That was hilarious. It's always good to laugh, by the way. It's always good to laugh. So lower trap. So let's start with the basics, OK? Like, you need a rotator cuff to stabilize the shoulder for the deltoid to function. And you need a stable scapula for the motion. And whenever we aim to reconstruct the rotator cuff, reconstruction of the mechanics is very important. What you spoke about is correct. But, OK, if there is no deltoid, you can have full range of, oops, can you go back? Slide? So if you don't have a deltoid, this patient has no deltoid. Full range of motion of the shoulder. Why? Because of the rotator cuff. Because of the power of the rotator cuff, OK? Now, if you have a deltoid, but the rotator cuff is fat, you cannot repair it. So in this case, you end up with this kind of function, OK? No muscle. And JT Tokic is here. I learned this one from him. No life if there is no muscle. And this is a big question. You get this patient. This is a 50-year-old with no infra, no supra. This one is tricky because of the teres minor. But if there is no muscle, will you try to get soft tissue coverage? Or do you try to repair fat? Or do you try to reconstruct the muscle with a muscle that looks really very much like it? And I have the highest respect for the scapula. So I will not do a transfer that will jeopardize the scapula function. In fact, if anything, this stabilizes scapula function. So yes, I will choose tendon transfer. What is the available transfer? You have the lat, which is the classic. You have teres major. And you have the lower trap. And for us, for the posterior superior rotator cuff, the lower trap to go. Why? The scapula is the house. It has all this rotator cuff. If you look at the lower trap compared to the scapula, it is exactly the same line of pull. And if you look at it here, anatomically, this I present this so many times before you see the beautiful line of pull. And so anatomically, kinematically, biomechanically is the best transfer to reconstruct the posterior superior rotator cuff. And there are a lot of studies that confirm this in the past. And because it matches the right rotator cuff, early on we did it for the brachial plexus. There was no muscle to get shoulder external rotation. And we were able to do it in more than 700 cases of brachial plexus. And then we said, it worked in brachial plexus. Why wouldn't that work for the rotator cuff? And we start to do it for the rotator cuff. Indication is very important. Young, like the one we saw, active, massive rotator cuff there with pseudoparesis or pseudoparalysis. And how is it done? In four minutes, I cannot show you it. I'll show you pictures. This was the open approach before. But we changed from open to arthroscopic, very minimal, not what John has shown. We call it SALT-scope assisted lower trapezius, small incision. We make it. We get the lower trap. I can extend an allograft. Overseas, I just came back from India. They do perunus longus. They do hamstring. You pass, you fix, and you attach it to the muscle. And everything changed over time. So we were open, arthroscopic, and then now we do a triple team. Now my PA will be preparing the Achilles tendon, and the fellow will be harvesting, and myself will be inside the shoulder. In fact, I saw Anna Murphy showing something similar to this. This is a triple. And the outcome, as everyone's showing, you can have fantastic outcome. And the most important is an active transfer. You can look at it. It's an active transfer from the back. Whenever the patient moves, many times you don't need imaging to confirm it's still in continuity. Again, if you look at it from the back, it's an active transfer. When the patient moves, you can see the lower trap, and you can see how it's going to the shoulder. Now, again, active transfer. And then the question I get, why don't you SCR on top? Because when I don't do anything, and there's patients, I did not do biceps. I went after three years. I looked. The shoulder was completely sealed. So when you restore the mechanics, your body is going to heal it. You do not need to cover it for extra tissues or extra anchors. The other question I get, but using allograft, what's going to happen over time? This patient has arthritis. We don't do it for arthritis anymore. Look at the lower trap. It looks beautiful. And then the biopsy showed a living fibroblast. So you have now multiple study to show the superiority and the good outcome of the lower trapezius. And for this reason, I would say definitely lower trapezius is the way to go for me. And I would like to invite all of you for our transfer course and scapula course this November in Boston. Thank you.

shoulder mechanics

rotator cuff

scapula

lower trapezius muscle

tendon transfer