1) Massive rotator cuff tears lower the functional capacity of the shoulder and can cause clinical symptoms when functional demands exceed capacity. 2) Treatment aims to restore equilibrium between demands and capacity by lowering demands, increasing capacity, repairing the cuff, or using tendon transfers or reverse shoulder arthroplasty. 3) Complete release of the torn tendons from surrounding structures is required to properly assess reparability before attempting repair without tension or considering alternative treatments.

1. | Emmanouil Antonogiannakis
| Director
| 3rd Orthopaedic Department
| Centre of Shoulder Arthroscopy and Open Surgery
| Hygeia General Hospital
Massive Rotator Cuff Tears
7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery
Thessaloniki 2016 .

2. Massive Rotator Cuff Tears
Rotator Cuff disease from a
functional point of view
Tears of the rot cuff lower the functional
reserves of the shoulder
When the functional demands of the
patient exceeds the reserves of the
remaining intact rot cuff clinical symptoms
are produced
www.shoulder.gr

3. Massive Rotator Cuff Tears
Philosophy of treatment:
Restore the equilibrium between the
functional demands and the capacity of the cuff
 Lower the functional demands of the patient (persuation)
 Increase the functional capacity of the remaining intact cuff
physiotherapy , InSpace balloon, reconstruction of the superior capsule
 Repair the cuff
 Tendon transfers
 By-pass the rot cuff – Reverse shoulder arthroplasty
www.shoulder.gr

4. Massive Rotator Cuff Tears
Ideally
Repair the cuff
But when this is not possible
what to do ?
www.shoulder.gr

5. Massive Rotator Cuff Tears
When to suspect irreparability?
Age of the patient
Chronicity of tear (duration of symptoms)
Fatty infiltration more than stage 3-4 according to
Goutallier classification (more fat than muscle)
Patte tendon retraction stage 3 (tendons to the
glenoid)
Acromiohumeral distance <2mm
Rot cuff arthropathy
www.shoulder.gr

6. Massive Rotator Cuff Tears
Goutallier classification
Stage 0: normal muscle
Stage 1: some fatty streaks
Stage 2: <50 % fatty muscle atrophy
Stage 3: 50 % fatty muscle atrophy
Stage 4: >50 % fatty muscle atrophy
www.shoulder.gr

7. Massive Rotator Cuff Tears
Patte classification
of tendon retraction in the frontal plane
Stage 1: proximal stump near the bony
insertion
Stage 2: proximal stump at level of the
humeral head
Stage 3: proximal stump at level of glenoid
www.shoulder.gr

8. Massive Rotator Cuff Tears
Posterosuperior and anterosuperior are two
most common tear types seen.
The prevalence of massive tears reported in
the literature has ranged from 10 to 40%of
all RCT tears
www.shoulder.gr

9. Massive Rotator Cuff Tears
Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear End-to-bone repair Good to excellent
2
Longitudinal
(L or U)
Long and narrow tear Margin convergence Good to excellent
3 Massive contracted
Long and wide
> (2 x 2 cm)
Interval slides or partial repair Fair to good
4 Cuff tear arthropathy Cuff tear arthropathy Arthroplasty Fair to good.
www.shoulder.gr

10. Massive Rotator Cuff Tears
What to do ?
Type 1 and 2 repair
Type 3 we will consider
Type 4 reverse arthroplasty
www.shoulder.gr

11. Massive Rotator Cuff Tears
Repair the cuff the first option
 Balanced force couples
 Stability of the edges
 Strong fixation
 Repair without tension
www.shoulder.gr

12. Massive Rotator Cuff Tears
How to perform a repair
When to consider a tear as irreparable
or
When to stop the repairing effort
We must be able to:
 Recognize the tendons
 Release the tendons completely
 Fix the tendons without tension
www.shoulder.gr

13. Massive Rotator Cuff Tears
How to perform a repair
Find and recognize the tendons
Identify recognizable landmarks
 the undersurface of the acromion and
 the anterolateral corner
 the acromio-clavicular joint
 the spine of the scapula
 the lateral border of the tuberosity
www.shoulder.gr

14. Massive Rotator Cuff Tears
Tips and tricks
Remove the thickened bursa till to see the posterior edge of the cuff ending
to the greater tuberosity.
Everything that goes around the tuberosity to the deltoid is bursa
www.shoulder.gr

15. Massive Rotator Cuff Tears
Tips and tricks
Remove the thickened bursa till to see the posterior edge of the cuff ending
to the greater tuberosity.
Everything that goes around the tuberosity to the deltoid is bursa
Don’t suture the bursa instead of the cuff
It doesn’t work
www.shoulder.gr

16. Massive Rotator Cuff Tears
Tips and tricks
 Recognize the tendons
 Release the tendons completely
 Fix the tendons
www.shoulder.gr

17. Massive Rotator Cuff Tears
Tips and tricks
 Recognize the tendons
 Release the tendons completely
 Fix the tendons
You can’t consider repairability
before a complete release
www.shoulder.gr

18. Massive Rotator Cuff Tears
Release the tendons from:
 The coracoid
 The acromion
 The glenoid
www.shoulder.gr

19. Massive Rotator Cuff Tears
www.shoulder.gr
Release from the interval

20. Massive Rotator Cuff Tears
Release from the coracoid
www.shoulder.gr

21. Massive Rotator Cuff Tears
Release from the glenoid
P o s t e r i o r l y S u p e r i o r l y A n t e r i o r l y
www.shoulder.gr

22. Massive Rotator Cuff Tears
Release from the glenoid
P o s t e r i o r l y I n f e r i o r l y A n t e r i o r l y
www.shoulder.gr

23. Massive Rotator Cuff Tears
All around
thylacotomy
P o s t e r i o r l y
S u p e r i o r l y
A n t e r i o r l y
www.shoulder.gr

24. Massive Rotator Cuff Tears
Release from the interval and thylacotomy
www.shoulder.gr

25. Massive Rotator Cuff Tears
Release the tendons from the acromion
P o s t e r i o r l yA n t e r i o r l y
www.shoulder.gr

26. Massive Rotator Cuff Tears
Pre-operatively Post-operatively
www.shoulder.gr

27. Massive Rotator Cuff Tears
Decisions after complete release
 Complete repair
 Medialized repair
 Partial repair
 Debridement, biceps tenotomy
www.shoulder.gr

28. Massive Rotator Cuff Tears
www.shoulder.gr
Repair without Tension

29. Massive Rotator Cuff Tears
Rotator Cuff Grafts
www.shoulder.gr
Our Experience is limited

30. Massive Rotator Cuff Tears
TENDON TRANSFERS
www.shoulder.gr
Latissimus dorsi transfer for posterosuperior tears

31. Massive Rotator Cuff Tears
Latissimus Dorsi Transfer
www.shoulder.gr
The goal is not to cover the humeral head but to
establish a balanced force couple centering the head
Subscapularis
Lat. Dorsi

32. Massive Rotator Cuff Tears
Latissimus Dorsi Transfer
www.shoulder.gr
Indications
 Intact Subscapularis
 Intact Deltoid
 No Stiffness

33. Massive Rotator Cuff Tears
Latissimus Dorsi Transfer
www.shoulder.gr

34. Massive Rotator Cuff Tears
Results (6 months post-op)
www.shoulder.gr

35. Massive Rotator Cuff Tears
Passive spacers
www.shoulder.gr
Superior capsule reconstraction

36. Massive Rotator Cuff Tears
Subacromial Spacer (InSpace Balloon)
www.shoulder.gr

37. 11 cases with irreparable cuff tears
treated by balloon implantation only
11 cases
treated with partial repair augmented by balloon implantation
1 case
treated with complete repair augmented by balloon implantation
1 revision balloon case due to balloon failure
treated by revision balloon implantation
Our experience
24 cases no psheudoparalytic
shoulder
Massive Rotator Cuff Tears
www.shoulder.gr

38. Our experience 24 cases
During the rehabilitation:
No pain or very slight pain
Very satisfied patients
Most regained good active ROM
They declare that their life quality has changed
Massive Rotator Cuff Tears
www.shoulder.gr

39. Our experience 24 cases
Average VAS
Rest
Motion
Night
1.5
5.4
7.4
0.0
0.4
0.0
Parameter Pre-op Post-op
Average follow-up: 3.9 months
Massive Rotator Cuff Tears
www.shoulder.gr

40. Our experience 24 cases
Parameter Pre-op Post-op
ROM
FF
ER side
ER 90 abd
IR
119.4
48.8
48.2
L1
148.5
61.8
50.8
Th11
Average follow-up: 3.9 months
Massive Rotator Cuff Tears
www.shoulder.gr

41. Our experience 24 cases
Parameter Pre-op Post-op
Function
Constant
ASES
Oxford
44.2
50.8
28.6
55.6
80.2
41.4
Average follow-up: 3.9 months
Massive Rotator Cuff Tears
www.shoulder.gr

42. Our experience 24 cases
All patients had:
Significant pain relief
Increased ROM
Less pain during rehabilitation
Massive Rotator Cuff Tears
www.shoulder.gr

43. Massive Rotator Cuff Tears
Take home message
In every massive cuff tear
follow the steps
 Recognize the tendons
 Release the tendons completely
 Fix the tendons without tension if possible
 Use alternative methods
www.shoulder.gr

44. | Emmanouil Antonogiannakis
| Director
| 3rd Orthopaedic Department
| Centre of Shoulder Arthroscopy and Open Surgery
| Hygeia General Hospital
7th Balkan Congress of Arthroscopy, Sports, Traumatology & Knee Surgery
Thessaloniki 2016 .
Thank you
…for your attention

45. Massive Rotator Cuff Tears
Release the anterior capsule
www.shoulder.gr

46. Massive Rotator Cuff Tears
Release from the posterior capsule
www.shoulder.gr