Massive soft tissue tears of the rotator cuff pose significant challenges to the shoulder surgeon. Although most tears can be successfully repaired in a primary fashion, some massive tears of the rotator cuff are termed irreparable, either due to their severely contracted state or simply because of their size. Cofield has defined the term massive rotator cuff tear as greater than 5 cm, whereas others have defined it as involvement of at least two tendons.

Chronic tears, commonly seen in older patients, have evidence of attritional changes in both the tendon substance and the muscle fibers. This has been termed fatty degeneration by Gerber and can be best characterized and graded based on its appearance on T1 weighted magnetic resonance imaging (MRI) of the shoulder in the oblique sagittal plane. The presence of fatty degeneration of the musculotendinous unit may compromise the results of even a seemingly successful repair due to poor tissue quality and limited regenerative capacity. The limitations of successful tendon repair are thus a function of the length of time since injury, the degree of tissue contraction, and extent of fatty degeneration.

Management of such tears often begins with conservative management. If this fails, surgical management may include debridement of the cuff tear, which may result in satisfactory pain relief, but will not restore strength or function. Partial repair may be possible in some instances, but this does not restore normal function. Other options include allograft or synthetic tendon augmentation, but these have met with varying success in the literature.

Long-standing rotator cuff tears result in altered kinematics of the glenohumeral joint, and rotator cuff tear arthropathy may eventually develop as a painful end-stage condition. Hemiarthroplasty can be a reasonable option in patients who have an intact coracoacromial arch limiting anterior superior escape of the humeral head. The reverse shoulder prosthesis has recently been shown to be an effective treatment option for patients with irreparable rotator cuff tears and anterior superior instability of the humeral head. At mid-term follow-up, improvements in range of motion and pain relief have been reported in the majority of cases. However, this is generally reserved for select indications in an elderly patient. The long-term results of this prosthesis have yet to be determined.

A patient who has had a previously failed massive rotator cuff repair may be challenging to treat. Tendon transfers are another option for salvaging massive rotator cuff defects. They have the distinct advantage in their ability to restore strength, in addition to providing pain relief. Local tendon transpositions historically have included superior subscapularis, teres minor, and teres major transfers. Deltoid flap reconstruction has also been reported. Our preferred method of tendon transfer for posterior superior rotator cuff tears is the latissimus dorsi transfer.

Gerber et al described the procedure of latissimus dorsi transfer as an option for the treatment of massive posterior superior rotator cuff defects in 1988. This procedure has been shown to restore an active external rotation and forward flexion moment at the shoulder, which are the primary functional deficits for this type of massive rotator cuff tear.

Latissimus transfer in cases of a failed previous rotator cuff tear results in overall improvement in function and pain relief, but is generally inferior to that observed after a primary transfer. A comparative analysis on the results of latissimus dorsi transfer for primary irreparable rotator cuff tears, versus for salvage reconstruction for a failed previous rotator cuff repair was performed by Warner and Parsons. Patients’ satisfaction and function were superior in primary latissimus dorsi transfer when compared with patients undergoing salvage reconstruction of failed previous rotator cuff repairs.

Subscapularis tendon ruptures occur less frequently than supraspinatus and infraspinatus ruptures. However, they can occur in isolation, during anterior shoulder dislocation, or an as extension of a massive rotator cuff tear. Our preferred method of tendon transfer for irreparable subscapularis tendon tears is the pectoralis major transfer. Combined latissimus dorsi transfer with pectoralis major transfer may be indicated in massive rotator cuff deficiency involving both the posterior superior cuff and the subscapularis.

The primary indication for latissimus dorsi transfer is the loss of active external rotation due to an irreparable tear of the posterior superior rotator cuff. The patient is dissatisfied with increased functional demands, which are beyond the limitations of conservative treatment.

The primary indication for pectoralis major tendon transfer is irreparable rupture of the subscapularis, characterized by retraction of the musculotendinous unit to the glenoid, and fatty infiltration of the muscle. In a patient with posterosuperior rotator cuff tear with extension of the defect into the subscapularis, isolated latissimus transfer is contraindicated unless there is either concomitant repair of the subscapularis, or transfer of the pectoralis major, to compensate for subscapularis dysfunction.

We begin with the history and physical examination, which are essential in diagnosis and assessment of the nature of the rotator cuff tear. Often, the patient complains of pain or dysfunction with an insidious onset. Other times, the patient complains of fatigue during forward elevation or external rotation of the shoulder. No history of trauma can be recalled and the symptoms have been chronic over months or years, which leads us to believe that the etiology is attritional. Thus, we suspect poor tendon quality and the possibility of an irreparable tear.

The physical examination of the shoulder begins by inspection of both shoulders. Deformity associated with anterior superior escape of the humeral head indicates anterosuperior rotator cuff tear, which is a contraindication for latissimus transfer. Spinati muscle atrophy is noted, and often indicates an irreparable rotator cuff tear is present. A defect of the deltoid is a relative contraindication for this procedure. Manual motor testing of shoulder forward elevation, abduction, external rotation, and internal rotation are recorded.

The hornblower’s sign, or external rotation lag sign (discrepancy between active and passive external rotation of greater than 30 degrees), is important to recognize. A positive sign is highly suggestive of a massive rotator cuff tear, amenable to latissimus dorsi transfer.

Another physical examination finding that is important to recognize is the lift-off test (the inability to actively lift the dorsum of the hand off from a resting position on the lower back), or belly press test (the inability to actively maintain the elbow anterior to the midline of the trunk as viewed from the side). An inability to perform these maneuvers is highly suggestive of involvement of the subscapularis in the rotator cuff tear. If a subscapularis tear is present and determined irreparable, then a pectoralis major transfer should be performed in conjunction with the latissimus transfer.

Active and passive range of motion in forward elevation, external rotation, and internal rotation are documented. Loss of passive external rotation and forward elevation is a contraindication to this procedure. Active range of motion is also measured. Patients need to be able to achieve active forward elevation to 90 degrees to be candidates for the procedure. If the patient has pseudoparalysis and minimal forward elevation, the procedure will fail. The main goal of the procedure is to promote active external rotation to eliminate the hornblower’s sign and enable the patient to reach the top of the head.

It should be noted that some patients with massive cuff tears are amenable to conservative treatment, and eventually may experience minimal pain and satisfactory function, especially in the elderly
population. Latissimus dorsi transfer is more commonly performed in those individuals with higher functional demands.

Imaging studies are useful for assessing the patient who is suspected of having a painful, torn rotator cuff, unresponsive to conservative treatment. Our standard radiographic views include a true anteroposterior (AP) view of the shoulder and an axillary view. The true AP view best demonstrates superior migration of the humeral head in the context of massive rotator cuff tears. The acromiohumeral distance (ACHD) is measured on this view. A normal ACHD value is 10.5 mm. An ACHD value of 7 mm or less suggests an irreparable tear of the infraspinatus and is a strong indicator to consider a latissimus dorsi transfer, in the context of the previously mentioned physical examination findings. The true AP and axillary views demonstrate degenerative changes of the glenohumeral joint, which would be a contraindication to tendon transfer.

Magnetic resonance imaging is commonly performed at our institution in patients with suspected large rotator cuff tears in whom we are considering surgical treatment. It is useful for assessing not only the size of the tear, but the degree of muscle atrophy and the degree of fatty degeneration. Advanced fatty degeneration and a massive tear indicate a low likelihood of successful repair, but may be considered for latissimus dorsi transfer with or without pectoralis major transfer. In many patients with massive rotator cuff tears, we are able to repair the rotator cuff tear arthroscopically. Therefore, in almost all patients who are candidates for a latissimus dorsi transfer, we recommend an attempted arthroscopic repair as the initial surgical procedure.