Hello, everyone. Thank you very much for having me. I'm sorry I could not be there with you in person. I'll be presenting to you today about lower trapezius transfer, and based on my discussion with Rafi, we're going to focus on the technical aspect of it. So how do we do it? How do we do our SALT, Scope Assisted Lower Trapezius Transfer? We're going to show you some drawing about the technique, and then we'll show you the live surgery. The patient will be in the beach chair position, the arm on dynamic arm holder, and we try to place the shoulder in slight flexion and traction. This position protracts the scapula on the chest wall and gives you a direct visualization of the posterior scapula and the trapezius. And once you position it, don't change the position because you know when the scapula moves, the trapezius moves with it. Now we do our marking for the acromion, span of the scapula, and medial border of the scapula. And remember that the lower trapezius tendon is always located at this angle between the medial span of the scapula and the medial border, always. And usually we do our incision just distant to it, about two finger breadth. Again, I'll show it to you more in the live surgery, and we harvest the lower trapezius muscle and tendon, and usually we place reinforcing sutures to the tendinous portion of the lower trapezius because this is where we're going to pass the Achilles tendon allograft around it later. Once you do this step, you open the infraspinatus fascia. A member of the team will be preparing the Achilles tendon allograft. We prepare the greater tuberosity, and then we pass the Achilles tendon through this opening in the infraspinatus fascia in the door between the deltoid and infraspinatus toward the subacromial space. And when we prepare the Achilles tendon, we place two Krakow sutures, using number two suture tape of different colors, spanning around five centimeter length of the thick portion of the Achilles tendon allograft. And then using a swivel lock, we anchor the medial sutures on the anterior footprint of the supraspinatus, the lateral sutures on the anterior lateral footprint of the supraspinatus, and usually I add additional two anchors around two centimeter posterior medial anchor that I place it here, and I use the suture from this anchor to compress the Achilles tendon on the footprint of the supraspinatus and anchor those sutures laterally. Of course, if you are using sutures here or anchors here to repair some of the rotator cuff, you can use the same sutures to push them or place them on top of the Achilles tendon. For the posterior superior rotator cuff tear, the best biomechanical construct is to place the Achilles tendon on the footprint of the supraspinatus. If you have an isolated tear of the musculotendinous junction of the infraspinatus, you can anchor the Achilles tendon on the lateral footprint of the infraspinatus. And once you finish your fixation, the shoulder placement, abduction, external rotation, we split the graft and we use one half and we vertaft it on the slight tension in the lower trapezius, and then we cut the extra length of the tendon. Now let's show you how we do it in the operating room. The patient is in the picture position, again, slight flexion and traction on the arm, the video in front of you, the instruments around you, either the back or on the side, and then we do the marking while keeping the arm in one position. Now here I'm going to show you some detail. Now this is the spine, this is a medial spine, this is a medial border. If you want to be more technical, like more technical, this is how we can even do it. This is a medial spine of the scapula. If you measure around four to five centimeter length and you mark it here and you place a vertical line and you bisect it, that bisecting line is exactly the lateral border of the lower trapezius tendon. So this is one. Two, what we mentioned before, medial spine, medial border, that angle is the house of the lower trapezius, that's the second one. Third, the third trick is, again, the same angle, if you put your thumb, you feel a soft spot. That soft spot is exactly where the lower trapezius tendon is sitting. So if you put your thumb on that soft spot and you mark, put the marking slightly medial to the thumb, more lateral to it, this is exactly our marking. The fourth point is, when you do your marking, is around one to two finger breadth distal to the medial spine. You don't want to be on the spine directly, you don't want to be through this deli because you cannot see the rota pieces very well. So and this is just here, again, reinforcing everything I said, this is essentially the lateral border of the trapezius. We make our incision around two finger breadth distal to the medial spine and we make the incision. What's the first step? Always you take the fat out. How do you take it out? You carve it, you don't cut straight vertically, you just carve it until you look laterally, sorry, I look medially and you pull on these tissues that looks like around the same angle as the lateral aspect of the trapezius. If you put that angle and you put your thumb on it, this is exactly the same location. If you pull on those tissues, this lower trapezius, if you pull the skin to look at your, where you did your marking, is going to be the same location, always the same location. And when we try to detach it, we always detach it from distal to proximal. Okay, so some people ask me like, where's the, how much proximal you go? The interval between the middle and the lower trapezius is usually at the top part of the medial spine of the scapula. Here I'm taking more fat, then you're gonna see, I'm gonna make a marking at the top part of the medial spine of the scapula, which essentially delineate the interval between the lower trapezius and the middle trapezius. That's exactly it. That's it, you don't have to dissect, you don't have to find anything else, and now we're gonna detach the lower trapezius from the medial spine of the scapula, and this is all safe to do it with electrocortis. Once you detach it and you start to reach more medially, you should be more careful. Usually with the arm interaction, forward traction, you have around one to two finger breadth before reaching the spinal accessory, and the spinal accessory is on the undersurface of the muscle, so if you dissect superficially, it's all safe. And regardless, you don't need too much excursion of this muscle, because remember, the rotator cuff, they don't have much excursion. So once you get this muscle, you have some enough tension, you're done. That's it. This essentially will be satisfied, and if you look at this clamp, if you place them along the fibers of the trapezius, look at the line, it's exactly like the infraspinatus line. Okay, so now we're going to place sutures in the lower trapezius tendon to reinforce it, because later we're going to pass the Achilles tendon allograft around it, and now the muscle is ready for the transfer. So we're done with this part of the procedure. The next part, you can do it now, you can do it later, usually I do it now, but it's up to you. I like to open the infraspinatus fascia. You can make a big opening in it, it doesn't matter. The most important, once you open that fascia, it opens the door between the infraspinatus and the deltoid, and this patient doesn't, there's not much muscle, you can see this is all patiotropy. So if you put any larger clamp at this opening, it goes between the deltoid and infraspinatus towards the subacromial space. Now the Achilles tendon allograft is prepared, as we mentioned before, with two cracker sutures, and we color usually the top part of it. And we start to do the arthroscopy, and usually, almost always, we have two major portal, a lateral and anterolateral, and also we add sometimes a post-lateral portal to make the retrieval easier, and we add also an advisor portal mostly as an accessory portal for the sutures. And you can see right now, we just, you put portals, cannulas, because it makes your surgery easier. And here, in this case, we already placed and fixed the Achilles tendon anteriorly, medial and lateral. We already placed the posterior medial anchor with a suture we're going to pass on top of the Achilles tendon to compress it, and this is what we're doing exactly right now. And so once you do it, you can pull and rotate the tendon, you can see the fixation very nicely. This is done, and then the next part will be to try to feel it, you tension it, you can see a very nice external rotation when you put on the Achilles tendon allograft. We place the shoulder abduction external rotation, because it's shortened, the Achilles tendon length, we make it very good for tension, and then you split it into half, you excise one half, you leave the other half, you pull the top through the lower trapezius tendon, and you place it on slight tension, and you try to suture it. Now, you don't have to pull too hard, because when you place the shoulder abduction external rotation, you already shorten the tendon. When you place an adduction, now it places tension on the construct, and after you finish the repair, if you rotate, you can see a very nice motion of the lower trapezius and Achilles tendon as one unit, almost like an infraspinatus tendon. That's essentially the technique. In terms of the outcome, we have really excellent outcomes with this technique, and I'm very glad a lot of people now are using it and seeing the outcome. And the transfer is active, it's not like just, you know, this is because in many patients right now you can see them visually, or you can palpate, you can see how the tendon is moving during external rotation. This is another patient you can see, because she's skinny, you can either palpate, or you can see it visually how during external rotation the muscle and tendon move as one unit. And now I try to show more and more the outcome of some of my colleagues, Adam Murphy, most of you know him, and he has been doing it now for most of his patients for massive post-surgical pre-uterine catheter with excellent outcome, and these are his patients, and I'm very pleased that he's very happy with the outcome. In Barcelona, Felipe Valente did operate on a patient and did use the hamstring because not having Achilles tendon allograft, and the patient after three months had an excellent outcome, and this is a patient three months after surgery with excellent flexion and external rotation, and she's very happy and pleased about her surgery. And we see more and more, this is Pedro Lopez from Mexico, he's showing all these happy patients after the orthopedic transfer. I want to just end this by saying that we can use even the orthopedic to salvage SCR field, SCR for patients that had SCR and they have no supra-infraonterior spinal, and after surgery were able to regain also flexion and external rotation. And with this, I will end up my talk, and I want to thank you very much for listening to me, I hope it was helpful for you. Thank you very much, and have a great conference. Bye-bye.

lower trapezius transfer

SALT procedure

beach chair position

Achilles tendon allograft

SCR field