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.

Keywords: BAR; InSpace balloon; LHBT; SCR; margin convergence; massive irreparable rotator cuff tear; orthobiologics; superior capsular reconstruction.

Figure 1

Neer Circle Consensus Paper on the treatment algorithm for MIRCTs: Displayed are the conditions in the patients where consensus was reached on treatment for MIRCTs (24). Starting with the patient’s age (bottom left bubble) and adding clinical findings (top right bubble), recommendations for treatment can be seen in this chart.

Figure 2

Possible treatment options for massive irreparable rotator cuff tears. This flowchart gives an overview of novel arthroscopic as well as established techniques.

Figure 3

(A) Massive rotator cuff tear. (B) Snake technique by Kim et al. using the LHBT in a snake-like formation for SCR. (C) Box shape technique by Denard et al. using the LHBT in a box shape for SCR. (D) Biceps rerouting technique by Kim et al. using an intraarticular biceps tenodesis for SCR.

Figure 4

(A) Arthroscopic view of a right shoulder from the posterolateral portal demonstrating a massive irreparable tear of the supraspinatus and infraspinatus prior to capsular reconstruction. (B) Arthroscopic view of the right shoulder showing the completed capsular reconstruction with medial fixation to the superior glenoid and lateral fixation to the greater tuberosity (GT).