Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options

Abstract

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

Arthroscopic Treatment for Massive Cuff Tears

“…The superior capsule of glenohumeral joint spans from the superior labrum to the greater tuberosity of humerus; it covers the footprint of the supraspinatus tendon, and from a biomechanical point of view, it acts like a static stabilizer for the glenohumeral joint [19,20,[84][85][86][87].…”

“…Despite the rapidly increasing numbers of reverse shoulder arthroplasties, alternative options are available [6][7][8][9][10][11][12][13][14][15][16][17][18]; among those, we mention biceps tenotomy or tenodesis, arthroscopic debridement, partial repair, complete repair, augmentation of repair with different types of patches, superior capsular reconstruction, and muscle tendon transfer [19]. Recently, superior capsular deficiency can be treated by the use of various autografts/allograft; respected shoulder surgeons present several surgical techniques such as: rerouting the long head of biceps tendon, use of long head of biceps tendon as an autograft, use of semitendinosus as an allograft, or simpler methods -subacromial spacers [20]. In the literature [19,21], there is a lack of consensus and lack of guidelines on the appropriate indications for specific surgical treatment options, although, recent work from [20,22] present an agreement on treatment of massive irreparable rotator cuff tears by the Neer Circle of the American Shoulder and Elbow Surgeons [20,22].…”

“…Recently, superior capsular deficiency can be treated by the use of various autografts/allograft; respected shoulder surgeons present several surgical techniques such as: rerouting the long head of biceps tendon, use of long head of biceps tendon as an autograft, use of semitendinosus as an allograft, or simpler methods -subacromial spacers [20]. In the literature [19,21], there is a lack of consensus and lack of guidelines on the appropriate indications for specific surgical treatment options, although, recent work from [20,22] present an agreement on treatment of massive irreparable rotator cuff tears by the Neer Circle of the American Shoulder and Elbow Surgeons [20,22].…”

Up to date diagnosis and treatment of massive irreparable cuff tears: Results of the survey of the U45 ESSKA Committee

“…Other parameters include acromiohumeral distance of less than 5.8 mm, chronic pseudoparalysis, large mediolateral tear size, positive tangent sign and three or four tendon tears [17]. Some authors report that up to 30% of total rotator cuff tears can be classified as irreparable [10,17]. Literature reports of high retear rates in massive posterosuperior rotator cuff repair range from 40% to 91% [2,11,14,18]; this represents a real problem, especially in young and active patients.…”

Long head of biceps tendon augmentation for massive rotator cuff tears improves clinical results regardless of the number of tendons involved

“…Superior capsule reconstruction normalises superior humeral head translation improving glenohumeral kinematics and allowing more effective function of the deltoid and RC [40]. The long head of the biceps tendon (LHBT) is one of the major stabilisers of the humeral head [7,17,51,58], depressing it, similar to the superior capsule, preventing superior migration and reinforcing RC repairs [37,38,41]. For these reasons, augmentation or incorporation techniques have been developed to improve clinical outcomes in MRCTs [24,43].…”