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. 2026 Aug 5;6(4):100841. doi: 10.1016/j.xrrt.2026.100841

Comparative outcomes and complication rates of lower trapezius versus latissimus dorsi tendon transfer for irreparable posterosuperior rotator cuff tears: a systematic review

Ross Clarke a, Brian S Tao a, Peter Boufadel a, Mohammad Abdelaal a, Neal Shah a, Abhishek Suresh a, Brian R Waterman b, Joseph W Galvin c, Josef K Eichinger d, Xinning Li a,∗
PMCID: PMC13633925  PMID: 42830749

Abstract

Background

Latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT) for irreparable posterosuperior rotator cuff tears have been shown to have favorable outcomes. There has been no systematic comparison of clinical outcomes between the 2 techniques. We aimed to compare clinical outcome measures, complications, and rates of conversion to reverse shoulder arthroplasty between LDT and LTT with a minimum of 1-year post-operative follow-up.

Methods

We performed a systematic review using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, querying MEDLINE (PubMed) and Embase databases for studies reporting outcomes and complications following LDT and LTT with a minimum of 1-year follow-up. We assessed the methodological quality of each study using the MINORS score and extracted patient demographics, clinical, and patient-reported outcome data.

Results

Sixty-nine studies, including 2,476 patients (2,495 shoulders), met the inclusion criteria. The LDT and LTT groups consisted of 1,834 and 661 shoulders, respectively. The weighted mean age ( ± standard deviation) was 60.2 ± 4.1 years, follow-up was 49.2 ± 23.7 months, and 33.4% were female. Compared with LTT, LDT group showed a greater improvement in the Constant score (28.9 vs. 23.6, P < .01), University of California Los Angeles scores (15.1 vs. 8.5, P = .03), and lower visual analog scale scores for pain (−4.4 vs. −3.3, P = .02). LTT group gained more active external rotation (21.9° vs. 15.2°, P < .01) compared to the LDT group. Active forward elevation, active abduction, American Shoulder and Elbow Surgeons and Activities of Daily Living External Rotation scores, patient satisfaction, complication rates, and conversion rates to reverse shoulder arthroplasty were similar between groups, with the exception of a higher incidence of nerve injury in the LDT group (0.8% vs. 0%, P < .01).

Conclusion

Both LDT and LTT are viable options for irreparable posterosuperior rotator cuff tears. While differences in reported outcomes were observed across studies—such as greater improvements in external rotation in LTT cohorts and slightly higher improvements in certain patient-reported outcomes in LDT cohorts—these findings are derived from indirect comparisons of heterogeneous populations and should be interpreted with caution.

Keywords: Tendon transfer, Lower trapezius, Latissimus dorsi, Rotator cuff tears, Clinical outcomes, Range of motion

Irreparable posterosuperior rotator cuff tears (iPRCTs) represent a common cause of shoulder pain and functional impairment. Management of iPRCT remains challenging, with multiple treatment options described but without a clinical unanimity on a gold standard approach. Joint-preserving procedures considered for iPRCTs include tenotomy or tenodesis of the long head of the biceps, arthroscopic débridement, partial rotator cuff repair, patch augmentation, superior capsular reconstruction, and implantation of an inflatable balloon.4 While these procedures aim to provide pain relief and improve function, reported outcomes are inconsistent.4 When these measures fail, reverse shoulder arthroplasty (rTSA) is usually considered for patients with rotator cuff insufficiency. While rTSA can restore shoulder function, it has associated limitations, such as reduced functional range of motion and risks of complications, including prosthetic dislocation, acromial or scapular spine fractures, periprosthetic fracture.17,18

Muscle tendon transfer procedures emerged as an alternative joint-preserving option for the management of iPRCT, particularly in younger, more active patients. The goal of muscle tendon transfer is to reconstruct the posterosuperior cuff in order to restore the dynamic stability and force couples of the glenohumeral joint, improve range of motion, and reduce pain.6,16 The choice of muscle tendon is influenced by tear pattern and surgeon preference. The most commonly utilized procedures for iPRCTs are latissimus dorsi transfer (LDT), with or without the teres major, and, more recently, lower trapezius transfer (LTT).

In LDT, the latissimus dorsi is mobilized and reattached laterally and posteriorly to the greater tuberosity, thereby restoring external rotation and contributing to improved glenohumeral joint stability by distalizing the center of rotation.10 Favorable outcomes have been reported after LDT, especially pain reduction; however, its ability to restore shoulder function has been considerably variable.5,13 As a primary internal rotator, the latissimus dorsi generates a vertical force vector that is directed posteriorly and inferiorly when transferred, which fails to effectively reestablish the normal glenohumeral force couple.12 This limitation has been associated with suboptimal long-term results, including progressive fatty degeneration, subscapularis insufficiency, and advanced glenohumeral joint degenerative changes.21 Conversely, in LTT, the tendinous insertion of the lower segment of the trapezius muscle is harvested from the medial scapular spine, lengthened with a tendon allograft, and attached anteriorly and laterally at the supraspinatus and infraspinatus footprint.7 LTT has gained increasing attention as its force vector and muscle activation patterns more closely mimic those of the native infraspinatus tendon.20 Compared with LDT, LTT provides several biomechanical advantages, including a more favorable line of pull and an in-phase transfer that is easier for patients to retrain, potentially making it a superior option for restoring function in iPRCT.7,19,22

Despite growing interest in tendon transfers for iPRCT, most available studies remain limited to cadaveric models or computational simulations. To date, no clear clinical consensus has been established regarding the superiority of one technique over the other. The aim of this systematic review and meta-analysis is to directly compare functional and clinical outcomes between Latissimus Dorsi Tendon and Lower Trapezius Tendon Transfer in the treatment of posterosuperior irreparable rotator cuff tears.

Materials and methods

Search strategy

PubMed and Embase were queried utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles that reported on patient outcomes following latissimus dorsi tendon transfer and/or lower trapezius tendon transfer for posterosuperior rotator cuff tears with minimum 1-year follow-up were included. Databases were accessed and searched on February 6, 2025, using the following Boolean search terms, such as: (("trapezius") OR ("latissimus dorsi")) AND ("transfer") AND (("cuff") or ("tear") OR ("rotator")). Filters were not used to increase the sensitivity of the search criteria.

Eligibility criteria

Articles were reviewed by (N.S., A.S., R.C., P.B.) and duplicates were excluded. Title and abstracts were screened and excluded based on the following criteria: (1) non-English text; (2) only abstract available; (3) review, meta-analysis, biomechanical, or technique paper; (4) case series with less than 10 patients; (5) less than 1-year follow-up; (6) indication other than posterior superior rotator cuff tears; (7) non-latissimus dorsi or lower trapezius muscle tendon transfer; (8) data not individualized for reference groups; and (9) overlapping cohort from another trial. After title and abstract screening, the remaining articles underwent a full text review to ensure that the inclusion and exclusion criteria was satisfied. Conflicts were discussed among the reviewers and resolved by a primary conflict resolver (X.L.).

Data extraction

The following study, demographic, and surgical data were extracted by (N.S., A.S., R.C., P.B.) from the eligible studies that met inclusion criteria: first author, year, level of evidence, country of study, type of study, patient collection window, number of shoulders, patient age at surgery, sex ratio, follow-up period, prior ipsilateral surgery, and graft augmentation. Clinical outcomes collected included range of motion (active forward elevation, active abduction, active external rotation), Constant score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, Activities of Daily Living External Rotation (ADLER) score, and visual analog scale (VAS) pain score. Progression of osteoarthritis (Hamada score and acromiohumeral distance), complications and reoperations were also recorded. After completion, the data was reviewed for accuracy and analyzed. When both latissimus dorsi and lower trapezius tendon transfers were included in a study, data was individually extracted for each muscle transfer into separate cohorts. Additional stratifications were done to preserve granularity of the cohorts represented.

Statistical analysis

Analysis was done in R Studio (version 2023.09.0 + 473; R Foundation for Statistical Computing, Vienna, Austria) with the metafor and tidyverse packages. Patient characteristics such as age and follow-up time were reported using weighted means to accurately measure the contributions of articles with varying sample sizes. Meta-analysis of proportions was performed on total complications, infection, graft retear, total nerve injury, subsequent ipsilateral surgery, and conversion to rTSA. Meta-analysis of mean outcomes was performed on range of motion measures, patient-reported outcome measures, Hamada score, and acromiohumeral distance. All meta-analysis was performed using a random effects model to pool revision rates and estimate the 95% confidence intervals. Using a random effects model allows us to account for differences among studies, such as the methodology, patient characteristics, and surgical characteristics. A heterogeneity analysis of the included studies was represented using the I-squared statistic, which represents the estimated percentage of error attributed to interstudy variation. Abiding the Cochrane review handbook, non-important values of I-squared are between 0% and 40%, moderate heterogeneity is from 30% to 60%, and considerable heterogeneity is from 75% to 100%. The remainder of the outcome measures were not included in meta-analysis due to too many zero events or the data was not consistently reported. Sub-analysis was performed to compare outcomes following latissimus dorsi and lower trapezius tendon transfer procedures.

Results

Our search returned 955 publications, of which 567 were unique. We excluded 416 articles during title and abstract screening after application of inclusion and exclusion criteria, leaving 151 for full-text review. Subsequently, 82 articles were excluded after full text review, leaving 69 distinctive articles reporting on 78 patient cohorts for analysis (Fig. 1).

Figure 1.

Figure 1

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PRISMA flowchart for article selection process. PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Article characteristics

Our review included 69 unique articles. There were 78 unique cohorts, of which 62 were LDT and 16 were LTTs. A majority of the articles came from France (n = 11, 16%), the United States (n = 10, 14%), and Germany (n = 9, 13%). Europe was the most common continent, making up 54% (n = 37) of all the articles. Of the included studies, 18 were retrospective case series (26%), 30 were retrospective cohorts (44%), 18 were prospective cohorts (26%), 2 were prospective case series (3%), and there was 1 prospective randomized cohort (1%). For the MINORS assessment, non-comparative studies had an average score of 11/16 and comparative studies had an average score of 17/24, indicating moderate quality of evidence for both comparative and non-comparative studies.

Patient characteristics

Our review included 2,476 patients (2,495 shoulders), of which 33.4% were female. The weighted mean age was 60.2 ± 4.1 years (range: 26–84 years), and the weighted mean follow-up was 49.2 ± 23.7 months (range: 12–240 months). LDT was performed in 1,834 shoulders with a weighted mean age of 59.9 ± 4.0 (range: 26–84 years), a follow-up of 52.9 ± 25.7 months (range:12–240 months), and 35.1% were female. LTT was performed in 661 shoulders with a weighted mean age of 61.0 ± 4.5 years (range: 31–77 years), a follow-up of 38.0 ± 9.9 months (range: 12–83 months), and 28.7% were female. A significantly higher proportion of females was found in the LDT cohort compared to the LTT cohort (35.1% vs. 28.7%, P < .001). There was no significant difference in the mean patient age and mean follow-up between the 2 cohorts. LTT was predominantly performed arthroscopic-assisted (91.2% arthroscopic-assisted vs. 8.8% open), whereas LDT was more commonly performed using an open technique (43.0% arthroscopic-assisted vs. 57.0% open) (P < .001). Patient characteristics are summarized in Table I.

Table I.

Patient characteristics.

Characteristic Total Lat dorsi transfer Lower trap transfer P value
No. of patients 2,476 1815 661
No. of shoulders 2,495 1834 661
Female (n, %) 827 (33.4) 643 (35.1) 187 (28.3) <.001∗
Patient age (yr) .887
 Mean ± SD 60.2 ± 4.1 59.9 ± 4.0 61.0 ± 4.5
 Range 26-84 26-84 31-77
Follow-up (mo) .078
 Mean ± SD 49.2 ± 23.7 52.9 ± 25.7 38.0 ± 9.9
 Range 12-240 12-240 12-83
Surgical technique (n, %) <.001∗
 Arthroscopic-assisted 1,392 (55.8) 789 (43.0) 603 (91.2)
 Open 1,103 (44.2) 1,045 (57.0) 58 (8.8)
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SD, standard deviation.

∗

Significant P values are in bold.

Range of motion

The weighted mean improvement in active external rotation was significantly higher in the LTT group compared to the LDT group (21.9° vs. 15.2°, P < .01, I2 = 77%) (Fig. 2A). There was no significant difference between LTT and LDT groups in the weighted mean improvements for the range of active forward elevation (26.3° vs. 32.7°, P = .13, I2 = 92%) (Fig. 2B) and active abduction (40.3° vs. 38.2°, P = .83, I2 = 86%) (Fig. 2C).

Figure 2.

Figure 2

Figure 2

Figure 2

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Forest plot comparing range of motion changes between latissimus dorsi and lower trapezius tendon transfers: (A) active external rotation, (B) active forward elevation, and (C) active abduction.

Functional outcomes

The LDT group demonstrated significantly higher weighted mean improvements in the Constant score (28.9 vs. 23.6, P < .01, I2 = 81%) (Fig. 3A), UCLA score (15.1 vs. 8.5, P = .03, I2 = 97%) (Fig. 3B), and VAS score (−4.4 vs. −3.3, P = .02, I2 = 92%) (Fig. 3C) compared to the LTT group. There was a similar improvement in the ADLER score (7.7 vs. 7.2, P = .93, I2 = 93%) (Fig. 3D) and ASES score (33.6 vs. 28.6, P = .33, I2 = 88%) (Fig. 3E) between both groups. Overall, patient satisfaction was similar for both procedures (85% vs. 88%, P = .82, I2 = 65%) (Fig. 3F).

Figure 3.

Figure 3

Figure 3

Figure 3

Figure 3

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Forest plot comparing changes in functional outcome scores between latissimus dorsi and lower trapezius tendon transfers: (A) Constant score, (B) UCLA score, (C) VAS score, (D) ADLER score, (E) ASES score, and (F) satisfaction. UCLA, University of California Los Angeles; VAS, visual analog scale; ASES, American Shoulder and Elbow Surgeons; ADLER, Activities of Daily Living External Rotation.

Progression of rotator cuff tear arthropathy

Thirteen studies comprising 837 patients reported on changes in pre-operative and post-operative Hamada classification grades (440 in the LDT group and 397 in the LTT group). There was a significantly higher weighted mean increase in Hamada grade in the LDT group compared to the LTT group (0.6 vs. 0.1, P < .01, I2 = 78%) (Fig. 4A). Twenty-one studies comprising 1,065 patients reported on acromiohumeral distance changes (652 in LDT group and 413 in LTT group), finding no significant difference between the 2 groups (−0.1 vs. 0.2, P = .56, I2 = 89%) (Fig. 4B).

Figure 4.

Figure 4

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Forest plot comparing osteoarthritic changes between latissimus dorsi and lower trapezius tendon transfers: (A) Hamada classification grade, (B) acromiohumeral distance.

Complications and reoperations

Total complication rates were similar between LDT and LTT groups (16.4% vs. 12.7%, P = .30 (Fig. 5A). There was no significant difference in rates of infection (1.0% vs. 1.4%, P = .66) (Fig. 5B) and retear (3.5% vs. 7.1%, P = .13) (Fig. 5C) but increased risk of total nerve injury in the LDT group (0.8% vs. 0%, P < .01) (Fig. 5D). The rates of subsequent ipsilateral surgery (6.3% vs. 6.3%, P = .95) (Fig. 6A) and conversion to rTSA (1.6% vs. 1.8%, P = .91) (Fig. 6B) were also similar between groups.

Figure 5.

Figure 5

Figure 5

Figure 5

Figure 5

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Forest plot comparing complication rates between latissimus dorsi and lower trapezius tendon transfers: (A) total complication, (B) infection, (C) graft retear, and (D) nerve injury.

Figure 6.

Figure 6

Figure 6

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Forest plot comparing reoperation rates between latissimus dorsi and lower trapezius tendon transfers: (A) total reoperation and (B) conversion to reverse total shoulder arthroplasty.

Discussion

The goal of muscle tendon transfers for massive posterosuperior cuff tears is to restore shoulder function while preserving joint mechanics. This current systematic review and meta-analysis demonstrated that both latissimus dorsi and lower trapezius tendon transfers provide favorable outcomes in achieving these objectives. While both resulted in improved patient-reported outcomes, LDT was associated with greater improvements in the Constant score, UCLA score, and VAS pain score compared to LTT. However, LTT provided significantly better restoration of active external rotation and a more favorable profile in mitigating the progression of cuff tear arthropathy. Total complication and reoperation rates were similar between the 2 techniques. However, there was an increased risk of nerve injury in the LDT group.

LTT provided greater improvement in active external rotation compared to LDT (21.9° vs. 15.2°), while forward elevation and abduction were similar between the 2 groups. Previous literature has shown LTT to be superior in restoring active external rotation. In a retrospective cohort study of 48 patients who underwent arthroscopic-assisted LDT and 42 who underwent arthroscopic-assisted LTT for iPRCTs, Baek et al2 reported significantly greater post-operative external rotation at neutral abduction (55° vs. 33°). This can be attributed to several potential biomechanical advantages. The lower trapezius tendon more closely replicates the physiological line of pull of the infraspinatus due to its more cranial origin. Its natural function in external rotation and abduction allows for in-phase contraction and dynamic synchrony with the infraspinatus. In a three-dimensional computational biomechanical study, LTT produced greater external rotation and abduction moment arms compared with LDT when transferred to the native infraspinatus insertion site.22 Although, the clinical improvement in active abduction was similar between the 2 procedures in our study. Moreover, LTT can maintain glenohumeral stability across various degrees of abduction, owing to similar scapulohumeral kinematics to the infraspinatus.19 A three-dimensional kinematic tracking study demonstrated that LDT failed to restore normal scapulothoracic mechanics.9 Conversely, LTT can effectively normalize scapulothoracic motion due to its role in generating scapular external rotation. Future studies incorporating electromyography and nerve conduction testing may further elucidate muscle activation patterns, tendon transfer function, and their relationship to post-operative scapulothoracic kinematics.

While LDT is an effective treatment option, its biomechanical mismatch and functional limitations, particularly in force vector alignment and contraction synchrony, reduce its ability to adequately restore external rotation in comparison to LTT. The vertical orientation of its force vector creates a non-physiological line of pull that does not mimic the native infraspinatus, contributing to poor restoration of the force couple. Additionally, as the latissimus dorsi is an internal rotator and adductor, it lacks phase-specific contraction during shoulder external rotation and abduction. This mismatch undermines its ability to reproduce native muscle firing patterns, requiring cognitive and neuromuscular adaptation and biofeedback to fulfill the role of external rotation. For these reasons, LTT is more commonly performed in cases with external rotation deficits, which likely explains the greater improvement in active external rotation observed in our study.

LDT patients demonstrated greater improvements in Constant and UCLA scores as well as greater reductions in VAS pain scores compared with LTT. Although these differences were statistically significant, the between-group differences were small, and may not hold clinical relevance. Additionally, changes in outcome scores may be influenced by baseline values, as groups with lower pre-operative scores have greater potential for apparent improvement, which should be considered when interpreting these results. Moreover, the ASES and ADLER scores and overall patient satisfaction were comparable between the 2 groups. Successful patient outcomes following either procedure heavily depend on careful patient selection and appropriate indications. Prior studies have demonstrated good to excellent clinical outcomes following LDT, particularly in cases where the transferred tendon achieved successful healing and the subscapularis remained intact and functional.14 However, outcomes may be less favorable under certain conditions. In a study by Kany et al,15 patients undergoing LDT were more likely to report dissatisfaction if they had a history of prior rotator cuff repair, concurrent subscapularis repair, severe fatty infiltration of the infraspinatus (greater than Goutallier stage 3), or involvement of more than 3 rotator cuff tendons. In such cases–particularly extensive, irreparable posterosuperior cuff tears without pseudoparalysis, LTT or the L'Episcopo procedure may offer more favorable biomechanical advantages. According to Boileau et al,3 LTT is specifically indicated in patients with isolated loss of active external rotation, defined by a non-pseudoparalytic shoulder with a positive Hornblower sign, a positive external rotation lag sign, and a Collin type E tear. Of note, rTSA remains the treatment of choice for restoring active elevation or forward flexion in patients with true pseudoparalysis. These findings underscore the critical importance of appropriate patient selection in optimizing surgical outcomes for patients with advanced shoulder dysfunction.

When comparing progression of osteoarthritis and cuff tear arthropathy, our analysis showed that LDT was associated with a statistically significant greater increase in post-operative Hamada grade compared to LTT. However, despite this difference, the change in acromiohumeral distance did not differ between the 2 groups, and considerable heterogeneity was observed across studies, likely due to variability in radiographic measurement techniques. This suggests a lack of consistent or clinically meaningful difference between the procedures and may be explained by the longer mean follow-up observed in the LDT cohort. However, previous studies have demonstrated significant glenohumeral osteoarthritic changes following LDT. Gerber et al11 found that 30% of patients exhibited osteoarthritic changes, evidenced by a reduction in acromial humeral interval and superior subluxation of the humeral head. Similarly, Aoki et al1 reported that 41% of patients who underwent LDT showed progression of glenohumeral osteoarthritis. This progression may be attributed to the inability of LDT to fully restore normal glenohumeral kinematics and joint reaction forces, potentially leading to subsequent degenerative changes. LDT often results in weaker excursion and tension, insufficient humeral head depression, and inadequate control of humeral head centering within the glenohumeral joint factors that may lead to abnormal joint loading and stability.9,12 Additionally, the loss of the tenodesis effect, due to adaptive elongation of the transferred latissimus dorsi muscle-tendon unit, may further contribute to joint deterioration.8 It is worth noting, however, that the progression of arthritic changes does not necessarily correlate with clinical outcomes, as highlighted by Gerber et al.11 In the current study, only 3.8% (59/1,532) of the LDT patients and 3.2% (21/651) of LTT patients underwent rTSA conversation.

Compared to LDT, the LTT may be considered technically simpler, as it involves a smaller surgical exposure and allows for easier identification and mobilization of the muscle-tendon unit.6 However, although technically demanding, LDT can be performed entirely arthroscopically and typically does not require the use of an allograft. In contrast, LTT still necessitates an open approach for tendon harvest from the scapular spine, despite the possibility of arthroscopic assistance in other steps of the procedure–thereby limiting its minimally invasive potential. Additionally, when an interposition graft is required, the use of allograft contributes to increased operative time due to preparation and fixation at both ends and further adds to the overall procedural cost.23 Nevertheless, the rates of failure, complication, and reoperation were similar between both procedures, with the exception of a statistically significant higher incidence of total nerve injury in LDT (0.8% vs. 0%).

Despite the valuable insights, this systematic review provides regarding muscle transfer options in massive posterior rotator cuff tears and its potential benefits, several limitations must be considered. There was a lower number of LTT studies to review, and an overall modest sample of LTT because of its relatively more recent adoption. Additionally, although not statistically significant, the LDT cohort had a mean follow-up duration that was 15 months longer than the LTT cohort, which may have influenced outcome scores. Long-term outcomes and complication profiles are not yet fully established, and no prospective studies directly comparing LTT with LDT have been conducted, which may increase the risk of confounding bias. Moreover, the available data largely originate from a small number of specialized centers and high-volume surgeons, which may limit the generalizability of findings to broader clinical practice. Another limitation is that most included studies were non-comparative and of lower methodological quality, and heterogeneity was high across comparisons, which may affect the validity of the findings. Importantly, data on subscapularis status and concomitant repair, pre-operative pseudoparalysis and external rotation lag, post-operative recovery, rehabilitation protocols, and surgical time were inconsistently reported across studies and therefore could not be assessed. Future prospective, comparative studies with long-term follow-up are needed to determine the relative efficacy, reproducibility, and safety of LTT compared to more established procedures like LDT.

Conclusion

LDT and LTT are both viable options for treating iPRCTs, each offering distinct advantages. While differences in reported outcomes were observed across studies—such as greater improvements in external rotation in LTT cohorts and slightly higher improvements in certain patient-reported outcomes in LDT cohorts—these findings are derived from indirect comparisons of heterogeneous populations and should be interpreted with caution.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: Brian R. Waterman would like to disclose: grants, personal fees, and other from Arthrex; grants and other from Smith & Nephew; personal fees from DePuy Mitek/Johnson & Johnson; other from Vivorte, Kaliber AI, and Sparta Bioscience; personal fees and other from Arthroscopy; personal fees and other from FH Ortho; and personal fees from Vericel. Josef K. Eichinger would like to disclose: consultant for Exactech. Xinning Li would like to disclose: consultant and receives royalties from FH Orthopedics. Any additional authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Footnotes

No institutional review board/ethical approval was applicable.

References

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