RSA is ‘safe and reliable’ for grade 3 or greater rotator cuff tears
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WAIKOLOA, Hawaii — Outcomes and return to sport in patients with posterior-superior rotator cuff deficiency and related shoulder problems are better with reverse shoulder arthroplasty than other contemporary procedures, a presenter said.
At Orthopedics Today Hawaii, here, Anthony A. Romeo, MD, discussed RSA for this patient population. “Out of all the options available, it’s the most safe and reliable. [It has] faster recovery than most of them, and it’s going to have the best longevity,” he said.
He compared and contrasted indications for RSA, superior capsular reconstruction (SCR) and the InSpace subacromial balloon spacer (Stryker) in patients with massive rotator cuff tear arthropathy, Hamada stage 3 or greater shoulders, anterior-superior escape with pseudoparalysis or an irreparable subscapularis tear.
“In a 60-year-old, the reason why you’re going to do these others is because it’s a small tear with no arthritis. OK, that’s fine. I’m not going to use the reverse on that. Most of the other people, that’s going to be your better outcome,” Romeo said.
Repair, tendon transfer and RSA can be considered in a patient with a rotator cuff deficiency that is 5 cm2 or larger and, at minimum, two tendons that are affected and “certainly, supraspinatus involved,” he said.
According to Romeo, SCR and balloon spacer procedures are better for patients with Hamada stage 1 or 2 shoulders and no arthritis.
“Why did I say posterior-superior? Because, if the subscap[ularis] is out, nothing else works, but a reverse. If you can’t get the subscap to function, the balloon’s not going to work and superior capsule reconstruction is going to be iffy, at best,” he said when explaining why he favors RSA in these cases. “If you can get it repaired, you might make it work, but that’s a big differential.”
Regarding patients with pseudoparalysis, Romeo said they were initially described in the European literature as being unable to raise their arm to 90°. “They had no balance of their rotator cuff. There was nothing that could be done other than an arthroplasty to make this work,” he said, and noted the definition of pseudoparalysis has since changed to include any individual who cannot raise an arm past 90°.
“In a lot of people,” Romeo said, “that is a pseudoparesis. It looks bad but, if you get rid of their pain, many of these people can move their arm.”
Regardless of the condition of the shoulder that makes the patient eligible for RSA, SCR or the balloon spacer procedure, it is important to consider the patient’s lifestyle and how the patient’s commitment postoperative rehabilitation may impact that, Romeo said. A patient who undergoes RSA without subscapularis repair has the ability to begin shoulder movement earlier than with the other procedures, he said.
“If I have a 70-year-old and older patient, particularly a woman who’s by herself and has to take care of herself, I don’t repair the subscap. I let her start moving her arm within 2 days of the surgery and use her arm to take care of herself. You don’t have to. The rehab is so fast, it’s ridiculous,” Romeo said.
By comparison, Romeo said Steven S. Burkhart, MD, a now retired physician champion of SCR, “told us 4 months of limited activity. Most of us were strict at about 6 weeks and then another 6 weeks. The balloon – the actual study was 6 weeks – protected. But most patients were moving faster than that because the patients it works on, it works well. And they want to move their arm, which is great.”
Reports in the international literature that Romeo cited show good return to sport rates for patients who underwent RSA. “Return to sport after reverse – [it’s] remarkable how much people do,” he said.
Regarding outcomes, “It’s going to be a while before we have 20-year outcomes on SCR or InSpace balloon. We have that on reverse,” Romeo said.
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Romeo AA. Indication for reverse in 60-year-old with massive cuff tear. Presented at: Orthopedics Today Hawaii. Jan. 9-13, 2022; Waikoloa, Hawaii.
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