Management of the Irreparable Rotator Cuff Tear

Gregory L. Cvetanovich, MD; Brian R. Waterman, MD; Nikhil N. Verma, MD; Anthony A. Romeo, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(24):909-917. 

In This Article

Abstract and Introduction

Abstract

When evaluating patients with irreparable rotator cuff tears, orthopaedic surgeons have an increasingly wide array of surgical options, including both established techniques and emerging technologies. However, significant variability exists in the clinical evaluation and surgical indications in this subset, and definitions for pseudoparalysis and tear irreparability are inconsistent. In older patients with symptomatic rotator cuff arthropathy and relatively sedentary demands, the reverse total shoulder arthroplasty has been established as the preferred treatment option, producing reliable improvements in both pain and function. In younger patients without glenohumeral arthritis or pseudoparalysis, joint-preserving options are preferred, with recent literature highlighting alternative options including partial repair, bridging or interpositional graft placement, tendon transfers (ie, latissimus, trapezius, and pectoralis major), superior capsular reconstruction, and subacromial spacer placement. In this review article, we address the topic of irreparable rotator cuff tears, emphasizing the workup, indications for various treatment options, and clinical outcomes.

Introduction

Rotator cuff pathology is the most common source of shoulder disability and among the most prevalent conditions treated by practicing orthopaedic surgeons.[1] Rotator cuff tears may reflect acute or acute-on-chronic onset of symptoms or most commonly may develop as a result of a chronic degeneration process, with both intrinsic and extrinsic risk factors noted. An estimated 50% of patients will have radiographic evidence of bilateral rotator cuff tear after age 66 years,[1] although symptoms may vary. Massive rotator cuff tears—defined as defects measuring >5 cm or involving two or more torn tendons[2,3]—are not necessarily synonymous with irreparable tears because many massive tears can be repaired with adequate mobilization and advanced arthroscopic techniques.[4,5] Although repair can be performed, structural failure after primary repair of large- to massive-size tears may occur in up to 25% to 94% of cases by 2 years, most commonly at the bone-tendon interface.[4,5] Ongoing research is evaluating the effects of newer, advanced rotator cuff repair techniques including graft augmentation, superior capsular reconstruction (SCR), and subacromial balloon spacer to improve functional outcomes in treatment of massive rotator cuff tears.

The identification and management of true irreparable rotator cuff tears present unique challenges for the orthopaedic surgeon, both in terms of cost containment and immediate versus delayed long-term patient benefit. In older patients with symptomatic rotator cuff arthropathy and relatively sedentary demands, nonsurgical management and reverse total shoulder arthroplasty (RSA) have been established as the preferred treatment options, producing reliable improvements in both pain and function.[6–8] For younger patients without secondary arthritis, advanced acromiohumeral remodeling, and/or pseudoparalysis, joint-preserving options are preferred whenever possible because of concerns about patient-specific demands and long-term implant survivorship. In this review article, we address the topic of irreparable rotator cuff tears, emphasizing the workup, indications for various treatment options, and clinical outcomes.

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