Optimal Nonarthroplasty Management of Massive Irreparable Rotator Cuff Tears: A Case-Based Approach

The management of massive irreparable rotator cuff tears is commonly debated without consensus. With reverse shoulder arthroplasty often reserved for the older patient (older than 60 years) with rotator cuff arthropathy, treatment of the younger patient population (younger than 60 years) without arthritis is more complex. When determining a surgical approach, the clinical presentation including history and physical examination plays a vital role in the decision tree. The nonarthroplasty surgical treatment options include débridement, partial repair, superior capsule reconstruction, tendon transfer, and balloon spacers. It is important to discuss the overall approach to management, with a focus on the evidence-based advantages and disadvantages of each treatment option. The fundamental conclusion is that in the setting of insufficient randomized controlled trials comparing treatment options, surgical decisions should be based on surgeon experience, patient history, examination, advanced imaging findings, patient expectations, ability to complete postoperative rehabilitation, and shared decision making.