Good morning, everyone. Thank you very much for having me virtually. I'm really sorry I could not be there in person. Peter, thank you very much for organizing this ICL. I'm sure it's going to be amazing, especially in the presence of Fadi Sabwa and Joe Abood. My task is to present about low trapezius transfer in the setting of massive irreparable posterior suprarotative calf tear. In this situation, in order to make it less controversial, I'm specifically going to address the massive irreparable posterior suprarotative calf tear advanced fatty atrophy of the supra infraenteric and or teres minor with profound weakness of the supraspinatus and infraspinatus with ER lag, both in external rotation, A deduction and AB deduction. Also, we'll tackle and have the same scenario, and they had a prior SCR that did not work because of the same problem when you have profound deficiency or significant deficiency of the supraspinatus, infraspinatus, and or teres minor. So how can we apply our understanding of the anatomy and the biomechanics of the shoulder to be able to reconstruct massive irreparable posterior suprarotative calf tear? To start with, the principle of the force couple is very important, and it should know the importance of the force couple in stabilizing the glenohumeral joint to achieve deltoid function and shoulder function. For this reason, if you have the force couple working, the shoulder should function well. So as most of you know, that if the supraspinatus is deficient, as long as you have the subscapular infraspinatus, the patient can function very well. They can have pain, they can have some weakness, but they should not lose really the shoulder function. However, when you lose the force couple secondary to massive irreparable posterior suprarotative calf tear, this is when the patient develops significant limitation of ratio of motion and pseudoparalysis. Interestingly, on the contrary, if the rotator cuff are working, but the deltoid is completely paralyzed, the patient can achieve near full ratio of motion of the shoulder. And if you do any of the standard testing like job test, ER, external rotation strengths, all of them, they're going to be within normal. But if you do specific testing for the deltoid, this is how we uncover the deltoid weakness. Even normal healthy young patient, if the rotator cuff are dysfunctional or paralyzed, it can lead to significant limitation of motion. Like if you inject the suprascapular nerve to shut it down, the patient can develop symptom similar to pseudoparalysis or deficient rotator cuff. So with this understanding of the importance of the force couple, how to best restore the force couple in the setting of massive irreparable posterior suprarotative calf tear? We have to restore it by finding a muscle that best matches the posterior suprarotative cuff. So if we want to reconstruct the posterior suprarotative cuff with the tendon transfer, we have to pick the muscle that has the best matches to the deficient cuff. And in the setting, in order to choose the right muscle, we should have good understanding of the anatomy and biomechanics of the rotator cuff. And remember that the scapula is the house of the rotator cuff and that house is sitting on the posterior chest. So if we put all this rotator cuff on the scapula and collect the shoulder, and then you see it sitting on the posterior chest, it's very important. Which means if we want to transfer any muscle to reconstruct the rotator cuff, it has to originate from the posterior chest in order to match the line of pull of these muscles. For this reason, if you look at the lower trapezius, you see that the line of pull and the anatomy perfectly match those of the rotator cuff. It originates from the posterior chest, and the vectors are essentially the same as the rotator cuff, whether it's supra-infinite, teres minor, or subscapular, all the same line, the same vectors, but specifically the posterior rotator cuff. In addition, the excursion or the shortening of the muscle of the trapezius is very similar to the rotator cuff, while the excursion of the latissimus is much bigger, which you usually don't need for the rotator cuff. The tension, which is the strength, also the trapezius and the intraspinatus are very similar. But if you look at the latissimus, it has low tension. So the rotator cuff, they have high tension, low excursion. Latissimus has high excursion, low tension. Trapezius has high tension, low excursion. So it matches better the rotator cuff. And biomechanically, if the shoulder is deficient of deltoid and you do a latissimus transfer, the shoulder subluxate, boom, it goes down. And this is logical because of the line of pull of the latissimus. However, if you try to mimic a deficient deltoid and you do lower trapezius, the trapezius can stabilize the shoulder and cause external rotation because the line of pull is essentially the same as the intraspinatus. And there are a lot of biomechanical studies, started by our studies and followed by others, that confirm the similar biomechanic and kinematic using the trapezius muscle compared to the rotator cuff. Now to take it to the next level, when we do surface EMG to determine how the muscles activate during shoulder flexion, for example, this is what we noticed. When the patient tried to flex their shoulder activating different muscles, these are the muscles in general that activates in certain sequences. Trapezius, anterior deltoid, pectoralis serratus, and rotator cuff muscles. But what we noticed, what's interesting, the muscle that had very low to no activation until almost he reached the horizontal are the pectoralis minor, rhomboid major, and the latissimus dorsi, which means the latissimus, when you try to flex your shoulder, does not activate until horizontal, does not activate much, which is very important when you talk about this muscle transfer and the setting of mass rotator cuff there. And do a surface EMG or real EMG with a needle and ask the patient to externally rotate the shoulder, the lower trapezius muscle activates spontaneously while the latissimus remains completely quiet or silent. So when we take all these principles, the line of pull, the vector, tension, excursion, spontaneous firing during external rotation, it fires during shoulder flexion, and dynamically, even if you don't have deltoid, it stabilizes the shoulder. All of these will make it for us an optimal transfer to reconstruct the massive posterior superior rotator cuff. And when we started to do the trapezius transfer, originally it was for brachial plexus injury, for patients who have no cuff at all muscle, there's no deltoid, and this is how we started. For this reason, we've done a lot of cases early on, we've done more than 500 cases, but to restore shoulder external rotation, the trapezius in the setting is not going to restore flexion, because you have no rest of the rotator cuff, you have no deltoid, but it does stabilize the shoulder, and it does restore shoulder external rotation in the patient who have no deltoid and no rotator cuff, and this is very important. And this is how we used it very early on. And the main reason I'm showing these is just to show that if you can restore at least external rotation in the setting of brachial plexus, why can't you use it for a massive rotator cuff tear, where you have a deltoid, you have subscap, usually why we cannot use it, and you'll have a very good outcome. For this reason, we extended the indication of the rotator trapezius to massive irreparable posterior superior rotator cuff tear that most of you deal with. So in the first, and though the first rotator trapezius transfer with it was through a big massive incision for the brachial plexus, and we use an Achilles tendon allograft, later for the brachial plexus only, because the usually the rotator cuff muscles in general, or the tendon are not torn, they're paralyzed. So in this situation, if you dissect the infraspinatus tendon, and it is usually a nice long tendon, if you dissect it, you'll be able to direct the transfer of the lower trapezius to the infraspinatus to restore shoulder external rotation, and you see the very very nice line of pull. However, in the setting of massive rotator cuff tear, you need an augmentation, and usually we use an Achilles tendon allograft. So in the setting of massive rotator cuff tear, originally, we have done it through a transacromial approach, and we do the transfer. Now with the transacromial, we do only five millimeter osteotomy, but we do a lot of suturing to repair this osteotomy to make sure it heals well, but this is very early on, and for the past years, we don't do it anymore, we usually do the arthroscopic approach. So we progressed from an open to arthroscopic assisted approach, and the arthroscopic assisted approach is the one I get asked about the most in term of the technique. So we do it in the beach chair, you can do it later if you want to, but the beach chair for us, it's easier. You place the shoulder in a slight traction forward, and wherever you place the arm, keep it in place because the scapula moves with the motion of the arm. You do a very good marking, the medial border of the scapula and the medial spine, this angle here is the house of the lower trapezius tendon, and usually we make an incision extended from medial to lateral, more lateral than medial because our repair of the tendon allograft is going to be more lateral, I'll show it to you later. You harvest the muscle and tendon, and I will show you how we do it live. So this is our instrument, the patient in the beach chair position, slight traction anteriorly, you do a very good marking to determine and to identify the medial spine of the scapula, this medial border and the medial spine of the scapula make an angle which is the house of the trapezius. The trapezius is going to be here, the tendon trapezius is going to be here. So right now we make an incision which is slightly medial more lateral, around two centimeters distant to this like location of the triangle. The first step is take the fat out, always take the fat out, and then look into that angle that I spoke about, and the tendon is going to be there. When you pull on it, you're going to find it. If you don't see it very well, it means you still have a little bit more fat on top of the tendon, so you can release it. But in general, when you pull, you can see the border of the tendon, and once you see it, you start to detach it. I usually use electrocautery on the bone, it's very safe. Once you get out of the bone, you have around one centimeter to two centimeters safety before you get to the spinal accessory nerve. Now you have the tendon which is triangular in shape, we place suture in it to reinforce it because later we're going to push the allograft through it. Now the infraspinatus fascia here, usually we open it big time, we put like five centimeter opening, nothing, you're not going to harm anything, you make a nice opening. That opening is the door between the deltoid and the infraspinatus that will take you all the way to the subacromial space. So we make this opening, and this is like around five centimeter opening, you can see the infraspinatus here is gone, you can almost see the bone, and then we can use this long instrument and we'll be able to pass it through this opening between the deltoid and infraspinatus toward the subacromial space. And then Achilles tendon allograft will be prepared on the table. Now, in fact, the triple teaming, like a member of the team will prepare the Achilles tendon, you place a crack or sutures into around five centimeter segment or length of the Achilles tendon, and you do two of them, and you color the top part of the Achilles tendon allograft. As a member of the team is doing this, I will be essentially doing the scope and the fellow will be harvesting the tendon at the same time. We have three people working at the same time to make it even much quicker. And then you prepare the tuberosity and you pass the allograft through that opening I told you about, and the door between the infraspinatus and the deltoid toward the subacromial space. And then you have the two main sutures that are attached to the Achilles tendon allograft. We're going to place them in the anterior footprint of the supraspinatus, one anterior medial, one anterior lateral, and then we're going to put an anchor slightly more posterior medial from medial to lateral to compress. But why we put it here is important because if you look at the anatomy of the rotator calf and the rotator cuff cable, look at the infraspinatus how it goes and extend almost more laterally than you think. It's not as posterior, it goes more lateral, and almost the supraspinatus comes on it to form the cable of the rotator cuff. So if you reflect the supra and infraspinatus to look, and you can see the cable goes all the way anteriorly and laterally. And this is why when you place the Achilles tendon more anterior on the footprint of the supraspinatus, essentially it reconstructs both the supra and infra at the same time. So and here you can see the attachment, and after you do the attachment and secure the Achilles tendon attachment, you place the shoulder in abduction external rotation, you split the graft, the thin portion, one half you discarded, the second half you pulvertafted in the lower trapezius and flip it on itself and repair it. Now for the arthroscopic part of the case, we create our working portals. Arthroscopic portals, we have the posterior portal, anterior portal, and the lateral portal. These are the three portals that we almost always use for the arthroscopic trapezius transfer. In addition to the divisal portal that I use it mostly for suture retrieval, we use it to retrieve the sutures when we place the anchor in the posterior medial aspect of the footprint of the supraspinatus. And the main viewing portal is the lateral portal, in fact, and we can use the post-lateral portal to perform dissection between the infraspinatus and the deltoid, and this is where we pass our instrument to retrieve the sutures from the Achilles tendon allograft, and these sutures are going to be passed through the anterior portal because the fixation is going to go through that portal. So we retrieve the sutures through the anterior portal. Now before we fix the Achilles tendon anteriorly, we place this posterior medial anchor on the footprint of the supraspinatus, and we retrieve the sutures from the divisal portal to keep them out of the way, and then we use them at the very end to compress the Achilles tendon from medial to lateral. This is very important. So now retrieving the sutures, and this is a fixation. This is anterior medial footprint of the supraspinatus anchor fixation, and then the lateral one, and then we take the sutures from the divisal portal from medial to lateral to compress the Achilles tendon on the footprint of the supraspinatus, and you can see the nice motion of the Achilles tendon, and when you pull on it, it goes in external rotation, which is what we want to see in this setting. And at the very end, we place the shoulder in abduction external rotation, and we pulvertaft the Achilles tendon through the tendons portion of the trapezius, and then we tie it on itself, and this will be the end of the case, and we mobilize the shoulder a little just to see the mobility of the construct. Now what happens to the Achilles tendon after a period of time or years? And in this patient, we went back because we left the bicep tendon, the patient developed bicep tendonitis, so we went in to do biceps tenotomy and tenodesis, and we looked at the subacromial space to look at the Achilles tendon, and this is what we saw. It's very interesting that the Achilles tendon is maintained, it became vascularized, and though we did not do any form of capsule reconstruction, we just did the Achilles tendon repair the way I showed you technically with a surgical technique. With that, the superior capsule portion was completely sealed over time, and this is very, very interesting. We did not do any kind of reconstruction of the capsule, but after the tendon transfer over time, the capsule was sealed fully, whether this is from fibrous tissue, fibrocartilage tissues, it is just a form of tissue that will seal the capsule fully. The outcome, the patient really do very well, but the main reason I want to show you the outcome here is just to show the functionality of the outcome. Like this patient, for example, other than she has a very good flexion, abduction, external rotation, I will show you how the tendon is functional. Look at the trapezius muscle and tendon here transfer. During flexion, it's active. During shoulder external rotation, it is active transfer. It's functional, it's active, it's not static, and you can see it. When you do the job test, you see it, so it's active throughout this motion, not only external rotation, inflection, abduction, and this is how the infraspinatus in general function, and you can see it function very well. This is another patient. Also, you can see it very well as she's trying to do her motion in external rotation. You can see how the lower trapezius move with a shoulder external rotation along the same line of the external rotation that you reproduce by, let's say, the infraspinatus. These days, I'm trying to show more the works of my colleagues. This is Adam Murphy. Probably most of you know him. He's an excellent surgeon. He has been doing lower trapezius for the indications that I mentioned about massive erythropoietic osteoporotic cuff tear, especially with the ER lag and advanced pathiography of the infraspinatus and or the terespinor. I show the strengths that the patient can regain after such an intervention. This is my friend Hashem from Barcelona, and he had a patient that Philippe Valenti operated on, and I was with them helping them in the surgery, but he did use a hamstring instead of the Achilles tendon allograft, and this is a patient who has ER lag on the left side, and this is his incisions, different than mine, but he used a hamstring, and this is a patient three months after surgery, full motion, full external rotation. She was very happy with her outcome, and this is my friend Pedro Lopez from Mexico. In fact, he sent me this picture from a series of patients he has been doing lower trapezius transfer on, and they're already gaining a very good mobility of the shoulder with deflection and external rotation. They're very happy with the outcome, and we published about the outcome, and there are many publications right now, whether using the Achilles tendon or a hamstring, demonstrating the outcome of the lower trapezius tendon, which is very favoring and very promising. The last I want to mention, what about patients with failed SCR in the setting of deficient supraninfra and teres minor? Do they have hope without doing, like before, doing reversal of the arthroplasty? And I would say yes, and we have a paper now, it is in reviews, it's about the outcome of scopastas in lower trap to salvage faked pericarpus reconstruction, and we have 16 patients with prior SCR with young age, 49 years old. The majority were male, 15 male, and indication was persistent symptoms, specifically weakness, and 11 patients have advanced atrophy of the supraspinatus, infraspinatus, and teres minor, and interestingly on the MRI, six patients have completely intact SCR, completely intact, and they still have profound weakness. 11 patients had failed SCR, seven from the humerus side, four from the myeloid, and an average follow-up 29 months, I know relatively early, but still fair follow-up. 15 patients had significant improvement, constant score, showed subjective value in SAS, and the pain, however, was not significantly improved because usually they improve after the SCR, but the most significant improvement was external rotation from minus 20 to 30. So I want to thank all of you, Peter, this is a picture, and this is Buddy as well, and Amy, this is from the last Athens meeting, Buddy, if you remember, and Peter, thank you very much for inviting me, and this is Joab Wood during his Miami, his shorter 360 course with Rafi and Paul, it was really fantastic course. Well, I hope you have fantastic time in California, I wish I could be with you, enjoy it, I'm pretty sure the ICER is going to be fantastic. Thank you very much for having me, have a great day, thank you.

lower trapezius transfer

rotator cuff tear

force couple

shoulder joint

surgical technique

outcomes