The Eden–Lange procedure is an

orthopedic Orthopedic surgery or orthopedics ( alternative spelling orthopaedics) is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...

procedure to alleviate the symptoms of trapezius palsy when more conservative measures, such as spontaneous resolution and surgical nerve repair are not promising. The rhomboid major,

rhomboid minor In human anatomy, the rhomboid minor is a small skeletal muscle of the back that connects the scapula to the vertebrae of the spinal column. It arises from the nuchal ligament, the 7th cervical and 1st thoracic vertebrae and intervening suprasp ...

, and

levator scapulae The levator scapulae is a slender skeletal muscle situated at the back and side of the neck. It originates from the transverse processes of the four uppermost cervical vertebrae; it inserts onto the upper portion of the medial border of the scapu ...

muscles are transferred laterally along the

scapula The scapula (: scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on either side ...

to replace the functions of the lower, middle, and upper fibers of the

trapezius The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the human spine, spine and laterally to the spine of the scapula. It moves the scapula and ...

, respectively. The transferred muscles hold the scapula in a more medial and upwardly rotated position, without winging.

Versions

Eden–Lange procedure

The original technique was first described by Eden in 1924 and verified by Lange in the 1950s. The rhomboid major and rhomboid minor were transferred laterally from the medial border of the scapula to the

infraspinatous fossa The infraspinous fossa (infraspinatus fossa or infraspinatous fossa) of the scapula The scapula (: scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone ...

, and the levator scapulae was transferred laterally to the

spine of the scapula The spine of the scapula or scapular spine is a prominent plate of bone, which crosses obliquely the medial four-fifths of the scapula at its upper part, and separates the supra- from the infraspinatous fossa. Structure It begins at the vertica ...

, near the

acromion In human anatomy, the acromion (from Greek: ''akros'', "highest", ''ōmos'', "shoulder", : acromia) or summit of the shoulder is a bony process on the scapula (shoulder blade). Together with the coracoid process, it extends laterally over the sh ...

Modified Eden–Lange procedure

The procedure was first modified by Bigliani et al. in 1996. The change was transferring the rhomboid minor to the

supraspinatous fossa The supraspinous fossa (supraspinatus fossa, supraspinatous fossa) of the posterior aspect of the scapula (the shoulder blade) is smaller than the infraspinous fossa, concave, smooth, and broader at its vertebral than at its humeral end. Its me ...

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 Mayo Clinic () is a Nonprofit organization, private American Academic health science centre, academic Medical centers in the United States, medical center focused on integrated health care, healthcare, Mayo Clinic College of Medicine and Science ...

in 2015, and since 2010 no other technique for intractable trapezius palsy has been used there. 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. 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.

Indications

Symptomatic trapezius palsy lasting longer than one 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. Symptomatic trapezius agenesis or hypogenesis, although rare, could be mitigated with an Eden–Lange procedure.

Contraindications

Additional muscle deficits can contraindicate tendon transfer, namely the

serratus anterior muscle The serratus anterior is a muscle of the chest. It originates at the side of the chest from the upper 8 or 9 ribs; it inserts along the entire length of the anterior aspect of the medial border of the scapula. It is innervated by the long tho ...

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 Pectoral may refer to: * The chest region and anything relating to it. * Pectoral cross, a cross worn on the chest * a decorative, usually jeweled version of a gorget * Pectoral (Ancient Egypt), a type of jewelry worn in ancient Egypt * Pectorali ...

Muscular dystrophy Muscular dystrophies (MD) are a genetically and clinically heterogeneous group of rare neuromuscular diseases that cause progressive weakness and breakdown of skeletal muscles over time. The disorders differ as to which muscles are primarily affe ...

often contraindicates tendon transfer, because the muscles transferred are either dystrophic or capable of becoming dystrophic. A pertinent example is

facioscapulohumeral muscular dystrophy Facioscapulohumeral muscular dystrophy (FSHD) is a type of muscular dystrophy, a group of heritable diseases that cause degeneration of muscle and progressive weakness. Per the name, FSHD tends to sequentially weaken the muscles of the fac ...

(FSHD), which commonly affects the trapezius, causing a need for scapular stabilization, but also commonly affects other periscapular muscles, which contraindicates the transfer. Collagen disorders contraindicate tendon transfers in general, including the Eden–Lange procedure.

Scapulothoracic fusion The shoulder girdle or pectoral girdle is the set of bones in the appendicular skeleton which connects to the arm on each side. In humans, it consists of the clavicle and scapula; in those species with three bones in the shoulder, it consists of ...

, a salvage procedure, can be done when tendon transfer is contraindicated or in cases of failed tendon transfers.

Risks

The

dorsal scapular nerve The dorsal scapular nerve is a branch of the brachial plexus, usually derived from the ventral ramus of cervical nerve C5. It provides motor innervation to the rhomboid major muscle, rhomboid minor muscle, and levator scapulae muscle. Dorsal ...

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

References

{{Reflist Orthopedic surgical procedures