Compared with smaller tears, massive rotator cuff tears present significant clinical management dilemmas for the treating surgeon because they are often fraught with structural failure and poor outcomes. To optimize healing, current surgical methods look to optimize footprint coverage and enhance the biological environment for healing. Double-row techniques have demonstrated clear biomechanical advantages in controlled cadaveric studies, but have yet to demonstrate clear clinical efficacy over more simple repair techniques. When repairs for massive rotator cuff tears fail, options include revision repair or superior capsular reconstruction, an option to bridge the tissue gap with human dermal allograft or fascia lata autograft in hopes of containing the humeral head from superior migration and precluding rotator cuff arthropathy. Although latissimus transfers remain a reasonable option for massive, irreparable rotator cuff tears in appropriately indicated patients, clinical results are often unpredictable. Older patients with chronic, massive rotator cuff tears with pseudoparalysis can achieve predictable, often excellent clinical results with a reverse total shoulder arthroplasty. [Orthopedics. 2016; 39(3):145-151.].
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