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Muscle advancement in massive rotator cuff repair

Current Research
Muscle advancement in massive rotator cuff repair


Need exists for an improved massive RCT repair technique to maximise both repair success and patient outcomes

Good to excellent clinical outcomes and high healing rates have long been achieved in arthroscopic and mini open rotator cuff repair for small- to medium-sized rotator cuff tears (RCTs)2, 31, 34, 39. However, high failure rates persist for large to massive RCTs 12, 19, 37. Whether we should aim for complete or partial repair for massive RCTs is controversial and while some surgeons have designed ingenious procedures to improve healing after massive RCT repair, the question remains whether their excellent results depend on their skill more than technique27, 38.

Associated with poorer outcomes and increased failure following rotator cuff repair is the presence of high muscle tension at the repair site9. In addressing this, some surgeons e.g. Debeyre et al10 have reported using a technique in which the supraspinatus (SSP) muscle is elevated from the supraspinatus fossa and advanced laterally. While this decreases the tension of the distal SSP tendon with acromial osteotomy, the technique involves very invasive surgery and runs the risk of complications including nonunion at the osteotomy site41. In addition, only SSP muscles are advanced, not infraspinatus (ISP) muscles which is problematic given massive tears usually involve both. Further to this, Warner et al40 point out that suprascapular nerve (SSN) palsy may occur with excessive advancement of SSP muscles.

There appears to be a clear need for an improved massive RCT repair technique which takes into account both SSP and ISP muscles and is minimally invasive. Such a technique which is also simple and efficient would increase the probability of repair success and help maximize surgical outcomes for these patients.


  • To determine how adding muscle advancement affects the healing rate and functional outcomes of massive rotator cuff tear repair.


Prospective case series compared to age-matched historical cases.

Study Procedure

All consecutive patients indicated for elective rotator cuff repair will be considered eligible. After reading the information sheet and signing the consent form, they will be enrolled. Baseline characteristics of age, sex, hand dominance and relevant comorbidities will be recorded in a deidentified Patient Data Form (PDF) along with cuff tear size and type, associated pathology (from pre-operative imaging), pre-operative range of motion from the Constant Score and scores from 2 x Patient Reported Outcome Measures (PROMs): the American Shoulder and Elbow Society (ASES) and Western Ontario Rotator Cuff Index (WORC).

The surgery will proceed as follows:

(1) the surgeon will evaluate the rotator cuff tear via shoulder arthroscopy (as usual) and release the suprascapular nerve (if warranted);

(2) muscle advancement (the new technique) will be performed;

(3) the cuff will be repaired (as usual).

Depending on presentation, the repair will include biceps tenodesis or tenotomy. If tenodesis is performed, the type (i.e. groove or subpec) will be recorded on the PDF. Should subacromial decompression or AC Joint excision be performed (again, due to presentation) these too will be recorded along with presence (or absence) of glenohumeral arthritis (which may not have been previously diagnosed radiologically or clinically).

After the surgery, pain at 2 weeks, PROMs and range of motion at 8, 24 and 52 weeks will be recorded on the PDF and all data will then be collated and analysed.

Inclusion Criteria

  • Patients diagnosed with a massive rotator cuff tear (defined as involving at least 2 tendons) and more than 2 cm tendon retraction
  • Patients consented for shoulder arthroscopy and rotator cuff repair
  • Patients capable of giving informed consent to participate in the study

Exclusion Criteria

  • Patients with incomplete rotator cuff tears
  • Patients with isolated subscapularis or supraspinatus tendon tears
  • Patients with a failed rotator cuff repair requiring revision
  • Patients with irreparable rotator cuff tears
  • Patients with acute post trauma rotator cuff tears
  • Patients whose rotator cuff tears have a neurologic lesion such as cervical spondylotic myelopathy
  • Patients with glenohumeral osteoarthritis or rheumatoid arthritis
  • Patients with history of infection in the affected shoulder
  • Patients who are unable to have an MRI

Ethics and Governance

Approved by St Vincent’s Hospital Human Research Ethics Committee. HREC reference 2020/ETH01267.




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Lead Investigator:

Dr Ben Cass




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