These authors present a literature review and their extensive personal experience in the use of reverse shoulder arthroplasty in the treatment of massive rotator cuff tear.
They concludes that patients best suited for this procedure are elderly, lower-demand individuals with chronic, irreparable cuff tears, and pseudoparalysis (simply defined as the inability to actively elevate the arm above 90 degrees in the presence of preserved passive motion). Age < 60, better pre-operative function (i.e. Simple Shoulder Test Score of 7 or more) and upper extremity neurologic dysfunction are potential risk factors for poor outcome with RSA in this population.
Comment: Some important points are made here.
Management of the chronic massive cuff tear should always start with a rehabilitation program designed to maintain range of motion and to strengthen the deltoid, periscapular muscles and residual cuff muscles. Not infrequently we see patients referred to us for a reverse that respond to a simple exercise program that resolves their pseudoparalysis. There is time to try this cost-effective approach.
Anterosuperior escape is a serious iatrogenic complication of acromioplasty in the presence of a compromised rotator cuff.
An important goal of reverse total shoulder is to restore the normal relationships of the proximal humerus to the glenoid, avoiding distal or medial displacement of the humerus.
The reported complication rate of reverse total shoulder arthroplasty is high - up to 20% in some series. It appears that the complication rate is affected by component design, surgeon experience and patient selection.
The implant cost of reverse total shoulder arthroplasty is high, often amounting to over 60% of the hospital's reimbursement for the patient's treatment.
In summary, the indications for a reverse total shoulder in the treatment of a massive cuff tear seem clear: an informed patient over the age of 60 with sufficiently good health to withstand a major surgical procedure who has pseudoparalysis that has not responded to a concerted effort at rehabilitation and who has compromised shoulder comfort and function as reflected by a low self-assessment (for example a Simple Shoulder Test score of less that 6).
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