Pectoralis minor transfer represents a joint preserving alternative to reverse total shoulder arthroplasty for younger, high-demand patients with irreparable anterosuperior rotator cuff tears.

The subscapularis is a dynamic structure serving as part of a shoulder force couple in the transverse plane, conferring stability, strength and optimizing motion. Full thickness, retracted anterosuperior rotator cuff tears with fatty infiltration pose a significant challenge to surgeons particularly in younger patients with high functional demands where primary repair may not be feasible. This clinical scenario is rare, and most investigations on this topic are limited to small, retrospective case-series with short-term follow-up. For patients in whom joint preservation is desired, pectoralis major transfer or latissimus dorsi transfers are the most reported surgical options with heterogeneity in techniques and clinical outcomes. Recent research describes an alternative of pectoralis minor transfer for this same purpose with promising short-term outcomes. However, as with pectoralis major transfers for management of anterosuperior irreparable, the outcome is highly dependent on the integrity of the posterosuperior rotator cuff. Thus, when faced with a patient with a massive anterosuperior rotator cuff tear with atrophy, retraction, and other demographic or medical conditions that may predispose that patient to a lower likelihood of healing and doing the extensive rehabilitation from a tendon transfer, consider the alternative of a reverse total shoulder arthroplasty. The reverse is a reliable operation that affords patients excellent pain relief, reasonable function typically lifting up to 25-30 pounds, with good patient reported outcomes even in patients as young as 60 years of age. Tendon transfers, including pectoralis minor transfers, have a role, but we need to be thoughtful about indications and counsel patients on expected outcomes and the durability of those outcomes over time.