Editorial Commentary: Put Down Your Saw and Pick Up Your Scope! Or, Why Burn Down the Bridge When the Road Ahead Is Full of Potholes? Reverse Total Shoulder Replacement Versus Arthroscopic Rotator Cuff Repair.

Are we doing too many reverse total shoulder replacements and not fixing enough repairable rotator cuff tears? A convincing argument can be made for attempting to repair most, not all, very large rotator cuff tears in patients who do not have a significant arthritic change in the shoulder. My experience over more than 25 years of arthroscopic rotator cuff repair (ARCR) is that the only good way to know if it is repairable is to try. But some patients really do not pass my "eyeball test" as to whether they can rehabilitate and heal enough to make an ARCR reasonable. Magnetic resonance imaging scans are useful, mostly to help me with tear pattern recognition, how much time and skill I might need for the repair, and to help me council my patients as to their ultimate functional recovery. I have had surprises both ways: some ARCRs that I thought would be easy turned out to be very challenging and others that I thought would be "mission impossible" turned out to be "mission accomplished"! The rationale for jumping ahead primarily to reverse total shoulder replacements reminds me of certain tax cut plans I have heard talk of lately. Sounds great now (well, maybe the complication rate is a little high) but there might be a price to pay down the road.