Tears of the rotator cuff are a common cause of shoulder pain and dysfunction. Although the prevalence of rotator cuff tears increase with age, not all patients develop symptoms necessitating surgery, and many patients benefit from conservative management. However, if symptoms persist, surgery can provide significant pain relief and improvements in function across many patient ages and demographics.
Massive rotator cuff tears are particularly challenging to manage clinically, which is concerning given that they have a reported prevalence to be as high as 40% of all rotator cuff tears. One difficulty is that many classification systems have been proposed to assist in the evaluation and treatment of massive cuff tears, however, no consensus currently exists. A commonly used classification system is one originally proposed by DeOrio and Cofield which defines a massive tear as one that is greater than 5 centimeters in size. A classification system used often in Europe was one defined by Gerber in which a rotator cuff tear is considered massive if it is a full thickness tear involving at least two tendons. A recent classification system proposed by Davidson and Burkhart links rotator cuff tear patterns to treatment and prognosis. Millett and Warth emphasize that it is crucial that management of the patient with a rotator cuff tear be based on an interpretation of the clinical situation and patient presentation.
Another challenge when treating massive tears is that several studies have indicated a higher rate of structural failure of repairs when compared to smaller tears. However, it is important to note that even patients with retears noted postoperatively on magnetic resonance imaging (MRI) had significantly improved function and pain. Therefore, it has to be emphasized that structural failure does not necessarily equate to a clinical failure. Many surgical treatment options exist for managing massive tears, including arthroscopic debridement with a biceps tenotomy or tenodesis, complete repair if the rotator cuff tendon is of good quality and not severely retracted, partial repair, use of an allograft patch to augment a repair or to bridge over a defect, superior capsular reconstruction, muscle tendon transfer, and reverse total shoulder arthroplasty. The purpose of this article is to highlight the indications and clinical outcomes of muscle tendon transfers in the treatment of massive irreparable rotator cuff tears.