Preoperative Single Assessment Numeric Evaluation Score Predicts Poor Outcomes After Reverse Shoulder Arthroplasty for Massive Rotator Cuff Tears Without Arthritis

These authors conducted a retrospective case-control study for 60 patients (mean age, 71.4±7.4 years) who underwent reverse total shoulder (RSA) for massive rotator cuff tear without glenohumeral arthritis (Hamada score ≤3) and had a minimum of 2 years of follow-up.

Criteria for a poor outcome included post op ASES score <50, change in ASES score <12, change in SANE score ≤ 29, change in Simple Shoulder Test Score ≤ 1, revision surgery and active forward elevation < 90.

18 of these 60 patients (30%) met the criteria for a poor outcome (see "cases" below).

Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7, respectively; P=.021).

The authors suggest that patients with better overall preoperative function, as represented by higher SANE scores, have a greater likelihood of poor functional outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis.

Comment: While it is apparent that patients with low preoperative SANE scores have a greater opportunity for a substantial preoperative to postoperative improvement improvement in the SANE score, it is not clear why patients with higher preoperative SANE scores would have lower postoperative SANE scores. Perhaps the issue lies with the SANE score itself. One of the weaknesses of the SANE score is that it does not separate the patient's assessment of pain, function, and satisfaction. In assessing the value of different methods for managing shoulders with massive cuff tears it is important to differentiate these three elements separately to inform discussions with prospective patients.

We live in a world where new methods for managing irreparable cuff tears without arthritis are rapidly coming and going: rehabilitation, debridement, partial repairs, Teflon grafts, GraftJacket, Restore patches, tendon transfers, superior capsular reconstruction, balloons and reverse total shoulder arthroplasty.

When we treat a patient with an irreparable cuff tear, we need to know which clinical manifestations we are treating. Patients with irreparable cuff tears without arthritis range widely in their symptomatology, from asymptomatic to stiff, painful, unstable and/or pseudoparalytic. Thus it is not the diagnosis of massive cuff tear that indicates the choice of treatment, but rather the clinical manifestations of the cuff defect. The treatment for a patient with painful stiffness should start with a rehabilitation program whereas a patient with the same cuff pathology but with profound pseudoparalysis may wish to consider a reverse total shoulder.

Understanding the value to the patient of these different management approaches will come from studies that stratify patients by their pre-treatment comfort and function in addition to the specifics of their shoulder pathology.

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