Sunday, June 13, 2021

Treatment of massive irreparable cuff tears - do experienced surgeons agree?

 Consensus Statement on the Treatment of Massive Irreparable Rotator Cuff Tears – A Delphi Approach by the Neer Circle of the American Shoulder and Elbow Surgeons

These authors note two definitions of "massive irreparable cuff tears" that are in common use: (1) a tear greater than centimeters in the anterior-posterior dimension or a complete tear of two or more rotator cuff tendons or (2)  a retraction of tendons to the glenoid rim in either the coronal or axial plane and/or a tear with > 67% of the greater tuberosity exposed in the sagittal plane measured by MRI or intraoperatively.

Comment: These definitions refer to only to the size of the tear, and not its reparability. Acute tears involving two tendons, especially in physiologically young patients, may well be acutely reparable. 

The most agreed-upon characteristics in deciding treatment were (in order of degree of agreement) were

(1) Anterosuperior escape

(2) Pseudoparesis

(3) Patient age

(4) Fatty atrophy on MRI

(5) History of infection

(6) Occupational demands

(7) Integrity of the subscapularis

Comment: The top two characteristics indicate the degree to which the humeral head is stabilized so that shoulder function is enabled. As the authors point out, this stabilization often occurs in the absence of rotator cuff integrity thorough the concavity-compression mechanism. 

There was a high level of consensus that 

(1) reverse total shoulder arthroplasty was the preferred treatment for shoulders with pseudoparesis, especially in the presence of dynamic instability and an irreparable subscapularis

(2) deb ridement and/or partial repair was the preferred treatment for shoulders with an intact or anatomically reparable subscapularis, no dynamic instability, low occupational demand, and no pseudoparesis, 

(3) reverse total shoulder was not the preferred treatment for patients younger than 50 years old presenting with an intact or reparable subscapularis and no dynamic instability or pseudoparesis, and 

(4) superior capsular reconstruction was not the preferred treatment for patients greater than 70 years old with pseudoparesis and irreparable subscapularis

Comment: While there are many intermediate scenarios presented for the surgeons' consideration, those listed above had the highest levels of agreement. 

This presentation of consensus provides a useful framework that can be useful in individualizing the care of individual patients with massive irreparable cuff tears.

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The total shoulder arthroplasty (see this link).
The ream and run technique is shown in this link.
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).