These authors point out that as high as 40% of all cuff tears are described as "massive", i.e. involvement of ≥2 tendons or tears measuring ≥5 cm in greatest dimension.
They performed a retrospective chart review of 95 cuff repairs (RCRs) and 92 reverse total shoulders (rTSAs) performed by an individual surgeon. To quality for this review patients had to be >65 years at the time of surgery, to have a massive cuff tear with no preoperative glenohumeral arthritis, a minimum follow-up of 12 months, a functional deltoid muscle on physical examination, and no prior shoulder surgery except for prior attempt at cuff repair.
Patients having repair averaged 71 years of age and were 60% male with an average preoperative flexion of 113 degrees and SST of 3.1. 6% had had prior repair attempts.
Patients having a rTSA averaged 74 years of age, were 30% male with an average preoperative flexion of 57 degrees and SST of 1.9. 51% had anterosuperior escape. 36% had had prior repair attempts.
The one-year surgical outcomes are shown below
Comment: This is an interesting observational study of the practice of an individual surgeon highly experienced in cuff repair and in reverse total shoulder arthroplasty.
However, the readers are not provided with data on the integrity of the repairs these massive cuff tears in individuals averaging over 70 years of age. We can only surmise that a high percentage of these repairs will not heal. As the authors state, the relationship between tendon healing and clinical outcomes after RCR is unclear. Many authors have reported failure rates of 80% or higher in this population, yet patients report high satisfaction even in the setting of retear.
This observation makes us wonder when it is of value to attempt to repair massive tears in older individuals.
For cuff tears that are not reparable in patients with retained active elevation, we offer a smooth and move procedure without attempting cuff repair. A recent study is presented below:
The authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery.
In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.
Smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
The video below shows such a patient six weeks after a smooth and move procedure for a failed prior repair attempt. At surgery he had the irreparable loss of both the supraspinatus and infraspinatus. Here's what was removed from his subacromial space:
He began his active rehab the evening of surgery without the need for any postoperative protection.
He began his active rehab the evening of surgery without the need for any postoperative protection.
We can conclude that different procedures can benefit selected older patients with massive cuff tears. It seems clear that the reverse total shoulder is the "go to" surgery for informed patients with pseudo paralysis and/or anterosuperior escape. The value of attempting to get a massive cuff tear to heal back to the tuberosity against strong odds of failure in an older patient remains to be determined.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
