Arthroscopic treatment of massive and irreparable cuff tears

Authors: Peter Habermeyer

References: SECEC, Rome 2005

Definition of Massive cuff tears:
- Bateman & Cofield: Massive = greater than 5 cm
- Gerber : Massive = Two or more tendons

Irreparable Cuff tears:
- Fatty muscle degeneration > 11°
- Fixed tendon retraction more than Grade II° 
- Acromiohumeral distance less than 7 mm

Ability to mobilize a tear to the tuberosity is a better determinant of outcome than the size of the tear [Jones and Savoir III, Arthroscopy 2003]

MASSIVE LESIONS: SIDE TO SIDE OR TENDON TO BONE REPAIR:
Biomechanical rationals:
- force couple
- suspension bridge
- edge stability

Side to side repair: = creating a functional rotator cuff tear / force couple repair

Arthroscopic repair of massive cuff tears
Analysis of results by tear size and by repair technique:
- Margin convergence versus tendon to bone repair:
- Modified UCLA Score: 95% good and excellent results
- Results were independent of tear size
- No difference in repair technique
[Burkhart SS et al., Arthroscopy 2001, Nice 2004]

Arthroscopic repair of large and massive tears
- 37 large tears, 13 massive tears
- Follow-up 32 months, 88% good and excellent outcomes
-Patients with massive tears had outcomes equal to those with large tears [Jones and Savoie III, Arthroscopy 2003]

Arthroscopic complete Tendon to bone repair
- 50% healed (3/6) [Boileau AAOS 2004]
- 94% Retear rate, excellent pain relief (17/18) [Galatz et al., J Bone Surg Am 2004]
No significant differences in outcomes after complete or partial repair
[Lo and Burkhart Arthroscopy 2004; Bennett WF, Arthroscopy 2004]
-Tendon to bone repair if the tendons can be mobilised and reconstructed without tension
-Side to side repair if a tendon to bone repair is not possible without tension
-Reconstruction of the force couple is the key!