Reverse total shoulder arthroplasty (rTSA) using an allograft-prosthetic composite (APC) combined with a lower trapezius transfer (LTT) is an option for patients with posterosuperior rotator cuff deficiency associated with substantial proximal humeral bone loss. This combined approach aims to address both structural and functional deficits: the APC component restores humeral bone stock and provides structural support while the LTT helps to restore active external rotation. This approach represents a highly technically demanding procedure performed in a relatively uncommon and complex patient population. Sanchez-Sotelo et al. should be commended for addressing this complex and relatively uncommon clinical scenario. They followed 26 shoulders for a minimum of 2 years after rTSA was performed using an APC with an LTT. They reported substantial improvements in active elevation and external rotation at the final follow-up. The study, which presents a relatively large retrospective case series in a patient population that is inherently difficult to sample, addresses one of the most challenging scenarios in shoulder arthroplasty: rTSA in the setting of substantial humeral bone loss and soft-tissue deficiency. This scenario can be encountered in certain revision procedures, in reimplantation following periprosthetic joint infection, and in tumor resection1,2. In such situations, combining rTSA with an APC and an LTT represents an attempt to compensate for both proximal humeral bone loss and posterosuperior cuff deficiency3. Nevertheless, there are several important considerations when interpreting the findings reported by Sanchez-Sotelo et al. Despite the surgeries having been performed by experts, the study showed an overall reoperation rate of 30%, with 8 patients requiring reoperation for reasons such as instability, infection, periprosthetic fracture, hematoma, and nonunion. Such a reoperation rate raises important questions regarding the reproducibility and broader applicability of this approach in less specialized settings. While the technique may represent a valuable option for select cases, its generalizability should be interpreted cautiously. Moreover, the true incidence of adverse events may be underestimated in the literature, as the reported outcomes for such complex procedures are largely derived from specialized, high-volume centers with substantial surgical expertise. These complex reconstructions require advanced technical skills, meticulous surgical execution, and careful patient selection. Another important consideration is the fact that the surgery itself is relatively uncommon and the indications to combine an LTT with rTSA are not clearly defined. Over the last decade, rTSA has evolved significantly, with modern implant designs improving posterior cuff tensioning and external rotation without the need for additional tendon transfers. Therefore, the decision to augment rTSA with a tendon transfer should be carefully justified, and the development of more precise indications will be critical to guide surgical decision-making and to avoid unnecessary procedural complexity. The small sample size and the heterogeneity of the population in the study by Sanchez-Sotelo et al. are important considerations that must be noted. The included patients varied widely in age (21 to 78 years), degree of humeral bone loss, and preoperative range of motion. Additionally, the patients had a range of surgical indications, including tumor resection, trauma, periprosthetic joint infection, and revision arthroplasty. These conditions represent fundamentally different patient populations with distinct rehabilitation expectations and prognoses. Pooling such heterogeneous cases within a single cohort makes it difficult to interpret the results and to attribute those results to the surgical technique itself or to the underlying pathology. Larger studies focusing on more homogeneous patient populations are needed to better understand the role of this combined procedure. Furthermore, the outcomes in the study by Sanchez-Sotelo et al. were limited to a relatively short-term follow-up period. Although the early improvements in range of motion are encouraging, a longer follow-up is critical to determining whether the improvements diminish or are maintained over time. Despite these considerations, this study provides valuable insights into the management of a highly complex and uncommon challenge in shoulder arthroplasty. Patients with combined posterosuperior cuff deficiency and substantial proximal humeral bone loss represent a small but particularly complex subgroup in shoulder arthroplasty practice. The concept of combining rTSA with an APC and an LTT may offer a promising approach for providing structural support and restoring external rotation in these highly complex cases. As such, this technique should likely remain reserved for carefully selected patients being treated at experienced centers by experienced surgeons until further data can clarify its true role in this population.
Hantouly et al. (Thu,) studied this question.
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