In This Article
- Bassem Elhassan, MD, has developed several novel approaches to shoulder reconstruction for non-arthritic patients based on the principle of transferring a patient's own muscle tissue that has the same "line of pull" as the injured muscle
- One of these new surgical techniques, called arthroscopically assisted lower trapezius transfer, has greatly reduced pain and increased range-of-motion in patients with irreparable posterior-superior rotator cuff tears
- Another novel shoulder surgery technique, called anterior latissimus dorsi transfer, results in significant clinical improvements for patients presenting with irreparable subscapularis tear
- Dr. Elhassan's tendon transfer techniques can help active patients avoid reverse shoulder arthroplasty, reduce pain, speed recovery and greatly increase range-of-motion
Bassem Elhassan, MD, professor of orthopaedics at Harvard Medical School, co-chief of the Shoulder Service and program director for the Shoulder Surgery Fellowship in the Massachusetts General Hospital Department of Orthopaedic Surgery, has developed novel surgical approaches to improve range-of-motion and alleviate pain for patients with certain types of shoulder injuries. The techniques repair, rather than replace, shoulder muscle.
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"Injury of the rotator cuff is very common, and injury to the subscapularis is not as common, but is often traumatic," says Dr. Elhassan. "For many of these injuries that have been labeled as irreparable, there are now options that involve same-day surgery, often minimally invasive, that should be considered before other procedures such as reverse shoulder arthroplasty (RSA) are performed."
Scope-assisted Lower Trapezius Transfers
Large rotator cuff tears are often caused by trauma, such as falls or dislocations. After such an injury, the tendons can degenerate rapidly without treatment. The tear can get larger, the muscle can become infiltrated with fat and the joint may become arthritic, all increasing pain and further limiting movement.
"Posterior-superior rotator cuff tears can lead to something we often call 'pseudo-paralysis,' because the range of motion is so limited, and the weakness is so significant, that it looks like paralysis," Dr. Elhassan says. "Many of these patients are offered RSA, which, in my opinion, should not be done, especially if the patient is active and has no arthritis."
RSA, or shoulder replacement, is an extensive surgery that can limit long-term function, especially in younger and more active patients. As an alternative to shoulder replacement, Dr. Elhassan developed a procedure called lower trapezius transfer (LTT), a minimally invasive, scope-assisted outpatient procedure, which has shown to be clinically effective in improving pain and restoring function in patients with massive irreparable rotator cuff tears.
Dr. Elhassan believes that the choice of muscle for transfer is key to successful outcomes. "One of the most important principles of my approach is that if you have a muscle in a certain place with a certain direction, then in order to reconstruct it, you have to get the muscle from the same place, and it has to have the same vector," he says.
Outcomes have been excellent. "If someone has no arthritis, has a massive posterior-superior rotator cuff tear, has some elevation, and has weak external rotation and pain, I can tell them reliably that this will help," he says. "You can almost say you can hit a home run with it. The patients feel much, much better after surgery. Pain relief is very early after surgery, and there are few possible complications."
Similar to other shoulder procedures, the area is immobilized for eight weeks, followed by eight weeks of physical therapy and eight weeks of strengthening. "At six months, I let them fly, to do whatever they want to do," Dr. Elhassan says.
The team has treated more than 200 patients with scope-assisted lower trapezius transfer (SALT), and long-term follow-up after seven to eight years continues to show success. "More than 90% of patients who have this procedure have lasting pain relief. More than 90% experience restored shoulder external rotation, and range of motion is restored to 80% to 100%," he says.
Dr. Elhassan has numerous peer-reviewed publications on tendon transfer, and his arthroscopically assisted LTT outcome data was published in the Journal of Shoulder and Elbow Surgery in 2020.
Latissimus Dorsi Transfer for Irreparable Subscapularis Tears
Subscapularis tears typically occur after traumatic injury, often causing debilitating pain and dysfunction in the shoulder and upper arm. Patients experiencing this injury have historically had few promising surgical options, as many subscapularis tears have previously been classified as irreparable.
"If the injury is not repaired early, a fair percentage of patients will develop what we call fatty atrophy, or fatty replacement of the muscle. If you try to repair it, it will not last. It will become pliable, and it may tear again," Dr. Elhassan says. "Other times, if someone has had a tendon in the shoulder repaired, the tendon can shorten, putting the shoulder under such high tension that it will tear again."
Graft-augmented reconstruction and pectoralis major transfer (PMT) have been popular reconstruction options for subscapularis tears, but outcomes are variable, with failure rates as high as 80% in certain patient populations. Many surgeons recommend RSA to repair these tears, but, as mentioned previously, shoulder replacement in active patients should only be considered when more conservative measures fail or other surgical options are not available.
Again applying the principle that muscle should be transferred from an area with the same line of pull, Dr. Elhassan developed a new approach for treating subscapularis tears by harvesting and transferring the latissimus dorsi.
Latissimus dorsi transfer (LDT) is an ideal option for healthy and active patients with subscapularis tears that were previously considered irreparable. The outpatient surgery is often arthroscopically assisted, in order to be as minimally invasive as possible. It has resulted in excellent outcomes, improving motion, reducing pain and increasing strength, as published in the Journal of Shoulder and Elbow Surgery in 2020. According to Dr. Elhassan, data on patients who are five or six years out from LDT shows good function without the need for additional surgery.
LDT has a similar path to recovery as lower trapezius transfer, which is immobilization for six to eight weeks, followed by physical therapy. Exclusion criteria for the procedure are advanced arthritis or a fixed anterior-superior escape, "when the shoulder is escaping the socket and is sitting out in a fixed way," Dr. Elhassan says. "Those patients may be better served with RSA."
Changing the Standard of Care in Shoulder Surgery
A third novel shoulder surgery technique, called the parachute procedure, entails transferring the lower trapezius posteriorly and the latissimus anteriorly to reconstruct massive anterior-superior-posterior rotator cuff tear. This technique also has shown promising results in active patients.
Dr. Elhassan is teaching other surgeons around the world how to perform these techniques, and demand has been high for training. His novel surgeries are poised to become treatment standards for so-called "irreparable" shoulder tears.
"Some patients with these types of injuries may be better served with RSA, such as those who are older and inactive, with advanced arthritis and those who don't want to go through lengthy rehab after being immobilized for two months," he says. "But in active patients, these procedures should be offered first, and they are changing the treatment algorithm."
Learn more about the Shoulder Service at Mass General
Refer a patient to the Shoulder Service at Mass General