Managing Massive Irreparable Rotator Cuff Tears

The Problem

Management of massive rotator cuff tears is a technically challenging problem in orthopedic surgery. Poor tissue quality, tendon retraction, muscular atrophy, and scarring all contribute to poor healing and a high rate of recurrence after massive rotator cuff tear repair. Irreparable massive rotator cuff tears, or those that are retracted with degenerated and non-functional muscle bellies not amenable to repair, can be treated with several surgical procedures. Treatment should be guided by patient-specific and injury-specific factors.

Clinical Presentation

Rotator cuff tears can be the result of an acute injury or chronic degeneration. Acute rotator cuff tears usually occur after a fall on an outstretched arm or attempting to lift a heavy object with a jerking motion. Degenerative tears occur naturally over time with age, but can be affected by several different factors. Repetitive motion, particularly overhead activities, or lifting can stress and weaken the rotator cuff tendons. Impingement syndrome, where the rotator cuff tendons rub on the underside of the acromion, is a condition where rotator cuff tendons are weakened from mechanical abrasion.

Symptomatic massive rotator cuff tears usually present with pain. Pain is often worse at night and exacerbated by lying on the affected side. Pain is usually worsened by activity, though does occur at rest, and patients may report weakness. Acute traumatic tears can be associated with a notable popping sensation, immediate weakness, and severe pain. Chronic degenerative tears also present with pain and weakness, but the onset is more insidious and may progress from only being associated with certain activities to being pervasively debilitating.

Diagnostic Workup

Physical Exam

In chronic injuries, there may be visible atrophy of the supraspinatus and infraspinatus on physical exam. Patients may have weakness and decreased range of active motion.

In posterosuperior cuff tears involving the supraspinatus and infraspinatus, there is usually loss of active forward elevation, abduction, and external rotation of the shoulder. Patients with a posterosuperior tear pattern demonstrate weakness of external rotation and can have a positive external rotation lag sign (inability to hold the arm externally rotated at the side when it is placed there by the examiner).

In larger tear patterns that include the teres minor, patients will also have loss of external rotation strength in abduction and may demonstrate a positive Hornblower’s test (inability to hold the arm in external rotation with the shoulder in 90 degrees of abduction and 90 degrees of external rotation).

In anterosuperior cuff tears involving the supraspinatus and subscapularis, there is usually loss of forward elevation and abduction of the shoulder. In rotator cuff tears involving the subscapularis, physical exam may be notable for a positive belly-press or lift-off test, as well as increased passive external rotation.

Imaging

Radiographs in patients with small or medium rotator cuff tears may be relatively normal, but massive rotator cuff tears can show a decreased acromiohumeral interval (<7 mm is pathognomonic for rotator cuff tear) on anteroposterior (AP) views of the shoulder. There will also be loss of the normal “gothic arch” contour of the humerus and the inferior glenoid. (Figure 1)

Figure 1.

Ultrasound examination of the rotator cuff can also be useful. Sensitivity and specificity of ultrasound is affected by operator skill, but can be used as a dynamic examination during provocative maneuvers. It can also be useful in patients with prostheses or other metallic implants as these patients may have significant artifact on magnetic resonance imaging (MRI) or computed tomography (CT). Ultrasound does not easily demonstrate complex tear patterns, concomitant intra-articular pathology, or muscular atrophy.

Computed tomography is frequently used in patients with rotator cuff tear arthropathy (massive rotator cuff tears associated with glenohumeral arthritis). It can be used to evaluate glenoid bone stock during pre-operative planning for reverse total shoulder arthroplasty.

Magnetic resonance imaging is very useful in evaluating rotator cuff pathology. It provides a detailed view of the tear pattern of the rotator cuff, including tendon retraction and muscular atrophy. The Goutallier classification of muscle atrophy and fatty infiltration in rotator cuff tears can be used to estimate the chronicity of injury and prognosticate whether a tear is irreparable. (Although the Goutallier classification was originally described relative to CT-arthrography most have adapted it to MRI given the increased familiarity and elimination of radiation.) (Figure 2)

Figure 2.

Non–Operative Management

Non-operative management of irreparable massive rotator cuff tears can be successful, particularly in elderly patients with low physical demands. Non-operative management usually consists of pain control with anti-inflammatories or steroid injections, rest or activity modification, and physical therapy.

Patients with “well-balanced” massive rotator cuff tears may still have good active motion and be able to perform their activities of daily living. This is usually achieved through balanced force coupling across the glenohumeral joint (intact subscapularis and teres minor) and recruitment of the deltoid muscle. Rehabilitation programs that focus on strengthening the anterior deltoid to substitute for the deficient rotator cuff have shown good success.

Other areas of focus for rehabilitation of massive rotator cuff tears include posture correction to optimize glenoid position and proprioceptive training. Favorable outcomes of non-operative management of massive rotator cuff tears are more successful in patients who have had symptoms for 6 months or less. While non-operative management may improve symptoms, disease progression of muscular atrophy, including fatty degeneration and muscular retraction, and glenohumeral arthritis will still likely occur.

Indications for Surgery

Surgical treatment of massive irreparable rotator cuff tears is indicated in patients with pain and weakness.

Arthroscopic debridement and subacromial decompression can have good short-term outcomes in patients with massive rotator cuff repairs. This procedure is indicated for elderly patients with low functional demand who have pain but preserved active range of motion. Pre-operative relief of pain with a steroid injection is a good prognostic predictor of success of debridement. Biceps tenotomy may also be indicated as a limited goals procedure to decrease pain in elderly and low-demand patients and can be combined with debridement and subacromial decompression.

Tendon transfers can be used to treat massive irreparable rotator cuff tears in patients with weakness, pain, and impaired motion. Ideal patients for tendon transfers are young patients (<60 years old), including manual laborers, who have weakness and loss of external rotation without glenohumeral arthritis. Patients must also be willing and able to participate in a rigorous rehabilitation program.

Latissimus dorsi transfer is used to reconstruct a massive posterosuperior rotator cuff tear. It requires an intact subscapularis and deltoid to create balanced force couples across the glenohumeral joint. Factors associated with improved prognosis for latissimus dorsi tendon transfer include age <60 years old, male gender, ability to forward elevate above chest level, intact subscapularis and deltoid function, and no previous shoulder surgery. Pectoralis major transfer is used to treat massive irreparable subscapularis tears without anterosuperior escape.

Arthroplasty is typically indicated in patients with massive irreparable rotator cuff tears and glenohumeral arthritis, or cuff tear arthropathy, though indications are expanding to include patients with massive irreparable rotator cuff tears without arthritis.

Hemiarthroplasty can be used in patients with symptomatic cuff tear arthropathy and modest functional goals. Outcomes are best if the subscapularis is intact and balanced force couples are maintained and in patients who have pre-operative forward elevation of 90 degrees or more. Fixed anterosuperior escape is a contraindication to hemiarthroplasty.

Reverse total shoulder arthroplasty is indicated in patients with severe rotator cuff tear arthropathy and loss of motion or pseudoparalysis. Most reverse total shoulder replacements medialize the center of rotation and re-tension the deltoid, thus allowing increased deltoid recruitment and efficiency.

Surgical Technique

Arthroscopic Debridement, Subacromial Decompression, Biceps Tenotomy, Partial Repair

Arthroscopic debridement, subacromial decompression, and biceps tenotomy are typically performed with the patient in the beach chair position. Placing the operative arm in an arm holder facilitates positioning during the procedure. Standard arthroscopic instrumentation and portals are used.

Debridement of the torn rotator cuff tendons, intra-articular synovitis, and subacromial space are performed with a shaver or cautery. A thorough debridement to address all possible sources of pain should be performed. During debridement and subacromial decompression in patients with massive rotator cuff tears, it is important to leave the coracoacromial ligament intact. The coracoacromial ligament is a static stabilizer to anterosuperior escape of the humeral head. In order to obtain further subacromial decompression without detaching the coracoacromial ligament, a tuberoplasty can be performed to smooth the greater tuberosity and create a smooth articulation with the acromion.

A biceps tenotomy can be performed by sharply dividing the biceps tendon at its proximal insertion at the supraglenoid tubercle with or without resection of the entire intra-articular portion to facilitate retraction of the tendon into the bicipital groove. Biceps tenodesis may be performed as an alternative to simple biceps tenotomy to improve cosmesis and supination strength. The cut tendon can be fixed into the bicipital groove with a variety of methods, including suture fixation or interference screws. A partial repair of the torn rotator cuff tendons can also be performed to attempt to convert a massive tear to a somewhat “functional” cuff tear where the coronal and axial forces of the glenohumeral joint are better balanced. Mobility of retracted rotator cuff tendons can be achieved with anterior or posterior interval slides.

Tendon Transfers

Latissimus dorsi transfer

To perform latissimus dorsi transfer, patients are placed in the lateral decubitus position. A bean-bag is used to secure the patient. An arm holder is used to allow for dynamic positioning throughout the procedure. Latissimus dorsi tendon transfer for massive irreparable rotator cuff tear is performed through a single-incision or two-incision technique, though most surgeons prefer a two-incision technique with one incision for release of the latissimus dorsi and another for preparation of the rotator cuff.

The approach to the rotator cuff is performed through an incision at the lateral edge of the acromion parallel to the lateral border. The anterior deltoid should be sub-periosteally removed from the acromion from the acromioclavicular joint to the junction between the anterior and posterior halves of the acromion. The deltoid should be split at the posterolateral acromion and a bursectomy performed.

The rotator cuff is debrided. Acromioplasty should not be performed in these patients. A biceps tenotomy or tenodesis is performed if indicated. The rotator cuff tendon should be mobilized and an attempt to reduce it to the footprint should be performed; unsuccessful reduction and inability to perform a repair of the tendon back to the anatomic footprint is an indication to proceed with tendon transfer.

An incision is made along the posterolateral border of the latissimus dorsi that extends proximally to the posterior axillary fold. The inferior or lateral border of the tendon is identified and blunt dissection is used to define the tendon. Sharp dissection between the latissimus dorsi and teres major tendons may be required. The latissimus dorsi tendon is sharply detached from its attachment to bone.

In some cases both the latissimus dorsi (long and narrow) and the teres major (short and broad) are taken off their humeral attachment in preparation for transfer (Figure 3). It should be prepared with a Krakow stitch along the superior and inferior borders. The tendon is brought over the top of the humeral head and repaired to the supraspinatus footprint. Performing the repair with the arm at 45 degrees of abduction and 30 degrees external rotation allows for further tensioning of the tendon transfer as the arm is brought to the side and internally rotated. A number of techniques have been described for repair including the use of suture anchors, transosseous tunnels, or an osteotomy. The torn edges of the rotator cuff tendon should also be sutured to the medial edge of the transferred latissimus dorsi tendon.

Figure 3.

Pectoralis major transfer

Pectoralis major transfers for massive irreparable rotator cuff tear are performed through a deltopectoral approach. The patient can be positioned in the beach chair position with an arm holder. The native subscapularis tendon should be debrided, mobilized, and an attempt at even partial repair should be performed prior to tendon transfer. Early techniques of tendon transfer include passing the entire pectoralis major tendon underneath the conjoined tendon (a subcoracoid technique), however there are many modified techniques described meant to decrease risk of injury to the musculocutaneous nerve.

One such modification is transfer of the inferior sternal portion of the pectoralis major beneath the clavicular head and superior to the conjoined tendon. Another example is to dissect the musculocutaneous nerve from the overlying conjoined tendon and passing the pectoralis tendon beneath the conjoined tendon while staying superficial to the musculocutaneous nerve. The tendon can be affixed to the humerus with several techniques including suture anchors or transosseous tunnels.

Arthroplasty

Shoulder arthroplasty is reliably performed through a standard deltopectoral approach in the beach chair position with the use of an arm holder.

Hemiarthroplasty

Exposure with a 360-degree subscapularis release should be performed. The humeral canal should be progressively reamed until endocortical bite is achieved. The humeral head should be resected in 30 degrees of retroversion. The humeral head can be morselized for autograft. If a partial rotator cuff repair can be performed, it should be done prior to sizing the component as repair can decrease the available volume of space for the prosthesis. The appropriate component size allows for 40 degrees of external rotation with the subscapularis approximated, 50% posterior translation on posterior drawer, and 60 degrees of internal rotation with the arm abducted to 90 degrees.

For patients with cuff tear arthropathy, a cuff tear arthropathy (CTA) specific head can be used to provide a smooth lateral articulation of the shoulder (although there is still lack of evidence to support this prosthesis).

After the final prosthesis is in place, the subscapularis should be sutured to the anterior humeral neck and the wound closed with a post-operative drain in place to decrease risk of hematoma formation.

Reverse total shoulder arthroplasty

The subscapularis tendon should be directly incised from the lesser tuberosity to preserve tendon length and, again, a full 360-degree subscapularis release should be performed. The humeral head should be resected using an intramedullary resection guide in 10-20 degrees of retroversion. The joint capsule should be resected from the anterior glenoid and down along the inferior pole. The labrum should be resected. The glenoid should be marked and a guidewire placed just posterior and inferior to bisecting vertical and horizontal lines. The glenoid should be reamed after verification of the central point with the baseplate. The baseplate is then impacted and secured with locking screws (some implants have locking and non-locking screws).

Trial the glenosphere and humeral components and check for impingement of the polyethylene component against the glenoid, minimal distraction, as well as stability and range of motion. Place the final components, repair the subscapularis (controversial – some surgeons prefer closure while others do not), and close the wound over a post-operative drain (Figure 4).

Figure 4.

Pearls and Pitfalls of Technique

Pearls

• Careful selection of procedure based on patient demographics, patient expectations, and injury pattern can help optimize success in treating massive irreparable rotator cuff tears.

• Always consider indolent infection in revision shoulder surgery or arthroplasty and hold cultures for up to 28 days to allow for growth of Propionibacterium acnes.

• Massive irreparable rotator cuff tears can often be partially repaired as an augment in other surgical procedures including tendon transfers or arthroplasty.

Pitfalls

• Reverse total shoulder arthroplasty should not routinely be used in the treatment of massive irreparable rotator cuff tear in young patients with high functional demands, especially those with greater than 90 degrees of forward elevation pre-operatively.

• Resection of the coracoacromial ligament can destabilize a functional shoulder with a massive rotator cuff tear and lead to anterosuperior escape and to decreased forward elevation.

• Even the most favorable patient undergoing tendon transfer is unlikely to experience normal function or full pain relief and should be appropriately counseled pre-operatively.

Potential Complications

Arthroscopic Debridement, Subacromial Decompression, Biceps Tenotomy, Partial Repair

Subacromial decompression with aggressive resection of the coracoacromial ligament can remove a buttress against superior migration and can actually decrease a patient’s functional status and ability to forward elevate the shoulder. Partial rotator cuff repair of massive rotator cuff tears using a posterior interval slide can pose a risk to the suprascapular nerve with aggressive lateral mobilization.

Tendon Transfers

Latissimus dorsi transfer

The radial nerve passes near the superior border of the latissimus dorsi and the arm should be placed in external rotation and abduction to increase the distance between the tendon and nerve in order to decrease risk of injury. The axillary nerve also runs superior to the latissimus dorsi tendon and is also best protected with external rotation and abduction. Other complications of latissimus dorsi transfer include deltoid detachment, rupture of the tendon transfer attachment, and decreased active forward elevation.

Pectoralis major transfer

Damage to the musculocutaneous nerve by passing the pectoralis major tendon under the conjoined tendon is one potential complication; surgeons have developed modified techniques as described above in an attempt to decrease risk of injury to the musculocutaneous nerve. Transfer of the pectoralis major tendon can create significant dead space and placement of a post-operative drain can decrease risk of post-operative hematoma.

Other complications of pectoralis major transfer include pectoral nerve injury, rupture of the tendon transfer attachment, and impingement with the coracoid either deep or superficial to the conjoint tendon.

Arthroplasty

Deep infections of any joint prosthesis is a dreaded complication that will require implant removal, irrigation and debridement, and likely use of an antibiotic impregnated cement spacer. After long-term treatment with intravenous antibiotics, revision arthroplasty may be attempted. Other complications include peri-prosthetic fracture, component loosening, impingement or scapular notching, or dislocation.

Hemiarthroplasty should not be performed in patients who have pre-operative pseudoparalysis as this procedure will fail to restore active functional forward elevation.

The rate of complications after reverse total shoulder arthroplasty has been reported anywhere from 19% to 50% and patients should be counseled on potential complications as the risk of revision surgery for many of them is considerable. Patients undergoing shoulder arthroplasty are also at risk for development of deep venous thrombosis and should be placed on appropriate prophylaxis post-operatively.

Post–operative Rehabilitation

Arthroscopic Debridement, Subacromial Decompression, Biceps Tenotomy, Partial Repair

Post-operative management of patients undergoing an arthroscopic debridement of massive irreparable rotator cuff tears typically involves sling immobilization for about 4 weeks post-operatively. If no repair of the tear was attempted, they may resume full range of motion of forward elevation and internal rotation immediately post-operatively. After 4 weeks, full unrestricted range of motion in all planes may be started. Strengthening exercises should begin at approximately 6 to 8 weeks post-operatively.

If a partial repair was performed, patients should be limited from active external rotation and overhead stretching immediately post-operatively in order to protect the repair for approximately 4-6 weeks post-operatively. Strengthening exercises and scapular stabilization exercises should again be delayed until approximately 6-8 weeks post-operatively.

Tendon Transfers

Latissimus dorsi transfer

There is a wide variation of post-operative protocols for patients undergoing latissimus dorsi transfer for massive posterosuperior irreparable rotator cuff tears in the literature. Most protocols include 4-6 weeks of sling immobilization fixed in slight abduction and near full external rotation. Gentle passive abduction and external rotation can be started immediately post-operatively to prevent stiffness, but patients should be restricted from internal rotation and adduction for approximately 6 weeks.

At 6 weeks post-operatively, patients may remove the sling and begin active range of motion to retrain the latissimus dorsi to act as an external rotator and abductor. Strengthening and proprioceptive training should be started approximately 12-16 weeks post-operatively. Patients may expect improvement in function up to one year post-operatively, but should be counseled that they will be unlikely to experience full restoration of normal function or complete pain relief.

Pectoralis major transfer

Post-operative protocols also vary widely for pectoralis major transfer of massive irreparable anterior tear. Again, patients are usually restricted with rigid sling immobilization for 4-6 weeks post-operatively to protect the tendon transfer during healing, though limited passive range of motion is initiated immediately post-operatively to decrease stiffness.

Many surgeons follow a similar post-operative protocol for pectoralis major transfer that is prescribed for massive rotator cuff repair. Passive range of motion of internal rotation and forward elevation is usually started 4-6 weeks post-operatively. Patients typically progress to active range of motion around 6 weeks post-operatively. Patients may expect improvement in function up to 1 year post-operatively. Less focus is needed on proprioceptive or biofeedback training as the function of the pectoralis major is similar to the subscapularis.

Arthroplasty

Hemiarthroplasty

Post-operative protocols for hemiarthroplasty typically include early active assisted motion immediately post-operatively. Patients should forward elevate to 140 degrees immediately. For approximately 6 weeks post-operatively, terminal external rotation is limited to avoid stress to the subscapularis repair. Strengthening exercises are started after approximately 6 weeks.

Reverse total shoulder arthroplasty

Post-operative protocols after reverse total shoulder arthroplasty typically begin with a period of sling immobilization for approximately 4 weeks with only pendulum activities and elbow, wrist, and hand motion allowed. After 4 weeks, sling immobilization can be relaxed to use only outside of the home and patients may begin supine active range of motion exercises.

At approximately 6 weeks post-operatively, the patient may discontinue use of the sling entirely and begin gentle strengthening exercises. After about 6 months, patients are generally encouraged to perform all routine activities but permanent weight-lifting restrictions (no more than 10 lbs in forward elevation) are recommended.

Outcomes/Evidence in the Literature

Ainsworth, R. “Physiotherapy rehabilitation in patients with massive, irreparable rotator cuff tears”. Musculoskeletal Care. vol. 4. 2006. pp. 140-151. (A physical therapy program for massive irreparable rotator cuff tears that focuses on re-education of muscle recruitment, particularly the anterior deltoid, can have good outcomes in patients including improved pain and function.)

Boileau, P, Baque, F, Valerio, L, Ahrens, P, Chuinard, C, Trojani, C. “Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears”. J Bone Joint Surg Am. vol. 89. 2007. pp. 747-57. (Biceps tenotomy or tenodesis can be used to effectively decrease pain or dysfunction in patients with an irreparable rotator cuff tear with associated biceps tendon pathology. Isolated biceps tenotomy or tenodesis should not be used in patients with pseudoparalysis or severe cuff tear arthropathy, but can be used as an adjunct in treatment.)

Boileau, P, Watkinson, D. “Neer Award 2005. The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty”. J Shoulder Elbow Surg. vol. 15. 2006. pp. 527-540. (Primary reverse total shoulder arthroplasty has good results and low complication rates in patients with cuff tear arthropathy. Results of reverse total shoulder arthroplasty are better for cuff tear arthropathy than revision surgery.)

Burkhart, SS, Nottage, WM, Ogilvie-Harris, DJ, Kohn, HS., Pachelli, A. “Partial repair of irreparable rotator cuff tears”. Arthroscopy. vol. 10. 1994. pp. 363-370. (Partial repair of irreparable rotator cuff tears converts the injury to a “functional” cuff tear while maintaining near normal kinematics of the shoulder that are not possible with other procedures such as tendon transfer. Partial repair was found to increase strength, range of motion, and subjective patient outcome in this study.)

Franceschi, F, Papalia, R, Vasta, S, Leonardi, F, Maffulli, N, Denaro, V. “Surgical management of irreparable rotator cuff tears”. Knee Surg Sports Traumatol Arthrosc. 2012. (Arthroscopic debridement and arthroscopic partial rotator cuff tear for irreparable rotator cuff tears are both effective techniques in reducing pain, but partial repair was associated with higher functional outcomes in this prospective case control study. Patient daily activities should be considered when choosing a surgical technique.)

Gerber, C. “Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff”. Clin Orthop Relat Res. vol. 275. 1992. pp. 152-60. (Irreparable massive rotator cuff tears can be successfully treated with latissimus dorsi transfer. Pain relief is good both at rest and with exertion. However, latissimus dorsi transfer is only successful with an intact subscapularis tendon.)

Hamada, K, Fukuda, H, Mikasa, M, Kobayashi, Y. “Roentgenographic findings in massive rotator cuff tears: A long-term observation”. Clin Orthop Relat Res. vol. 254. 1990. pp. 92-6. (Progression of rotator cuff tear arthropathy is classified with the radiographic findings described by Hamada. The corresponding mechanism of pathogenesis includes arm elevation in daily activities, rupture of the long head of the biceps, abnormal fulcrum of the humeral head against the acromion and coracoacromial ligament, and weakness of external rotation.)

Lo, IK, Burkhart, SS. “Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: Technique and preliminary results”. Arthroscopy. vol. 20. 2004. pp. 22-33. (Interval slides can be used to help mobilize contracted rotator cuff tears. This technique can help convert irreparable tears to a reparable tear or at least allow for partial repair in conjunction with other surgical procedures.)

Mulieri, P, Dunning, P, Klein, S, Pupello, D, Frankle, M. “Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis”. J Bone Joint Surg Am. vol. 92. 2010. pp. 2544-56. (Reverse total shoulder arthroplasty can be a successful treatment option for patients who have failed non-operative management of massive irreparable rotator cuff tear without glenohumeral arthritis if other non-arthroplasty surgical options have failed or have low likelihood of success.)

Zingg, PO, Jost, B, Sukthankar, A, Buhler, M, Pfirmmann, CWA, Gerber, C. “Clinical and structural outcomes of nonoperative management of massive rotator cuff tears”. J Bone Join Surg Am. vol. 89. 2007. pp. 1928-34. (Non-operative treatment of symptomatic rotator cuff tear can successfully decrease pain and preserve function, but disease progression and degenerative changes of the rotator cuff and glenohumeral joint can progress. There is a risk of converting a reparable cuff tear to an irreparable cuff tear with continued non-operative treatment.)

Summary

Management of massive rotator cuff tears is a challenging problem in orthopedic surgery that requires careful consideration of patient demographics, injury pattern, and treatment goals to successfully select the appropriate surgical procedure. Surgical options for patients who have failed non-operative treatment of massive irreparable rotator cuff tears include arthroscopic debridement (with or without biceps tenotomy/tenodesis or partial repair), latissimus dorsi or pectoralis major tendon transfer, or arthroplasty. Post-operative rehabilitation should be dictated by the chosen procedure and tissue quality to maximize patient function while decreasing risk of surgical failure.

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