**1. Introduction**

Rotator cuff arthropathy has gained increased attention in recent years, partially because the ageing population has made it more prevalent. Cuff arthropathy is now one of the major problems a shoulder surgeon has to face nowadays in clinical practise. It is caused by a longstanding large or massive rotator cuff tear, leading to functional upriding of the humeral head due to unrestrained deltoid action and elevation of the effective centre of rotation of the glenohumeral joint, often providing patients with a serious disability. The classic pseudoparalytic or flail shoulder with pain may be associated with degenerative changes in the gleno-humeral joint, but patients are frequently seen with minimal arthritic changes. The most definitive solution for treatment of rotator cuff arthropathy is the reverse Total Shoulder Arthroplasty (RTSA or RSA). Indications for RSA are mostly pain and to lesser extent loss of function. It often dramatically improves pain and function in patients with irreparable rotator cuff tears

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

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?

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)

Options Before Reverse Total Shoulder Replacement http://dx.doi.org/10.5772/intechopen.70795 101

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

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

• static anterosuperior subluxation with the head under the skin in front of the anterior acro-

• positive lag sign and Hornblower's sign (both associated with substantial fatty infiltration

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

• dynamic anterosuperior subluxation of the humerus upon resisted abduction

signs which suggest that a repair is unlikely to be successful include:

mion and associated pseudoparalysis of anterior elevation

of infraspinatus and teres minor respectively) [14, 15].

subluxation of the humeral head, and ultimately, osteoarthritis [1].

with the arm abducted to 90) [13].

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 senior author and used in our daily practise.
