The authors of Clinical outcomes of reverse shoulder arthroplasty and rotator cuff repair in patients with massive rotator cuff tears without osteoarthritis: comparison using propensity score matching defined massive rotator cuff tears (MRCTs) as those with tendon defects greater than 5 cm or those with 2 complete tendon tears on preoperative magnetic resonance imaging (MRI). They studied patients with MRCT without significant osteoarthritis, i.e. those with Hamada grades 1,2 or 3.

They compared and contrasted those patients that the senior author chose to treat by attempting rotator cuff repair and those he elected to treat with reverse shoulder arthroplasty (RSA) based on his assessment of factors such as age, sex, tear size and fatty infiltration of the cuff muscles.

The retrospective data analysis found 68 patients treated for MRCTs via RSA and 215 patients treated for MRCTs via arthroscopic RCR. As can be seen from the table below, the patients chosen for RSA were different than those chosen for RCR.

The authors then used propensity score matching for sex, age, tear size, and global fatty degeneration index to reduce the initial cohort of 283 patients to 78 (28%): 39 in each treatment group.

By comparing tables I and III one can see that 43% of the RSAs and 82% were eliminated by the matching, and that while "matched" with each other are not representative of the original cohorts with respect to age, sex, and tear size.

For the 39 reverses the Biomet Comprehensive (n=33), the Biomet Comprehensive Nano Stemless Shoulder (n=3), and the Exactech Equinox Reverse Shoulder (n=3) were used.

For the 39 cuff repairs a substantial number of ancillary procedures were performed.

While the included patients with massive cuff tears had preoperative pain (byVAS scale) and loss of function (by the Simple Shoulder Test), they had very good average active elevation as shown in the table below. This is consistent with the findings presented in the previous post (see this link), that patients with two-tendon rotator cuff tears can have preserved active elevation. The table below shows similarity in the postoperative results for matched patients from the two treatment groups.

Of interest is the observation that the anatomic success of the rotator cuff repair surgery did not have a statistically significant effect on the clinical outcome of the procedure (see Failure of healing of cuff repair and its effect on the clinical outcome).

Comment: As surgeons, we are not treating massive rotator cuff tears, we are treating patients with massive cuff tears. In that regard, the patient's preoperative active range of motion may carry more weight in the choice of treatment than the size of the tear. A reverse total shoulder may be "overkill" for the patient with a massive cuff tear, no arthritis and active elevation of 135 degrees of active elevation (see table IV second column). Many massive cuff tears cannot be durable repaired because of severe retraction and muscle/tendon degeneration. In those patients with irreparable massive cuff tears and retained active elevation, a simple "smooth and move" procedure (see this link) may restore comfort and function without the down time and risks associated with more complex surgical procedures.