Proximal Scaphoid Reconstruction Techniques Comparison of Three Techniques for Proximal Scaphoid Recontruction.

Introduction The costo-osteochondral autograft, vascularized medial femoral trochlear osteochondral autograft, and proximal hamate autograft have been used for the reconstruction of unsalvageable proximal pole scaphoid nonunions. Our hypothesis is that there is no difference in carpal kinematics after the proximal pole of the scaphoid is reconstructed with these three graft options. Methods Wireless sensors were mounted to the carpus that was loaded through cyclical motion. Each specimen was tested under a series of the three reconstructed conditions and their kinematics compared. Results No significant differences were found in scapholunate and lunocapitate joint motion during wrist flexion-extension and wrist radioulnar deviation between the three reconstructed conditions ( p > 0.05). Discussion and Conclusion There are minimal differences in carpal kinematics when comparing reconstruction of the proximal pole of the scaphoid with the costoosteochondral, medial femoral trochlear, and proximal hamate grafts.

Tendon transfers for the management of irreparable subscapularis tears.

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane - anterior to the rib cage - is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Arthroscopic assisted brachial plexus catheter placement: an alternative to the percutaneous interscalene approach.

Background: Brachial plexus catheter placement at the interscalene level is beneficial for shoulder analgesia but presents logistical challenges due to the superficial nature of the plexus at this level, increased patient movement in the neck, and therefore higher likelihood for catheter dislodgement. Methods: Patients requiring shoulder arthroscopy and suprascapular nerve decompression were identified. Under arthroscopic guidance, a catheter was placed percutaneously into the scalene medius muscle next to the suprascapular nerve and the upper trunk of the brachial plexus. Patients were followed postoperatively for perioperative analgesic outcomes. Results: Ten patients were identified and consented for intraoperative brachial plexus catheter placement. Patient demographics and surgical details were determined. Postoperative adjunctive pain management and pain scores were variable. Two patients required catheter replacement using ultrasound guidance in the perioperative anesthesia care unit due to poorly controlled pain. There were no incidents of catheter failure due to dislodgement. Discussion: This study presents the first description of arthroscopically-assisted brachial plexus catheter placement. This method may present an alternative to traditional ultrasound guided interscalene catheter placement. Further study is needed to determine if analgesic outcomes, block success, and dislodgement rates are improved with this method.

Investigation Into the Effects of Intra-Articular Steroid on Post-Traumatic Osteoarthritis in Distal Radius Fractures: A Randomized Controlled Pilot Study.

PURPOSE: The aim of this prospective, randomized, controlled, double-blinded pilot study was to determine the rates of post-traumatic osteoarthritis and assess joint space width in the presence or absence of a single intra-articular injection of corticosteroid after an acute, intra-articular distal radius fracture (DRF). METHODS: Forty patients received a single, intra-articular, radiocarpal joint injection of 4 mg of dexamethasone (DEX) (n = 19) or normal saline placebo (n = 21) within 2 weeks of a surgically or nonsurgically treated intra-articular DRF. The primary outcome measure was minimum radiocarpal joint space width (mJSW) on noncontrast computed tomography scans at 2 years postinjection. Secondary outcomes were obtained at 3 months, 6 months, 1 year, and 2 years postinjection and included Disabilities of the Arm, Shoulder, and Hand; Michigan Hand Questionnaire; Patient-Rated Wrist Evaluation; wrist range of motion; and grip strength. RESULTS: At 2-year follow-up, there was no difference in mean mJSW between the DEX group (2.2 mm; standard deviation, 0.6; range, 1.4-3.2) and the placebo group (2.3 mm; standard deviation, 0.7; range, 0.9-3.9). Further, there were no differences in any secondary outcome measures at any postinjection follow-up interval. CONCLUSIONS: Radiocarpal joint injection of corticosteroid within 2 weeks of an intra-articular DRF does not appear to affect the development of post-traumatic osteoarthritis within 2 years follow-up in a small pilot cohort. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Anterior Latissimus Dorsi Transfer for Irreparable Subscapularis Tears Improves Shoulder Kinematics in a Dynamic Biomechanical Cadaveric Shoulder Model.

BACKGROUND: In young patients with irreparable subscapularis deficiency (SSC-D) and absence of severe osteoarthritis, anterior latissimus dorsi transfer (aLDT) has been proposed as a treatment option to restore the anteroposterior muscular force couple to regain sufficient shoulder function. However, evidence regarding the biomechanical effect of an aLDT on glenohumeral kinematics remains sparse. PURPOSE/HYPOTHESIS: The purpose of this study was to investigate the effects of an aLDT on range of glenohumeral abduction motion, superior migration of the humeral head (SM), and cumulative deltoid force (cDF) in a simulated SSC-D model using a dynamic shoulder model. It was hypothesized that an aLDT would restore native shoulder kinematics by reestablishing the insufficient anteroposterior force couple. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle (gAA), SM, and cDF were compared across 3 conditions: (1) native, (2) SSC-D, and (3) aLDT. gAA and SM were measured using 3-dimensional motion tracking, while cDF was recorded in real time during dynamic abduction motion by load cells connected to actuators. RESULTS: The SSC-D significantly decreased gAA (Δ-9.8°; 95% CI, -14.1° to -5.5°; P < .001) and showed a significant increase in SM (Δ2.0 mm; 95% CI, 0.9 to 3.1 mm; P = .003), while cDF was similar (Δ7.8 N; 95% CI, -9.2 to 24.7 N; P = .586) when compared with the native state. Performing an aLDT resulted in a significantly increased gAA (Δ3.8°; 95% CI, 1.8° to 5.7°; P < .001), while cDF (Δ-36.1 N; 95% CI, -48.7 to -23.7 N; P < .001) was significantly reduced compared with the SSC-D. For the aLDT, no anterior subluxation was observed. However, the aLDT was not able to restore native gAA (Δ-6.1°; 95% CI, -8.9° to -3.2°; P < .001). CONCLUSION: In this cadaveric study, performing an aLDT for an irreparable subscapularis insufficiency restored the anteroposterior force couple and prevented superior and anterior humeral head migration, thus improving glenohumeral kinematics. Furthermore, compensatory deltoid forces were reduced by performing an aLDT. CLINICAL RELEVANCE: Given the favorable effect of the aLDT on shoulder kinematics in this dynamic shoulder model, performing an aLDT may be considered as a treatment option in patients with irreparable SSC-D.

Advances in Oncologic Shoulder Girdle Resection and Reconstruction.

The bony shoulder girdle consists of the clavicle, humerus, and scapula, which work synergistically to form a complex articulation that is essential for use of the upper extremity. The shoulder girdle is the most common location for primary and secondary bone tumors in the upper extremity, and following resection of these tumors, reconstruction of the upper extremity is challenging. Compared with those in the lower extremity, reconstructive techniques in the upper extremity have historically been unreliable and fraught with complications and poor functional outcomes. Newer reconstructive techniques using reverse total shoulder arthroplasty and functional muscle flaps have shown promise to improve outcomes while reducing complications for proximal humerus reconstructions. Despite these advancements, reconstruction following scapulectomy remains challenging and is still associated with more frequent complications and compromised function.

Scapular Dyskinesia: How to Differentiate Between Etiologies.

It is important to discuss the importance of synchronous balance between periscapular muscles for scapulothoracic motion and resultant scapulohumeral rhythm. Abnormalities in this balance can lead to scapular dyskinesia and winging, affecting shoulder motion and leading to impingement. Strategies exist to diagnose and differentiate between pathologies such as muscle paralysis (eg, trapezius or serratus anterior) or overactivity (eg, pectoralis minor). The physician should be aware of the role of diagnostic imaging, as well as the unique considerations for patients with Ehlers-Danlos syndrome. Overall, a comprehensive physical examination to accurately diagnose and treat scapular pathologies is particularly important.

The Scapula: The Greater Masquerader of Shoulder Pathologies.

A comprehensive review of scapular pathologies and their effect on shoulder function is necessary to determine the best treatment options. The coordinated motion between the scapulothoracic and glenohumeral joints is essential for shoulder motion and depends on the balanced activity of the periscapular muscles. Disruption in these muscles can cause abnormal scapular motion and compensatory glenohumeral movements, leading to misdiagnosis or delayed diagnosis. Scapular pathologies can arise from muscle overactivity or underactivity/paralysis, resulting in a range of scapulothoracic abnormal motion (STAM). STAM can lead to various glenohumeral pathologies, including instability, impingement, or nerve compression. It is important to highlight the critical periscapular muscles involved in scapulohumeral rhythm (such as the upper, middle, and lower trapezius; rhomboid major and minor; serratus anterior; levator scapulae; and pectoralis minor). A discussion of the different etiologies of STAM should include examples of muscle dysfunction, such as overactivity of the pectoralis minor, underactivity or paralysis of the serratus anterior or trapezius muscles, and dyskinesis resulting from compensatory mechanisms in patients with recurrent glenohumeral instability due to Ehlers-Danlos syndrome. The evaluation and workup of STAM has shown that patients typically present with radiating shoulder pain, especially in the posterior aspect of the shoulder and scapula, and limitations in active shoulder overhead motion associated with glenohumeral pain, instability, or rotator cuff pathologies.

InSpace Balloon for the Management of Massive Irreparable Rotator Cuff Tears: A Systematic Review and Meta-Analysis.

Background: The best course of action for massive irreparable rotator cuff tears (MIRCTs) is not universally agreed upon. Numerous surgical techniques have been discussed. The implantation of a biodegradable spacer into the subacromial area has been documented since 2012 by several authors. The implantation method is touted as being simpler, repeatable, and less invasive than other solutions that are now available. The purpose of this systematic review and meta-analysis, being the first of its kind, was to evaluate the literature to see the efficacy of InSpace balloon (ISB) implantation in the management of MIRCTs. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, and with 2 researchers assessing and analyzing each study separately, an extensive electronic search of the literature was conducted in the PubMed database from 1961 until July 27, 2022. Results: Fourteen studies were included in this systematic review and three in the meta-analysis. Eleven out of fourteen studies favored ISB use for MIRCTs, while only three were against its use. All spacers were arthroscopically implanted in the subacromial space. Three studies were included in the meta-analysis. The differences in the compared outcomes were statistically insignificant. Conclusions: A controversy about the use of ISB remains in patients with MIRCTs. Both good and bad outcomes were reported. However, the majority of patients had good clinical outcomes across several grading scales, radiographic evidence of improved impingement, and self-report that they would redo the procedure in hindsight. To draw more solid conclusions and have statistically significant results in the meta-analysis, more randomized controlled trials and comparative studies comparing this device to other treatments are needed.

Physiological Tensioning During Lower Trapezius Transfer for Irreparable Posterosuperior Rotator Cuff Tears May Be Important for Improvement in Shoulder Kinematics.

BACKGROUND: Lower trapezius transfer (LTT) has been proposed for restoring the anteroposterior muscular force couple in the setting of an irreparable posterosuperior rotator cuff tear (PSRCT). Adequate graft tensioning during surgery may be a factor critical for sufficient restoration of shoulder kinematics and functional improvement. PURPOSE/HYPOTHESIS: The purpose was to evaluate the effect of tensioning during LTT on glenohumeral kinematics using a dynamic shoulder model. It was hypothesized that LTT, while maintaining physiological tension on the lower trapezius muscle, would improve glenohumeral kinematics more effectively than undertensioned or overtensioned LTT. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 10 fresh-frozen cadaveric shoulders were tested using a validated shoulder simulator. Glenohumeral abduction angle, superior migration of the humeral head, and cumulative deltoid force were compared across 5 conditions: (1) native, (2) irreparable PSRCT, (3) LTT with a 12-N load (undertensioned), (4) LTT with a 24-N load (physiologically tensioned according to the cross-sectional area ratio of the lower trapezius muscle), and (5) LTT with a 36-N load (overtensioned). Glenohumeral abduction angle and superior migration of the humeral head were measured using 3-dimensional motion tracking. Cumulative deltoid force was recorded in real time throughout dynamic abduction motion by load cells connected to actuators. RESULTS: Physiologically tensioned (Δ13.1°), undertensioned (Δ7.3°), and overtensioned (Δ9.9°) LTT each significantly increased the glenohumeral abduction angle compared with the irreparable PSRCT (P < .001 for all). Physiologically tensioned LTT achieved a significantly greater glenohumeral abduction angle than undertensioned LTT (Δ5.9°; P < .001) or overtensioned LTT (Δ3.2°; P = .038). Superior migration of the humeral head was significantly decreased with LTT compared with the PSRCT, regardless of tensioning. Physiologically tensioned LTT resulted in significantly less superior migration of the humeral head compared with undertensioned LTT (Δ5.3 mm; P = .004). A significant decrease in cumulative deltoid force was only observed with physiologically tensioned LTT compared with the PSRCT (Δ-19.2 N; P = .044). However, compared with the native state, LTT did not completely restore glenohumeral kinematics, regardless of tensioning. CONCLUSION: LTT was most effective in improving glenohumeral kinematics after an irreparable PSRCT when maintaining physiological tension on the lower trapezius muscle at time zero. However, LTT did not completely restore native glenohumeral kinematics, regardless of tensioning. CLINICAL RELEVANCE: Tensioning during LTT for an irreparable PSRCT may be important to sufficiently improve glenohumeral kinematics and may be an intraoperatively modifiable key variable to ensure postoperative functional success.

Muscular Retraining and Rehabilitation after Shoulder Muscle Tendon Transfer.

Muscle tendon transfers around the shoulder involve transferring the tendon of a well-functioning muscle-tendon unit to the site of damaged muscle-tendon insertion. In turn, this restores function and strength of the injured shoulder muscle through dynamic muscular contraction and a tenodesis effect. Rehabilitation after shoulder muscle tendon transfers requires extensive and lengthy rehabilitation to achieve satisfactory clinical outcomes. It is crucial to gain detailed understanding of the rehabilitation requirements for different tendon transfer procedures such as the type of immobilization and specific range of motion limitations at specific time points during rehabilitations.

Teres Major and Latissimus Dorsi Repair With Biceps Tenodesis Utilizing Cortical Suspensory Fixation Buttons.

Teres major (TM) and latissimus dorsi (LD) ruptures are relatively rare in the general population and have primarily been observed in overhead throwing athletes. Although the gold standard of care has traditionally been nonoperative, surgical repair of TM and LD tendon ruptures has become increasingly prevalent in high-level athletes who fail to return to play. Literature is scarce regarding operative repair of these tendon ruptures. Therefore, our goal is to present a potential technique for open repair to surgeons who may be faced with this unique orthopedic injury. Our technique details an open TM and LD repair, in addition to biceps tenodesis, using cortical suspensory fixation buttons with a combined anterior and posterior approach.

Outcomes of scapulothoracic fusion in patients with facioscapulohumeral dystrophy: a comparison of allograft versus autograft bone grafting.

BACKGROUND: Scapulothoracic (ST) fusion for facioscapulohumeral muscular dystrophy (FSHD) is an established treatment that corrects scapular instability, although it has high reported complication rates. The purpose of our study was to characterize the outcomes of ST fusion for FSHD in a large patient cohort and compare the outcomes based on bone graft type and fixation technique. Our hypothesis was that union rates would not differ by bone graft type during ST fusion. METHODS: A retrospective chart review was undertaken to identify patients who underwent ST fusion at multiple institutions performed by a single surgeon between 2013 and 2019 with minimum 2-year follow-up. Patient demographic characteristics, surgical technique, time to union, complications, and clinical outcomes including patient-reported outcome measures were recorded. Univariate and multivariate statistical analyses including regression analyses were performed to compare preoperative and postoperative outcomes. RESULTS: A total of 50 patients with 54 ST fusions (bilateral in 4 patients) and an average follow-up period of 5.8 years (standard deviation, 1.6 years) were included for analysis. Active forward elevation (77° vs. 124°, P < .00001) and abduction (60° vs. 90°, P < .00001) both improved significantly after fusion. Average internal rotation after fusion was at spinal level L3-L4. The visual analog scale pain score (2.6 vs. 1.2, P < .00001), Subjective Shoulder Value score (33 vs. 76, P < .00001), and American Shoulder and Elbow Surgeons (ASES) score (41.8 vs. 76.1, P < .00001) all improved significantly postoperatively. Of the shoulders, 50% (27 of 54) received treatment with cerclage wires and 50% (27 of 54) received treatment with Luque wires. Femoral head allograft was used in 53.7% of shoulders (29 of 54), whereas iliac crest autograft was used in 46.3% (25 of 54). Average radiographic time to healing was 11.1 weeks (standard deviation, 3.2 weeks), with no incidence of nonunion, and did not significantly differ by bone graft type (P = .26) or technique (P = .20). The complication rate was 24.1%, including seroma (n = 3), superficial infection (n = 2), transient neurologic injury (n = 2), hemothorax (n = 1), rib fracture (n = 1), pneumothorax (n = 1), and shortness of breath (n = 1), although none requiring reoperation. There was no significant difference in the rate of postoperative complications when compared by surgical technique (P = .81) and bone graft type (P = .93). There were no independently predictive factors influencing the rate of postoperative complications by multivariate regression. Regression analysis showed that the postoperative ASES score was independently associated with the preoperative ASES score (P < .0001), use of iliac crest autograft (P < .011), and presence of complications (P < .043). CONCLUSION: Patients receiving ST fusion for FSHD demonstrate globally improved active motion and patient-reported outcome measures. Fusion construct or type of bone graft does not affect time to union or complication rates. Surgeons should be aware of a relatively high complication rate in the early postoperative period.

Anterior glenoid bone reconstruction and anterior latissimus transfer for failed Latarjet associated with irreparable subscapularis tear.

Background: Management of combined persistent anterior glenoid bone deficiency with irreparable subscapularis tear can be very complicated and challenging especially if associated with arthritis. The objective of this study was to report the outcome of combined reconstruction of the anterior glenoid with bone autograft or allograft with additional anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement. Methods: Nineteen patients (average age 29 years old) who underwent open anterior glenoid bone reconstruction with iliac crest bone autograft or ostechondral bone allograft (distal tibia or glenoid allograft), with anterior latissimus transfer to reconstruct irreparable subscapularis tear with or without humeral head replacement were included in this study. Outcome measures included preoperative and postoperative pain score, visual analog scale, Subjective Shoulder Value, American Shoulder and Elbow Surgeons score, and Constant Score. Results: Out of the 19 patients, 5 patients underwent humeral resurfacing arthroplasty. Anterior glenoid bone reconstruction was performed with iliac crest bone autograft in 8 patients, glenoid osteochondral allograft in 7 patients, and tibial plafond in 4 patients. At mean 31-month follow-up of (13-63 months), 15 patients (79%) considered their shoulder stable and were able to return to their work and 14 (74%) patients returned to their sport activity. Redislocation had occurred in 1 of the 18 shoulders (5%), subluxation had occurred in 3 patients (16%) of the shoulders and apprehension was reported for 4 patients, 21% of the operated shoulders. All outcome measures showed significant improvement compared to before surgery. No intraoperative or immediate postoperative complications were observed. Four patients (21%) had to be revised to reverse shoulder arthroplasty. Conclusion: The combination of anterior latissimus transfer, anterior glenoid bone grafting with or without humeral head resurfacing is an effective salvage surgical reconstruction that can stabilize shoulders in the setting of recurrent anterior instability after a failed Latarjet with an irreparable subscapularis tear. This could be a potential alternative reconstruction option that might be offered to patients with this difficult problem. Long-term outcome is needed to better evaluate the validity of this technique.

Does Proximal Hamate Graft for Proximal Scaphoid Reconstruction Restore Native Wrist Kinematics?

BACKGROUND: The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics. METHODS: A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft." RESULTS: The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction. CONCLUSIONS: Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.

Upper limb injuries in mixed martial arts.

OBJECTIVE: Mixed-Martial-Arts(MMA) is a worldwide growing sport that incorporates different fighting styles and disciplines and is often associated with the Ultimate Fighting Championship(UFC) . The aim of this study is to explore the patterns and trends of upper limb injuries in MMA. METHODS: Ringside physician reports of the UFC fights between 2016 and 2019(inclusive) were extracted and screened from the Nevada State Athletic Commission(NSAC). The following variables were included: sex, weight division, injury mechanism, injury type, injury location, and type of finish. Injury rates were calculated and expressed per 100 athletic exposures (AE). An independent t-test, a one way analysis of variance(ANOVA), and a Joinpoint regression analysis were conducted to explore any significant differences or trends among variables. P-values<0.05 were considered significant(95% CI). RESULTS: A total of 81 upper limb injuries in 408 fights were recorded between 2016 and 2019. The injury rate was 9.9 injuries per 100 athletic-exposures(AE). Striking opponents was the most common mechanism of injury(p < 0.001). The hand was the most commonly injured location with an injury rate of 6.61 per 100AE(p < 0.001). Females had a higher upper limb injury rate than their male counterparts, but the difference failed to reach significance(p = 0.454). Similarly, no significant differences existed between rates of different types of injures. Matches ending with decision had the highest number of upper limb injuries with a rate of 12.6 per 100AE; however, no significant difference was determined between the rates of different ways of finish(p = 0.115). The strawweight(20.5 per 100AE), female flyweight(19.2 per 100AE), and male flyweight(13.8 per 100AE) divisions had the highest upper limb injury rates. CONCLUSION: The hand was the most commonly injured upper limb location in MMA, and 'striking opponent' was the most common injury mechanism. Increasing padding in gloves and implementing medical examinations during bouts can help reduce injury rates.

Emerging Treatment Options for Massive Rotator Cuff Tears: Biologic Tuberoplasty, Balloon Arthroplasty, Anterior Cable Reconstruction, Lower Trapezius Transfer.

There are several emerging treatments for patients with massive rotator cuff tears. Biologic tuberoplasty is still in its infancy but holds promise for improving pain and function by biologically covering a bare tuberosity with a dermal allograft to prevent bone-to-bone contact between the tuberosity and the undersurface of the acromion. Balloon arthroplasty is a technique of widespread interest, with the device recently gaining FDA approval. Anterior cable reconstruction uses the autologous long head of the biceps tendon to reconstruct the anterior cable of the rotator cuff. Tendon transfers, specifically lower trapezius tendon transfer, have now been established as a viable option especially in patients who want to regain active external rotation.