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 point out that the most commonly accepted definitions of a massive rotator cuff tear are a tear > 5 cm in the anterior-posterior dimension or a complete tear of 2 rotator cuff tendons. However, a recent Delphi consensus study defined a MRCT as 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 magnetic resonance imaging or intraoperatively.

They report the results of applying the Delphi process to the management of massive irreparable rotator cuff tears (MIRCTs) based on the response of 72 shoulder surgeons surveyed regarding management by debridement and partial cuff repair, graft augmentation, reverse shoulder arthroplasty (RSA), superior capsular reconstruction (SCR), and tendon transfer in 60 patient scenarios.

There was strong consensus for RSA as the preferred treatment strategy in patients, especially those >70 years, with pseudoparesis, an irreparable subscapularis, and dynamic instability.

The authors point out that while clinical improvements in patients aged < 65 years have been shown with RSA, there are numerous concerns about using RSA in this population. Studies have shown that after 6 years, there is a considerable decline in Constant scores and pain scores. RSA survivorship at 10 years has been reported at 60%. Some reports have demonstrated a complication rate of 37.5% and a failure rate of 15% in patients after RSA for MIRCTs.

There was strong consensus for debridement and/or partial repair as the treatment of choice for individuals with an intact or reparable subscapularis and without pseudoparalysis or dynamic instability.

The authors identified certain unacceptable treatments such as (a) SCR in older patients with pseudoparesis and an irreparable subscapularis or (b) RSA in young patients (<50 years) with an intact

or reparable subscapularis without pseudoparesis or dynamic instability.

There was no strong consensus for performing superior capsular reconstruction (SCR) or tendon transfer in any of the 60 clinical scenarios.

Comment: Our experience is consistent with this report: reverse total shoulder is the most dependable treatment for pseudoparalysis and anterosuperior escape in cuff deficient shoulders, especially in older patients.

As stated above, there was strong consensus for debridement and/or partial repair as the treatment of choice for individuals with an intact or reparable subscapularis and without pseudoparalysis or dynamic instability.

In patients with irreparable cuff tears or failed prior repairs that have preserved active elevation, we consider the smooth and move procedure (see this link). This procedure enables immediate postoperative active use of the arm without the need to protect a repair. A full shoulder motion program can be started right away after surgery and progressed to gentle shoulder strengthening as rapidly as shoulder comfort permits.

While this case does not fit one of the high consensus scenarios, it is illustrative. A sixty year old rancher had bilateral 'smooth and move' procedures without any attempt to repair his large supraspinatus or infraspinatus tendon defects. While some may have considered 'marginal convergence', a cuff graft, a tendon transfer, a superior capsular reconstruction or even a reverse total shoulder, none of these seemed appropriate for this active man who wanted to get back to roping cattle on his ranch.

From his operative note on the right side: "This rancher has pain and loss of function of his right shoulder. He has had a rotator cuff tear which was treated with a graft jacket. Unfortunately, this became infected and required debridement, leaving him with a stiff, painful shoulder.

There was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. The undersurface of the coracoacromial arch was smooth. The previous sutures and graft jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. The subscapularis was identified, freed from scar and reattached anteriorly.

Two years later he had a similar procedure performed on left side for a failed prior repair. His operative note states that there was "abundant scar in the humeroscapular motion interface. The supraspinatus was absent. The subscapularis was absent. The infraspinatus was absent in its upper 1/2. The biceps tendon was absent. The undersurface of the acromion was smooth.There was substantial scar and retained sutures. The deltoid was deficient in the area of the prior surgery. The abundant scar in the humeroscapular motion interface was lysed. The prior sutures were removed. The prominences on the humeral tuberosity were resected. The rough edges of the cuff were smoothed. The weakened area of deltoid was reinforced by imbrication of the weakened area with six sutures of #2 Tevdek."

In a followup note two months after his second side surgery he reported that both shoulders are dramatically improved and that he was back to roping and branding as shown in the photos below