Massive irreparable rotator cuff tears

Abstract

Management of massive irreparable posterosuperior rotator cuff tears is a surgical challenge, particularly in young active patients without any signs of osteoarthritis. Different surgical techniques have been described. To the three main deficits of active range of motion previously reported for a massive irreparable cuff tear, i.e., isolated loss of active elevation (ILEA), isolated loss of active external rotation (ILER), and combined loss of elevation and external rotation (CLEER), we add two new entities: isolated loss of active internal rotation (ILIR) and combined loss of active elevation and active internal rotation (CLEIR). We suggest that a combined deficit (CLEER or CLEIR) could lead to a new definition of a pseudoparalytic shoulder and propose a novel algorithm to redefine the role of latissimus dorsi transfer in each of these situations. We also describe a fully arthroscopic latissimus dorsi transfer technique that prevents any deltoid muscle insult, offers better visualization of the neighboring neurovascular structures at risk, and allows simultaneous management of biceps pathology and partial rotator cuff repair.