Eden-Lange procedure

The Eden-Lange procedure is an orthopedic procedure to alleviate the symptoms of trapezius palsy when more conservative measures, such as spontaneous resolution and surgical nerve repair are not promising.[1][2][3] The rhomboid major, rhomboid minor, and levator scapulae muscles are transferred laterally along the scapula to replace the functions of the lower, middle, and upper fibers of the trapezius, respectively. The transferred muscles hold the scapula in a more medial and upwardly rotated position, without winging.

Eden-Lange procedure
SpecialtyOrthopedic surgery
UsesAccessory nerve disorder
TypesModified Eden-Lange procedure, Triple Tendon Transfer
FrequencyRare

Versions

Eden-Lange procedure

The original technique was first described by Eden[4] in 1924 and verified by Lange in the 1950s.[5][6] The rhomboid major and rhomboid minor were transferred laterally from the medial border of the scapula to the infraspinatous fossa, and the levator scapulae was transferred laterally to the spine of the scapula, near the acromion.

Modified Eden-Lange procedure

The procedure was first modified by Bigliani et al. in 1996.[7] The change was transferring the rhomboid minor to the supraspinatous fossa to allow the rhomboid minor to better replicate line of pull of the middle trapezius.

Triple tendon transfer

The triple tendon transfer (T3 transfer) was described by Elhassan et al. at the Mayo Clinic in 2015, and since 2010 no other technique for intractable trapezius palsy has been used there.[8] Like the original and modified Eden-Lange procedures, the levator scapulae is transferred to the scapular spine. In the T3 transfer, rather than transferring the rhomboids to the scapular fossae, they are transferred to the scapular spine, which better replicates the trapezius’ action of scapular upward rotation.[9] In detail, the rhomboid minor is transferred to just medial of the transferred levator scapulae, and the rhomboid major is transferred to the medial scapular spine.

Another modified version that has been described is transferring the levator scapula and rhomboid minor to the scapular spine, like the T3 transfer, with transfer of the rhomboid major to the infraspinous fossa, like the original Eden-Lange.[10]

Indications

Symptomatic trapezius palsy lasting longer than 1 year indicates tendon transfer, since spontaneous recovery and nerve repair are unlikely to be successful then. Conservative management, such as physical therapy, is generally unsuccessful.[8]

Symptomatic trapezius agenesis or hypogenesis, although rare, could be mitigated with an Eden-Lange procedure.[11]

Contraindications

Additional muscle deficits can contraindicate tendon transfer, namely the serratus anterior muscle or the muscles-to-be-transferred themselves. Serratus anterior muscle deficit is another cause of scapular winging and decreases the efficacy of an Eden-Lange procedure, but it can be overcome with a simultaneous pectoralis major transfer.[12]

Muscular dystrophy often contraindicates tendon transfer, because the muscles transferred are either dystrophic or capable of becoming dystrophic. A pertinent example is facioscapulohumeral muscular dystrophy (FSHD), which commonly affects the trapezius, causing a need for scapular stabilization, but also commonly affects other periscapular muscles, which contraindicates the transfer.[13]

Collagen disorders contraindicate tendon transfers in general, including the Eden-Lange procedure.[14]

Scapulothoracic fusion, a salvage procedure, can be done when tendon transfer is contraindicated or in cases of failed tendon transfers.[14]

Risks

The dorsal scapular nerve is at risk for intraoperative injury when detaching the rhomboid and levator scapulae insertions due to its proximity to the medial scapular border.[15] This is of particular concern because the dorsal scapular nerve innervates all three muscles transferred in the Eden-Lange procedure.

References
  1. Amroodi, Morteza Nakhaei; Salariyeh, Mostafa (2018-03-01). "Single-incision Eden-Lange procedure in trapezius muscle paralysis: A report of 11 cases". Acta Orthopaedica et Traumatologica Turcica. ScienceDirect. 52 (2): 115–119. doi:10.1016/j.aott.2017.12.002. PMC 6136329. PMID 29426800.
  2. Romero, J.; Gerber, C. (November 2003). "Levator scapulae and rhomboid transfer for paralysis of trapezius. The Eden-Lange procedure". The Journal of Bone and Joint Surgery. British Volume. 85 (8): 1141–1145. doi:10.1302/0301-620x.85b8.14179. PMID 14653596. S2CID 27055571.
  3. "The modifed[sic] Eden-Lange procedure for paralysis of the trapezius muscle". ResearchGate. Retrieved 2019-09-20.
  4. Eden, R. (1924). "Zur Behandlung der Trapeziuslähmung mittlest Muskelplastik". Deutsche Zeitschr. Chir. 184 (5–6): 387–397. doi:10.1007/BF02791242. S2CID 37997894.
  5. Lange, M. (1951). "Die Behandlung der irreparablem Trapeziuslähmung". Lagenbecks Arch. Klin. Chir. 270: 437–439.
  6. Lange, M. (1959). "Die operative Behandlung der irreparablem Trapeziuslähmung". TIP Fakult. Mecmuasi. 22: 137–141.
  7. BIGLIANI, LOUIS U.; COMPITO, CATHERINE A.; DURALDE, XAVIER A.; WOLFE, IRA N. (October 1996). "Transfer of the Levator Scapulae, Rhomboid Major, and Rhomboid Minor for Paralysis of the Trapezius*". The Journal of Bone & Joint Surgery. 78 (10): 1534–40. doi:10.2106/00004623-199610000-00011. PMID 8876581. S2CID 42444490.
  8. Elhassan, BT; Wagner, ER (August 2015). "Outcome of triple-tendon transfer, an Eden-Lange variant, to reconstruct trapezius paralysis". Journal of Shoulder and Elbow Surgery. 24 (8): 1307–13. doi:10.1016/j.jse.2015.01.008. PMID 25842024. Retrieved 10 August 2019.
  9. Werthel, JD; Wagner, ER; Sperling, JW; Elhassan, B (1 March 2019). "Tendon Transfer Options for Trapezius Paralysis: A Biomechanical Study". The Journal of the American Academy of Orthopaedic Surgeons. 27 (5): e235–e241. doi:10.5435/JAAOS-D-16-00731. PMID 30216241. S2CID 52278118.
  10. Gustin, M; Olszewski, N; Parisien, RL; Li, X (October 2020). "The Modified Eden-Lange Tendon Transfer for Lateral Scapular Winging Secondary to Spinal Accessory Nerve Injury". Arthroscopy Techniques. 9 (10): e1581–e1589. doi:10.1016/j.eats.2020.06.026. PMC 7587927. PMID 33134064.
  11. Witbreuk, Melinda M.; Lambert, Simon M.; Eastwood, Deborah M. (May 2007). "Unilateral hypoplasia of the trapezius muscle in a 10-year-old boy: a case report". Journal of Pediatric Orthopaedics B. 16 (3): 229–232. doi:10.1097/BPB.0b013e32808f252e. PMID 17414789.
  12. Galano, GJ; Bigliani, LU; Ahmad, CS; Levine, WN (March 2008). "Surgical treatment of winged scapula". Clinical Orthopaedics and Related Research. 466 (3): 652–60. doi:10.1007/s11999-007-0086-2. PMC 2505206. PMID 18196359.
  13. Gerevini, Simonetta; Scarlato, Marina; Maggi, Lorenzo; Cava, Mariangela; Caliendo, Giandomenico; Pasanisi, Barbara; Falini, Andrea; Previtali, Stefano Carlo; Morandi, Lucia (27 June 2015). "Muscle MRI findings in facioscapulohumeral muscular dystrophy". European Radiology. 26 (3): 693–705. doi:10.1007/s00330-015-3890-1. PMID 26115655. S2CID 24650482.
  14. PhD, Joaquin Sanchez-Sotelo MD (2018). Mayo Clinic Principles of Shoulder Surgery. Oxford University Press. p. 289. ISBN 9780190602772. Retrieved 2 September 2019.
  15. Pinto, MC; Johnson, JL; Patel, HA; Lehtonen, EJ; Momaya, AM; Brooks, WS; Brabston, EW; Ponce, BA (January 2019). "The surgical anatomy of the dorsal scapular nerve: a triple-tendon transfer perspective". Journal of Shoulder and Elbow Surgery. 28 (1): 137–142. doi:10.1016/j.jse.2018.07.005. PMID 30318275.
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