Rotator cuff tears can be treated non-operatively with physical therapy and injections or operatively with repair or tendon transfer depending on factors like tear size and chronicity. Arthroscopic repair is now the gold standard and aims to restore the footprint with techniques like margin convergence and interval slides. Post-operatively, healing takes 8-12 weeks and rehabilitation focuses on early passive range of motion. Tendon transfers are indicated for massive, irreparable tears while arthroplasty is used for arthritis.

1. Rotator cuff tear

2. Treatment
• activity and age of patient
• mechanism of tear (degenerative or traumatic
avulsion)
• characteristics of tear (size, depth, retraction,
muscle atrophy)
• partial thickness tears vs. complete tear
• articular sided (PASTA lesion) vs. bursal sided
• bursal sided tears treated more aggressively

3. Nonoperative
• physical therapy, NSAIDS, subacromial corticosteroid
injections
• first line of treatment for most tears
• partial tears often can be managed with therapy
• technique
• avoidance of overhead activities
• physical therapy with aggressive rotator cuff and
scapular-stabilizer strengthening over a 3-6 month
treatment course
• subacromial injections if impingement thought to be
major cause of symptoms

4. Operative
subacromial decompression and rotator cuff debridement alone
indications:
• select patients with a low-grade partial articular sided rotator cuff tear
rotator cuff repair (arthroscopic or mini-open)
indications
• acute full-thickness tears
•
• bursal-sided tears >3 mm (>25%) in depth
• release remaining tendon and debride degenerative tissue
• partial articular-side tears>50% can be treated with tear completion and repair
• Partial articular-side tears <50% treated with debridement alone
• PASTA with >7mm of exposed bony footprint between the articular surface and intact tendon
represents significant (>50%) cuff tear (must have at least 25% healthy bursal sided tissue)
• younger patients with acute, traumatic tears
• in situ repair leave bursal sided tissue intact
• older patients with degenerative tears
• tendon release, debridement of degenerative tissue and repair

5. Postoperative
• rate-limiting step for recovery is biologic healing of RTC
tendon to greater tuberosity, which is believed to take 8-12
weeks
• peribursal tissue and holes drilled in greater tuberosity are
major source of vascularity to repaired rotator cuff
• vascularity can increase with exercise
• postop with limited passive ROM (no active ROM)
outcomes
• Worker's Compensation patients report worse outcomes
• higher postop disability and lower patient satisfaction
• patients should expect to return to full work duty by 6-10
months after surgery

6. Tendon transfer
Indications
• massive cuff tears
techniques
• pectoralis major transfer
• latissimus dorsi transfer - best for irreparable posterosuperior tears with
intact subscapularis
superior capsular reconstruction
indications
• massive irreparable rotator cuff tear with intact subscapularis
reverse total shoulder arthroplasty
indications
• massive cuff tears with glenohumeral arthritis with intact deltoid

7. TECHNIQUE
Mini-open rotator cuff repair
• once was gold standard but has been largely been replaced by
arthroscopic techniques
• approach
• small horizontal variant of shoulder lateral (deltoid splitting)
approach
• advantages over open approach
• decreased risk of deltoid avulsion
• faster rehabilitation (do not need to protect deltoid repair)
• may begin passive ROM immediately to prevent adhesive
capsulitis
• most surgeons wait ~6 weeks before initiating active ROM

8. Arthroscopic rotator cuff repair
advantages
• studies now show equivalent results to open or mini-open repair
important concepts
margin convergence
• shown to decrease strain on lateral margin in U shaped tears
anterior interval slide
• release supraspinatus from the rotator interval (effectively incising
coracohumeral ligament). This increases the mobility of
supraspinatus and allows it to be fixed to the lateral footprint.
posterior interval slide
• release supraspinatus from infraspinatus. This further increases the
mobility of supraspinatus and allows it to be fixed to the lateral
footprint. Then repair supraspinatus to infraspinatus with margin
convergence.

9. subscapularis repair
• although arthroscopic repair is technically challenging, new
studies show superior outcomes (motion and pain) compared to
open repair
• stabilize biceps tendon with tenodesis
• posterior lever push maneuver useful to identify insertional
humeral footprint tears
• superolateral margin of subscapularis identified by the "comma
sign"
• superior glenohumeral and coracohumeral ligaments attach to
the subscapularis tendon
long head biceps tendon repair
• most studies show negligible difference between tenotomy vs.
tenodesis after concurrent rotator cuff repair

10. Footprint restoration
• it is hypothesized that a larger footprint will
improve healing and the mechanical strength of the
rotator cuff repair
• double row suture techniques (mattress sutures in
medial row and simple sutures in lateral row) have
been shown to create a more anatomic repair of
the footprint
• lower retear rate compared with single row
• no difference in functional score, pain score, time
to healing (compared to single row)

11. coracoacromial ligament release
• release leads to an increased anterior/inferior
translation of the glenohumeral joint

12. Tendon transfer
• indicated for massive and irreparable rotator cuff
tears
pectoralis major transfer
• indicated in chronic subscapularis tears
• transferring pectoralis major under the conjoined
tendon more closely replicates the vector forces of
the native subscapularis
• requires 4-6 weeks of rigid immobilization

13. latissimus dorsi transfer
• indicated in large supraspinatus and infraspinatus tears
• best candidate is young laborer
• attach to cuff muscles, subscapularis, and GT
• brace immobilize for 6 wks. in 45° abduction and 30° ER.
• nerves at risk - radial nerve
• runs along anterior surface of latissimus dorsi, ~3cm medial to
humeral insertion
• at risk during tenotomy
• posterior branch of the axillary nerve
• runs in deep fascia of posterior deltoid
• at risk during passage of tendon deep to deltoid to
subacromial space

14. Superior capsular reconstruction with biologic or synthetic
grafts
• some recent evidence of improved outcomes with the use of
xenograft, allograft, or synthetic patches for massive cuff tears
• limited human and long-term studies
xenograft
• from bovine dermis or intestine
• mixed functional outcomes and graft incorporation
allograft
• from human skin or muscular fascia
• some evidence of good function and survival at short-term
synthetics
• concern for foreign body reaction
• mixed functional results

15. Lateral acromionectomy
• historic significance only
• contraindicated due to high complication rate

16. Thank you