Combined Arthroscopic Assisted Lower Trapezius Tendon Transfer and Achilles Tendon Allograft plus Superior Capsular Reconstruction using Long Head Biceps Autograft for Massive Irreparable Rotator Cuff Posterosuperior Tears: The "Pull-Over" Technique.

Massive, irreparable posterosuperior rotator cuff tears, particularly those involving the infraspinatus, remain challenging to manage. In recent years, superior capsular reconstruction (SCR) and lower trapezius transfer (LTT) have been two techniques that have gained popularity. Superior capsular reconstruction aims to restore superior glenohumeral stability, but on its own, it may not restore the dynamic anteroposterior force couple, particularly in cases with significant infraspinatus dysfunction. Lower trapezius tendon transfer provides dynamic external rotation and replicates the posterior force couple by providing a line of pull that mimics native infraspinatus, but it may not restore superior stability, especially in early abduction. We describe a combined technique integrating arthroscopically assisted LTT with SCR using the long head of the biceps tendon as a biological graft. This method seeks to combine the static stability benefits of SCR with the dynamic rotational advantages of LTT, in a cost-effective and reproducible approach.