Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique  Bassem T. Elhassan, M.D., Eduard Alentorn-Geli, M.D., M.Sc., Ph.D., F.E.B.O.T., Andrew T. Assenmacher, M.D., Eric R. Wagner, M.D.  Arthroscopy Techniques  Volume 5, Issue 5, Pages e981-e988 (October 2016) DOI: 10.1016/j.eats.2016.04.025 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Intraoperative picture showing the patient's positioning. The patient is placed in a beach chair position with an open-backed chair and use of a McConnell head holder. Note that the entire ipsilateral half of the back is uncovered by the drapes so that there is easy access to the medial aspect of the scapula for lower trapezius tendon harvesting. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Surgical field drawing of most important landmarks: the borders of the scapula, origin of the lower trapezius from T4 to T12, and its insertion on medial 2-3 cm of the spine of the scapula. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Lower trapezius tendon harvesting. (A) Identification of the fat area (white arrow) below the inferior border of the lower trapezius tendon. The lower trapezius muscle belly (black arrow) may be a helpful landmark to identify the triangular fat area. (B) Dissection of the lower trapezius tendon up (white arrow) to its insertion in the spine of the scapula (black arrow). (C) Release of the lower trapezius by incising the muscle fascia superficially toward its origin following the upper border of the tendon (white arrow) in line with the spine of the scapula. (D) Final appearance of the lower trapezius harvest. Note that the line of pulling of the lower trapezius muscle (white arrows) is the same as the infraspinatus muscle (black arrows). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Final appearance of the lower trapezius tendon harvest with 2 No. 2 Orthocord sutures (DePuy Synthes, Warsaw, IN) in a Krakow configuration placed in the tendinous part. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Achilles allograft preparation. The osseous portion of calcaneus is removed and 2 No. 2 Orthocord sutures (DePuy Synthes, Warsaw, IN) are placed in a Krakow configuration at the thick end of the allograft. We recommend using sutures of different colors or mark one of them to clearly distinguish the proximal and distal sides. The ventral or dorsal (dark blue lines) part of the allograft should also be marked. The thin side of the allograft is tagged with another suture to avoid lateral migration of the thin part of the allograft while passing it to the joint in cases of large patients or short grafts. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Main portals used in this technique: posterior (P), anterolateral (AL), and lateral portals (L). The posterior portal is placed more proximal and lateral than usual, which allows a better visualization of the tuberosity and repair. The anterolateral portal is placed 1-2 cm lateral from the anterolateral edge of the acromion. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Incision over the infraspinatus fascia. The first step to create the passing plane for the allograft is the opening of the infraspinatus fascia. In the medial incision, the lower trapezius tendon is first retracted medially (thick white arrow), and the infraspinatus fascia is easily identified because it is usually distended with arthroscopic fluid. The fascia is incised (thin white arrow) and the infraspinatus muscle can be clearly visualized underneath the fascia (black arrow). Opening of the fascia medially is crucial to allow adequate allograft passage. Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Intraoperative demonstration of a large grasping clamp (white arrow) introduced into the joint through the anterolateral portal and aimed posteromedially toward the medial incision (black arrow). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 Achilles allograft passage. The allograft tendon has been brought into the joint by pulling its sutures (white arrow) anteriorly using the large grasping clamp (white arrow head). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Achilles allograft intra-articular fixation. The 2 ends of one of the No. 2 Orthocord sutures (DePuy Synthes, Warsaw, IN) placed in a Krakow configuration at the thick end of the allograft are passed through (white arrow) a 5.5-mm SwiveLock anchor (Arthrex, Naples, FL). Note that the other No. 2 Orthocord sutures (DePuy Synthes) placed at the thick end of the allograft are grabbed by the assistant (black arrow). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 Final appearance of the allograft tendon attached to the greater tuberosity. (A) Intra-articular view showing the anterior-lateral (white arrow) 5.5-mm SwiveLock anchor (Arthrex, Naples, FL) and the posterolateral (black arrow) 5.5-mm Corkscrew anchors (Arthrex) placed in the greater tuberosity. (B) Transacromial approach showing the final appearance of the allograft fixation in a cadaver. Note the two 5.5-mm SwiveLock anchors (Arthrex) placed anteriorly (red dots) and the two 5.5-mm Corkscrew anchors (Arthrex) placed posteriorly (black dots). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 Attachment of the allograft to the lower trapezius tendon. (A) Using a free needle, the No. 2 Orthocord sutures (DePuy Synthes, Warsaw, IN) placed in the lower trapezius tendon (white arrows) are passed through the thin part of the Achilles allograft. It is important to keep the allograft in tension using small clamps (black arrows) and place the arm in maximal external rotation at 0° of abduction or slightly extended before the sutures are tied. (B) After the lower trapezius tendon and Achilles allograft tendons are tied together (white arrow), the excess of allograft tendon is removed with scissors (black arrow). Arthroscopy Techniques 2016 5, e981-e988DOI: (10.1016/j.eats.2016.04.025) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions