Daniel Kaplan:

Welcome to the Arthroscopy Journal Podcast. I'm Dr. Daniel Kaplan from NYU Langone Medical Center in New York City. Today I have the pleasure of speaking with Dr. Berkcan Akpinar, assistant professor of orthopedic surgery at NYU Langone, West Palm Beach, and a former co-resident of mine. He also did a sports medicine and shoulder fellowship at Harvard's Mass General Program under Doctors Elhassan and Warner, who are some of the most prolific trap transfers in the country. Dr. Akpinar was the first author of the article titled Arthroscopic-Assisted Lower Trapezius Tendon Transfer Using Achilles Tendon Allograft for Irreparable Rotator Cuff Tears Demonstrate Excellent Short-Term Outcomes in the Setting of Concomitant Subscapularis Repair, which is currently in press on the Arthroscopy Journal website. Welcome Dr. Akpinar. It's a privilege to have you on.

Berkcan Akpinar:

Thanks so much for having me. Appreciate it.

Daniel Kaplan:

Good to see you, buddy. So just to start managing irreparable rotator cuff tear patients without arthritis is always a challenge. I've been really excited to have you on and talk about this. Let's dive right in. To start, can you discuss what surgical options exist for patients with irreparable cuff tears, aside from lower trap transfers?

Berkcan Akpinar:

Definitely. First off, thanks so much for having me on the podcast. And yeah, there's literature on temporary or partial fixes such as arthroscopy and debridement along with a partial repair versus balloon interposition arthroplasty. And then additionally, there's other reconstructive techniques out there such as tuberoplasty or superior capsule reconstructions with either commercial grafts or even the biceps tendon for a bio-SCR that's been described. And then lastly, arthroplasty is the other option in the form of a reverse.

Daniel Kaplan:

It's one of the old orthopedic adages, if there's a million solutions for a problem, there's probably not a good one. What are some of the advantages and disadvantages of some of the options that you just gave?

Berkcan Akpinar:

Sure. Yeah. So the advantages of course of debridement and balloon or partial repairs are the brevity and the relative ease of the recovery for the patients without much of a post-op restriction depending on which studies you reference. These patients do well in the short term, but the long-term reliance on these procedures' somewhat limited. And then with SCR and bio-SCR, my mentors in Boston weren't fans of these procedures. The outcomes were mixed and they thought that relying on this kind of graft tissue or even the biceps to bridge the gap between poor tissue to begin with in the setting of irreparable cuff tear just doesn't work all in all.

Additionally, for tuberoplasty, you have to alter the joint with the hope that placing a fixed head depressor will give you some relief. However, I'm not sure if that functional benefit has really been teased out in the literature yet in terms of the outcomes. And then you have reverse, which is probably the most reliable in terms of being able to promise a patient a certain type of outcome after surgery. And it's definitely one of the better options in patients who have pain and restricted range of motion, but it's at the cost of the joint. In the absence of arthritis, you don't really want to cut out the joint, in my opinion.

Daniel Kaplan:

Yeah, I agree. I mean, I love reverses as much as the next person and it is a great, and I agree with you, the most reliable option, but it's certainly despite its name an irreversible surgery. Is that joke funny? I don't know. So let's just touch on arthroscopic assisted lower trap transfer. So in broad terms, what do you see as the advantages of that technique compared to some of the other ones you went over?

Berkcan Akpinar:

Yeah, so I think I like to think of it in my junior attending sense as especially with that Achilles tendon allograft, it's a tuberoplasty with a viable motor attached to it. So if you're able to successfully depress the humeral head, centering that coronal imbalance while also generating power overhead with external rotation, that's a huge win. And also, you avoid having to sacrifice the joint while doing so. Even if the Achilles repair fails at the tuberosity insertion, patients still have some pain relief just from the sheer fact that that thick graft is held there as an inner position.

Daniel Kaplan:

And we'll talk about it more, in my brief experience with it so far I've been very pleasantly surprised with it. This procedure is catching fire now and it's getting really exciting, but is this actually a new technique or is this something that's been around for a little bit of time? Can you give us a brief history of the procedure at least as you're aware of it?

Berkcan Akpinar:

Sure. So Christian Gerber actually described lat dorsi transfers as early as the 1980s. And then one of my mentors, J.P. Warner and others really popularized the surgery in the setting of irreparable cuff tears. And then a little bit later in the '90s and the 2000s, the thought of using the trapezius muscle for tendon transfers really in the setting of brachial plexus palsy happened. And that was championed by Dr. Elhassan and others. And then shortly after in the late 2000s and the 2000 teens Dr. Elhassan began to employ it in the setting of irreparable rotator cuff tears similar to the lat dorsi. And first he did this, it was quite an open procedure, and then with time he refined it to an arthroscopic assisted procedure. So that's kind of like the broad overview for it.

Daniel Kaplan:

Now, most of our listeners probably have never seen a lower trap transfer. It's still on the newer cutting edge. Can you describe what the procedure consists of?

Berkcan Akpinar:

Absolutely. So in an ideal OR you have an assistant preparing your graft on the back table while another fellow or assistant surgeon is harvesting lower trap in the back. And you're doing the arthroscopic prep work in the subacromial space from the start through a lateral viewing portal. For experienced surgeons, the harvest should take on the order of about five to 10 minutes after incision. And further the arthroscopic prepping the joint shouldn't be that involved as there's typically not much cuff or tissue present in that space. So visualization's actually pretty straightforward in these situations. Then you develop the plane between the infraspinatus and teres minor and the deltoid fascia arthroscopically, while at the same time the person responsible for the harvest has already excised a strip of the deltoid fascia that allows that passage of that Achilles graft.

And you know this is successful when that arthroscopy saline starts rushing out of the back once that person excises the fascia. And then once you're ready to pass the graft, you do so and then it just becomes a big double row rotator cuff repair on the joint. After all that intraarticular work is done, you weave the tendon through the trap like in a forward tap fashion, and then you just whip stitch everything together as much as possible with the arm kind of held in maximal external rotation abduction to set your tension.

Daniel Kaplan:

Got it. So you harvest, you prep intraarticular, you link the trapezius to the shoulder with that Achilles graft.

Berkcan Akpinar:

Right.

Daniel Kaplan:

Now, I think for most of us that didn't have the type of training that you did, the trap harvest is the most intimidating aspect. I know you said you can do it in five, 10 minutes once you're good at it, but for those of us who aren't quite good at it yet, do you have any pearls for us?

Berkcan Akpinar:

Oh, absolutely. I mean, there were times in fellowship where I thought I had a great trap harvest, and then Dr. Elhassan would look and go, "You missed the entire thing." So it's very daunting to start out. But to start, there's a tubercle on the scapular spine where the posterior deltoid originates and the lower trap inserts, it's about four centimeters lateral to the medial border of the spine on palpation. So you reference this along with the intersection of the scapular spine and the medial border of the scapula for your incision. Then you need to make sure you get down to the tendon before actually starting the harvest, which entails resecting, and I like to think of it as a pedicle of fat after you get through that subcutaneous layer. And this fat, it exists even in the thinnest of patients, and then you can't start the harvest until you really see that tendinous structure that is the lower trap.

Elhassan mentions he's seen patients with supposed lower trap transfers where the trap was actually never harvested, and instead the Achilles graft has been tenodesed to this thick fatty, fibrous layer. But in any case, Ryan Lohre is actually another co-author and a shoulder surgeon at Harvard really broke it down nicely for me when I was there, and he described it as looking at the face of a compass. So you really need to make sure you address the harvest in the north, south, east and west appropriately. So for example, for a right shoulder, the east would be making sure to appreciate the trap tendon really inserts on the inferior aspect of that spine tubercle. And so you have to get underneath it before you even release it to begin with. And then in the north you have to find the... There's like a raphe between the middle and the lower trap.

And so you have to identify that and make sure that you're not getting too much into the middle trap while you're harvesting, because then you'll risk destabilizing the scapula. Then in the west you need to make sure you free it up enough so that you have decent excursion, but you also don't denervate it because the nerve that supplies it runs just along the underbelly, just medial to the scapular border. And then finally in the south, there's always this fascial band that tethers the lower border of the trap. And if you don't excise it, then you're not going to get as much excursion. And then finally deep, you need to make sure that you see the orthogonal fibers of the infraspinatus fascia, then that just indicates that you got all the lower trap tendon because the most robust part of the tendon is the deepest layer.

Daniel Kaplan:

Yeah. And the ones that I've done finding the interval or developing that plane between the infra and the trap is always a little harrowing because it's a little hard to see. I kind of feel like I'm making it.

Berkcan Akpinar:

Yeah.

Daniel Kaplan:

Yeah. Like I said, I didn't see any in fellowship. So when I started I just looked at as many technique articles and videos as I could find, and the harvest tends to be the same. But the one thing that's been different between all of them, I must've seen 20 different ways of fixing the Achilles to the humerus, and I'm still trying to figure out my own technique. What's your preferred method of doing that?

Berkcan Akpinar:

So I really love the way Elhassan does it, I mean, in my mind it's like if it's not broke, don't try to fix it. So he creates a diamond in the shoulder really effectively. The first anchor loaded with suture tape is posterior and at the medial articular margin with the sutures parked through Neviaser's portal, and you put that in right away after you start the shoulder scope. And then the second anchor is again on the medial articular margin, and it's essentially right at the top of the bicipital groove and you dunk the medial tails of the graft, whip stitch into this anchor as well as the sutures from an upper border subscap tear, for instance, if you're trying to repair that concomitantly.

And then the second anchor is again anterior, but it's lateral to the first anchor. And you try to get it basically space it as lateral as the width of the Achilles tendon allograft. And this anchor, you put the lateral whip stitch suture tails of the graft in, and you can also do an arthroscopic biceps tenodesis in this anchor as well. And then you have to realize that once these anchors go in, your visibility really does drop. And now the Achilles is fixed in the shoulder. The last sutures that you're really managing are those suture tails that came from the Neviaser that medial posterior anchor. And you've retrieved them from the Neviaser portal, and then you pull them over the Achilles graft and you dunk them in a posterior lateral row anchor. And this kind of restores your rotator cable. Elhassan calls it like a seatbelt anchor.

Daniel Kaplan:

Yeah. I guess I settled on something doing fairly similar. Maybe I've only been doing one anchor for the two sets of sutures in the Achilles, but maybe doing the second one would be helpful for an extra fixation point.

Berkcan Akpinar:

Yeah.

Daniel Kaplan:

Two points about technical was the article mentions incorporating occasionally the remnant supra and infra into the graft, but it was also a little iffy on if this was necessary, the clinical importance of it, and it seemed heterogeneous. What's your experience with that? Is that something you always try to do? Is that something that's... If you can do it, great, if not, whatever.

Berkcan Akpinar:

So it's really in the setting of patients who've failed multiple cuff repairs in the past. And you can still see that there's like some remnant cuff behind the tissues. The muscle bellies maybe aren't that fatty degenerated, but just because of repetitive surgery is that there's just not as much cuff left, so there's no excursion to it. And in that case, you can pass those Neviaser suture tails through that cuff tissue and then again park it up top. And then once your graft goes in, you can retrieve the suture tails that have already been passed through the residual cuff over the Achilles graft. And when you dunk that tail through the lateral row anchor, it's almost like you're bridging the gap between the cuff and the Achilles with those suture tails. But it's not like a formal repair, so to speak, it's just closing things down a little bit.

Daniel Kaplan:

Got it. Last thing on technical, the biceps has also been getting a lot of attention recently as a means of augmenting cuff repairs. I really like doing anterior cable reconstructions. A lot of your cases might be revisions where the biceps has already been tenotomized, but if it's present, how are you thinking about the biceps? Is that something you can incorporate? Are you just tenodesing it? What's your thought process?

Berkcan Akpinar:

Great question. Again, I think it's a balance of visibility and the ultimate goal of surgery and drop. I personally have seen Elhassan and Warner tenodesing arthroscopically into that lateral row anterior anchor. And I think that's fine because just the sheer mass of that Achilles tendon is just... It can be overwhelming in the shoulder joint or you can do a standard subpec biceps tenodesis. I've done that in patients that I've done a lower trap on and it seems to be just fine.

Daniel Kaplan:

Got it. And then the last thing, what's your post-op protocol for these patients? Is it regular abduction sling? Do you need them in a gunslinger to really get that external rotation?

Berkcan Akpinar:

Yeah.

Daniel Kaplan:

Is the recovery slower than a rotator cuff repair or about the same?

Berkcan Akpinar:

For sure. Again, I do what they do in Boston. It's really that big gunslinger brace for eight weeks, no heavy lifting, really just fully immobilized in that as much as possible. 'Cause you really want to let that tenodesis site in the back scar in with as much tension as well. It's only going to get looser once they get out of that sling. And then it's certainly slower than a rotator cuff repair. The overall recovery until the patients are more or less graduated from physical therapy is technically six months. But even after six months, we will get to, when we discuss the findings of the paper, they're still improving up to a year and change. So absolutely, it's slower than a rotator cuff repair. But it's also tricky because as early as two weeks, these patients come back and they're like, "I don't feel pain anymore in my shoulder." And so they want to be more active as a result. So it's your job to kind of stop them from being overly aggressive in the recovery.

Daniel Kaplan:

All right. So now we know how to do the procedure, but who should get one? What are your indications for a lower trap transfer?

Berkcan Akpinar:

Yeah, so irreparable cuff tears in younger patients in their fifties or early sixties with high-grade fatty infiltration, grade three, grade four, especially if they failed prior cuff repairs and they have a really severe tendon retraction, the glenoid rim less than a centimeter of remaining tendon. And they really have to prove, and this is kind of... You understand this when you've interacted with these patients, you establish a relationship with these patients, but they really have to be invested in that rehab protocol and really appreciate all the restrictions. And then it's also patients who have external rotation lag. If it's really appreciable and especially if it's one of their main complaints, that's a fantastic indication. And then patients who have pain with the above radiographic parameters in good baseline active range of motion do very well from this procedure. And yeah, those are my big things that I look out for.

Daniel Kaplan:

Now, are there any specific exclusion criteria? So who shouldn't get a lower trap transfer?

Berkcan Akpinar:

For sure. Poor passive range of motion, arthritis, and then patients looking purely for maximal strength gain, but they don't really have a lot of pain associated. And then older patients or patients that simply can't comply with those rehab restrictions.

Daniel Kaplan:

So things like pseudo paralysis, let's say they're passive motions maintained, but they're active, they get less than chest height. Would that be an acceptable patient?

Berkcan Akpinar:

Yeah, I think that patient would be a good patient to do it on.

Daniel Kaplan:

Perfect. You talk about in the paper a little bit, acromiohumeral interval and humeral head subluxation. Are these things we need to look out for or less relevant?

Berkcan Akpinar:

So this is actually my question in the impetus for the research study. I really thought going into it that these intervals, the acromiohumeral interval, and then how much subluxation there was on the pre-op MRIs and the x-ray was going to make an impact on how these patients did, but there's no difference in the outcome. So you can do this surgery on patients with a large or small acromiohumeral interval and subluxation on the axial plane as well as long as you address the subscap, which might be contributing to that anterior-posterior imbalance. And then as long as there's no like acetabularization of the acromion indicating like cuff arthropathy or arthritic changes,

Daniel Kaplan:

Right. And I'm sure we'll get to this a little bit more after the results of the study, but you mentioned subscap tears. So prior to your study, what was the conversation on whether patients with subscap tears could be treated with trap transfers? Was it definitively no, was it controversial?

Berkcan Akpinar:

So there's a lot of studies that suggested that it was just a straight contraindication for lower trap transfers in the setting of subscap tears. But on the contrary, we show that these patients do very well still. And Elhassan and Warner will even do, it's crazy, they'll do concomitant lat dorsi transfers to the subscap in the setting of irreparable subscap tears with lower trap transfers for the posterior-superior cuff, and Elhassan calls it a parachute procedure 'cause you have both tendons kind of parachuting over the humeral head. That's personally above my pay grade, but they do it.

Daniel Kaplan:

Yeah. Yeah, that would be a heck of a surgery. So with that background in mind, you sort of started getting into the impetus for the study. Can you describe the study design for us? How did you go about answering your questions about the AHI and subluxation?

Berkcan Akpinar:

Sure. Yeah. So Christian Gerber actually designed or described a sagittal subluxation index or an axial subluxation index, sorry, which I referenced for that anterior subluxation measurement that I performed on the axial MRI cuts. And then there's a radiology paper I referenced for just normalizing that acromiohumeral interval to the humeral head diameter for the patients. And then with these values, we went on to collect PROs scores and given little is known about the recovery process for these patients, I wanted to take serial measurements with one being at that six month mark and then the other being a final follow-up to see how these patients evolve with respect to their recovery. But other than that, it was just a standard retrospective chart review.

Daniel Kaplan:

I really like that standardization of the acromiohumeral interval because why wouldn't it make a difference if the patient's 6'5" or 5'6"?

Berkcan Akpinar:

Right, right.

Daniel Kaplan:

And I did also really appreciate the serial measurement because you're right, I don't know what to tell someone at six months versus a year and stuff like this is helpful. Before we get to the actual results, what were you expecting to find based on existing data and what you had seen?

Berkcan Akpinar:

Yeah, so I thought the patients with high-riding humeral heads or significant subluxation in the anterior-posterior plane were going to do worse. I think paradoxically the graph depresses the head back to normal for those patients. And with respect to the anterior-posterior subluxation going through all the patients, I realized there wasn't a lot of significant variation in that plane. And then most patients indicated for the surgery were typically well-centered or just mildly off-center posteriorly. And I think addressing the subscap further kind of normalizes that imbalance as well.

Daniel Kaplan:

Got it. Okay. So that's what we were expecting. Tell us what your main findings were.

Berkcan Akpinar:

Yeah, so the SANE score, the subjective shoulder value score at baseline was around mid-thirties, 35, and this jumped up to almost 80 at six months in final follow up. External rotation lag was essentially eliminated at six-month follow-up and interestingly forward elevation continued to improve from six months to final follow-up. Then lastly, some patients got some strength back as well. So I think it's really a testament to how long the physical therapy is and how patients have to really be on top of retraining that lower trap and engaging it with all the periscapular therapy that they're doing post-op.

Daniel Kaplan:

Got it. All right. Let's get into some of those results. So for the improved strength, I was pretty surprised by how much power patients got post-operably, especially in the forward elevation. Was that something that you would've expected or just more in the resisted external rotation?

Berkcan Akpinar:

Yeah. So both those markers seem to improve, but we also need to realize that a lot of the patients started with pretty good strength. You can see in the paper, like the pre-op strength scores, a lot of them had five out of five strength to begin with. And of course that's limited by examiner judgment, but predominantly pain with range of motion was a lot of the reasons why some of those patients were indicated. The notion that the lower trap will restore full strength of the rotator cuff is just not correct. The strength generated is probably around 40% of the cuff itself, but no studies are really teased this out yet. Lastly, we also need to appreciate, I mean, it is a retrospective study, the data is only going to be as good as the documents generating it, and those were clinical notes and exams post-op for these patients. I think as a sum, you can tell patients that some strength will be restored, but it's not going to be full throttle like your strength is going to be like you never had a rotator cuff tear.

Daniel Kaplan:

Can you, not guarantee, but can you tell patients to expect if they were pseudo-paralytic, maybe only getting range of motion to like 80 that they can get more forward elevation?

Berkcan Akpinar:

Yeah. So I think range of motion-wise, I think the lower trap will generate the power needed to lift their arms up for sure. Yeah.

Daniel Kaplan:

Got it. And now let's dive more into the subscap. So based on your results, should a subscap tear be considered a relative contraindication or as long as it's repairable, do you think it's okay to do?

Berkcan Akpinar:

Yeah, I think if they're repairable, I mean clearly if you can do a lat transfer, even if they're irreparable.

Daniel Kaplan:

Yeah, fair. All right. Can you touch on some of the regression analysis? I really liked this part of the study and there's a couple of things that were surprising. So first you found increased subscap fatty infiltration was associated with worse SSV scores, which to me makes sense, the subscap's worse off. But I was surprised that increased age and increased supraspinatus fatty infiltration were associated with improved outcomes. Can you explain that one a little bit or what your thoughts are?

Berkcan Akpinar:

Yeah, yeah. We rationalize it in the sense that these people were most likely the patients who had gone longer with symptoms related to their irreparable cuff tears rather than kind of presenting early on in the disease. And so that improvement that they experienced was probably very drastic for them. Additionally, it highlights that the patients with extensive fatty infiltration, especially that posterior superior cuff, are the best indicated for this surgery.

Daniel Kaplan:

And then based on the results of this study as well as your clinical experience, this is to me, I think the million-dollar question. How do you counsel a prospective patient regarding expectations? So let's say it's a 50-year-old irreparable tear, extensor lag, active forward elevation to 60 degrees, but full passive range of motion. What are you telling them they can expect reasonably following completion of rehab out to one year?

Berkcan Akpinar:

Yeah, I mean I've personally seen patients in the offices at MGH where the patient scenario you outlined has full active forward elevation post-op and they come with videos of how they were pre-op and they show the staff in the office. So strength restoration, like we touched on before is another thing entirely, but I think the range of motion is definitely a feasible goal after surgery.

Daniel Kaplan:

That's awesome. Okay. So really this helps fit in that empty space we have for that irreparable tear to at least get them their motion back, if not full strength. But for most people that would be a huge win. All right, so as we start to include what's next on the horizon in the world of lower traps, is there anything you and your team are working on or you're particularly excited about as the next phase?

Berkcan Akpinar:

We have another paper in review comparing Achilles allograft to hamstring autograft in the setting of lower trap. And I think the big question that everyone wants answered is lower trap versus reverse for irreparable cuff tears. Because reverse is such a tried and true thing, but lower trap... There's no head-to-head studies looking at that. And then additionally, I know some efforts are in place to perform a multicenter outcomes large prospective study on this to really tease out all the outcomes.

Daniel Kaplan:

And then just before we wrap up, any closing thoughts you have to share with the listeners?

Berkcan Akpinar:

Yeah, sure. I just want to thank my mentors at MGH for expanding my perspective on the shoulder. It's definitely more than just the glenohumeral and AC joints and the quicker you realize that as an orthopedic surgeon, I think you can take better care of these patients.

Daniel Kaplan:

That's great. All right, Dr. Akpinar, thank you so much again for your time and your insights. It was a pleasure speaking with you. Dr. Akpinar's article titled Arthroscopic Assisted Lower Trapezius Tendon Transfer Using the Achilles Tendon Allograft for Irreparable Rotator Cuff Tears Demonstrates Excellent Short-Term Outcomes in the Setting of Concomitant Subscapularis Repair is currently available at the Arthroscopy Journal website at www.arthroscopyjournal.org. Thank you for joining us. Now, this concludes this edition of the Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.

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