Woodmass (2018) — Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears

Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears

·JBJS Rev·2018·17 citations·Shoulder & Elbow

This critical analysis review covers arthroscopic management of massive posterosuperior rotator cuff tears. It walks through how to predict irreparability preoperatively and how to choose among repair, augmentation, reconstruction, and tendon transfer. It organizes irreparable-tear options into palliative, force-couple restoration, and reconstructive categories.

Key Findings

Even when a complete repair is achieved, the pooled retear rate is 79%. This single number frames the whole problem and explains why augmentation and reconstruction techniques exist.
Irreparability can be predicted on MRI. A Patte classification >3 combined with an infraspinatus fatty infiltration grade >2 gives 96% specificity for an irreparable tear, letting you plan a reconstruction before you scope.
Tendon length is a key threshold. A supraspinatus tendon length <15 mm raises failure risk, and combined with Goutallier stage ≥2 the risk of repair failure reaches 92%.
Graft augmentation improves healing. In an RCT of 42 patients, repairs were intact in 85% with augmentation vs 40% without, so consider a reinforcing patch to cut the retear rate.
Partial repair helps symptoms but often fails structurally, with a 42% repair failure rate and nearly half of patients dissatisfied at 2 years, especially with teres minor fatty infiltration.
Bridging a partial repair with fascia lata autograft dropped the retear rate to 8.3% vs 41.7% for partial repair alone, converting a partial into a complete construct.
Superior capsular reconstruction with dermal allograft healed in only 45% of patients on 1-year MRI, with an 18.6% reoperation rate, so counsel patients that early data are promising but graft healing is unreliable.
Latissimus dorsi transfer gives the most durable long-term data, improving subjective shoulder value from 29% to 69% at a mean of 147 months follow-up (p<0.0001).

Board PearlMassive cuff repair fails 79% of the time — preoperative MRI predicts irreparability, and irreparable tears need force-couple restoration or transfer, not just repair.

Clinical Relevance

Start every massive posterosuperior tear by deciding reparable versus irreparable, because that fork drives everything else. Use the MRI: quantify fatty infiltration (Goutallier), retraction (Patte), and tendon length. A Patte >3 with infraspinatus fatty infiltration >2 is 96% specific for an irreparable tear, so plan a reconstruction before you enter the OR rather than improvising.

Remember the 79% pooled retear rate. Even a technically complete repair frequently fails, which is why acute repair in good tissue, double-row fixation, and graft augmentation matter.

For irreparable tears, match the tool to the goal: palliative debridement, biceps tenotomy, or nerve release for low-demand pain relief; partial or bridging repair to restore the force couple; and reconstruction (superior capsular reconstruction or tendon transfer) in younger patients without arthritis.

Critical shoulder angle >36°, subscapularis or deltoid insufficiency, and teres minor fatty infiltration all predict worse transfer outcomes.

Supplemental

Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears

Woodmass, Warner, et al.·JBJS Rev·2018·17 citations·Shoulder & Elbow

Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears

Key Findings

Clinical Relevance

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Arthroscopic Treatment of Massive Posterosuperior Rotator Cuff Tears

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