Treatment options for massive rotator cuff tears.

Various classifications of rotator cuff tears have been proposed. Many authors currently define a tear as massive if there is a detachment of at least 2 complete tendons. Whereas small tears can occur without symptoms, massive tears are always associated with weakness and, especially in young patients, often with painful disability. Massive tears are only rarely due to an acute injury; rather, they are usually chronic and are associated with myotendinous retraction, loss of musculotendinous elasticity, fatty infiltration of muscles, static (superior) subluxation of the humeral head, and ultimately, osteoarthritis. If fatty infiltration of the respective muscles is beyond Goutallier stage 2 and/or if there is cranial migration of the humerus resulting in an acromiohumeral distance of less than 7 mm, the probability that successful cuff repair can be achieved becomes so low that these massive tears are called irreparable. Whereas small tears with no or little retraction relatively frequently remain small, large, reparable tears usually increase in size and can rapidly become irreparable with no further increase in pain or disability. It is therefore important to determine the definitive treatment of a massive, reparable tear at the time of its identification. The key parameters that are decisive for the definitive treatment are the patient’s symptoms, reparability of the lesion, and shortand longer-term functional demands.