Certain groups of patients benefit most from RSA for massive rotator cuff tears
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KOLOA, Hawaii — Reverse shoulder arthroplasty for massive rotator cuff tears is indicated for patients who are aged 70 years or older, patients with pseudoparalysis or patients who are aged 65 or older with arthritis, a presenter said.
At Orthopedics Today Hawaii, Anthony A. Romeo, MD, discussed management of posterior rotator cuff deficiency in patients with massive rotator cuff tears and indications for RSA. “We want to make sure that we individualize or personalize the care for each and every one of our patients,” he said.
The key to that personalized care, Romeo said, is determining in which patients RSA will produce superior long-term outcomes compared with a soft tissue procedure, such as superior capsular reconstruction (SCR) or the newer subacromial balloon spacer procedures.
“Reverse shoulder arthroplasty is a great operation for the right patient. Arthritis tips the scale in that direction. Soft tissue-wise, if they have pseudoparalysis or you can’t balance the force-couple, the reverse shoulder arthroplasty is going to be a great option for them and, fortunately, we’ve learned how to put it in to make them last long and get them back to their sports,” Romeo, who is Orthopedics Today Hawaii Course Director and Chief Medical Editor of Healio/Orthopedics Today, said.
Indications
In general, with regard to RSA, it is best if patients who undergo the surgery are aged 70 years or older, he said. “But, if we have an irreparable cuff that’s not doing well, it may be a good option” regardless of the age of the patient, according to Romeo.
In older patients with shoulder arthritis, RSA is nearly always indicated vs. a shoulder soft tissue procedure, according to Romeo.
“If they are under the age of 65 [years], we would like to consider the possibility of these other procedures that we’ve talked about today,” such as SCR, rotator cuff augmentation and lower trapezius transfer, Romeo said.
Shoulder pseudoparalysis considerations
The exception to this rule is if a 65-year-old patient with arthritis has pseudoparalysis.
“If, in fact, there is pseudoparalysis, we don’t have a good solution for that if it’s ‘true’ pseudoparalysis,” Romeo said.
A patient with true pseudoparalysis cannot raise the arm above 90°, he said.
In addition, Romeo said researchers from Europe defined pseudoparalysis this same way, also describing it in the early literature on the topic as a condition present in patients who “acted as if their muscles were paralyzed.” Furthermore, Romeo noted, those researchers determined this condition was not reversible.
Patients with anterior-superior escape, whose humeral head comes out from underneath the acromion, will never be able to raise their arms without undergoing an RSA, according to Romeo. “That’s true pseudoparalysis. You will fail with any soft tissue operation.”
Arthritis as an indication
In older patients with shoulder arthritis, RSA is nearly always indicated vs. a shoulder soft tissue procedure, according to Romeo, who said arthritis, particularly grade 3 arthritis, plays a role in the success of soft tissue procedures to treat massive rotator cuff tears.
“It might work, but there’s a higher chance the results are not going to be so good,” he said.
“Once they have significant arthritis, you’re wasting your time on most of the soft tissue operation,” he said.
For patients younger than 65 years, “we would like to consider the possibility of these other procedures that we’ve talked about today,” such as SCR, rotator cuff augmentation and lower trapezius transfer, Romeo said.
In patients with a massive rotator cuff tear, imaging can help in the decision-making process regarding whether a soft tissue procedure is indicated vs. RSA, and which treatment is more likely to yield the best functional outcomes postoperatively, according to Romeo.
Imaging for diagnosis, decision-making
Radiologists typically provide a diagnosis based on a shoulder MRI for patients with massive rotator cuff tears and may occasionally explain the extent of muscle atrophy seen on the scans, but they rarely detail the extent of the atrophy or provide guidance about the prognosis or best overall treatment, Romeo said. “You’ve got to read your own MRIs,” he said.
He suggested surgeons “figure out” how certain rotator cuff tears appear on imaging, saying that if a subscapularis tear is suspected, “you look at the axial view and you can see that tendon coming off the edge. You can see a dislocation of the biceps. It’s a torn subscap til proven otherwise.”
The sagittal oblique view is useful for appreciating the appearance of the muscle and it also shows the status of the tendon attachment. “You can read [the sagittal oblique view] and know that this is going to be a different case because their subscap is not there. And fatty infiltration plays a role. I know some people don’t think it does, but it does. Even if you get it repaired, the muscle is not normal. It’s not healthy and it’s either going to retear or it’s not going to work well. So you have to keep that in mind, too,” Romeo said.
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Romeo AA. When is it better to treat a massive rotator cuff tear with a reverse? Presented at: Orthopedics Today Hawaii; Jan. 8-12, 2023; Koloa, Hawaii.
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