Clinical Faceoff: Management of Massive Rotator Cuff Tears in Patients Younger than 65 Years of Age

Rotator cuff pathology is a common source of shoulder pain, disability, and dysfunction [5, 6], with rotator cuff tears generally occurring in patients 65 years of age or older. While almost everything on the topic is controversial, the treatment of massive rotator cuff tears, defined as defects measuring > 5 cm or involving two or more torn tendons, is especially fraught. These large lesions are difficult to manage [11], but they can be repaired.

The conversation is even tougher among patients younger than 65 years of age who hope to return to an active lifestyle or sport. In younger patients, the choice may come down to a repair that is likely to come apart or an implant that may not last. But reliable long-term solutions remain mostly elusive.

To sort this all out, I have engaged two national experts on the topic: Allison Rao MD, an orthopaedic surgeon who specializes in sports medicine and shoulder surgery, and Bryan M. Saltzman MD, the Director of Sports Medicine Research at OrthoCarolina.

Lisa K. Cannada MD, FAAOS: In patients older than 65 years of age, the use of reverse total shoulder arthroplasty (RTSA) is a well-accepted treatment for massive, chronic rotator cuff tears. But in younger patients, it may impose too severe a tradeoff. How do you assess your options in those younger patients?

Allison Rao MD: In my view, RTSA has become overused in the treatment of massive rotator cuff tears. In patients older than 65 years of age, RTSA is dependable and offers patients both pain relief and restoration of function [19]. But for younger patients, especially those who want to return to high activity levels or manual labor, the goal is often joint preservation [8].

Any good treatment algorithm considers patient age, demand, as well as physical exam and imaging characteristics. First, the functional age versus actual age of a patient truly matters. Some younger patients have few functional demands, while others have serious medical problems; for those patients, joint preservation may not be the right choice. RTSA may be more reliable.

For higher-functioning patients (who usually, though not always, are younger), I would look next at the MRI to assess the tear size, shape, tendon involvement, and fatty infiltration. Additionally, if not readily apparent on the radiographs, MRI can be helpful in assessing the glenohumeral cartilage and whether the humeral head is starting to ride high. The Hamada classification of rotator cuff arthropathy can be a useful quantifiable tool, with a Grade 3 usually indicating chronic remodeling that should tend to push the surgeon towards RTSA over repair [10]. Likewise, an irreparable subscapularis tear would be an indication for RTSA.

Finally, I would use the physical exam. If the patient has developed pseudoparalysis (the inability to forward elevate actively), this shows a level of anterosuperior escape that would likely be an indication for RTSA.

Bryan M. Saltzman MD: After identifying the patient’s function and treatment goals, one must differentiate between a massive but reparable cuff tear and one that is truly irreparable. It can be difficult to distinguish reparable versus irreparable prior to surgery, but many preoperative imaging and examination variables can help.

Studying preoperative imaging helps to identify large anteroposterior/medial-lateral dimension tears, those with substantial retraction, superior humeral migration, muscular atrophy, Goutallier 3 or 4 fatty infiltration, poor tissue quality, or prior failed reparative efforts, which make healing less likely [4]. There are certain physical examination features that I find concerning: cuff muscle atrophy around the scapula, axillary nerve dysfunction, poor cuff strength or pseudoparalysis, and positive lag signs come to mind.

Dr. Cannada: The superior capsular reconstruction and balloon spacer are newer techniques, and so a learning curve exists. What has been your experience with these new techniques, and do you have any suggestions for success?

Dr. Saltzman: I find superior capsular reconstruction helpful for the massive, irreparable rotator cuff tear because of its success in terms of pain reduction, ROM improvement, pseudoparalysis reversal, improvement in the acromiohumeral distance, and reasonably low revision risk [14, 24]. I believe that superior capsular reconstruction is best for the physiologically young patient with high activity levels and functional demands. Cartilage status is important, as superior capsular reconstruction will not address pain coming from cuff tear arthropathy or arthritis.

While I agree that the procedure can be challenging to learn, I think a few tips can help. First, make sure not to miss tears along the upper subscapularis border tear, which may benefit from arthroscopic fixation. Consider a subacromial decompression with a conservative acromioplasty but an aggressive bursectomy. I incorporate a knotless approach to the superior capsular reconstruction itself, with three evenly spaced glenoid anchors, and double-row fixation laterally to prevent loss of fixation on the humeral side, which may result from tensile forces there or acromiohumeral contact abrasion [6]. I use the commercially available dermal allograft, as opposed to the thicker fascia lata autograft, as this decreases surgical time, avoids donor-site morbidity, and seems to provide comparable clinical results [24]. Finally, I use a penetrating device to suture the anterior and posterior graft side-to-side to the native anterior and posterior cuff.

I do not yet have experience with subacromial spacer (“balloon”) implantation, as it is only recently available. Interestingly, the spacer deflates within 3 months after implantation, and is supposed to be bioabsorbed over a period of 12 months, with its efficacy purportedly coming from a maintained ability to restore the force coupling of the shoulder during glenohumeral joint motion [22]. Its technical implantation seems simple, intuitive, and fast, avoiding the otherwise steeper learning curve of the superior capsular reconstruction. The few studies on this technique suggest satisfactory clinical outcomes with a low risk of complications, although clinical heterogeneity, use of coprocedures, and variations in patient selection criteria cloud our ability to interpret this evidence base [17, 25].

Indeed, the subacromial balloon spacer still leaves us with several questions including how the biomechanics of the device alter the shoulder long-term in pre- and postresorption, whether the implant could have any negative local affects to the native remaining tissues, and whether insufficient filling of the balloon could lead to migration and resultant concerns therein.

Dr. Rao: The superior capsular reconstruction has a big learning curve, but here are a few technical pearls that have helped me. I agree with Dr. Saltzman that subacromial decompression can help provide space for graft passage and improve visualization, and that three knotless anchors on the glenoid provide good tension. After placing these sutures, I use a hemostat to separate and clip these sutures to the drapes to help with suture management. And like Dr. Saltzman, I use a commercially available dermal allograft. I like a thick graft that is slightly oversized compared to in vivo measurements. I utilize a double row repair and try to incorporate side-to-side sutures into any remaining viable native cuff tissue.

Like Dr. Saltzman, I do not have clinical experience with subacromial spacer implantation. Interestingly, early clinical trials described this technique as a “quick and easy” implantation and recovery. But as its usage grows, indications and techniques are evolving [17, 25]. One concern I have is how much native tissue to repair. In superior capsular reconstruction, we generally try to repair of as much viable cuff tissue as possible to improve functional motion and pain. I would think the same principle will hold true for the subacromial spacer. But this may negate the purported “quick and easy” recovery if a partial repair is done, which makes me question the utility of the spacer. For those with massive, irreparable tears, the subacromial spacer may have a role in younger patients to delay RTSA and potentially limit longer-term complications associated with RTSA, but we have a paucity of long-term clinical data, limited knowledge of its effect on adjacent tissues, including local inflammatory reaction, and sparse outcomes for those who may ultimately have a RTSA. Use of the subacromial spacer, while enticing, should be approached with caution. A preoperative discussion with patients about potential unknown long-term effects is warranted.

Dr. Cannada: It is often worth trying nonsurgical management prior to offering a patient rotator cuff repair surgery. How do you educate patients who see advertisements for biologics and believe those products are the nonsurgical solution to the problem?

Dr. Saltzman: I believe that nonsurgical options in the setting of a massive cuff tear should be discussed as a first-line option when the cuff is deemed to be truly irreparable (related to tear size, chronicity, fatty infiltration, and cartilage changes/arthropathy). Outside of acute traumatic tears, patients with milder symptoms or minimal dysfunction are particularly worth trialing a course of nonoperative treatment [10]. Physical therapy can be incorporated to stretch and strengthen the periscapular musculature, the remaining rotator cuff tissue, and to reeducate and strengthen the deltoid [27]. The focus is on supine exercises with gradual progression to upright activity against gravity and/or resistance [23]. Additionally, NSAIDs may be helpful with pain and inflammation on an as-needed basis, and injections with corticosteroids can be incorporated as well.

It is common to see advertisements on the “regenerative potential” of biologic injections, from platelet-rich plasma (PRP) to bone marrow or adipose-derived preparations. While there is recent data highlighting the efficacy of PRP in comparison with corticosteroid in the setting of partial-thickness rotator cuff tear treatment in the short-term [13], to my knowledge, there are no high-quality studies showing longer-term benefit from any available biologics, including PRP, bone marrow-based products, or adipose-derived cell therapy.

Dr. Rao: Maneuvering around advertisements and false information in our digital society can be difficult, and providing patients with accurate information is an important part of any discussion. Orthobiologics have gained plenty traction in the last few years, but randomized trials have found them to be less impressive than hoped, with no significant effect on patient-reported outcomes and long-term tendon healing [15, 26]. With the substantial out-of-pocket cost to patients, as well as morbidity associated with more-invasive procedures like bone marrow aspirate concentrate (BMAC) or adipose-derived stem cells, I would counsel caution.

In the case of rotator cuff tears, there are, as of this writing, eight Level I or II studies evaluating PRP in augmentation of rotator cuff repair, with no definitive answers, poorly reproducible effects on tendon healing, no significant difference in patient-reported outcomes, and ultimately no difference in retear or revision surgery. We lack high-quality studies, free of selection, transfer, and assessment biases, that support the use of BMAC, adipose, or amniotic tissue-based stem cell derivatives in the setting of rotator cuff repair [12]. While we know that tendon-to-bone healing is one of the biggest areas of advancement in tendon healing of massive rotator cuff repairs, I tell patients that with their large out-of-pocket costs and the general lack of clinical data to support the use of these treatments, orthobiologics currently do not have enough evidence to support routine use in rotator cuff repair

Dr. Cannada: What kind of expectations do you discuss with patients before surgery?

Dr. Rao: First, I try to determine whether pain or weakness is the primary issue. This can really help set the expectations for a patient. For example, if the primary complaint is pain in a patient with an isolated, irreparable supraspinatus tear, either a superior capsular reconstruction or a balloon spacer would be a good treatment option. Both have been shown to improve VAS and American Shoulder and Elbow Surgeons shoulder scores and result in improvement in forward elevation [2, 9].

For those whose main complaint is pain, an attempt at partial repair with superior capsular reconstruction or balloon spacer will improve patient-reported pain scores with comparable motion and function, while limiting the complications associated with tendon transfers.

For those whose main issue is shoulder weakness, a superior capsular reconstruction or balloon may not give as much return of function as a latissimus dorsi transfer. In these patients, a latissimus dorsi transfer or lower trapezius transfer with repair of as much viable cuff as possible will, I believe, give patients better restoration of function [3, 7, 20].

Finally, for patients having a salvage joint restoration procedure like a superior capsular reconstruction, balloon spacer, or tendon transfer, it is important to convey that the procedure is unlikely to be definitive, particularly if the patient is younger, and we do not know for certain what impact these joint salvage procedures have on the long-term outcome from RTSA.

Dr. Saltzman: I agree that setting expectations is key. I tell my patients that these are nonanatomic solutions for a major problem, and as Dr. Rao says, the results vary based on a host of patient- and shoulder-specific variables that may result in further surgery. We do not know how much these joint-sparing procedures adversely affect the results of later revision to RTSA, though we suspect they will.

Tendon transfer surgery can improve patient pain, strength, and motion to some degree, but with variable functional improvements, there is potential for morbidity from “robbing Peter to pay Paul,” and the possibility still of cuff tear arthropathy over time [18, 21]. I believe superior capsular reconstruction is a powerful option that demonstrates success in terms of reduction in pain, ROM improvement, reversal of pseudoparalysis, improvement in the acromiohumeral distance, and reasonable failure/revision rates at both short and intermediate postoperative time points [14, 24]. I am optimistic that these results will be borne out in longer-term follow-up. The subacromial balloon spacer may have similar promise from early adopters of the technique, but as the newest technology available, data are tremendously limited.

Dr. Cannada: Some have raised concerns about expanding indications for RTSA. What are the pros and cons of use of RTSA in patients younger than 65 years of age who have massive rotator cuff tears?

Dr. Saltzman: While RTSA often feels like a “nothing-can-go-wrong” procedure, that is not the case. Still, because of improved implant designs and techniques, I do sometimes use it in patients younger than 65 years of age who have massive, irreparable rotator cuff tears. However, younger patients, compared with their older counterparts, often achieve lower functional scores after RTSA, and while RTSA does reduce pain and improve function, it can be associated with poorer patient-perceived levels of function [16]. This is likely related to patients’ perception of limitations imposed by the arthroplasty and the greater expectations these patients have about returning to prior levels of activity [16]. I also have concerns about implant durability over the long-term in younger patients and higher levels of stress placed on the implant, which may cause complications like periprosthetic fractures, instability, or loosening. For these reasons, I am cautious about performing RTSA in patients younger than 60 years of age with irreparable rotator cuff tear when they have reasonable remaining cartilage, high preoperative function/motion, and expectations for higher activity levels or job-related requirements. But in young patients who have severe arthritis, who have pseudoparalysis, and who are not terribly active, I might use a short-stem RTSA, and I would take particular care to avoid overtensioning the device.

Dr. Rao: While RTSA can often feel like the easier option and the more-definitive procedure, it carries real risks, especially in younger patients. In patients younger than 60 years of age, RTSA has been shown to have a 4.8-fold increased risk of revision compared to patients older than 60 [1, 8]. Especially in those who desire return to high-demand activities, RTSA at a young age can lead to scapular notching, loosening, stress fracture, periprosthetic fracture, and dislocation. These are hard problems to treat over time as bone loss, revision risk, infection, and patient expectations become increasingly difficult to manage. To help avoid complications such as bone loss in younger patients, I, like Dr. Saltzman, try to avoid overtensioning. I use short humeral stems, and I preserve the subscapularis when possible. Still, if I can find a reasonable alternative to RTSA in patients who are so young, I try to do what I think is best in the long run, even if it is not as easy in the short-term.