Efficacy of Arthroscopic Assisted Lower Trapezius Tendon Transfer versus Reverse Shoulder Arthroplasty in Patients with Posterosuperior Irreparable Rotator Cuff Tear without Arthritis: Propensity score Matching Study

Efficacy of Arthroscopic Assisted Lower Trapezius Tendon Transfer versus Reverse Shoulder Arthroplasty in Patients with Posterosuperior Irreparable Rotator Cuff Tear without Arthritis: Propensity score Matching 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 Efficacy of Arthroscopic Assisted Lower Trapezius Tendon Transfer versus Reverse Shoulder Arthroplasty in Patients with Posterosuperior Irreparable Rotator Cuff Tear without Arthritis: Propensity score Matching Study Chang Hee Baek, Chaemoon Lim, Jung Gon Kim, Bo Taek Kim, Seung Jin Kim This is a preprint; it has not been peer reviewed by a journal.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-5335586/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 May, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction: Shoulder dysfunction, including loss of active forward elevation (FE) and external rotation (ER), is challenging in posterosuperior irreparable rotator cuff tears (PSIRCTs). We compared the clinical outcomes of reverse shoulder arthroplasty (RSA) and arthroscopy-assisted lower trapezius tendon transfer (aLTT) in PSIRCTs patients without arthritis. Material and Methods: Approximately 29 patients were included in each group(RSA group and aLTT group), using propensity score matching based on demographic variables with a minimum 2-year follow-up period. Clinical results were compared with the visual analogue scale score, Constant shoulder score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and activities of daily living requiring active external rotation (ADLER) score, active range of motion and rotational strength between the two groups. Subsequently, the arthritic change of shoulder joint was evaluated using the acromiohumeral distance (AHD) and Hamada grade. Results: The clinical outcomes were significantly improved in both groups. However, ADLER score (20.6 ± 4.0 vs. 27.3 ± 3.7, p <.001), ER at 0˚ of abduction (34.2 ± 13.2 vs. 47.5 ± 11.1, p < .001), ER at 90˚ of abduction (49.6 ± 15.4 vs. 66.5 ± 19.5, p <.001) and ER strength (16.4 ± 4.0 vs. 24.1 ± 9.1, p < .001) of aLTT group were significantly better than that of RSA group. No significant increase of AHD and no significant progression of arthritis change were observed in aLTT group. Conclusions: Although both RSA and aLLT improved overall patient outcomes postoperatively, aLTT was superior inclinical scores, notably the ADLER score, active ER, and ER strength in PSIRCTs patients without arthritis. These findings suggest that aLTT could be a first-line joint-preserving treatment option for PSIRCTs patients without arthritis, given the longevity and related complications associated with arthroplasty. posterosuperior irreparable rotator cuff tear reverse shoulder arthroplasty lower trapezius tendon transfer external rotation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Shoulder dysfunction, including loss of active forward elevation (FE) and external rotation (ER), is a challenge in posterosuperior irreparable rotator cuff tears (PSIRCTs).[ 9 ] The optimal management of active FE and ER loss in PSIRCTs patients without arthritis remains a debated topic.[ 28 ] There are several surgical options for PSIRCTs, such as arthroscopic debridement, partial repair with/without augmentation. biceps rerouting, superior capsular reconstruction, and subacromial balloon spacer.[ 18 , 20 , 25 , 31 , 36 ] However, these treatments are limited to restoring the active range of motion (ROM) of the shoulder.[ 11 ] There are several tendon transfers for alleviating shoulder pain and improving shoulder function in PSIRCTs. Recently, lower trapezius tendon (LTT) transfer has attracted interest as an effective management for the restoration of glenohumeral kinematics, including superior-inferior and anterior-posterior force coupling in PSIRCTs.[ 1 , 12 ] Moreover, reverse shoulder arthroplasty (RAS) has been reported as a possible treatment for PSIRCTs.[ 24 ] LTT transfer has become a joint-saving treatment for PSIRCTs patients.[ 2 , 3 , 11 , 12 , 35 ] Recently, arthroscopically-assisted LTT (aLTT) transfer reportedly, has favorable clinical outcomes and fewer complications associated with the open approach.[ 1 , 11 , 35 , 38 ] Significant pain relief and functional improvement, especially for external rotation (ER), were observed after aLTT transfer in PSIRCTs.[ 1 ] Good clinical outcomes are believed to result from the biomechanical efficacy of aLTT transfer. In a biomechanical study, it was confirmed that glenohumeral kinematics and joint reaction force were restored after aLTT transfer in PSIRCTs.[ 26 ] Therefore, the rebalancing of the force couple in the coronal (compressive-distractive) and transverse (anterior-posterior) plane may have contributed to the dynamic joint centering effect.[ 2 , 3 ] Thereby, a viable treatment option for PSIRCTs patients may be the aLTT. Furthermore, RSA has been a widely preferred treatment option for irreparable rotator cuff tear or rotator cuff tear arthropathy.[ 4 ] Recently, several studies reported that RSA can be a treatment option for irreparable massive rotator cuff tears without glenohumeral arthritis.[ 23 ] In an irreparable massive rotator cuff tear, the restoration of internal rotation (IR) and ER of the shoulder has been limited even though RSA shows good clinical outcomes and reliable restoration of range of motion (ROM) of the shoulder.[ 7 , 12 ] Moreover, a lateralized reverse shoulder prosthesis may be insufficient to restore ER in irreparable massive rotator cuff tears.[5; 29] High rates of complication, including loosening of implant, are the major cause of failure in relatively young patients (under 65-year-old).[ 6 , 37 ] There is no clinical comparative study between RSA and aLTT transfer in PSIRCTs; however, RSA and aLTT transfer can be selected for PSIRCTs patients without arthritis. In this study, we compared the clinical outcomes of aLTT transfer and RSA in patients with active high-demand PSIRCTs with no arthritis. We hypothesized that aLTT transfer would have similarly good clinical outcome as RSA, whereas aLTT transfer may show better results in the ER. Methods Patient selection We retrospectively reviewed the cases of patients with PSIRCTs who underwent surgery between January 2017 and December 2020. This study received approval from institutional review board (No. P01-202407-01-055). The diagnostic criteria for PSIRCT were as follows: (1) massive posterosuperior rotator cuff (combined supraspinatus [SSP] and ISP) tears, (2) severe medial displacement of SSP (Patte classification III) on magnetic resonance image (MRI), (3) high-grade fat infiltration in SSP and ISP (Goutallier fat infiltration (FI) grade of III or IV) (4) intact or reparable subscapularis (SSC) with Goutallier FI grade of I or II. The inclusion criteria were as follows: (1) symptomatic PSIRCT with severe pain and/or shoulder dysfunction that disturbs daily activity, (2) failed conservative treatment, (3) underwent surgical treatment, and (4) little or no progressive arthritic change in the shoulder joint (Hamada grade I or II) (Fig. 1 ). Patients who underwent partial repair, partial repair with augmentation, superior capsular reconstruction (SCR), or posterior latissimus dorsi (LD) tendon transfer were excluded. The decision to perform RSA or aLTT was made according to the patient’s overall condition, such as patient’s willingness to rehabilitate and return to their previous work, desired activity level, and medical comorbidity. The mechanism, surgical procedure, skin incision, possible complications, advantage and disadvantage of RSA or aLTT technique was explained to patients before the operations. In most cases, RSA or aLTT was performed according to the patient’s decision. In total, 103 patients underwent, RSA, and 101 underwent aLTT tendon transfer for PSI RCTs between January 2017 and December 2020. We excluded patients who had surgical treatment using RSA with non-lateralized glenoid or non-lateralized humeral prostheses (n = 47), RSA with LD tendon transfer with or without teres major tendon transfer (n = 5), were lost to follow-up at 2 years (n = 4) or had incomplete clinical data (n = 13). In total, 143 patients were initially enrolled for propensity score matching (PSM) (Fig. 2 ). There was a significant difference in the variables used for matching before PSM (Table 1 ). Table 1 Demographic and clinical characteristics of patients before propensity score matching Variables RSA Group aLTT Group p Number of patients 42 101 N/A Age, mean ± SD, yr 72.0 ± 5.7 62.8 ± 6.2 < .001 Female, % 25 (59.5) 34 (33.7) 0.013 BMI, mean ± SD, kg/m 2 23.6 ± 2.6 24.4 ± 2.7 0.159 Arm dominance, n, % 41 (97.6) 99 (98.0) 0.745 Smoking, n, % 4 (9.5) 14 (13.9) 0.921 Diabetes mellitus, n, % 10 (23.8) 20 (19.8) 0.544 Hypertension, n, % 19 (45.2) 38 (36.6) 0.349 Hamada grade, n, % - Grade 1 13 (31.0) 41 (40.6) 0.361 - Grade 2 29 (69.0) 61 (60.4) SSC fatty infiltration grade, n, % 0.032 - Grade 1 25 (59.5) 79 (78.2) - Grade 2 22 (40.5) 23 (22.8) SSP fatty infiltration grade, n, % 0.058 - Grade 3 18 (42.9) 62 (61.4) - Grade 4 24 (47.1) 40 (39.6) ISP fatty infiltration grade, n, % 0.884 - Grade 3 14 (33.3) 43 (42.6) - Grade 4 28 (66.7) 59 (58.4) Tm fatty infiltration grade, n, % 0.016 - Grade 1 23 (54.8) 56 (55.4) - Grade 2 8 (19.0) 15 (14.9) - Grade 3 4 (9.5) 17 (16.8) - Grade 4 7 (16.7) 13 (12.9) *Significant p-value is < 0.05; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; SD, standard deviation; BMI, body mass index; SSC, subscapularis; SSP, supraspinatus; ISP, infraspinatus; Tm, teres minor; f/u, follow up Propensity score matching PSM was used to minimize the selection bias between surgical treatment, RAS, or aLTT transfer. The matching was performed in triplicates. First, the propensity score was assessed using multivariate logistic regression analysis regarding factors affecting surgical options or clinical outcomes, including age, sex, dominant hand, and FI grade. Second, a greedy matching was performed with a caliper of 0.2 times × standard deviation. In this step, each patient included in the RSA was paired with another who underwent combined aLTT transfer. Finally, the balance in factor distribution was checked between the two groups, and the absolute standard mean difference of 0.1 or 0.25 represents an acceptable balance. Propensity score matching was conducted with R program (version 13.0; R Development Core Team, Vienna, Austria). After PSM, 26 patients of each group were matched for analysis. Differences did not differ significantly. in age, sex, dominant hand, FI grade and follow-up periods between the two groups (Table 2 ). Table 2 Demographic and clinical characteristics of patients after propensity score matching Variables RSA Group aLTT Group p Number of patients 26 26 N/A Age, mean ± SD, yr 68.8 ± 4.5 68.5 ± 4.6 0.085 Female, % 15 (57.7) 13 (50.0) 0.694 BMI, mean ± SD, kg/m 2 23.5 ± 2.6 23.8 ± 2.0 0.159 Arm dominance, n, % 25 (96.2) 26 (100.0) 0.745 Smoking, n, % 3 (11.5) 4 (15.4) 0.921 Diabetes mellitus, n, % 6 (23.1) 5 (19.2) 0.544 Hypertension, n, % 15 (57.7) 11 (42.3) 0.349 Hamada grade, n, % - Grade 1 11 (42.3) 15 (57.7) 0.361 - Grade 2 15 (57.7) 11 (42.3) SSC fatty infiltration grade, n, % 0.083 - Grade 1 18 (59.2) 19 (72.1) - Grade 2 8 (30.8) 7 (26.9) SSP fatty infiltration grade, n, % 0.098 - Grade 3 10 (38.5) 10 (38.5) - Grade 4 16 (61.5) 16 (61.5) ISP fatty infiltration grade, n, % 0.276 - Grade 3 9 (34.6) 8 (30.8) - Grade 4 17 (65.4) 18 (69.2) Tm fatty infiltration grade, n, % 0.070 - Grade 1 15 (57.7) 13 (50.0) - Grade 2 5 (19.2) 4 (15.4) - Grade 3 2 (7.7) 4 (15.4) - Grade 4 4 (15.4) 5 919.2) Pseudoparalysis 4 (15.4) 3 (11.5) Mean f/u period, months (range) 39.0 ± 9.6 36.5 ± 8.4 0.569 *Significant p-value is < 0.05; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; SD, standard deviation; BMI, body mass index; SSC, subscapularis; SSP, supraspinatus; ISP, infraspinatus; Tm, teres minor; f/u, follow up Surgical technique A single experienced senior surgeon (XXX) performed all surgical procedures. Reverse shoulder arthroplasty procedure A Beach chair position was used to prepare the patients under the general anesthesia and interscalene brachial plexus block. A lateralized humeral head and glenoid prosthesis (Comprehensive Reverse Shoulder System) were used in all patients. A skin incision of was made in the coracoid process along the deltopectoral groove approximately 10 ~ 12 cm, using the deltopectoral approach. With caution, the cephalic vein was mobilized medially or laterally according to the tension. After identification of the deltoid and pectoralis major muscle, the deltoid muscle was pulled laterally and the pectoralis major muscle was pulled medially. The musculocutaneous nerve is preserved before the conjoint tendon is retracted. The long-head biceps tendon (LHBT) underwent tenotomy and tenodesis after final prosthesis implantation. The SSC tendon was released carefully from the lesser tuberosity (LT) and preserved for reattachment. After dislocation of glenohumeral joint, a head resection was performed using a cutting guide with a 132.5 °inclination and 20 °retroversion. After humeral head resection, humeral canal preparation was performed with reamers in 1 mm increase until cortical contact. This procedure was performed carefully to preserve the cancellous bone for press-fit fixation of the humeral stem. Subsequently, three suture loops were passed around the humeral metaphysis for reattachment of the subscapularis after the final impaction of the humeral stem. Extensive circumferential capsulectomy was performed to prepare the glenoid. The glenoid labrum, cartilage, and inferior glenoid osteophytes were removed. After confirming the glenoid orientation, a central hole was positioned with a stopper drill. The glenoid was scraped using a glenoid-resurfacing reamer. The baseplate was placed at the inferior glenoid and tilted inferiorly to avoid the scapular notch. Following this procedure, the humeral stem was placed downward through the humerus. The humerus was reduced in the glenosphere after placing the humeral stem, and the SSC tendon was reattached at the insertion point of the LT using suture loops. After RSA, arm sling was applied to all patients for 6 weeks immobilization. After 6 weeks, passive ROM was started and progressed to aROM, as tolerated under the standard physical therapy protocol. Then, gentle strengthening exercises were allowed, and return to previous level of activities were encouraged at postoperative six months. Arthroscopy-assisted lower trapezius tendon transfer The patients were placed in the lateral decubitus position on the operating table after the induction of general anesthesia with an interscalene nerve block, and the operative arm was pulled with a traction device. An arthroscopic diagnostic examination was performed using four standard 4 portals (posterior, anterior, lateral, and posterolateral). We further assessed the repairability and mobility of the rotator cuff tendons after removing the non-viable scar tissue around the torn rotator cuff. Regarding reparable SSC, the SSC was repaired. Despite the soft tissue release and interval sliding technique, if the SSP and ISP could not be reduced to the footprint, PSIRCTs were diagnosed, and the patient decided to undergo aLTT transfer (Fig. 3 A). Several preparations were made before aLTT transfer. First, subacromial decompression was performed to prevent the wear of the interpositional bridging graft, which could be irritated by the subacromial spur during the excursion of the transferred tendon. LHBT was managed using tenotomy, tenodesis, or superior capsular reconstruction according to biceps-associated clinical symptoms, physical examination, or biceps pathology including degeneration, subluxation, or tear. Notably, the footprints of the SSP and ISP were prepared from the cartilage of the humeral head to the lateral aspect of the GT until the subchondral bone was exposed. The graft-bone healing was promoted by extending the footprint area and exposing the subchondral bone of the GT. We further developed an interval space that transferred the LTT passes between the deltoid and remnant ISP. In addition, an Achilles tendon allograft was utilized as the interpositional bridging graft. Calcaneal bony portion was removed. One end of the Achilles tendon allograft was prepared with the Krakow suturing method. The Krakow sutures were attached to SSP footprint, and the other side of the Achilles tendon allograft was sutured to the inferior border of the LTT by using the Krakow suture method (Fig. 4 ). Two medial row anchors were inserted into the SSP footprint near the prepared cartilage margin of the GT. One anchor was inserted at anterior portion and the other was posterior portion of SSP footprint. Three threads of posterior medial-row anchors were pierced through the ISP remnant utilizing Suture Lasso. These three threads were used for side-to-side sutures with the interpositional bridging graft. The other three threads were taken out through the posterolateral portal and pierced through an interpositional bridging graft for attachment to the SSP footprint. A large grasper was inserted from the lateral portal to the infraspinatus fascia of the skin incision, allowing the passage of the interpositional bridging graft. A Krakow sutures of the interpositional bridging graft was grasped and taken out through the lateral portal. The interpositional bridging graft was placed on the SSP footprint and fixed with posterior and anterior medial row anchors. Then, a side-to-side suture between posterior ISP remnant and interpositional bridging graft was made by tie the threads through the posterior ISP remnant and interpositional bridging graft. Three lateral row anchors were inserted at the anterolateral, mid-lateral, and posterolateral aspects of GT using the suture bridge technique (Fig. 5 A). After aLTT transfer, the shoulder abduction brace was maintained at 0 °ER for 6 weeks after aLLT transfer. The patient performed only flexion and extension ROM exercises of the elbow, wrist, and fingers, during this period. However, patients were prohibited from performing internal rotation to avoid damage to the transferred tendon. The patients were further allowed to take off the brace and encouraged to start gentle passive ROM exercises for 4 weeks. After then, full ROM and gentle strengthening exercises started after at least 3 months postoperatively. Sports and high-level activities were allowed at 6 months postoperatively according to the preoperative activity levels and the patient’s willingness. Clinical evaluation The visual analog scale (VAS) score for pain, active ROM (aROM), and patient-reported outcome measurements were used to evaluate preoperative and postoperative clinical outcomes. Pain was measured at a subjective level using a 10-point VAS score. The aROM including forward elevation, abduction, ER at 0° abduction, and ER at 90° abduction, was measured using a standard goniometer. In addition, the IR was evaluated as the height at which the patient’s thumb reached the back when the patient rotated the arm internally backward (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; and 10, T7). The patient-reported clinical outcomes were evaluated preoperatively and postoperatively with activities of daily living using active external rotation (ADLER) score, University of California Los Angeles (UCLA) shoulder score, American Shoulder and Elbow Surgeons (ASES) score, and constant shoulder score. Furthermore, aROM was evaluated at every visit of outpatient department. The strength of ER and IR was evaluated using a hand-held dynamometer. Patients were positioned supine with shoulder 45° abduction and elbow 90° flexion. The dynamometer was placed on the volar and dorsal aspects of the wrist to measure ER and IR strength. All patients reported clinical outcome, and measurements were collected by a research coordinator. In addition, complications including nerve injury, infection, fracture, dislocation and infection were collected. Radiologic evaluation Radiological outcomes were evaluated using plane radiography and MRI scans. Pre- and postoperative plane radiographs, including true anteroposterior (AP) (Grashey)[ 19 ] were taken. The acromiohumeral distance (AHD) was measured as the shortest distance between the inferior cortex of the acromion undersurface and the top of the humeral head in the true AP view at preoperative period and postoperative 2 years. In addition, arthritic changes of the shoulder joint were assessed using the Hamada grade in true AP view. Grades 3, 4, or 5 at the last follow-up indicated the progression of arthritic changes. The postoperative AHD and Hamada grades were evaluated in the aLTT group. Furthermore, the fatty degeneration of the rotator cuff muscles (SSC, SSP, ISP, and teres minor) were evaluated using the Goutallier[ 15 ] grading system in sagittal oblique images of preoperative MRI scans. Postoperative MRI was performed at 6 months, 1 year, and 2 years to evaluate the graft integrity in aLTT group. The transferred graft was assessed with Sugaya classification [ 34 ]; types IV and V were considered as re-tear of graft. Although the Sugaya classification originally was used for integrity of repaired rotator cuff, complete discontinuity of the graft was defined re-tear according to the Sugaya classification types IV and V. Statistical analysis Statistical analyses were performed using the Statistical Package for Social Sciences for Windows (version 11.0; SPSS Inc., Chicago, Illinois, USA). The significance level was set at 95%. Preoperative and postoperative continuous data were analyzed using the Wilcoxon signed-rank test and categorical data were analyzed using McNemar’s test. Furthermore, continuous data between the two groups were analyzed using the Nonparametric Mann–Whitney U test. However, categorical data between the groups were analyzed using Fisher’s exact test. The inter-observer reliabilities of the radiographic measurements (AHD and Hamada grade) were evaluated using the intraclass correlation coefficient (ICC)[ 21 ]. Two authors measured the preoperative and last follow-up AHD and Hamada grades to evaluate inter-observer reliability. Results Postoperative clinical outcomes were significantly improved in both groups. However, the postoperative ADLER (20.6 ± 4.0 vs. 27.3 ± 3.7, p < .001) of aLTT group were significantly better than that of RSA group. Similarly, postoperative ROM was significantly improved in both groups, and the mean postoperative ER at 0˚ of abduction (34.2 ± 13.2 vs. 47.5 ± 11.1, p = .001) and ER at 90˚ of abduction (49.6 ± 15.4 vs. 66.5 ± 19.5, p < .001) of aLTT group were significantly better than that of RSA group. All patients with preoperative pseudoparalysis in both groups showed improvements. The final follow-up ER strength of aLTT group was significantly better than that of RSA group (16.4 ± 4.0 vs. 24.1 ± 9.1, p < .001) (Table 3) (Fig 6 and 7). Table 3. Comparisons in clinical outcomes between the two surgical groups Variables RSA Group aLTT Group p VAS score Preoperative 4.7 ± 0.9 4.4 ± 1.4 0.551 Postoperative 1.7 ± 0.6 1.5 ± 0.8 0.233 P < 0.001 < 0.001 Constant score Preoperative 43.0 ± 7.5 49.7 ± 13.3 0.065 Postoperative 70.0 ± 4.6 72.4 ± 12.1 0.049 P < 0.001 < 0.001 ASES score Preoperative 46.4 ± 6.6 49.8 ± 12.6 0.260 Postoperative 76.2 ± 6.0 79.1 ± 12.6 0.178 P < 0.001 < 0.001 UCLA Preoperative 14.8 ± 5.1 14.7 ± 5.4 0.912 Postoperative 24.3 ± 4.8 25.5 ± 4.1 0.496 P < 0.001 < 0.001 ADLER Preoperative 16.7 ± 5.8 17.6 ± 6.1 0.463 Postoperative 20.6 ± 4.0 27.3 ± 3.7 < 0.001 P 0.001 < 0.001 Active FE, ˚ Preoperative 113.8 ± 34.7 119.0 ± 30.7 0.484 Postoperative 150.4 ± 21.4 154.2 ± 20.0 0.531 P < 0.001 < 0.001 ABD, ˚ Preoperative 87.3 ± 38.7 88.3 ± 29.8 0.103 Postoperative 138.8 ± 24.7 131.2 ± 27.3 0.081 P 0.001 < 0.001 ER at 0˚ of abduction, ˚ Preoperative 25.2 ± 12.7 22.7 ± 15.4 0.539 Postoperative 34.2 ± 13.2 47.5 ± 11.1 0.001 P 0.005 < 0.001 ER at 90˚ of abduction, ˚ Preoperative 39.2 ± 19.7 40.0 ± 19.5 0.638 Postoperative 49.6 ± 15.4 66.5 ± 19.5 < 0.001 P 0.032 0.034 IR at back Preoperative 5.6 ± 2.0 6.1 ± 1.7 0.104 Postoperative 6.3 ± 1.4 6.6 ± 1.4 0.609 P 0.056 0.256 Pseudoparalysis, n (%) Preoperative 4 (15.4) 2 (7.7) 0.530 Postoperative 0 (0.0) 0 (0.0) - P 0.027 0.014 Strength, N IR at side 23.4 ± 8.7 25.6 ± 8.1 0.384 ER at side 16.4 ± 4.0 24.1 ± 9.1 < 0.001 *Significant p-value is < 0.05; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; 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; Internal rotation was measured as the level that could be reached by the thumb (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; 10, T7). The interobserver reliability for preoperative and postoperative AHD (ICC pre−AHD = 0.91 [0.86–0.95], p < .001, ICC post−AHD = 0.92 [0.88–0.95], p < .001) and Hamada grade (ICC pre−Hamada = 0.85 [0.79–0.90], p < .001, ICC post−Hamada = 0.93 [0.86–0.96], p < .001) were all excellent. [ 10 ] In aLTT group, no significant decrease of AHD change (preoperatively 9.1 ± 2.2 to postoperatively 8.4 ± 2.3, p = 0.256) and no significant progression of cuff tear arthropathy (Hamada grade: preoperatively 1.4 ± 0.5 to postoperatively 1.5 ± 0.5, p = 0.798) were observed (Table 4 ). Table 4 Radiologic outcome of arthroscopic lower trapezius tendon transfer group Outcomes Preoperative (mean ± SD) Postoperative (mean ± SD) p AHD (mm) 9.1 ± 2.2 8.4 ± 2.3 0.256 Hamada grade 1.4 ± 0.5 1.3 ± 0.5 0.798 *Significant p-value is < 0.05; SD, standard deviation; AHD, acromiohumeral distance Furthermore, two patients had acromial fractures in the RSA group, and all were treated conservatively. Two patients experienced transient axillary nerve palsy in the aLTT group; however, the nerve palsy was fully recovered after three months. In addition, two patients had a partial tear of transferred graft and one patient had a complete re-tear of the transferred graft at the final follow-up in the aLTT group. All graft tear occurred at medial to the footprint. Discussion The loss of FE and ER is a challenging problem for PSIRCTs patients without arthritis, among shoulder dysfunctions. In this study, we evaluated the clinical outcomes and ROM recovery between aLTT transfer and RSA in PSIRCTs patients without arthritis. We confirmed that ADLER, ER at 0° of abduction, and ER at 90°, and ER strength were superior in the aLTT group than in the RSA group. However, no significant decrease in AHD changes or progression of arthritic changes was observed in the aLTT group. Therefore, aLTT transfer could be a first-line, joint-saving treatment for PSIRCTs patients without arthritis. RSA is a commonly used and effective management for massive irreparable rotator cuff tears,[23; 24] particularly effective in restoring coronal plane muscle imbalance and FE by improving deltoid power against weak superior rotator cuff muscle.[ 7 , 32 ] However, RSA could not restore the axial plane muscle imbalance and ER in the case of poor posterior cuff (ISP and Tm) muscle.[ 6 , 7 ] Resulting from weak ER rotator cuff muscles (ISP and Tm) being unable to provide counterforce to the strong IR muscles (SSC, latissimus dorsi and teres major).[ 5 ] The patient who underwent RSA and had weak ER rotator cuff muscle complained of difficulty in activities of daily living, including eating, drinking, or hair washing.[ 5 ] Several studies reported that the lateralized prosthetic design could restore the active ER.[ 14 , 16 ] However, another study pointed out that lateralized prosthetic design could restore the active ER, only if the posterior ER rotator cuff muscle was functional. In its absence, the posterior portion of the deltoid muscle cannot provide a counterforce to the strong IR muscles.[ 7 , 8 ] Moreover, a lateralized prosthetic design may increase the risk of prosthetic loosening because the lateralized center of rotation increases the shear force in the glenoid. In contrast, RSA with combined latissimus dorsi and teres major (cLDTM) tendon transfer is effective in restoring active ER in weak posterior rotator cuff muscles. Furthermore, in RAS with cLDTM tendon transfer, the RSA could restore the coronal plane force couple, and the transferred LDTM could restore the transverse plane force couple.[ 5 ] In this study, ADLER and ER at 0° of abduction, ER at 90° of abduction, and ER strenth were significantly inferior in the RSA group compared with the aLTT group. However, the lateralized RSA could not provide a counterforce to the strong IR muscle in the poor posterior rotator cuff muscle on PSIRCTs. The complications after RSA may be that its application is limited in patients with active, high-demand without arthritis. RSA showed pain relief and functional improvement in patients with low-grade osteoarthritis for 10–15 years; however, high adverse events (notching or implant loosening) rate of up to 39% deteriorated the functional improvement.[ 13 ] Moreover, relatively young male patients (< 65 years) should be careful when performing RSA because implant loosening may be the main cause of RSA failure.[ 6 , 37 ] As a result, RSA may not be appropriate for patients with active high-demand PSIRCTs without arthritis. Furthermore, aLTT transfer is an effective treatment for restoring active ER of the shoulder in these patients.[ 1 , 2 , 11 ] It is because aLTT transfer follows the principle of tendon transfer and has a biomechanical advantage.[ 2 , 3 ] The line of pull of transferred LTT is closely similar to that of native ISP (posterior ER rotator cuff muscle).[ 27 ] The excursion and tension of LTT are adequate to replace the function of ISP.[ 17 ] Furthermore, the in-phase contraction of LTT during ER make possible retention of LTT in patients because the LTT functions during shoulder ER.[ 33 ] In a biomechanical study, LTT transfer recovered the joint reaction force and glenohumeral kinematics in the transverse (anterior-posterior) plane.[ 26 ] In the three-dimensional kinematic study, LTT promotes scapular ER by normalizing scapularthoracic motion because the insertion of LTT is the medial aspect of the scapular spine.[ 16 ] This sticks to the principle of tendon transfer, and the biomechanical advantage of aLTT transfer makes restoring active ER of the shoulder possible in PSIRCTs patients without arthritis. Moreover, aLTT transfer is also an effective treatment for restoring active FE of the shoulder in patients with active high-demand PSIRCTs without arthritis.[ 2 , 3 , 11 ] In the biomechanical study, LTT transfer restored the joint reaction force and glenohumeral kinematics in the coronal (compressive and distractive) plane and mimicked the intact supraspinatus.[ 26 , 30 ] Recently, the static spacing effect improving glenohumeral kinematics by supressing the humeral head has gained attention because improving the FE against the deltoid force is important.[ 22 ] The transposition of LTT through the subacromial space and attachment to the SSP footprint makes static spacing and dynamic joint centering effects in PSIRCTs.[ 2 ] In this study, LTT was transposed through the subacromial space to restore superior stability by creating a static spacing effect. Moreover, to increase this static spacing effect, we attached the interpositional bridging graft to the SSP footprint rather than to the ISP footprint. The static spacing effect is crucial in active FE as a humeral head depressor against the powerful force exerted by the deltoid muscle. Several adverse events, including nerve injury, infection, hematoma formation, and re-tear of transferred graft, may occur after aLTT transfer.[ 12 ] However, there was no irreversible adverse events in this study. One patient experienced axillary nerve palsy, which was recovered after three months. two patients had a partial tear of transferred graft and one patient had a complete re-tear of the transferred graft at the final follow-up of the aLTT transfer. These patients did not complain of any discomfort due to pain or limited ROM. This study has some limitations. Because of its retrospective nature, patients were not randomly grouped according to RSA or aLTT transfer. The deciding whether to perform RSA or aLTT transfer was influenced by various factors, such as patients’ intension for rehabilitation, willingness of return to work, previous activity level, and existing medical conditions. The significant differences in preoperative demographics between the two groups were adjusted using PSM; however, a performance bias or selection bias may occur by this limitation. The small study population and the short study period may have decresed the validity of this study. Nevertheless, to our knowledge, this study is the first to present comparative results after RSA and aLTT transfer in PSIRCTs. Conclusion Lateralized RSA and aLTT improved overall patient outcomes postoperatively; however, aLTT transfer was superior in clinical scores, notably the ADLER score, ER of aROM, and ER strength in patients with PSIRCTs. Our findings suggest that aLTT could be a first-line joint-preserving treatment option for PSIRCTs patients without arthritis, given the longevity and related adverse events associated with arthroplasty. Declarations Acknowledgement Funding No funds, grants, or other support was received. Conflict of interest disclosure The authors declare no financial conflict of interest with regard to the content of this report References Baek CH, Kim BT, Kim JG, Kim SJ (2024) Mid-term outcomes of arthroscopically assisted lower trapezius tendon transfer using Achilles allograft in treatment of posterior-superior irreparable rotator cuff tear. J Shoulder Elbow Surg, 33(6):1293-1305 Baek CH, Lee DH, Kim JG (2022) Latissimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears. J Shoulder Elbow Surg, 31(9):1810-1822 Baek CH, Lim C, Kim JG (2022) Superior capsular reconstruction versus lower trapezius transfer for posterosuperior irreparable rotator cuff tears with high-grade fatty infiltration in the infraspinatus. Am J Sports Med, 50(7):1938-1947 Berhouet J, Samargandi R, Jacquot A, Favard L, Boileau P, Gauci M-O (2024) Restoration of Internal Rotation After Reverse Shoulder Arthroplasty May Vary Depending on Etiology in Patients Younger Than 60 Years Old: A Multicenter Retrospective Study. J ISAKOS Boileau P, Chuinard C, Roussanne Y, Bicknell RT, Rochet N, Trojani C (2008) Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res, 466(3):584-593 Boileau P, Gonzalez J-F, Chuinard C, Bicknell R, Walch G (2009) Reverse total shoulder arthroplasty after failed rotator cuff surgery. J Shoulder Elbow Surg, 18(4):600-606 Boileau P, Watkinson DJ, Hatzidakis AM, Balg F (2005) Grammont reverse prosthesis: design, rationale, and biomechanics. J shoulder Elbow Surg, 14(1):S147-S161 Boulahia A, Edwards TB, Walch G, Baratta RV (2002) Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear(ed)^(eds). SLACK Incorporated Thorofare, NJ, Orthopedics, pp 129-133 Carver TJ, Kraeutler MJ, Smith JR, Bravman JT, McCarty EC (2018) Nonarthroplasty surgical treatment options for massive, irreparable rotator cuff tears. Orthop J Sports Med, 6(11):2325967118805385 Cicchetti DV, Sparrow SA (1981) Developing criteria for establishing interrater reliability of specific items: applications to assessment of adaptive behavior. Am J Ment Defic, 86(2):127-137 Elhassan BT, Sanchez-Sotelo J, Wagner ER (2020) Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. J Shoulder Elbow Surg, 29(10):2135-2142 Elhassan BT, Wagner ER, Werthel J-D (2016) Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear. J Shoulder Elbow Surg, 25(8):1346-1353 Ernstbrunner L, Suter A, Catanzaro S, Rahm S, Gerber C (2017) Reverse total shoulder arthroplasty for massive, irreparable rotator cuff tears before the age of 60 years: long-term results. J Bone Joint Surg, 99(20):1721-1729 Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M (2005) The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients. J Bone Joint Surg, 87(8):1697-1705 Goutallier D, Postel J-M, Bernageau J, Lavau L, Voisin M-C (1994) Fatty muscle degeneration in cuff ruptures: pre-and postoperative evaluation by CT scan. Clinical Orthopaedics Related Research, 304:78-83 Grammont P, Baulot E (1993) Delta shoulder prosthesis for rotator cuff rupture(ed)^(eds). SLACK Incorporated Thorofare, NJ, Orthopedics, pp 65-68 Herzberg G, Urien JP, Dimnet J (1999) Potential excursion and relative tension of muscles in the shoulder girdle: relevance to tendon transfers. J Shoulder Elbow Surg, 8(5):430-437 Kim Y-S, Lee H-J, Park I, Sung GY, Kim D-J, Kim J-H (2018) Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon. Arthrosc Tech, 7(2):e97-e103 Koh KH, Han KY, Yoon YC, Lee SW, Yoo JC (2013) True anteroposterior (Grashey) view as a screening radiograph for further imaging study in rotator cuff tear. Journal of Shoulder Elbow Surgery, 22(7):901-907 Kovacevic D, Suriani Jr RJ, Grawe BM, et al. (2020) Management of irreparable massive rotator cuff tears: a systematic review and meta-analysis of patient-reported outcomes, reoperation rates, and treatment response. J Shoulder Elbow Surg, 29(12):2459-2475 Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. J biometrics:159-174 Makovicka JL, Patel KA, Tokish JM (2018) Superior capsular reconstruction with the addition of an acromial acellular dermal allograft spacer. Arthroscopy techniques, 7(11):e1181-e1190 Muh SJ, Streit JJ, Wanner JP, et al. (2013) Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am, 95(20):1877-1883 Mulieri P, Dunning P, Klein S, Pupello D, Frankle M (2010) Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am, 92(15):2544-2556 Oh JH, Park MS, Rhee SM (2018) Treatment strategy for irreparable rotator cuff tears. Clin Orthop Surg, 10(2):119-134 Omid R, Heckmann N, Wang L, McGarry MH, Vangsness Jr CT, Lee TQ (2015) Biomechanical comparison between the trapezius transfer and latissimus transfer for irreparable posterosuperior rotator cuff tears. J Shoulder Elbow Surg, 24(10):1635-1643 Omid R, Lee B (2013) Tendon transfers for irreparable rotator cuff tears. J Am Acad Orthop Surg, 21(8):492-501 Pogorzelski J, Fritz EM, Horan MP, et al. (2019) Minimum five-year outcomes and clinical survivorship for arthroscopic transosseous-equivalent double-row rotator cuff repair. J Am Acad Orthop Surg, 27(24):e1093-e1101 Puskas GJ, Catanzaro S, Gerber C (2014) Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder. J Shoulder Elbow Surg, 23(1):49-57 Reddy A, Gulotta LV, Chen X, et al. (2019) Biomechanics of lower trapezius and latissimus dorsi transfers in rotator cuff–deficient shoulders. J Shoulder Elbow Surg, 28(7):1257-1264 Rhee S-M, Youn S-M, Park JH, Rhee YG (2021) Biceps rerouting for semirigid large-to-massive rotator cuff tears. Arthroscopy, 37(9):2769-2779 Sirveaux F, Favard L, Oudet D, Huquet D (2005) Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. J Bone Joint Surg, 87(2):ADV62 Smith J, Padgett DJ, Dahm DL, et al. (2004) Electromyographic activity in the immobilized shoulder girdle musculature during contralateral upper limb movements. J Shoulder Elbow Surg, 13(6):583-588 Sugaya H, Maeda K, Matsuki K, Moriishi J (2007) Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg, 89(5):953-960 Valenti P, Werthel J-D (2018) Lower trapezius transfer with semitendinosus tendon augmentation: Indication, technique, results. Obere Extrem, 13(4):261 Vecchini E, Gulmini M, Peluso A, et al. (2021) The treatment of irreparable massive rotator cuff tears with inspace balloon: rational and medium-term results. Acta Biomed, 92(Suppl 3) Virk M, Nicholson G, Romeo A (2016) Irreparable rotator cuff tears without arthritis treated with reverse total shoulder arthroplasty.(ed)^(eds). Open Orthop J pp 296-308 Ye L, Han D, Zhang Q, Yang X, Tung T-H, Zhou X (2022) Early efficacy assessment of arthroscopic lower trapezius transfer with tendon autograft in the management of massive irreparable posterosuperior rotator cuff tears. Front Surg, 8:796359 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 May, 2025 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 08 Apr, 2025 Reviews received at journal 07 Apr, 2025 Reviewers agreed at journal 06 Apr, 2025 Reviews received at journal 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers invited by journal 06 Nov, 2024 Editor assigned by journal 02 Nov, 2024 Submission checks completed at journal 02 Nov, 2024 First submitted to journal 26 Oct, 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. 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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-5335586","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374797471,"identity":"a5e68582-caf8-4785-a0af-64367cfaad6b","order_by":0,"name":"Chang Hee Baek","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYLACxgYGBgl2IMFgYEGKFp4DIC0SpGiRSAAxidBicLz58GfeHXZykjOfX93wo0CCgb+9OwG/ljPH0qR5zyQbS0vnlN3sATpM4szZDfi13MgxY+ZtY06cJ52TdoMHqMVAIpeAlvtvjD/zttXXz5M8k3bzD1FagCZL87YdTpCWYD92myhbgGanSc49c9xwZk8O220ZAwkegn7hO3748Ie3O6rlJY4ff3bzzR8bOf72XvxaFA7AmTwGYBKvchCQb4Az2R8QVD0KRsEoGAUjEwAAe5BITc+HsjMAAAAASUVORK5CYII=","orcid":"","institution":"Yeosu Baek Hospital","correspondingAuthor":true,"prefix":"","firstName":"Chang","middleName":"Hee","lastName":"Baek","suffix":""},{"id":374797477,"identity":"d9b20aac-9fa9-4ce5-a4ad-c3b520370441","order_by":1,"name":"Chaemoon Lim","email":"","orcid":"","institution":"Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chaemoon","middleName":"","lastName":"Lim","suffix":""},{"id":374797478,"identity":"25b98faf-0b74-4078-9999-cc95a1520f56","order_by":2,"name":"Jung Gon Kim","email":"","orcid":"","institution":"Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jung","middleName":"Gon","lastName":"Kim","suffix":""},{"id":374797479,"identity":"ed8e7125-17be-4b8f-b39b-820827b315a6","order_by":3,"name":"Bo Taek Kim","email":"","orcid":"","institution":"Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"Taek","lastName":"Kim","suffix":""},{"id":374797480,"identity":"bd2f1b1f-7889-4cf0-9a72-3bfebc5463b3","order_by":4,"name":"Seung Jin Kim","email":"","orcid":"","institution":"Yeosu Baek Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Jin","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2024-10-26 05:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5335586/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5335586/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00402-025-05901-0","type":"published","date":"2025-05-12T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70043490,"identity":"e8375b77-976f-4c4f-8784-97a94d7dc610","added_by":"auto","created_at":"2024-11-27 18:38:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1548022,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative clinical photograph, plane radiograph, and magnetic resonance imaging (MRI) scans. The patient shows preoperative loss of forward elevation (A) and external rotation at 0˚ of abduction of the left shoulder (B). The preoperative anteroposterior simple radiograph showed no arthritic change in the shoulder joint (Hamada grade I) (C). Preoperative T2-weighted coronal image of MRI showed supraspinatus (SSP) tendon (asterisk) was displaced to the glenoid level (D). Preoperative T2-weighted oblique image of MRI shows severe fatty degeneration of the SSP and infraspinatus (ISP) tendon (E).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/ecc7514a4fea826c9d286dc6.png"},{"id":70043488,"identity":"d4071f6e-bebd-4f43-98bc-485f02dbd214","added_by":"auto","created_at":"2024-11-27 18:38:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":678296,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing patient selection. PSIRCT, posterosuperior irreparable rotator cuff tear; SSP, supraspinatus; ISP, infraspinatus; LD, latissimus dorsi; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic assisted lower trapezius tendon; LDTM, latissimus dorsi and teres major, MRI, magnetic resonance image.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/b15e57c11403cab8d56c98fb.png"},{"id":70043489,"identity":"693130d7-f0d1-4710-8549-f375d20d0bf7","added_by":"auto","created_at":"2024-11-27 18:38:52","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1605094,"visible":true,"origin":"","legend":"\u003cp\u003eArthroscopic preparation of greater tuberosity and harvesting of lower trapezius tendon. Arthroscopic image of the left shoulder shows a posterosuperior irreparable rotator cuff tear (A). The harvested lower trapezius tendon was prepared with the Krakow suture technique (B).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/806cd1f741f8d3bd41e4b8f5.png"},{"id":70043486,"identity":"87e51382-a483-4cb0-bd6f-e01a390c448a","added_by":"auto","created_at":"2024-11-27 18:38:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1658253,"visible":true,"origin":"","legend":"\u003cp\u003eAchilles tendon allograft harvest.\u003cem\u003e \u003c/em\u003eAchilles tendon allograft was prepared with Krakow sutures technique at the Achilles tendon – calcaneal bone junction.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/0fb334503ada15e3c63080f1.png"},{"id":70043467,"identity":"c6f4adf3-e0de-41a7-8dca-e4b0b7755110","added_by":"auto","created_at":"2024-11-27 18:38:47","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":2698941,"visible":true,"origin":"","legend":"\u003cp\u003eArthroscopic image and intraoperative photograph of the interpositional bridging graft fixation. The interpositional bridging graft was attached to the supraspinatus footprint (A). Anastomosis between interpositional bridging graft and lower trapezius tendon (LTT) was carried out in the shoulder position of maximal external rotation and 60° abduction for physiologic tensioning (B). The interpositional bridging graft was anastomosed along the inferior margin of the LTT using the Krakow method (C).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/0396ac1256d4f83b76d9e31c.png"},{"id":70043487,"identity":"a8662bd5-edfb-45aa-82fc-46d161a159fb","added_by":"auto","created_at":"2024-11-27 18:38:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1218071,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative clinical photograph and magnetic resonance imaging of transferred graft. The patient shows restoration of forward elevation (A) and external rotation at 0˚ of abduction of left shoulder (B).Postoperative T1-weighted oblique axial (A) and coronal (B) views demonstrate normal integrity of transferred graft (asterisk).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/c7870ebc084d0454e50aa3f8.png"},{"id":70043491,"identity":"74c548fd-512f-4573-91ad-4e2fcb07beba","added_by":"auto","created_at":"2024-11-27 18:38:52","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":1337889,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative anteroposterior simple radiograph of reverse shoulder arthroplasty (A) and clinical presentation. The patient exhibits no restoration of active external rotation of the right shoulder (B).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/b6fb6c648568c51c688f627f.png"},{"id":83068504,"identity":"0ee33b89-a08e-4809-8f18-170bba2d043d","added_by":"auto","created_at":"2025-05-19 16:10:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":18727916,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5335586/v1/31913688-9aa4-4df7-abdb-e4cea87b5533.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Arthroscopic Assisted Lower Trapezius Tendon Transfer versus Reverse Shoulder Arthroplasty in Patients with Posterosuperior Irreparable Rotator Cuff Tear without Arthritis: Propensity score Matching Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eShoulder dysfunction, including loss of active forward elevation (FE) and external rotation (ER), is a challenge in posterosuperior irreparable rotator cuff tears (PSIRCTs).[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] The optimal management of active FE and ER loss in PSIRCTs patients without arthritis remains a debated topic.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] There are several surgical options for PSIRCTs, such as arthroscopic debridement, partial repair with/without augmentation. biceps rerouting, superior capsular reconstruction, and subacromial balloon spacer.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e] However, these treatments are limited to restoring the active range of motion (ROM) of the shoulder.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] There are several tendon transfers for alleviating shoulder pain and improving shoulder function in PSIRCTs. Recently, lower trapezius tendon (LTT) transfer has attracted interest as an effective management for the restoration of glenohumeral kinematics, including superior-inferior and anterior-posterior force coupling in PSIRCTs.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Moreover, reverse shoulder arthroplasty (RAS) has been reported as a possible treatment for PSIRCTs.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eLTT transfer has become a joint-saving treatment for PSIRCTs patients.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] Recently, arthroscopically-assisted LTT (aLTT) transfer reportedly, has favorable clinical outcomes and fewer complications associated with the open approach.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Significant pain relief and functional improvement, especially for external rotation (ER), were observed after aLTT transfer in PSIRCTs.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Good clinical outcomes are believed to result from the biomechanical efficacy of aLTT transfer. In a biomechanical study, it was confirmed that glenohumeral kinematics and joint reaction force were restored after aLTT transfer in PSIRCTs.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] Therefore, the rebalancing of the force couple in the coronal (compressive-distractive) and transverse (anterior-posterior) plane may have contributed to the dynamic joint centering effect.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Thereby, a viable treatment option for PSIRCTs patients may be the aLTT.\u003c/p\u003e \u003cp\u003eFurthermore, RSA has been a widely preferred treatment option for irreparable rotator cuff tear or rotator cuff tear arthropathy.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Recently, several studies reported that RSA can be a treatment option for irreparable massive rotator cuff tears without glenohumeral arthritis.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] In an irreparable massive rotator cuff tear, the restoration of internal rotation (IR) and ER of the shoulder has been limited even though RSA shows good clinical outcomes and reliable restoration of range of motion (ROM) of the shoulder.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Moreover, a lateralized reverse shoulder prosthesis may be insufficient to restore ER in irreparable massive rotator cuff tears.[5; 29] High rates of complication, including loosening of implant, are the major cause of failure in relatively young patients (under 65-year-old).[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThere is no clinical comparative study between RSA and aLTT transfer in PSIRCTs; however, RSA and aLTT transfer can be selected for PSIRCTs patients without arthritis. In this study, we compared the clinical outcomes of aLTT transfer and RSA in patients with active high-demand PSIRCTs with no arthritis. We hypothesized that aLTT transfer would have similarly good clinical outcome as RSA, whereas aLTT transfer may show better results in the ER.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed the cases of patients with PSIRCTs who underwent surgery between January 2017 and December 2020. This study received approval from institutional review board (No. P01-202407-01-055).\u003c/p\u003e \u003cp\u003eThe diagnostic criteria for PSIRCT were as follows: (1) massive posterosuperior rotator cuff (combined supraspinatus [SSP] and ISP) tears, (2) severe medial displacement of SSP (Patte classification III) on magnetic resonance image (MRI), (3) high-grade fat infiltration in SSP and ISP (Goutallier fat infiltration (FI) grade of III or IV) (4) intact or reparable subscapularis (SSC) with Goutallier FI grade of I or II.\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: (1) symptomatic PSIRCT with severe pain and/or shoulder dysfunction that disturbs daily activity, (2) failed conservative treatment, (3) underwent surgical treatment, and (4) little or no progressive arthritic change in the shoulder joint (Hamada grade I or II) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients who underwent partial repair, partial repair with augmentation, superior capsular reconstruction (SCR), or posterior latissimus dorsi (LD) tendon transfer were excluded.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe decision to perform RSA or aLTT was made according to the patient\u0026rsquo;s overall condition, such as patient\u0026rsquo;s willingness to rehabilitate and return to their previous work, desired activity level, and medical comorbidity. The mechanism, surgical procedure, skin incision, possible complications, advantage and disadvantage of RSA or aLTT technique was explained to patients before the operations. In most cases, RSA or aLTT was performed according to the patient\u0026rsquo;s decision.\u003c/p\u003e \u003cp\u003eIn total, 103 patients underwent, RSA, and 101 underwent aLTT tendon transfer for PSI RCTs between January 2017 and December 2020. We excluded patients who had surgical treatment using RSA with non-lateralized glenoid or non-lateralized humeral prostheses (n\u0026thinsp;=\u0026thinsp;47), RSA with LD tendon transfer with or without teres major tendon transfer (n\u0026thinsp;=\u0026thinsp;5), were lost to follow-up at 2 years (n\u0026thinsp;=\u0026thinsp;4) or had incomplete clinical data (n\u0026thinsp;=\u0026thinsp;13). In total, 143 patients were initially enrolled for propensity score matching (PSM) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a significant difference in the variables used for matching before PSM (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \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 of patients before propensity score matching\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=\"left\" 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\u003eRSA Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaLTT 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\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \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\u003e72.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\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\u003e25 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (33.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.013\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\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.159\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\u003e41 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99 (98.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.745\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 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (13.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.921\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\u003e10 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (19.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.544\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\u003e19 (45.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHamada 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\u003e13 (31.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (40.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.361\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\u003e29 (69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 (60.4)\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\u003eSSC fatty infiltration 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 \u003cp\u003e0.032\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 (59.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (78.2)\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 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (40.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (22.8)\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\u003eSSP fatty infiltration 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 \u003cp\u003e0.058\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\u003e18 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (61.4)\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\u003e24 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40 (39.6)\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\u003eISP fatty infiltration 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 \u003cp\u003e0.884\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\u003e14 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (42.6)\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\u003e28 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 (58.4)\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\u003eTm fatty infiltration 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 \u003cp\u003e0.016\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\u003e23 (54.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (55.4)\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 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (14.9)\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 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (9.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (16.8)\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\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (12.9)\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; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; SD, standard deviation; BMI, body mass index; 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 \u003c/div\u003e\n\u003ch3\u003ePropensity score matching\u003c/h3\u003e\n\u003cp\u003ePSM was used to minimize the selection bias between surgical treatment, RAS, or aLTT transfer. The matching was performed in triplicates. First, the propensity score was assessed using multivariate logistic regression analysis regarding factors affecting surgical options or clinical outcomes, including age, sex, dominant hand, and FI grade. Second, a greedy matching was performed with a caliper of 0.2 times \u0026times; standard deviation. In this step, each patient included in the RSA was paired with another who underwent combined aLTT transfer. Finally, the balance in factor distribution was checked between the two groups, and the absolute standard mean difference of 0.1 or 0.25 represents an acceptable balance. Propensity score matching was conducted with R program (version 13.0; R Development Core Team, Vienna, Austria). After PSM, 26 patients of each group were matched for analysis. Differences did not differ significantly. in age, sex, dominant hand, FI grade and follow-up periods between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eDemographic and clinical characteristics of patients after propensity score matching\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=\"left\" 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\u003eRSA Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaLTT 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\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \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\u003e68.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.085\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\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.694\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\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\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=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.159\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\u003e25 (96.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.745\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\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.921\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\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.544\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\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHamada 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\u003e11 (42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.361\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\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (42.3)\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\u003eSSC fatty infiltration 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 \u003cp\u003e0.083\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\u003e18 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (72.1)\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 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (26.9)\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\u003eSSP fatty infiltration 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 \u003cp\u003e0.098\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\u003e10 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (38.5)\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 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (61.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (61.5)\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\u003eISP fatty infiltration 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 \u003cp\u003e0.276\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\u003e9 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (30.8)\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\u003e- Grade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (69.2)\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\u003eTm fatty infiltration 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 \u003cp\u003e0.070\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\u003e15 (57.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (50.0)\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\u003e- Grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\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 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\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\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 919.2)\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\u003ePseudoparalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5)\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\u003eMean f/u period, months (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.0\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.569\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; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; SD, standard deviation; BMI, body mass index; 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\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eA single experienced senior surgeon (XXX) performed all surgical procedures.\u003c/p\u003e\n\u003ch3\u003eReverse shoulder arthroplasty procedure\u003c/h3\u003e\n\u003cp\u003eA Beach chair position was used to prepare the patients under the general anesthesia and interscalene brachial plexus block. A lateralized humeral head and glenoid prosthesis (Comprehensive Reverse Shoulder System) were used in all patients. A skin incision of was made in the coracoid process along the deltopectoral groove approximately 10\u0026thinsp;~\u0026thinsp;12 cm, using the deltopectoral approach. With caution, the cephalic vein was mobilized medially or laterally according to the tension. After identification of the deltoid and pectoralis major muscle, the deltoid muscle was pulled laterally and the pectoralis major muscle was pulled medially. The musculocutaneous nerve is preserved before the conjoint tendon is retracted. The long-head biceps tendon (LHBT) underwent tenotomy and tenodesis after final prosthesis implantation. The SSC tendon was released carefully from the lesser tuberosity (LT) and preserved for reattachment.\u003c/p\u003e \u003cp\u003eAfter dislocation of glenohumeral joint, a head resection was performed using a cutting guide with a 132.5 \u0026deg;inclination and 20 \u0026deg;retroversion. After humeral head resection, humeral canal preparation was performed with reamers in 1 mm increase until cortical contact. This procedure was performed carefully to preserve the cancellous bone for press-fit fixation of the humeral stem. Subsequently, three suture loops were passed around the humeral metaphysis for reattachment of the subscapularis after the final impaction of the humeral stem.\u003c/p\u003e \u003cp\u003eExtensive circumferential capsulectomy was performed to prepare the glenoid. The glenoid labrum, cartilage, and inferior glenoid osteophytes were removed. After confirming the glenoid orientation, a central hole was positioned with a stopper drill. The glenoid was scraped using a glenoid-resurfacing reamer. The baseplate was placed at the inferior glenoid and tilted inferiorly to avoid the scapular notch. Following this procedure, the humeral stem was placed downward through the humerus. The humerus was reduced in the glenosphere after placing the humeral stem, and the SSC tendon was reattached at the insertion point of the LT using suture loops.\u003c/p\u003e \u003cp\u003eAfter RSA, arm sling was applied to all patients for 6 weeks immobilization. After 6 weeks, passive ROM was started and progressed to aROM, as tolerated under the standard physical therapy protocol. Then, gentle strengthening exercises were allowed, and return to previous level of activities were encouraged at postoperative six months.\u003c/p\u003e\n\u003ch3\u003eArthroscopy-assisted lower trapezius tendon transfer\u003c/h3\u003e\n\u003cp\u003eThe patients were placed in the lateral decubitus position on the operating table after the induction of general anesthesia with an interscalene nerve block, and the operative arm was pulled with a traction device. An arthroscopic diagnostic examination was performed using four standard 4 portals (posterior, anterior, lateral, and posterolateral). We further assessed the repairability and mobility of the rotator cuff tendons after removing the non-viable scar tissue around the torn rotator cuff. Regarding reparable SSC, the SSC was repaired. Despite the soft tissue release and interval sliding technique, if the SSP and ISP could not be reduced to the footprint, PSIRCTs were diagnosed, and the patient decided to undergo aLTT transfer (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003eSeveral preparations were made before aLTT transfer. First, subacromial decompression was performed to prevent the wear of the interpositional bridging graft, which could be irritated by the subacromial spur during the excursion of the transferred tendon. LHBT was managed using tenotomy, tenodesis, or superior capsular reconstruction according to biceps-associated clinical symptoms, physical examination, or biceps pathology including degeneration, subluxation, or tear. Notably, the footprints of the SSP and ISP were prepared from the cartilage of the humeral head to the lateral aspect of the GT until the subchondral bone was exposed. The graft-bone healing was promoted by extending the footprint area and exposing the subchondral bone of the GT. We further developed an interval space that transferred the LTT passes between the deltoid and remnant ISP.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition, an Achilles tendon allograft was utilized as the interpositional bridging graft. Calcaneal bony portion was removed. One end of the Achilles tendon allograft was prepared with the Krakow suturing method. The Krakow sutures were attached to SSP footprint, and the other side of the Achilles tendon allograft was sutured to the inferior border of the LTT by using the Krakow suture method (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTwo medial row anchors were inserted into the SSP footprint near the prepared cartilage margin of the GT. One anchor was inserted at anterior portion and the other was posterior portion of SSP footprint. Three threads of posterior medial-row anchors were pierced through the ISP remnant utilizing Suture Lasso. These three threads were used for side-to-side sutures with the interpositional bridging graft. The other three threads were taken out through the posterolateral portal and pierced through an interpositional bridging graft for attachment to the SSP footprint. A large grasper was inserted from the lateral portal to the infraspinatus fascia of the skin incision, allowing the passage of the interpositional bridging graft. A Krakow sutures of the interpositional bridging graft was grasped and taken out through the lateral portal. The interpositional bridging graft was placed on the SSP footprint and fixed with posterior and anterior medial row anchors. Then, a side-to-side suture between posterior ISP remnant and interpositional bridging graft was made by tie the threads through the posterior ISP remnant and interpositional bridging graft. Three lateral row anchors were inserted at the anterolateral, mid-lateral, and posterolateral aspects of GT using the suture bridge technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter aLTT transfer, the shoulder abduction brace was maintained at 0 \u0026deg;ER for 6 weeks after aLLT transfer. The patient performed only flexion and extension ROM exercises of the elbow, wrist, and fingers, during this period. However, patients were prohibited from performing internal rotation to avoid damage to the transferred tendon. The patients were further allowed to take off the brace and encouraged to start gentle passive ROM exercises for 4 weeks. After then, full ROM and gentle strengthening exercises started after at least 3 months postoperatively. Sports and high-level activities were allowed at 6 months postoperatively according to the preoperative activity levels and the patient\u0026rsquo;s willingness.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical evaluation\u003c/h2\u003e \u003cp\u003eThe visual analog scale (VAS) score for pain, active ROM (aROM), and patient-reported outcome measurements were used to evaluate preoperative and postoperative clinical outcomes. Pain was measured at a subjective level using a 10-point VAS score. The aROM including forward elevation, abduction, ER at 0\u0026deg; abduction, and ER at 90\u0026deg; abduction, was measured using a standard goniometer. In addition, the IR was evaluated as the height at which the patient\u0026rsquo;s thumb reached the back when the patient rotated the arm internally backward (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; and 10, T7). The patient-reported clinical outcomes were evaluated preoperatively and postoperatively with activities of daily living using active external rotation (ADLER) score, University of California Los Angeles (UCLA) shoulder score, American Shoulder and Elbow Surgeons (ASES) score, and constant shoulder score. Furthermore, aROM was evaluated at every visit of outpatient department. The strength of ER and IR was evaluated using a hand-held dynamometer. Patients were positioned supine with shoulder 45\u0026deg; abduction and elbow 90\u0026deg; flexion. The dynamometer was placed on the volar and dorsal aspects of the wrist to measure ER and IR strength. All patients reported clinical outcome, and measurements were collected by a research coordinator. In addition, complications including nerve injury, infection, fracture, dislocation and infection were collected.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRadiologic evaluation\u003c/h3\u003e\n\u003cp\u003eRadiological outcomes were evaluated using plane radiography and MRI scans. Pre- and postoperative plane radiographs, including true anteroposterior (AP) (Grashey)[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] were taken. The acromiohumeral distance (AHD) was measured as the shortest distance between the inferior cortex of the acromion undersurface and the top of the humeral head in the true AP view at preoperative period and postoperative 2 years. In addition, arthritic changes of the shoulder joint were assessed using the Hamada grade in true AP view. Grades 3, 4, or 5 at the last follow-up indicated the progression of arthritic changes. The postoperative AHD and Hamada grades were evaluated in the aLTT group.\u003c/p\u003e \u003cp\u003eFurthermore, the fatty degeneration of the rotator cuff muscles (SSC, SSP, ISP, and teres minor) were evaluated using the Goutallier[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] grading system in sagittal oblique images of preoperative MRI scans. Postoperative MRI was performed at 6 months, 1 year, and 2 years to evaluate the graft integrity in aLTT group. The transferred graft was assessed with Sugaya classification [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]; types IV and V were considered as re-tear of graft. Although the Sugaya classification originally was used for integrity of repaired rotator cuff, complete discontinuity of the graft was defined re-tear according to the Sugaya classification types IV and V.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the Statistical Package for Social Sciences for Windows (version 11.0; SPSS Inc., Chicago, Illinois, USA). The significance level was set at 95%. Preoperative and postoperative continuous data were analyzed using the Wilcoxon signed-rank test and categorical data were analyzed using McNemar\u0026rsquo;s test. Furthermore, continuous data between the two groups were analyzed using the Nonparametric Mann\u0026ndash;Whitney U test. However, categorical data between the groups were analyzed using Fisher\u0026rsquo;s exact test. The inter-observer reliabilities of the radiographic measurements (AHD and Hamada grade) were evaluated using the intraclass correlation coefficient (ICC)[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Two authors measured the preoperative and last follow-up AHD and Hamada grades to evaluate inter-observer reliability.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003ePostoperative clinical outcomes were significantly improved in both groups. However, the postoperative ADLER (20.6 \u0026plusmn; 4.0 vs. 27.3 \u0026plusmn; 3.7, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) of aLTT group were significantly better than that of RSA group. Similarly, postoperative ROM was significantly improved in both groups, and the mean postoperative ER at 0˚ of abduction (34.2 \u0026plusmn; 13.2 vs. 47.5 \u0026plusmn; 11.1, \u003cem\u003ep\u003c/em\u003e = .001) and ER at 90˚ of abduction (49.6 \u0026plusmn; 15.4 vs. 66.5 \u0026plusmn; 19.5, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) of aLTT group were significantly better than that of RSA group. All patients with preoperative pseudoparalysis in both groups showed improvements. The final follow-up ER strength of aLTT group was significantly better than that of RSA group (16.4 \u0026plusmn; 4.0 vs. 24.1 \u0026plusmn; 9.1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) (Table 3) (Fig 6 and 7).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv\u003e\n \u003cdiv align=\"left\"\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eComparisons in clinical outcomes between the two surgical groups\u003c/div\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRSA Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eaLTT Group\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVAS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.551\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.233\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConstant score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e72.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eASES score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.260\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e79.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUCLA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.912\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADLER\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.463\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive FE, ˚\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e113.8\u0026thinsp;\u0026plusmn;\u0026thinsp;34.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e119.0\u0026thinsp;\u0026plusmn;\u0026thinsp;30.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e150.4\u0026thinsp;\u0026plusmn;\u0026thinsp;21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e154.2\u0026thinsp;\u0026plusmn;\u0026thinsp;20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.531\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eABD, ˚\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.3\u0026thinsp;\u0026plusmn;\u0026thinsp;38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.3\u0026thinsp;\u0026plusmn;\u0026thinsp;29.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.103\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138.8\u0026thinsp;\u0026plusmn;\u0026thinsp;24.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e131.2\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.081\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eER at 0˚ of abduction, ˚\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eER at 90˚ of abduction, ˚\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.2\u0026thinsp;\u0026plusmn;\u0026thinsp;19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIR at back\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.104\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePseudoparalysis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.530\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStrength, N\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIR at side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.384\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eER at side\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; RSA, reverse shoulder arthroplasty; aLTT, arthroscopic lower trapezius tendon; 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; Internal rotation was measured as the level that could be reached by the thumb (0, greater trochanter; 2, buttock; 4, lumbosacral junction; 6, L3; 8, T12; 10, T7).\u003c/p\u003e\n\u003cp\u003eThe interobserver reliability for preoperative and postoperative AHD (ICC\u003csub\u003epre\u0026minus;AHD\u003c/sub\u003e = 0.91 [0.86\u0026ndash;0.95], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, ICC\u003csub\u003epost\u0026minus;AHD\u003c/sub\u003e = 0.92 [0.88\u0026ndash;0.95], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and Hamada grade (ICC\u003csub\u003epre\u0026minus;Hamada\u003c/sub\u003e = 0.85 [0.79\u0026ndash;0.90], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, ICC\u003csub\u003epost\u0026minus;Hamada\u003c/sub\u003e = 0.93 [0.86\u0026ndash;0.96], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) were all excellent. [\u003cspan\u003e10\u003c/span\u003e] In aLTT group, no significant decrease of AHD change (preoperatively 9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 to postoperatively 8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.256) and no significant progression of cuff tear arthropathy (Hamada grade: preoperatively 1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 to postoperatively 1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.798) were observed (Table \u003cspan\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 4\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eRadiologic outcome of arthroscopic lower trapezius tendon transfer group\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOutcomes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePreoperative (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePostoperative\u003c/p\u003e\n \u003cp\u003e(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAHD (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.256\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHamada grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.798\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*Significant p-value is \u0026lt;\u0026thinsp;0.05; SD, standard deviation; AHD, acromiohumeral distance\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFurthermore, two patients had acromial fractures in the RSA group, and all were treated conservatively. Two patients experienced transient axillary nerve palsy in the aLTT group; however, the nerve palsy was fully recovered after three months. In addition, two patients had a partial tear of transferred graft and one patient had a complete re-tear of the transferred graft at the final follow-up in the aLTT group. All graft tear occurred at medial to the footprint.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe loss of FE and ER is a challenging problem for PSIRCTs patients without arthritis, among shoulder dysfunctions. In this study, we evaluated the clinical outcomes and ROM recovery between aLTT transfer and RSA in PSIRCTs patients without arthritis. We confirmed that ADLER, ER at 0\u0026deg; of abduction, and ER at 90\u0026deg;, and ER strength were superior in the aLTT group than in the RSA group. However, no significant decrease in AHD changes or progression of arthritic changes was observed in the aLTT group. Therefore, aLTT transfer could be a first-line, joint-saving treatment for PSIRCTs patients without arthritis.\u003c/p\u003e \u003cp\u003eRSA is a commonly used and effective management for massive irreparable rotator cuff tears,[23; 24] particularly effective in restoring coronal plane muscle imbalance and FE by improving deltoid power against weak superior rotator cuff muscle.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] However, RSA could not restore the axial plane muscle imbalance and ER in the case of poor posterior cuff (ISP and Tm) muscle.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Resulting from weak ER rotator cuff muscles (ISP and Tm) being unable to provide counterforce to the strong IR muscles (SSC, latissimus dorsi and teres major).[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] The patient who underwent RSA and had weak ER rotator cuff muscle complained of difficulty in activities of daily living, including eating, drinking, or hair washing.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Several studies reported that the lateralized prosthetic design could restore the active ER.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] However, another study pointed out that lateralized prosthetic design could restore the active ER, only if the posterior ER rotator cuff muscle was functional. In its absence, the posterior portion of the deltoid muscle cannot provide a counterforce to the strong IR muscles.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Moreover, a lateralized prosthetic design may increase the risk of prosthetic loosening because the lateralized center of rotation increases the shear force in the glenoid. In contrast, RSA with combined latissimus dorsi and teres major (cLDTM) tendon transfer is effective in restoring active ER in weak posterior rotator cuff muscles. Furthermore, in RAS with cLDTM tendon transfer, the RSA could restore the coronal plane force couple, and the transferred LDTM could restore the transverse plane force couple.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] In this study, ADLER and ER at 0\u0026deg; of abduction, ER at 90\u0026deg; of abduction, and ER strenth were significantly inferior in the RSA group compared with the aLTT group. However, the lateralized RSA could not provide a counterforce to the strong IR muscle in the poor posterior rotator cuff muscle on PSIRCTs.\u003c/p\u003e \u003cp\u003eThe complications after RSA may be that its application is limited in patients with active, high-demand without arthritis. RSA showed pain relief and functional improvement in patients with low-grade osteoarthritis for 10\u0026ndash;15 years; however, high adverse events (notching or implant loosening) rate of up to 39% deteriorated the functional improvement.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Moreover, relatively young male patients (\u0026lt;\u0026thinsp;65 years) should be careful when performing RSA because implant loosening may be the main cause of RSA failure.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] As a result, RSA may not be appropriate for patients with active high-demand PSIRCTs without arthritis.\u003c/p\u003e \u003cp\u003eFurthermore, aLTT transfer is an effective treatment for restoring active ER of the shoulder in these patients.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] It is because aLTT transfer follows the principle of tendon transfer and has a biomechanical advantage.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The line of pull of transferred LTT is closely similar to that of native ISP (posterior ER rotator cuff muscle).[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] The excursion and tension of LTT are adequate to replace the function of ISP.[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Furthermore, the in-phase contraction of LTT during ER make possible retention of LTT in patients because the LTT functions during shoulder ER.[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] In a biomechanical study, LTT transfer recovered the joint reaction force and glenohumeral kinematics in the transverse (anterior-posterior) plane.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] In the three-dimensional kinematic study, LTT promotes scapular ER by normalizing scapularthoracic motion because the insertion of LTT is the medial aspect of the scapular spine.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] This sticks to the principle of tendon transfer, and the biomechanical advantage of aLTT transfer makes restoring active ER of the shoulder possible in PSIRCTs patients without arthritis.\u003c/p\u003e \u003cp\u003eMoreover, aLTT transfer is also an effective treatment for restoring active FE of the shoulder in patients with active high-demand PSIRCTs without arthritis.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] In the biomechanical study, LTT transfer restored the joint reaction force and glenohumeral kinematics in the coronal (compressive and distractive) plane and mimicked the intact supraspinatus.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] Recently, the static spacing effect improving glenohumeral kinematics by supressing the humeral head has gained attention because improving the FE against the deltoid force is important.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] The transposition of LTT through the subacromial space and attachment to the SSP footprint makes static spacing and dynamic joint centering effects in PSIRCTs.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In this study, LTT was transposed through the subacromial space to restore superior stability by creating a static spacing effect. Moreover, to increase this static spacing effect, we attached the interpositional bridging graft to the SSP footprint rather than to the ISP footprint. The static spacing effect is crucial in active FE as a humeral head depressor against the powerful force exerted by the deltoid muscle.\u003c/p\u003e \u003cp\u003eSeveral adverse events, including nerve injury, infection, hematoma formation, and re-tear of transferred graft, may occur after aLTT transfer.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] However, there was no irreversible adverse events in this study. One patient experienced axillary nerve palsy, which was recovered after three months. two patients had a partial tear of transferred graft and one patient had a complete re-tear of the transferred graft at the final follow-up of the aLTT transfer. These patients did not complain of any discomfort due to pain or limited ROM.\u003c/p\u003e \u003cp\u003eThis study has some limitations. Because of its retrospective nature, patients were not randomly grouped according to RSA or aLTT transfer. The deciding whether to perform RSA or aLTT transfer was influenced by various factors, such as patients\u0026rsquo; intension for rehabilitation, willingness of return to work, previous activity level, and existing medical conditions. The significant differences in preoperative demographics between the two groups were adjusted using PSM; however, a performance bias or selection bias may occur by this limitation. The small study population and the short study period may have decresed the validity of this study. Nevertheless, to our knowledge, this study is the first to present comparative results after RSA and aLTT transfer in PSIRCTs.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLateralized RSA and aLTT improved overall patient outcomes postoperatively; however, aLTT transfer was superior in clinical scores, notably the ADLER score, ER of aROM, and ER strength in patients with PSIRCTs. Our findings suggest that aLTT could be a first-line joint-preserving treatment option for PSIRCTs patients without arthritis, given the longevity and related adverse events associated with arthroplasty.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConflict of interest disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial conflict of interest with regard to the content of this report\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaek CH, Kim BT, Kim JG, Kim SJ (2024) Mid-term outcomes of arthroscopically assisted lower trapezius tendon transfer using Achilles allograft in treatment of posterior-superior irreparable rotator cuff tear. J Shoulder Elbow Surg, 33(6):1293-1305\u003c/li\u003e\n\u003cli\u003eBaek CH, Lee DH, Kim JG (2022) Latissimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears. J Shoulder Elbow Surg, 31(9):1810-1822\u003c/li\u003e\n\u003cli\u003eBaek CH, Lim C, Kim JG (2022) Superior capsular reconstruction versus lower trapezius transfer for posterosuperior irreparable rotator cuff tears with high-grade fatty infiltration in the infraspinatus. Am J Sports Med, 50(7):1938-1947\u003c/li\u003e\n\u003cli\u003eBerhouet J, Samargandi R, Jacquot A, Favard L, Boileau P, Gauci M-O (2024) Restoration of Internal Rotation After Reverse Shoulder Arthroplasty May Vary Depending on Etiology in Patients Younger Than 60 Years Old: A Multicenter Retrospective Study. 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SLACK Incorporated Thorofare, NJ, Orthopedics, pp 129-133\u003c/li\u003e\n\u003cli\u003eCarver TJ, Kraeutler MJ, Smith JR, Bravman JT, McCarty EC (2018) Nonarthroplasty surgical treatment options for massive, irreparable rotator cuff tears. Orthop J Sports Med, 6(11):2325967118805385\u003c/li\u003e\n\u003cli\u003eCicchetti DV, Sparrow SA (1981) Developing criteria for establishing interrater reliability of specific items: applications to assessment of adaptive behavior. Am J Ment Defic, 86(2):127-137\u003c/li\u003e\n\u003cli\u003eElhassan BT, Sanchez-Sotelo J, Wagner ER (2020) Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. J Shoulder Elbow Surg, 29(10):2135-2142\u003c/li\u003e\n\u003cli\u003eElhassan BT, Wagner ER, Werthel J-D (2016) Outcome of lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tear. 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Front Surg, 8:796359\u003c/li\u003e\n\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":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"posterosuperior irreparable rotator cuff tear, reverse shoulder arthroplasty, lower trapezius tendon transfer, external rotation","lastPublishedDoi":"10.21203/rs.3.rs-5335586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5335586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eShoulder dysfunction, including loss of active forward elevation (FE) and external rotation (ER), is challenging in posterosuperior irreparable rotator cuff tears (PSIRCTs). We compared the clinical outcomes of reverse shoulder arthroplasty (RSA) and arthroscopy-assisted lower trapezius tendon transfer (aLTT) in PSIRCTs patients without arthritis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterial and Methods: \u003c/strong\u003eApproximately\u003cstrong\u003e \u003c/strong\u003e29 patients were included in each group(RSA group and aLTT group), using propensity score matching based on demographic variables with a minimum 2-year follow-up period. Clinical results were compared with the visual analogue scale score, Constant shoulder score, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and activities of daily living requiring active external rotation (ADLER) score, active range of motion and rotational strength between the two groups. Subsequently, the arthritic change of shoulder joint was evaluated using the acromiohumeral distance (AHD) and Hamada grade.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The clinical outcomes were significantly improved in both groups. However, ADLER score (20.6 ± 4.0 vs. 27.3 ± 3.7, \u003cem\u003ep\u003c/em\u003e \u0026lt;.001), ER at 0˚ of abduction (34.2 ± 13.2 vs. 47.5 ± 11.1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), ER at 90˚ of abduction (49.6 ± 15.4 vs. 66.5 ± 19.5, \u003cem\u003ep\u003c/em\u003e \u0026lt;.001) and ER strength (16.4 ± 4.0 vs. 24.1 ± 9.1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) of aLTT group were significantly better than that of RSA group. No significant increase of AHD and no significant progression of arthritis change were observed in aLTT group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eAlthough both RSA and aLLT improved overall patient outcomes postoperatively, aLTT was superior inclinical scores, notably the ADLER score, active ER, and ER strength in PSIRCTs patients without arthritis. These findings suggest that aLTT \u0026nbsp;could be a first-line joint-preserving treatment option for PSIRCTs patients without arthritis, given the longevity and related complications associated with arthroplasty.\u003c/p\u003e","manuscriptTitle":"Efficacy of Arthroscopic Assisted Lower Trapezius Tendon Transfer versus Reverse Shoulder Arthroplasty in Patients with Posterosuperior Irreparable Rotator Cuff Tear without Arthritis: Propensity score Matching Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-27 18:38:40","doi":"10.21203/rs.3.rs-5335586/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-08T07:39:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-07T16:00:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50245716263563135526120709961901310378","date":"2025-04-06T11:31:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-06T10:49:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62258318361945780691192731003714706116","date":"2024-11-06T10:44:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-06T10:39:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-02T06:44:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-02T06:43:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2024-10-26T05:02:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"88582d06-2ed7-4d46-8d17-6db243f76ab3","owner":[],"postedDate":"November 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:08:33+00:00","versionOfRecord":{"articleIdentity":"rs-5335586","link":"https://doi.org/10.1007/s00402-025-05901-0","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2025-05-12 15:57:46","publishedOnDateReadable":"May 12th, 2025"},"versionCreatedAt":"2024-11-27 18:38:40","video":"","vorDoi":"10.1007/s00402-025-05901-0","vorDoiUrl":"https://doi.org/10.1007/s00402-025-05901-0","workflowStages":[]},"version":"v1","identity":"rs-5335586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5335586","identity":"rs-5335586","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}