Massive rotator cuff tears without arthropathy: when to consider reverse shoulder arthroplasty.

Massive rotator cuff tears often present a challenge for the treating orthopaedic surgeon. A multitude of surgical approaches have been described to manage this condition, ranging from biceps tenotomy to complex muscle transfers to reverse shoulder arthroplasty. Among these procedures, reverse shoulder arthroplasty is increasingly advocated to relieve pain and restore function; however, the exact role of this arthroplasty procedure continues to be defined, particularly in patients without any evidence of associated glenohumeral arthritis. In this patient population, the reverse shoulder prosthesis is used primarily to address the instability associated with massive rotator cuff tears, as opposed to the more common application of arthroplasty to manage cartilage disease. Currently accepted indications for reverse shoulder arthroplasty include patients with pseudoparalysis and irreparable rotator cuff tears, with or without anterosuperior escape. Surgeons must be aware of conditions that may clinically mimic pseudoparalysis caused by a rotator cuff tear, such as axillary nerve injury, deltoid dehiscence, or cervical radiculopathy. These conditions produce deltoid insufficiency and are unlikely to benefit from a reverse shoulder arthroplasty. Caution is also warranted when considering this procedure in patients with massive rotator cuff tears in whom active forward elevation greater than 90° is preserved. These patients may achieve little benefit in range of motion and pain relief with a reverse shoulder arthroplasty.