Latissimus Dorsi Transfer. Gianezio Paribelli Editor

Transcription

1 Latissimus Dorsi Transfer Gianezio Paribelli Editor 123

2 Latissimus Dorsi Transfer

3 Gianezio Paribelli Editor Latissimus Dorsi Transfer

4 Editor Gianezio Paribelli Domus Nova Clinic Maria Cecilia Hospital (MCH) Ravenna Italy ISBN DOI / ISBN (ebook) Library of Congress Control Number: Springer International Publishing AG 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

5 Foreword In recent decades, some knowledge and application of new techniques in shoulder surgery have been recorded that cannot be compared with other articular districts. Especially, the advent of arthroscopic techniques has deepened anatomical knowledge and pathological observations, paving the way for new therapeutic guidelines, even for traditional surgery. Many orthopedic colleagues have deepened and strengthened this huge knowledge base, shifting it toward a patient-centered approach, leading to hyperspecialisation, which has already become a reality worldwide. As a consequence, over time, several orthopedic surgeons have become authoritative pioneers in this area, acknowledged all over Europe. Among them is Professor Gianezio Paribelli, my dear friend, past president of the Arthroscopy Italian Society and the developer and editor of this publication. This book, which approaches shoulder surgery from a peculiar point of view, bears witness to the author s commitment and skills in the field and will surely guide many shoulder specialists and deepen their understanding. Therefore, it is with great pleasure and satisfaction that I recommend this book to our scientific community and stress the diligence, the careful preparation, and the high competence that have led the authors to prepare this significant publication. Piero Volpi President of Arthroscopy Italian Society (S.I.A.) Milan Italy v

6 Contents 1 Massive Rotator Cuff Lesion: Arthroscopic Repair Andrew J. Sheean, Robert U. Hartzler, and Stephen S. Burkhart 2 History and Biomechanics of Latissimus Dorsi Transfer Enrico Gervasi, Enrico Sebastiani, and Alessandro Spicuzza 3 Functional Anatomy of the Latissimus Dorsi Nicole Pouliart and Giovanni Di Giacomo 4 Surgical Indications for Latissimus Dorsi Tendon Transfer Stefano Boschi, Roberto Castricini, and Gianezio Paribelli 5 Transfer in Posterior and Superior Cuff Lesions: Arthroscopic Surgical Technique Gianezio Paribelli, Stefano Boschi, Francesco Leonardi, and Alfonso Massimiliano Cassarino 6 Transfer in Subscapularis Lesions: Open Surgical Technique William R. Aibinder and Bassem T. Elhassan 7 Latissimus Dorsi Transfer in The Irreparable Subscapularis Lesions: Arthroscopic Surgical Technique Gianezio Paribelli, Stefano Boschi, Francesco Leonardi, and Alfonso Massimiliano Cassarino 8 Transfer in Shoulder Replacement D. Petriccioli and C. Bertone 9 Rehabilitation After Latissimus Dorsi Tendon Transfer Michele Ciani 10 Complications José Luis Avila Lafuente, Miguel García Navlet, and Miguel A. Ruiz Iban vii

7 viii Contents 11 Latissimus Dorsi Transfer: Results and Systematic Review F. Franceschi, G. Paribelli, S. Boschi, E. Gervasi, R. Castricini, D. Petriccioli, and B. Elhassan 12 Future Prospectives Pietro Randelli, Carlo Stoppani, Alessandra Menon, and Riccardo Compagnoni

8 About the Editor Gianezio Paribelli, M.D., is an Orthopedic Surgeon and Sports Medicine Specialist, Director of Arthroscopic and Prosthesis Surgery at the private Domus Nova Clinical Institute in Ravenna, (Italy), and at Maria Cecilia Hospital MCH (Italy). After receiving his first medical degree from the University of Padua, he spent many years at IOR Institute in Bologna, where he highly specialized in endoscopic and arthroscopic procedures. Dr. Paribelli is Past President of the Italian Arthroscopy Society (SIA) and a member of several national and international scientific societies, including SIOT, SIGASCOT, and AANA. He was a speaker at numerous conferences on knee, shoulder, and elbow in the USA, Europe, and Italy, and the author of many publications, among which is Arthroscopy: complete subscapularis tendon visualization and axillary nerve identification by arthroscopy technique (2005; Journal of Arthroscopy and Related Surgery). Dr. Paribelli s activity is specially devoted to surgery for massive cuff tears, and he has experience with more than 400 cases of latissimus dorsi transfer, thus becoming an authority in the field. A frequent lecturer at national and international congresses, he has also contributed as author to other Springer publications. ix

9 Massive Rotator Cuff Lesion: Arthroscopic Repair 1 Andrew J. Sheean, Robert U. Hartzler, and Stephen S. Burkhart Abstract The treatment of massive rotator cuff tears is challenging, and a number of different surgical tactics have been proposed. Advancements in shoulder arthroscopy allow for enhanced visualization of rotator cuff tear morphology and a thorough assessment of tissue quality and mobility. A number of arthroscopic techniques have been described to visualize relevant pathology, mobilize contracted or less compliant tissues, and promote durable, tension-free repairs. In cases of truly irreparable rotator cuff tears, superior capsular reconstruction has emerged as a viable alternative to open tendon transfers and arthroplasty procedures. Keywords Arthroscopic Massive rotator cuff tear Advanced mobilization techniques Margin convergence Load-sharing rip stop Double-row repair 1.1 Introduction Massive rotator cuff (RC) tears defined as tears 5 cm and/or two or more completely torn tendons are a significant challenge for the shoulder surgeon, and the optimal approach to management remains controversial [1 5]. While published results support the use of arthroscopic techniques regardless of tear size or A.J. Sheean (*) Department of Orthopaedic Surgery, San Antonio Military Medical Center, Fort Sam Houston, San Antonio TX, 78234, USA ajsheean@gmail.com R.U. Hartzler S.S. Burkhart The San Antonio Orthopaedic Group, Burkhart Research Institute for Orthopaedics (BRIO), San Antonio TX, USA Springer International Publishing AG 2017 G. Paribelli (ed.), Latissimus Dorsi Transfer, DOI / _1 1

10 2 A.J. Sheean et al. a b c d Fig. 1.1 Case example of a 57-year-old woman with a massive 3 tendon rotator cuff tear with unfavorable imaging characteristics. (a) Radiograph of the right shoulder demonstrates superior humeral head migration in the absence of significant glenohumeral arthritis. (b) T2 coronal magnetic resonance imaging (MRI) shows the very retracted supraspinatus tear. (c) T1 sagittal MRI demonstrates atrophy and significant fatty infiltration of the supraspinatus and infraspinatus muscle bellies. (d) Intraoperative arthroscopic photograph after completion of a linked, double row RC repair characteristics [1 3], others have advocated alternative open procedures, such as tendon transfers and reverse total shoulder arthroplasty even in the absence of glenohumeral arthritis [4 10]. Often, these approaches rely on preoperative findings thought to be predictive of irreparability. In our experience, nearly all primary, massive RC tears (approximately 90%) even in the face of superior humeral migration and significant atrophy or fatty infiltration (Fig. 1.1) are able to be fully repaired. Therefore, in the absence of arthritis, our approach has been to only classify a massive cuff tear irreparable after thorough arthroscopic examination and attempted repair. For truly irreparable massive tears that are confirmed arthroscopically, either a well-done partial repair [11, 12] or superior capsular reconstruction [13 16] can

11 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 3 be of great benefit to the patient and allow for minimally invasive joint preservation. 1.2 Principles of Management Assessing Reparability Other authors have asserted that certain preoperative factors (primarily imaging characteristics) can predict RC tear reparability [17]. But few have attempted to establish which preoperative factors, if any, are associated with operative irreparability using the modern arthroscopic techniques described in this chapter [18]. Many massive rotator cuff tears appear irreparable on MRI and with casual arthroscopic examination. However, we have found that these tears may be amenable to repair using the correct surgical techniques. Thus, in the absence of glenohumeral arthritis, we offer arthroscopy (over tendon transfer or arthroplasty) to nearly all patients with massive cuff tears, and we consider attempted arthroscopic RC repair to be the gold standard for determining reparability Role of Tendon Healing Our goal in arthroscopic massive rotator cuff surgery is to maximize patients clinical improvement by achieving tendon-to-bone healing in as many repairs as possible. While the importance of healing remains controversial, a critical appraisal of published results has led us to conclude that healed repairs result in increased shoulder strength, improved pain relief, and superior functional outcomes [19 23]. Thus, the surgeon should endeavor to optimize the potential for tendon-to-bone healing by minimizing tension on the repair and maximizing the strength of the repair construct. The importance of these principles is especially magnified among older patients and in tears with poorer tissue quality, both of which have been shown to be independent risk factors for repair failure [24, 25]. 1.3 Surgical Technique: A Stepwise Approach to Repair Keys to Visualization Arthroscopic repair of a massive RC tear is best accomplished with the patient in the lateral decubitus position for several reasons. Lateral decubitus positioning enhances the safety of hypotensive anesthesia, which is of particular importance when working in the subacromial space where bleeding can obscure visualization and dramatically enhance the difficulty of the procedure. Furthermore, with the patient in the lateral decubitus and leaned back 15 20, an adequate working space anterior to

12 4 A.J. Sheean et al. Table 1.1 Overview of repair steps 1. Diagnostic glenohumeral arthroscopy 2. Address biceps tendon pathology 3. Subscapularis repair 4. Subacromial bursectomy and acromioplasty 5. Tear assessment and pattern recognition 6. Tendon mobilization 7. Repair and v a b Fig. 1.2 Intraarticular portion of the bicipital groove when viewed from the posterior viewing portal in the left shoulder. (a) The arthroscopic view of the bicipital groove when viewed with a 30 arthroscope. (b) The arthroscopic view of the bicipital groove is dramatically enhanced when viewed with a 70 arthroscope the chest, neck, and head is maintained allowing for a second surgical technician to manipulate the humerus. Abduction of the humerus combined with traction aids in maintaining the subacromial working space as soft tissue swelling increases during the procedure. Pump pressure should be adequate to achieve good visualization (typically 60 mmhg), and an assistant should take care to control turbulence by controlling egress of fluid from portals with digital pressure. The use of a posterior lever push (humeral head pushed posteriorly by the assistant) greatly increases the anterior working space when addressing biceps tendon and subscapularis pathology (Table 1.1) Diagnostic Glenohumeral Arthroscopy A 70 arthroscope is an important adjunct used to optimize visualization during glenohumeral arthroscopy. The 70 arthroscope greatly enhances the surgeon s viewing of the lesser tuberosity and nearly doubles the length of the viewable bicipital groove distally from the articular margin distally (Fig. 1.2) [26]. Enhanced viewing of the bicipital groove is of particular diagnostic importance as tears in the

13 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 5 medial sidewall of the bicipital sling can be indicative of occult tears of the subscapularis Address Biceps Tendon Pathology Abnormalities of the long head of the biceps tendon are a common associated finding with massive RC tears. Either tenotomy or tenodesis is performed depending on patient factors and the tissue quality of the biceps tendon. We perform the tenodesis high in the bicipital groove at the articular margin with a biceps tenodesis anchor. This method most closely recreates the length-tension relationship of the long head of the biceps and has yielded exceptionally low rates of revision procedures, residual pain, and significantly improved objective shoulder outcome scores among a cohort of over 1000 patients [27] Subscapularis Repair The surgeon should maintain a high index of suspicion for subscapularis pathology in the setting of massive RC tears, as subscapularis tears have been observed in up to 69% of massive RC tears [2]. The 70 arthroscope and posterior lever push are powerful tools to fully scrutinize the intraarticular portion of the bicipital groove, the lesser tuberosity, and the subscapularis tendon. Failure to address subscapularis tears is a major pitfall of arthroscopic repair of massive RC tears for several reasons. The subscapularis generates the greatest amount of force of any of rotator cuff muscle, and it is the only anterior muscle capable of balancing posterior forces of the remainder of the cuff musculature. Moreover, the anterior attachment of the supraspinatus is confluent with the upper border of the subscapularis insertion via the comma tissue [28], and repairs of its upper border diminish the stress on adjacent repairs of the supraspinatus. In non-retracted subscapularis tears, visualization and repair are usually straightforward. After tear identification, establish an anterosuperolateral (ASL) working portal through the rotator interval. The skin location is typically just off the anterosuperior acromion, but always use a spinal needle to establish this portal to ensure a good angle of approach to the tendon and lesser tuberosity. View with a 30 arthroscope from posterior, open the rotator interval, and identify the coracoid tip. Work from the ASL portal both anterior and posterior to the comma tissue and switch between 30 and 70 scopes, as necessary, to debride the lesser tuberosity and the subcoracoid space. Perform coracoplasty, as needed, to achieve a normal coracohumeral interval of at least 7 mm. In retracted subscapularis tears, tear identification may be more difficult and the surgeon may have to perform a three sided release of the tendon to gain adequate excursion. Medialization of the lesser tuberosity footprint may be necessary [29]. A detailed discussion of advanced techniques for subscapularis repair is beyond the scope of the chapter, and we would direct the reader elsewhere for further reading on this important topic [29, 30].

14 6 A.J. Sheean et al. Numerous repair constructs can be used for arthroscopic subscapularis repair. For smaller, upper border tears (<50%), we often use a knotless technique with a tape suture [31]. The suture limbs of an arthroscopic biceps tenodesis construct (placed slightly medially at the top of the groove) can also be used to repair the upper border of the subscapularis. Larger tears (>50%) of the subscapularis typically require repair with 2 medial row anchors, and often benefit from linked, double-row fixation Subacromial Bursectomy and Acromioplasty In preparation for arthroscopic repair of a posterosuperior tear, subacromial decompression is undertaken systematically starting by viewing from the posterior portal with a 30 scope. A lateral working portal is established using a spinal needle. Bursectomy is performed with an arthroscopic shaver introduced from a lateral working portal. Once the lateral internal deltoid fascia is clearly visualized, electrocautery is used to split the internal deltoid fascia inferiorly to the bursal sulcus and superiorly to the lateral acromion. Splitting the internal fascia in this fashion greatly helps the free passage of instruments into the shoulder and increases instrument excursion within the subacromial space. Next, the arthroscope is then switched to the lateral portal and bursectomy is continued working from posterior until the entirety of each muscle-tendon unit of the posterosuperior rotator cuff is exposed. The surgeon should continue the debridement with switching as needed between posterior and lateral portals and with 30 and 70 scopes until all bony landmarks are clearly seen (AC joint, spine of scapula, anterior and lateral borders of acromion). In the setting of massive RC tears, extensive scarring may be encountered and the surgeon may have to liberate the torn cuff from the undersurface of the acromion. Massive RC tears commonly have bursal leaders, which are sheets of scar tissue that can mimic RC tissue. This tissue can be distinguished from cuff by its insertion into the internal deltoid fascia, whereas the true intact cuff margin inserts on to the greater tuberosity. Internal rotation of the humerus can be very helpful during this dissection, as can the use of a 70 scope. In massive cuff repair, we recommend preservation of the coracoacromial (CA) ligament. We usually perform a limited acromioplasty (especially a lateral acromial bevel) or smoothing to increase the working space and to protect the repair from abrasion Tear Pattern Recognition Through a posterior portal, a 70 arthroscope improves the view of the posterosuperior RC tears and greatly aids the surgeon in characterizing the configuration of the tear. Accurate characterization of the RC tear type is crucial as the repair pattern is governed by the tear pattern. The ability to completely visualize the tear

15 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 7 a IS SS b IS SS Posterior leaf P A c IS SS d IS SS Anterior leaf P A P A Fig. 1.3 Characteristic RC tear patterns. (a) Crescent tear, (b) L-shaped tear, (c) reverse-l shaped tear, (d) U-shaped tear morphology is a major advantage of arthroscopic repair over open repair techniques, where surgeons had a tendency to try always to advance the cuff tissue from medial to lateral. However, many massive rotator cuff tears require a significant component of anterior-posterior (AP) mobilization to be repaired in an anatomic and tension free manner. Viewing from the posterior portal with a 70 arthroscope, a grasper is used to assess the excursion of the entire margin of the tear. Massive RC tears can display any of the following configurations [32] (Fig. 1.3): 1. Crescent Tears: Medial-lateral (ML) mobility of the tear margin is equal along the entire tear margin. This mobility allows excursion to the bone bed without significant tension. The AP tear length is typically greater than the ML length.

16 8 A.J. Sheean et al. 2. L-Tears and Reverse L-Tears: In L-tears, the posterior leaf of the tear will have a corner that reduces to the anterolateral bone bed. A ML split in the rotator interval or supraspinatus allows the tissue to assume the characteristic shape. The ML tear length is typically greater than the AP length. Reverse L-Tears have an anterior leaf of the tear, which will have a corner that reduces to the posterolateral bone bed. A ML split usually occurs in the infraspinatus, which allows the tissue to assume the characteristic shape. The ML tear length is typically greater than the AP length. 3. U-Tears: The ML tear length that is greater than the AP tear length, but each0 of the two tear leaves has equal mobility, primarily in the AP direction. 4. Contracted, Immobile Tears: These tears are typically retracted and scarred to adjacent structures. In general, immobile crescent-shaped tears are more difficult to repair owing to their wider (in the AP direction) morphology compared to that of massive, longitudinal tears Tendon Mobilization Massive rotator cuff tears are often contracted and require advanced mobilization techniques (>40% cases) to achieve the tendon excursion needed to perform reliable and durable tendon-to-bone repairs [33 35]: 1. Anterior Interval Slide in Continuity: The retracted supraspinatus tendon is identified (Fig. 1.4a). A traction stitch is placed in the lateral aspect of the tendon and retrieved through an accessory lateral portal. Traction usually reveals tethering of the supraspinatus anteriorly by contracted coracohumeral and superior glenohumeral ligaments (Fig. 1.4b). Release these ligaments by dissecting the medial portion of the rotator interval from the base of the coracoid, preserving the lateral margin of the rotator interval (Fig. 1.4c). This tactic preserves the lateral connection between the supraspinatus and subscapularis (Fig. 1.4d). The anterior interval slide in continuity often provides approximately 1 2 cm of ML excursion of the supraspinatus tendon. 2. Posterior Interval Slide: If the tear margin is still contracted posteriorly, significant excursion can be achieved using a posterior interval slide. The raphe between supraspinatus and infraspinatus is incised in a lateral to medial fashion towards the scapular spine (Figs. 1.5 and 1.6) with traction sutures in the supraspinatus and infraspinatus on either side of the raphe. Care is taken to lift the arthroscopic scissors away from the bone as the release progresses medially so as to avoid injury to the suprascapular nerve. The posterior interval slide often affords the surgeon an additional 3 4 cm of lateral excursion of the supraspinatus tendon. When the posterior interval slide is combined with the anterior interval slide in continuity a double interval slide it is not uncommon to achieve 4 5 cm of increased excursion of the posterosuperior cuff. Arthroscopic interval slides have given many of our patients the opportunity to have excellent results with rotator cuff repair and to avoid shoulder arthroplasty.

17 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 9 a CHL b Subscapularis muscle Subscapularis muscle c CHL d Subscapularis muscle Fig. 1.4 Anterior interval slide in continuity illustration. (a) A massive rotator cuff tear with retraction and scarring of the anterosuperior portion. (b) After preparation of the subcoracoid space and subscapularis releases, the dotted box outlines the proposed location of the anterior interval slide in continuity. (c) The posterolateral base of the coracoid is exposed and the coracohumeral ligament is released. The medial rotator interval tissue is excised, creating a window through the rotator interval. Note that the lateral margin of the rotator interval is preserved, thereby maintaining continuity between the subscapularis and supraspinatus tendons. (d) Subscapularis repair allows the supraspinatus and infraspinatus to be repaired using a margin convergence technique. (CHL coracohumeral ligament). (Reproduced with permission from Lo et al. [28]) Repair and Fixation of Posterosuperior Tears In spite of existing evidence that has suggested clinically equivalent outcomes between single and double-row suture anchor repair constructs, we favor linked, double-row constructs (Fig. 1.7) for several reasons. First, we would caution against drawing substantive conclusions from existing clinical data comparing clinical outcomes between single-row and double-row constructs because these studies are underpowered, underrepresent shoulder strength as an outcome measure, and lack

18 10 A.J. Sheean et al. a b c d Fig. 1.5 Posterior Interval Slide illustration. (a) An immobile, posterosuperior RC tear is encountered. (b) Arthroscopic scissors are used to incise the raphe between the supraspinatus and infraspinatus. (c) Once mobilized, the infraspinatus is advanced and fixed to the greater tuberosity. (d) The supraspinatus can then similarly be mobilized and fixed laterally longer-term follow-up. Second, biomechanical studies have demonstrated that linked, double-row constructs offer larger pressurized contact areas, greater contract pressures, and higher load-to-failure compared to independent, double-row and single-row constructs [36 40]. Third, the linked, double-row construct has been associated with improved tendon healing in a rabbit model and lower re-tear rates in a meta-analysis of 7 Level I studies [41, 42]. In addition to skill in using linked, double-row repair constructs, the surgeon who performs arthroscopic massive rotator cuff repair surgery should have knowledge of additional repair techniques:

19 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 11 Fig. 1.6 Arthroscopic photograph of a posterior interval slide. The raphe separating the supraspinatus tendon (SS) and infraspinatus tendon (IS) has been incised in a lateral to medial direction (blue arrow) working towards the scapular spine (S) A traction stitch has been placed in the IS in order to assist with mobilizing the tendon Fig. 1.7 Schematic representation of a linked, double-row repair construct

20 12 A.J. Sheean et al. a b Fig. 1.8 Margin convergence technique. (a) U-shaped rotator cuff tear. (b) Partial side-to-side repair causes margin convergence of the tear towards the greater tuberosity, increasing the crosssectional area and decreasing the length of the tear, which decreases the overall strain seen by the final repair construct. (Reproduced with permission from Burkhart [44]) 1. Margin Convergence: For massive, longitudinal tears (L-, reverse-l, and U-shaped), the margin convergence technique incorporates a side-to-side repair of the anterior and posterior margins of the tear, thereby shortening the medial-to-lateral tear length. This technique converges the lateral margin of the tear towards the greater tuberosity (Fig. 1.8, U-tear) and greatly reduces the strain seen at the repaired tendon bone interface [43, 44]. In this way, margin convergence protects against suture failure and mitigates the likelihood of tear propagation. 2. Load-Sharing Rip Stop (LSRS): Lateral tendon loss may prevent the surgeon from performing a true double row repair without undue tension. In this setting, a LSRS construct allows a linked, double-row equivalent repair. An inverted mattress ( rip stop ) suture tape stitch is passed 3 mm lateral to the musculotendinous junction. Medial anchors are placed in the greater tuberosity bone bed, approximately 5 mm lateral to the articular margin and suture limbs from these anchors are passed medial to the rip stop tape. The rip stop suture tape limbs are retrieved and secured laterally before the suture limbs from the medial anchors are retrieved and tied (Fig. 1.9) [45]. The LSRS construct avoids the loss of loop security that occurs in other grasping type suture configurations during cyclic loading and offers superior load-to-failure properties compared to other single row constructs [46].

21 1 Massive Rotator Cuff Lesion: Arthroscopic Repair 13 a b c d e f Fig. 1.9 Load sharing rip stop schematic. (a) Rotator cuff tear with lateral tendon loss or poor quality tissue (b) Two suture tapes placed as an inverted mattress rip stops. (c) Two medial anchors are placed approximately 5 mm lateral to the articular margin. (d) Suture limbs from these anchors are passed medial to rip stop stich (e) The rip stop stiches are secured to the bone with two lateral knotless anchors before the suture limbs from the medial anchors are tied (f) (Reproduced with permission from Denard et al. [2, 30]) Even when tendon tissue quality is good and there is adequate tendon excursion to accommodate relatively tension-free repairs, massive RC tears often require complex repair constructs. These mixed constructs can include free margin convergence sutures, margin-to-bone sutures incorporating independent anchors, and other double-row anchor pairs. Additionally, should a RC tear be deemed truly irreparable through a thorough arthroscopic assessment, partial RC repair remains a viable option with good reported results among older patients [11, 12]. 1.4 Aftercare Our philosophy on rehabilitation following arthroscopic repair of massive RC tears is governed by an understanding of the biology of tendon to bone healing, which does not occur via Sharpey s fibers until approximately 12 weeks from repair [47]. Given this fact, patients undergoing arthroscopic repair of massive RC tears are progressed slowly so as to not subject the repair to unnecessary stresses. Immediately