Editorial Commentary: Dermal Grafts for Irreparable Rotator Cuff Tears-"Bridge Over Troubled Waters".

The treatment of an irreparable rotator cuff tear is an enigma. There are so many treatment options, with different experts recommending different treatments. These include physical therapy, partial repairs, tendon transfers such as the latissimus dorsi and the lower trapezius, biceps tenotomy, tissue augmentation with allografts or autografts, balloon spacers, and finally a reverse prosthesis. It is an easy decision when the patient is physiologically old with many medical comorbidities and arthritis. It is much more difficult when the patient is younger with no arthritis. Many patients with a failed massive cuff repair do well with a supervised therapy program despite the absence of 2 tendons (the supraspinatus and infraspinatus). Nothing works well when the subscapularis and/or teres minor are irreparable. I will usually try a 3-month physical therapy program, and if this is not successful in improving pain and function, consider surgery. If I can do an adequate partial repair, where the residual defect is small enough that the humeral head does not button hole through the defect like a boutonniere deformity, that is my treatment of choice. I will only do grafts with Hamada stage 1 or 2, as stage 3 with a fixed humeral head against the acromion do not do well. I am intrigued by the balloon spacer and why the results are still adequate, even when there is no balloon present after about 1 year. I'm holding judgment on that until there are more published studies. A reverse prosthesis I use as a last resort.