(i) The management of irreparable rotator cuff tears

MINI-SYMPOSIUM: LESS COMMON SHOULDER PROBLEMS

(i) The management ofirreparable rotator cuff tearsJ Charles Talbot

David Limb

AbstractThe management of massive irreparable rotator cuff tears can be chal-

lenging. There are, however, a number of operative and non-operative

options available to the shoulder surgeon.

Non-operative management with simple analgesics, steroid injections

and a deltoid re-education programme may be appropriate for patients

with few symptoms, particularly elderly, lower demand patients with lower

expectations. In more symptomatic patients, especially younger patients

with higher demands, surgical interventionmaybe considered. Arthroscopic

debridement and/or, sub-acromial decompression (with or without biceps

tenotomy) may suffice, but partial or augmented rotator cuff repair or

tendon transfer surgery is available. In the presence of arthrosis, cuff tear

arthroplasty or reverse geometry arthroplasty are valid options.

Treatment should be individualized depending on the patient’s symp-

toms, age, expectations, needs and the presence or absence of associated

glenohumeral joint arthrosis.

Keywords irreparable rotator cuff tear; partial cuff repair; reverse

geometry shoulder arthroplasty; tendon transfer surgery

Introduction

The management options of irreparable rotator cuff tears (IRCT)

are diverse and treatment choice is informed by patient symp-

toms, age, expectations, needs and the presence or absence of

associated glenohumeral joint arthrosis. This review aims to

highlight the alternatives, both operative and non-operative, and

present a treatment algorithm for the management of patients

with irreparable rotator cuff tears.

The rotator cuff

The rotator cuff comprises four muscles arising from the scapula,

which merge to form a confluent tendinous hood or sleeve

around the humeral head. The rotator cuff contributes to

shoulder movements and acts to stabilize the glenohumeral joint.

While the static stabilizers such as the glenohumeral ligaments of

the joint are employed at end ranges of movement, the joint gains

significant mid range stability from the rotator cuff itself. The cuff

J Charles Talbot MBChB MSc(Eng) FRCS(Tr&Orth) SpR., Department of Ortho-

paedics and Trauma, Leeds General Infirmary, Leeds, UK. Conflicts of

interest: none declared.

David Limb BSc FRCSEd(Orth) Consultant Orthopaedic Surgeon, Depart-

ment of Orthopaedics and Trauma, Leeds General Infirmary, Leeds, UK.

Conflicts of interest: none declared.

ORTHOPAEDICS AND TRAUMA 26:6 367

acts to maintain the humeral head centred within the glenoid

concavity and resists upward translation of the humeral head

during abduction caused by activation of the deltoid muscle, in

what is known as the coronal force couple.1 Normal shoulder

kinematics relies on a similar antero-posterior antagonistic force

couple of the subscapularis and infraspinatus/teres minor

tendons. Burkhart et al. developed this line of thinking, which

gave rise to the biomechanical concept of partial rotator cuff

repair, which has been described as anatomically deficient but

biomechanically intact,2,3 and will be discussed later.

The rotator cuff is liable to injury and the intrinsic and extrinsic

theories of rotator cuff tear have been proposed and much

debated. The extrinsic, or impingement, theory relates cuff

damage to repetitive micro trauma of the tendon under the

acromion, resulting in cuff tears. The morphology of the acromion

has been implicated, with more rotator cuff tears seen in patients

with Bigliani type II (curved) and III (hooked) acromions.4 Simi-

larly, the non-operative management of cuff tears is progressively

less effective in type II (curved) and type III (hooked) acromions

respectively in comparison to type I (flat) acromions, supporting

the theory. The intrinsic theory however considers degeneration

of the rotator cuff with age, with relative devascularization of the

tendon, making the cuff more prone to injury.

Massive IRCTs are not common and in most series the inci-

dence of massive tears is about a third of all cuff tears, and even

this may be a result of selection bias. There are two types of

massive rotator cuff tear: antero-superior and, more commonly,

postero-superior. Postero-superior tears involve the supra- and

infra-spinatus but can involve the teres minor. Antero-superior

deficiency is seen with massive retracted subscapularis tears in

combination with supraspinatus tears; these tears inevitably

involve the biceps tendon which often subluxes medially. Signif-

icant tears result in a loss of the normal shoulder kinematics, and

proximalmigration of the humeral headmay result. Arthrosismay

or may not be present at presentation; abnormal shoulder kine-

matics and an adverse biological environment are proposed as the

causative contributors to the development of the arthropathy.

Patients with massive IRCT present with a wide variety of

symptoms from mild pain with little functional deficit to severe

debilitating pain and pseudo-paralysis, and the treatment should

be tailored to symptoms and expectations.

Irreparable rotator cuff tears

Clinical findings, imaging and arthroscopic assessment

Patients with massive IRCT present with variable amounts of

pain and functional loss. In cases with postero-superior tears,

functional loss typically results from weakness in abduction and

external rotation. Loss of active external rotation can occur in

isolation but may be combined with loss of active elevation.

Clinically, wasting of both the supra- and infra-spinatus fossae

may be apparent (Figure 1). An external rotation lag sign may be

elicited and, if the tear involves the teres minor, a Hornblower’s

sign will be identified.5 In antero-superior tears patients report

pain and functional loss that typically stems from poor elevation

and abduction. Clinically an increase in passive external rotation

with a deficiency of internal rotation power is seen. The sub-

scapularis belly press, bear hug and Gerber’s lift-off tests will be

positive.

� 2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.mporth.2012.07.002

Figure 1 A patient with hollowing of the supraspinatus and infraspinatus

fossae due to wasting of the muscles consequent upon a massive rotator

cuff tear.

Figure 2 Plain AP radiograph of the shoulder showing rotator cuff

arthropathy, with upward migration of the humeral head, which is

beginning to articulate against the acromion with loss of the normal

acromiohumeral space and sub-acromial sclerosis.


Plain radiographs of the shoulder may show proximal

migration of the humerus, with a reduced acromio-humeral

interval (AHI) in massive cuff tears (Figure 2). The normal AHI

measures 7e14 mm in healthy shoulders and is reduced in

massive IRCTs. The AHI has been shown to correlate with the

size of the tear and, with time, the interval has been shown to

reduce further.6 The plain radiograph will also confirm the

presence or absence of associated rotator cuff arthropathy, which

may alter the management options available. Ultrasound scan-

ning can confirm the presence of a massive tear and delineate the

involved tendons, whilst an MRI scan will provide information

regarding the extent and retraction of the tear (classified in the

frontal plane by Patte) and the level of atrophy and fatty infil-

tration of the individual muscles (Figure 3), although Goutallier’s

original four stage classification of fat atrophy was based on

computerized tomography (CT). CT arthrography can therefore

be used successfully to define the outline of the tear, its retraction

and the degree of fatty degeneration, though MRI is more widely

used in the UK.

Direct visualization and manipulation during arthroscopic

evaluation of a rotator cuff tear is the gold standard for deter-

mining its reparability. The tendon and bone quality can be

assessed, as can the quality of the articular surfaces of the

humerus and glenoid. The tendon edges can be assesses for

mobility, before and after any necessary bursal releases or

interval slides (see later), and it will also allow an assessment of

whether a partial rotator cuff repair is viable or not.

Figure 3 MR imaging showing wasting and fatty infiltration of both
Definition
supraspinatus and infraspinatus (arrows) due to a massive rotator

cuff tear.

Massive rotator cuff tears have been classified as those greater

than 5 cm in size, involving at least two tendons,7 though as yet


there is no universally accepted definition of an irreparable cuff

tear. Size and retraction of the tear have been used as indicative

measures,7,8 though Gerber et al9,10 also incorporated the ease

with which the tendon could be mobilized to restore it to its

normal site of insertion in their classification. Tears were deemed

irreparable if the rotator cuff tendon edges could not be reduced

to the tuberosities without excessive tension with the shoulder

abducted to 60�.9,10




The presence of a symptomatic massive irreparable rotator

cuff tear represents a significant therapeutic challenge. The

management options, both surgical and non-surgical, are plen-

tiful and are shown in Table 1; these will be discussed in more

detail.

Non-operative management

Non-operative management should always be considered as an

option, particularly in the older, lower demand patient with few

symptoms. Regular simple analgesics, possibly intra-articular

steroid injections, and activity adaptations may suffice.

However, strengthening the anterior deltoid and peri-scapular

musculature with movement and proprioception training under

physiotherapy guidance has been shown to be effective in large

rotator cuff tears.11e13 Levy et al13 demonstrated a 37 point

increase in the Constant score (from 26 to 63 points) following

a deltoid re-education programme in elderly patients who were

unsuitable for surgical intervention. This management option

should therefore be the mainstay of initial treatment of elderly

patients with symptomatic massive rotator cuff tears, in the

absence of arthrosis.

Operative management

There are a number of operative interventions in the armamen-

tarium of the shoulder surgeon, and decision making should be

individualized.

Arthroscopic debridement D/L sub-acromial

decompression D/L biceps tenotomy

The least invasive surgical option is an arthroscopic washout,

with rotator cuff, synovial and joint surface debridement.

A limited arthroscopic sub-acromial decompression (ASD),

preserving the coraco-acromial ligament (CAL) by undermining,

can also be performed and biceps tenotomy can also be consid-

ered, particularly if the tendon is degenerate and subluxing. This

option should be reserved for lower demand, elderly patients in

whom pain is the chief complaint, as function will not be

addressed directly though may still improve significantly if pain

is the main inhibitor of muscle function. A post-operative deltoid

rehabilitation programme should be included in the management

of these patients.

Open debridement and sub-acromial decompression of

massive rotator cuff tears has been reported, with successful

Non-operative Operative e no arthrosis

Simple analgesics

Corticosteroid injections

Adaptation of daily living activities

Deltoid re-education programme

Arthroscopic debridement þ/�decompression þ/� biceps ten

Supra-scapular nerve ablation

Tuberoplasty

Partial rotator cuff repair

Augmented rotator cuff repair

Tendon transfer surgery

? Reverse geometry arthroplas

Treatment options for massive, irreparable rotator cuff tears

Table 1


outcomes reported for pain relief by Rockwood8 and Gartsman,14

though less favourable outcomes for functional gain were noted.

Arthroscopic techniques are now favoured and the results are

similar, with improved pain scores but again limited gains in

strength are achieved.2

Techniques of limited sub-acromial decompression with

preservation of the CAL have been advocated to reduce the risk

of antero-superior escape. It is worth noting, however, that

Rockwood’s8 original description of his open technique divided

the CAL without there being any reported adverse effects;

however preserving the CAL is recommended on a theoretical

basis in the operative management of these patients.

Biceps tenotomy may be considered controversial in patients

with massive IRCTs due to fears of exacerbating proximal

humeral migration. The biceps tendon has been considered to

be a humeral head depressor, though reports of tenotomy per-

formed with or without arthroscopic decompression have

shown improvement in pain scores and statistically significant

improvements in the Constant and American Shoulder and

Elbow Surgeons (ASES) scores post-operatively.15e17 In

younger, more active patients biceps tenodesis, rather than

tenotomy, has been advocated to reduce muscle weakness and

the associated cosmetic deformity of a long head of biceps

tenotomy.18 However, it is more likely that this group of

patients will undergo more interventional reconstructive

procedures, as described later, rather than opt for debridement

and tenodesis.

Unfortunately, the short term benefits of debridement and

decompression are not maintained with time and there are

reports of deterioration in symptoms in the medium term.19 The

benefits however are shorter operative times, faster rehabilitation

and lower complications rates in comparison to more interven-

tional surgical options.

Tuberoplasty or reverse sub-acromial decompression

Reverse sub-acromial decompression or tuberoplasty has been

advocated on the basis that debridement of the tuberosity, with

or without biceps tenotomy, preserves the integrity of the coraco-

acromial arch (under surface of the acromion, the CAL and the

coracoid), and reduces the risk of antero-superior escape of the

humeral head when compared with classical sub-acromial

decompression. Outcomes are reported to be similar to ASD with

regard to pain relief, function and subjective satisfaction in the

mid-term.20

Operative with arthrosis

sub-acromial

otomy

ty

Arthroscopic debridement þ/� sub-acromial

decompression þ/� biceps tenotomy


Cuff tear arthroplasty (CTA)

Reverse geometry arthroplasty





The supra-scapular nerve (SSN) provides around 70% of the

sensory innervation to the shoulder joint via its inferior and

superior articular branches.21 The nerve passes through the

supra-scapular notch, where it underlies the transverse scapula

ligament, to enter the supraspinatus fossa and it goes on to

supply both the supra- and infraspinatus muscles. SSN blocks

have been used successfully to modify shoulder pain from

different pathologies, utilizing many techniques22 and forms the

basis for the rationale that SSN ablation will block the sensori-

neural pathway and improve pain scores. Pulsed radiofrequency

ablation has been shown to be effective in improving shoulder

related pain in rotator cuff disease, with or without glenohumeral

joint arthrosis, though this may be a relatively short-lived

benefit. Kane et al22 reported their findings and showed statisti-

cally significant improvements in pain as assessed by a visual

analogue scale. These improvements were not, however, fully

maintained after 3 months. Nizlan et al23 reported a technique of

arthroscopic neurectomy of the SSN with good levels of pain

relief in patients with various shoulder pathologies, but

predominantly in those with cuff tear arthropathy.

SSN ablation, either via percutaneous radiofrequency or

arthroscopic means, offers a minimally invasive option for pain

management. Additionally, a SSN ablation does not preclude

subsequent reverse geometry shoulder arthroplasty.

Partial rotator cuff repair

The rationale for partial rotator cuff repair when dealing with

massive IRCTs relates to the observation that small rotator cuff

tears rarely result in decompensation of shoulder function, and

that the restoration of the force couples, particularly the antero-

posterior couple, results in a shoulder that is biomechanically

competent while it remains anatomically deficient. Burkhart3

introduced this concept; essentially a “functional” repair of the

posterior rotator cuff is performed, leaving the greater tuberosity

uncovered. A massive tear is thereby converted to a small or

moderate tear with an intact subscapularis and the repaired

infraspinatus providing the competent antero-posterior couple.

There have been a number of studies advocating the benefits

of a partial rotator cuff repair, with reports of improved func-

tional outcome scores.2,3,24,25 Additional benefits of partial repair

over simple debridement have also been shown,26 and Burkhart3

has even challenged the requirement for tendon transfer surgery

on account of the results that can be obtained with a partial

repair. These results appear to be maintained with good reported

outcome scores at a minimum 5 years follow-up.25

The ability to perform partial, or even complete, rotator cuff

repairs may be improved by adequate releases of sub-acromial

bursal adhesions and if necessary interval slide procedures that

facilitate mobilization of the tendon of the rotator cuff footprint.

The anterior interval slide releases the rotator interval and the

coraco-humeral ligament between the subscapularis and supra-

spinatus tendons.27 The posterior interval slide is a release

between the infra- and supra-spinatus up to, though not medial

to, the scapular spine.

Augmented rotator cuff repair

Augmented rotator cuff repairs, or biological bridging, aim to

convert or bridge a partial repair of a massive IRCT into


a “complete” repair. Augmentation aims to reinforce the

mechanical properties of a repair and to stimulate and enhance

the biological healing potential of the repair.

There has been significant interest in tissue engineering

techniques to provide scaffolds for tendon augmentation over

recent years and there have been numerous studies, using both

natural and synthetic materials, for the augmentation of massive

IRCTs in animal models. Currently, extracellular matrix derived

from dermis, small intestinal submucosa, fascia lata, and peri-

cardium are commercially available for rotator cuff repair.28

These biological scaffolds of protein-based extracellular

matrices are derived from human or animal connective tissue.

The scaffolds have a 3-dimensional microstructure that allows

cellular infiltration, attachment and proliferation; this induces

quick interaction with the host tissue and new tissue formation.29

Some common examples include GraftJacket�(Wright Medical),

TissueMend� (Stryker), Restore� (DePuy) and CuffPatch�

(Arthrotek). Synthetic materials have been used but biocompat-

ibility has been an issue, with relatively higher rates of infection

and chronic immune response reported.30 The use of animal or

human tissue carries a theoretical risk of disease transmission,

though this has not been reported.29

Wong et al31 published statistically significantly improved

outcome scores in 45 patients treated with arthroscopic

GraftJacket� augmentation of massive IRCTs, followed for

a minimum 2 years post-operatively. Bond et al32 also reported

good outcomes following GraftJacket� augmentation and MRI

scans showed full incorporation of the graft into the native tissue

in the majority of patients.32 Augmentation is an interesting

option for massive IRCTs, though longer term outcomes are

required.

Tendon transfer surgery

Tendon transfers around the shoulder were originally employed

for loss of motor function of the deltoid, rotator cuff and trape-

zius muscles following brachial plexus injuries, most commonly

obstetric brachial plexus injuries. However, in 1988, Gerber et al9

first published a report on the use of a latissimus dorsi transfer

(LDT) for postero-superior rotator cuff deficiency.

Tendon transfer surgery aims to restore function in cuff

deficiency and should be considered in younger, higher demand

patients with pain and functional loss. There are several reports

of the benefits of tendon transfer surgery in IRCTs.33e36 Lat-

issimus dorsi transfer, with or without teres major transfer, has

been shown to benefit patients with postero-superior cuff tears

and likewise pectoralis major transfer is advantageous to patients

with massive irreparable subscapularis tears.

There are a number of techniques published for LDT and

mini-open harvest of the tendon with arthroscopic re-attachment

is gaining popularity. Prerequisites for LDT include an intact

subscapularis tendon, a functioning deltoid, a mobile joint with

no evidence of arthrosis and compliance with the relatively

prolonged rehabilitation.

The results for LDT generally report around a 25% increase in

the functional scores following surgery. LDT does not however

appear to correct for loss of strength,37,38 though the functional

gains patients appear to make, particularly with respect to

improvement of external rotation, do improve patient satisfac-

tion. The major contributory factors to better post-operative




outcomes scores are improved pain and function rather than

strength. This should be discussed before surgery and patients

can be advised that any strength gain is likely to be modest at

best, but daily activities should subsequently be possible with

little or no pain.38

Pectoralis major transfer for massive irreparable sub-

scapularis tears has been reported with some success. Jost et al36

reported good overall results of 30 transfers of the entire pec-

toralis major tendon to the subscapularis footprint. They re-

ported 23 good or excellent results with reported improvement in

both the Subjective Shoulder Value and the Constant score (from

47 to 70 points). The results of transfer were significantly better

in the absence of a supraspinatus tear, suggesting that a massive

tear involving the superior cuff is a relative contraindication to

the procedure.36 Warner,39 in an attempt to improve the line of

pull of the transfer rerouted the sternal portion of the tendon

under the clavicular head and re-attached the tendon to the

greater tuberosity; all patients experienced improved pain and

stability, but only two patients had “good” improvement.39

Subcoracoid transfer was introduced by Resch et al.40 who

showed improved flexion, abduction and Constant scores

following a split pectoralis transfer under the coracobrachialis

avoiding the musculocutaneous nerve.40 The overall results are

not impressive and, where possible, release of the subscapularis

and early direct repair is recommended.

Reverse geometry arthroplasty (without arthrosis)

Figure 4 Reverse geometry total shoulder arthroplasty used to manage

a patient with intractible shoulder pain with an irreparable massive

rotator cuff tear.

Reverse geometry arthroplasty was developed for patients with

massive rotator cuff deficiency with or without the presence of

arthropathy (Figure 4). More recently, it has gained popularity and

the indications for its use appear to have broadened. The rationale

for reverse arthroplasty relies on medialization of the centre of

rotation of the joint, thereby placing the deltoid at a biomechanical

advantage by increasing its lever arm. This provides prosthetic

joint stability and increases the range of movement of the

shoulder; functional results can therefore be better.

Reverse shoulder replacement is controversial to many for the

treatment of cuff deficiency in the absence of arthrosis. However,

for patients who have failed the options outlined previously and

who have on-going symptoms of pain and pseudo-paralysis of

the affected arm, the options are limited. Shoulder hemi-

arthroplasty (as discussed later) does not offer significant resto-

ration of function but can be useful to moderate the pain asso-

ciated with cuff tear arthrosis. Reverse shoulder replacement

may however be a valid option.

Mulieri et al41 reported the outcomes of reverse arthroplasty

in 69 patients (72 shoulders) without evidence of arthrosis; some

patients had undergone prior surgery but not all. For all patients,

the average American Shoulder and Elbow Surgeons score

improved from 33.3 to 75.4 (p < 0.0001), the average visual

analogue score for pain improved from 6.3 to 1.9 (p < 0.0001),

and the average forward flexion improved from 53� to 134�

(p < 0.0001) at a mean 53 months post-operatively.41

Boileau et al42 have also reported encouraging results with

reverse arthroplasty following failed cuff surgery at a mean 50

months post-operatively. The best results were seen in patients

with pseudo-paralysis with an increase in active anterior eleva-

tion from 56� to 123�, and only 7% of patients were dissatisfied

with the results.


However, these encouraging results come at a price and the

complication rate associated with reverse shoulder replacement

is high. The two aforementioned studies reported complication

rates of 20% and 10% respectively, though if scapular notching

is considered a complication this was actually reported in 74% of

cases by Boileau.42 Throughout the literature complication rates

for reverse shoulders are significant, being quoted at rates of up

to 50%. The procedure is technically demanding and complica-

tions include infection, dislocation, scapular notching (though

the true significance of this is not fully understood), and acro-

mion fracture due to the higher forces exerted through the new

lever arm of the deltoid. Reverse shoulder replacement should be

used judiciously and be performed by experienced surgeons.

Operative management with arthrosis

In 1983, Neer43 coined the term “cuff tear arthropathy”: arthrosis

in the presence of a massive rotator cuff tear. As previously

stated, the humeral head migrates proximally due to cuff defi-

ciency under the influence of deltoid, made possible by the

altered kinematics of the shoulder. The humeral head comes to

articulate with the upper portion of the glenoid and the under

surface of the acromion, and the abnormally articulating surfaces

become eroded.

The presence of cuff tear arthropathy is a relative contrain-

dication to partial or augmented rotator cuff repairs, as pain will




prevail following surgery and outcomes will be poor. The oper-

ative management does include arthroscopic rotator cuff and

joint surface debridement (with or without limited sub-acromial

decompression and biceps tenotomy) and SSN ablation, as

described previously, but if symptoms dictate it, then shoulder

arthroplasty can be offered. Total shoulder replacement is con-

traindicated in cuff deficiency as the tendency for superior

migration of the head results in the “rocking horse” phenom-

enon, with eccentric loading of the glenoid component leading to

early loosing and failure of the glenoid. The options are therefore

a shoulder hemi-arthroplasty, with or without an extended head

for articulation with the acromion, or a reverse geometry

shoulder arthroplasty.

Hemiarthroplasty or cuff tear arthroplasty (CTA)

Stemmed shoulder hemi-arthroplasty or surface replacement

arthroplasty, with or without extended coverage (cuff tear

arthroplasty), have been performed for cuff tear arthropathy with

satisfactory reported clinical outcomes and the risk of glenoid

failure is negated by performing a hemi-arthroplasty alone.

Zuckerman et al44 reported that 87% of patients were satisfied

with their surgery after this procedure, though the average active

forward elevation only increased from 69� to 86�. Patients re-

ported improved pain scores and an improvement in their ability

to perform activities of daily living but, as with other studies,

limited range of shoulder motion was noted. In addition to rela-

tively poor gains in movement, instability of the prostheses in

cuff deficiency remains a concern. The Mayo clinic reported

antero-superior instability in seven of 30 patients treated with

hemi-arthroplasty; this was, however, in association with prior

sub-acromial decompression, and overall a success rate of only

67% at 5 years was documented.45 Goldberg et al46 reported

similar overall results of hemi-arthroplasty but noted that patients

with pre-operative forward elevation of greater than or equal to

90� benefitted the most and overall complication rates were low.

The results of hemi-arthroplasty also appear to deteriorate in the

medium to long term due to glenoid or acromial erosion.

Hemi-arthroplasty should be avoided in patients with

previous shoulder surgery, especially sub-acromial decompres-

sion or if antero-superior instability already exists. However,

hemi-arthroplasty remains a viable option for pain relief without

significant functional gains and may be appropriate for some

patients as a more straightforward procedure with fewer reported

complications than the more invasive reverse shoulder

arthroplasty.

Reverse geometry arthroplasty

The biomechanical rationale of reverse shoulder replacement has

been noted above. Its use in rotator cuff arthropathy has been

well documented and good results have been reported in terms of

functional gains, range of movement and pain relief. However,

despite these encouraging results, the complication rates are

relatively high and judicious use of reverse arthroplasty by

experienced surgeons is recommended.

Summary

The management of massive IRCTs, in the presence or absence of

arthrosis, can be challenging. There are many treatment options

available and management should be tailored to the individual


patient. The interventions that have the capability to provide the

best results are also those that are associated with the most

significant and frequent complications therefore shared decision

making with the patient is imperative. A

REFERENCES

1 Sharkey NA, Marder RA. The rotator cuff opposes superior translation

of the humeral head. Am J Sports Med 1995; 23: 270e5.

2 Burkhart SS. Arthroscopic treatment of massive rotator cuff tears:

clinical results and biomechanical rationale. Clin Orthop Relat Res

1991; 267: 45e56.

3 Burkhart SS, Nottage WM, Ogilvie-Harris DJ, et al. Partial repair of

irreparable rotator cuff tears. Arthroscopy 1994; 10: 363.

4 Bigliani LU, Ticker JB, Flatow EL, Soslowsky LJ, Mow VC. The rela-

tionship of acromial architecture to rotator cuff disease. Clin Sports

Med 1991; 10: 823e38.

5 Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and

‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint

Surg Br 1998; 80: 624e8.

6 Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic

findings in massive rotator cuff tears. A long-term observation. Clin

Orthop Relat Res 1990; 254: 92e6.

7 Cofield RH. Rotator cuff disease of the shoulder. J Bone Joint Surg Am

1985; 67: 974e9.

8 Rockwood Jr CA, Williams Jr GR, Burkhead Jr WZ. D�ebridement of

degenerative irreparable lesions of the rotator cuff. J Bone Joint Surg

Am 1995; 77: 857e66.

9 Gerber C, Vinh TS, Hertel R, et al. Latissimus dorsi transfer for the

treatment of massive tears of the rotator cuff. A preliminary report.

Clin Orthop 1988; 232: 51e61.

10 Gerber C. Latissimus dorsi transfer for the treatment of irreparable

tears of the rotator cuff. Clin Orthop Relat Res 1992; 275: 152e60.

11 Ainsworth R. Physiotherapy rehabilitation in patients with massive,

irreparable rotator cuff tears. Musculoskeletal Care 2006; 4: 140e51.

12 Zingg PO, Jost B, Sukthankar A, Buhler M, Pfirrmann CW, Gerber C.

Clinical and structural outcomes of nonoperative management of

massive rotator cuff tears. J Bone Joint Surg Am 2007; 89: 1928e34.

13 Levy O, Mullett H, Roberts S, Copeland S. The role of anterior deltoid

reeducation in patients with massive irreparable degenerative rotator

cuff tears. J Shoulder Elbow Surg 2008; 17: 863e70.

14 Gartsman GM. Massive, irreparable tears of the rotator cuff. Results

of operative debridement and subacromial decompression. J Bone

Joint Surg Am 1997; 79: 715e21.

15 Klinger HM, Spahn G, Baums MH, Steckel H. Arthroscopic debride-

ment of irreparable massive rotator cuff tears - a comparison of

debridement alone and combined procedure with biceps tenotomy.

Acta Chir Belg 2005; 105: 297e301.

16 Walch G, Edwards TB, Boulahia A, Nove-Josserand L, Neyton L,

Szabo I. Arthroscopic tenotomy of the long head of the biceps in the

treatment of rotator cuff tears: clinical and radiographic results of

307 cases. J Shoulder Elbow Surg 2005; 14: 238e46.

17 Liem D, Lengers N, Dedy N, Poetzl W, Steinbeck J, Marquardt B.

Arthroscopic debridement of massive irreparable rotator cuff tears.

Arthroscopy 2008; 24: 743e8.

18 Kelly AM, Drakos MC, Fealy S, Taylor SA, O’Brien SJ. Arthroscopic

release of the long head of the biceps tendon: functional outcome

and clinical results. Am J Sports Med 2005; 33: 208e13.




19 Zvijac JE, Levy HJ, Lemak LJ. Arthroscopic subacromial decompression

in the treatment of full thickness rotator cuff tears: a 3- to 6-year

follow-up. Arthroscopy 1994; 10: 518e23.

20 Scheibel M, Lichtenberg S, Habermeyer P. Reversed arthroscopic

subacromial decompression for massive rotator cuff tears. J Shoulder

Elbow Surg 2004; 13: 272e8.

21 Aszmann O, Dellon AL, Birely BT, McFarland EG. Innervation of the

human shoulder joint and its implications for surgery. Clin Orthop

Relat Res 1996; 330: 202e7.

22 Kane TP, Rogers P, Hazelgrove J, Wimsey S, Harper GD. Pulsed radi-

ofrequency applied to the suprascapular nerve in painful cuff tear

arthropathy. J Shoulder Elbow Surg 2008; 17: 436e40.

23 Nizlan NM, Skirving AP, Campbell PT. Arthroscopic suprascapular

neurectomy for the management of severe shoulder pain. J Shoulder

Elbow Surg 2009; 18: 245e50.

24 Duralde XA, Bair B. Massive rotator cuff tears: the result of partial

rotator cuff repair. J Shoulder Elbow Surg 2005; 14: 121e7.

25 Porcellini G, Castagna A, Cesari E, Merolla G, Pellegrini A, Paladini P.

Partial repair of irreparable supraspinatus tendon tears: clinical and

radiographic evaluations at long-term follow-up. J Shoulder Elbow

Surg 2011; 20: 1170e7.

26 Berth A, Neumann W, Awiszus F, Pap G. Massive rotator cuff tears:

functional outcome after debridement or arthroscopic partial repair.

J Orthop Traumatol 2010; 11: 13e20.

27 Tauro JC. Arthroscopic “interval slide” in the repair of large rotator

cuff tears. Arthroscopy 1999; 15: 527e30.

28 Aurora A, McCarron J, Iannotti JP, Derwin K. Commercially available

extracellular matrix materials for rotator cuff repairs: state of the art

and future trends. J Shoulder Elbow Surg 2007; 16: S171e8.

29 Longo UG, Lamberti A, Maffulli N, Denaro V. Tendon augmentation

grafts: a systematic review. Br Med Bull 2010; 94: 165e88.

30 Chen J, Xu J, Wang A, Zheng M. Scaffolds for tendon and ligament

repair: review of the efficacy of commercial products. Expert Rev Med

Devices 2009; 6: 61e73.

31 Wong I, Burns J, Snyder S, et al. Arthroscopic GraftJacket repair of

rotator cuff tears. J Shoulder Elbow Surg 2010; 19: 104e9.

32 Arthroscopic replacement of massive, irreparable rotator cuff tears

using a GraftJacket allograft: technique and preliminary results.

Arthroscopy 2008; 24: 403e9. e1.


33 Gerber C, Maquiera G, Espinosa N. Latissimus dorsi transfer for the

treatment of irreparable rotator cuff tears. J Bone Joint Surg 2006;

88: 113e20.

34 Valenti P, Kalouche I, Diaz LC, Kaouar A, Kilinc A. Results of latissimus

dorsi tendon transfer in primary or salvage reconstruction of irrepa-

rable rotator cuff tears. Orthop Traumatol Surg Res 2010; 96: 133e8.

35 Moursy M, Forstner R, Koller H, Resch H, Tauber M. Latissimus dorsi

tendon transfer for irreparable rotator cuff tears: a modified tech-

nique to improve tendon transfer integrity. J Bone Joint Surg Am

2009; 91: 1924e31.

36 Jost B, Puskas GJ, Lustenberger A, et al. Outcome of pectoralis major

transfer for the treatment of irreparable subscapularis tears. J Bone

Joint Surg Am 2003; 85: 1944e51.

37 Nov�e-Josserand L, Costa P, Liotard JP, Safar JF, Walch G, Zilber S.

Results of latissimus dorsi tendon transfer for irreparable cuff tears.

Orthop Traumatol Surg Res 2009; 95: 108e13.

38 Weening AA, Willems WJ. Latissimus dorsi transfer for treatment of

irreparable rotator cuff tears. Int Orthop 2010; 34: 1239e44.

39 Warner JJ. Management of massive irreparable cuff tears: the role of

tendon transfer. Instr Course Lect 2001; 50: 63e71.

40 Resch H, Povacz P, Ritter E, et al. Transfer of the pectoralis major

muscle for the treatment of irreparable rupture of the subscapularis

tendon. J Bone Joint Surg Am 2000; 82: 372e82.

41 Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder

arthroplasty for the treatment of irreparable rotator cuff tear without

glenohumeral arthritis. J Bone Joint Surg Am 2010; 92: 2544e56.

42 Boileau P, Gonzalez JF, Chuinard C, Bicknell R, Walch G. Reverse total

shoulder arthroplasty after failed rotator cuff surgery. J Shoulder

Elbow Surg 2009; 18: 600e6.

43 Neer 2nd CS, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint

Surg Am 1983; 65: 1232e44.

44 Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff tear

arthropathy. J Shoulder Elbow Surg 2000; 9: 169e72.

45 Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemi-

arthroplasty for glenohumeral arthritis associated with severe rotator

cuff deficiency. J Bone Joint Surg Am 2001; 83: 1814e22.

46 Goldberg SS, Bell JE, Kim HJ, Bak SF, Levine WN, Bagliani LU. Hemi-

arthroplasty for the rotator cuff-deficient shoulder. J Bone Joint Surg

Am 2008; 90: 554e9.



Documents

(i) The management of irreparable rotator cuff tears