Nonarthroplasty Surgical Treatment Options for Massive, Irreparable Rotator Cuff Tears

Abstract

Massive, irreparable rotator cuff tears (MIRCTs) provide a significant dilemma for orthopaedic surgeons. One treatment option for MIRCTs is reverse total shoulder arthroplasty. However, other methods of treating these massive tears have been developed. A search of the current literature on nonoperative management, arthroscopic debridement, partial repair, superior capsular reconstruction (SCR), graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer for MIRCTs was performed. Studies that described each surgical technique and reported on clinical outcomes were included in this review. Arthroscopic debridement may provide pain relief by removing damaged rotator cuff tissue, but no functional repair is performed. Partial repair has been suggested as a technique to restore shoulder functionality by repairing as much of the rotator cuff tendon as possible. This technique has demonstrated improved clinical outcomes but also fails at a significantly high rate. SCR has recently gained interest as a method to prohibit superior humeral head translation and has been met with encouraging early clinical outcomes. Graft interposition bridges the gap between the retracted tendon and humerus. Balloon spacer arthroplasty has also been recently proposed and acts to prohibit humeral head migration by placing a biodegradable saline-filled spacer between the humeral head and acromion; it has been shown to provide good clinical outcomes. Both trapezius and latissimus dorsi transfer techniques involve transferring the tendon of these respective muscles to the greater tuberosity of the humerus; these 2 techniques have shown promising restoration in shoulder function, especially in a younger, active population. Arthroscopic debridement, partial repair, SCR, graft interposition, balloon spacer arthroplasty, trapezius transfer, and latissimus dorsi transfer have all been shown to improve clinical outcomes for patients presenting with MIRCTs. Randomized controlled trials are necessary for confirming the efficacy of these procedures and to determine when each is indicated based on specific patient and anatomic factors.

Keywords: balloon spacer arthroplasty; graft interposition; massive, irreparable rotator cuff tear; superior capsular reconstruction; tendon transfer.

Figure 1.

Arthroscopic images of superior capsular reconstruction (SCR). (A) Massive rotator cuff tear. (B) Anchor placement. (C) Graft passage and coupling the graft to the posterior rotator cuff. (D) Coupling sutures tied. (E) Completed SCR.

Figure 2.

Arthroscopic images of balloon spacer arthroplasty. (A) Cylindrical insertion device entering the subacromial space. (B) Deflated spacer within the subacromial space. (C) Spacer inflating with saline solution.