Review Article
Management of the Irreparable
Gregory L. Cvetanovich, MD
Brian R. Waterman, MD
Nikhil N. Verma, MD
Anthony A. Romeo, MD
From the Ohio State University
Wexner Medical Center, Columbus,
OH (Dr. Cvetanovich), Wake Forest
Baptist Health, Wake Forest
University School of Medicine,
Winston-Salem, NC (Dr. Waterman),
Midwest Orthopaedics at Rush, Rush
University Medical Center, Chicago,
IL (Dr. Verma), and Rothman Institute,
New York, NY (Dr. Romeo).
Dr. Verma or an immediate family
member serves as a paid consultant
to Arthrex and has received research
or institutional support from Arthrex.
Dr. Romeo or an immediate family
member has received IP royalties
from; is a member of a speakers’
bureau or has made paid
presentations on behalf of; serves
as a paid consultant to; and has
received research or institutional
support from Arthrex. Neither of the
following authors nor any immediate
family member has received anything
of value from or has stock or stock
options held in a commercial company
or institution related directly or
indirectly to the subject of this article:
Dr. Cvetanovich and Dr. Waterman.
J Am Acad Orthop Surg 2019;27:
909-917
DOI: 10.5435/JAAOS-D-18-00199
Copyright 2019 by the American
Academy of Orthopaedic Surgeons.
December 15, 2019, Vol 27, No 24
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Rotator Cuff Tear
Abstract
When evaluating patients with irreparable rotator cuff tears,
orthopaedic surgeons have an increasingly wide array of surgical
options, including both established techniques and emerging
technologies. However, significant variability exists in the clinical
evaluation and surgical indications in this subset, and definitions for
pseudoparalysis and tear irreparability are inconsistent. In older
patients with symptomatic rotator cuff arthropathy and relatively
sedentary demands, the reverse total shoulder arthroplasty has been
established as the preferred treatment option, producing reliable
improvements in both pain and function. In younger patients without
glenohumeral arthritis or pseudoparalysis, joint-preserving options
are preferred, with recent literature highlighting alternative options
including partial repair, bridging or interpositional graft placement,
tendon transfers (ie, latissimus, trapezius, and pectoralis major),
superior capsular reconstruction, and subacromial spacer placement.
In this review article, we address the topic of irreparable rotator cuff
tears, emphasizing the workup, indications for various treatment
options, and clinical outcomes.
R otator cuff pathology is the most
common source of shoulder
disability and among the most prev-
scopic techniques.4,5 Although re-
pair can be performed, structural
failure after primary repair of large-
alent conditions treated by practicing to massive-size tears may occur in up
orthopaedic surgeons.1 Rotator cuff to 25% to 94% of cases by 2 years,
tears may reflect acute or acute-on- most commonly at the bone-tendon
chronic onset of symptoms or most interface.4,5 Ongoing research is
commonly may develop as a result evaluating the effects of newer,
of a chronic degeneration process, advanced rotator cuff repair techni-
with both intrinsic and extrinsic risk ques including graft augmentation,
factors noted. An estimated 50% of superior capsular reconstruction
patients will have radiographic evi- (SCR), and subacromial balloon
dence of bilateral rotator cuff tear spacer to improve functional out-
after age 66 years,1 although symp- comes in treatment of massive rota-
toms may vary. Massive rotator tor cuff tears.
cuff tears—defined as defects The identification and manage-
measuring .5 cm or involving two ment of true irreparable rotator cuff
or more torn tendons2,3—are not tears present unique challenges for
necessarily synonymous with irrep- the orthopaedic surgeon, both in
arable tears because many massive terms of cost containment and
tears can be repaired with adequate immediate versus delayed long-term
mobilization and advanced arthro- patient benefit. In older patients with
909
Management of the Irreparable Rotator Cuff Tear
symptomatic rotator cuff arthropathy
and relatively sedentary demands,
nonsurgical management and reverse
total shoulder arthroplasty (RSA)
have been established as the preferred
treatment options, producing reliable
improvements in both pain and func-
tion.6-8 For younger patients without
secondary arthritis, advanced acro-
miohumeral remodeling, and/or
pseudoparalysis, joint-preserving op-
tions are preferred whenever possible
because of concerns about patient-
specific demands and long-term
implant survivorship. In this review
article, we address the topic of
irreparable rotator cuff tears,
emphasizing the workup, indications
for various treatment options, and
clinical outcomes.
Identification of the
Irreparable Rotator Cuff
Tear
Preoperatively, irreparable tears can
frequently be difficult to distinguish
from large or massive repairable
tears based on examination and
imaging studies alone, although
certain criteria have been pro-
posed.9,10 Irreparable rotator cuff
tears are generally large (in both AP
and medial-lateral dimensions) and
retracted with poor or attenuated
tissue quality, muscular atrophy,
and fatty infiltration.10,11 The ulti-
mate assessment of reparability is
determined intraoperatively after
tendon mobilization and interval
releases. Burkhart found that 85%
of massive rotator cuff tears were
completely repairable, although
only 57% of tears with Goutallier 3
to 4 fatty infiltration of the supra-
spinatus were repairable.12,13 Nev-
ertheless, a thorough preoperative
assessment is critical in surgical
planning to identify tear patterns
that are potentially irreparable to
prepare for alternative treatment
strategies.
910
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Patient Evaluation
Patients undergo a detailed history to
assess for pain and disability of the
affected shoulder. Occupational de-
mands, involvement in leisure or
sporting activities, hand dominance,
tobacco use, and medical comorbid-
ities are assessed. The degree of pain
and disability may not correlate
with the size and reparability of the
associated rotator cuff tear.14 Trau-
matic versus atraumatic onset and
symptom chronicity are important
variables to assess because traumatic
tear or those with more acute pre-
sentation may be more likely to be
repairable, particularly when associ-
ated with pseudoparalysis. Finally,
previous surgical history, including
advanced radiographic imaging,
arthroscopic images, and surgical
reports, should be obtained and
scrutinized to determine initial tear
pattern, tissue quality, concomitant
procedures, untreated pathology,
and potential technical errors (eg,
violation of the myotendinous junc-
tion and implant prominence).
Physical examination starts with
inspection of the affected shoulder
and periscapular musculature, with
care to assess for atrophy of the su-
praspinatus and infraspinatus in
their respective fossae. Visible atro-
phy on examination is suggestive of
chronicity and advanced rotator cuff
fatty infiltration that contribute to
poor tissue mobility and difficulty
with primary repair. Neurovascular
examination is performed to assess
axillary nerve function with sensa-
tion and deltoid motor function.
Active and passive range of motion
are then evaluated and compared
with the unaffected, contralateral
shoulder, while bearing in mind that
patients may present with bilateral
rotator cuff pathology. Patients with
disrupted rotator cuff force couples
or cable involvement due to a massive
or irreparable tear may exhibit sig-
nificant losses of active range forward
Journal of the American Academy of Orthopaedic Surgeons
elevation with relatively preserved
passive range of motion.15 When the
patient is unable to elevate the arm
beyond 90° actively despite intact
passive motion, the patient is com-
monly said to have pseudoparalysis,
although we prefer the more nuanced
terminology of pseudoparesis for
active elevation that falls short of 90°
with pseudoparalysis reserved for
patients essentially without active
elevation and anterior translation on
attempted elevation consistent with
anterior-superior escape or migra-
tion.15 It is important to attempt to
distinguish true weakness-mediated
pseudoparalysis from pain-mediated
and effort-mediated false positives.
Subacromial injection or lidocaine
challenge can reduce the contribution
of pain in equivocal cases and help to
discern between effort- and pain-
mediated etiologies and structural
deficits. Ultimately, the identifica-
tion of pseudoparalysis is based
on a combination of clinical exami-
nation and imaging studies con-
firming massive cuff pathology with
superior humeral migration.
Rotator cuff strength is evaluated
and compared with the contralateral
side, with significant weakness pre-
sent in patients with poorly compen-
sated massive or irreparable tears.
The supraspinatus is assessed with
resisted forward elevation in the
scapular plane and maximal internal
rotation. The infraspinatus is as-
sessed with resisted external rotation
with the arm adducted. The sub-
scapularis is assessed with belly
press, lift-off, and bear hug testing,
which may differentially assess the
upper and lower aspects of the
subscapularis.16 Resisted external
rotation or a Hornblower test is
performed in 90° of abduction and
90° of external rotation to assess
the teres minor.17 Furthermore,
increased passive motion and lag
signs may be identified, including
increased passive internal rotation
and external rotation lag for
 Gregory L. Cvetanovich, MD, et al

infraspinatus, increased passive exter- Figure 1

nal rotation and internal rotation lag
for subscapularis, and drop arm sign
for supraspinatus.

Imaging
Patients are initially evaluated with
standard, three-view radiographic
series of the shoulder, including a true
AP (Grashey), outlet (scapular Y),
and axillary lateral images. Radio-
graphs are used to identify associated
glenohumeral arthritis or rotator cuff
arthropathy according to the Hamada
classification,18 reciprocal remodeling
changes in the greater tuberosity and
corresponding undersurface of the
acromion, acromiohumeral distance,
presence of subluxation or ante-
rosuperior escape, and acromial
morphology (Figure 1). Narrowing
of the acromiohumeral distance Hamada classification of rotator cuff arthropathy. (Reproduced with permission
below 5 to 6 mm has been associated from Hamada K et al: A radiographic classification of massive rotator cuff tear
with massive tears with advanced arthritis. Clin Orthop Relat Res 2011;469[9]:2452-2460.)
fatty infiltration that may render
tissue irreparable.19
respectively, and are generally found head or less. Therefore, surgeons
MRI is the predominant advanced
in irreparable tears. should be aware that irreparable
imaging modality used for evaluation
Several authors have correlated rotator cuff tear is likely in patients
of the potentially irreparable rotator
preoperative MRI findings with rep- with narrowing of the acromiohu-
cuff tear, used to define tear size,
arability of rotator cuff tears. Sugihara meral distance below 5 to 6 mm,
shape, involved tendons, and fatty
et al11 found that irreparable tears severe (grade 3 and 4) fatty infiltra-
infiltration. However, CT or CT ar-
correlated with tear length or width tion of the supraspinatus and infra-
thrography is generally reserved for over 4 cm, severe fatty infiltration of spinatus, and tears retracted to the
patients with contraindications to the supraspinatus and infraspinatus. glenoid (Figure 2).
MRI, metal artifact, or severe rotator Similarly, Yoo et al10 found that ir-
cuff arthropathy where glenoid ver- reparabile tears correlated with grade
sion, bone stock in the glenoid vault, 4 supraspinatus fatty infiltration, Nonsurgical Treatment
and/or digital templating is to be grade 3 or 4 infraspinatus fatty infil-
performed for RSA. Although ini- tration, and tear length and width over Nonsurgical treatment is used as the
tially described by Goutallier et al20 3.1 to 3.2 cm. Dwyer et al9 ascertained first-line treatment for patients with
on the basis of CT, the Fuchs mod- that retraction of the tear to or beyond irreparable rotator cuff tear and can
ification assessing rotator cuff fatty the glenoid, severe fatty infiltration of be successful in many patients,
infiltration on the T1 sagittal oblique the supraspinatus and infraspinatus, a although there may be significant
image immediately lateral to the positive tangent sign, and superior progression of tear size, fatty infiltra-
scapular spine’s attachment to the humeral migration were associated tion, and rotator cuff arthropathy.14
body of the scapula given the pre- with irreparable tears. A recent study Nonsurgical treatment involves physi-
dominant role of MRI in evaluating by Kim et al22 analyzed multiple MRI cal therapy to strengthen and re-
rotator cuff pathology.21 Grade 3 factors finding that the best pre- educate the deltoid, remaining rotator
and 4 represent severe fatty infiltra- dictors of reparable tears were in- cuff tissue, and the periscapular mus-
tion with equal or greater amounts fraspinatus fatty infiltration grade ,3 culature.23 Typically, we recommend a
of fat compared with muscle, and tear retraction to the humeral supine deltoid reactivation program to

December 15, 2019, Vol 27, No 24 911

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of the Irreparable Rotator Cuff Tear
Figure 2
MRI sagittal and coronal images showing findings suggestive of irreparable
rotator cuff tear including grade 4 atrophy of the supraspinatus and infraspinatus
with massive tear retracted to the glenoid.
determine whether elevation can be
restored.23 NSAIDs and subacromial
corticosteroid injections can also
reduce pain and improve function,
while also allowing more accurate
assessment of active and passive range
of motion in the absence of pain.
Nonsurgical management is favored in
patients with lower functional de-
mands, those who are poor medical
candidates for surgery, and those with
relatively mild pain and mild shoulder
dysfunction. Some patients with poorly
compensated force couples resulting in
clinical pseudoparalysis may improve
with nonsurgical treatment as well,15
although many will go on to elect
surgical treatment in our experience.
Although anterior deltoid re-education
has been explored as a potential
treatment, recent results indicate only
40% success.23
Surgical Treatment Options
Reverse Total Shoulder
Arthroplasty
If nonsurgical treatment fails, various
surgical treatment options are con-
sidered. In patients with Hamada
grade 3 or greater reflecting more
intermediate- to advanced-stage rota-
tor cuff arthropathy, those with
912
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
anterosuperior escape or severe pseu-
doparalysis, or those older than age
65 years, the RSA is our preferred
treatment option. Age is generally a
relative contraindication and is ad-
justed based on individual patient
assessment. Long-term outcomes of
RSA for rotator cuff arthropathy in a
generally older patient population
have resulted in reliable pain relief
and improved function.6 Outcomes
of RSA for irreparable rotator cuff
tear without arthritis are promising
in short- to mid-term follow-up, with
most studies addressing patients
older than 65 years with pseudo-
paralysis.7,8 Hartzler et al24 analyzed
patients who underwent RSA for
irreparable rotator cuff tear without
arthritis at a minimum 2-year follow-
up, finding that age ,60 years, high
preoperative function, and neurologic
dysfunction were associated with poor
outcomes. Boileau et al8 found that the
subgroup of patients with preoper-
ative active elevation over 90° had
loss of active elevation with 27%
dissatisfaction rate. Ernstbrunner
et al25 recently reported a series of
RSA for patients younger than age
60 years with a mean follow-up
period of 11.7 years, finding sub-
jective and functional improvement
but with 39% complication rate and
Journal of the American Academy of Orthopaedic Surgeons
9% failure rate. Therefore, we urge
caution in applying RSA to younger
patient populations with irreparable
tears, minimal arthritis, and good
preoperative function because they
may not obtain their desired func-
tional improvement and implant
longevity remains a potential con-
cern with higher activity levels and
occupational demands.
Partial Repair
Traditionally, irreparable rotator
cuff tears were treated with a combi-
nation of débridement, subacromial
decompression, partial repair, and/or
biceps tenotomy or tenodesis.26 Par-
tial repair is thought to work by
restoring the force couple and the
resultant cable system for force
transmission. Tension free repair is
important to achieve, and medializa-
tion by up to 10 mm for the supra-
spinatus may enhance the ability to
achieve partial repair, although it
changes shoulder biomechanics. Shon
et al27 found that partial repair re-
sulted in initial improvement of
symptoms, but functional outcome
was variable and results deteriorated
over time with 50% dissatisfaction at
2-year follow-up. Cuff et al28 found
that at 5 years after partial repair for
patients who had intact preoperative
active elevation averaging 168°, pa-
tients had improved American
Shoulder and Elbow Surgeons (ASES)
and simple shoulder test scores and
reduction in pain, but that Hamada
grade progressed in 36% and there
was a 29% failure rate based on a
composite end point of ASES ,70,
revision, or development of pseudo-
paralysis. Tuberoplasty has also been
proposed as an option for irreparable
rotator cuff tear without pseudopar-
alysis, with one study reporting mean
8-year outcomes in a series of 16
patients showing pain relief from
visual analog scale (VAS) 6.9 to 2.3
and Constant score improvement
from 27.2 to 59.2.29 Although partial

repair can improve pain and function
by restoring the force couple, the
authors generally opt for other op-
tions for an irreparable tear because
the results of partial repair have ten-
ded to be less reliable in our
experience.
Tendon Transfers
Tendon transfers have been described
for restoring force couples in the
shoulder with irreparable rotator cuff
tear.30 Latissimus dorsi transfer is
generally used to replace the irrepa-
rable posterosuperior rotator cuff
and has been shown to improve
pain for patients with irreparable
posterosuperior rotator cuff tears,
although functional outcomes are
more variable.31,32 Inferior out-
comes can be expected for patients
with subscapularis dysfunction,
severe teres minor fatty infiltration,
revision procedures, and those with
arthritic changes.31,32 Furthermore,
there may be glenohumeral arthritis
progression in a third of patients.33
Iannotti et al34 performed an elec-
tromyography study showing that
the latissimus tendon contracted in
phase during active external rotation
for 6/9 patients with a good clinical
result and 0/5 patients with a poor
clinical result.
Lower trapezius transfer has been
more recently popularized for man-
agement of irreparable postero-
superior rotator cuff tear.35 At
average 47-month follow-up, Elhas-
san et al35 found improved pain,
functional scores, and range of
motion, especially for patients with
preoperative active elevation of
.60°. Biomechanical evidence sug-
gests that the lower trapezius trans-
fer may be superior to latissimus
transfer to restore joint reactive force
and shoulder kinematics.36 Further
study will be necessary to define the
role of lower trapezius transfer and
relative merits of this transfer com-
pared with latissimus dorsi transfer
December 15, 2019, Vol 27, No 24
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
or other options for irreparable
posterosuperior rotator cuff tears.
Pectoralis major transfer has been
described to replace an irreparable
anterosuperior tear involving the
subscapularis, with multiple described
techniques and literature mostly lim-
ited to retrospective case series with
short-term follow-up. Moroder et al37
reported that 27 patients with
average 10-year follow-up had
improved pain and internal rota-
tion, with 77% satisfaction. Rotator
cuff arthropathy progressed in 67%
of patients, but only one patient
underwent revision to RSA.37 Lat-
issimus dorsi transfer has also been
described for the treatment of sub-
scapularis insufficiency, although
clinical outcomes data are lacking to
date.38
Bridging Interpositional Graft
Bridging interpositional grafts have
been described for irreparable rota-
tor cuff tears, with results predomi-
nantly from small case series with
short-term follow-up.39 The graft is
secured to the irreparable rotator
cuff tendon and bridges the re-
maining cuff and the footprint on
the humerus. Grafts used include
autograft biceps tendon and fascia
lata, allografts, xenografts, and
synthetic materials. Structural healing
has varied from 58% to 100%, and
patients have had improved out-
comes compared with preoperative.39
Mori et al40 reported a comparative
study in which patients underwent
either partial repair or partial repair
with fascia lata autograft bridging
interposition. They found that at
36-month follow-up, both groups
had significant improvement com-
pared with preoperative. The graft
group achieved superior Constant
and ASES scores, with no difference
in UCLA scores compared with the
partial repair group. The percentage
of intact repairs was 79% for the
graft group versus 58% for the
Gregory L. Cvetanovich, MD, et al
partial repair group on postopera-
tive imaging.40
Subacromial Spacer
An emerging strategy for manage-
ment of irreparable rotator cuff tear
has been the implantation of a de-
gradable subacromial spacer that
seeks to prevent humeral head eleva-
tion, thereby centering the humeral
head in the glenoid and improving the
ability of the deltoid to actively ele-
vate the arm.41 This device (InSpace;
OrthoSpace, Israel) can be inserted
arthroscopically into the sub-
acromial space and inflated with
saline before being sealed (Figure 3).
The balloon is designed to degrade
between 2 and 12 months postop-
eratively. It is currently the subject
of an ongoing clinical trial in the
United States. Senekovic et al41
reported 5-year follow-up of a series
of 20 patients with a mean age of
69 years who underwent this pro-
cedure without rotator cuff repair.
The rate of follow-up for this study
was poor with only 63%, with one
patient undergoing RSA at 4 years,
two patients dying of unrelated
causes, and six patients otherwise
lost to follow-up. They found that
over 50% of subjects exceeded
the minimal clinically significant
improvement of .10 points on the
Constant Score, with over 40%
showing .25-point improvement.
Deranlot et al42 reported mean 32.8-
month outcomes after spacer im-
plantation in 37 patients with
Hamada grade 1 or 2 rotator cuff
tears and an average age of 69.8
years. They found improved forward
elevation from 130° to 160°, exter-
nal rotation from 30° to 45°, and
Constant Score from 44.8° to 76.0°.
One patient underwent revision for
spacer migration, and Hamada
progression was observed in 19% of
patients.42
913
Management of the Irreparable Rotator Cuff Tear

Figure 3

Arthroscopic insertion of the subacromial balloon spacer (OrthoSpace) for massive irreparable rotator cuff tear. A,
Diagnostic arthroscopy viewing from the mid-lateral portal showing massive irreparable rotator cuff tear. B, The deflated
balloon spacer is inserted from the mid-lateral portal, and (C) saline is inserted to expand the balloon in subacromial space.

Figure 4

SCR with acellular dermal allograft for massive irreparable rotator cuff tear. A, Diagnostic arthroscopy revealing massive
rotator cuff tear retracted to the glenoid that was found to be irreparable. B, Anchors are inserted on the superior glenoid and
greater tuberosity adjacent to the articular margin. C, Measurements are taken from the anchors, and the graft is cut to the
appropriate size. D, The graft is secured with lateral row fixation and side-to-side repair of the graft to the residual posterior
rotator cuff. E, Completed SCR is shown. SCR = superior capsular reconstruction

Superior Capsular
Reconstruction
SCR has recently been proposed as a
strategy for management of irrepa-
rable rotator cuff tears by re-
constructing the superior capsule as a
static restraint to prevent superior
migration of the humeral head and
maintain native glenohumeral sta-
tion.43 This technique involves an-
chors into the superior glenoid and
greater tuberosity with an autograft
fascia lata or acellular dermal allo-
graft to recreate the superior capsule
(Figure 4). Biomechanical data have
shown promising results of SCR,43
and the limited clinical outcomes
available reveal potential to relieve

914 Journal of the American Academy of Orthopaedic Surgeons

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Gregory L. Cvetanovich, MD, et al

pain and restore function for patients Figure 5

with irreparable rotator cuff tear and
intermittently, pseudoparalysis.44
Mihata et al44 reported the initial
series of SCR with fascia lata auto-
graft in 24 shoulders predominantly
Hamada grade 1 and 2 (92.2%) at
mean 34.1-month follow-up (range,
24 to 51). Four cases were revisions,
and 20/24 cases (83.3%) were pri-
mary procedures. After SCR, pa-
tients had markedly improved
forward elevation from 84° to 148°,
external rotation from 26° to 40°,
and American Shoulder and Elbow
Surgeons score from 23.5 to 92.9,
whereas the acromiohumeral dis-
tance reversed from 4.6 6 2.2 mm
preoperatively to 8.7 6 2.6 mm
postoperatively. Postoperative MRI
showed that the SCR graft and
rotator cuff tendon were intact in
Authors’ current treatment algorithm for the irreparable posterosuperior rotator
20/24 shoulders (83.3%), with three cuff tear assuming failure of nonsurgical treatment and that the tear is truly
cases of retear of the infraspinatus irreparable intraoperatively. RSA = reverse total shoulder arthroplasty, SCR =
(12.5%) and one case of graft tear superior capsular reconstruction.
(4.2%). In a further larger series of
102 SCRs with fascia lata autograft, survivorship of this and determine athy (Hamada grade 3 or greater). We
Mihata et al45 found similar im- whether the results of Mihata et al also favor RSA for those with ante-
provements of motion and func- using a 4-ply thickness fascia lata rosuperior escape, pseudoparalysis,
tional scores, 95/102 (93%) with autograft differ from results using a and/or lower demand individuals
intact graft and tendon, return to thinner 3- to 4-mm dermal allograft older than 65 years. The RSA pro-
previous work in 32/34 (94%), and as is currently done in the United vides the most reliable pain relief
return to recreational sports for States. and restoration of function in these
26/26 (100%).
situations, although we will consider
Denard et al46 recently published
nonarthroplasty options such as
preliminary results of SCR with Authors’ Preferred SCR in younger patients with pseu-
dermal allograft in 59 patients Treatment Algorithm doparalysis or older patients with
with minimum 1-year follow-up,
high functional demands.
finding improved forward flexion Treatment is individualized to each
(130° to 158°), external rotation For patients with Hamada grades 1
patient, taking into account factors
(36° to 45°), VAS pain (5.8 to 1.7), including age, preoperative function, and 2 younger than 65 years without
and ASES (43.6 to 77.5). They found shoulder pathology, and patient pseudoparalysis, our preferred treat-
that 45% (9/20) of grafts were goals and demands. Initial treatment ment is arthroscopic SCR, assuming
completely healed on postoperative is nonsurgical, involving physical that the rotator cuff is truly irrepa-
MRI, with graft failure occurring therapy, activity modification, oral rable intraoperatively. The authors’
most commonly on the humeral side medications, and cortisone injections. experience has been that SCR with
(7 cases), followed by intrasubstance If nonsurgical treatment fails, surgi- an acellular dermal allograft offers
(3 cases) and glenoid side (1 case). cal options are discussed according to reliable pain relief and more consis-
The success rate was 74.6% (46/59), our preferred treatment algorithm tent functional improvements than
but 11 patients (18.6%) went on to a (Figure 5). alternative techniques such as ten-
revision procedure including seven The RSA is our preferred treatment don transfers or partial rotator cuff
RSAs. Future studies are needed to option for patients with intermediate- repair. In the uncommon situation of
confirm the long-term viability and to advanced-stage rotator cuff arthrop- an irreparable subscapularis tear

December 15, 2019, Vol 27, No 24 915

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Management of the Irreparable Rotator Cuff Tear
combined with irreparable postero-
superior rotator cuff tear, we would
generally perform RSA, although
SCR with combined split pectoralis
major transfer to address the sub-
scapularis deficiency could be an
option for a patient who wished to
avoid arthroplasty. We have limited
experience with balloon arthroplasty
and interpositional grafts, although
these are also promising non-
arthroplasty treatment options.
Summary
Patients with irreparable rotator cuff
tears present diagnostic and treat-
ment challenges for orthopaedic sur-
geons. Careful physical examination
and imaging evaluation with radio-
graphs and MRI can help to delineate
patients with pseudoparalysis and
predict those with reparable versus
irreparable tears. In older patients
with rotator cuff arthropathy and
relatively sedentary demands, the
RSA has been established as the pre-
ferred treatment option, producing
reliable improvements in pain and
function. In younger patients without
significant arthritis, joint-preserving
options are preferred, with an
increasing array of treatment options
including partial repair, bridging in-
terpositional graft placement, tendon
transfers (ie, latissimus, trapezius,
and pectoralis major), SCR, and
subacromial spacer. We present our
preferred treatment algorithm for
these patients, which currently in-
cludes RSA for Hamada grade 3 and
above rotator cuff arthropathy and
patients older than 65 years. Because
of our experience of more reliable
pain relief and functional improve-
ment, SCR has become our preferred
approach for patients younger than
65 years with irreparable rotator cuff
tear and no rotator cuff arthropathy
(Hamada grades 1 and 2). Existing
literature has little in the way of
comparative studies of the various
916
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
treatment options for irreparable
rotator cuff tear, and future studies
will be needed to define the in-
dications and contraindications for
the available techniques in a range of
patients.
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