Operative Technique: Arthroscopic Repair of Massive Rotator Cuff Tears

Introduction Rotator cuff tears are a common cause of pain and disability. 2 With modern advances in arthroscopy and arthroscopic techniques, most rotator cuff tears can now be repaired arthroscopically, with several authors reporting successful results. However, the optimal management of massive rotator cuff tears is controversial and evolving. In general, a massive rotator cuff tear (MRCT) is defined as a tear in which the major tear diameter is greater than 5 cm or tears that involve more than one tendon. Despite the imposing retraction, most massive tears can be reduced to their native configuration once the tear configuration is recognized. Burkhart et al have classified massive cuff tears into one of three categories: crescent shaped, U-shaped, and Lshaped. Crescent shaped tears are mobile and reduce easily to the anatomic footprint without excessive tension. U-shaped tears extend medially with the apex of the tear at the level of the glenoid. L-shaped tears are massive rotator cuff tears with a longitudinal component along the fibers of the rotator cuff as well as a transverse component along the cuff insertion. Arthroscopic repair of massive rotator cuff tears presents a challenge to the orthopaedic shoulder surgeon due to tendon retraction, adhesions, and poor tissue quality making tension free repair difficult. Several arthroscopic techniques have been reported with the goal of gaining adequate tendon mobility, including margin convergence, interval slides, as well as release of fibrous bursal tissue and adhesions. 10 Several open options are available to treat this condition, including tendon transfer, the use of allograft and synthetic grafts, arthrodesis, hemiarthroplasty, and reverse total shoulder arthroplasty (RTSA). However, there is currently no consensus on the appropriate surgical treatment of massive irreparable tears when non-operative management fails. There has been a recent broadening of the indications for RTSA for the treatment of patients with massive rotator cuff tears but without arthritis. We urge caution to surgeons performing RTSA for this indication, as the Corresponding author: Michael H. McGraw, MD Department of Orthopaedic Surgery University of Pennsylvania 3400 Spruce Street, 2 Silverstein Pavilion Philadelphia, PA 19104 [email protected] Michael H. McGraw, MD John D. Kelly IV, MD