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Comparison of Partial Versus Complete Arthroscopic Repair of Massive Rotator Cuff Tears
Nicholas D. Iagulli, Larry D. Field, E. Rhett Hobgood, J. Randall Ramsey and Felix H. Savoie III
Am J Sports Med 2012 40: 1022 originally published online March 13, 2012
DOI: 10.1177/0363546512438763

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Comparison of Partial Versus
Complete Arthroscopic Repair
of Massive Rotator Cuff Tears
Nicholas D. Iagulli,*y MD, Larry D. Field,y MD, E. Rhett Hobgood,y MD,
J. Randall Ramsey,y MD, and Felix H. Savoie III,z MD
Investigation performed at Mississippi Sports Medicine
and Orthopaedic Center, Jackson, Mississippi

Background: Complete repair of massive rotator cuff tears can be limited by tendon retraction and poor tissue quality. When
a complete repair cannot be accomplished, a significant partial repair may be possible.
Hypothesis: A partial repair will yield comparable outcomes to complete repair of massive rotator cuff tears in this specific patient
population.
Study Design: Cohort study; Level of evidence, 3.
Methods: All consecutive arthroscopic rotator cuff repairs done at the authors’ institution over a 2-year period were identified. A
retrospective chart review was performed. Inclusion criteria required that each patient have a massive rotator cuff tear (30 cm2 or
greater). Patients were categorized as either partial or complete repair. The University of California, Los Angeles (UCLA) shoulder
scores were used to measure patient outcomes at an average follow-up of 24 months (10-40 months).
Results: Of 1128 consecutive arthroscopic rotator cuff repairs, 97 (9%) patients were noted intraoperatively to have massive
tears measuring 30 cm2 or greater. Complete repair was achieved in 52 patients, whereas partial repair was possible in 45 pa-
tients. Eleven patients were lost to follow-up. The 41 remaining patients with only partial repair achieved a postoperative mean
UCLA score of 29.49, and the 45 patients with complete repair achieved a mean UCLA score of 29.64, yielding significant
improvement in both the partial repair group (P = .0001) and the complete repair group (P = .0001) compared with preoperative
UCLA scores. However, no statistically significant differences in postoperative outcomes were noted when the 2 groups were
compared with one another (P = .89).
Conclusion: Partial repair of massive rotator cuff tears yielded outcomes comparable with complete repair of massive tears.
Keywords: partial repair; complete repair; massive tear; rotator cuff

Massive rotator cuff tears represent a challenging patient
group for the shoulder surgeon to treat and are the cause
of significant shoulder pain and disability.9 Codman8
described the operative treatment of full-thickness tears of
the rotator cuff in 1911. Since then, both open and arthro-
scopic techniques have improved our surgical manage-
ment.20,24 Arthroscopic techniques have advanced and
allow surgeons to repair larger rotator cuff tears that previ-
*Address correspondence to Nicholas D. Iagulli, MD, Trinity Orthope-
dics, 809 W. Harwood Rd, Suite 101, Hurst, TX 76054 (e-mail: nickiagulli
@hotmail.com).
y
Mississippi Sports Medicine and Orthopaedic Center, Jackson,
Mississippi.
z
Tulane Institute of Sports Medicine, New Orleans, Louisiana.
Presented at the 37th annual meeting of the AOSSM, San Diego,
California, July 2011.
The authors declared that they have no conflicts of interest in the
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 40, No. 5
DOI: 10.1177/0363546512438763
Ó 2012 The Author(s)
ously were repaired using an open procedure.6,9 Even so,
massive rotator cuff tears may not be amenable to complete
primary repair due to the large size of the defect, poor tissue
quality, tendon retraction, and extensive peritendinous
adhesions.7,16,22 However, the less retracted edges of the
tear near the anterior and posterior margins are usually
reparable, even when the central portion of the tear with
the greatest retraction may be irreparable.7 Multiple proce-
dures have been described to address these irreparable
defects: simple debridement,22,25 supraspinatus slide proce-
dures,14 freeze-dried allograft interpositions,19 subscapula-
ris muscle transposition,10 latissimus dorsi transfer,15 free
tendon transfers,26 interval slides,6,25 margin convergence,6
and partial repair of the rotator cuff.2,7,11,18
Burkhart4 introduced the concept of the ‘‘functional rota-
tor cuff tear,’’ a tear that is anatomically deficient yet biome-
chanically intact, resulting in a more balanced shoulder.
Patients with functional rotator cuff tears may have near-
normal function despite unrepaired defects in the rotator
cuff.7 This invariably leads to the concept and rationale of
partial rotator cuff repair as a treatment alternative for

1022
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Vol. 40, No. 5, 2012
the irreparable tear, essentially converting the tear to
a smaller but potentially more functional rotator cuff tear
that is more biomechanically sound.7 When a complete
repair cannot be accomplished, a very significant partial
repair may be possible.2,7,11,18
A limited number of studies are available reporting on
partial repair of massive rotator cuff tears, and the results
are inconsistent.2,7,11,18 Indications for surgery vary widely
among these reports. One report excluded patients with
rotator cuff tears involving the subscapularis.2 Another
study included patients with superior migration of the
humeral head.11 In addition, partial rotator cuff repair in
most of these studies7,11,18 was done using a traditional
open or a mini-open technique. The purpose of this study
is to evaluate the outcome of a consecutive series of patients
undergoing arthroscopic repair of massive rotator cuff tears.
MATERIALS AND METHODS
All consecutive arthroscopic rotator cuff repairs done by one
surgeon from January 1, 2008, to January 1, 2010, were
identified by a computer database search. All operative
notes and clinic encounters were dictated by the same sur-
geon. A retrospective chart review was performed. All
patients in our study group had rotator cuff tears preopera-
tively documented by magnetic resonance imaging (MRI).
Inclusion criteria included all patients with massive rotator
cuff tears measuring 30 cm2 or greater as noted and mea-
sured intraoperatively. Exclusion criteria included any
patient who had significant superior humeral head migra-
tion such that the acromion-humeral distance was less
than 6 mm.21 In addition, patients with glenohumeral
arthritis of grade II or higher following the Samilson-Prieto
classification23 were excluded. Revision rotator cuff repairs
were not excluded, and 4 patients in the study had each
undergone 1 previous arthroscopic rotator cuff repair by
the authors. Operative reports and intraoperative photogra-
phy of all patients were reviewed, and the repair configura-
tion was documented. Patients were then categorized into 1
of 2 groups (partial repair or complete repair).
Evaluation of Rotator Cuff Tears
All patients in the study were classified as possessing mas-
sive rotator cuff tears by satisfying all of the following 3
criteria: a diameter greater than 5 cm,9 involving 2 or
more tendons,13 and having an area of 30 cm2 or greater5
as noted intraoperatively. Rotator cuff tear size was mea-
sured arthroscopically using an Elite calibrated probe
(Smith & Nephew, Andover, Massachusetts) to obtain
maximum medial-to-lateral and anterior-to-posterior
dimension of the tear for each patient from which a rotator
cuff tear size area (cm2) was then calculated.
Clinical Assessment
University of California, Los Angeles (UCLA) shoulder
scores12 were collected in the clinic setting preoperatively
and at latest follow-up to assess patient outcome in all
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Partial vs Complete Repair Massive Tears 1023
patients. The results were graded on the UCLA Shoulder
Rating Scale and divided into excellent (34-35 points),
good (28-33 points), fair (21-27 points), and poor (0-20
points). Scores greater than or equal to 28 were classified
as satisfactory, whereas scores less than 28 were consid-
ered unsatisfactory.12,20 Average follow-up for these
patients was 24 months (10-40 months).
Operative Technique
All operative procedures were performed by 1 surgeon with
the patient in beach-chair position under general anesthe-
sia in combination with an interscalene block. Three rou-
tine arthroscopic portals (anterior, lateral, posterior)
were used to perform the arthroscopy, and accessory por-
tals were created as needed.
After glenohumeral arthroscopy and subtotal removal of
the subacromial bursa, the rotator cuff was debrided. While
viewing from the lateral portal, the surgeon assessed the
mobility of the rotator cuff of these massive rotator cuff
tears by use of an arthroscopic grasper, usually through
an accessory lateral portal. The amount of tension required
to lateralize the tendon edge to the footprint region was
noted. With lateral traction applied to the rotator cuff tis-
sue, peritendinous adhesions and rotator cuff capsular con-
tractures were routinely and thoroughly released. If
necessary, anterior or posterior rotator interval slides
were also performed. To minimize potential devasculariza-
tion of the tendon, the authors attempted to limit perform-
ing both an anterior and a posterior slide concomitantly
when possible. The arthroscopic anterior interval slide
improves mobility of the rotator cuff by releasing the inter-
val between the supraspinatus tendon and the rotator inter-
val, effectively incising the coracohumeral ligament.6,25
Arthroscopic scissors were introduced through an accessory
lateral portal with the release oriented along the anterior
border of the supraspinatus and directed toward the base
of the coracoid. The arthroscopic posterior interval slide
improves mobility of the rotator cuff by releasing the inter-
val between the infraspinatus and supraspinatus.6 When
a posterior interval slide was carried out, the scapular spine
was identified and cleared of any subacromial fibroadipose
tissue. The scapular spine served as a marker between the
supraspinatus and infraspinatus and helped orient and
direct the posterior interval release.
Once the rotator cuff tissue was mobilized to its fullest
extent, careful assessment was made as to which repair
configuration would yield the most complete repair at the
lowest tension possible. Margin convergence6 was often
used to lateralize the free margin of the rotator cuff tear
and to minimize strain at the repair site. Suture anchors
were placed to repair the rotator cuff to the bone by
single-row or double-row fixation techniques depending
on tissue quality and mobility. Attempts were made to
completely repair all massive rotator cuff tears. However,
if reapproximation of the tendon to bone could not be
accomplished even after extensive rotator cuff mobilization
without undue tension on the mobilized tendon, repair of
only the adequately mobilized tissue was carried out.
Whether a partial or complete repair became possible after
1024 Iagulli et al
rotator cuff mobilization, rotator cuff mobilization
attempts usually started with an extensive capsular
release along with release of any peritendinous adhesions.
If additional rotator cuff mobilization was still thought to
be necessary, an anterior or posterior interval slide was
accomplished. Occasionally, both an anterior and posterior
interval slide was carried out in an effort to maximize lat-
eral rotator cuff mobility and thus reduce tension on the
reattached tissue.
Concomitant procedures were performed when neces-
sary. These included acromioplasty, distal clavicle exci-
sion, biceps tenodesis, glenohumeral capsular release,
and labral repair. No tendon transfers were carried out
and no supplemental tendon augmentation grafts were
used on any of these patients.
Postoperative Rehabilitation
All patients in this study had the surgical procedure per-
formed on an outpatient basis. Patients were immobilized
in a sling postoperatively. Physical therapy consisting of
passive mobilization and pain-free assisted active exercises
were initiated from 1 to 4 weeks postoperatively depending
on individual tears and repairs, at the discretion of the
operating surgeon. At 6 to 8 weeks, gentle active exercises
were usually initiated. Organized physical therapy contin-
ued for an average of 4.9 months in the partial repair group
and an average of 4.3 months in the complete repair group.
Statistical Analysis
Parametric paired t tests were used to compare preopera-
tive and postoperative outcome measures within each
group. An unpaired t test was used when comparing out-
come measures between the 2 groups. The data were tested
for normality using the Kolmogorov-Smirnov test. A signif-
icance level less than .05 was considered statistically sig-
nificant. GraphPad Prism Software Version 5 (GraphPad
Software, La Jolla, California) was used to calculate the
mean, standard deviation, and level of significance for all
outcome measures evaluated.
RESULTS
Patients
A total of 1128 patients underwent arthroscopic rotator
cuff repair by 1 surgeon during the period of the study.
Of those consecutive cases, 97 (9%) patients were noted
intraoperatively to have massive rotator cuff tears measur-
ing 30 cm2 or greater. In these patients with massive cuff
tears, complete repair was achieved in 52 patients, and
partial repair was possible in 45 patients. No patients dur-
ing the study period had debridement alone. Four patients
from the partial repair group and 7 patients from the com-
plete repair group were lost to follow-up, leaving 86 of 97
patients (88.7%) for evaluation. The mean 6 SD age was
64.5 6 9.5 years (range, 44-83 years) for the partial repair
group and 63.4 6 12.2 years (range, 37-82 years) for the
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The American Journal of Sports Medicine
complete repair group. No significant difference between
the 2 groups with respect to age was found (P = .6542).
Clinical Assessment
The 41 patients with partial repairs had a preoperative
mean 6 SD UCLA score of 12.10 6 3.05 (range, 7-18).
The 45 patients with a complete repair had a preoperative
mean 6 SD UCLA score of 11.22 6 2.89 (range, 5-18). No
significant difference in the preoperative UCLA scores
between the partial versus complete repair groups was
noted (P = .1754). The 41 patients with a partial repair
achieved a postoperative mean 6 SD UCLA score of
29.49 6 5.90 (range, 10-35). The 45 patients with a com-
plete repair achieved a postoperative mean 6 SD UCLA
score of 29.64 6 4.92 (range, 14-35). There was no signifi-
cant difference in the postoperative UCLA shoulder scores
between the partial versus complete repair groups (P =
.8937). In patients who underwent a partial repair, there
was a significant improvement in postoperative UCLA
scores (P = .0001). Also, among the patients who under-
went complete repair, significant improvement was noted
in postoperative UCLA scores (P = .0001) as well. In the
partial repair group, there were 12 excellent results, 19
good results, 7 fair results, and 3 poor results. Thirty-one
of 41 patients (75.6%) attained satisfactory results, and
10 patients (24.4%) had unsatisfactory results. In the com-
plete repair group, there were 14 excellent results, 18 good
results, 11 fair results, and 2 poor results. Therefore, the
complete repair group had 32 of 45 patients (71.1%) with
satisfactory results and 13 patients (28.9%) with unsatis-
factory results.
Evaluation of Rotator Cuff Tears
For the partial repair group, the average intraoperatively
measured medial-to-lateral width of the rotator cuff tear
was 6.07 6 0.26 cm, and the average anterior-to-posterior
length was 6.54 6 0.64 cm, creating an average tear size of
39.73 6 4.57 cm2. For the complete repair group, the aver-
age intraoperatively measured medial-to-lateral width of
the tears was 5.96 6 0.21 cm, the average anterior-to-
posterior length was 5.91 6 0.70 cm, and the average
tear size was 35.20 6 4.36 cm2. The rotator cuff tear size
of the partial repair group was noted to be significantly
larger than that of the complete repair group (P = .0001).
In the partial repair group, the residual rotator cuff defect
was measured and recorded in all patients as well. The
average medial-to-lateral residual defect width was
2.34 6 1.49 cm, and the average anterior-to-posterior
length was 2.39 6 0.92 cm, creating an average residual
defect area of 5.68 6 4.59 cm2.
The individual tendons involved in these massive rota-
tor cuff tears were also noted. In the partial repair group,
the supraspinatus was completely detached in all 41
patients, whereas the infraspinatus was at least partially
detached in 40 patients. The subscapularis was at least
partially detached in 11 patients, whereas the teres minor
was torn in 4 patients. After partial repair was accom-
plished, the tendons that were unable to be completely
Vol. 40, No. 5, 2012
repaired were noted. The supraspinatus was unable to be
completely repaired 83% of the time (34 patients), whereas
the infraspinatus was unable to be completely repaired
28% of the time (11 patients). There were only 4 patients
in whom the supraspinatus was completely repairable
but the infraspinatus was not. Complete repair could not
be achieved for the subscapularis in 4 patients and for
the teres minor in 1 patient. In the complete repair group,
the supraspinatus was completely detached in all 45
patients, whereas the infraspinatus was at least partially
torn in 44 patients. The subscapularis was at least par-
tially detached in 14 patients, whereas the teres minor
was torn in 1 patient. Complete repair was achieved on
all tendons in this group of patients.
Concomitant procedures performed in the partial repair
group included acromioplasty in 33 patients, distal clavicle
excision in 32 patients, biceps tenodesis in 22 patients, cir-
cumferential capsular release in 8 patients, microfracture
of the glenoid in 2 patients, and labral repair in 1 patient.
In the complete repair group, acromioplasty was performed
in 44 patients, distal clavicle excision in 43 patients, biceps
tenodesis in 32 patients, circumferential capsular release
in 4 patients, microfracture of the glenoid in 3 patients,
and labral repair in 1 patient.
Complications and Reoperations
In the partial repair group, 3 patients underwent subse-
quent revision partial rotator cuff repair. In these 3
patients, a significant functional deterioration with a sig-
nificant increase in pain was noted at approximately 4 to
6 months postoperatively and was thought by the authors
to be most likely due to a significant re-tear of the partial
repair. After revision partial repair, these patients had
UCLA shoulder scores of 34, 32, and 24 at follow-up, repre-
senting 1 excellent, 1 good, and 1 fair outcome. In the com-
plete repair group, 1 patient sustained a significant re-tear
in the early postoperative period (2 months) after a trau-
matic injury and underwent revision complete rotator
cuff repair. At latest follow-up, this patient had a UCLA
shoulder score of 26, signifying a fair outcome.
DISCUSSION
Massive rotator cuff tears represent a challenging patient
group for the shoulder surgeon. Arthroscopic techniques
continue to advance, and with an understanding of
advanced techniques, the great majority of rotator cuff
tears can be completely repaired.16 Even when grade 3
and 4 fatty degeneration of the rotator cuff is noted on
MRI, repair can provide significant functional improve-
ments in certain patients.5 These massive tears, however,
can be retracted and have poor tissue quality. Although
extensive soft tissue and capsular releases can help mobi-
lize even a retracted rotator cuff, there are occasions
when the lateral tendon edge is unable to be completely
reapproximated to even the medial rotator cuff footprint.
Short-term and mid-term results of simple arthroscopic
cuff debridement for massive rotator cuff tears have shown
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Partial vs Complete Repair Massive Tears 1025
promising results.12,16 However, several long-term studies
have demonstrated that these initial results deteriorate
significantly with time.1,12,15-17 In the present study,
patients indicated for surgery with massive rotator cuff
tears all underwent at least partial repair. In this series
of 97 massive tears, complete repair was achieved in 54%
and partial repair was accomplished in 46%. No rotator
cuff tear was found to be completely irreparable, and no
tears were treated with debridement alone.
Proper surgical indications play a major role in the suc-
cess of surgical repairs for massive rotator cuff tears. A
thorough history must be obtained to determine important
information such as the length of time the patient has had
shoulder dysfunction, any recent decline in shoulder func-
tion, and the specific circumstances surrounding those
changes in function. A patient with a presumed longstand-
ing rotator cuff tear may present for treatment only after
developing a relatively recent and significant decline in
function and/or increase in symptoms. In this setting,
such a patient may have sustained an acute extension of
an otherwise chronic tear, resulting in increased shoulder
dysfunction and pain, and may have significant functional
improvement even if only the acute extension of the tear
can be repaired. If, however, such a patient has radio-
graphic evidence of superior humeral head migration
with an acromion-humeral distance of less than 6 mm,
rotator cuff repair may be less likely to be successful as
a treatment option.21
Recognizing rotator cuff tear patterns is critical to the
appropriate mobilization and reapproximation of massive
rotator cuff tears. Attempting to laterally mobilize and
repair the apex of a retracted tear to a lateral bone bed
will often result in high tensile stresses in the repaired tis-
sue, causing tensile overload and subsequent failure.6
Techniques such as margin convergence not only allow
repair of some very large tears but also minimize strain
at the repair site, thereby providing an added degree of
protection for the tendon-to-bone component of the repair.6
An incorrectly reapproximated and/or inadequately mobi-
lized rotator cuff tear may have such large stresses at
the tear margin that achieving and/or maintaining a secure
repair cannot be accomplished.6 Adhering to these princi-
ples is important in an effort to maintain a low tension par-
tial or complete repair, and the authors made a concerted
effort to do so.
Patients in this study had massive tears that extended
anteriorly or posteriorly to such an extent that the trans-
verse plane force couple was no longer balanced. Similar
to the study by Burkhart et al,7 the authors’ goal was to
convert these dysfunctional rotator cuff tears into more
functional tears by attempting to restore the force couples,
even if complete repair was not possible.
The concept of partial repair using tissue releases and
margin convergence has been well defined.3,6,7 The partial
repair serves to help restore the shoulder’s essential force
couples. Thus, the ‘‘suspension bridge’’ system of force
transmission in the shoulder is potentially reestab-
lished.6,7 The rebalanced force couples of the remaining
anterior and posterior components of the rotator cuff can
improve stability and function.
1026 Iagulli et al
Porcellini et al21 found that partial repair of the infraspi-
natus in patients with irreparable rotator cuff tears of the
supraspinatus gives good results in terms of patient satis-
faction and in restoring the acromion-humeral distance
even at long-term follow-up. Berth et al2 recently evaluated
functional outcomes after debridement versus partial repair
of massive rotator cuff tears. This study determined that
patients treated with partial rotator cuff repair had greater
improvements in shoulder function compared with patients
treated with arthroscopic debridement alone. These find-
ings are consistent with a study done by Duralde and
Bair,11 which also concluded that the results of partial
repair were superior to those of debridement alone. Bur-
khart3 also found that partial repair of large and massive
rotator cuff tears leads to significant pain relief and
improvement of shoulder function. Moser et al18 compared
a series of massive rotator cuff tears treated with complete
repair, partial repair, or debridement. A significant differ-
ence in their study was improvement in active external
rotation among the complete repair group.
The present study demonstrates statistically significant
improvements in postoperative outcomes after both partial
repair and complete repair of massive rotator cuff tears.
Both partial and complete repair of these massive rotator
cuff tears measuring 30 cm2 or greater resulted in signifi-
cant improvement in the postoperative UCLA scores. Bur-
khart et al5 also found complete repair resulted in clinical
improvement in 86.4% of massive rotator cuff tears that
were classified as Goutallier stage 3 and 4 fatty degenera-
tion. In our study, there were no significant differences
found among the parameters assessed between the com-
plete and partial repair groups except for the finding that
the group undergoing partial repair had a larger average
preoperative tear size. The authors believe that the results
of the present study emphasize the potential value of par-
tial repair in selected patients with massive tears.
Strengths of this study include the fact that it repre-
sents a consecutive series of arthroscopic rotator cuff
repairs done by a single surgeon and employed a consistent
arthroscopic repair technique. Weaknesses of the study
include the retrospective design and relatively short-term
follow-up.
In summary, there are instances when a complete
repair of the rotator cuff insertion is not possible due to sig-
nificant retraction and poor tissue quality. In such cases,
partial repair of the rotator cuff in appropriately selected
patients appears to yield results comparable to complete
repair in short-term follow-up.
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