**2. Massive and irreparable rotator cuff tears**

Massive rotator cuff tears (MRCT) make up to about 20% of all cuff tears [4, 5]. The number gets higher if we look at recurrent tears: in this group MRCT constitute of up to 80% [4, 5]. Cofield described cuff tear as a massive if its anteroposterior dimension reached or exceeded 5 cm [6]. Davidson and Burkhart in an attempt to add to their definition a second dimension, defined a massive tear as tears in which both coronal length and sagittal width were at least 2 cm long [7]. Gerber et al. defined a cuff tear as a massive once it involved a complete tear of at least two tendons [8]. Lädermann et al. advocated that to constitute a massive tear, at least one of two tendons should be involved, and should retract beyond the level of humeral head apex [9].

Once identified, massive tears can then be further classified by chronicity or with regard of a tear pattern.

If subdivided by the chronicity, tears can be defined as acute, acute on-chronic and chronic [10]. Acute MRCT are very infrequent, usually occurring after traumatic events and are more common among younger population [1, 10]. Individuals with a truly acute, traumatic massive cuff tear often present with a completely pseudoparalytic shoulder [1]. Plain radiographs should be taken to exclude a fracture and/or dislocation and may also document a wide joint space due to interposition of an avulsed cuff. MRI is used to assess the cuff, and in the presence of a massive tendon tear without the radiological signs of chronic tendon involvement (such as fatty muscle infiltration), earliest possible repair should be undertaken [1].

Apart from dramatic circumstances described above, most acute massive tears are actually acute on chronic tears where new onset or acutely deteriorating shoulder pain is due to underlying long lasting cuff pathology. These tears show often some signs of degeneration of the cuff and bony changes on greater tuberosity and acromion on radiograph [11].

Finally, the chronic massive tears are the most common and are found almost exclusively in older patients. They are associated with degenerative tendon changes such as myotendinous retraction, loss of musculotendinous elasticity, fatty infiltration of muscles, static (superior) subluxation of the humeral head, and ultimately, osteoarthritis [1].

associated with pseudoparalysis. Satisfactory results can even be obtained in patients who have undergone previous procedures, such as rotator cuff repair [1]. Current available literature documents an implant survival rate of 91% at 10 years [2]. Given these promising results, it is no wonder that reverse total shoulder replacement is increasingly commonly used, making in 2015 over 45% of shoulder replacements performed in the UK according to the National Joint registry [3]. For patients with irreparable cuff tears aged 70 years or greater, it has practically replaced the other procedures. However successful, the longevity of reverse TSR does not yet match those expected for replacements of the hip and knee. For that reason, replacement before the age of 70 is not recommended by some authors [1, 3]. What are the options then for patients with symptomatic large and massive tears of the rotator cuff and little evidence of arthropathy, particularly in the younger patients unsuitable for reverse TSR? In this chapter we will go through the most current concepts regarding massive and irreparable cuff tears, as well as cuff tear arthropathy. We will show the reader contemporary view on diagnosis and treatment of these conditions, but also share technique developed by the

Massive rotator cuff tears (MRCT) make up to about 20% of all cuff tears [4, 5]. The number gets higher if we look at recurrent tears: in this group MRCT constitute of up to 80% [4, 5]. Cofield described cuff tear as a massive if its anteroposterior dimension reached or exceeded 5 cm [6]. Davidson and Burkhart in an attempt to add to their definition a second dimension, defined a massive tear as tears in which both coronal length and sagittal width were at least 2 cm long [7]. Gerber et al. defined a cuff tear as a massive once it involved a complete tear of at least two tendons [8]. Lädermann et al. advocated that to constitute a massive tear, at least one of two tendons should be involved, and should retract beyond the level of humeral head apex [9].

Once identified, massive tears can then be further classified by chronicity or with regard of a

If subdivided by the chronicity, tears can be defined as acute, acute on-chronic and chronic [10]. Acute MRCT are very infrequent, usually occurring after traumatic events and are more common among younger population [1, 10]. Individuals with a truly acute, traumatic massive cuff tear often present with a completely pseudoparalytic shoulder [1]. Plain radiographs should be taken to exclude a fracture and/or dislocation and may also document a wide joint space due to interposition of an avulsed cuff. MRI is used to assess the cuff, and in the presence of a massive tendon tear without the radiological signs of chronic tendon involvement

Apart from dramatic circumstances described above, most acute massive tears are actually acute on chronic tears where new onset or acutely deteriorating shoulder pain is due to underlying long lasting cuff pathology. These tears show often some signs of degeneration of

(such as fatty muscle infiltration), earliest possible repair should be undertaken [1].

the cuff and bony changes on greater tuberosity and acromion on radiograph [11].

senior author and used in our daily practise.

tear pattern.

100 Advances in Shoulder Surgery

**2. Massive and irreparable rotator cuff tears**

If classified by anatomic tear pattern, MRTC usually fall into two distinct groups: posterosuperior and anterosuperior tears [12]. Most tears involve the supraspinatus and the infraspinatus, with or without the teres minor tendon, and these are considered as posterosuperior tears. Anterosuperior tears involve a complete tear of supraspinatus and subscapularis tendons [12]. Collin et al. made the tear pattern classification more precise and detailed, dividing the rotator cuff into five components: lower subscapularis, upper subscapularis, supraspinatus, infraspinatus and teres minor [13]. Depending on which component is involved in a tear, 5 tears patterns can be distinguished: Type A are supraspinatus and superior subscapularis tears; Type B are supraspinatus and entire subscapularis tears; Type C are supraspinatus, superior subscapularis, and infraspinatus tears; Type D, supraspinatus and infraspinatus tears; Type E are supraspinatus, infraspinatus, and teres minor tears [13]. This classification not only organizes all tears into tear pattern groups, but also aims at linking tear patterns with specific function loss. Therefore, Type A disruption typically causes a decrease in internal rotation strength with positive Belly press and Bear Hug tests, combined with a positive test for superior cuff insufficiency, e.g. empty can test. To a different extent the same is true for type B and C. Type D may show weakness of external rotation, while posterosuperior MRCT with an extension to the teres minor (Type E) may have an external rotation lag sign and often exhibit a positive Hornblower's sign (the inability to maintain external rotation with the arm abducted to 90) [13].

Fortunately irreparable rotator cuff tears (IRCT) are just a subgroup of massive tears, as some of the latter are amenable for repair. Exact incidence of IRCT is unknown, with some studies estimating it between 6.5% and 22.4% [10]. To be considered irreparable, a defect should be impossible to close at the time of surgery or show traits which have been empirically determined to be associated with structural failure of the repair [1]. According to Gerber, clinical signs which suggest that a repair is unlikely to be successful include:


The imaging finding most commonly associated with irreparability of the cuff tear is a fatty infiltration of cuff muscle which equals or exceeds 50% of muscle's volume determined by CT or MRI (stages 3 and 4 of fatty infiltration according to Goutallier) [16]. Fatty degeneration is irreversible even with successful complete repair and leads to reduced function of the rotator cuff musculature [8, 17]. Some authors reported that in higher stages (Goutallier 3 and 4) of fatty infiltration, MRCT may fail to heal in up to 92% of cases. Another key imaging finding helping to predict irreparability of a tear is a static superior subluxation of a glenohumeral joint with an acromiohumeral interval of 7 mm or less. Also static anterior subluxation observed in CT scan or MRI appears to be indicative of irreparability of the tear [1].

Active and passive range of movement should of course be assessed and compared with the contralateral side. Active shoulder motion is usually decreased. Limitations of passive motion may be due to scar tissue formation associated with chronic tears, but these are usually mild and not very painful. It is important to discern this from the often much more painful adhe-

Options Before Reverse Total Shoulder Replacement http://dx.doi.org/10.5772/intechopen.70795 103

In patients with anterosuperior tears, significant weakness of the subscapularis will be noted. The bear hug test will most likely be positive. The belly-press manoeuvre, which tests the upper portion of the subscapularis muscle, is more likely to be abnormal than the lift-off test, which mainly reflects the lower subscapularis muscle function [10, 23]. Increased passive

Two provocative manoeuvres can determine the extent of the posterosuperior cuff involvement. The external rotation lag sign. If the patient cannot actively maintain maximal external rotation of the shoulder with the elbow by his side, the test is considered positive for the infraspinatus tendon tear. The Hornblower's sign tests the integrity of teres minor [10]. With the elbow supported, the patient is asked to maintain maximal shoulder external rotation with the shoulder abducted to 90°. Inability to maintain this position is highly sensitive for teres minor tear [15]. The supraspinatus tendon tear is always involved and so patients from both these groups should show weakness of supraspinatus strength (posi-

Plain radiographs are of a great value to the evaluation. They provide information on the glenohumeral joint, acromial morphology, and the position of the humeral head. Standard evaluation consists of anteroposterior, axillary, and an outlet or scapular Y views. Grashey view (a true anteroposterior view) is most helpful to show the status of the glenohumeral joint, whereas an outlet and scapular Y views can be useful to examine acromial pathology [10]. Plain anteroposterior views will demonstrate any upriding of the humeral head and any osteoarthritic changes. Decreased interval between the humeral head and undersurface of the acromion is often associated with massive and irreparable cuff tears. This distance, the acromiohumeral interval (AHI), measures 7–14 mm in healthy shoulders [24] and as previously mentioned if it falls below 7 mm, the probability of successful cuff repair drastically decreases [25]. Hamada et al. [26] demonstrated correlation between progression of rotator cuff tear and reduction of AHI. He developed a radiographic classification of massive rotator cuff tear arthritis which divides massive rotator cuff tears into 5 grades: in Hamada Grade 1 the AHI is maintained, and narrows in Grade 2. Acetabulization (concave deformity of the acromion undersurface) in addition to the Grade 2 narrowing is classified as Grade 3. In Grade 4, narrowing of the glenohumeral joint is added to the Grade 3 features, and Grade 5 comprises instances of humeral head collapse [26]. Walch et al. recognized a group with massive tears that demonstrated glenohumeral narrowing without acromial acetabulization. Thus, they divided Grade 4 of Hamada into two subtypes: Grade 4A, glenohumeral arthritis without

external rotation of the shoulder may also be present [10].

sive capsulitis.

tive empty can test).

**4. Investigations**
