The “healability” of a massive rotator cuff tear is a key consideration when determining the appropriate treatment. Other factors that play a role in treatment decisions include the patients’ pain, function, as well as short- and long-term goals/expectations. Symptomatic patients below the age of 60 who have low levels of atrophy and fatty infiltration are ideal candidates for repair. Patients older than 60 should also be offered repair, but their age is a poor prognostic factor [18]. In patients with advanced atrophy or high-grade fatty infiltration, alternative treatments such as simple debridements, tendon transfers, or reverse arthroplasty should be considered.

Successful anatomic reconstruction of the rotator cuff leads to optimal short- and long-term outcomes as well as possibly decreased rates of arthropathy [19, 20], and complete repair of massive rotator cuff tears should be done whenever possible. The is little evidence to support the exclusive use of either the beach chair or lateral decubitus position, and setup should be done based on surgeon preference. A variety of portals facilitate this operation by allowing assessment of the torn tendon via different angles. Although many portals have been described, the surgeon should not feel constrained to only the use of these named portals. Ideal portal placement can be made at any location that does not risk injury to the neurovascular structures (Fig. 5.1).

Tension on a repaired tendon impairs tendon to bone healing [21]. Tendon retraction and scarring are common with chronic, massive tears and must be addressed to achieve adequate mobilization for a successful repair. Mobilization is critical not only for repair but also to free the muscle-tendon units to freely glide for motion.

A stepwise method of releasing the scarred and medialized tendons can be used and is greatly facilitated by the use of traction stitches (Fig. 5.2). The principles of this method are the same as with open repair. Traction stitches are placed at the apex of the tear and externalized through small mini-portals placed to create an optimal vector for tear reduction. Tendon excursion can first be increased by release of all bursal-sided adhesions, both subacromial and subdeltoid [22]. This is best done by viewing through a lateral or posterolateral portal and dissecting in the plane immediately above the rotator cuff.

If bursal-sided releases do not produce sufficient excursion, articular-sided adhesions are then addressed. With chronic retracted tendon tears, the tendon and capsule may become scarred to the glenoid rim and must be released (Fig. 5.3). This can safely be performed by starting at the rotator interval and working posteriorly [23]. Dissection should not extend more than 2 cm past the glenoid neck in order to avoid suprascapular nerve injury.

If the above techniques do not afford sufficient mobility and there is differential retraction of adjacent tendons, interval slides can be performed. These arthroscopic techniques are modifications to those originally performed during open surgery. If the supraspinatus is retracted and scarred to an intact subscapularis, the arthroscopic anterior slide is performed by releasing the interval between the subscapularis and supraspinatus tendons [24, 25]. The coracohumeral ligament, which has often become contracted and tethered, is also incised off of the coracoid process.

The posterior interval slide can provide additional tendon excursion if there is unequal retraction of the supraspinatus and infraspinatus. This release is performed between the two adjacent musculotendinous units [26]. The scapular spine can be delineated by removing excess subacromial fibroadipose tissue. This anatomical landmark serves as the boundary between the two units and directs the accurate release of the interval between them. The posterior interval slide allows increased excursion of both muscle units.

Collectively, double-interval slides can afford over 5 cm of mobility to the posterosuperior rotator cuff. However, because suprascapular nerve injuries have been reported with greater than 3 cm of mobility, surgeons should be cautious with over-mobilization [27].

Some massive rotator cuffs can be further mobilized with utilization of margin convergence. Though initially described by Inman [28], Burkhart coined the term to describe a side-to-side closure of the anterior and posterior tendon leafs [29]. Traditionally, U-shaped tears were closed by mobilizing the medial, retracted margin back to its bony bed. This technique resulted in high tensile stresses that predisposed to eventual repair failure. The technique of margin convergence utilizes sequential tendon sutures, starting medially and working laterally, causing the free margin of the tear to converge toward its bone bed, offloading the strain on the repair and leaving a tension-free cuff margin to be repaired to the footprint (Fig. 5.4). The biomechanical benefits of margin convergence have been borne out in several studies, with side-to-side repair of two-thirds of a U-shaped tear resulting in one-sixth the strain across the repair site. Mazzocca [30] showed in an open cadaveric study that margin convergence also has a significant role for large retracted rotator cuff tears, with sequential side-to-side sutures resulting in progressive gap closure as well as decreased repair strain.

The optimal technique for reattachment of the tendon to the bone has been widely researched, but no consensus has been reached yet. Gerber et al. [31] described the characteristics of the optimal rotator cuff repair as having (1) high initial fixation strength, (2) minimal gap formation, and (3) sustained mechanical stability until healing has occurred. Some factors analyzed to enhance repair constructs include utilization of stronger suture, various methods of knot tying, and analysis of anchor fixation biomechanics. Recently, much interest has focused on the results of single-/double-row repairs and transosseous equivalent repairs. Double-row fixation has been shown to have improved initial strength and stiffness and decreased gap formation compared with single-row repairs [32]. In a cadaveric study by Brady et al. [33], more than half of the anatomic footprint remained uncovered with single-row fixation, whereas near complete coverage was gained with double-row fixation. The transosseous equivalent technique utilizes a medial row of suture anchors placed lateral to the articular surface, with crossing sutures to a lateral row of suture anchors placed in the greater tuberosity. This technique compresses the free edge of the rotator cuff tendon down onto its footprint, thereby increasing surface area contact for tendon to bone healing (Fig. 5.2c). Transosseous equivalent repairs better recreate the native footprint of the cuff compared with single- and double-row repairs and improve contact area for healing.

Despite these theoretical structural benefits, most studies have not shown a clinical benefit to double-row repairs when analyzing arthroscopic tendon repairs of all tear sizes. Park et al. [34] stratified patients by tear size and found that large or massive rotator cuff tears (>3 cm) had significantly improved function with double-row fixation, suggesting that this technique may be more suitable for larger tears. Careful consideration should be made when using double-row fixation particularly in massive rotator cuff tears since over-tensioning of the repair is potentially higher in these cases (as compared with smaller tears). Since few studies have investigated this issue in massive rotator cuff tears, additional research must be done to further assess for any potential clinical benefits and to define the circumstances for the utilization of either technique.

In the past, anterosuperior tears were less commonly diagnosed and treated, likely because they were not diagnosed [1, 31, 39]. Improved methods of clinical and radiographic evaluation, as well as the widespread use of arthroscopy, have led to increased recognition and an improved understanding of their significance [40–42]. Arthroscopic treatment of these tears has lagged behind that of other rotator cuff pathology because it is technically difficult, and there is potential for injury to the neurovascular structures which are in close proximity to a medially retracted tendon. Promising results with arthroscopic repairs have been reported, however [40, 43–46]. The subscapularis is an integral part of the anterior-posterior force couple which maintains ball and socket kinematics during humeral abduction [47], and rotator cuff tears which involve the subscapularis have inferior outcomes following repair compared with those that do not [48].

Arthroscopic treatment of anterosuperior tears generally can be performed through three working portals. Due to the retroversion of the humeral neck, the anterior deltoid muscle naturally drapes over the footprint of the subscapularis tendon and limits visualization during the repair. With increased operative time, swelling from fluid extravasation can exacerbate this problem [49]. After general diagnostic arthroscopy, the subscapularis tendon is repaired before the biceps or any of the other rotator cuff tendons.

Identification of the tendon edge may be difficult, depending the severity of muscle retraction (Fig. 5.5). The inferior muscular portion of the subscapularis may be intact and attached to the lesser tuberosity [49]. In these cases, this retained segment can be followed proximally to the retracted tendinous portion. Recognition of the tendon can also be identified by the “comma sign,” a structure formed by parts of the superior glenohumeral ligament and the coracohumeral ligament that is consistently located along the superolateral aspect of the tendon [6, 40]. During tearing of the tendon, this complex avulses off of the humerus along with the medial sling of the biceps tendon.

The retracted tendon is often scarred and tethered, and circumferential releases should be performed. The releases done arthroscopically mimicked those used in open surgery. The superior edge is freed from rotator interval tissue and from adhesions to the coracoid. Again, mobilization is aided by the use of traction sutures placed through the tendon edge and externalized through percutaneous mini-portals made so that the vector of the traction stitch draws the tendon to its anatomic location. The subscapularis tendon is then released from the anterior joint capsule and freed of adhesions in the subcoracoid space, as needed. If dissection below the inferior half of the tendon is required, the axillary nerve is identified and protected. This is best done by blunt dissection anteromedially in the subcoracoid space. The comma is preserved when the tear includes the supraspinatus (Fig. 5.6). Coracoplasty may also be required in select cases. A burr is used to resect the lateral tip and posterior aspect of the coracoid to widen the coracohumeral window for the subscapularis tendon [49]. Narrow windows have been associated with increased subscapularis tear rates.

An outside-in technique for passing sutures is a safe and effective method of repair. Viewing intra-articularly from the posterior portal, sutures from anchors in the lesser tuberosity are laid posteriorly to the subscapularis tendon. A pointed grasper is then used to pierce the subscapularis tendon from the superficial through the deep surface of the tendon to grasp the suture. It is then pulled back through the tendon and tied in the subdeltoid space. This is repeated for each suture starting from the most distal and moving proximally. Once the subscapularis tendon has been repaired, attention can be turned to the supraspinatus/infraspinatus repairs as needed. Biceps pathology should also be addressed with either tenodesis or tenotomy.