What I know is that we have techniques for predictable arthroscopic repair and healing of the vast majority of rotator cuff tears, even massive tears,15-17 and patients do very well clinically. Yet, among many orthopedic surgeons, there is a trend to go straight to reverse total shoulder arthroplasty (rTSA) for massive tears—despite the evidence against it. As reported in the literature, rTSA results are not as good as arthroscopic cuff repair results, and the complication rate for rTSA is much higher.
Why has this trend toward rTSA for massive tears gained so much momentum? The only reason I can surmise is that, for the average surgeon, rTSA is easier and quicker than arthroscopic repair for massive tears. But the reason for choosing a specific type of surgery for a given problem should not be that it is easiest for the surgeon; it should be that it is best for the patient.
The surgeon should start by asking what procedure he or she would want if the roles were reversed—if the surgeon were the patient with the massive rotator cuff tear. If a surgeon does not have the skill set for the best procedure for a particular patient, he or she is obligated to send that patient to a surgeon who does have the skills. In addition, given that infection is the most feared complication in most shoulder surgeries, the surgeon should ask which infection rate would be personally acceptable. Arthroscopic rotator cuff repair has a reported infection rate of 1.6 per 1000, or .0016,18 whereas rTSA has an infection rate about 25 times higher, or .04.19 Further, the surgeon must consider the relative severity of the consequences of infection. By any measure, an infected arthroscopy is a straightforward treatable complication, but an infected shoulder replacement is a human tragedy. Patients vastly prefer the minimally invasive arthroscopic approach, and through online searches can easily identify who can offer an arthroscopic solution.
To reproducibly achieve successful arthroscopic repair of massive rotator cuff tears, the surgeon must know advanced techniques, including subscapularis repair techniques,20,21 interval slides,22,23 and self-reinforcing constructs.24,25
“It’s a poor carpenter who blames his tools.” This 18th-century English proverb is as true today as it was 300 years ago. The tools for arthroscopic cuff repair exist, and they are excellent. The burden of craft is the surgeon’s burden and obligation. As surgeons, we must accept that obligation and the responsibility of that burden.
As mentioned earlier, Dr. Rob Bell’s charge to me when he invited me to give the Neer Lecture was to sum up my involvement in the development of arthroscopic shoulder surgery. The short version is that I have been doing shoulder arthroscopy for 31 years; have received 28 US patents related to shoulder instruments and implants and have 12 US patents pending; have published 167 peer-reviewed articles, a couple dozen book chapters, and 2 textbooks on shoulder arthroscopy; have trained 25 fellows; and have hosted approximately 3000 visiting surgeons in my operating room. My greatest professional dream was to see the standard of care for rotator cuff repair and shoulder instability transition from open to arthroscopic techniques, and I have been fortunate enough to have observed that paradigm shift during my career.
What do I envision over the next 31 years? As we all know, history runs in both directions, and some things simply have not happened yet. In terms of rotator cuff treatment, I think over the next few years the guiding principle of treatment will be joint preservation. All rotator cuff tears, even massive tears, will be repaired arthroscopically. Patients and insurers will demand arthroscopic repair, and surgeons without the skill set will migrate to other subspecialties. As for the role of arthroplasty in the treatment of rotator cuff tears, rTSA will be indicated only for pseudoparalysis after failed cuff repair in low-demand elderly patients.
In rotator cuff treatment, I envision a standard of care that is almost entirely arthroscopic. This standard will demand that surgeons who treat rotator cuff tears be proficient in arthroscopic repair of the full range of tears. Acquiring the skills for arthroscopic repair may not be easy, but then “there’s the easy way, and there’s the Cowboy Way.” As my dad used to tell me when I complained about working too hard, “No man ever drowned in his own sweat.” We shoulder surgeons must accept the burden of craft that accompanies the new standard of arthroscopic cuff repair, and we must offer our patients the same level of care we would choose for ourselves.