contact pressure with
the use of 8-mm fascia lata graft compared to
4-mm acellular humeral dermal allograft
u Fascia lata allograft has less elongation and
thinning than dermal graft
Ø Clinical outcome data between 2 graft
methods should not be generalized
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Mihata 2013
Ø Level 4
Ø 23 patients (24 shoulders)
Ø Age 65.1 (52-77), Duration of follow up 34.1 months
(24-51)
Ø Graft: Fascia lata autograft (6-8 mm)
Ø 83.3% healed
u Mean active forward elevation: 84o to148o
u Mean external rotation: 26o to 40o
u Mean acromial humeral distance: 4.6 mm to 8.7 mm
Ø Mean ASES score improved: 23.5 to 92.9
Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, Kinoshita M. Clinical results of arthroscopic superior capsule
reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013 Mar;29(3):459-70. Epub 2013 Jan 28.
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Hirahara 2017
Ø Level 3
Ø 8 patients
Ø Age 61.3 (47-78), Duration of follow up 32.4 months (25-39)
Ø Graft: Acellular dermal allograft
Ø VAS score decreased: 6.25 to 0.38
u Mean acromial humeral distance increased: 4.5 mm to 8.48 mm
immediately after surgery and 7.6 mm at 2 years
Ø Mean ASES score improved: 43.54 to 86.46
Ø 2 Failures
u 1 patient revised to rTSA and 1 graft rupture after MVA
Hirahara AM, Andersen WJ, Panero AJ. Superior capsular reconstruction: clinical outcomes after minimum 2-year follow-up. Am J Orthop
(Belle Mead NJ). 2017 Nov/Dec;46(6): 266-78.
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Mihata 2018
Mihata T, Lee TQ, Fukunishi K, Itami Y, Fujisawa Y, Kawakami T, Ohue M, Neo M. Return to sports and physical work after
arthroscopic superior capsule reconstruction among patients with irreparable rotator cuff tears. Am J Sports Med. 2018
Apr;46(5):1077-83. Epub 2018 Mar 2.
Ø 100 patients
Ø Age 66.9 (43-82), Duration of follow up 48 months
(24-88)
Ø Graft: Fascia lata autograft (6-8 mm)
Ø Complication rate: 16%
u Includes 5 graft tears
u Mean active forward elevation increased: 91o to147o
u Mean external rotation increased: 26o to 41o
u Mean internal rotation increased: L4 to L1
Ø Mean ASES score improved: 36 to 92
Ø Mean Japanese Orthopaedic Association score
improved: 53 to 91 Level 3
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Dinard 2018
u Level 4 Graft: Acellular dermal allograft
u 59 patients
u 1-year f/u (16-28); Mean age 62 ± 8.7years
u42% with prior cuff repair
u VAS 5.8 à 1.7
u ASES 43.5 à 77.5
u Mean forward flexion increased: 130o to 158o
u Mean external rotation increased: 36o to 45o
u AHI unchanged; only 45% (9 of 20 studied) healed
u “Healed” group with better outcomes
u Success: 67.8% (if 1 mm grafts excluded, 73%)
Arthroscopy. 2018 Jan;34(1):93-99. doi: 10.1016/j.arthro.2017.08.265. Epub 2017 Nov 13.
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Denard 2018
u 11 Failures
u 7 failures on humeral side; 3
intrasubstance; 1 glenoid
u 100% success rate in those with
healed graft
u Takeaway points:
u Hamada I and II best candidates
u Higher subscapularis atrophy
significant for poorer prognosis
Arthroscopy. 2018 Jan;34(1):93-99. doi: 10.1016/j.arthro.2017.08.265. Epub 2017 Nov 13.
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Pennington 2018
Pennington WT, Bartz BA, Pauli JM, Walker CE, Schmidt W. Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment
of massive irreparable rotator cuff tears: short-term clinical outcomes and the radiographic parameter of superior capsular distance. Arthroscopy. 2018
Jun;34(6):1764-73. Epub 2018 Feb 15.
Ø Level 4
Ø 86 patients (88 shoulders)
Ø Follow up consecutive SCR for MRCT; min 1 yr f/u
Ø Age 59.4 (27-59)
Ø Graft: Acellular dermal allograft
u VAS 4.0 à 1.5
u ASES 52 à 82
u AHI: pre-op 7.1 à post op 9.7
Ø Superior capsular distance: pre-op 53 mm; post op 46 mm
u Distance from humerus to glenoid
u Strength and ROM improved
Ø 90% satisfied
Shariff K. Bishai, DO, PC © 2021SCR Outcomes – Mihata 2019
u Level 4
u 30 patients
u 5-year f/u (16-28); Mean age 62
± 8.7years
u Graft: Tensor fascia lata
autograft
u At 5 years, healed SCR
restored shoulder shoulder
function and resulted in higher J Bone Joint Surg Am.2019;101:1921-30 http://dx.doi.org/10.2106/JBJS.19.00135
rates of return to sport and work
u Patients with graft failure had
severe cuff tear arthropathy
Shariff K. Bishai, DO, PC © 2021Shariff K. Bishai, DO, PC © 2021
SCR vs. Partial Infraspinatus
Repair for Irreparable Tears
Ø 21 SCR patients, 20/60 partial repair patients matched in a 1:1 ratio by sex,
age, and tear configuration, (Goutallier grade ≥3)
Ø Minimum follow-up 2 yrs, mean 29.4 mo (range, 24-53 mo)
Ø Mean age of both groups 62.3 yrs (range, 47-79 yrs)
Ø No significant differences seen between the SCR vs. PR groups in Constant
score, Age- and sex- adapted Constant score, DASH score and WORC index
u Reoperation rate was 4.8% (1/21) SCR cohort & 15% (9/60) PR cohort
Ø Conclusion: SCR and PR resulted in significant improvements in patient-
reported outcomes at 2-year follow-up, with no significant differences in
clinical outcomes
Shariff K. Bishai, DO, PC © 2021 2021,Cohort study; Level of evidence, 3.SCR Technical Tips
u Position:
u Fix lateral SCR at 45o of abduction and 20o of internal
rotation
u Graft thickness:
u 8mm better than 4 mm for decreasing superior translation
u 4mm+ decreases subacromial contact pressure
u Grafts not at least 3 mm will elongate by 15% leading to
thinning of the graft
Shariff K. Bishai, DO, PC © 2021SCR 2021: Conclusions
Ø Indications (evolving) for SCR:
u Younger, active, SSc intact or repairable, absence OA,
absence acetabularization, external rotation 3-4/5, compliant
Ø SCRs are technically challenging
Ø Dermal allograft (4-8 mm) is currently the best
ECM option
Ø Primary repair is the first goal (+/- augmentation)
Ø Fix what you can
Shariff K. Bishai, DO, PC © 2021TENDON TRANSFERS
LOWER TRAPEZIUS VS. LATISSIMUS
DORSI
Shariff K. Bishai, DO, PC © 2021Rotator Cuff Disease
Irreparable Tears
Ø Arthroscopic Assisted Lower
Trapezius Tendon Transfer
u Symptomatic irreparable RCT
u No anterosuperior escape or
pseudoparesis
u Good subscapularis (or repairable)
u External rotation lag sign
u Intact Teres minor
Shariff K. Bishai, DO, PC © 2021Posterosuperior Rotator Cuff Tears
Ø Not all repairable
Ø Irreparability
u Massive tears (2+ tendons)
u Fatty atrophy (Goutallier III-IV)
u Substantial retraction (glenoid)
u Proximal humeral migration
Shariff K. Bishai, DO, PC © 2021Trapezius Anatomy
Ø Origin
u Medial third superior nuchal line, ligament nuchae, spinous
processes and supraspinous ligaments to T12
Ø Insertion
u Upper fibers to lateral third of posterior border of clavicle; lower
to medial acromion and superior lip of spine of scapula to deltoid
tubercle
Ø Action
u laterally rotates, elevates and retracts scapula. If scapula is
fixed, extends and laterally flexes neck
Ø Innervation
u Spinal accessory nerve (C1-5) (spinal nerves C3 and C4 for
proprioception) Shariff K. Bishai, DO, PC © 2021Principles of Tendon Transfers
Ø The transferred and recipient muscles should have a similar
excursion and tension
Ø The transferred muscle must be expendable
Ø The transferred and recipient tendons should have a similar
line of pull
Ø The transferred muscle should be designed to replace only 1
function of the recipient muscle
Brand PW, Beach RB, Thompson DE. Relative tension and potential excursion of muscles in the forearm
and hand. J Hand Surg Am 1981;6:209-19.
Shariff K. Bishai, DO, PC © 2021Why Lower Trapezius Transfer?
Ø Fairly simple transfer
Ø Arthroscopically assisted
Ø Better restoration of shoulder biomechanics
u The line of pull of the lower trapezius more closely mimics the
infraspinatus tendon
Ø Ease of post operative training the transfer
u trapezius contracts during shoulder external rotation
Ø Partial subscapularis tear is not a contraindication
Shariff K. Bishai, DO, PC © 2021Rotator Cuff Disease
Petriccioli et al, 2016 JSES Irreparable Tears
Ø Latissimus Dorsi Transfer
u 25 patients with Lat Transfer anterior to the triceps
ü Follow-up, 35.7 months (range, 12-60 months)
u Revision and primary patients with mean increase in
Constant-Murley scores of 29.5 and 30.5 points,
respectively
u Osteoarthritis progression in 33.3% of patients
u Good clinical outcomes at a midterm follow-up,
especially in active men 60 years of age or younger
and in patients with low preoperative elevation (Latissimus vs. Lower
Trap Transfers
Ø Good results reported with latissimus transfer
u Not reproducible by all surgeons
u Out of phase transfer
u More difficult
u Morbidity if pedical injuried
Ø Biomechanical testing comparison
Ø Lower trap superior restoring native GH kinematics
and joint reaction forces
Shariff K. Bishai, DO, PC © 2021Lower Trapezius
Transfer
Ø Originally describe by Elhassan for
the paralytic shoulder (trauma,
obstetrical)
Ø Significant improvement of external
rotation
Ø Marginal improvements of abduction
and flexion
Shariff K. Bishai, DO, PC © 2021Ø Anatomically distinct insertion sites for
u Lower trapezius - inserted at the scapular
spine dorsum
u Middle trapezius- broadly along the superior
surface of the scapular spine
Ø Lower trapezius reliably identified without
violating fibers of the middle trapezius
Ø Muscle splitting
u Spinal accessory nerve approximately 2 cm
medial to the medial scapular border
Shariff K. Bishai, DO, PC © 2021Ø 33 patients with an average age of 53
years
Ø Average follow-up of 47 months
Ø 32 patients had significant improvement
in pain, SSV, and DASH score
Ø ROM
u Flexion-120°
u Abduction- 90°
u ER-50°
Shariff K. Bishai, DO, PC © 2021Ø Patients with>60 degree of preoperative flexion
u more significant gains in ROM
Ø Shoulder ER improved in all patients
u Not related to pre-op ROM
Ø Complications
u 4 seromas- observation only
u 1 infection (BMI=36) requiring shoulder fusion
Ø Conclusion
u LT transfer may lead to good outcome in most patients
Shariff K. Bishai, DO, PC © 2021Lower Trapezius Transfer MRI at 3 Months
Shariff K. Bishai, DO, PC © 2021Bishai Algorithm for Full Thickness
Rotator Cuff Tears
Cuff Repair with Dermal SCR with Dermal Lower Trapezius with Achilles
Allograft, Xenograft, or Allograft Allograft
Synthetic • Irreparable supraspinatus • Irreparable supraspinatus and infraspinatus
and intact or repairable +External Rotation Lag sign
• Thin Tissue •
infraspinatus
• None to minimal glenohumeral
• Smoker • None to minimal osteoarthritis
glenohumeral osteoarthritis
• Diabetic, hypothyroid • Intact or repairable subscapularis
• Intact or repairable
• Revision subscapularis
Shariff K. Bishai, DO, PC © 2021THANK YOU
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