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April 17, 2026Open Access

Onlay versus Inlay Lower Trapezius Tendon transfer for posterosuperior functional irreparable rotator cuff tears: a 2-year clinical and imaging study

Key Points

This study aims to compare the clinical and radiological outcomes of Onlay and Inlay Lower Trapezius Tendon transfer techniques.
Retrospective comparative study of patients undergoing Onlay and Inlay LTT transfer.
Inclusion criteria: irreparable posterosuperior rotator cuff tears with specific characteristics.
Outcome measures included active range of motion, acromiohumeral distance, and multiple scoring systems.
Both Onlay and Inlay techniques significantly improved active forward elevation and external rotation.
The Onlay group showed greater improvement in acromiohumeral distance compared to Inlay (7.3 mm vs 4.8 mm, p = 0.001).
All outcome scores (ASES, SANE, Constant) improved significantly in both groups, achieving clinical importance.

Abstract

• Both Onlay and Inlay techniques of LTT transfer effectively improved shoulder function in patients with irreparable posterosuperior rotator cuff tears. • The Onlay technique resulted in better AHD at the final follow-up. • This study provides evidence to guide surgical decision-making of the Onlay technique for LTT transfer in this patient population. This study compared the clinical and radiological outcomes of Onlay and Inlay Lower Trapezius Tendon (LTT) transfer techniques in managing posterosuperior Functional Irreparable Rotator Cuff Tears (FIRCTs). This retrospective comparative study included patients who underwent Onlay and Inlay LTT transfer. The inclusion criteria were FIRCTs defined by tendon retraction to the glenoid, fatty infiltration > 2 grade according to Goutallier, and with a positive External Rotation (ER) lag sign. Patients with irreparable subscapularis, dysfunctional deltoid, advanced glenohumeral osteoarthritis, cuff tear arthropathy, and revision surgeries were excluded. Outcomes measures included the active Range Of Motion (ROM), Acromiohumeral Distance (AHD), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score and Constant score. The study included 39 patients (21 Onlay and 18 Inlay LTT) with at least 2-year follow-up. Both groups achieved significant improvement in active forward elevation from 118.6 ± 57.6° to 145.7 ± 18° in the Onlay group ( p = 0.046) and 112.2 ± 49.2° to 140.6 ± 30.6° in the Inlay group ( p = 0.046). The ER improved from 31 ± 21.2°to 44.3 ± 16° in the Onlay ( p = 0.027) and 29.4 ± 27.1° to 45 ± 16.9° in the Inlay group ( p = 0.046). The postoperative AHD was better in the Onlay group (7.3 ± 2.5 vs. 4.8 ± 3.2 mm, p = 0.001). The ASES, SANE, and Constant scores all improved significantly at final follow-up (all p < 0.001) in both groups and reached the Minimal Clinically Important Difference. Both the onlay and Inlay techniques of LTT transfer effectively improved shoulder function in patients with irreparable posterosuperior rotator cuff tears. The Onlay technique resulted in better AHD at final follow-up.

Onlay versus Inlay Lower Trapezius Tendon transfer for posterosuperior functional irreparable rotator cuff tears: a 2-year clinical and imaging study

Key Points

Abstract

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