Accelerating Efficiency in Arthroscopically Assisted Lower Trapezius Transfer: How Can We Shorten the Learning Curve?

Introduction: Arthroscopic lower trapezius tendon transfer (aLTT) is an effective strategy to treat massive rotator cuff tears by dynamically restoring the posterior aspect of the rotator cuff force couple and improving range of motion, strength, pain, and stability. aLTT is technically challenging with higher complication rates, and its learning curve has yet to be defined. We aimed to establish a learning curve for aLTT through trends in surgical time, postoperative outcomes, and complications. We hypothesized that increased surgeon experience would be associated with decreased surgical time, improved outcomes, and reduced complication rates.

Methods: All patients who underwent primary aLTT at our institution between October 2018 and November 2022 were identified and included. Perioperative data, including diagnosis, operative time, complications, revisions, postoperative functional data, and patient-reported outcomes, were recorded and analyzed. A shoulder and elbow fellowship-trained surgeon's learning curve was determined using linear regression and cumulative sum (CUSUM) analyses. The CUSUM analysis evaluated objective differences in surgical time over the surgeon's course of practice and elucidated the completion of the learning curve.

Results: Thirty-nine patients were included, with an average follow-up of 29 months. Mean surgical time was 163 minutes, with a linear decrease in surgical time throughout the study. CUSUM analysis of surgical times demonstrated a learning curve of 14 patients. When comparing the first 14 patients to the remaining 25, no difference was found in range of motion, American Shoulder and Elbow Surgeon score, and subjective shoulder value score, whereas visual analog scale pain scores at the final follow-up decreased in the proficiency phase.

Conclusion: This study found a notable linear decrease in surgical time and the number of cases completed without associated detriment to postoperative outcomes. At least 14 cases were required to exit the "learning phase." Further work is needed to find superior metrics to assess proficiency.

Level Of Evidence: 4, case series.