Modified Eden-Lange Triple-Tendon Transfer for Chronic Trapezius Palsy

Abstract

Background:

Trapezius palsy can occur due to traumatic or idiopathic spinal accessory nerve injury. As a result of trapezius palsy, shoulder girdle imbalance can develop and present as lateral scapular winging and diminished shoulder range of motion and function. The modified Eden-Lange triple-tendon transfer procedure is a notable salvage operation which can treat chronic trapezius palsy after failure of conservative and nonsalvage interventions.

Indications:

A 42-year-old right-hand dominant woman who underwent a cervical lymph node biopsy 3 years before presents with chronic left shoulder weakness, severe shoulder pain, and scapular winging. On presentation, she has failed conservative treatments and operative interventions including attempted spinal accessory nerve exploration and repair with ansa cervicalis autograft.

Technique Description:

A modified Eden-Lange triple-tendon transfer, using the Elhassan modification, was performed to treat the patient’s chronic trapezius palsy. The levator scapulae, rhomboid minor, and rhomboid major were sequentially transferred to the lateral scapular spine, central scapular spine, and medial scapular spine, respectively.

Results:

At interval follow-up, the patient was recovering well from her operation and with progressively improving range of motion and strength.

Discussion/Conclusion:

The modified Eden-Lange triple-tendon transfer technique is a salvage procedure for treating chronic trapezius palsy by anatomically reconstructing the force vectors of the native trapezius muscle. Effective restoration of proper scapular and shoulder kinematics via the triple-tendon transfer technique can result in improved pain and shoulder girdle function.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video demonstrates a modified Eden-Lange triple-tendon transfer operative technique for treating chronic trapezius palsy.

Here are our authors’ disclosures.

Here is an outline of the presentation topics we will discuss today.

Beginning with pertinent anatomy, the trapezius is a major suspensory muscle of the upper extremity with a large fan-shaped structure comprising 3 functional components. The upper fibers elevate the scapula and rotate the scapula during arm abduction. The middle fibers retract the scapula. Finally, the lower fibers depress the scapula. The trapezius is innervated entirely by cranial nerve XI, the spinal accessory nerve.

Additional pertinent anatomy includes the levator scapulae, which elevate the scapula, and the rhomboid major and minor, which retract and rotate the scapula such that the glenoid cavity is depressed inferiorly. The levator is innervated by the nerve to the levator scapulae and the rhomboids are innervated by the dorsal scapular nerve.

Trapezius palsy occurs due to dysfunction of the spinal accessory nerve, with notable causes including iatrogenic injury during surgical procedures, blunt trauma, cervical stretch injuries, or idiopathic injury.

Clinically, patients may present with severe shoulder pain and difficulty with overhead activity in the involved extremity. Inquiring about a past surgical history is important. Notable physical examination findings include an asymmetric neckline due to trapezius atrophy and a depressed shoulder girdle, lateral scapular winging, and limited active forward flexion and abduction compared with the uninvolved extremity.

Electromyography (EMG) and nerve conduction studies are important to the diagnostic workup, as confirmation of trapezius palsy in the setting of preserved rhomboid and levator scapula function is a prerequisite for performing a triple-tendon transfer with a successful functional outcome.

Once the diagnosis has been made, treatment options include conservative management with rest, anti-inflammatories, and physical therapy. Operative management options include static stabilizing or dynamic stabilizing procedures. Previously performed static stabilizing procedures demonstrated poor outcomes due to stretching of grafted tissue. Dynamic stabilizing procedures, first pioneered by Eden and Lange, involve transferring the tendons of the levator scapulae, rhomboid minor, and rhomboid major muscles, with the ultimate goal of recreating the 3 functional components of the deficient trapezius muscle.

Several adaptations of the original Eden-Lange transfer exist. In the classic procedure, tendons were transferred with a bony block, with the levator transferred to the lateral scapular spine and the rhomboids transferred to the infraspinatus fossa. The Bigliani modification avoided harvesting a bony block due to concern for intrusion into the origin of the serratus anterior and subscapularis muscles. In addition, the rhomboid minor was transferred to the supraspinatus fossa. The Elhassan modification transferred the rhomboid minor to the scapular spine just medial to the transferred levator tendon and the rhomboid major to the medial scapular spine.

In our case, a 42-year-old right-hand dominant woman with a history of sentinel lymph node biopsy presents with 3 years of postoperative chronic left shoulder weakness and pain. Five months before her presentation, she underwent spinal accessory nerve exploration and repair with ansa cervicalis autograft without improvement.

On examination, the patient had marked lateral scapular winging, scapular dyskinesia, and diminished active forward flexion. An EMG obtained demonstrated severe left spinal accessory neuropathy with intact left dorsal scapular nerve and nerve to the levator scapula function.

The surgical demonstration follows.

The patient was positioned in a straight lateral decubitus position. Skin exposure was just beyond the midline, and the ability to position the shoulder in external and internal rotation was assessed. The arm was then secured in a TRIMANO (Arthrex; Naples, Florida) arm holder positioned on the far side of the surgical table.

After prepping and draping, anatomic landmarks were drawn using a skin marker, including the lateral border, medial border, superior angle, inferior angle, scapular spine, and acromion.

A #7 planned surgical incision was then drawn using the posterolateral corner of the acromion, the superomedial corner of the scapula, and the inferior scapular angle as anatomic landmarks.

An incision was made, with thick skin flaps superficial to the infraspinatus fascia developed with tagging stitches. The trapezius was then identified at its obliquely oriented inferolateral border and dissected off the underlying fascia. In an important step for exposure, the trapezius was split perpendicular to its inferolateral border at the superomedial margin of the scapula and reflected off the scapular spine using electrocautery. This “episiotomy” of the trapezial fascia, as illustrated, aids in exposing the entire scapular spine. Intraoperatively, the trapezius may appear thin and atrophic, and a nonreactive spinal accessory nerve may be visible on the undersurface of the medial trapezius.

Once the trapezius is retracted, muscle elevation begins. The arm is brought behind the body into internal rotation, which exposes the medial border of the scapula. A bone hook can be placed on the scapular spine with distal traction to expose the superior scapula. Blunt dissection is then performed to reveal the borders of the levator, rhomboid minor, and rhomboid major.

The plane under the levator is then developed. First, ~2 cm of the medial aspect of the supraspinatus and infraspinatus is reflected to help reveal the true medial border of the scapula, and electrocautery is used to mark a ~4-mm-thick bone cut from the levator insertion site. The bone cut is made with an oscillating saw, blunt dissection is performed to further develop the plane deep to the levator, and the muscle is tagged with 3 sutures. During the deep blunt dissection, it is important to be mindful of the dorsal scapular nerve and transverse cervical artery, which are found on the undersurface of this muscle medially. The levator should be mobilized at least 5 cm proximally such that it can be transferred to the lateral scapular spine.

Mobilization is next performed on the rhomboid minor. Of note, it can be challenging to find the deep intermuscular plane, which is over the serratus posterior muscle.

Finally, the rhomboid major is mobilized in a similar fashion. After the bone cut is made, further deep dissection should be performed to reflect the muscle off the thick tendinofascial insertion near the serratus anterior and subscapularis origin on the medial border of the scapula. After appropriate mobilization, a smooth chest wall with palpable ribs should be deep to the mobilized rhomboid major.

Attention should then be paid to releasing the soft tissue over (or deep to) the dorsal scapular nerve to ensure the nerve is not entrapped. Use of a nerve stimulator can be performed at this point to help identify and prevent injury to the dorsal scapular nerve.

Once the levator and rhomboids have been mobilized, the transfer portion of the procedure begins by bringing the arm into 90° of abduction and 20° of forward flexion to reduce the scapula to the chest wall.

Electrocautery is performed to expose the lateral margin of the scapular spine. A wide Bennett retractor can be placed in the superolateral corner of the incision to improve exposure. Any residual soft tissue is then rongeured off, and the cortex of the spine is removed with a burr to stimulate healing. The region is prepared sufficiently when a few millimeters of the lateral margin of the spine are accessible both superiorly and inferiorly.

Seven equally spaced tunnels are then drilled through the scapular spine in an inferior to superior orientation. The most lateral tunnel is around 5 cm medial to the posterolateral corner of the acromion. The most medial tunnel is positioned at the medial margin of the scapular spine. This tunnel placement ensures the transferred levator will insert 5 cm medial to the posterolateral corner of the acromion, as any further lateral transfer would result in an iatrogenic webbed neck.

Two heavy #2 sutures are passed through each tunnel from inferior to superior. The 3 tagged muscles are pulled over to where they will ultimately insert to estimate positioning and soft tissue tensioning. The illustration shown demonstrates the intended tunnel and suture placement technique.

Fixation begins by passing 6 sutures from the lateral 3 bone tunnels through the distal levator tendon or muscle. Holding tension on the sutures demonstrates the amount of tension needed to reduce the transferred tendon to the scapular spine. After suture placement, the scapula is reduced to the chest wall with manual pressure down on the scapula with the arm in 90° in abduction. While holding the levator reduced, each suture is tied to its corresponding inferior limb from lateral to medial. The tied sutures can then be tied to the other tied sutures for added reinforcement.

This technique is repeated with the rhomboid minor. The tied sutures should be pulled to show reduction of the rhomboid minor to the scapular spine. Four sutures are then passed and tied in a similar fashion.

This technique is then repeated with the rhomboid major. Before transfer, the rhomboid major is split from the lateral edge inwards, around halfway up the muscle in line with the muscle fibers. The superior half is transferred to the superior aspect of the remaining medial scapular spine and the inferior half to the inferior aspect, respectively, using the 2 remaining bone tunnels.

Closure is performed beginning with the atrophic trapezius. The superior half of the trapezius is repaired to the lateral upper border of the infraspinatus, while the inferior half is repaired to the medial border of the infraspinatus using #2 Ethibond suture. The remaining closure is then performed in a standard surgical fashion.

Postoperatively, the patient is made nonweightbearing with sling immobilization for 6 to 8 weeks. The anticipated postoperative protocol is shown, with patients expected to return to full activity around 9 to 12 months after surgery. Elhassan and Wagner reported excellent outcomes, with 21 of the 22 patients returning to full activity without limitation.

We will now conclude by discussing pearls and pitfalls. During positioning, the ability to freely mobilize the shoulder and retract or protract the scapula is critical to achieving good surgical exposure. Development of thick subcutaneous flaps during the approach and performing a meticulous layered closure are critical to optimizing wound-healing capacity.

During the deep dissection, adequate elevation of the infraspinatus off the medial scapular spine is important for exposing and ultimately harvesting the levator and rhomboid muscles with sufficient bony attachment. Prevention of injury to both the dorsal scapular nerve and nerve to the levator can be optimized by a good understanding of the anatomic course, avoiding an aggressive medial dissection, and using a nerve stimulator.

Finally, during the transfer portion of the procedure, overlateralization of the transferred levator should be avoided to prevent an iatrogenic webneck deformity.

Please see below for our presentation references.

Thank you for viewing our video presentation of a modified Eden-Lange triple-tendon transfer technique.