Surgical Management of Massive Irreparable Posterosuperior Rotator Cuff Tears: Arthroscopic-Assisted Lower Trapezius Transfer

The Evolution of Arthroscopic Shoulder Surgery: Current Trends and Future Perspectives

Arthroscopic shoulder surgery has undergone significant advancements over the past decades, transitioning from a primarily diagnostic tool to a comprehensive therapeutic approach. Technological innovations and refined surgical techniques have expanded the indications for arthroscopy, allowing minimally invasive management of shoulder instability and rotator cuff pathology. Methods: This narrative review explores the historical evolution, current trends, and future perspectives in arthroscopic shoulder surgery. Results: Key advancements in shoulder instability management include the evolution of the arthroscopic Bankart repair, the introduction of the remplissage technique for Hill-Sachs lesions, and the development of arthroscopic Latarjet procedures. Additionally, novel techniques such as Dynamic Anterior Stabilization (DAS) and bone block procedures have emerged as promising solutions for complex instability cases. In rotator cuff repair, innovations such as the suture-bridge double-row technique, superior capsular reconstruction (SCR), and biological augmentation strategies, including dermal allografts and bioinductive patches, have contributed to improving tendon healing and functional outcomes. The role of biologic augmentation, including biceps tendon autografts and subacromial bursa augmentation, is also gaining traction in enhancing repair durability. Conclusions: As arthroscopic techniques continue to evolve, the integration of biologic solutions and patient-specific surgical planning will likely define the future of shoulder surgery. This review provides a comprehensive assessment of current state-of-the-art techniques and discusses their clinical implications, with a focus on optimizing patient outcomes and minimizing surgical failure rates.

Lower trapezius tendon transfer vs. reverse shoulder arthroplasty for massive irreparable rotator cuff tears: an in-vivo scapulohumeral rhythm dynamic radiography study

BACKGROUND

Reverse shoulder arthroplasty (RSA) and arthroscopic-assisted lower trapezius tendon (aLTT) transfer are both treatment options for massive irreparable rotator cuff tears (MIRCTs) without glenohumeral arthritis; however, the indications for each remain controversial. Although RSA is an excellent reconstructive option, preserving the joint, recentering the humeral head, and restoring in-line active external rotation with an aLTT transfer may be preferred in certain patients to better restore more normal shoulder biomechanics. In-vivo kinematics, however, have been historically difficult to evaluate. Dynamic digital radiography (DDR) provides a novel way to examine shoulder function following surgical intervention by estimating the scapulohumeral rhythm (SHR)-the ratio of humerothoracic and scapulothoracic motion. The purpose of this study was to compare SHR between aLTT transfer and RSA in the setting of nonarthritic MIRCTs with the use of DDR. We hypothesized that aLTT transfer would restore SHR to values more typical of native shoulders compared to RSA.

METHODS

DDR > 6 months postoperatively was performed on 48 shoulders, comprised of 30 RSA and 18 aLTT transfer shoulders, secondary to nonarthritic MIRCT-the diagnosis for which was validated on radiographs and magnetic resonance imaging. Manual measurements of the angle between the humerus and the midline and the lateral border of the scapula and midline were taken by 2 readers at rest, 30°, 60°, and 90° of shoulder abduction. The ratio of these measurements formed the SHR. A paired subgroup analysis was performed on 7 RSA and 7 aLTT transfer shoulders with both preoperative and postoperative DDR to evaluate for precise changes in SHR. Data were compared using descriptive statistics, and inter-rater reliability of the manual measurements was assessed with intraclass correlations.

RESULTS

The aLTT transfer cohort had a higher median rest-90° range of motion SHR of 2.30, compared to 1.83 for the RSA cohort. Subgroup analysis of the RSA cohort demonstrated a nonsignificant improvement in median rest-90° range of motion SHR from 1.84 to 2.23 following surgical intervention. The aLTT transfer subgroup's median rest-90° SHR improved significantly from 2.20 to 2.46 following surgical intervention. The inter-rater reliability was 0.99.

CONCLUSIONS

aLTT transfer is associated with an increased SHR compared to RSA in patients with nonarthritic MIRCTs by establishing a higher glenohumeral contribution compared to scapulothoracic contribution. Further work is needed to understand scapular motion in multiple planes after these surgeries and correlate SHR changes with clinical outcomes.

Short-term functional, imaging, and electrodiagnostic outcomes of arthroscopy-assisted lower trapezius transfer

BACKGROUND

The purpose of this study was to evaluate the short-term functional outcomes, structural healing, and neuromuscular activity after arthroscopy-assisted lower trapezius transfer for irreparable posterior superior rotator cuff tears.

METHODS

All patients who underwent arthroscopy-assisted lower trapezius tendon transfer for an irreparable posterior superior rotator cuff tear between 2017 and 2021 by 2 surgeons with a minimum of 2-year follow-up were identified. Functional outcome scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] score, visual analog scale [VAS] for pain), range of motion, shoulder strength, magnetic resonance imaging (MRI) to assess transfer healing, and needle electromyographic (EMG) examination to assess lower trapezius muscle activity were performed at a minimum of 2 years postoperatively. Contralateral nonoperative lower trapezius muscle activity was assessed by EMG. Grafts were defined as completely healed if anatomic graft healing occurred, partial healing if some graft was healed to the proximal humerus, and unhealed if no graft was attached to the proximal humerus on postoperative MRI.

RESULTS

Twenty-four eligible patients (25 shoulders) were identified through chart review. Mean age and follow-up were 54.9 ± 9.5 and 2.9 ± 1.7 years, respectively. Overall, 72% (18/25) clinical follow-up was obtained. All functional outcomes including ASES (preoperative, 48.8 ± 19.6; postoperative, 80.9 ± 15.4; P < .001), VAS pain (4.9 ± 2.3; 1.4 ± 1.5; P < .001), and active forward flexion (110° ± 53.2°; 141.7° ± 40.4°; P = .024) statistically significantly improved. Twelve shoulders (48%) presented for EMG follow-up. All 12 patients demonstrated EMG activity of the lower trapezius in forward elevation, external rotation at the side, and external rotation at 90° of abduction, which was symmetric to the contralateral shoulder. Fifteen shoulders (60%) were available for MRI follow-up. Thirteen patients (87%) demonstrated complete or partial healing of the allograft to the greater tuberosity, whereas 2 (13%) demonstrated a complete tear of the graft.

CONCLUSIONS

Arthroscopy-assisted lower trapezius transfer demonstrates improved functional outcomes 2 years postoperatively. Complete retear of the transfer is relatively uncommon (13%). The lower trapezius fired in phase in forward flexion, external rotation at the side, and external rotation in 90° of abduction in all patients who underwent EMG testing, which was consistent with the firing pattern of the contralateral normal lower trapezius muscle. These results may support the theory that active function of the muscle transfer itself, as opposed to a tenodesis effect, is a potential mechanism by which this procedure improves shoulder function as it consistently fires in phase.

Return to Work and Sports After Lower Trapezius Tendon Transfer for Posterosuperior Irreparable Rotator Cuff Tears

BACKGROUND

Lower trapezius tendon (LTT) transfer has demonstrated promising results for patients with posterosuperior irreparable rotator cuff tears (PSIRCTs). However, there has been no study evaluating return to work (RTW) and return to sports (RTS) after LTT transfer.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the rates of RTW and RTS and identify associated factors among patients who have undergone LTT transfer for PSIRCTs. It was hypothesized that LTT transfer would result in favorable functional outcomes and high rates of RTW and RTS.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review was conducted on patients who underwent LTT transfer for symptomatic PSIRCTs with minimal glenohumeral arthritis. The clinical assessment included patient-reported outcome measures, testing of active range of motion, and a radiological evaluation of arthritis. Patients were surveyed on occupation, sports activity, RTW or RTS status, time to return, and degree of resumption of previous work and sports levels. Exclusion criteria included a follow-up period of <1 year, revision surgery, postoperative infections, loss to follow-up, and unavailability of data.

RESULTS

A total of 110 patients (mean age, 63.0 ± 6.9 years; mean follow-up, 35.3 ± 15.7 months) were included. Clinical scores and active range of motion significantly improved at the final follow-up, with no significant differences between the different work levels. For RTW, 93.6% (n = 103) returned to work (63.1% completely, 36.9% partially), with a mean time to return of 5.2 ± 1.7 months; 6.4% (n = 7) did not return. Patients with lighter work levels had higher return rates and quicker times to return than those with heavier work levels. For RTS, 90.7% (n = 86) returned to sports (70.5% completely, 29.5% partially), with a mean time to return of 5.7 ± 1.3 months. For patients who participated in shoulder sports, 89.9% returned, and 10.1% failed to return. Multivariable logistic regression showed significant associations of higher RTW rates with lighter work levels (odds ratio [OR], 2.72; P = .005) and lower retear rates (OR, 5.41; P = .021). A lower retear rate was also significantly associated with a higher RTS rate (OR, 7.66; P = .010).

CONCLUSION

LTT transfer for PSIRCTs yielded favorable functional outcomes with high rates of RTW and RTS. Patient-related factors, notably work level and retears, influenced successful RTW and RTS.

Restoring the Anteroposterior Shoulder Force Couple: Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Partially Augmented Rotator Cuff Repair for Irreparable Massive Rotator Cuff Tears

Lower trapezius transfer presents a highly encouraging therapeutic approach for addressing posterosuperior irreparable massive rotator cuff tears. Based on studies on the balance of force couples of the rotator cuff, more scholars believe that attention should be paid to the reconstruction of the force couples of the rotator cuff. This study proposes a modified surgical approach that integrates an arthroscopic-assisted lower trapezius transfer with autologous hamstring tendon and partially augmented rotator cuff repair for irreparable massive rotator cuff tears, with a focus on restoring the anterior-posterior shoulder force couple.

Mid- to long-term outcomes of latissimus dorsi tendon transfer for massive irreparable posterosuperior rotator cuff tears: a systematic review and meta-analysis

BACKGROUND

This study aims to analyze the mid-to long-term results of the latissimus dorsi tendon for the treatment of massive posterosuperior irreparable rotator cuff tears as reported in high-quality publications and to determine its efficacy and safety.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Scopus, and EMBASE databases were searched until December 2022 to identify studies with a minimum 4 year follow-up. Clinical and radiographic outcomes, complications, and revision surgery data were collected. The publications included were analyzed quantitatively using the DerSimonian Laird random-effects model to estimate the change in outcomes from the preoperative to the postoperative condition. The proportion of complications and revisions were pooled using the Freeman-Tukey double arcsine transformation.

RESULTS

Of the 618 publications identified through database search, 11 articles were considered eligible. A total of 421 patients (432 shoulders) were included in this analysis. Their mean age was 59.5 ± 4 years. Of these, 277 patients had mid-term follow-up (4-9 years), and 144 had long-term follow-up (more than 9 years). Postoperative improvements were considered significant for the following outcome parameters: Constant-Murley Score (0-100 scale), with a mean difference (MD) = 28 points (95% confidence interval [CI] 21, 36; I2 = 89%; P < .001); visual analog scale, with a standardized MD = 2.5 (95% CI 1.7, 3.3; P < .001; I2 = 89%; P < .001); forward flexion, with a MD = 43° (95% CI 21°, 65°; I2 = 95% P < .001); abduction, with a MD = 38° (95% CI 20°, 56°; I2 = 85%; P < .01), and external rotation, with a MD = 8° (95% CI 1°, 16°; I2 = 87%; P = .005). The overall reported mean complication rate was 13% (95% CI 9%, 19%; I2 = 0%), while the reported mean revision rate was 6% (95% CI: 3%, 9%; I2 = 0%).

CONCLUSIONS

Our pooled estimated results seem to indicate that latissimus dorsi tendon transfer significantly improves patient-reported outcomes, pain relief, range of motion, and strength, with modest rates of complications and revision surgery at mid-to long-term follow-up. In well-selected patients, latissimus dorsi tendon transfer may provide favorable outcomes for irreparable posterosuperior cuff tears.

Outcomes after arthroscopically assisted lower trapezius transfer with Achilles tendon allograft

BACKGROUND

Lower trapezius tendon transfer is 1 option to improve pain and function with massive irreparable rotator cuff tears. Magnetic resonance imaging (MRI) evaluation of tendon healing with the procedure has not yet been reported. The purpose of this study was to evaluate early tendon transfer healing using postoperative MRI scans and to assess early clinical outcomes in patients after arthroscopically assisted lower trapezius tendon transfer (AALTT) for massive irreparable rotator cuff tears.

METHODS

This was a single institution retrospective review of consecutive patients with massive irreparable rotator cuff tears who underwent AALTT with a single surgeon from January 2017 to July 2020 with a minimum 6-month follow-up. Patient information including age, sex, follow-up, prior surgical history, and type of work (sedentary or labor-intensive) was recorded. Preoperative and postoperative range of motion, external rotation strength, presence of a lag sign, and pain visual analog scale data were extracted from medical records. Patient-reported outcomes were extracted from patient charts. Six-month postoperative MRIs were reviewed for tendon transfer healing at both the greater tuberosity and the trapezius-allograft interface.

RESULTS

A total of 19 patients met inclusion criteria with average age 56.7 (range, 29-72 years). Of these patients, 17 (89.5%) were male. The average follow-up was 14.6 (range, 6-45) months. Fifteen (78.9%) patients had unsuccessful previous rotator cuff repair. Six-month MRI demonstrated complete healing of the transferred tendon in 17 of 19 patients (89.5%). There were significant improvements in postoperative pain visual analog scale (5.9 ± 2 vs. 1.8 ± 2), ASES score (44.6 ± 18 vs. 71.2 ± 24), and Patient Reported Outcomes Measurement Information System Physical (46.3 ± 6 vs. 51.3 ± 11) and in external rotation motion (10.5 ± 17° vs. 40.5 ± 13°) and strength (2.8/5 ± 1 vs. 4.7/5 ± 0.5) at final follow-up. All patients with a preoperative external rotation lag sign had reversal of their lag sign at final follow-up (15/15). Of 17 work-eligible patients, 13 (76.4%) were able to return to work.

CONCLUSION

In this series, AALTT showed a high rate of healing of the transferred tendon on MRI by 6 months postoperatively. The current findings of a high rate of early tendon transfer healing are consistent with the good early and mid-term outcomes that have been observed in AALTT and provide support for surgeon and patient expectations, postoperative rehabilitation, and return to work following AALTT for massive posterior superior rotator cuff tears.

Superior Capsular Reconstruction Combined With Lower Trapezius Tendon Transfer Improves the Biomechanics in Posterosuperior Massive Rotator Cuff Tears

BACKGROUND

Surgical treatments for chronic posterosuperior massive rotator cuff tear (MRCT) are still controversial. Superior capsular reconstruction (SCR), which provides a static stabilizer to decrease superior humeral head translation, and lower trapezius tendon transfer (LTTT) with centralization of the humeral head, which prevents superior humeral head migration, are potential surgical options. To date, SCR combined with LTTT has not been fully investigated.

HYPOTHESIS

Restoration of static stabilizer and dynamic stabilizer together would effectively improve shoulder kinematics in posterosuperior MRCT.

STUDY DESIGN

Controlled laboratory study.

METHODS

A custom-made shoulder mechanics testing system was used to test 8 fresh-frozen cadaveric shoulders. The testing conditions were as follows: (1) intact; (2) posterosuperior MRCT (supraspinatus and infraspinatus removed); (3) SCR using the fascia lata; (4) LTTT; and (5) SCR combined with LTTT. The total rotational range of motion (ROM), superior translation, anteroposterior translation, and peak subacromial contact pressure were evaluated at 0°, 30°, and 60° of shoulder abduction. Repeated-measures analysis of variance and Tukey post hoc tests were performed.

RESULTS

The total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure increased in posterosuperior MRCTs (all, P < .05). The rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0° and 30° of shoulder abduction decreased in SCR (all, P < .05). However, there was no significant improvement in rotational ROM, superior translation, and peak subacromial contact pressure at 60° of shoulder abduction (P > .05). LTTT resulted in a significant decrease in the superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (P < .05). SCR combined with LTTT restored the total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (all, P < .05).

CONCLUSION

In the cadaveric model, SCR combined with LTTT showed improved shoulder kinematics and contact pressures in the posterosuperior MRCT model compared with SCR or LTTT alone.

CLINICAL RELEVANCE

SCR combined with LTTT may be regarded as an alternative surgical procedure for posterosuperior MRCTs.

Long-Term Results of Primary Reverse Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears Without Glenohumeral Arthritis with a Mean Follow up of 9.4 Years

Background

The aim of this single-center study was to analyze the long-term clinical results of reverse shoulder arthroplasty in patients with massive, irreparable rotator cuff tears without glenohumeral arthritis.

Methods

A retrospective cohort study of 105 patients (115 shoulders) was conducted. The mean age of the patient group was 76 years (range, 65 to 87 years). The mean clinical follow-up was 9.4 years (range, 5 to 17 years). Pain, range of motion, and complication rates were analyzed pre-operatively and at the last follow-up.

Results

The mean Constant-Murley score increased from 29 points (range, 21 to 34 points) preoperatively to 68.1 points (range, 57 to 81 points) postoperatively (p<0.05). Scapular notching was present in 50 shoulders (43.5%) and it was grade 1 or 2 in 47 of 115 cases (40.9%) and grade 3 or 4 in 3 of 115 cases (2.6%). Complications occurred in 19 patients (17%). Seven patients (6%) underwent revision surgery. The mean satisfaction rate was 94%.

Conclusions

Reverse shoulder arthroplasty is a viable treatment for massive, irreparable rotator cuff tears without glenohumeral arthritis with satisfactory clinical outcomes and low complication and reoperation rates with a mean follow up of 9.4 years after surgery.

Combined Arthroscopic-Assisted Lower Trapezius Tendon Transfer and Superior Capsule Reconstruction for Massive Irreparable Posterior-Superior Rotator Cuff Tears: Surgical Technique

Primary or revision irreparable rotator cuff tears remain a challenge. Clear algorithms do not exist. Several joint-preserving options are available, but no technique has been definitely proven to be better than another. Although superior capsule reconstruction has been shown to be effective in restoring motion, lower trapezius transfer can provide strong external rotation and abduction moment. The aim of the present article was to describe an easy and reliable technique to combine both options in 1 surgery, aiming to maximize the functional outcome by getting motion and strength back.

Arthroscopic Superior Capsular Reconstruction (ASCR): All Soft Anchors Technique

Rotator cuff tears are among the most common orthopaedic injuries. If not treated, they can result in a massive irreparable tear because of tendon retraction and muscle atrophy. Mihata et al. in 2012 described the technique of superior capsular reconstruction (SCR) using fascia lata autograft. This has been considered an acceptable and effective method for treating irreparable massive rotator cuff tears. We describe an arthroscopically assisted superior capsular reconstruction (ASCR) technique using all soft anchors to preserve the bone stock and reduce possible hardware complications. Moreover, knotless anchors for the lateral fixation make the technique easier to reproduce.

The clinical results of lower trapezius tendon transfer with the peroneus longus allograft augmentation combined with interpositional repair with fascia lata in massive irreparable rotator cuff tears

OBJECTIVES

To investigate the clinical results of lower trapezius (LT) tendon transfer and interpositional repair that were performed simultaneously in patients with massive irreparable rotator cuff tears.

METHODS

Between 2018 and 2020 years, 16 patients with massive irreparable rotator cuff tears that were treated with LT tendon transfer and interpositional repair at the same time were included in this study. The mean follow-up period was 29±3 months (24-39 months) and the mean age of patients was 62±9 years (42-73 years). The acromio-humeral distance, active range of motions, Visual Analog Scale (VAS) scores, University of California-Los Angeles (UCLA) scores and Constant-Murley scores were made preoperatively and at the final follow-up.

RESULTS

At the final follow-up, forward flexion was increased from 109˚±24.7 to 144˚±22.21 (p=0.005), abduction from 60˚±16.33 to 135˚±16.33 (p=0.005) and external rotation from 12˚±16.87 to 35˚±14.34 (p=0.005). Total UCLA scores were 5.9±2.13 to 22.7±5.29 (p=0.005), Constant-Murley scores were 24±9.43 to 50.2±14.28 (p=0.008), VAS scores were 6.1±1.1 to 2.4±1.35 (p=0.007), mean acromio-humeral distances were 4.64±0.85 mm (3.42-6.23 mm) to 6.58 mm (5.25-8.21 mm) (p=0.005) preoperatively and at the final follow-up. Except one patient who had a frozen shoulder any significant complication was detected.

CONCLUSION

Adding interpositional repair to the LT tendon transfer in patients with posterior superior irreparable rotator cuff tear seems to have satisfactory short to mid-term clinical outcomes without an increase in complications.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

Treatment Options for Massive Irreparable Rotator Cuff Tears

PURPOSE OF REVIEW

Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.

RECENT FINDINGS

Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.

Advancement in Arthroscopic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tear

Irreparable massive rotator cuff tear (IMRCT) was one of the causes of shoulder dysfunction, despite technical improvement, the failure rate of IMRCT was still demonstrated to be high. Traditional treatments like non-surgical treatments, partial rotator cuff repair, and tendon transfers could only achieve a slight improvement. A potential cause for high failure rate was the fact that traditional treatments cannot restore the superior stability of glenohumeral joint, and thus restricted the movement of shoulder joint severely. Superior capsular reconstruction (SCR) using a variety of grafts (autograft, allograft, xenograft, or synthetic grafts) provided a promising option for IMRCT. In surgery, graft was fixed medially to superior glenoid and laterally to the footprint of humeral greater tuberosity. SCR could increase the stability of the superior glenohumeral joint, decrease the subacromial pressure and acromiohumeral distance. This review summarized the relevant literature regarding the alternative grafts, surgery indications, operative techniques and clinical outcomes of SCR. we compared the different grafts, key surgical steps, the advantages and disadvantages of different surgical methods to provide clinicians with new surgical insights into the treatments of IMRCT. In conclusion, IMRCT without severe glenohumeral arthritis was the best suitable indication for SCR. The clinical outcomes were positive in the short-term and middle-term following-up. More studies were necessary to determine long-term results of this surgical procedure.

Tendon transfers for irreparable rotator cuff tears

Symptomatic irreparable rotator cuff tears pose a challenge for shoulder surgeons. Whilst reverse polarity shoulder arthroplasty is an effective option for older symptomatic patients who have exhausted conservative management, the optimal treatment for younger patients remains controversial. In this article we outline the main tendon transfer options, including anatomical considerations, indications, contraindications, surgical technique, complications and a review of the evidence. Tendon transfers provide an alternative joint-preserving surgical option, but the evidence so far is limited, with a clear need for well-designed comparative studies to confirm their effectiveness.

Surgical Technique: Lower Trapezius Transfer in Paediatric Paralytic Shoulder

The therapeutic management of the paralytic shoulder after an obstetric brachial plexus injury is complex. When nerve repair or neurotization fail, or if the biological times for nerve reconstruction is over, tendon transfer to restore active external rotation of the shoulder becomes the main surgical alternative. The purpose of this manuscript is to describe the surgical technique of the lower trapezius muscle transfer to the infraspinatus muscle, to restore active shoulder external rotation in the child with paralytic shoulder, step by step with details and pearls.