Anterior versus Posterior Transfer of Latissimus Dorsi and Teres Major Tendon in Irreparable Rotator Cuff Tears: A Retrospective Comparative Study

Anterior versus Posterior Transfer of Latissimus Dorsi and Teres Major Tendon in Irreparable Rotator Cuff Tears: A Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anterior versus Posterior Transfer of Latissimus Dorsi and Teres Major Tendon in Irreparable Rotator Cuff Tears: A Retrospective Comparative Study Chang Hee Baek, Chaemoon Lim, Jung Gon Kim, Bo Taek Kim, Seung Jin Kim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5437755/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background: There are various options of tendon transfer according to the different types of irreparable rotator cuff tears (IRCTs). However, there were no clear treatment options for the IRCTs involving the anterior, superior and posterior rotator cuff tears (global IRCTs). Latissimus dorsi and teres major (LDTM) could be transferred anteriorly or posteriorly in global IRCTs. The purpose of this study is to evaluate the efficacy of anterior LDTM (aLDTM) transfer and posterior LDTM (pLDTM) transfer in IRCTs. Methods: The patients who underwent aLDTM transfer (aLDTM group, n=35) for anterosuperior IRCTs or pLDTM transfer (aLDTM group, n=33) for posterosuperior IRCTs between January 2017 and December 2020 were reviewed retrospectively. Clinical and functional outcomes were evaluated based on pain, patient-reported outcome scores, active range of motion (aROM) and strength of aROM. Radiological outcomes were evaluated using arthritic changesin the glenohumeral joint and transferred tendon integrity. Arthritic changes in the glenohumeral joint were evaluated using the acromiohumeral distance (AHD) and Hamada classification on the true anteroposterior radiograph. Results: No significant intergroup difference was confirmed in patient demographics except for preoperative fat infiltration grade of subscapularis and infraspinatus. The postoperative Constant score, and University of California and Los Angeles (UCLA) score of aLDTM group were significantly higher than that of pLDTM group ( p <0.001 and <0.001, respectively). Moreover, the achievement of minimal clinically important difference (MCID) for American Shoulder and Elbow Surgeons score and UCLA score showed a significant difference between two groups ( p =0.021 and 0.042, respectively). The postoperative forward elevation (FE) was significantly higher in aLDTM group ( p = 0.046). The postoperative FE strength and abduction strength were significantly higher in aLDTM group ( p =0.001 and 0.025, respectively). Moreover, the mean improvement of internal rotation strength in aLDTM group was significantly higher than mean improvement of external rotation strength in pLDTM group ( p =0.011). The progression of arthritic change was significantly higher in pLDTM group ( p =0.002). Conclusion: Although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles. Level of study: level III irreparable rotator cuff tears Latissimus dorsi and teres major transfer Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The surgical treatment for irreparable rotator cuff tears (IRCTs) vary according to the patient’s conditions including age, previous activity level, willingness to rehabilitate, presence of osteoarthritis and associated injury.[ 1 ] Reverse shoulder arthroplasty (RSA) may be considered for older patients with glenohumeral arthritic change.[ 2 ] However, joint preserving surgery including arthroscopic debridement, partial repair with/without augmentation, biceps rerouting, superior capsular reconstruction, and subacromial balloon space may be considered for the relatively young patients without arthritic change.[ 3 – 7 ] Recently, tendon transfer has emerged as an excellent treatment for relatively young IRCTs patients without arthritic change.[ 7 ] There are various options of tendon transfer according to the different types of IRCTs. To address the anterosuperior IRCTs (ASIRCTs), the pectoralis major (PM) transfer or anterior latissimus dorsi with/without teres major (LD or LDTM) transfer can be used.[ 8 – 10 ] Recently, middle trapezius tendon transfer (MTT) showed favorable outcomes in isolated superior IRCTs (ISIRCTs).[ 11 ] Moreover, for posterosuperior IRCTs (PSIRCTS), posterior latissimus dorsi with/without teres major (LD or LDTM) transfer or lower trapezius tendon transfer (LTT) has been well known for good treatment options.[ 12 – 14 ] However, there were no clear treatment options for the IRCTs involving the anterior, superior and posterior rotator cuff tears (global IRCTs). Among various tendon transfers for IRCTs, LD or LDTM transfer could be used for addressing ASIRCTs or PSIRCTs.[ 9 , 10 , 12 , 13 ] In ASIRCTs, the anterior LDTM (aLDTM) transfer showed a more favorable outcome when compared to anterior LD transfer due to its biomechanical effectiveness.[ 15 ] Moreover, the posterior LDTM (pLDTM) transfer could provide a stronger tendon unit and external rotation strength than that of posterior LD transfer.[ 16 ] According to this point of view, the LDTM could be transferred anteriorly or posteriorly in global IRCTs. However, there was no study for evaluating the efficacy of aLDTM transfer and pLDTM transfer in IRCTs. The purpose of this study is to evaluate the efficacy of aLDTM transfer and pLDTM transfer in IRCTs. We hypothesize that although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles. Material and Methods This study was approved by the Institutional Review Board (ethics committee) of the Ministry of Health and Welfare (IRB No. P01-202411-01-005). The institutional review board permitted this study and exempted the necessity for informed consent because this study was performed retrospectively. Patient population The patients who underwent aLDTM transfer for ASIRCTs or pLDTM transfer for PSIRCTs between January 2017 and December 2020 were reviewed retrospectively. The diagnostic criteria for ASIRCTs were as follows: (1) massive anteroposterior rotator cuff tears (combined subscapularis [SSC] and supraspinatus [SSP]), (2) severe medial retraction and shortening of the tendons corresponding to Patte[ 17 ] stage III on magnetic resonance imaging (MRI), (3) high-grade fatty infiltration in SSC and SSP (Goutallier[ 18 ] fatty infiltration grade [FI] of 3 or 4), and (4) intact or reparable infraspinatus (ISP) and teres minor tendon with Goutallier FI grade of 1 or 2 on MRI. The indication for aLDTM transfer were as follows: (1) symptomatic ASIRCT or isolated supraspinatus IRCTs (ISIRCTs) presenting with severe shoulder pain and dysfunction that interferes with daily activities, (2) failure of conservative treatment, (3) little or no advanced arthritis in the shoulder joint (Hamada classification grade I or II), and (4) no neurologic deficits or infectious diseases. The patients who were ISIRCTs (n = 31), were lost to follow-up at 2 years (n = 4) or had incomplete clinical data (n = 13) were excluded. Finally, 35 patients who underwent aLDTM transfer (aLDTM group) were enrolled for the study population. The diagnostic criteria for PSIRCTs were as follows: (1) massive posterosuperior rotator cuff (combined SSP and ISP) tears, (2) severe medial retraction and shortening of the tendons corresponding to Patte classification III on MRI, (3) high-grade fat infiltration in SSP and ISP (Goutallier FI grade of 3 or 4), and (4) intact or reparable SSC with Goutallier FI grade of 1or 2 on MRI. The indication for pLDTM transfer were as follows: (1) symptomatic PSIRCT with severe pain and/or shoulder dysfunction that disturbs daily activity, (2) failed conservative treatment, (3) little or no progressive arthritic change in the shoulder joint (Hamada grade I or II), and (4) no neurologic deficits or infectious diseases. The patients who were lost to follow-up at 2 years (n = 4) or had incomplete clinical data (n = 13) were excluded. Finally, 31 patients who underwent posterior LDTM transfer (pLDTM group) were enrolled for the study population. Surgical technique A single experienced surgeon (C.H.B) performed all the operations for this study period. Anterior Latissimus Dorsi and Teres Major Transfer The patient was placed in the beach chair position under general anesthesia. The SSC and SSP tendons were assessed during diagnostic arthroscopic examination. When the SSC and SSP could not be reduced to its footprint area, the tendons were considered irreparable. If the ISP tendon is torn and reparable, the ISP is repaired using the double-row suture bridge technique. The long head of biceps tendon (LHBT) was managed with debridement, tenotomy or tenodesis according to the biceps pathology. After confirming the ASIRCTs, the LD and teres major (TM) tendon were harvested. Using standard deltopectoral approach, pectoralis major muscle was identified and released to provide adequate excursion of the LD and TM tendons. Anterior humeral circumflex vessels (“the three sisters”) and radial nerve were identified and carefully preserved. The LD and TM tendon was harvested in a periosteal manner without separating the individual tendons (Fig. 1 ). A traction suture was made at the end of the harvested LD and TM tendon using non-absorbable suture material and the Krakow method. The LD and TM muscle were bluntly released from surrounding adhesions to make further mobilization and excursion. A triple-loaded suture anchor was placed just lateral to the bicipital groove and 2 ~ 3cm distal to the great tuberosity (GT). The six threads of the anchor passed the end of the harvested LDTM tendon. Each passed thread was tied with the full IR and 45° abduction of arm to ensure physiological tension. The combined LDTM tendon was attached just lateral to the biceps groove and distal to the lateral edge of the GT using three lateral anchors. Fixing the combined tendon just distal to the GT positioned the tendon diagonally and more tautly, achieving tendon tensioning and avoiding axillary nerve impingement (Fig. 2 ). After the operation, patients were applied with an abduction brace for six weeks. Scapular stabilization exercises, pendulum exercises, and elbow exercise were only permitted for this period. After then, the patient started to perform passive range of motion (ROM) exercises for 4 weeks. The patient was encouraged to perform active ROM and strength exercises after restoring passive ROM. After three postoperative months, the patient progressed to full ROM and gentle strengthening exercises. Posterior Latissimus Dorsi and Teres Major Transfer Patients were placed in the lateral decubitus position under general anesthesia. The SSP and ISP tendons were assessed during diagnostic arthroscopic examination. When the SSP and ISP could not be reduced to its footprint area, the tendons were considered irreparable. If the SSC tendon is torn and reparable, the SSC is repaired using the double-row suture bridge technique. The LHBT was managed with debridement, tenotomy or tenodesis according to the biceps pathology. After confirming PSIRCTs, the interval between the remaining posterior rotator cuff (ISP and teres minor [Tm]) and the deltoid was secured. A urinary catheter was inserted from the posterolateral portal to this interval and the balloon of the urinary catheter was inflated to generate a passage for the LDTM. To harvest the LD and TM tendon, the arm was flexed, internally rotated, and abducted. An L-shaped skin incision was made along the anterior belly of the LD and posterior axillary line. Anterior humeral circumflex vessels (“the three sisters”) and radial nerve were identified and carefully preserved. The LD and TM tendon was harvested in a periosteal manner without separating the individual tendons (Fig. 3 ). A traction suture was made at the end of the harvested LD and TM tendon using non-absorbable suture material and the Krakow method. The LD and TM muscle were bluntly released from surrounding adhesions to make further mobilization and excursion. The inflated balloon extruded at the interval between the teres minor and the deltoid. Sutures attached to the LDTM tendon were connected to the inflated balloon of the urinary catheter. Then the urinary catheter was pulled and the LDTM tendon was inserted into the subacromial space (Fig. 4 ), the LDTM tendon was located to the SSP footprint and immediately posterior to the bicep groove under arthroscopy. Then, the LDTM tendon was attached to the SSP footprint with maximum external rotation of arm (Fig. 5 ). After the operation, patients were applied with an abduction brace for six weeks. Scapular stabilization exercises, pendulum exercises, and elbow exercise were only permitted for this period. After then, the patient started to perform passive range of motion (ROM) exercises for 4 weeks. The patient was encouraged to perform active ROM and strength exercises after restoring passive ROM. After three postoperative months, the patient progressed to full ROM and gentle strengthening exercises. Clinical evaluation Clinical and functional outcomes were evaluated based on pain, patient-reported outcome scores, active range of motion (aROM) and strength of aROM. Shoulder pain was evaluated using a visual analog scale (VAS). The patient-reported outcome scores included the Constant Score, American Shoulder and Elbow Surgeons (ASES) score, and University of California and Los Angeles (UCLA) score. The minimal clinically important difference (MCID) of the Constant, ASES, and UCLA scores reflected the smallest change in a clinical outcome that a patient would identify as important. The MCIDs of the Constant, ASES, and UCLA scores were 10.4, 15.2, and 3.5, respectively. The aROM of the shoulder including forward elevation (FE), abduction (ABD), external rotation (ER) at 0° ABD was evaluated using a standard goniometer. The internal rotation (IR) at the back was measured as the level that could be reached with a thumb when the patient rotated the arm behind the back (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; 10, T7). The strength of aROM was measured objectively with a hand-held dynamometer. Patients were positioned supine with shoulder 45° ABD and elbow 90° FE for measuring measure IR and ER strength. The FE strength and ABD strength were measured in the position of 90° FE and 90° ABD, respectively. The dynamometer was placed on the volar and dorsal aspects of the wrist. All clinical and functional outcomes were evaluated preoperatively and at prespecified postoperative time-points. The preoperative clinical status was compared with the clinical outcomes evaluated during the last follow-up period. Radiologic evaluation Arthritic changes of the shoulder joint and transferred tendon integrity were evaluated for radiological outcomes. Acromiohumeral distance (AHD) and Hamada classification were measured for evaluating the arthritic changes of the shoulder joint on the true anteroposterior radiograph (Grashey[ 19 ] view). If the Hamada grade is 3, 4, or 5 at the last follow-up, it is considered as a progression of arthritic changes. Preoperative and postoperative plain radiography were evaluated at each follow-up visit. Transferred tendon integrity was assessed with Sugaya[ 20 ] classification on MRI. Although the Sugaya classification was made for evaluating the integrity of repaired rotator cuff tendon, any discontinuity of the transferred tendon (Sugaya classification IV and V) was considered a transferred tendon retear. Any signal change or small gap in the transferred tendon was not considered a transferred tendon retear. Postoperative MRIs were obtained at 1 week, 6 months, and 1 year after surgery, and every year thereafter. The preoperative radiologic status was compared with the radiologic outcomes evaluated during the last follow-up period. Statistical analysis Statistical Package for the Social Science (SPSS) (version 21.0; IBM Corp., Armonk, NY, USA) were used for analyses with the level of significance at 95%. The Nonparametric Wilcoxon signed-rank test was used for analysis of preoperative and postoperative continuous data. McNemar’s test was used for analysis of preoperative and postoperative categorical data. The Nonparametric Mann–Whitney test was used for analysis of continuous data of clinical and radiological outcomes between two groups. Fisher’s exact test was used for analysis of categorical data of clinical and radiological outcomes between two groups. Inter-observer reliability of AHD and Hamada grade was assessed using the intraclass correlation coefficient. Preoperative and last follow-up AHD and Hamada grade were evaluated using the inter-observer reliability by two authors.[ 21 ] Results No significant intergroup difference was confirmed in patient demographics, underlying diseases, previous cuff repair, biceps management, and follow-up periods. However, preoperative FI grade of SSC and ISP were significantly different due to the difference between ASIRCTs and PSIRCTs (Table 1 ). Significant improvement in the VAS score and patients-reported clinical scores was observed in both groups. The postoperative Constant score and UCLA score of aLDTM group were significantly higher than that of pLDTM group ( p < 0.001 and < 0.001, respectively). Moreover, the achievement of MCID for ASES score and UCLA score showed a significant difference between two groups ( p = 0.021 and 0.042, respectively) (Table 2 ). In both groups, the FE and ABD were significantly improved postoperatively. The postoperative FE of aLDTM group was significantly higher than that of pLDTM group ( p = 0.046). Although all patients with preoperative pseudoparalysis in aLDTM groups showed improvements, only one patient with preoperative pseudoparalysis in pLDTM groups showed improvement (Table 3 ). In both groups, the FE strength and ABD strength were significantly improved postoperatively. The postoperative FE strength and ABD strength of aLDTM group were significantly higher than that of pLDTM group ( p = 0.001 and 0.025, respectively). (Tabe 4). However, the mean improvement of IR strength in aLDTM group was significantly higher than mean improvement of ER strength in pLDTM group (7.2 ± 4.5 vs 4.6 ± 4.2, p = 0.011). Regarding radiologic outcomes, although AHD significantly decreased postoperatively in both groups, there was no significant difference in postoperative AHD between the two groups. However, postoperative Hamada grade was significantly different between the two groups ( p = 0.005). The rate of progression of arthritic change was significantly higher in pLDTM group ( p = 0.002). (Table 5 ). The intra- and interobserver reliabilities for preoperative and postoperative AHD were excellent. As a postoperative complication, two patients of aLDTM group and one patient of pLDTM showed temporary axillary nerve palsy, which recovered after 3 months. One patient of pLDTM group was diagnosed with a postoperative infection, and these were successfully treated with arthroscopic debridement and antibiotics. Table 1 Demographic and clinical characteristics Variables aLDTM Group pLDTM Group p Number of patients 35 33 Age, mean ± SD, yr 66.3 ± 5.7 63.5 ± 4.6 0.710 Female, % 16 (45.7) 16 (48.5) 0.894 BMI, mean ± SD, kg/m 2 24.0 ± 1.8 23.8 ± 2.0 0.429 Arm dominance, n (%) 34 (97.1) 31 (93.9) 0.191 Smoking, n (%) 4 (11.4) 4 (15.4) 0.507 Diabetes mellitus, n (%) 7 (20.0) 5 (19.2) 0.307 Hypertension, n (%) 14 (40.0) 11 (42.3) 1.000 Preop-Hamada grade, n (%) 1.000 - Grade 1 32 (91.4) 30 (90.9) - Grade 2 3 (8.6) 3 (8.1) SSC FI grade, n (%) < 0.001 - Grade 1 - 24 (72.7) - Grade 2 - 9 (27.3) - Grade 3 11 (31.4) - - Grade 4 24 (68.6) - SSP FI grade, n (%) 0.507 - Grade 3 22 (62.9) 20 (60.6) - Grade 4 13 (37.1) 13 (39.4) ISP FI grade, n (%) < 0.001 - Grade 1 26 (74.3) - - Grade 2 9 (25.7) - - Grade 3 - 14 (42.4) - Grade 4 - 19 (57.6) Tm FI grade, n (%) - Grade 1 31 (88.6) 28 (84.8) 0.237 - Grade 2 3 (8.6) 3 (9.1) - Grade 3 1 (2.8) 2 (6.1) - Grade 4 - Management of biceps, n (%) 0.053 - No management 5 - Auto-tenotomy 12 4 - Tenotomy 2 3 - Tenodesis 21 21 Pseudoparalysis 6 (17.1) 5 (15.2) 1.000 Mean f/u period, months (range) 49.0 ± 9.6 46.5 ± 8.4 0.879 *Significant p-value is < 0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; SD, standard deviation; BMI, body mass index; FI, fat infiltration; SSC, subscapularis; SSP, supraspinatus; ISP, infraspinatus; Tm, teres minor; f/u, follow up Table 2 Comparisons in pain and patient-reported clinical score between two groups Variables aLDTM Group pLDTM Group p VAS score Preoperative 4.7 ± 1.1 4.9 ± 1.1 0.436 Postoperative 1.5 ± 0.9 1.9 ± 1.0 0.070 P < 0.001 < 0.001 Constant score Preoperative 48.2 ± 5.9 48.4 ± 7.8 0.078 Postoperative 69.2 ± 8.2 62.9 ± 13.6 < 0.001 P < 0.001 < 0.001 ASES score Preoperative 50.2 ± 7.7 53.0 ± 7.1 0.176 Postoperative 77.3 ± 11.6 72.1 ± 13.5 0.094 P < 0.001 < 0.001 UCLA Preoperative 14.5 ± 3.0 13.0 ± 3.0 0.073 Postoperative 25.8 ± 5.0 21.1 ± 6.8 < 0.001 P < 0.001 < 0.001 MCID for Constant, n (%) 0.128 Success 32 (85.7%) 24 (72.7%) Failure 3 (14.3%) 9 (27.3%) MCID for ASES, n (%) 0.021 Success 33 (88.6%) 24 (72.7%) Failure 2 (11.4%) 9 (27.3%) MCID for UCLA, n (%) 0.042 Success 33 (88.6%) 25 (75.8%) Failure 2 (11.4%) 8 (24.2%) *Significant p-value is < 0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; VAS, Visual Analogue Scale; ASES, American Shoulder and Elbow Surgeons; MCID, minimal clinically important difference Table 3 Comparisons in active range of motion between two groups Variables aLDTM Group pLDTM Group p Active FE, ˚ Preoperative 101.4 ± 18.7 106.9 ± 18.6 0.213 Postoperative 158.0 ± 20.8 140.9 ± 34.9 0.046 P < 0.001 < 0.001 ABD, ˚ Preoperative 85.9 ± 14.4 82.6 ± 18.0 0.414 Postoperative 133.1 ± 16.4 120.6 ± 29.1 0.870 P < 0.001 < 0.001 ER at 0˚ of abduction, ˚ Preoperative 42.6 ± 9.2 23.2 ± 10.8 < 0.001 Postoperative 44.1 ± 9.2 36.8 ± 8.5 0.018 P 0.840 < 0.001 IR at back Preoperative 2.9 ± 1.9 5.6 ± 2.4 < 0.001 Postoperative 6.7 ± 2.0 5.8 ± 1.5 0.040 P < 0.001 0.670 Pseudoparalysis, n (%) Preoperative 6 (17.1) 5 (15.2) 1.000 Postoperative 0 (0.0) 4 (12.1) 0.049 P < 0.001 0.845 *Significant p-value is < 0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; VAS, Visual Analogue Scale; ASES, American Shoulder and Elbow Surgeons; ADLER, activities of daily living requiring active external rotation; FE, forward elevation; ABD, abduction; ER, external rotation; IR, internal rotation Table 4 Comparisons in strength between the two surgical groups Variables aLDTM Group pLDTM Group p FE strength, N Preoperative 16.8 ± 3.7 16.2 ± 2.4 0.496 Postoperative 28.4 ± 5.9 23.5 ± 6.1 0.001 P < 0.001 < 0.001 ABD strength, N Preoperative 14.3 ± 3.3 14.9 ± 2.1 0.515 Postoperative 24.2 ± 4.8 21.2 ± 5.4 0.025 P < 0.001 < 0.001 ER strength, N Preoperative 21.2 ± 5.1 15.3 ± 2.1 < 0.001 Postoperative 21.8 ± 5.1 22.9 ± 4.7 0.569 P 0.310 < 0.001 IR strength, N Preoperative 13.6 ± 3.1 22.4 ± 2.9 < 0.001 Postoperative 26.9 ± 4.5 22.9 ± 2.8 < 0.001 P < 0.001 0.180 *Significant p-value is < 0.05; LDTM, latissimus dorsi and teres major; FE, forward elevation; ABD, abduction; ER, external rotation; IR, internal rotation Table 5 Radiologic outcome between the two surgical groups Variables aLDTM Group pLDTM Group p AHD (mm) Preoperative 8.4 ± 1.8 8.5 ± 2.6 0.096 Postoperative 7.6 ± 1.7 6.4 ± 3.4 0.144 P 0.009 0.003 Postop-Hamada grade, n (%) 0.005 - Grade 1 25 (71.4) 16 (48.5) - Grade 2 8 (21.1) 9 (27.3) - Grade 3 - 6 (18.2) - Grade 4 - 2 (6.0) Progression of arthritic change, n (%) 0 (0.0) 8 (24.2) 0.002 Transferred tendon re-tear, n (%) 2 (6.1) 3 (9.1) 0.693 *Significant p-value is < 0.05; SD, standard deviation; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; AHD, acromiohumeral distance Discussion To our knowledge, this study is the first to evaluate the efficacy of aLDTM transfer and pLDTM transfer in IRCTs. Significant improvement in clinical outcomes was observed in both groups. However, the mean improvements in Constant, ASES, UCLA scores, FE, and ABD were significantly better in aLDTM group than those of pLDTM group. Although the IR strength was significantly improved postoperatively in aLDTM group, the ERstrength was not significantly improved postoperatively in pLDTM group. Moreover, OA progression was significantly higher in pLDTM group, and graft retear was significantly higher in pLDTM group. As a result, although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer in terms of clinical and radiologic outcomes. aLDTM transfer has emerged as an excellent treatment for ASIRCTs patients without arthritic change.[ 10 ] Recently, aLDTM transfer showed good clinical and radiologic outcomes in short-term clinical study for ASIRCTs patient without arthritic change.[ 10 ] In comparative clinical study on RSA versus RSA combined aLDTM transfer, RSA combined aLDTM transfer was superior in terms of IR at back and IR strength to that of RSA.[ 22 ] Traditionally, LD transfer has been used for the treatment of ASIRCTs.[ 23 ] However, aLDTM transfer is better at restoring the force couple in both the coronal and transverse plane of shoulder joint.[ 15 ] First, the aLDTM transfer contributes to the recovery of coronal force couple and superior stability by playing the role of humeral head depressor.[ 10 ] It was confirmed that the transferred LD plays the role of humeral head depressor during ABD, and the transferred TM also acts as a humeral head depressor due to its scapular origin in biomechanical study.[ 24 ] The transferred LDTM has been proven to have an effect of superior stabilizers and depressor of shoulder joint in computed remodeling study.[ 25 ] Moreover, in a cadaveric study, aLDTM transfer showed a significant decrease of superior translation for all shoulder positions in ASIRCTs.[ 26 ] Second, the aLDTM transfer contributes to the recovery of transverse force couple and anterior stability by playing the role of counterpart for posterior rotator cuff muscles.[ 15 ] These biomechanical advantages of aLDTM transfer may lead to good clinical outcome in ASIRCTs. Traditionally, posterior LDTM transfer was performed in patients with isolated loss of active external rotation as a modified L’Episcopo technique.[ 27 ] In modified L’Episcopo technique, the LDTM was attached posterolateral aspect of humerus to restore the horizontal imbalance due to the deficiency of ISP and Tm. Modified L’Episcopo improved only the active external rotation.[ 28 ] However, in this study, the LDTM was attached to the SSP footprint and positioned immediately posterior to the bicep groove to restore the force couple in both the coronal and transverse plane. This technique improved the active forward elevation and external rotation in PSIRCTs patients. Although there was no biomechanical study, we thought that the posteriorly transferred LDTM may improve ER and restore transverse force couple by replacing posterior rotator cuff. In addition, pLDTM transfer also may improve FE and restore superior stability by functioning the role of humeral head depressor. These biomechanical advantages of pLDTM transfer provide favorable clinical outcomes in PSIRCTs. However, the line of pull of pLDTM transfer works posterior and inferior vector compared to the vertical force of normal ISP.[ 29 ] The transferred LDTM tendon does not have an in-phase contraction during ER because the LD and TM are originally internal rotators.[ 30 ] These biomechanical disadvantages of pLDTM transfer may cause progression of arthritic changes in the glenohumeral joint. However, the clinical and biomechanical study on pLDTM in PSIRCTs are needed. To our knowledge, there are no biomechanical or clinical studies comparing aLDTM transfer and pLDTM transfer in IRCTs. Although the patient population of two groups were different in FI grade, this study is meaningful as a first clinical study comparing aLDTM transfer and pLDTM transfer because LDTM could be transferred anteriorly or posteriorly in global IRCTs. As a result of this study, we speculated that aLDTM transfer may be more effective than pLDTM transfer in terms of clinical and radiologic outcomes due to biomechanical advantage of aLDTM transfer. A similar line of pull of aLDTM with that of SSC may effectively restore transverse force couple and anterior stability.[ 26 ] The transferred LDTM tendon has an in-phase contraction during IR because the LDTM tendon is originally an internal rotator.[ 30 ] The excursion of anteriorly transferred LDTM was enough to be attached to the lateral edge of the GT than the LT or the SSC footprint. This attachment resulted in a tensioning effect of aLDTM, which may facilitate the restoration of superior stability.[ 10 ] With this biomechanical advantage, aLDTM may restore effectively the force couple and stability of shoulder joint. As a result, aLDTM transfer not only has good clinical and radiologic outcomes, but also has fewer progression of arthritic change. This study has several limitations. The most important limitation of this study was that the FI grade of preoperative rotator cuff was different between the two groups. However, it is not possible to compare aLDTM and pLDTM in the same patient population due to the different surgical indication of aLDTM transfer and pLDTM transfer. In the future, study comparing aLDTM and pLDTM in global IRCTs is needed. Moreover, comparing the clinical and radiologic outcome of the two groups may be a limitation because the main purpose of aLDTM is restoration of the anterior rotator cuff, and pLDTM is restoration of the posterior rotator cuff. However, since both aLDTM transfer and pLDTM transfer are aimed at restoration of transverse and coronal plane force couple of glenohumeral joint, it will be reasonable to compare the shoulder pain, patient-reported clinical score, FE, ABD, and radiologic outcomes except for IR and ER. Nonetheless, this study is meaningful as a first clinical study comparing aLDTM transfer and pLDTM transfer because LDTM could be transferred anteriorly or posteriorly in global IRCTs. Moreover, this study will provide useful information to shoulder surgeons when choosing aLDTM or pLDTM in global IRCTs. The relatively small study population and short study periods may limit the study’s validity for clinical practice. In the future, a randomized clinical trials study with a large population and long-term follow-up period is needed. Conclusion Although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles. Abbreviations ABD abduction ASES American Shoulder and Elbow Surgeons aLDTM anterior LDTM ASIRCTs anterosuperior IRCTs AHD acromiohumeral distance aROM active range of motion ER external rotation FE forward elevation GT great tuberosity ISP infraspinatus IR internal rotation IRCTs irreparable rotator cuff tears ISIRCTs isolated superior IRCTs LD latissimus dorsi LDTM latissimus dorsi and teres major LHBT long head of biceps tendon LTT lower trapezius tendon transfer MRI magnetic resonance imaging MTT middle trapezius tendon transfer MCID minimal clinically important difference PM pectoralis major pLDTM posterior LDTM PSIRCTS posterosuperior IRCTs RSA reverse shoulder arthroplasty SPSS Statistical Package for the Social Science SSC subscapularis SSP supraspinatus TM teres major Tm teres minor UCLA University of California, Los Angeles VAS visual analog scale Declarations Ethical approval and consent to participate This study was approved by the Institutional Review Board (ethics committee) of the Ministry of Health and Welfare (IRB No. P01-202411-01-005). The institutional review board permitted this study and exempted the necessity for informed consent because this study was performed retrospectively. Consent for publication Not applicable Availability of data and materials Not applicable Competing interests The authors declare no financial conflict of interest regarding the content of this paper. Funding Not applicable Author contributions Conceptualization: CHB; Methodology: CHB, CL; Formal analysis and investigation: SJK; Writing - original draft preparation: CL; Writing - review and editing: JGK, BTK; Supervision: CHB Acknowledgments None. References Saremi H, Amini M, Seifrabiei M. Comparison of Anterior and Posterior Transfer of Latissimus Dorsi Tendon to Humeral Head in Patients with Massive and Irreparable Rotator Cuff Tear. Arch Bone Jt Surg. 2023;11(4):236. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Researc. 2010;468:1526–33. Kovacevic D, Suriani RJ Jr, Grawe BM, Yian EH, Gilotra MN, Hasan SA, et al. Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response. J Shoulder Elb Surg. 2020;29(12):2459–75. Kim Y-S, Lee H-J, Park I, Sung GY, Kim D-J, Kim J-H. Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon. Arthrosco tech. 2018;7(2):e97–103. Mihata T, Lee TQ, Hasegawa A, Fukunishi K, Kawakami T, Fujisawa Y, et al. Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears: comparison of clinical outcomes with and without subscapularis tear. Am J Sports Med. 2020;48(14):3429–38. Vecchini E, Gulmini M, Peluso A, Fasoli G, Anselmi A, Maluta T et al. The treatment of irreparable massive rotator cuff tears with inspace balloon: rational and medium-term results. Acta Bio Med. 2021;92(Suppl 3). Elhassan BT, Wagner ER. Outcome of transfer of the sternal head of the pectoralis major with its bone insertion to the scapula to manage scapular winging. J Shoulder Elb Surg. 2015;24(5):733–40. 10.1016/j.jse.2014.08.022 . Burnier M, Lafosse T. Pectoralis major and anterior latissimus dorsi transfer for subscapularis tears. Curr Rev Musculoskelet Med. 2020;13:725–33. Mun SW, Kim JY, Yi SH, Baek CH. Latissimus dorsi transfer for irreparable subscapularis tendon tears. J Shoulder Elb Surg. 2018;27(6):1057–64. Baek CH, Kim JG, Baek GR. Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears. J Shoulder Elb Surg. 2022;31(11):2298–307. Baek CH, Kim JG. Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up. Arch Ortho Trauma Surg. 2023;143(5):2547–56. Gerber C, Vinh TS, Hertel R, HESS CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff a preliminary report. Clin Orthop Relat Res. 1988;232:51–61. Lichtenberg S, Magosch P, Habermeyer P. Are there advantages of the combined latissimus-dorsi transfer according to L’Episcopo compared to the isolated latissimus-dorsi transfer according to Herzberg after a mean follow-up of 6 years? A matched-pair analysis. J Shoulder Elb surg. 2012;21(11):1499–507. Elhassan BT, Sanchez-Sotelo J, Wagner ER. Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. J Shoulder Elb Surg. 2020;29(10):2135–42. 10.1016/j.jse.2020.02.018 . Baek CH, Kim JG, Kim BT, Kim SJ. Isolated Latissimus Dorsi Transfer versus Combined Latissimus Dorsi and Teres Major Tendon Transfer for Irreparable Anterosuperior Rotator Cuff Tears. Clin Orthop Surg. 2024;16(5):761. Boileau P, Chuinard C, Roussanne Y, Neyton L, Trojani C. Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty. J Shoulder Elb Surg. 2007;16(6):671–82. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990;254:81–6. Goutallier D, Postel J-M, Bernageau J, Lavau L, Voisin M-C. Fatty muscle degeneration in cuff ruptures: pre-and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83. Koh KH, Han KY, Yoon YC, Lee SW, Yoo JC. True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear. J Shoulder Elb Surg. 2013;22(7):901–7. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953–60. Landis JR, Koch GG. The measurement of observer agreement for categorical data. J biometrics. 1977:159–74. Baek CH, Kim JG, Baek GR. Restoration of active internal rotation following reverse shoulder arthroplasty: anterior latissimus dorsi and teres major combined transfer. J Shoulder Elb Surg. 2022;31(6):1154–65. Kany J, Guinand R, Croutzet P, Valenti P, Werthel JD, Grimberg J. Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency. Eur J Ortho Surg Traumatol. 2016;26:329–34. Halder A, Zhao K, O'driscoll S, Morrey B, An K. Dynamic contributions to superior shoulder stability. J Orthop Res. 2001;19(2):206–12. Mulla DM, Hodder JN, Maly MR, Lyons JL, Keir PJ. Glenohumeral stabilizing roles of the scapulohumeral muscles: implications of muscle geometry. J Biomech. 2020;100:109589. Baek GR, Kim JG, Kwak D, Nakla AP, Chung M-S, McGarry MH, et al. Biomechanical comparison of combined latissimus dorsi and teres major tendon transfer vs. latissimus dorsi tendon transfer in shoulders with irreparable anterosuperior rotator cuff tears. J Shoulder Elb Surg. 2023;32(4):703–12. Boileau P, Baba M, McClelland WB Jr, Thélu C-É, Trojani C, Bronsard N. Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer. J Shoulder Elb Surg. 2018;27(3):499–509. Gerhardt C, Lehmann L, Lichtenberg S, Magosch P, Habermeyer P. Modified l’episcopo tendon transfers for irreparable rotator cuff tears: 5-year followup. Clini Orthop Relat Res. 2010;468:1572–7. Omid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21(8):492–501. 10.5435/JAAOS-21-08-492 . Checchia CS, Silva LAD, Sella GDV, Fregoneze M, Miyazaki AN. Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears. Rev Bras Ortop (Sao Paulo). 2021;56(3):281–90. 10.1055/s-0040-1709988 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Dec, 2024 Reviews received at journal 08 Dec, 2024 Reviewers agreed at journal 24 Nov, 2024 Reviewers agreed at journal 19 Nov, 2024 Reviewers invited by journal 19 Nov, 2024 Editor assigned by journal 14 Nov, 2024 Submission checks completed at journal 14 Nov, 2024 First submitted to journal 12 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5437755","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":387617497,"identity":"ff817d5d-cac5-4d99-8f3f-674a81ad0ae8","order_by":0,"name":"Chang Hee Baek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYLACxgYGBgl2IMFgYEGKFp4DIC0SpGiRSAAxidBicLz58GfeHXZykjOfX93wo0CCgb+9OwG/ljPH0qR5zyQbS0vnlN3sATpM4szZDfi13MgxY+ZtY06cJ52TdoMHqMVAIpeAlvtvjD/zttXXz5M8k3bzD1FagCZL87YdTpCWYD92myhbgGanSc49c9xwZk8O220ZAwkegn7hO3748Ie3O6rlJY4ff3bzzR8bOf72XvxaFA7AmTwGYBKvchCQb4Az2R8QVD0KRsEoGAUjEwAAe5BITc+HsjMAAAAASUVORK5CYII=","orcid":"","institution":"Department of Orthopaedic Surgery, Yeosu Baek Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chang","middleName":"Hee","lastName":"Baek","suffix":""},{"id":387617498,"identity":"36c2c5e2-d0ef-4bab-a46b-5345daf40483","order_by":1,"name":"Chaemoon Lim","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chaemoon","middleName":"","lastName":"Lim","suffix":""},{"id":387617499,"identity":"08409cdc-c880-4544-aca6-27823fcd9236","order_by":2,"name":"Jung Gon Kim","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jung","middleName":"Gon","lastName":"Kim","suffix":""},{"id":387617500,"identity":"ec046854-d96d-49e2-b783-5d2669700047","order_by":3,"name":"Bo Taek Kim","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"Taek","lastName":"Kim","suffix":""},{"id":387617501,"identity":"32414b4c-7927-41eb-b6b9-6e9bb5c7c817","order_by":4,"name":"Seung Jin Kim","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Jin","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-11-12 08:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5437755/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5437755/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71740548,"identity":"1297823c-5ae0-4886-8ee7-eb0ee5c72379","added_by":"auto","created_at":"2024-12-18 08:08:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31154792,"visible":true,"origin":"","legend":"\u003cp\u003eHarvest of\u003cstrong\u003e \u003c/strong\u003eLDTM tendon for aLDTM transfer. The latissimus dorsi and teres major tendon (asterisk) was harvested from the insertion in a periosteal manner without separating the individual tendons. LDTM; latissimus dorsi and teres major, aLDTM; anterior LDTM\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/1d1d5d293c0b57b96eef5e97.png"},{"id":71741643,"identity":"92a28005-03ec-4dd0-916f-7e59bb1b9c23","added_by":"auto","created_at":"2024-12-18 08:16:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26145776,"visible":true,"origin":"","legend":"\u003cp\u003eFixation of aLDTM transfer. The latissimus dorsi and teres major (LDTM, asterisk) tendon was attached just lateral to the biceps groove and distal to the lateral edge of the greater tuberosity (GT). Fixing theLDTM tendon just distal to the GT positioned the tendon diagonally and more tautly, achieving tendon tensioning and avoiding axillary nerve impingement. aLDTM; anterior LDTM, GT; greater tuberosity, BG; biceps groove, LT; lesser tuberosity\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/a7e21b4b8187fcc784c0a9b9.png"},{"id":71741644,"identity":"006296bf-5ddd-4843-a82a-cccee5ccb5ea","added_by":"auto","created_at":"2024-12-18 08:16:06","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":14851797,"visible":true,"origin":"","legend":"\u003cp\u003eHarvest of\u003cstrong\u003e \u003c/strong\u003eLDTM tendon for pLDTM transfer. The latissimus dorsi and teres major tendon (asterisk) was harvested from the insertion in a periosteal manner without separating the individual tendons. LDTM; latissimus dorsi and teres major, pLDTM; posterior LDTM\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/b342fe7a5e4fa0d30fc9e367.png"},{"id":71740544,"identity":"0c5893ca-3bec-481d-82b0-d7a63fa479d2","added_by":"auto","created_at":"2024-12-18 08:08:05","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":11888678,"visible":true,"origin":"","legend":"\u003cp\u003eIntroducing atissimus dorsi and teres major tendon into the subacromial space. The latissimus dorsi and teres major tendon (asterisk) were introduced into the subacromial space using the inflated balloon of the urinary catheter.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/e42f36db57f244f16cbd0cbb.png"},{"id":71740545,"identity":"f953b96f-6497-4e80-85c8-9f206dcdfa2b","added_by":"auto","created_at":"2024-12-18 08:08:06","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":11447373,"visible":true,"origin":"","legend":"\u003cp\u003eFixation of pLDTM transfer. The latissimus dorsi and teres major tendon (asterisk) was attached to the supraspinatus footprint and positioned immediately posterior to the bicep groove. pLDTM; posterior LDTM\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/c7fe7862a9ad9d46e94b7888.png"},{"id":71741726,"identity":"8e4ddf27-ba1c-413a-8274-ae19f768e21e","added_by":"auto","created_at":"2024-12-18 08:16:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":87773897,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5437755/v1/797dd94d-b8fc-4191-8af9-deaf0752fccd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anterior versus Posterior Transfer of Latissimus Dorsi and Teres Major Tendon in Irreparable Rotator Cuff Tears: A Retrospective Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe surgical treatment for irreparable rotator cuff tears (IRCTs) vary according to the patient\u0026rsquo;s conditions including age, previous activity level, willingness to rehabilitate, presence of osteoarthritis and associated injury.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Reverse shoulder arthroplasty (RSA) may be considered for older patients with glenohumeral arthritic change.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] However, joint preserving surgery including arthroscopic debridement, partial repair with/without augmentation, biceps rerouting, superior capsular reconstruction, and subacromial balloon space may be considered for the relatively young patients without arthritic change.[\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Recently, tendon transfer has emerged as an excellent treatment for relatively young IRCTs patients without arthritic change.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere are various options of tendon transfer according to the different types of IRCTs. To address the anterosuperior IRCTs (ASIRCTs), the pectoralis major (PM) transfer or anterior latissimus dorsi with/without teres major (LD or LDTM) transfer can be used.[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Recently, middle trapezius tendon transfer (MTT) showed favorable outcomes in isolated superior IRCTs (ISIRCTs).[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Moreover, for posterosuperior IRCTs (PSIRCTS), posterior latissimus dorsi with/without teres major (LD or LDTM) transfer or lower trapezius tendon transfer (LTT) has been well known for good treatment options.[\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] However, there were no clear treatment options for the IRCTs involving the anterior, superior and posterior rotator cuff tears (global IRCTs).\u003c/p\u003e \u003cp\u003eAmong various tendon transfers for IRCTs, LD or LDTM transfer could be used for addressing ASIRCTs or PSIRCTs.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] In ASIRCTs, the anterior LDTM (aLDTM) transfer showed a more favorable outcome when compared to anterior LD transfer due to its biomechanical effectiveness.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Moreover, the posterior LDTM (pLDTM) transfer could provide a stronger tendon unit and external rotation strength than that of posterior LD transfer.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] According to this point of view, the LDTM could be transferred anteriorly or posteriorly in global IRCTs. However, there was no study for evaluating the efficacy of aLDTM transfer and pLDTM transfer in IRCTs.\u003c/p\u003e \u003cp\u003eThe purpose of this study is to evaluate the efficacy of aLDTM transfer and pLDTM transfer in IRCTs. We hypothesize that although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eThis study was approved by the Institutional Review Board (ethics committee) of the Ministry of Health and Welfare (IRB No. P01-202411-01-005). The institutional review board permitted this study and exempted the necessity for informed consent because this study was performed retrospectively.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient population\u003c/h2\u003e \u003cp\u003eThe patients who underwent aLDTM transfer for ASIRCTs or pLDTM transfer for PSIRCTs between January 2017 and December 2020 were reviewed retrospectively.\u003c/p\u003e \u003cp\u003eThe diagnostic criteria for ASIRCTs were as follows: (1) massive anteroposterior rotator cuff tears (combined subscapularis [SSC] and supraspinatus [SSP]), (2) severe medial retraction and shortening of the tendons corresponding to Patte[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] stage III on magnetic resonance imaging (MRI), (3) high-grade fatty infiltration in SSC and SSP (Goutallier[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] fatty infiltration grade [FI] of 3 or 4), and (4) intact or reparable infraspinatus (ISP) and teres minor tendon with Goutallier FI grade of 1 or 2 on MRI. The indication for aLDTM transfer were as follows: (1) symptomatic ASIRCT or isolated supraspinatus IRCTs (ISIRCTs) presenting with severe shoulder pain and dysfunction that interferes with daily activities, (2) failure of conservative treatment, (3) little or no advanced arthritis in the shoulder joint (Hamada classification grade I or II), and (4) no neurologic deficits or infectious diseases. The patients who were ISIRCTs (n\u0026thinsp;=\u0026thinsp;31), were lost to follow-up at 2 years (n\u0026thinsp;=\u0026thinsp;4) or had incomplete clinical data (n\u0026thinsp;=\u0026thinsp;13) were excluded. Finally, 35 patients who underwent aLDTM transfer (aLDTM group) were enrolled for the study population.\u003c/p\u003e \u003cp\u003eThe diagnostic criteria for PSIRCTs were as follows: (1) massive posterosuperior rotator cuff (combined SSP and ISP) tears, (2) severe medial retraction and shortening of the tendons corresponding to Patte classification III on MRI, (3) high-grade fat infiltration in SSP and ISP (Goutallier FI grade of 3 or 4), and (4) intact or reparable SSC with Goutallier FI grade of 1or 2 on MRI. The indication for pLDTM transfer were as follows: (1) symptomatic PSIRCT with severe pain and/or shoulder dysfunction that disturbs daily activity, (2) failed conservative treatment, (3) little or no progressive arthritic change in the shoulder joint (Hamada grade I or II), and (4) no neurologic deficits or infectious diseases. The patients who were lost to follow-up at 2 years (n\u0026thinsp;=\u0026thinsp;4) or had incomplete clinical data (n\u0026thinsp;=\u0026thinsp;13) were excluded. Finally, 31 patients who underwent posterior LDTM transfer (pLDTM group) were enrolled for the study population.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eA single experienced surgeon (C.H.B) performed all the operations for this study period.\u003c/p\u003e\n\u003ch3\u003eAnterior Latissimus Dorsi and Teres Major Transfer\u003c/h3\u003e\n\u003cp\u003eThe patient was placed in the beach chair position under general anesthesia. The SSC and SSP tendons were assessed during diagnostic arthroscopic examination. When the SSC and SSP could not be reduced to its footprint area, the tendons were considered irreparable. If the ISP tendon is torn and reparable, the ISP is repaired using the double-row suture bridge technique. The long head of biceps tendon (LHBT) was managed with debridement, tenotomy or tenodesis according to the biceps pathology. After confirming the ASIRCTs, the LD and teres major (TM) tendon were harvested. Using standard deltopectoral approach, pectoralis major muscle was identified and released to provide adequate excursion of the LD and TM tendons. Anterior humeral circumflex vessels (\u0026ldquo;the three sisters\u0026rdquo;) and radial nerve were identified and carefully preserved. The LD and TM tendon was harvested in a periosteal manner without separating the individual tendons (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A traction suture was made at the end of the harvested LD and TM tendon using non-absorbable suture material and the Krakow method. The LD and TM muscle were bluntly released from surrounding adhesions to make further mobilization and excursion. A triple-loaded suture anchor was placed just lateral to the bicipital groove and 2\u0026thinsp;~\u0026thinsp;3cm distal to the great tuberosity (GT). The six threads of the anchor passed the end of the harvested LDTM tendon. Each passed thread was tied with the full IR and 45\u0026deg; abduction of arm to ensure physiological tension. The combined LDTM tendon was attached just lateral to the biceps groove and distal to the lateral edge of the GT using three lateral anchors. Fixing the combined tendon just distal to the GT positioned the tendon diagonally and more tautly, achieving tendon tensioning and avoiding axillary nerve impingement (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter the operation, patients were applied with an abduction brace for six weeks. Scapular stabilization exercises, pendulum exercises, and elbow exercise were only permitted for this period. After then, the patient started to perform passive range of motion (ROM) exercises for 4 weeks. The patient was encouraged to perform active ROM and strength exercises after restoring passive ROM. After three postoperative months, the patient progressed to full ROM and gentle strengthening exercises.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePosterior Latissimus Dorsi and Teres Major Transfer\u003c/h3\u003e\n\u003cp\u003ePatients were placed in the lateral decubitus position under general anesthesia. The SSP and ISP tendons were assessed during diagnostic arthroscopic examination. When the SSP and ISP could not be reduced to its footprint area, the tendons were considered irreparable. If the SSC tendon is torn and reparable, the SSC is repaired using the double-row suture bridge technique. The LHBT was managed with debridement, tenotomy or tenodesis according to the biceps pathology. After confirming PSIRCTs, the interval between the remaining posterior rotator cuff (ISP and teres minor [Tm]) and the deltoid was secured. A urinary catheter was inserted from the posterolateral portal to this interval and the balloon of the urinary catheter was inflated to generate a passage for the LDTM. To harvest the LD and TM tendon, the arm was flexed, internally rotated, and abducted. An L-shaped skin incision was made along the anterior belly of the LD and posterior axillary line. Anterior humeral circumflex vessels (\u0026ldquo;the three sisters\u0026rdquo;) and radial nerve were identified and carefully preserved. The LD and TM tendon was harvested in a periosteal manner without separating the individual tendons (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A traction suture was made at the end of the harvested LD and TM tendon using non-absorbable suture material and the Krakow method. The LD and TM muscle were bluntly released from surrounding adhesions to make further mobilization and excursion. The inflated balloon extruded at the interval between the teres minor and the deltoid. Sutures attached to the LDTM tendon were connected to the inflated balloon of the urinary catheter. Then the urinary catheter was pulled and the LDTM tendon was inserted into the subacromial space (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), the LDTM tendon was located to the SSP footprint and immediately posterior to the bicep groove under arthroscopy. Then, the LDTM tendon was attached to the SSP footprint with maximum external rotation of arm (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter the operation, patients were applied with an abduction brace for six weeks. Scapular stabilization exercises, pendulum exercises, and elbow exercise were only permitted for this period. After then, the patient started to perform passive range of motion (ROM) exercises for 4 weeks. The patient was encouraged to perform active ROM and strength exercises after restoring passive ROM. After three postoperative months, the patient progressed to full ROM and gentle strengthening exercises.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eClinical evaluation\u003c/h3\u003e\n\u003cp\u003eClinical and functional outcomes were evaluated based on pain, patient-reported outcome scores, active range of motion (aROM) and strength of aROM. Shoulder pain was evaluated using a visual analog scale (VAS). The patient-reported outcome scores included the Constant Score, American Shoulder and Elbow Surgeons (ASES) score, and University of California and Los Angeles (UCLA) score. The minimal clinically important difference (MCID) of the Constant, ASES, and UCLA scores reflected the smallest change in a clinical outcome that a patient would identify as important. The MCIDs of the Constant, ASES, and UCLA scores were 10.4, 15.2, and 3.5, respectively.\u003c/p\u003e \u003cp\u003eThe aROM of the shoulder including forward elevation (FE), abduction (ABD), external rotation (ER) at 0\u0026deg; ABD was evaluated using a standard goniometer. The internal rotation (IR) at the back was measured as the level that could be reached with a thumb when the patient rotated the arm behind the back (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; 10, T7). The strength of aROM was measured objectively with a hand-held dynamometer. Patients were positioned supine with shoulder 45\u0026deg; ABD and elbow 90\u0026deg; FE for measuring measure IR and ER strength. The FE strength and ABD strength were measured in the position of 90\u0026deg; FE and 90\u0026deg; ABD, respectively. The dynamometer was placed on the volar and dorsal aspects of the wrist.\u003c/p\u003e \u003cp\u003eAll clinical and functional outcomes were evaluated preoperatively and at prespecified postoperative time-points. The preoperative clinical status was compared with the clinical outcomes evaluated during the last follow-up period.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRadiologic evaluation\u003c/h2\u003e \u003cp\u003eArthritic changes of the shoulder joint and transferred tendon integrity were evaluated for radiological outcomes. Acromiohumeral distance (AHD) and Hamada classification were measured for evaluating the arthritic changes of the shoulder joint on the true anteroposterior radiograph (Grashey[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] view). If the Hamada grade is 3, 4, or 5 at the last follow-up, it is considered as a progression of arthritic changes. Preoperative and postoperative plain radiography were evaluated at each follow-up visit.\u003c/p\u003e \u003cp\u003eTransferred tendon integrity was assessed with Sugaya[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] classification on MRI. Although the Sugaya classification was made for evaluating the integrity of repaired rotator cuff tendon, any discontinuity of the transferred tendon (Sugaya classification IV and V) was considered a transferred tendon retear. Any signal change or small gap in the transferred tendon was not considered a transferred tendon retear. Postoperative MRIs were obtained at 1 week, 6 months, and 1 year after surgery, and every year thereafter.\u003c/p\u003e \u003cp\u003eThe preoperative radiologic status was compared with the radiologic outcomes evaluated during the last follow-up period.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical Package for the Social Science (SPSS) (version 21.0; IBM Corp., Armonk, NY, USA) were used for analyses with the level of significance at 95%.\u003c/p\u003e \u003cp\u003eThe Nonparametric Wilcoxon signed-rank test was used for analysis of preoperative and postoperative continuous data. McNemar\u0026rsquo;s test was used for analysis of preoperative and postoperative categorical data. The Nonparametric Mann\u0026ndash;Whitney test was used for analysis of continuous data of clinical and radiological outcomes between two groups. Fisher\u0026rsquo;s exact test was used for analysis of categorical data of clinical and radiological outcomes between two groups.\u003c/p\u003e \u003cp\u003eInter-observer reliability of AHD and Hamada grade was assessed using the intraclass correlation coefficient. Preoperative and last follow-up AHD and Hamada grade were evaluated using the inter-observer reliability by two authors.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eNo significant intergroup difference was confirmed in patient demographics, underlying diseases, previous cuff repair, biceps management, and follow-up periods. However, preoperative FI grade of SSC and ISP were significantly different due to the difference between ASIRCTs and PSIRCTs (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSignificant improvement in the VAS score and patients-reported clinical scores was observed in both groups. The postoperative Constant score and UCLA score of aLDTM group were significantly higher than that of pLDTM group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and \u0026lt;\u0026thinsp;0.001, respectively). Moreover, the achievement of MCID for ASES score and UCLA score showed a significant difference between two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021 and 0.042, respectively) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn both groups, the FE and ABD were significantly improved postoperatively. The postoperative FE of aLDTM group was significantly higher than that of pLDTM group (\u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;0.046). Although all patients with preoperative pseudoparalysis in aLDTM groups showed improvements, only one patient with preoperative pseudoparalysis in pLDTM groups showed improvement (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn both groups, the FE strength and ABD strength were significantly improved postoperatively. The postoperative FE strength and ABD strength of aLDTM group were significantly higher than that of pLDTM group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001 and 0.025, respectively). (Tabe 4). However, the mean improvement of IR strength in aLDTM group was significantly higher than mean improvement of ER strength in pLDTM group (7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 vs 4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011).\u003c/p\u003e \u003cp\u003eRegarding radiologic outcomes, although AHD significantly decreased postoperatively in both groups, there was no significant difference in postoperative AHD between the two groups. However, postoperative Hamada grade was significantly different between the two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005). The rate of progression of arthritic change was significantly higher in pLDTM group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The intra- and interobserver reliabilities for preoperative and postoperative AHD were excellent.\u003c/p\u003e \u003cp\u003eAs a postoperative complication, two patients of aLDTM group and one patient of pLDTM showed temporary axillary nerve palsy, which recovered after 3 months. One patient of pLDTM group was diagnosed with a postoperative infection, and these were successfully treated with arthroscopic debridement and antibiotics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, yr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.710\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, %\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (45.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.894\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.429\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArm dominance, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (97.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (93.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreop-Hamada grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (91.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (90.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSC FI grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (68.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSSP FI grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (62.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (37.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (39.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISP FI grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (74.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (42.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (57.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTm FI grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (88.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement of biceps, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- No management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Auto-tenotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Tenotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Tenodesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudoparalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean f/u period, months (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; SD, standard deviation; BMI, body mass index; FI, fat infiltration; SSC, subscapularis; SSP, supraspinatus; ISP, infraspinatus; Tm, teres minor; f/u, follow up\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons in pain and patient-reported clinical score between two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.436\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASES score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.176\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUCLA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCID for Constant, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.128\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (85.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (14.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCID for ASES, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (88.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (72.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCID for UCLA, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuccess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (88.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (75.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFailure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (11.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (24.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; VAS, Visual Analogue Scale; ASES, American Shoulder and Elbow Surgeons; MCID, minimal clinically important difference\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons in active range of motion between two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive FE, ˚\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101.4\u0026thinsp;\u0026plusmn;\u0026thinsp;18.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.213\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158.0\u0026thinsp;\u0026plusmn;\u0026thinsp;20.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140.9\u0026thinsp;\u0026plusmn;\u0026thinsp;34.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eABD, ˚\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.6\u0026thinsp;\u0026plusmn;\u0026thinsp;18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120.6\u0026thinsp;\u0026plusmn;\u0026thinsp;29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eER at 0˚ of abduction, ˚\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIR at back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.040\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.670\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudoparalysis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.845\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; VAS, Visual Analogue Scale; ASES, American Shoulder and Elbow Surgeons; ADLER, activities of daily living requiring active external rotation; FE, forward elevation; ABD, abduction; ER, external rotation; IR, internal rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons in strength between the two surgical groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFE strength, N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eABD strength, N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eER strength, N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIR strength, N\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; LDTM, latissimus dorsi and teres major; FE, forward elevation; ABD, abduction; ER, external rotation; IR, internal rotation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiologic outcome between the two surgical groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eaLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003epLDTM Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAHD (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.096\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostop-Hamada grade, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (6.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgression of arthritic change, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransferred tendon re-tear, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (9.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.693\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; SD, standard deviation; aLDTM; anterior latissimus dorsi and teres major; pLDTM; posterior latissimus dorsi and teres major; AHD, acromiohumeral distance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this study is the first to evaluate the efficacy of aLDTM transfer and pLDTM transfer in IRCTs. Significant improvement in clinical outcomes was observed in both groups. However, the mean improvements in Constant, ASES, UCLA scores, FE, and ABD were significantly better in aLDTM group than those of pLDTM group. Although the IR strength was significantly improved postoperatively in aLDTM group, the ERstrength was not significantly improved postoperatively in pLDTM group. Moreover, OA progression was significantly higher in pLDTM group, and graft retear was significantly higher in pLDTM group. As a result, although the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer in terms of clinical and radiologic outcomes.\u003c/p\u003e \u003cp\u003eaLDTM transfer has emerged as an excellent treatment for ASIRCTs patients without arthritic change.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Recently, aLDTM transfer showed good clinical and radiologic outcomes in short-term clinical study for ASIRCTs patient without arthritic change.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] In comparative clinical study on RSA versus RSA combined aLDTM transfer, RSA combined aLDTM transfer was superior in terms of IR at back and IR strength to that of RSA.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] Traditionally, LD transfer has been used for the treatment of ASIRCTs.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] However, aLDTM transfer is better at restoring the force couple in both the coronal and transverse plane of shoulder joint.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] First, the aLDTM transfer contributes to the recovery of coronal force couple and superior stability by playing the role of humeral head depressor.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] It was confirmed that the transferred LD plays the role of humeral head depressor during ABD, and the transferred TM also acts as a humeral head depressor due to its scapular origin in biomechanical study.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] The transferred LDTM has been proven to have an effect of superior stabilizers and depressor of shoulder joint in computed remodeling study.[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Moreover, in a cadaveric study, aLDTM transfer showed a significant decrease of superior translation for all shoulder positions in ASIRCTs.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Second, the aLDTM transfer contributes to the recovery of transverse force couple and anterior stability by playing the role of counterpart for posterior rotator cuff muscles.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] These biomechanical advantages of aLDTM transfer may lead to good clinical outcome in ASIRCTs.\u003c/p\u003e \u003cp\u003eTraditionally, posterior LDTM transfer was performed in patients with isolated loss of active external rotation as a modified L\u0026rsquo;Episcopo technique.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] In modified L\u0026rsquo;Episcopo technique, the LDTM was attached posterolateral aspect of humerus to restore the horizontal imbalance due to the deficiency of ISP and Tm. Modified L\u0026rsquo;Episcopo improved only the active external rotation.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] However, in this study, the LDTM was attached to the SSP footprint and positioned immediately posterior to the bicep groove to restore the force couple in both the coronal and transverse plane. This technique improved the active forward elevation and external rotation in PSIRCTs patients. Although there was no biomechanical study, we thought that the posteriorly transferred LDTM may improve ER and restore transverse force couple by replacing posterior rotator cuff. In addition, pLDTM transfer also may improve FE and restore superior stability by functioning the role of humeral head depressor. These biomechanical advantages of pLDTM transfer provide favorable clinical outcomes in PSIRCTs. However, the line of pull of pLDTM transfer works posterior and inferior vector compared to the vertical force of normal ISP.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] The transferred LDTM tendon does not have an in-phase contraction during ER because the LD and TM are originally internal rotators.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] These biomechanical disadvantages of pLDTM transfer may cause progression of arthritic changes in the glenohumeral joint. However, the clinical and biomechanical study on pLDTM in PSIRCTs are needed.\u003c/p\u003e \u003cp\u003eTo our knowledge, there are no biomechanical or clinical studies comparing aLDTM transfer and pLDTM transfer in IRCTs. Although the patient population of two groups were different in FI grade, this study is meaningful as a first clinical study comparing aLDTM transfer and pLDTM transfer because LDTM could be transferred anteriorly or posteriorly in global IRCTs. As a result of this study, we speculated that aLDTM transfer may be more effective than pLDTM transfer in terms of clinical and radiologic outcomes due to biomechanical advantage of aLDTM transfer. A similar line of pull of aLDTM with that of SSC may effectively restore transverse force couple and anterior stability.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] The transferred LDTM tendon has an in-phase contraction during IR because the LDTM tendon is originally an internal rotator.[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] The excursion of anteriorly transferred LDTM was enough to be attached to the lateral edge of the GT than the LT or the SSC footprint. This attachment resulted in a tensioning effect of aLDTM, which may facilitate the restoration of superior stability.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] With this biomechanical advantage, aLDTM may restore effectively the force couple and stability of shoulder joint. As a result, aLDTM transfer not only has good clinical and radiologic outcomes, but also has fewer progression of arthritic change.\u003c/p\u003e \u003cp\u003eThis study has several limitations. The most important limitation of this study was that the FI grade of preoperative rotator cuff was different between the two groups. However, it is not possible to compare aLDTM and pLDTM in the same patient population due to the different surgical indication of aLDTM transfer and pLDTM transfer. In the future, study comparing aLDTM and pLDTM in global IRCTs is needed. Moreover, comparing the clinical and radiologic outcome of the two groups may be a limitation because the main purpose of aLDTM is restoration of the anterior rotator cuff, and pLDTM is restoration of the posterior rotator cuff. However, since both aLDTM transfer and pLDTM transfer are aimed at restoration of transverse and coronal plane force couple of glenohumeral joint, it will be reasonable to compare the shoulder pain, patient-reported clinical score, FE, ABD, and radiologic outcomes except for IR and ER. Nonetheless, this study is meaningful as a first clinical study comparing aLDTM transfer and pLDTM transfer because LDTM could be transferred anteriorly or posteriorly in global IRCTs. Moreover, this study will provide useful information to shoulder surgeons when choosing aLDTM or pLDTM in global IRCTs. The relatively small study population and short study periods may limit the study\u0026rsquo;s validity for clinical practice. In the future, a randomized clinical trials study with a large population and long-term follow-up period is needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAlthough the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eABD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eabduction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASES\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Shoulder and Elbow Surgeons\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eaLDTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterior LDTM\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASIRCTs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanterosuperior IRCTs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eacromiohumeral distance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eaROM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eactive range of motion\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eexternal rotation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eforward elevation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003egreat tuberosity\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einfraspinatus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einternal rotation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIRCTs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eirreparable rotator cuff tears\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eISIRCTs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eisolated superior IRCTs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elatissimus dorsi\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLDTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elatissimus dorsi and teres major\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLHBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elong head of biceps tendon\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elower trapezius tendon transfer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emiddle trapezius tendon transfer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMCID\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eminimal clinically important difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epectoralis major\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003epLDTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterior LDTM\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePSIRCTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eposterosuperior IRCTs\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ereverse shoulder arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Science\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esubscapularis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esupraspinatus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eteres major\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTm\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eteres minor\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUCLA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversity of California, Los Angeles\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVAS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evisual analog scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board (ethics committee) of the Ministry of Health and Welfare (IRB No. P01-202411-01-005). The institutional review board permitted this study and exempted the necessity for informed consent because this study was performed retrospectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no\u0026nbsp;financial conflict of interest regarding the content of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization:\u0026nbsp;CHB; Methodology:\u0026nbsp;CHB, CL; Formal analysis and investigation:\u0026nbsp;SJK; Writing - original draft preparation:\u0026nbsp;CL; Writing - review and editing:\u0026nbsp;JGK,\u0026nbsp;BTK; Supervision:\u0026nbsp;CHB\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSaremi H, Amini M, Seifrabiei M. Comparison of Anterior and Posterior Transfer of Latissimus Dorsi Tendon to Humeral Head in Patients with Massive and Irreparable Rotator Cuff Tear. Arch Bone Jt Surg. 2023;11(4):236.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrake GN, O\u0026rsquo;Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Researc. 2010;468:1526\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKovacevic D, Suriani RJ Jr, Grawe BM, Yian EH, Gilotra MN, Hasan SA, et al. Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response. J Shoulder Elb Surg. 2020;29(12):2459\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim Y-S, Lee H-J, Park I, Sung GY, Kim D-J, Kim J-H. Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon. Arthrosco tech. 2018;7(2):e97\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMihata T, Lee TQ, Hasegawa A, Fukunishi K, Kawakami T, Fujisawa Y, et al. Arthroscopic superior capsule reconstruction for irreparable rotator cuff tears: comparison of clinical outcomes with and without subscapularis tear. Am J Sports Med. 2020;48(14):3429\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVecchini E, Gulmini M, Peluso A, Fasoli G, Anselmi A, Maluta T et al. The treatment of irreparable massive rotator cuff tears with inspace balloon: rational and medium-term results. Acta Bio Med. 2021;92(Suppl 3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElhassan BT, Wagner ER. Outcome of transfer of the sternal head of the pectoralis major with its bone insertion to the scapula to manage scapular winging. J Shoulder Elb Surg. 2015;24(5):733\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jse.2014.08.022\u003c/span\u003e\u003cspan address=\"10.1016/j.jse.2014.08.022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurnier M, Lafosse T. Pectoralis major and anterior latissimus dorsi transfer for subscapularis tears. Curr Rev Musculoskelet Med. 2020;13:725\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMun SW, Kim JY, Yi SH, Baek CH. Latissimus dorsi transfer for irreparable subscapularis tendon tears. J Shoulder Elb Surg. 2018;27(6):1057\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek CH, Kim JG, Baek GR. Outcomes of combined anterior latissimus dorsi and teres major tendon transfer for irreparable anterosuperior rotator cuff tears. J Shoulder Elb Surg. 2022;31(11):2298\u0026ndash;307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek CH, Kim JG. Outcomes of arthroscopic-assisted middle trapezius tendon transfer for isolated irreparable supraspinatus tendon tears: minimum 2-year follow-up. Arch Ortho Trauma Surg. 2023;143(5):2547\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerber C, Vinh TS, Hertel R, HESS CW. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff a preliminary report. Clin Orthop Relat Res. 1988;232:51\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLichtenberg S, Magosch P, Habermeyer P. Are there advantages of the combined latissimus-dorsi transfer according to L\u0026rsquo;Episcopo compared to the isolated latissimus-dorsi transfer according to Herzberg after a mean follow-up of 6 years? A matched-pair analysis. J Shoulder Elb surg. 2012;21(11):1499\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElhassan BT, Sanchez-Sotelo J, Wagner ER. Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. J Shoulder Elb Surg. 2020;29(10):2135\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jse.2020.02.018\u003c/span\u003e\u003cspan address=\"10.1016/j.jse.2020.02.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek CH, Kim JG, Kim BT, Kim SJ. Isolated Latissimus Dorsi Transfer versus Combined Latissimus Dorsi and Teres Major Tendon Transfer for Irreparable Anterosuperior Rotator Cuff Tears. Clin Orthop Surg. 2024;16(5):761.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoileau P, Chuinard C, Roussanne Y, Neyton L, Trojani C. Modified latissimus dorsi and teres major transfer through a single delto-pectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty. J Shoulder Elb Surg. 2007;16(6):671\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatte D. Classification of rotator cuff lesions. Clin Orthop Relat Res. 1990;254:81\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoutallier D, Postel J-M, Bernageau J, Lavau L, Voisin M-C. Fatty muscle degeneration in cuff ruptures: pre-and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoh KH, Han KY, Yoon YC, Lee SW, Yoo JC. True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear. J Shoulder Elb Surg. 2013;22(7):901\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLandis JR, Koch GG. The measurement of observer agreement for categorical data. J biometrics. 1977:159\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek CH, Kim JG, Baek GR. Restoration of active internal rotation following reverse shoulder arthroplasty: anterior latissimus dorsi and teres major combined transfer. J Shoulder Elb Surg. 2022;31(6):1154\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKany J, Guinand R, Croutzet P, Valenti P, Werthel JD, Grimberg J. Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency. Eur J Ortho Surg Traumatol. 2016;26:329\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalder A, Zhao K, O'driscoll S, Morrey B, An K. Dynamic contributions to superior shoulder stability. J Orthop Res. 2001;19(2):206\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMulla DM, Hodder JN, Maly MR, Lyons JL, Keir PJ. Glenohumeral stabilizing roles of the scapulohumeral muscles: implications of muscle geometry. J Biomech. 2020;100:109589.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaek GR, Kim JG, Kwak D, Nakla AP, Chung M-S, McGarry MH, et al. Biomechanical comparison of combined latissimus dorsi and teres major tendon transfer vs. latissimus dorsi tendon transfer in shoulders with irreparable anterosuperior rotator cuff tears. J Shoulder Elb Surg. 2023;32(4):703\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoileau P, Baba M, McClelland WB Jr, Th\u0026eacute;lu C-\u0026Eacute;, Trojani C, Bronsard N. Isolated loss of active external rotation: a distinct entity and results of L'Episcopo tendon transfer. J Shoulder Elb Surg. 2018;27(3):499\u0026ndash;509.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerhardt C, Lehmann L, Lichtenberg S, Magosch P, Habermeyer P. Modified l\u0026rsquo;episcopo tendon transfers for irreparable rotator cuff tears: 5-year followup. Clini Orthop Relat Res. 2010;468:1572\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOmid R, Lee B. Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg. 2013;21(8):492\u0026ndash;501. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5435/JAAOS-21-08-492\u003c/span\u003e\u003cspan address=\"10.5435/JAAOS-21-08-492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChecchia CS, Silva LAD, Sella GDV, Fregoneze M, Miyazaki AN. Current Options in Tendon Transfers for Irreparable Posterosuperior Rotator Cuff Tears. Rev Bras Ortop (Sao Paulo). 2021;56(3):281\u0026ndash;90. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0040-1709988\u003c/span\u003e\u003cspan address=\"10.1055/s-0040-1709988\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"irreparable rotator cuff tears, Latissimus dorsi and teres major transfer","lastPublishedDoi":"10.21203/rs.3.rs-5437755/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5437755/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThere are various options of tendon transfer according to the different types of irreparable rotator cuff tears (IRCTs). However, there were no clear treatment options for the IRCTs involving the anterior, superior and posterior rotator cuff tears (global IRCTs). Latissimus dorsi and teres major (LDTM) could be transferred anteriorly or posteriorly in global IRCTs. The purpose of this study is to evaluate the efficacy of anterior LDTM (aLDTM) transfer and posterior LDTM (pLDTM) transfer in IRCTs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe patients who underwent aLDTM transfer (aLDTM group, n=35) for anterosuperior IRCTs or pLDTM transfer (aLDTM group, n=33) for posterosuperior IRCTs between January 2017 and December 2020 were reviewed retrospectively. Clinical and functional outcomes were evaluated based on pain, patient-reported outcome scores, active range of motion (aROM) and strength of aROM. Radiological outcomes were evaluated using arthritic changesin the glenohumeral joint and transferred tendon integrity. Arthritic changes in the glenohumeral joint were evaluated using the acromiohumeral distance (AHD) and Hamada classification on the true anteroposterior radiograph.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eNo significant intergroup difference was confirmed in patient demographics except for preoperative fat infiltration grade of subscapularis and infraspinatus. The postoperative Constant score, and University of California and Los Angeles (UCLA) score of aLDTM group were significantly higher than that of pLDTM group (\u003cem\u003ep\u003c/em\u003e\u0026lt;0.001 and \u0026lt;0.001, respectively). Moreover, the achievement of minimal clinically important difference (MCID) for American Shoulder and Elbow Surgeons score and UCLA score showed a significant difference between two groups (\u003cem\u003ep\u003c/em\u003e=0.021 and 0.042, respectively). The postoperative forward elevation (FE) was significantly higher in aLDTM group (\u003cem\u003ep = \u003c/em\u003e0.046). The postoperative FE strength and abduction strength were significantly higher in aLDTM group (\u003cem\u003ep\u003c/em\u003e=0.001 and 0.025, respectively). Moreover, the mean improvement of internal rotation strength in aLDTM group was significantly higher than mean improvement of external rotation strength in pLDTM group (\u003cem\u003ep\u003c/em\u003e=0.011). The progression of arthritic change was significantly higher in pLDTM group (\u003cem\u003ep\u003c/em\u003e=0.002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eAlthough the aLDTM transfer and pLDTM transfer are effective and safe tendon transfer for IRCTs, aLDTM transfer is more effective than pLDTM transfer due to its biomechanical advantage and tendon transfer principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of study: level III\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Anterior versus Posterior Transfer of Latissimus Dorsi and Teres Major Tendon in Irreparable Rotator Cuff Tears: A Retrospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 08:08:00","doi":"10.21203/rs.3.rs-5437755/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-08T13:55:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-08T08:29:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39358797759692426753184731424057927994","date":"2024-11-25T00:32:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209920424990468031463944983218107666075","date":"2024-11-19T11:04:22+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-19T08:33:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-15T01:43:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-15T01:18:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2024-11-12T08:28:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88582d06-2ed7-4d46-8d17-6db243f76ab3","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-14T05:38:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-18 08:08:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5437755","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5437755","identity":"rs-5437755","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}