An Update on Surgical Management of the Repairable Large-to-Massive Rotator Cuff Tear

Abstract

➢ Despite an evolving array of surgical options and technologies available to perform rotator cuff repair, as well as advances in postoperative rehabilitation strategies, reported failure rates remain high, with large-to-massive rotator cuff tears showing higher failure rates than small-to-medium-sized tears.➢ Preoperative magnetic resonance imaging is critical for judging the potential repairability of a large-to-massive rotator cuff tear based on imaging characteristics, including tear size and retraction, length and attenuation of the tendon stump, and fatty infiltration or atrophy in the rotator cuff muscle bellies. Advanced fatty infiltration and atrophy in the rotator cuff muscles have been found to be independent predictors of retear following repair of large-to-massive tears.➢ While there is some evidence that double-row rotator cuff repairs have lower failure rates for larger tears, a double-row repair may not always be possible in some chronic, retracted large-to-massive rotator cuff tears that cannot be completely mobilized and have tendon loss.➢ Strategies to augment rotator cuff repairs are based on the desire to improve the mechanical integrity and biologic healing environment of the repair, and they have shown promise in improving healing rates following repair of large-to-massive tears.➢ While most patients report pain relief and have increased patient-reported outcomes scores after surgery, studies have shown that patients with an intact repair have better functional scores, range of motion, and strength, and less fatty degeneration compared with patients with a failed repair.

Advantages of 3–dimensional Measurements for Supraspinatus Intramuscular Fatty Evaluation in Patients With Medium to Massive Rotator Cuff Tears: Comparison With a Single Sagittal Slice

“…On the physician's side, there is 1 essential step that must be completed: planning. 20 3D-FF can aid in surgical planning by mapping the area of the fatty infiltration and helping the surgeon prevent unexpected complications. RC repair aims to remove the bursa, damaged tissue, and scar tissue and reattach the tendon to the humerus with suture anchors.…”

Follow-up on a Biological Revision Technique for Large, Recurrent, Retracted, Rotator Cuff Tears

“…Patient presentations that violate these conditions require an alternative surgical strategy such as a superior capsular reconstruction or tendon (latissimus dorsi or lower trapezius) transfer for massive tears with irretrievable tendons or reverse total shoulder arthroplasty for advanced degenerative glenohumeral joint changes. 42 The tendon/marrow patch graft technique has been performed only through a mini-open incision, not arthroscopically, because the volume of fluid required for arthroscopy might have diluted the concentration of mesenchymal cells and growth factors. To prove efficacy using an arthroscopic approach, a tissue biopsy of the processed biceps tendon graft once in place would be required for histological analysis of the viable mesenchymal cell concentration.…”

Crimped nanofiber scaffold mimicking tendon-to-bone interface for fatty-infiltrated massive rotator cuff repair

“…However, 10–40% of the patients with RCTs inevitably develop massive RCTs (MRCTs) with mild or severe fatty infiltration in the rotator cuff muscle, resulting in persistent pain or pseudo-paralysis [ [3] , [4] , [5] ]. The issue of fatty-infiltrated MRCT (fi-MRCT) requires an urgent solution, as current treatments are ineffective and the failure rate of surgery ranges from 62 to 95% [ [6] , [7] , [8] , [9] , [10] ]. The challenges of tendon-to-bone interface regeneration and muscle fat infiltration render difficulties in fi-MRCT repair.…”