[How to treat massive rotator cuff tears]

The treatment of massive rotator cuff tears must be adapted to the patient's individual needs and preoperative parameters to achieve the best outcome. First, the shoulder surgeon has to determine whether a direct transosseous repair is possible. If there is not enough remaining tissue, the tissue is atrophic, and the tendon stump can be reduced only with great tension, one can use a margin convergence technique for partial closure, perform a biceps tendoplasty, or perform local tendon transfers with the subscapularis or infraspinatus muscle. If the defect cannot be sufficiently closed, elderly patients with low demands can be treated with tubercleplasty/subacromial decompression, whereas patients younger than 60 years with higher demands should receive muscle and tendon transfers. A balanced posterosuperior defect can be reconstructed by a deltoid muscle transfer, in contrast to an unbalanced one, which is best treated with an active transfer of the latissimus dorsi muscle and tendon. Anterosuperior defects can be addressed by a pectoralis muscle transfer. If the humeral head is superiorly migrated, if signs of osteoarthritis are present, and if the patient is older than 70 years, a reverse prosthesis can be implanted as a salvage procedure.