WEBVTT 00:00:00.000 --> 00:00:04.400 Imagine a shoulder so damaged, so weak, that 00:00:04.400 --> 00:00:06.820 just lifting your arm feels like lifting a brick. 00:00:07.259 --> 00:00:09.259 It's not just a nagging ache, it's this profound 00:00:09.259 --> 00:00:11.699 loss of function. It stops you working, playing 00:00:11.699 --> 00:00:14.300 sport, even doing simple things day to day. So 00:00:14.300 --> 00:00:16.359 what happens when the usual fixes, the standard 00:00:16.359 --> 00:00:19.699 repairs, just aren't enough? Welcome back to 00:00:19.699 --> 00:00:21.839 The Deep Dive. We cut through the noise, bringing 00:00:21.839 --> 00:00:24.179 you the crucial insights from the latest research 00:00:24.179 --> 00:00:26.679 and expert thinking. Today, we're getting into 00:00:26.679 --> 00:00:29.100 a really significant challenge in orthopedics. 00:00:29.500 --> 00:00:31.859 The irreparable poster superior rotator cuff 00:00:31.859 --> 00:00:34.140 tear. We've got a stack of recent papers looking 00:00:34.140 --> 00:00:37.439 at this complex injury and a fascinating surgical 00:00:37.439 --> 00:00:39.799 solution, the lower trapezius tendon transfer 00:00:39.799 --> 00:00:42.820 or LTT. Our mission then is to unpack the thinking 00:00:42.820 --> 00:00:45.500 behind it, the techniques, the outcomes, really 00:00:45.500 --> 00:00:47.460 help you understand what matters in this evolving 00:00:47.460 --> 00:00:50.159 field. And guiding us through this is Professor 00:00:50.159 --> 00:00:52.299 Mo Imam, a leading expert whose work is right 00:00:52.299 --> 00:00:54.579 at the forefront of treating these complex shoulder 00:00:54.579 --> 00:00:56.219 problems. Professor, thanks so much for joining 00:00:56.219 --> 00:00:59.119 us. Thank you. It's a pleasure to be here. It's 00:00:59.119 --> 00:01:01.840 a field that's seeing some really quite exciting 00:01:01.840 --> 00:01:03.640 advancements, actually, pushing the boundaries 00:01:03.640 --> 00:01:07.239 for patients with these very difficult problems. 00:01:07.500 --> 00:01:09.239 Absolutely. So let's jump straight in, maybe 00:01:09.239 --> 00:01:11.519 with a few quick questions just to set the scene. 00:01:11.939 --> 00:01:14.780 Firstly, when we talk about an irreparable rotator 00:01:14.780 --> 00:01:17.400 cuff tear, are we just talking about a really, 00:01:17.719 --> 00:01:20.780 really big tear, or is there more to it? That's 00:01:20.780 --> 00:01:23.060 a great place to start. Well, size is often a 00:01:23.060 --> 00:01:25.799 factor, definitely, but irreparable goes beyond 00:01:25.799 --> 00:01:28.870 just the dimensions. It fundamentally means the 00:01:28.870 --> 00:01:31.489 tissue quality itself is too poor, or maybe the 00:01:31.489 --> 00:01:34.230 tears pulled back too far retracted, or the muscle 00:01:34.230 --> 00:01:36.870 has degenerated too much. Essentially, you can't 00:01:36.870 --> 00:01:39.810 get a durable tension -free repair back to where 00:01:39.810 --> 00:01:42.090 it's supposed to attach. Got it. So it's really 00:01:42.090 --> 00:01:44.209 about the quality and the state of the tissue, 00:01:44.329 --> 00:01:46.670 not just the size of the hole. Precisely. The 00:01:46.670 --> 00:01:49.219 biological environment, if you like. Okay. Second 00:01:49.219 --> 00:01:52.180 question, then. Traditionally, other tendon transfers 00:01:52.180 --> 00:01:54.439 have been used for large tiers, haven't they? 00:01:54.760 --> 00:01:57.140 Like the latissimus dorsi transfer. Why isn't 00:01:57.140 --> 00:01:59.459 that always the ideal fix, especially for these 00:01:59.459 --> 00:02:02.340 posterior superior ones? Right, the latissimus 00:02:02.340 --> 00:02:05.239 dorsi or LD transfer. It's certainly a valid 00:02:05.239 --> 00:02:07.480 option, and it has helped many patients, no question, 00:02:08.000 --> 00:02:11.680 particularly with the pain relief. But its main 00:02:11.680 --> 00:02:14.419 job naturally is internal rotation, turning the 00:02:14.419 --> 00:02:17.629 arm inwards. When you transfer it to try and 00:02:17.629 --> 00:02:20.090 restore external rotation, which is the key function 00:02:20.090 --> 00:02:23.229 lost in these post or superior tears, well, its 00:02:23.229 --> 00:02:25.669 biomechanical force vector, its line of pull, 00:02:26.310 --> 00:02:29.270 isn't quite ideal. So it pulls in the wrong direction, 00:02:29.449 --> 00:02:31.449 essentially. Not exactly the wrong direction, 00:02:31.509 --> 00:02:33.490 but it tends to give more of a vertical pull. 00:02:34.270 --> 00:02:36.669 What you really need for effective external rotation 00:02:36.669 --> 00:02:39.789 is more of a posterior and lateral pull, especially 00:02:39.789 --> 00:02:42.110 when the arm is close to the body, in adduction. 00:02:42.330 --> 00:02:45.210 The LD struggles to provide that specific rotational 00:02:45.210 --> 00:02:47.430 force effectively in that position. Right. So 00:02:47.430 --> 00:02:49.349 you're asking a muscle to do a job it wasn't 00:02:49.349 --> 00:02:51.030 really designed for, and the mechanics aren't 00:02:51.030 --> 00:02:53.110 quite optimal. That's a very good way of putting 00:02:53.110 --> 00:02:56.050 it. And that leads to, well, variable functional 00:02:56.050 --> 00:02:58.610 outcomes, especially when it comes to regaining 00:02:58.610 --> 00:03:01.629 strong external rotation. Pain relief might be 00:03:01.629 --> 00:03:03.750 good, but getting that outward turn back could 00:03:03.750 --> 00:03:06.199 be hit and miss. Okay, that paints a clear picture 00:03:06.199 --> 00:03:08.879 of the problem and, I suppose, the limitations 00:03:08.879 --> 00:03:11.460 of that traditional approach. So final quick 00:03:11.460 --> 00:03:14.900 setup question. What's the basic biomechanical 00:03:14.900 --> 00:03:17.919 argument for why the lower trapezius might actually 00:03:17.919 --> 00:03:21.180 be a better choice for restoring that external 00:03:21.180 --> 00:03:24.479 rotation? The core idea, and this is really backed 00:03:24.479 --> 00:03:26.520 up by the biomechanical studies we can talk about, 00:03:26.939 --> 00:03:29.680 is that the lower trapezius, the LT muscle, Its 00:03:29.680 --> 00:03:32.639 natural line of pull, its vector, much more closely 00:03:32.639 --> 00:03:35.340 mimics the infospinatus. That's one of the key 00:03:35.340 --> 00:03:38.259 muscles that's usually gone or badly damaged 00:03:38.259 --> 00:03:41.319 in these irreparable tears. Ah, so it pulls more 00:03:41.319 --> 00:03:43.620 like the original muscle did. Exactly. It provides 00:03:43.620 --> 00:03:45.819 a more suitable rotational moment. It gives you 00:03:45.819 --> 00:03:47.599 a better mechanical advantage for achieving that 00:03:47.599 --> 00:03:49.860 external rotation. That sounds like a potentially 00:03:49.860 --> 00:03:52.639 powerful advantage. Let's dive deeper into that 00:03:52.639 --> 00:03:54.639 then. We've established what an irreparable tear 00:03:54.639 --> 00:03:57.099 means, significant damage, often supraspinatus 00:03:57.099 --> 00:04:00.099 and infraspinatus involved, retraction, maybe 00:04:00.099 --> 00:04:02.860 poor muscle quality. Can you expand a bit on 00:04:02.860 --> 00:04:04.460 the clinical impact? What does this actually 00:04:04.460 --> 00:04:07.000 look like for the patient day to day? Yes, what's 00:04:07.000 --> 00:04:09.960 really crucial to grasp is the profound functional 00:04:09.960 --> 00:04:12.819 loss. It's not just pain, although pain is often 00:04:12.819 --> 00:04:16.230 there, it's significant weakness. An inability 00:04:16.230 --> 00:04:19.009 to actively lift the arm forwards, that's forward 00:04:19.009 --> 00:04:22.329 elevation or rotated outwards, external rotation. 00:04:22.629 --> 00:04:25.290 So simple things become impossible. Pretty much. 00:04:25.689 --> 00:04:27.389 Think about reaching for something just above 00:04:27.389 --> 00:04:29.810 shoulder height or even turning a key in a lock, 00:04:29.990 --> 00:04:32.310 lifting a cup of tea away from your body. These 00:04:32.310 --> 00:04:35.069 all need active elevation and that controlled 00:04:35.069 --> 00:04:38.069 outward rotation. When the supraspinatus and 00:04:38.069 --> 00:04:40.269 infraspinatus are effectively gone, that ability 00:04:40.269 --> 00:04:43.240 is severely compromised. The sources we looked 00:04:43.240 --> 00:04:46.279 at consistently highlight this. It's a debilitating 00:04:46.279 --> 00:04:48.819 loss of active movement, impacting their work, 00:04:49.000 --> 00:04:50.879 their sport, even just managing personal care. 00:04:51.160 --> 00:04:52.980 It really does fundamentally alter their daily 00:04:52.980 --> 00:04:55.100 life. It sounds like it's not just pain stopping 00:04:55.100 --> 00:04:58.000 them moving. The actual machinery for those specific 00:04:58.000 --> 00:05:00.420 movements is broken. That's a good analogy. the 00:05:00.420 --> 00:05:02.639 engine for those movements is offline. And you 00:05:02.639 --> 00:05:05.220 mentioned the limitations of the latissimus dorsi 00:05:05.220 --> 00:05:08.000 transfer. Let's really try and dissect why its 00:05:08.000 --> 00:05:10.120 biomechanics fall short for these particular 00:05:10.120 --> 00:05:12.879 tiers, drawing on what the research shows. Certainly. 00:05:13.759 --> 00:05:17.019 So the LE transfer, whilst valuable, faces these 00:05:17.019 --> 00:05:18.939 inherent biomechanical hurdles when you ask it 00:05:18.939 --> 00:05:21.540 to restore external rotation. As I mentioned, 00:05:21.860 --> 00:05:24.560 its native job is internal rotation, pulling 00:05:24.560 --> 00:05:26.720 inwards, and adduction, pulling down towards 00:05:26.720 --> 00:05:29.060 the body. When it's transferred, it's usually 00:05:29.060 --> 00:05:31.899 routed around the back. posteriorly. But the 00:05:31.899 --> 00:05:34.079 key issue remains its line of pull. The research 00:05:34.079 --> 00:05:36.620 points out that after transfer, the LD creates 00:05:36.620 --> 00:05:38.879 a force vector that's predominantly vertical. 00:05:39.220 --> 00:05:41.759 It lifts but doesn't rotate outwards effectively. 00:05:42.060 --> 00:05:44.600 So it helps pull the arm up maybe but not turn 00:05:44.600 --> 00:05:48.100 it out. In essence, yes. To restore active forward 00:05:48.100 --> 00:05:51.220 elevation and quickly external rotation, especially 00:05:51.220 --> 00:05:53.160 with the arm down by the side or only slightly 00:05:53.160 --> 00:05:55.699 lifted, you need muscles that provide rotational 00:05:55.699 --> 00:05:58.740 leverage. A force that pulls or pushes to create 00:05:58.740 --> 00:06:00.959 rotation around the joint center. Think of the 00:06:00.959 --> 00:06:02.860 shoulder joint, the glenochemeral joint, almost 00:06:02.860 --> 00:06:05.759 like a ball balanced on a small T. The rotator 00:06:05.759 --> 00:06:07.680 cuff muscles normally work together in pairs, 00:06:07.959 --> 00:06:09.519 force couples pulling in different directions 00:06:09.519 --> 00:06:12.079 but coordinated. To keep it stable. Yes, exactly. 00:06:12.420 --> 00:06:14.800 To stabilize the ball on the tee and produce 00:06:14.800 --> 00:06:17.259 smooth, controlled movement like rotation and 00:06:17.259 --> 00:06:20.800 lifting. The native supraspinatus and infraspinatus 00:06:20.800 --> 00:06:23.939 are key players in these force couples. The LD's 00:06:23.939 --> 00:06:26.620 primarily vertical pull struggles to replicate 00:06:26.620 --> 00:06:28.839 that essential rotational component effectively. 00:06:29.100 --> 00:06:32.639 especially for initiating external rotation or 00:06:32.639 --> 00:06:35.019 stabilizing the humeral head during the early 00:06:35.019 --> 00:06:37.649 phases of lifting the arm. So the LD provides 00:06:37.649 --> 00:06:40.129 some lift, maybe some stability by covering the 00:06:40.129 --> 00:06:42.870 defect, but not that specific rotational control 00:06:42.870 --> 00:06:45.389 and stabilization needed, particularly when the 00:06:45.389 --> 00:06:48.430 arm is down low. Precisely. And the sources reference 00:06:48.430 --> 00:06:51.850 studies using electromyography, EMG, which measures 00:06:51.850 --> 00:06:54.550 the electrical activity in muscles. These studies 00:06:54.550 --> 00:06:56.870 show there's actually quite limited EMG activity 00:06:56.870 --> 00:06:59.569 in the transferred LD when patients try to abduct 00:06:59.569 --> 00:07:02.149 or externally rotate their shoulder, especially 00:07:02.149 --> 00:07:03.790 in that crucial position with the arm by the 00:07:03.790 --> 00:07:06.230 side. So the muscle isn't even firing properly 00:07:06.230 --> 00:07:08.790 for that movement? Well, it's not being effectively 00:07:08.790 --> 00:07:11.610 recruited, or perhaps it's just not positioned 00:07:11.610 --> 00:07:14.709 biomechanically to generate the force and the 00:07:14.709 --> 00:07:17.850 moment arm the leverage needed for external rotation 00:07:17.850 --> 00:07:21.009 in that context. So this electrophysiological 00:07:21.009 --> 00:07:23.850 evidence really supports the biomechanical analysis. 00:07:24.170 --> 00:07:27.050 It might help with pain, might provide some passive 00:07:27.050 --> 00:07:29.910 stability, but active functional recovery, especially 00:07:29.910 --> 00:07:32.379 getting that external rotation back, remains 00:07:32.379 --> 00:07:35.220 quite variable. That really clarifies the mechanical 00:07:35.220 --> 00:07:37.800 mismatch, and that's precisely the gap the lower 00:07:37.800 --> 00:07:40.040 trapezius tendon transfer is trying to fill. 00:07:40.319 --> 00:07:43.279 So how do the LT's biomechanics differ? Why does 00:07:43.279 --> 00:07:45.620 the research suggest it's a more appealing candidate? 00:07:46.120 --> 00:07:48.220 Right, the core biomechanical advantage of the 00:07:48.220 --> 00:07:50.660 lower trapezius lies in its inherent line of 00:07:50.660 --> 00:07:52.720 pull and its position relative to the shoulder 00:07:52.720 --> 00:07:55.500 joint's center when it's transferred. The LT 00:07:55.500 --> 00:07:57.779 muscle, it originates lower down on the spine, 00:07:57.819 --> 00:08:00.560 the thoracic spine, and attaches onto the scapula, 00:08:00.660 --> 00:08:02.870 the shoulder blade. Its natural job involves 00:08:02.870 --> 00:08:05.310 pulling the scapula down and in, helping stabilize 00:08:05.310 --> 00:08:08.009 it for overhead movements. When you detach its 00:08:08.009 --> 00:08:10.209 insertion and transfer it to the humerus, its 00:08:10.209 --> 00:08:13.129 vector, its direction of pull, is more posterior 00:08:13.129 --> 00:08:15.569 and lateral compared to the LD. Closer to the 00:08:15.569 --> 00:08:18.410 original external rotators. Much closer. It mimics 00:08:18.410 --> 00:08:21.290 the line of action of the deficient infraspinatus 00:08:21.290 --> 00:08:24.110 and T -RES miners, those key external rotators, 00:08:24.410 --> 00:08:26.730 much more effectively. And the biomechanical 00:08:26.730 --> 00:08:29.329 studies cited in the papers provide quite compelling 00:08:29.329 --> 00:08:33.509 evidence for this. Research using cadaveric models 00:08:33.509 --> 00:08:36.570 and computer simulations has actually demonstrated 00:08:36.570 --> 00:08:39.950 that the LT transfer is more effective at restoring 00:08:39.950 --> 00:08:42.789 shoulder kinematics. That's how the bones move 00:08:42.789 --> 00:08:45.990 relative to each other and those critical glenohumeral 00:08:45.990 --> 00:08:48.009 force couples we talked about. And especially 00:08:48.009 --> 00:08:50.289 with the arm by the side. Particularly in the 00:08:50.289 --> 00:08:52.870 adducted position, yes, with the arm at the side. 00:08:53.309 --> 00:08:55.350 That's where it seems to have a distinct advantage 00:08:55.350 --> 00:08:57.610 in restoring stability and rotational potential. 00:08:58.049 --> 00:09:00.090 So the research isn't just theory, it's actually 00:09:00.090 --> 00:09:02.330 showing a measurable difference in how the joint 00:09:02.330 --> 00:09:05.210 moves after the transfer. Precisely. And the 00:09:05.210 --> 00:09:07.389 studies quantify this advantage. They use metrics 00:09:07.389 --> 00:09:10.470 like the external rotation moment, arm, the ERM. 00:09:10.710 --> 00:09:14.090 The leverage, basically. Exactly. The ERMA is 00:09:14.090 --> 00:09:16.950 essentially the leverage the muscle has. It's 00:09:16.950 --> 00:09:19.029 the perpendicular distance from the joint center 00:09:19.029 --> 00:09:21.509 of a rotation to the muscle's line of action. 00:09:22.330 --> 00:09:25.649 A bigger ERMA means more rotational power. And 00:09:25.649 --> 00:09:28.250 the sources highlight that the LD transfer results 00:09:28.250 --> 00:09:31.389 in a significantly larger ERMA for external rotation, 00:09:31.690 --> 00:09:33.769 specifically with the arm at the side compared 00:09:33.769 --> 00:09:36.269 to the LD transfer. Ah, so it gives the muscle 00:09:36.269 --> 00:09:38.990 much better leverage to actually turn the arm 00:09:38.990 --> 00:09:41.029 outwards, which is exactly the function you're 00:09:41.029 --> 00:09:43.389 trying to restore. That's the key. And what's 00:09:43.389 --> 00:09:45.429 particularly interesting is that the ERMA of 00:09:45.429 --> 00:09:48.929 the transferred LT in this position can be comparable 00:09:48.929 --> 00:09:51.789 to the native infospinatus and teres minor. So 00:09:51.789 --> 00:09:54.289 it really can potentially replace that lost function 00:09:54.289 --> 00:09:57.029 quite effectively. Biomechanically, yes, it has 00:09:57.029 --> 00:09:59.470 that potential. The studies also looked into 00:09:59.470 --> 00:10:01.570 the best place to attach it. They found that 00:10:01.570 --> 00:10:03.710 attaching the transferred LT tendon right onto 00:10:03.710 --> 00:10:06.149 the original infraspinatus insertion site on 00:10:06.149 --> 00:10:08.870 the greater tuberosity of the humerus, the bony 00:10:08.870 --> 00:10:11.470 prominence on the upper arm bone yields the greatest 00:10:11.470 --> 00:10:13.889 ear may. So it simulates the native setup best? 00:10:14.230 --> 00:10:17.409 It seems to, yes. It gives the best simulation 00:10:17.409 --> 00:10:19.970 of native external rotation. So that specific 00:10:19.970 --> 00:10:23.110 surgical target where you fix the tendon is guided 00:10:23.110 --> 00:10:26.159 directly by this biomechanical evidence. That 00:10:26.159 --> 00:10:29.740 level of detail guided by the mechanics is fascinating, 00:10:30.139 --> 00:10:32.120 knowing precisely where to put it for the best 00:10:32.120 --> 00:10:34.600 effect. It is. It really speaks to the precision 00:10:34.600 --> 00:10:37.580 involved in this type of surgery. But it's also 00:10:37.580 --> 00:10:39.700 important, you know, for both surgeons and patients 00:10:39.700 --> 00:10:44.100 to have realistic expectations. Whilst LTT significantly 00:10:44.100 --> 00:10:46.639 improves the biomechanics and function, the sources 00:10:46.639 --> 00:10:49.419 are quite clear. Even with a successful transfer, 00:10:49.879 --> 00:10:51.879 the joint kinematics, the way the joint moves 00:10:51.879 --> 00:10:54.259 and the reaction forces within the shoulder joint. 00:10:55.049 --> 00:10:57.370 They never completely normalize. Right. It's 00:10:57.370 --> 00:11:00.110 not perfect. No. You're improving a severely 00:11:00.110 --> 00:11:02.690 dysfunctional system, often dramatically, but 00:11:02.690 --> 00:11:04.909 you're not restoring it to perfect, pristine 00:11:04.909 --> 00:11:07.570 health. It's crucial to understand that limitation. 00:11:07.990 --> 00:11:09.649 That's a really important point. Significant 00:11:09.649 --> 00:11:11.950 improvement, not a magic wand. You also mentioned 00:11:11.950 --> 00:11:14.990 earlier that the LT muscle's ability to be selectively 00:11:14.990 --> 00:11:17.330 activated is important. What does that actually 00:11:17.330 --> 00:11:19.730 mean in practice for a tendon transfer? Right, 00:11:19.909 --> 00:11:21.970 selective activation means the patient can consciously 00:11:21.970 --> 00:11:24.649 learn to contract just the lower trapezius muscle, 00:11:24.990 --> 00:11:27.330 even after it's been surgically moved. Studies 00:11:27.330 --> 00:11:28.950 looking at voluntary contractions have shown 00:11:28.950 --> 00:11:32.110 this is possible. And it's vital because for 00:11:32.110 --> 00:11:34.789 the transfer to give active movement, not just 00:11:34.789 --> 00:11:37.850 passive support, the patient's brain needs to 00:11:37.850 --> 00:11:41.230 be able to find and fire that specific muscle 00:11:41.230 --> 00:11:43.769 in its new role. So they have to relearn how 00:11:43.769 --> 00:11:47.149 to use it. Exactly. It requires neuroplasticity, 00:11:47.610 --> 00:11:50.389 the brain's amazing ability to remap itself and 00:11:50.389 --> 00:11:52.490 learn new motor patterns. The patient has to 00:11:52.490 --> 00:11:54.809 essentially re -educate that muscle, guided by 00:11:54.809 --> 00:11:57.190 physio, of course. So the patient needs to be 00:11:57.190 --> 00:11:59.649 capable of that learning process. That ties back 00:11:59.649 --> 00:12:01.669 to the ideal patient profile, which I know we'll 00:12:01.669 --> 00:12:03.769 get to. It's interesting, though, this technique 00:12:03.769 --> 00:12:06.009 wasn't originally designed for rotator cuff tears 00:12:06.009 --> 00:12:08.409 at all, was it? It came from nerve injury cases. 00:12:08.769 --> 00:12:11.830 Yes, that's a key part of its history. The whole 00:12:11.830 --> 00:12:14.450 concept of using the lower trapezius for a transfer 00:12:14.450 --> 00:12:17.750 was first described for restoring external rotation 00:12:17.750 --> 00:12:20.809 in patients with specific nerve damage. Things 00:12:20.809 --> 00:12:23.309 like traumatic brachial plexus injuries or sometimes 00:12:23.309 --> 00:12:25.970 in children with obstetric brachial plexus injuries 00:12:25.970 --> 00:12:28.590 where the nerves supplying the normal external 00:12:28.590 --> 00:12:31.250 rotator muscles were permanently damaged. So 00:12:31.250 --> 00:12:33.429 the muscles themselves were okay but the signal 00:12:33.429 --> 00:12:36.830 wasn't getting through. Often, yes, or the muscles 00:12:36.830 --> 00:12:40.059 had wasted because of the nerve damage. Surgeons 00:12:40.059 --> 00:12:42.340 realized the LT had the right properties. It 00:12:42.340 --> 00:12:44.019 was expendable, meaning you could take it without 00:12:44.019 --> 00:12:46.360 causing a major new problem. It had enough length. 00:12:46.620 --> 00:12:49.259 It could move sufficiently. And crucially, it 00:12:49.259 --> 00:12:52.379 had that suitable line of pull. So it could substitute 00:12:52.379 --> 00:12:55.019 for the lost external rotation function in those 00:12:55.019 --> 00:12:57.559 nerve injury cases. It was only more recently 00:12:57.559 --> 00:12:59.980 adapted and popularized as a solution for these 00:12:59.980 --> 00:13:03.200 massive, irreparable rotator cuff tears, which 00:13:03.200 --> 00:13:05.419 cause a very similar functional problem that 00:13:05.419 --> 00:13:07.820 loss of external rotation, even though the root 00:13:07.820 --> 00:13:10.289 cause is different, Tendon failure rather than 00:13:10.289 --> 00:13:12.850 nerve failure. So applying a proven principle 00:13:12.850 --> 00:13:16.090 to a different but related problem. Precisely. 00:13:16.509 --> 00:13:18.610 It's a great example of how surgical principles 00:13:18.610 --> 00:13:20.789 can be translated across different conditions 00:13:20.789 --> 00:13:23.210 when the functional deficit is similar. That 00:13:23.210 --> 00:13:25.490 makes perfect sense. So given this is quite a 00:13:25.490 --> 00:13:28.090 sophisticated procedure with specific biomechanical 00:13:28.090 --> 00:13:31.129 aims, who is the right patient for a lower trapezius 00:13:31.129 --> 00:13:35.169 tendon transfer, patient selection must be absolutely 00:13:35.169 --> 00:13:37.860 critical. Paramount. is patient selection is 00:13:37.860 --> 00:13:40.159 absolutely key. And the sources are very clear 00:13:40.159 --> 00:13:42.200 on the criteria. Firstly, you must have confirmation 00:13:42.200 --> 00:13:44.980 of an irreparable posterior superior rotator 00:13:44.980 --> 00:13:47.820 cuff tear. And as we said, that's not just about 00:13:47.820 --> 00:13:50.659 size on an MRI. It involves looking at how far 00:13:50.659 --> 00:13:53.059 the tendon has retracted, the quality of any 00:13:53.059 --> 00:13:55.279 remaining tendon tissue, and very importantly, 00:13:55.399 --> 00:13:57.639 the quality of the muscle itself. The sources 00:13:57.639 --> 00:14:00.240 highlight that tears involving both the supraspinatus 00:14:00.240 --> 00:14:03.019 and infraspinatus, often with significant fatty 00:14:03.019 --> 00:14:04.860 degeneration of those muscles, are the typical 00:14:04.860 --> 00:14:07.019 indications. You mentioned fatty degeneration 00:14:07.019 --> 00:14:08.960 there. Can you just explain what that means and 00:14:08.960 --> 00:14:12.299 why it's so important in this context? Yes. Fatty 00:14:12.299 --> 00:14:15.200 degeneration or fatty infiltration is where muscle 00:14:15.200 --> 00:14:18.179 tissue gets replaced by fat over time. This tends 00:14:18.179 --> 00:14:20.120 to happen when a muscle is detached from its 00:14:20.120 --> 00:14:22.620 tendon, pronically, and isn't working properly. 00:14:23.019 --> 00:14:25.259 We assess it using scales like the Goutalier 00:14:25.259 --> 00:14:28.200 classification, grading it from zero, which is 00:14:28.200 --> 00:14:31.019 no fat, up to four, where there's more fat than 00:14:31.019 --> 00:14:33.720 actual muscle visible on the scan. The sources 00:14:33.720 --> 00:14:35.860 indicate that if the native infraspinatus muscle, 00:14:35.860 --> 00:14:37.980 for example, has Goutalier grade three or four 00:14:37.980 --> 00:14:40.580 changes, a standard repair is highly unlikely 00:14:40.580 --> 00:14:43.299 to work well. There just isn't enough healthy 00:14:43.299 --> 00:14:45.779 functioning muscle left. So that helps define 00:14:45.779 --> 00:14:48.580 it as irreparable. Exactly. It's part of classifying 00:14:48.580 --> 00:14:50.820 the tear as irreparable and assessing the overall 00:14:50.820 --> 00:14:54.090 state of the shoulder. For LTT, the quality of 00:14:54.090 --> 00:14:56.750 the remaining muscles like the deltoid and subscapularis 00:14:56.750 --> 00:14:59.529 and the LT itself are also key. But the state 00:14:59.529 --> 00:15:01.590 of the original torn muscles informs the decision 00:15:01.590 --> 00:15:04.509 that a standard repair isn't feasible. Secondly, 00:15:04.570 --> 00:15:07.110 and this is perhaps equally crucial, the patient 00:15:07.110 --> 00:15:10.169 must have minimal glenohumeral arthritis. Wear 00:15:10.169 --> 00:15:13.409 and tear in the main joint. Precisely. Wear and 00:15:13.409 --> 00:15:16.759 tear in the main ball and socket joint. The sources 00:15:16.759 --> 00:15:20.639 specify, ideally, hematograde 1 or less. Hematograting 00:15:20.639 --> 00:15:23.500 is a way we classify arthritis on x -rays specifically 00:15:23.500 --> 00:15:26.279 in the context of rotator cuff problems. Grade 00:15:26.279 --> 00:15:30.000 1 is very mild changes, whereas grade 5 is severe 00:15:30.000 --> 00:15:33.440 arthritis with significant bone changes. If there's 00:15:33.440 --> 00:15:36.240 significant arthritis, say, hematograde 2 or 00:15:36.240 --> 00:15:39.759 higher, certainly 3 or 4, the fundamental problem 00:15:39.759 --> 00:15:41.620 isn't just the missing cuff tendons anymore. 00:15:41.919 --> 00:15:44.620 The joint surfaces themselves are worn out. So 00:15:44.620 --> 00:15:46.960 the transfer wouldn't work properly? Trying to 00:15:46.960 --> 00:15:48.559 improve function with a tendon transfer when 00:15:48.559 --> 00:15:51.370 the underlying joint is arthritic. Well, it's 00:15:51.370 --> 00:15:53.049 like putting a new engine in a car with square 00:15:53.049 --> 00:15:55.389 wheels, as the saying goes. The basic mechanics 00:15:55.389 --> 00:15:57.330 of smooth movement are already compromised by 00:15:57.330 --> 00:15:59.289 the joint surface damage. Right, you need a reasonably 00:15:59.289 --> 00:16:01.549 healthy joint surface for the transfer to work 00:16:01.549 --> 00:16:03.490 effectively against. That makes complete sense. 00:16:04.129 --> 00:16:06.610 Okay, so beyond the tear itself and the arthritis 00:16:06.610 --> 00:16:08.889 level, what else defines the ideal candidate? 00:16:09.129 --> 00:16:11.250 What sort of person typically gets offered this? 00:16:11.529 --> 00:16:14.029 Well, typically patients present with that persistent 00:16:14.029 --> 00:16:17.179 pain. and the significant functional limitations, 00:16:17.779 --> 00:16:20.399 the inability to actively lift or externally 00:16:20.399 --> 00:16:23.519 rotate the arm that we discussed. And the sources 00:16:23.519 --> 00:16:26.740 also point towards the patient profile. LTT is 00:16:26.740 --> 00:16:29.460 often indicated for younger and more active individuals. 00:16:29.759 --> 00:16:32.000 As opposed to something like a shoulder replacement. 00:16:32.320 --> 00:16:35.320 Exactly. This contrasts with options like reverse 00:16:35.320 --> 00:16:37.539 shoulder arthroplasty, which is often a better 00:16:37.539 --> 00:16:40.379 choice for older, less active patients, especially 00:16:40.379 --> 00:16:42.639 if they do have significant arthritis at hematograde 00:16:42.639 --> 00:16:45.669 2 or higher. The younger, more active patient 00:16:45.669 --> 00:16:48.950 generally has greater demands, needs to regain 00:16:48.950 --> 00:16:51.549 significant function, and often has better capacity 00:16:51.549 --> 00:16:54.690 for the rigorous rehabilitation needed. And potentially 00:16:54.690 --> 00:16:57.649 better neuroplasticity to learn to use the transferred 00:16:57.649 --> 00:16:59.850 muscle effectively. They need to be motivated. 00:17:00.190 --> 00:17:03.429 Motivation sounds key. It really is. Other important 00:17:03.429 --> 00:17:05.329 factors include having a supple shoulder joint 00:17:05.329 --> 00:17:07.609 beforehand, meaning it doesn't have significant 00:17:07.609 --> 00:17:09.970 stiffness or fixed contractures preoperatively. 00:17:10.279 --> 00:17:12.819 Trying to restore active motion with the transfer 00:17:12.819 --> 00:17:15.319 when the joint is already very stiff passively 00:17:15.319 --> 00:17:17.960 is much more challenging. That paints a clear 00:17:17.960 --> 00:17:20.680 picture of who might be a good fit. What about 00:17:20.680 --> 00:17:23.380 the other side? Who is definitely not a candidate? 00:17:23.880 --> 00:17:26.740 What are the absolute non -starters? Right, the 00:17:26.740 --> 00:17:28.880 absolute contraindications are pretty clear -cut. 00:17:29.240 --> 00:17:32.079 Firstly, any active soft tissue infection in 00:17:32.079 --> 00:17:34.460 or around the shoulder simply can't do elective 00:17:34.460 --> 00:17:37.299 surgery in an infected area. Secondly, paralysis 00:17:37.299 --> 00:17:39.990 of the trapezius muscle itself. The transfer 00:17:39.990 --> 00:17:43.549 relies entirely on the LT being a working functional 00:17:43.549 --> 00:17:46.170 muscle that can be re -educated. If it's paralyzed, 00:17:46.569 --> 00:17:48.789 the procedure is impossible. Makes sense. And 00:17:48.789 --> 00:17:51.150 thirdly, as we discussed, advanced glenohumeral 00:17:51.150 --> 00:17:53.829 arthritis, often considered hematograde 2 or 00:17:53.829 --> 00:17:56.730 higher by some surgeons as a relative contraindication, 00:17:57.089 --> 00:18:00.109 but certainly grade 3 or 4 is an absolute contraindication 00:18:00.109 --> 00:18:02.369 for this specific procedure. A reverse replacement 00:18:02.369 --> 00:18:04.960 would likely be considered them. So infection, 00:18:05.220 --> 00:18:07.720 a non -working trapezius or significant joint 00:18:07.720 --> 00:18:10.420 wear rules it out completely. What about things 00:18:10.420 --> 00:18:14.619 that might make surgeons pause the relative contraindications? 00:18:15.039 --> 00:18:17.319 Yes, relative contraindications often involve 00:18:17.319 --> 00:18:19.240 the condition of the other key shoulder muscles. 00:18:19.559 --> 00:18:21.660 The state of the subscapularis muscle, for instance, 00:18:21.700 --> 00:18:23.200 which sits at the front of the shoulder. What 00:18:23.200 --> 00:18:25.880 does that one do? It's a key internal rotator 00:18:25.880 --> 00:18:28.099 and provides crucial stability at the front of 00:18:28.099 --> 00:18:30.720 the joint. Ideally, you want an intact or at 00:18:30.720 --> 00:18:34.170 least reprable subscapularis. While the LTT helps 00:18:34.170 --> 00:18:36.750 restore posterior stability and external rotation, 00:18:37.190 --> 00:18:39.769 the subscapularis provides the essential counterbalance 00:18:39.769 --> 00:18:43.630 at the front. If the subscapularis is also severely 00:18:43.630 --> 00:18:46.349 deficient and irreparable alongside the posterior 00:18:46.349 --> 00:18:49.109 superior tear, outcomes can be less predictable. 00:18:49.509 --> 00:18:51.710 It makes the whole shoulder more unstable. Okay, 00:18:51.789 --> 00:18:53.710 so the front needs to be holding up, too? Pretty 00:18:53.710 --> 00:18:56.269 much. Similarly, the deltoid muscle must be functional. 00:18:56.440 --> 00:18:58.960 The deltoid, that big muscle covering the shoulder, 00:18:59.319 --> 00:19:01.579 is the prime mover for lifting the arm away from 00:19:01.579 --> 00:19:04.440 the body abduction and gross elevation. The LTT 00:19:04.440 --> 00:19:06.880 helps restore external rotation and contributes 00:19:06.880 --> 00:19:09.299 to the dynamic stability needed for smooth elevation, 00:19:09.680 --> 00:19:11.980 but you absolutely need a working deltoid to 00:19:11.980 --> 00:19:14.279 achieve a good range of forward flexion and abduction 00:19:14.279 --> 00:19:17.339 overall. If the deltoid is severely compromised, 00:19:17.559 --> 00:19:19.759 maybe from previous surgery or nerve injury like 00:19:19.759 --> 00:19:22.460 an axillary nerve palsy, the patient won't get 00:19:22.460 --> 00:19:24.980 satisfactory lifting ability back, even if the 00:19:24.980 --> 00:19:27.299 LTT successfully restores external rotation. 00:19:27.529 --> 00:19:29.390 So you really need the rest of the shoulders 00:19:29.390 --> 00:19:32.190 team, the joint surface, the subscapularis, the 00:19:32.190 --> 00:19:34.910 deltoid, to be in reasonably good shape for the 00:19:34.910 --> 00:19:37.509 LT transfer to have the best chance. That's a 00:19:37.509 --> 00:19:39.869 very good summary. An advanced age, as you mentioned, 00:19:40.049 --> 00:19:42.089 is often considered a relative contraindication. 00:19:42.289 --> 00:19:45.150 Why is that just recovery? Primarily because 00:19:45.150 --> 00:19:47.630 of potentially reduced capacity for the very 00:19:47.630 --> 00:19:50.630 demanding rehabilitation and perhaps slightly 00:19:50.630 --> 00:19:53.490 less neuroplasticity compared to younger patients. 00:19:54.049 --> 00:19:56.769 Though it's important to say age itself isn't 00:19:56.769 --> 00:20:00.380 a strict cutoff. Physiological age, overall health, 00:20:00.960 --> 00:20:03.460 activity level, and motivation are often more 00:20:03.460 --> 00:20:05.400 relevant than just the chronological number. 00:20:05.700 --> 00:20:07.619 Right, it's the individual, not just the birth 00:20:07.619 --> 00:20:09.700 date. Exactly. That's a really comprehensive 00:20:09.700 --> 00:20:12.619 view of patient selection. Now let's turn to 00:20:12.619 --> 00:20:15.339 the surgery itself. The sources describe different 00:20:15.339 --> 00:20:18.880 ways of doing it open, mini -open, and this arthroscopic 00:20:18.880 --> 00:20:21.099 -assisted technique. Could you walk us through 00:20:21.099 --> 00:20:23.359 the general steps and maybe highlight the nuances, 00:20:23.440 --> 00:20:26.059 particularly of that less invasive arthroscopic 00:20:26.059 --> 00:20:28.839 approach? Certainly. So the procedure itself 00:20:28.839 --> 00:20:31.680 is typically done under general anesthesia. The 00:20:31.680 --> 00:20:33.500 patient is usually positioned either sitting 00:20:33.500 --> 00:20:36.440 up in a beach chair position or lying on their 00:20:36.440 --> 00:20:40.079 side, lateral decubitus. The arm is usually secured 00:20:40.079 --> 00:20:43.269 in an arm holder. It's quite a complex operation, 00:20:43.430 --> 00:20:46.089 generally taking around, say, one to two hours, 00:20:46.170 --> 00:20:47.970 maybe a bit longer, depending on the specifics. 00:20:48.369 --> 00:20:50.589 And it's often managed as an outpatient procedure 00:20:50.589 --> 00:20:52.930 these days in suitable patients and settings. 00:20:53.690 --> 00:20:55.990 Now, a really critical aspect which the sources 00:20:55.990 --> 00:20:58.710 consistently highlight is the frequent need for 00:20:58.710 --> 00:21:02.069 a biological graft to lengthen the lower trapezius 00:21:02.069 --> 00:21:04.910 tendon. Why is that needed? Isn't the LT tendon 00:21:04.910 --> 00:21:08.210 long enough? Often not, especially in these massive 00:21:08.210 --> 00:21:10.250 chronic tears where things have been retracted 00:21:10.250 --> 00:21:13.240 for a long time. The native LT tendon simply 00:21:13.240 --> 00:21:15.779 doesn't have enough natural length or excursion. 00:21:16.019 --> 00:21:18.200 That's the distance it can naturally travel when 00:21:18.200 --> 00:21:20.140 the muscle contracts to reach its new attachment 00:21:20.140 --> 00:21:22.500 point on the humerus without being under excessive 00:21:22.500 --> 00:21:24.420 tension. So you can't just stretch it further. 00:21:24.500 --> 00:21:26.099 You actually have to add a piece in the middle. 00:21:26.579 --> 00:21:30.500 Precisely. You need to bridge the gap. Achilles 00:21:30.500 --> 00:21:33.039 tendon allograft, that's tendon tissue from a 00:21:33.039 --> 00:21:35.559 human donor, is very commonly used for this. 00:21:35.960 --> 00:21:38.500 It's strong, readily available, and comes in 00:21:38.500 --> 00:21:41.650 suitable lengths. Semitendinosus autograft, taken 00:21:41.650 --> 00:21:43.930 from the patient's own hamstring tendons, is 00:21:43.930 --> 00:21:46.569 another possibility, although some sources suggest 00:21:46.569 --> 00:21:48.630 it might be slightly less robust than Achilles. 00:21:49.450 --> 00:21:53.890 Does using a graft add risks? Well, yes. Using 00:21:53.890 --> 00:21:56.950 any graft introduces potential factors. There's 00:21:56.950 --> 00:21:59.150 the integration of the graft, the healing process 00:21:59.150 --> 00:22:01.849 at both ends, and theoretically there's a risk 00:22:01.849 --> 00:22:04.730 of creep, the graft slowly stretching out over 00:22:04.730 --> 00:22:07.630 time. Would that make the transfer less effective? 00:22:08.190 --> 00:22:10.890 Potentially, yes. If it stretches significantly, 00:22:11.089 --> 00:22:13.410 it could reduce the resting tension, maybe affect 00:22:13.410 --> 00:22:15.829 the long -term function. Though the clinical 00:22:15.829 --> 00:22:18.390 significance of creeps, specifically in LTT outcomes, 00:22:18.869 --> 00:22:20.789 is still something being studied. It doesn't 00:22:20.789 --> 00:22:22.430 seem to be a major cause of outright failure, 00:22:22.650 --> 00:22:24.509 but subtle effects are possible. Okay, that's 00:22:24.509 --> 00:22:27.029 an important consideration. So how is the lower 00:22:27.029 --> 00:22:29.269 trapezius tendon actually harvested during the 00:22:29.269 --> 00:22:31.349 surgery? There are two main approaches described 00:22:31.349 --> 00:22:34.799 in the literature. One is the indirect or medial 00:22:34.799 --> 00:22:37.720 approach. This involves a vertical incision, 00:22:37.920 --> 00:22:40.380 usually about two centimeters medial to the inner 00:22:40.380 --> 00:22:43.420 border of the scapula, the shoulder blade. The 00:22:43.420 --> 00:22:46.200 surgeon finds the muscle belly first and then 00:22:46.200 --> 00:22:48.160 carefully traces it down to where the tendon 00:22:48.160 --> 00:22:51.099 inserts onto the scapular spine. Now, a crucial 00:22:51.099 --> 00:22:53.460 anatomical point with this approach, and the 00:22:53.460 --> 00:22:55.680 sources really stress this, is the proximity 00:22:55.680 --> 00:22:57.980 of the spinal accessory nerve. The nerve that 00:22:57.980 --> 00:23:01.039 makes the muscle work. Exactly. It's vital because 00:23:01.039 --> 00:23:03.819 it innervates the entire trapezius muscle. It 00:23:03.819 --> 00:23:06.319 typically runs on the undersurface of the trapezius. 00:23:07.059 --> 00:23:09.759 And studies cited show its location can be variable, 00:23:10.160 --> 00:23:12.220 but it's often around that two -thenometer medial 00:23:12.220 --> 00:23:14.759 mark, and potentially can be extremely close, 00:23:14.960 --> 00:23:17.579 even within 23 millimeters or so, to the actual 00:23:17.579 --> 00:23:19.940 tendon insertion point in some people. Wow, that's 00:23:19.940 --> 00:23:22.460 incredibly close. So surgeons have to be extremely 00:23:22.460 --> 00:23:24.539 careful not to damage it during the harvest. 00:23:25.000 --> 00:23:27.339 Absolutely paramount. Meticulous dissection is 00:23:27.339 --> 00:23:30.089 essential. Dissecting too far medially clearly 00:23:30.089 --> 00:23:32.630 increases the risk, but even working towards 00:23:32.630 --> 00:23:35.730 the tendon insertion requires great care to identify 00:23:35.730 --> 00:23:38.730 and protect that nerve. It's a non -negotiable 00:23:38.730 --> 00:23:41.509 part of this approach. The alternative is the 00:23:41.509 --> 00:23:44.450 direct or horizontal approach. This involves 00:23:44.450 --> 00:23:46.950 making an incision directly over the tendinous 00:23:46.950 --> 00:23:49.930 insertion on the scapular spine, usually running 00:23:49.930 --> 00:23:52.230 parallel to the spine itself. And is that safer 00:23:52.230 --> 00:23:55.069 for the nerve? Generally, yes. The sources indicate 00:23:55.069 --> 00:23:57.329 this approach is associated with less risk to 00:23:57.329 --> 00:23:59.690 the spinal accessory nerve because the dissection 00:23:59.690 --> 00:24:02.269 stays more lateral, closer to the bone of the 00:24:02.269 --> 00:24:04.710 scapular spine, and typically further away from 00:24:04.710 --> 00:24:06.930 the usual path of the nerve, which runs more 00:24:06.930 --> 00:24:09.430 medially. Okay, so the direct approach seems 00:24:09.430 --> 00:24:12.250 preferable from a nerve safety perspective. Once 00:24:12.250 --> 00:24:14.829 the tendon piece is harvested, how is it prepared? 00:24:15.269 --> 00:24:17.849 Whichever approach is used, the harvested LT 00:24:17.849 --> 00:24:21.029 tendon end is prepared with strong, non -absorbable 00:24:21.029 --> 00:24:23.819 sutures. often using a specific stitching pattern 00:24:23.819 --> 00:24:26.720 like the crack -out technique. This creates strong 00:24:26.720 --> 00:24:29.180 loops of suture at the end, which allows for 00:24:29.180 --> 00:24:31.859 secure handling and later attachment. Similarly, 00:24:32.319 --> 00:24:34.839 if an achilles allograft is used, the bone block 00:24:34.839 --> 00:24:37.640 is removed and the thick tendinous end The part 00:24:37.640 --> 00:24:39.640 that will attach to the humerus is prepared with 00:24:39.640 --> 00:24:42.220 similar strong crack -out sutures. The graft 00:24:42.220 --> 00:24:44.559 might also be marked or tagged to help keep it 00:24:44.559 --> 00:24:46.859 correctly oriented during the later steps. Right. 00:24:47.019 --> 00:24:49.380 Let's focus then on the arthroscopic assisted 00:24:49.380 --> 00:24:51.500 technique as it's described as less invasive. 00:24:51.960 --> 00:24:54.339 How does the graft actually get passed and attached 00:24:54.339 --> 00:24:57.119 inside the shoulder using cameras and small incisions? 00:24:57.460 --> 00:25:00.059 Okay, so the arthroscopic assisted technique 00:25:00.059 --> 00:25:02.859 usually pairs with the direct approach for harvesting 00:25:02.859 --> 00:25:05.920 the tendon. The surgery starts with a diagnostic 00:25:05.920 --> 00:25:08.279 arthroscopy camera in the joint through keyhole 00:25:08.279 --> 00:25:10.619 incisions. This lets the surgeon have a good 00:25:10.619 --> 00:25:13.240 look around, confirm the tear is truly irreparable, 00:25:13.720 --> 00:25:15.799 check the joint surface, and deal with any other 00:25:15.799 --> 00:25:18.180 issues, like maybe trimming a frayed biceps tendon. 00:25:19.039 --> 00:25:21.359 Then the crucial site on the humerus, the greater 00:25:21.359 --> 00:25:23.480 tuberosity footprint, where the original cuff 00:25:23.480 --> 00:25:25.819 tendon is attached, is prepared arthroscopically. 00:25:26.039 --> 00:25:29.400 This means using small shavers or burrs to debride 00:25:29.400 --> 00:25:31.900 the surface, cleaning it down to healthy bleeding 00:25:31.900 --> 00:25:34.160 bone to create a good bed for the graft to heal 00:25:34.160 --> 00:25:36.519 onto. Preparing the landing zone essentially. 00:25:36.940 --> 00:25:40.200 Exactly. Then, a really key technical step is 00:25:40.200 --> 00:25:42.559 creating a large enough opening in the infraspinitis 00:25:42.559 --> 00:25:45.819 fascia that's the tough layer covering the infraspinitis 00:25:45.819 --> 00:25:48.140 muscle, usually through the posterior incision 00:25:48.140 --> 00:25:50.900 site used for the harvest. This opening needs 00:25:50.900 --> 00:25:53.660 to be generous enough to allow the graft, which 00:25:53.660 --> 00:25:55.660 is quite bulky, especially if it's Achilles, 00:25:56.119 --> 00:25:58.420 to pass smoothly and without getting caught or 00:25:58.420 --> 00:26:00.599 kinked as it goes into the subacromial space. 00:26:01.180 --> 00:26:03.240 That's the space above the joint where the transfer 00:26:03.240 --> 00:26:05.589 needs to sit and function. So making sure there's 00:26:05.589 --> 00:26:08.829 a clear wide pathway for the graft is critical. 00:26:09.230 --> 00:26:11.750 Absolutely critical. Then comes the passage itself. 00:26:12.210 --> 00:26:14.430 This definitely requires skilled arthroscopic 00:26:14.430 --> 00:26:17.269 technique. Instruments like large graspers or 00:26:17.269 --> 00:26:19.809 sometimes a system using switching sticks and 00:26:19.809 --> 00:26:21.849 cannulas are introduced through the standard 00:26:21.849 --> 00:26:24.470 arthroscopy portals. Usually an anterolateral 00:26:24.470 --> 00:26:26.430 portal needs to be made large enough to let the 00:26:26.430 --> 00:26:28.910 graft pass through. These instruments are used 00:26:28.910 --> 00:26:31.529 to reach back to the harvest site, grab the sutures 00:26:31.529 --> 00:26:34.119 on the end of the graft, and carefully pull the 00:26:34.119 --> 00:26:36.480 graph through that prepared opening in the fascia, 00:26:36.599 --> 00:26:39.440 bringing it into the subacromial space positioned 00:26:39.440 --> 00:26:41.420 over the prepared footprint on the humerus. And 00:26:41.420 --> 00:26:44.220 avoiding twisting it. Yes. Ensuring the graph 00:26:44.220 --> 00:26:47.180 doesn't twist during passage is vital. You want 00:26:47.180 --> 00:26:49.480 it to lie flat and maintain its intended line 00:26:49.480 --> 00:26:52.380 of pull. That sounds like quite a delicate maneuver 00:26:52.380 --> 00:26:54.940 doing that through keyholes. It certainly is. 00:26:55.339 --> 00:26:58.039 It underscores why this technique has a definite 00:26:58.039 --> 00:27:01.539 learning curve. Once the graft is correctly positioned, 00:27:02.200 --> 00:27:05.019 its thick sutured end is attached down to that 00:27:05.019 --> 00:27:07.440 prepared footprint on the greater tuberosity. 00:27:08.099 --> 00:27:10.339 We use suture anchors for this small implants 00:27:10.339 --> 00:27:13.500 that screw or tap into the bone with strong sutures 00:27:13.500 --> 00:27:16.619 attached. Often a double row technique is used 00:27:16.619 --> 00:27:19.599 with two rows of anchors to get a broader stronger 00:27:19.599 --> 00:27:22.480 fixation of the graft onto the bone. The quality 00:27:22.480 --> 00:27:24.440 of the patient's bone in that area can influence 00:27:24.440 --> 00:27:26.579 the choice sometimes that the bone is soft. Different 00:27:26.579 --> 00:27:28.519 types of anchors or even techniques like using 00:27:28.519 --> 00:27:30.759 a cortical button might be needed for secure 00:27:30.759 --> 00:27:32.940 fixation. And getting the tension right must 00:27:32.940 --> 00:27:35.700 be crucial here. Absolutely paramount. Correct 00:27:35.700 --> 00:27:38.059 tensioning is key for the transfer to work optimally. 00:27:38.170 --> 00:27:40.890 This is achieved by holding the arm in specific 00:27:40.890 --> 00:27:42.970 degrees of abduction, lifting away from the body 00:27:42.970 --> 00:27:46.069 and external rotation whilst the graft is being 00:27:46.069 --> 00:27:48.289 secured to the humerus. The source has often 00:27:48.289 --> 00:27:50.509 mentioned positioning the arm at around, say, 00:27:50.809 --> 00:27:53.329 45 degrees of abduction and 45 degrees of external 00:27:53.329 --> 00:27:55.910 rotation when securing the graft to the humerus 00:27:55.910 --> 00:27:58.309 in the arthroscopic assisted procedure. This 00:27:58.309 --> 00:28:00.470 aims to set the right resting length and tension. 00:28:00.730 --> 00:28:02.769 Getting that tension just right sounds like a 00:28:02.769 --> 00:28:05.150 real Goldilocks situation. Not too tight, not 00:28:05.150 --> 00:28:08.369 too loose. It absolutely is. Too loose and it 00:28:08.369 --> 00:28:10.769 won't function effectively. Too tight and it 00:28:10.769 --> 00:28:13.130 might restrict motion or put excessive stress 00:28:13.130 --> 00:28:15.609 on the fixation. It requires careful judgment. 00:28:16.039 --> 00:28:18.940 The final step then is attaching the other end 00:28:18.940 --> 00:28:21.759 of the graft, the thinner end, to the patient's 00:28:21.759 --> 00:28:23.839 native lower trapezius tendon, which was harvested 00:28:23.839 --> 00:28:26.859 earlier. This is usually done using strong sutures 00:28:26.859 --> 00:28:29.119 again, often with techniques like a pulvertaft 00:28:29.119 --> 00:28:31.779 weave, which interlaces the tendons or side -to 00:28:31.779 --> 00:28:34.299 -side crack -out sutures to create a secure connection 00:28:34.299 --> 00:28:36.819 between the graft and the native tendon. And 00:28:36.819 --> 00:28:38.799 this connection is typically tensioned and tied 00:28:38.799 --> 00:28:40.960 with the arm position to achieve maximal tension 00:28:40.960 --> 00:28:43.880 on the whole transfer construct. often in maximal 00:28:43.880 --> 00:28:46.720 external rotation with the arm at zero degrees 00:28:46.720 --> 00:28:49.500 of abduction or even slight extension. And I 00:28:49.500 --> 00:28:51.380 imagine checking that nerve again is important 00:28:51.380 --> 00:28:54.720 here. Absolutely. Before tying those final knots 00:28:54.720 --> 00:28:56.980 connecting the graft to the native LT tendon, 00:28:57.500 --> 00:28:59.640 the sources reiterate that a final check must 00:28:59.640 --> 00:29:01.740 be done to ensure the spinal accessory nerve 00:29:01.740 --> 00:29:04.759 is well clear, not being impinged or stretched 00:29:04.759 --> 00:29:07.279 by the transfer or the surrounding tissues. If 00:29:07.279 --> 00:29:09.960 there's any concern, a small piece of the medial 00:29:09.960 --> 00:29:12.799 scapular spine, where the LT originally attached, 00:29:13.339 --> 00:29:16.150 might need to be carefully removed. resected 00:29:16.150 --> 00:29:18.430 to give the nerve more space. It's clear this 00:29:18.430 --> 00:29:21.210 is a highly technical procedure with really critical 00:29:21.210 --> 00:29:24.210 steps at each stage. How do these different approaches, 00:29:24.450 --> 00:29:27.269 the full open, the mini open, and this arthroscopic 00:29:27.269 --> 00:29:29.470 assisted one really stack up? What are the main 00:29:29.470 --> 00:29:31.589 pros and cons? Okay, so the traditional open 00:29:31.589 --> 00:29:34.089 approach often involves what's called a necromial 00:29:34.089 --> 00:29:36.759 osteotomy. where a piece of the acromion bone, 00:29:36.880 --> 00:29:38.400 the tip of the shoulder blade, is surgically 00:29:38.400 --> 00:29:40.940 cut and later fixed back on, usually with screws. 00:29:41.559 --> 00:29:44.519 This gives the surgeon excellent wide -open exposure 00:29:44.519 --> 00:29:46.579 for harvesting the tendon and attaching it to 00:29:46.579 --> 00:29:49.480 the humerus. However, it carries specific risks, 00:29:49.960 --> 00:29:51.599 like that piece of bone failing to heal back 00:29:51.599 --> 00:29:54.400 properly and non -union, or problems with reattaching 00:29:54.400 --> 00:29:56.619 the deltoid muscle, which has to be detached 00:29:56.619 --> 00:29:58.980 quite significantly to get that exposure. Does 00:29:58.980 --> 00:30:02.140 non -union cause problems? It can, but interestingly, 00:30:02.380 --> 00:30:04.740 some studies mentioned in the sources found surprisingly 00:30:04.740 --> 00:30:07.680 comparable clinical outcomes, even when a bony 00:30:07.680 --> 00:30:10.180 non -union occurred. It suggests that sometimes 00:30:10.180 --> 00:30:13.240 a strong fibrous union might be sufficient, but 00:30:13.240 --> 00:30:15.519 it's still a potential complication of that approach. 00:30:16.380 --> 00:30:18.759 The mini -open approach tries to avoid the acromial 00:30:18.759 --> 00:30:21.960 osteotomy. reducing that specific risk. But it 00:30:21.960 --> 00:30:24.359 still involves splitting or detaching part of 00:30:24.359 --> 00:30:26.799 the deltoid muscle and generally offers more 00:30:26.799 --> 00:30:29.220 limited exposure compared to the full open technique. 00:30:29.660 --> 00:30:32.720 Right. And arthroscopic assisted. The arthroscopic 00:30:32.720 --> 00:30:35.480 assisted technique, as we focused on, is highlighted 00:30:35.480 --> 00:30:38.660 primarily for being minimally invasive. It completely 00:30:38.660 --> 00:30:41.220 avoids the acromial osteotomy and significantly 00:30:41.220 --> 00:30:43.900 reduces any detachment of the deltoid muscle, 00:30:44.240 --> 00:30:46.480 often just splitting the muscle fibers rather 00:30:46.480 --> 00:30:49.250 than detaching the origin. And the sources link 00:30:49.250 --> 00:30:51.589 this to several potential benefits, potentially 00:30:51.589 --> 00:30:54.250 less post -operative pain, possibly lower infection 00:30:54.250 --> 00:30:56.849 rates, maybe a quicker initial recovery phase, 00:30:57.109 --> 00:30:59.190 and minimal scarring. And preserving the deltoid 00:30:59.190 --> 00:31:03.009 is a big deal. Potentially, yes. Minimizing disruption 00:31:03.009 --> 00:31:06.150 to the deltoid could, in theory, lead to better 00:31:06.150 --> 00:31:08.789 long -term strength and range of motion. Those 00:31:08.789 --> 00:31:11.690 benefits of the arthroscopic approach sound very 00:31:11.690 --> 00:31:13.789 appealing from a patient's perspective. They 00:31:13.789 --> 00:31:16.450 certainly do, particularly preserving the deltoid 00:31:16.450 --> 00:31:19.640 attachment. However, as we noted, it absolutely 00:31:19.640 --> 00:31:22.799 requires specific, advanced arthroscopic skills 00:31:22.799 --> 00:31:25.140 and definitely has a learning curve for the surgeon. 00:31:25.759 --> 00:31:27.980 Another significant advantage of the arthroscopic 00:31:27.980 --> 00:31:29.859 approach though, which shouldn't be overlooked, 00:31:30.400 --> 00:31:33.000 is the ability to simultaneously address other 00:31:33.000 --> 00:31:35.700 problems inside the joint, like tidying up a 00:31:35.700 --> 00:31:39.400 partial subscapularis tear or dealing with biceps 00:31:39.400 --> 00:31:42.000 tendon issues all arthroscopically during the 00:31:42.000 --> 00:31:44.319 same procedure. That's often less straightforward 00:31:44.319 --> 00:31:47.069 with the open techniques. So it sounds like a 00:31:47.069 --> 00:31:49.589 trade -off between invasiveness, the amount of 00:31:49.589 --> 00:31:51.710 exposure the surgeon gets, potential complications 00:31:51.710 --> 00:31:53.910 specific to each technique, and of course the 00:31:53.910 --> 00:31:55.970 surgeon's own expertise and experience. That's 00:31:55.970 --> 00:31:58.009 a very accurate summary. Okay, so once the surgery 00:31:58.009 --> 00:32:00.349 itself is complete, the journey is far from over. 00:32:00.670 --> 00:32:02.890 Rehabilitation is obviously critical. What does 00:32:02.890 --> 00:32:05.349 a typical rehab protocol or physio plan look 00:32:05.349 --> 00:32:08.609 like after an LTT? Yes, rehabilitation is absolutely 00:32:08.609 --> 00:32:11.230 fundamental to getting a good outcome. It's not 00:32:11.230 --> 00:32:13.839 optional, it's integral. The sources outline 00:32:13.839 --> 00:32:17.119 a pretty structured multi -phase protocol, and 00:32:17.119 --> 00:32:19.720 sticking to it is key. Phase I is usually the 00:32:19.720 --> 00:32:22.619 first six weeks or so. This is all about maximal 00:32:22.619 --> 00:32:25.059 protection, allowing that initial healing to 00:32:25.059 --> 00:32:27.539 occur. The shoulder is immobilized in a brace. 00:32:27.740 --> 00:32:30.539 And importantly, it's often positioned in a specific 00:32:30.539 --> 00:32:32.680 amount of abduction and external rotation, maybe 00:32:32.680 --> 00:32:35.339 30 degrees of abduction, and anywhere from 30 00:32:35.339 --> 00:32:38.019 up to perhaps 70 degrees of external rotation. 00:32:38.579 --> 00:32:41.019 The exact position can vary a bit based on surgeon 00:32:41.019 --> 00:32:43.720 preference and the tension felt during the repair. 00:32:43.900 --> 00:32:45.859 And that specific positioning, that's designed 00:32:45.859 --> 00:32:47.640 to take all the tension off the repair site. 00:32:48.099 --> 00:32:50.140 Precisely. It minimizes stress on the healing 00:32:50.140 --> 00:32:52.720 graft to bone fixation and the tendon to tendon 00:32:52.720 --> 00:32:54.940 junction, just protecting everything whilst it 00:32:54.940 --> 00:32:57.369 knits together. During this phase, pain control 00:32:57.369 --> 00:33:00.250 is important, often using cold therapy. Patients 00:33:00.250 --> 00:33:02.450 start some very early, gentle, passive range 00:33:02.450 --> 00:33:05.170 of motion exercises, usually guided by the physio, 00:33:05.309 --> 00:33:07.210 perhaps starting around week three. That's just 00:33:07.210 --> 00:33:09.029 to prevent stiffness. But critically, there's 00:33:09.029 --> 00:33:11.089 no active contraction of the transferred muscle 00:33:11.089 --> 00:33:13.650 allowed yet. Just keeping things moving gently. 00:33:13.970 --> 00:33:17.750 Exactly. And doing exercises for the elbow, wrist, 00:33:17.829 --> 00:33:19.869 and hand is important too, to keep the rest of 00:33:19.869 --> 00:33:22.829 the limb mobile. Phase two then typically runs 00:33:22.829 --> 00:33:25.799 from about six weeks up to 12 weeks. This is 00:33:25.799 --> 00:33:27.559 where the transition to active range of motion 00:33:27.559 --> 00:33:30.599 happens. Patients gradually progress from active 00:33:30.599 --> 00:33:32.940 assisted exercises where they might use their 00:33:32.940 --> 00:33:35.700 other arm or a stick to help move the operated 00:33:35.700 --> 00:33:39.039 arm towards full active range of motion, initially 00:33:39.039 --> 00:33:41.859 perhaps lying down, then against gravity. Weaning 00:33:41.859 --> 00:33:44.099 off the mobilization brace usually happens during 00:33:44.099 --> 00:33:46.440 this phase as well. And the sources note that 00:33:46.440 --> 00:33:48.880 patients often see quite significant visible 00:33:48.880 --> 00:33:50.680 improvements in their shoulder movement during 00:33:50.680 --> 00:33:52.859 this period, as they start to carefully recruit 00:33:52.859 --> 00:33:55.019 that transferred muscle. Do they have to avoid 00:33:55.019 --> 00:33:57.759 certain movements? Yes. Often exercises involving 00:33:57.759 --> 00:34:00.099 bringing the arm across the body, cross -goddy 00:34:00.099 --> 00:34:02.259 adduction, are restricted initially, as that 00:34:02.259 --> 00:34:04.420 can put stress on the posterior transfer site. 00:34:04.619 --> 00:34:06.819 Okay, so starting to actively use the shoulder 00:34:06.819 --> 00:34:08.960 again, but very much under careful guidance. 00:34:09.420 --> 00:34:12.150 Exactly. Then phase 3 begins around the 12 -week 00:34:12.150 --> 00:34:14.530 mark, maybe a bit later, and the focus shifts 00:34:14.530 --> 00:34:17.050 squarely onto strengthening. This usually starts 00:34:17.050 --> 00:34:19.789 with isometric exercises, contracting the muscles 00:34:19.789 --> 00:34:22.010 without actually moving the joint, targeting 00:34:22.010 --> 00:34:24.610 the key shoulder stabilizers, the periscapular 00:34:24.610 --> 00:34:26.829 muscles around the shoulder blade, the deltoid, 00:34:26.849 --> 00:34:29.789 and any remaining healthy rotator cuff. Then 00:34:29.789 --> 00:34:32.190 this progresses to isotonic strengthening, using 00:34:32.190 --> 00:34:34.210 resistance like therapy bands or light weights. 00:34:34.429 --> 00:34:37.170 This typically starts maybe around four months 00:34:37.170 --> 00:34:40.010 post -op, with a very gradual increase in the 00:34:40.010 --> 00:34:43.389 load and intensity over time. And when can people 00:34:43.389 --> 00:34:45.730 expect to get back to normal activities? Well, 00:34:45.909 --> 00:34:48.110 return to lighter work duties or modified recreational 00:34:48.110 --> 00:34:49.989 activities is often permitted around the six 00:34:49.989 --> 00:34:52.909 -month mark. But it's a gradual progression back 00:34:52.909 --> 00:34:55.570 to more demanding tasks or sports over the following 00:34:55.570 --> 00:34:58.440 months. Formal physiotherapy can often continue 00:34:58.440 --> 00:35:01.539 for up to a year, really, to fully optimize strength, 00:35:01.820 --> 00:35:03.639 endurance and those functional movement patterns 00:35:03.639 --> 00:35:06.239 as the brain continues to learn how to best use 00:35:06.239 --> 00:35:08.519 the transferred muscle. It's definitely a long 00:35:08.519 --> 00:35:11.039 road, but a necessary one. It certainly sounds 00:35:11.039 --> 00:35:13.619 like a significant commitment to recovery from 00:35:13.619 --> 00:35:16.820 the patient side. What kind of results are actually 00:35:16.820 --> 00:35:19.000 being reported in the studies for patients who 00:35:19.000 --> 00:35:21.440 go through all this? Are those functional improvements 00:35:21.440 --> 00:35:23.840 really happening? Yes, the clinical results reported 00:35:23.840 --> 00:35:26.079 in the literature are generally very encouraging. 00:35:26.360 --> 00:35:29.440 especially, as we keep saying, in carefully selected 00:35:29.440 --> 00:35:32.440 patients. Studies consistently show significant 00:35:32.440 --> 00:35:35.219 improvements in both pain levels, often measured 00:35:35.219 --> 00:35:38.280 using things like a visual analog scale, or VAS, 00:35:38.840 --> 00:35:41.480 and also in functional outcome scores. Common 00:35:41.480 --> 00:35:43.840 ones are the American shoulder and elbow surgeon 00:35:43.840 --> 00:35:47.940 score, the AC score, or the ADLR score. Patients 00:35:47.940 --> 00:35:50.559 report substantially less pain and a much better 00:35:50.559 --> 00:35:52.500 ability to do their daily activities. That's 00:35:52.500 --> 00:35:54.099 great. And crucially, what about the movement? 00:35:54.219 --> 00:35:56.739 Are they getting that lift and rotation back? 00:35:57.099 --> 00:35:59.179 Yes. And this is where the procedure really validates 00:35:59.179 --> 00:36:01.940 its biomechanical rationale. The sources cite 00:36:01.940 --> 00:36:04.260 data showing really substantial average increases 00:36:04.260 --> 00:36:07.039 in active range of motion. Active forward flexion, 00:36:07.159 --> 00:36:09.500 lifting the arm forwards and up, often improves 00:36:09.500 --> 00:36:12.059 significantly. Maybe from around 100 degrees 00:36:12.059 --> 00:36:14.719 before surgery up towards 140 degrees, sometimes 00:36:14.719 --> 00:36:17.469 even more afterwards. Active abduction, lifting 00:36:17.469 --> 00:36:20.730 out to the side, see similar gains, often increasing 00:36:20.730 --> 00:36:23.449 from perhaps 70 degrees pre -op to well over 00:36:23.449 --> 00:36:25.829 130 degrees post -op on average. Those are really 00:36:25.829 --> 00:36:27.869 big improvements in just the ability to lift 00:36:27.869 --> 00:36:30.369 the arm. And what about that key deficit you 00:36:30.369 --> 00:36:32.570 mentioned, the external rotation? That's where 00:36:32.570 --> 00:36:34.690 the LT transfer often really demonstrates its 00:36:34.690 --> 00:36:37.929 value compared to, say, an LD transfer. Active 00:36:37.929 --> 00:36:40.349 external rotation, which is often severely limited 00:36:40.349 --> 00:36:42.469 beforehand, maybe only 10 or 20 degrees out from 00:36:42.469 --> 00:36:45.360 neutral, typically improves significantly. often 00:36:45.360 --> 00:36:48.099 to 30, 40 degrees, sometimes even more, after 00:36:48.099 --> 00:36:50.340 the surgery. The sources frequently highlight 00:36:50.340 --> 00:36:52.500 the conversion of a positive external rotation 00:36:52.500 --> 00:36:55.159 lag sign. That's an objective clinical test showing 00:36:55.159 --> 00:36:57.760 the inability to hold the arm in external rotation 00:36:57.760 --> 00:37:00.639 converting to negative after LTT. That's a clear 00:37:00.639 --> 00:37:02.719 demonstration of restoring active control over 00:37:02.719 --> 00:37:05.000 that specific movement. Turning an objective 00:37:05.000 --> 00:37:07.079 sign of dysfunction into a sign of functional 00:37:07.079 --> 00:37:09.900 recovery that really is a powerful outcome. What 00:37:09.900 --> 00:37:11.960 about getting back to work or other activities? 00:37:12.440 --> 00:37:14.380 Studies report quite a high rate of return to 00:37:14.380 --> 00:37:17.199 work, with figures around 67 % mentioned in the 00:37:17.199 --> 00:37:19.920 materials we looked at. Remember, this procedure 00:37:19.920 --> 00:37:23.000 is often aimed at active individuals, so restoring 00:37:23.000 --> 00:37:25.119 their ability to return to their job, even if 00:37:25.119 --> 00:37:28.219 modified initially, is a really key measure of 00:37:28.219 --> 00:37:30.969 success. And what's also quite noteworthy is 00:37:30.969 --> 00:37:33.590 that LTT has shown good effectiveness even in 00:37:33.590 --> 00:37:36.429 more complex situations. For example, when there's 00:37:36.429 --> 00:37:38.829 a tear of the subscapularis at the front as well 00:37:38.829 --> 00:37:41.030 as the poster superior tear, although outcomes 00:37:41.030 --> 00:37:43.269 can be a bit more variable in those multi -tendon 00:37:43.269 --> 00:37:46.030 injuries. It's also shown promising results as 00:37:46.030 --> 00:37:47.989 a salvage option for patients who've had previous 00:37:47.989 --> 00:37:50.690 rotator cuff repairs that have failed. When less 00:37:50.690 --> 00:37:53.389 complex procedures haven't worked, LTT can still 00:37:53.389 --> 00:37:55.579 offer a viable route to improvement. that makes 00:37:55.579 --> 00:37:57.719 it a really valuable tool in the surgeon's toolkit 00:37:57.719 --> 00:37:59.860 for those very challenging situations. It sounds 00:37:59.860 --> 00:38:02.440 like patient satisfaction reflects this. Is it 00:38:02.440 --> 00:38:06.110 generally high? Yes, generally high patient satisfaction 00:38:06.110 --> 00:38:08.570 rates are reported. Some of the series looking 00:38:08.570 --> 00:38:10.929 specifically at the arthroscopic technique mention 00:38:10.929 --> 00:38:14.090 satisfaction levels around 90%, even when including 00:38:14.090 --> 00:38:17.170 those complex revision cases. It suggests that 00:38:17.170 --> 00:38:19.610 despite the complexity of the surgery and the 00:38:19.610 --> 00:38:22.590 undeniably long rehab commitment, patients generally 00:38:22.590 --> 00:38:24.829 perceive a very significant benefit in terms 00:38:24.829 --> 00:38:27.719 of pain relief and improved function. We touched 00:38:27.719 --> 00:38:30.360 on the comparison to the latissimus dorsi transfer 00:38:30.360 --> 00:38:32.840 earlier based on the biomechanics. Are there 00:38:32.840 --> 00:38:35.079 clinical studies directly comparing the actual 00:38:35.079 --> 00:38:37.860 outcomes of LTT versus LD transfer side by side? 00:38:38.219 --> 00:38:40.519 Yes, there are comparative studies emerging. 00:38:41.199 --> 00:38:43.340 The source materials mention one study by Bakes 00:38:43.340 --> 00:38:46.360 and colleagues which actually compared LTT with 00:38:46.360 --> 00:38:49.679 a lower deltoid transfer, or LDT, which is another 00:38:49.679 --> 00:38:52.309 transfer option sometimes considered. While studies 00:38:52.309 --> 00:38:54.789 like that show both procedures can offer significant 00:38:54.789 --> 00:38:57.329 functional improvements compared to the preoperative 00:38:57.329 --> 00:39:00.130 state, they help position LTT relative to other 00:39:00.130 --> 00:39:02.530 techniques. The consistent clinical findings 00:39:02.530 --> 00:39:04.710 of significant improvement and external rotation 00:39:04.710 --> 00:39:07.989 with LTT do seem to strongly support the theoretical 00:39:07.989 --> 00:39:10.489 biomechanical advantages we discussed earlier, 00:39:10.849 --> 00:39:13.309 compared to the known limitations of LD for rotation. 00:39:13.449 --> 00:39:16.510 While we probably still need more large -scale 00:39:16.510 --> 00:39:19.210 head -to -head randomized trials directly comparing 00:39:19.210 --> 00:39:22.409 LTT and LD transfer, particularly the arthroscopic 00:39:22.409 --> 00:39:24.969 versions, the current evidence suggests LTT is 00:39:24.969 --> 00:39:27.389 a very strong contender, especially when restoring 00:39:27.389 --> 00:39:29.530 active external rotation is the primary goal. 00:39:29.650 --> 00:39:31.469 It seems the clinical results are starting to 00:39:31.469 --> 00:39:33.969 align quite nicely with those biomechanical predictions, 00:39:34.050 --> 00:39:36.570 which must be reassuring. Looking ahead then, 00:39:36.670 --> 00:39:39.570 what are the lingering questions? Maybe controversies 00:39:39.570 --> 00:39:42.090 or areas where more research is still needed 00:39:42.090 --> 00:39:45.230 regarding LTT? Well, whilst is promising, there 00:39:45.230 --> 00:39:47.590 are definitely areas still under investigation 00:39:47.590 --> 00:39:50.510 and discussion. That potential for graft stretching 00:39:50.510 --> 00:39:53.469 or creep over the very long term is, as I mentioned, 00:39:53.929 --> 00:39:57.269 a theoretical concern. If the graft were to elongate 00:39:57.269 --> 00:40:00.090 significantly over many years, could it reduce 00:40:00.090 --> 00:40:02.250 the effective tension in the transfer and lead 00:40:02.250 --> 00:40:05.239 to some late decline in function? Some sources 00:40:05.239 --> 00:40:07.480 mention this hasn't been a major cause of actual 00:40:07.480 --> 00:40:10.139 fixation failure in their experience, but the 00:40:10.139 --> 00:40:12.780 subtle long -term clinical implications of gradual 00:40:12.780 --> 00:40:15.199 graft elongation probably need more study. Okay, 00:40:15.340 --> 00:40:17.199 so long -term durability of the graft is one 00:40:17.199 --> 00:40:20.280 area. What else? Another key area is really pinning 00:40:20.280 --> 00:40:23.199 down the long -term outcomes of the newer arthroscopic 00:40:23.199 --> 00:40:25.480 -assisted technique, compared directly against 00:40:25.480 --> 00:40:28.059 the more established open approaches. While the 00:40:28.059 --> 00:40:30.199 arthroscopic method clearly offers benefits like 00:40:30.199 --> 00:40:32.360 less invasiveness and potentially faster initial 00:40:32.360 --> 00:40:35.420 recovery, we really need more robust long -term 00:40:35.420 --> 00:40:38.469 clinical data. Ideally from randomized controlled 00:40:38.469 --> 00:40:40.929 trials comparing things like re -tear or failure 00:40:40.929 --> 00:40:43.769 rates, sustained functional improvement and complication 00:40:43.769 --> 00:40:46.289 rates over say five or ten years or more. Comparing 00:40:46.289 --> 00:40:48.889 it to OpenLTT and maybe other transfers too? 00:40:49.409 --> 00:40:52.309 Exactly. Comparing it rigorously against OpenLTT 00:40:52.309 --> 00:40:54.789 and also against other modern transfer techniques 00:40:54.789 --> 00:40:57.590 like arthroscopic assisted LD transfer. Plus, 00:40:57.889 --> 00:40:59.949 that learning curve associated with the arthroscopic 00:40:59.949 --> 00:41:02.230 technique means outcomes might vary more depending 00:41:02.230 --> 00:41:04.369 on surgeon experience, especially initially. 00:41:04.710 --> 00:41:07.309 So, while the minimally invasive approach is 00:41:07.309 --> 00:41:10.050 very appealing, the full long -term picture, 00:41:10.349 --> 00:41:12.429 and how it stacks up definitively against other 00:41:12.429 --> 00:41:15.050 options, still needs to be completely mapped 00:41:15.050 --> 00:41:17.409 out with more high -quality research. Precisely. 00:41:17.530 --> 00:41:19.429 It's still an evolving field in that respect. 00:41:19.909 --> 00:41:22.030 That being said, the success we have seen with 00:41:22.030 --> 00:41:25.030 LTT so far is attributed, in large part, to the 00:41:25.030 --> 00:41:27.429 fact that it adheres well to those fundamental 00:41:27.429 --> 00:41:30.030 principles of tendon transfer surgery. Wish R. 00:41:30.199 --> 00:41:32.619 Selecting a muscle that is expendable, its removal, 00:41:32.860 --> 00:41:35.179 doesn't cause a major new functional problem, 00:41:35.659 --> 00:41:38.300 ensuring it has similar excursion or travel and 00:41:38.300 --> 00:41:40.780 can be tensioned appropriately, and crucially, 00:41:41.179 --> 00:41:43.179 that it has a similar line of pull to the muscle 00:41:43.179 --> 00:41:45.539 it's replacing, allowing it to perform the desired 00:41:45.539 --> 00:41:48.880 function. LTT seems to score well on these key 00:41:48.880 --> 00:41:51.590 principles for restoring external rotation. That 00:41:51.590 --> 00:41:54.050 adherence to the basic principles provides a 00:41:54.050 --> 00:41:56.110 solid foundation for the procedure, doesn't it? 00:41:56.269 --> 00:41:58.289 It certainly does. This has been a remarkably 00:41:58.289 --> 00:42:01.289 detailed look at quite a complex solution for 00:42:01.289 --> 00:42:04.469 a very difficult clinical problem. Professor 00:42:04.469 --> 00:42:06.690 Imam, as we start to wrap up this deep dive, 00:42:06.909 --> 00:42:08.829 what would you say are the three to five key 00:42:08.829 --> 00:42:10.829 takeaways you'd hope listeners will carry with 00:42:10.829 --> 00:42:13.079 them from our discussion? Okay, I think I'd summarize 00:42:13.079 --> 00:42:15.860 the crucial points like this. First, irreparable 00:42:15.860 --> 00:42:18.780 posterior superior rotator cuff tears are a cause 00:42:18.780 --> 00:42:21.679 of severe functional loss, and LTT is a really 00:42:21.679 --> 00:42:23.679 valuable surgical option, but for a specific 00:42:23.679 --> 00:42:26.440 group, active patients without significant underlying 00:42:26.440 --> 00:42:29.260 arthritis in the joint. Second, the biomechanics 00:42:29.260 --> 00:42:31.980 matter. LTT offers a significant advantage over 00:42:31.980 --> 00:42:34.380 traditional transfers like the latissimus dorsi, 00:42:34.559 --> 00:42:36.880 specifically for restoring active external rotation, 00:42:37.159 --> 00:42:40.039 which is so often the key deficit. Third, patient 00:42:40.039 --> 00:42:42.360 selection is absolutely non -negotiable. You 00:42:42.360 --> 00:42:44.019 have to look carefully at the tear characteristics, 00:42:44.280 --> 00:42:46.599 the arthritis severity thinkamata grade, the 00:42:46.599 --> 00:42:48.960 muscle quality cutalia grade, and the patient's 00:42:48.960 --> 00:42:51.599 activity level and expectations. Getting this 00:42:51.599 --> 00:42:54.440 right is essential for success. Fourth, the surgical 00:42:54.440 --> 00:42:56.909 techniques are evolving. Arthroscopic -assisted 00:42:56.909 --> 00:42:59.590 LTT is less invasive, potentially speeds up early 00:42:59.590 --> 00:43:01.690 recovery, but it nearly always requires that 00:43:01.690 --> 00:43:03.989 graft augmentation, and we still need more long 00:43:03.989 --> 00:43:05.849 -term data to definitively compare it to other 00:43:05.849 --> 00:43:08.889 methods. And finally, fifth, the surgery is only 00:43:08.889 --> 00:43:11.150 half the battle. A structured, committed, multi 00:43:11.150 --> 00:43:14.429 -phase rehabilitation program, the physio, is 00:43:14.429 --> 00:43:16.730 absolutely fundamental to achieving those significant 00:43:16.730 --> 00:43:19.070 improvements in pain, movement, and function 00:43:19.070 --> 00:43:21.980 that we see after LTT. Those are incredibly clear 00:43:21.980 --> 00:43:24.619 and very actionable takeaways. Thank you. It's 00:43:24.619 --> 00:43:26.780 really fascinating to see how surgical innovation 00:43:26.780 --> 00:43:29.079 is tackling these complex shoulder problems. 00:43:29.860 --> 00:43:32.440 And as techniques like this archoscopic assisted 00:43:32.440 --> 00:43:35.079 lower trapezius tendon transfer continue to evolve, 00:43:35.579 --> 00:43:37.989 pushing the boundaries of what we can do. It 00:43:37.989 --> 00:43:39.929 does raise a compelling question, doesn't it? 00:43:40.250 --> 00:43:43.210 How do we ensure equitable access to these highly 00:43:43.210 --> 00:43:46.170 specialized procedures? And perhaps more fundamentally, 00:43:46.630 --> 00:43:49.510 how do we strike that right balance between the 00:43:49.510 --> 00:43:52.670 undeniable appeal of minimal invasiveness and 00:43:52.670 --> 00:43:55.570 the ongoing critical need for robust, long -term 00:43:55.570 --> 00:43:57.929 clinical data to prove sustained effectiveness? 00:43:58.869 --> 00:44:01.300 Definitely a lot to consider there. If you found 00:44:01.300 --> 00:44:03.420 this deep dive insightful, please do take a moment 00:44:03.420 --> 00:44:05.539 to rate and share it with a colleague. It genuinely 00:44:05.539 --> 00:44:08.440 helps us reach more professionals like you. Professor 00:44:08.440 --> 00:44:10.179 Mo 'imam, thank you so much again for sharing 00:44:10.179 --> 00:44:12.420 your expertise and guiding us so clearly through 00:44:12.420 --> 00:44:14.940 the nuances of the lower trapezius tendon transfer 00:44:14.940 --> 00:44:16.900 today. It was my pleasure entirely. Thank you 00:44:16.900 --> 00:44:18.320 for having me on the show. And thank you for 00:44:18.320 --> 00:44:20.500 joining us for this deep dive. We hope you feel 00:44:20.500 --> 00:44:22.780 a little more well informed on this important 00:44:22.780 --> 00:44:24.780 topic in orthopedics. Until next time.