Rotator cuff tear arthropathy - is reverse total shoulder arthroplasty the answer?

Reverse total shoulder arthroplasty (RTSA) is considered by many as the "go to" procedure for patients with rotator cuff tear arthropathy. However, its complications are well recognized, not uncommon, and difficult to manage; some are highlighted in recent articles: acromial/spine fractures, dislocation, baseplate failure, infection, humeral component loosening, and humeral fracture.

Here we present two patients referred to us for this procedure who wished to avoid RTSA out of concerns for its complications.

The first is a 75 year old woman having a painful right shoulder referred for RTSA after 10 steroid injections had failed to improve her comfort and function.  She had 60 degrees of active elevation and 80 degrees of passive elevation. Her x-rays (shown below) demonstrate classical findings of cuff tear arthropathy

Not wanting an RTSA, how should she be managed?

The second is a 80 year old retired banker with a failed prior cuff repair of the right shoulder referred for RTSA. He had 160 degrees of active elevation, but could not enjoy golf because of right shoulder pain and crepitance. His x-rays show the typical findings of cuff tear arthropathy.

Not wanting an RTSA, how should he be managed?

The first patient was placed on a gentle patient-conducted exercise program (see this link). Recently she reported "I have now been following the stretching regimen for just over 2 months and am nothing short of delighted with the results. I feel almost back to normal and have much greater use of my right arm than I had even hoped for."

The second patient elected a smooth and move procedure (see this link) and was able to return to his activities immediately after surgery. Two and a half years after his procedure, he reported that his right shoulder was giving him no problems with golf, but he wanted a smooth and move for his contralateral left shoulder.

Comment: These are but two of the many patients referred for RTSA who have done well with safer, more conservative management approaches. It seems reasonable to inform patients with cuff tear arthropathy of the management options, including the validated conservative approaches including exercises (see this link), a smooth and move procedure (see this link), and a CTA hemiarthroplasty (see this link) - none of which "burn the bridge" for an RTSA in event that it becomes necessary.

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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 ream and run procedure (see this link).
The total shoulder arthroplasty (see 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).