**7. Summary**

tendon [112, 113] and tensor fascia late [114] have also been used. Patch reinforcement can be performed as augmentation (onlay) of a cuff repair, in which the rotator cuff is repaired to nearly normal status and patch is then either implemented into the repair construct or sutured over the top of the repaired tendon [99]. The other method is interposition (intercalary), wherein the graft bridges the gap between the irreparable cuff edge and cuff footprint on the humerus [99]. As the use of patches for massive cuff tears repair is a subject of a great deal of interest, much has been published throughout last 20 years. Unfortunately most of the reports are case reports or short term case series on a relatively small groups of patients. Each of these studies typically represents the experience of one surgeon or one institution and therefore, when taken alone, may not be an accurate reflection of patch use more broadly. Comprehensive reviews can provide valuable summarized data, giving clinicians a broader picture on this interesting topic. A recent review was performed by Steinhaus et al. in 2016 [99]. They reviewed results of 24 studies, published between 1986 and 2014. The frequencyweighted mean age of patients was 61.9 years with 35.4 months' follow-up. There were a total of 566 patients included. The most common surgical technique used across the 24 studies was open patch repair, representing 54.6% of cases (309 of 566), followed by mini-open in 170 cases and arthroscopic in 87 cases. The most common graft source was synthetic, representing 44.3% of grafts (251 of 566), followed by allograft in 188 cases and xenograft in 127 cases. The graft was used to bridge the gap between the retracted cuff and humerus (interposition) in 56.3% of patients (319 of 566), whereas it was used to augment the repair in 43.6% (247 of 566). Augmentation and interposition techniques showed similar improvements in range of motion, strength, and patient-reported outcomes (PROs), pain and activities of daily living (ADLs) whereas xenografts showed less improvement in PROs and ADLs compared with other graft types. The overall retear rate was 25%, with rates of 34% and 12% for augmentation and interposition, respectively, and rates of 44%, 23%, and 15% for xenografts, allografts,

In summary, all studies showed improvements in clinical and functional outcomes, without much difference between augmentation and interposition techniques. Xenografts seem to do worse than allografts and synthetic materials. What is interesting and might be counterintuitive for many, is the fact that retear rate was lower with the interposition technique. Of course systemic reviews are only as good as the studies they are based on, so as promising as the results seem to be, there is no doubt that patch grafting needs well designed prospective com-

Our technique of choice in surgical treatment of irreparable rotator cuff tear was developed by the senior author. We utilize a non-absorbable polyester patch which is sutured over the torn rotator cuff. It thus provides reinforcement of incompletely repaired rotator cuff tears and those at high risk of re-tear due to poor quality soft tissue. It can be used both as a bridging graft and augmentation. Leeds Cuff Patch a synthetic patch that is indicated for reconstruction of chronic massive, full thickness rotator cuff tears where the retracted tear cannot be

parison studies to truly assess its value in massive cuff tears treatment.

and synthetic grafts, respectively.

114 Advances in Shoulder Surgery

**6. Leeds Cuff Patch**

There are a wide variety of options available to surgeon for the patient with a large to massive tear of the rotator cuff causing pain and loss of function. Most of these have been reported as having quite reasonable outcomes in the published literature. In the UK, less than 30% of upper limb surgeons, would consider a patch, and further research is required. Newer procedures such as superior capsular reconstruction and balloon arthroplasty warrant further investigation. Reverse TSR gives excellent outcomes in the older patient, but for younger patients with large or massive rotator cuff tears, though there are a number of surgical options available, the evidence to support each needs strengthening with further research into this exciting area of shoulder surgery.

[10] Neri BR, Chan KW, Kwon YW. Management of massive and irreparable rotator cuff

Options Before Reverse Total Shoulder Replacement http://dx.doi.org/10.5772/intechopen.70795 117

[11] Jeong JY et al. Comparison of outcomes with arthroscopic repair of acute-on-chronic within 6 months and chronic rotator cuff tears. Journal of Shoulder and Elbow Surgery.

[12] Warner JJ, Gerber C. Treatment of massive rotator cuff tears: Posterior-superior and anterior-superior. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1998 [13] Collin P, Matsumura N, Lädermann A, Denard PJ, Walch G. Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion. Journal

[14] Goutallier D, Postel JM, Lavau L, Bernageau J. Influence de la d eg en erescence graisseuse des muscles supra epineux et infra epineux sur le pronostic des r eparations

[15] Walch G, Boulahia A, Calderone S, Robinson AH. The 'dropping' and 'hornblower's' signs in evaluation of rotator-cuff tears. Journal of Bone and Joint Surgery. British

[16] Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clinical Orthopaedics and

[17] Gladstone JN, Bishop JY, Lo IK, Flatow EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome.

[18] Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of Bone and Joint Surgery.

[19] Gerber C, Galantay RV, Hersche O. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. Journal of Shoulder and Elbow

[20] Gerber C, Blumenthal S, Curt A, Werner CM. Effect of selective experimental suprascapular nerve block on abduction and external rotation strength of the shoulder. J Shoulder

[21] Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparalysis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. The Journal of Bone and Joint Surgery. American Volume.

[22] Denard PJ, Lädermann A, Jiwani AZ, Burkhart SS. Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis. Arthroscopy.

chirurgicales de la coiffe des rotateurs. Rev Chir Orthop. 1999;**85**:668-676

tears. Journal of Shoulder and Elbow Surgery. 2009;**18**:808-818

of Shoulder and Elbow Surgery. 2014;**23**(8):1195-1202

The American Journal of Sports Medicine. 2007;**35**:719-728

Volume (London). 1998;**80**:624-628

Related Research. 1994;**304**:78-83

American Volume. 1995;**77**:10-15

Surgery. 1998;**7**:352-355

2005;**87**:1476-1486

2012;**28**:1214-1219

Elbow Surg. 2007;**16**:815-820

2017;**26**(4):648-655
