Rotator cuff: surgical indications and reverse prosthesis
This detailed presentation covers the criteria for rotator cuff repair, arthroscopic surgical treatments, and the alternative of reverse total arthroplasty for irreparable tears. It also illustrates the postoperative course, functional expectations, and long-term success factors.
Doctors
Topics
Treatments
Advice
- Dr. Steve Brenn; Dr Ludovic Glanz
- Introduction to Médicol and speakers
- Rotator cuff injuries: anatomy, symptoms, examination
- MRI repairability criteria
- Arthroscopic surgical technique
- Post-operative and rehabilitation
- Arthroscopic repair
- Reverse total shoulder replacement
- MRI to make the diagnosis
- avoid infiltrations before surgery
- post-op passive rehabilitation
- precise repairability criteria
The rotator cuff: role and reasons for surgery
The rotator cuff ensures the centering of the humeral head and the coordination of shoulder movements. When one or more tendons are torn, pain, loss of strength and limited range of motion appear, with an impact on sleep and everyday movements (raising the arm, turning the steering wheel, carrying a load).
This pathology progresses over time, particularly when it involves a full-thickness tear. Tendon retraction and muscle atrophy progress, making repair more difficult and altering the biomechanics of the shoulder. In this context, the therapeutic strategy aims to relieve pain, restore function, and prevent secondary osteoarthritis by recentering the joint.
Repairability criteria and choice of treatment
The decision is based on clinical examination and imaging (preferably MRI-arthrography) to assess tendon retraction, fatty infiltration, muscle atrophy, and subacromial height. A cuff is considered "functionally repairable" when the tissue quality and residual mobility allow reliable reinsertion to the bone. Conversely, a very reduced acromio-humeral distance, high retraction, and advanced fatty infiltration point toward alternatives to repair.
Conservative treatment (analgesia, targeted physiotherapy, sometimes planned infiltrations) can reduce pain, but does not induce healing of a complete tear. In a painful, active patient with favorable criteria, arthroscopic repair is preferred.
Penetrating rotator cuff lesions do not heal spontaneously.
Arthroscopic repair: principles and consequences
The arthroscopic procedure involves freshening the bone footprint and then reinserting the tendon using strong inks and sutures. A double-row construction increases the contact surface and mechanical stability. When long biceps pain coexists, a thenodesis can be associated. The goal is to achieve progressive tendon-bone healing, an essential condition for functional results.
Rehabilitation begins early in the passive phase, with the use of a splint for approximately six weeks. Assisted active movements are then introduced, while resistance strengthening is only considered from the third month, the minimum time required for sufficiently solid healing.
When repair is no longer possible: reverse total prosthesis
In cases of irreparable tear and/or rotator cuff arthropathy, reverse total shoulder replacement is a reliable option. The reverse design medializes and lowers the center of rotation, allowing the deltoid to provide elevation despite rotator cuff insufficiency. This solution aims for a pain-free and functional shoulder for daily movements, with ranges of motion generally restored between 120° and 135° of anterior elevation.
The indication takes into account age, functional requirements, bone condition, and the level of osteoarthritis. Clear information about realistic expectations, rehabilitation, and implant longevity is essential.
Reverse prosthesis is an effective option, even in selected young patients.
Functional recovery and resumption of activities
Recovery follows a step-by-step progression: pain control, mobility recovery, then strengthening of the scapulothoracic chains and deltoids. An individualized program, adapted to the profession and sport, promotes a safe return. Non-impact sports can resume sooner; strength or contact activities require a longer period of time.
The gradual weaning of the splint, passive then active assisted rehabilitation, and the late reintroduction of efforts against resistance respect the biological healing times. This discipline determines the durability of the result.
Message to the patient: informed decision and support
Each situation is unique. The assessment combines symptoms, personal goals, and anatomical criteria. Depending on the assessment, arthroscopic repair or reverse prosthesis can restore a stable shoulder that is useful for daily life. Structured follow-up, physiotherapy, and therapeutic education ensure a safe return to activities and limit recurrence.
The goal remains constant: reduce pain, improve function and preserve the joint over time.
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