Adding a tendon transfer to a reverse shoulder restored external rotation in four of five shoulders

Design

retrospective single-technique case series, Level IV therapeutic evidence

Population

27 reverse shoulder arthroplasties with allograft-prosthetic composite and lower trapezius transfer, 2019-2023; 26 followed a mean of 2.7 years

Primary outcome

active external rotation and elevation, and complications requiring surgery

Effect

active external rotation past neutral in 15% before and 80% of surviving shoulders after; mean active elevation 79°; revision or reoperation for humeral complications 15%

Proximal humeral bone loss with posterosuperior cuff deficiency is among the hardest shoulder problems: a reverse arthroplasty can restore elevation but leaves the patient unable to rotate the arm outwards, which is what makes eating, dressing and reaching functional. Two surgeons performed 27 reverse shoulder arthroplasties using an allograft-prosthetic composite combined with a lower trapezius transfer, passing cuff-capsule allograft tissue posterior to the glenosphere and securing it to the harvested lower trapezius. Twenty-six shoulders were followed for a mean of 2.7 years.

Active external rotation past neutral rose from 4 of 27 shoulders (15%) before surgery to 80% of surviving shoulders at latest follow-up. Elevation improved less impressively: 11 shoulders had been pseudoparalytic before surgery and 3 still were, with mean active elevation of 79 degrees across the 25 assessable shoulders.

The complication rate is the number to weigh against that. Revision or reoperation for humeral complications ran at 15% - two secondary bone grafts, one resection for infection, one periprosthetic fracture fixation - with a further four operations for haematoma, dislocation and glenosphere disassociation. This is a Level IV series of 27 shoulders performed by two surgeons in a salvage population where the alternatives are poor, so the complication rate is not the objection it would be in primary arthroplasty. What it does mean is that this belongs in high-volume hands, and that the patient should be consented for external rotation rather than for elevation.

• Consider lower trapezius transfer at the time of reverse arthroplasty where proximal humeral bone loss coexists with posterosuperior cuff deficiency
• Consent specifically for external rotation - that is what improved; elevation largely did not
• Quote a reoperation rate around 15% for humeral complications alone, with further surgery for haematoma, dislocation and glenosphere problems
• Refer rather than attempt this outside a high-volume revision shoulder practice
• Note the follow-up is a mean of 2.7 years, so durability of the transfer beyond that is unknown

Why it matters

It targets the function a reverse arthroplasty characteristically fails to restore.

Don't overread it

A retrospective Level IV series by two surgeons with no comparison group and a mean follow-up under three years.

The statistics, in plain English

Twenty-seven shoulders is a technique series, not a comparison - there is no control arm, so the improvement cannot be separated from what the arthroplasty alone would have achieved, though the near-total absence of external rotation beforehand makes that objection weaker than usual. Level IV evidence means uncontrolled and retrospective. The 80% figure is 'of surviving shoulders', so it excludes the resected one and reads slightly better than an intention-to-treat figure would.

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