These authors conducted a retrospective case-control study on 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. Procedures were performed at major medical centers by fellowship trained surgeons. The prostheses used were not described.
Baseline demographics, including age, sex, body mass index, and Charlson Comorbidity Index, were similar between those with poor outcomes and the controls.
Patients who were identified as having at least 1 of the below criteria for poor outcome were defined as cases (i.e.failures), and the remainder of the patients served as control subjects:
change in Simple Shoulder Test score of 1 or less
a postoperative ASES score of less than 50
change in ASES score of less than 12
postoperative active forward elevation of less than 90°,
a change in SANE score of less than 29
or revision surgery.
By this definition, 18 (30%) of patients had poor outcomes (case group).
The case group had significantly worse postoperative Simple Shoulder Test (5.4±3.6 vs 8.5±2.4, Single Assessment Numeric Evaluation (SANE) (61.6±29.5 vs 84.9±14.1, and American Shoulder and Elbow Surgeons (58.9±22.5 vs 82.2±14.2 scores compared with the control group.
Patients with poor outcomes had significantly higher preoperative SANE scores compared with control subjects (40.4±28.4 vs 18.8±15.7.
The authors concluded 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. For these patients, alternative treatment options should be considered."
Comment: This article demonstrates that, in spite of having improvement in their outcome scores, a substantial percentage of patients receiving RSA for massive cuff tears failed to meet the authors' definition for a satisfactory result. From this one can see that the definition of "satisfactory" can have a strong influence on the conclusion. In this study, patients were not asked if they were satisfied or if they would have the same surgery again. However, Reverse Shoulder Arthroplasty for the Treatment of Irreparable Rotator Cuff Tear without Glenohumeral Arthritis : reported that despite improved overall outcome scores, 32% of patients having RSA for massive cuff tears without arthritis (Hamada score ≤3) would not have the same surgery again.
The Single Assessment Numeric Evaluation (SANE) is a patient rating from 0-100 in which patients rate their current status in relation to a normal baseline. The observation that a higher preoperative function (as assessed by the SANE score >33) was associated with a higher percentage of unsatisfactory results is perplexing. Why higher "preoperative SANE scores are associated with a greater likelihood of poor outcomes after RSA for massive rotator cuff tears without glenohumeral arthritis" is unexplained in this manuscript.
Our takeaway is that patients with "massive cuff tears" are a very heterogenous group. Some of these patients actually have excellent comfort and function in spite of their pathology. Others have profound inability to use the shoulder.
In our practice we often see patients with "massive cuff tears" referred for reverse total shoulder arthroplasty. Many of these achieve substantial improvement from a more conservative approach: either a simple exercise program (see this link) or from a less-invasive surgery, such as the smooth and move procedure (see this link).
We reserve reverse total shoulders for those patients with massive cuff tears who are substantially disabled by pseudoparalysis or instability.
Much more knowledge needs to be gained before we know which patients with "massive cuff tears" are best managed with reverse total shoulder arthroplasty.
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