Intraoperative Issues Dictated by Diagnosis: Cuff Deficiency: Allograft, Transfer, or Advance

A deficient rotator cuff in an arthritic shoulder is one of the most challenging problems that a surgeon faces in shoulder arthroplasty. Regardless of whether the cuff deficiency is identified preoperatively or intraoperatively, the reconstructive challenges—namely restoring static and dynamic balance to the shoulder, alleviating pain, and optimizing function—remain the same. The existing literature on the surgical treatment of this difficult problem has defined certain principles of management, but many questions remain. Patients with small rotator cuff tears can successfully undergo a total shoulder arthroplasty, provided a secure rotator cuff repair can be performed. Patients with larger irreparable tears should not undergo total shoulder arthroplasty, given a high rate of glenoid loosening. For patients with irreparable rotator cuff tears and glenohumeral arthropathy, the appropriate surgical procedure is indicated by age and functional level. Patients younger than 70 years old with preserved forward elevation >90° are best treated with humeral resurfacing arthroplasty; the role of tendon advancement in conjunction with humeral resurfacing is controversial. Patients older than 70 years old, with or without a pseudoparalytic shoulder, are best treated with reverse shoulder arthroplasty. Concomitant latissimus and teres major transfer with reverse shoulder arthroplasty may expand the indications for reverse shoulder arthroplasty in the future; however, caution must be exercised until more long-term outcome data are obtained. Given the dramatic failure of allograft augmentation in primary rotator cuff repair, there is little, if any, role for allograft augmentation in a cuff-deficient arthroplasty.