rotator cuff tear arthropathy: evaluation, diagnosis, and...

Exhibit Selection

Rotator Cuff Tear Arthropathy: Evaluation,Diagnosis, and Treatment

AAOS Exhibit Selection

Denis Nam, MD, Travis G. Maak, MD, Bradley S. Raphael, MD, Christopher K. Kepler, MD,Michael B. Cross, MD, and Russell F. Warren, MD

Investigation performed at the Sports Medicine and Shoulder Service, Department of Orthopaedic Surgery,Hospital for Special Surgery, New York, NY

Abstract: Rotator cuff tear arthropathy encompasses a broad spectrum of pathology, but it involves at least three criticalfeatures: rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeralhead. Although many patients possess altered biomechanics of the glenohumeral joint secondary to rotator cuff pathology,not all patients develop rotator cuff tear arthropathy, and thus the exact etiology of rotator cuff tear arthropathy remainsunclear. The objectives of this manuscript are to (1) review the biomechanical properties of the rotator cuff and theglenohumeral joint, (2) discuss the proposed causes of rotator cuff tear arthropathy, (3) provide a brief review of thehistorically used surgical options to treat rotator cuff tear arthropathy, and (4) present a treatment algorithm for rotator cufftear arthropathy based on a patient’s clinical presentation, functional goals, and anatomic integrity.

Rotator cuff tear arthropathy is a term coined by Neer in1983, and it encompasses a broad spectrum of pathology1.However, all patients with rotator cuff tear arthropathy

possess at least three critical features: (1) rotator cuff insufficiency,(2) degenerative changes of the glenohumeral joint, and (3) su-perior migration of the humeral head2. Neer et al. originallyproposed that, following a massive rotator cuff tear, both me-chanical and nutritional factors lead to degeneration of the gle-nohumeral joint and subsequent osteopenia of the humeral head1.However, this mechanism does not explain why only some pa-tients with a massive rotator cuff tear develop rotator cuff teararthropathy. Although the true etiology of rotator cuff tear ar-thropathy is unclear, what is evident is that it is a difficult con-dition to treat, and surgical techniques for the management ofrotator cuff tear arthropathy continue to evolve.

The objectives of this manuscript are to review the bio-mechanical properties of the rotator cuff and the glenohumeraljoint, to discuss the proposed causes of rotator cuff tear ar-thropathy, to provide a brief review of historically used surgicaloptions for the treatment of rotator cuff tear arthropathy, and topresent a treatment algorithm for rotator cuff tear arthropathy.Although a patient may present with characteristic clinical ex-amination findings and radiographs consistent with rotator cufftear arthropathy, appropriate management requires a global as-sessment of that patient’s initial presentation, anatomic integrity,and functional goals.

Biomechanics of the Glenohumeral Joint

The rotator cuff complex, consisting of the supraspinatus,infraspinatus, teres minor, and subscapularis muscles, plays

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of anyaspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of thiswork, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author hashad any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in thiswork. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

e34(1)

COPYRIGHT � 2012 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2012;94:e34(1-11) d http://dx.doi.org/10.2106/JBJS.K.00746

a pivotal role in providing dynamic stability to the glenohumeraljoint. The glenohumeral joint lacks substantial intrinsic osseousrestraints, and thus the joint’s stability relies heavily on the ro-tator cuff ’s ability to center the humeral head within the glenoidfossa3,4. This key concept has been coined concavity-compression,as the rotator cuff actively compresses the convex humeral headinto the concave glenoid, especially during the middle and endof the range of shoulder motion3. Through this mechanism, theshoulder musculature—including the rotator cuff—becomes theprimary stabilizer of the glenohumeral joint as the arm movesthrough positions in which the capsuloligamentous structures arelax3,5. This dynamic stability also relies on the interplay betweenthe deltoid muscle and the rotator cuff. Whereas the rotator cuffprovides a net inferiorly directed and compressive force vector, thestrong deltoid muscle provides a superiorly directed force, re-sulting in a net force balance or force coupling of the glenohumeraljoint6. Loss of rotator cuff integrity creates an unstable fulcrum ofmotion, leading to superior migration of the humeral head on theglenoid and altered glenohumeral joint biomechanics.

The glenohumeral joint’s remarkable mobility is attrib-utable to both the small contact surface area of the humeral headon the glenoid, estimated to be 4 to 5 cm2, and the shallowness ofthe glenoid fossa3,7,8. Itoi et al.9 noted the maximum depth of thecartilage-covered glenoid fossa to be approximately 2 to 4 mmtransversely and 7 to 9 mm vertically, leaving approximately 85�of humeral articular cartilage unconstrained by the glenoidtransversely and 65� unconstrained vertically (Fig. 1). However,although the osseous geometry of the glenohumeral jointprovides little intrinsic stability, static restraints including theglenoid labrum and the surrounding ligaments, tendons, andskeletal muscles play a crucial role in glenohumeral joint sta-bility. In addition, negative pressure within the glenohumeraljoint capsule, maintained by the presence of synovial fluid withina closed compartment, acts as a key static restraint9.

Thus, both dynamic and static restraints allow the gleno-humeral joint to maintain a wide range of motion yet remainstable. However, the development and progression of massiverotator cuff tears result in both a loss of mechanical stability anda change in the normal intra-articular milieu that contributes tocohesive stability of the joint.

Pathogenesis of Rotator Cuff Tear Arthropathy

In 1981, Halverson et al. proposed a crystal-mediated the-ory of rotator cuff tear arthropathy in which hydroxy-

apatite crystals induce a phagocytic degeneration of therotator cuff tendons and articular cartilage10. They coined theterm Milwaukee shoulder syndrome, and they hypothesizedthat rotator cuff tear arthropathy was in fact an inflammatoryarthropathy since basic calcium phosphate crystals such ashydroxyapatite were identified in diseased synovium andarticular cartilage. Phagocytosis of these crystals was hy-pothesized to result in further tissue degeneration, which inturn resulted in release of additional crystals, propagating acycle of increasing joint degeneration and instability4,10. Thus,this proposed etiology implies that the rotator cuff is notactually torn in rotator cuff tear arthropathy, but instead

undergoes a physiologic process of severe degeneration dueto a crystal-induced arthropathy.

In contrast, Neer et al. hypothesized in 1983 that amassive rotator cuff tear was the inciting event in the devel-opment of rotator cuff tear arthropathy, and that both me-chanical and nutritional factors contributed to the subsequentprogression of the arthropathy (Fig. 2)1. Mechanically, thepresence of a massive rotator cuff tear leads to unbalanced forcecoupling and loss of the concavity-compression mechanism,resulting in excessive upward migration of the humeral head,erosion of the superior glenoid or acromion, and abnormal

Fig. 1

Fig. 1-A Anterior view of the right glenohumeral joint. The glenoid fossa is

approximately 2 to 4 mm deep transversely and 7 to 9 mm deep vertically.

Fig. 1-B The humeral head presents 160� of articular cartilage in both the

transverse and the coronal plane. This is apposed by 75� of glenoid ar-

ticular cartilage in the transverse plane and 95� in the coronal plane,

leaving 85� and 65�, respectively, of humeral articular cartilage uncon-

strained by the glenoid. (Reprinted from J Hand Ther. 22[4], Hurov J.,

Anatomy and mechanics of the shoulder: review of current concepts,

328-42, Copyright [2009], with permission from Elsevier.

http://www.sciencedirect.com/science/journal//08941130.)

e34(2)

TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 94-A d NU M B E R 6 d M A R C H 21, 2012RO TAT O R CU F F TE A R AR T H R O PAT H Y: EVA LUAT I O N ,DI AG N O S I S , A N D TR E AT M E N T

joint forces. Without the inferiorly directed force of the rotatorcuff, superior migration of the humeral head resulting from theunopposed contraction of the deltoid leads to pseudoparalysis,defined as ‘‘inability to actively elevate the arm in the presenceof free passive range of motion [ROM] and in the absence of aneurologic lesion.’’11 The compromised rotator cuff integrityleads to loss of the negative pressure within the glenohumeraljoint, leakage of synovial fluid into the surrounding soft tissue,and a decrease in the quality of the synovial fluid remainingwithin the compartment. Accompanying the synovial fluid thatescapes the compartment are vital nutrients necessary for thehealth of articular cartilage. In addition, decreased shoulderactivity secondary to pain further reduces the delivery of sy-novial nutrients, hastening articular cartilage degeneration anddisuse osteopenia1,4. However, although numerous pathologicmechanisms for the development of rotator cuff tear ar-thropathy have been proposed, it remains unclear why onlysome patients with a massive rotator cuff tear progress torotator cuff tear arthropathy or why patients with similar ra-diographic findings may have widely variable clinical presen-tations, including retention of full active shoulder elevation insome cases.

History and Physical Examination

As in every orthopaedic examination, the physician shouldelicit basic information regarding the onset of pain,

qualitative weakness, prior injuries or surgical procedures,neurologic history, and functional deficits. Patients with rota-tor cuff arthropathy are typically elderly, have a history ofprogressively worsening pain, and have limited shoulder mo-tion and stiffness. These symptoms may or may not have beenprecipitated by an acute, traumatic event. Patients with a di-agnosis of rheumatoid arthritis or of another inflammatoryarthropathy may also present with polyarthralgia and a priorhistory of medical treatment for their systemic disease4.

The physical examination begins with a global inspectionof the shoulder joint. Patients with rotator cuff tear arthropathymay present with anterosuperior escape of the humeral headfrom the glenoid, indicating a grossly deficient subscapularisand supraspinatus12. However, more commonly, only markedatrophy of the shoulder musculature, especially of the supra-spinatus and infraspinatus muscles, is appreciated. A ‘‘fluidsign’’ or shoulder swelling, resulting from increased fluidpressure in the subacromial bursa, may also be observed4. Priorto assessing the range of motion of the glenohumeral joint, acervical spine examination should be performed to rule out acervical spine disorder that may be causing referral of pain tothe shoulder area. Both passive and active glenohumeral mo-tion in patients with rotator cuff tear arthropathy will be lim-ited by weakness, pain, and stiffness, but to varying degrees.Some patients will demonstrate a tolerable range of activeshoulder motion because of compensation by the deltoid muscleand a relatively stable fulcrum of motion, whereas others willpresent with pseudoparalysis during attempted abduction andforward flexion. Deficiencies in the active range of motion willalso be apparent in external rotation. In addition, patients maydevelop a painful hemarthrosis2,11.

The strength of the rotator cuff musculature should beassessed in the standard fashion. The supraspinatus can beassessed by applying a resisted downward pressure with theshoulder abducted 90� in the plane of the scapula, the elbow inextension, and the arm in maximal internal rotation. The in-fraspinatus can be assessed by testing external rotation strengthwith the arm in 0� of abduction and the elbow flexed to 90�.The lift-off test, as described by Gerber and Krushell, can beused to assess subscapularis strength. With the arm in maximalinternal rotation and the dorsum of the hand resting on themid-lumbar region, resisted movement away from the body isassessed13. Alternatively, the examiner can place the hand awayfrom the mid-lumbar region and assess the patient’s ability to

Fig. 2-A Fig. 2-B

Both mechanical factors (Fig. 2-A) and nutritional factors (Fig. 2-B) have been hypothesized to contribute to joint destruction in rotator cuff tear arthropathy.

(Reproduced, with modification, from: Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65:1232-44.)

e34(3)



maintain this position. In addition, the abdominal compres-sion test, initially described by Burkhart and Tehrany, can beperformed14. In this test, the patient presses the palm againstthe abdomen with the wrist in the neutral position and theelbow anterior to the thorax. If the wrist flexes volarly or ifthe elbow falls posterior to the thorax when pressed against theabdomen, this indicates a subscapularis tear. Lastly, the teresminor can be assessed by testing resisted external rotation ofthe arm with the shoulder in 90� of abduction in the plane ofthe scapula and the elbow in 90� of flexion. The inability tomaintain the externally rotated position, or difficulty bringingthe hand to the mouth without shoulder abduction, has beendescribed by Walch et al. as a positive hornblower’s sign (Fig.3)15. Patients with rotator cuff tear arthropathy often demon-strate severe pain and weakness with attempted strength testingof the rotator cuff musculature.

Diagnostic Imaging

Rotator cuff tear arthropathy can frequently be diagnosed onthe basis of only the clinical examination and radiographs,

as standard radiographic views (anteroposterior, scapular, andaxillary) may demonstrate characteristic findings. The examinershould assess for gross shifting or medialization of the gleno-humeral center of rotation, and the axillary view radiograph willprovide good visualization of the glenoid bone stock. Charac-teristic findings of rotator cuff tear arthropathy include, but arenot limited to, (1) femoralization, or erosion of the greater tu-berosity of the humerus due to contact with the acromion; (2)

acetabulization, or thinning of the coracoacromial arch anddestruction of the superior glenoid; (3) a decreased glenohu-meral distance secondary to superior migration of the humeralhead; (4) osteopenia in both the proximal aspect of the humerusand the glenoid; (5) glenohumeral subluxation; (6) osteophyteformation at points of fixed contact between the humeral headand glenoid; and (7) joint space narrowing (Fig. 4)16,17. In con-trast, patients with primary degenerative joint disease and anintact rotator cuff often demonstrate osteophytes on the inferiorand medial aspects of the humeral head, wear that predomi-nantly involves the posterior aspect of the glenoid, and no su-perior migration of the humeral head4.

Computed tomography (CT) of the glenohumeral joint canprovide useful preoperative information regarding the glenoidbone stock and version. If substantial subacromial wear is seen onradiographs, a CT scan can assess the competence of the coraco-acromial arch or detect the presence of an acromial stress fracture.Magnetic resonance imaging (MRI) is useful for assessing the in-tegrity of the rotator cuff and the presence of a reparable tear inpatients with physical examination findings that are difficult tointerpret. Key aspects for preoperative planning include the extentof the tear, the integrity of the articular cartilage, and the presence offatty infiltration of the muscles. Fatty muscle infiltration secondaryto disuse may occur following a chronic, massive rotator cuff tear,but infiltration may also indicate the presence of pathologic nervecompression. Although CT, MRI, or ultrasonography is beneficialfor confirmation of a suspected rotator cuff insufficiency and forpreoperative planning, they are often not required for diagnosis.

Fig. 3-A Fig. 3-B

Drawing demonstrating assessment of teres minor strength (Fig. 3-A) and photograph of a patient with a positive hornblower’s sign (Fig. 3-B). (Reproduced,

with permission, from: Walch G, Boulahia A, Calderone S, Robinson AH. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone

Joint Surg Br. 1998;80:624-8.)

e34(4)



Classification Systems

Classification systems applicable to rotator cuff tear arthrop-athy include the Hamada system18 and the Seebauer system19.

The Hamada classification system divides massive rotator cufftears into five radiographic stages, with successive stages dem-onstrating findings consistent with progression of the rotator cufftear arthropathy18. In Stage 1, the acromiohumeral interval is>6 mm. In Stage 2, the acromiohumeral interval is <5 mm. InStage 3, the acromiohumeral interval is <5 mm and acetabuliza-tion of the coracoacromial arch is present. In Stage 4, the gleno-humeral joint is narrowed, either without acetabulization (Stage4a) or with acetabulization (Stage 4b). In Stage 5, humeral headosteonecrosis results in collapse.

The Seebauer classification system is a biomechanical de-scription of rotator cuff tear arthropathy, in which each type isdistinguished on the basis of the degree of superior migrationfrom the center of rotation and the amount of instability. Theamount of decentralization seen on radiographs is dependent on‘‘the extent of the rotator cuff tear, the integrity of the coraco-acromial arch, and the degree and direction of the glenoid boneerosion,’’ and thus this classification system is intended to be aradiographic correlate of the underlying pathology seen in ro-tator cuff tear arthropathy (Fig. 5)19.

History of Treatment Options

The initial management of rotator cuff tear arthropathyshould begin with conservative measures, including

activity modification, oral analgesics, physical therapy, andintra-articular injections. Patients with an intact deltoid and anadequately stable fulcrum of motion may present with an ac-ceptable degree of shoulder motion, and such patients are idealcandidates for nonoperative management2,16. Intra-articular cor-ticosteroid injections may initially be effective, although re-peated injections are discouraged because of diminishingutility and a possibly increasing risk of infection20. Although

the initial management of rotator cuff tear arthropathy shouldbegin with conservative measures, surgical intervention isoften required.

Rotator cuff tear arthropathy remains a complicated path-ologic process to manage surgically, and a wide array of surgicaltechniques and prostheses have historically been used with limitedsuccess. The primary difficulty has involved reliably creating astable fulcrum of motion that eliminates pain but preservesshoulder motion and long-term survival. Past surgical optionshave varied with regard to the amount of constraint inherent inthe prosthesis design. In general, implants with greater constraintprovide greater initial stability but at the expense of shouldermotion and implant longevity.

One surgical option has been glenohumeral arthrodesis,which has the goal of relieving pain by eliminating motion.The most glaring drawback to this procedure is that the patientwill lack glenohumeral joint motion, and compensatory scap-ulothoracic motion may expose the acromioclavicular joint toexcessive motion and result in pain21,22. However, glenohumeralarthrodesis remains a possible salvage procedure in patients withrotator cuff arthropathy who have undergone multiple failedsurgical procedures, have an irreparable rotator cuff defect, havea history of infection, or have a deficient deltoid23. At the op-posite end of the spectrum with regard to constraint, resectionarthroplasty has been attempted to treat rotator cuff tear ar-thropathy, but the creation of a flail shoulder, with the accom-panying risk of brachial plexus traction neuritis, keeps this asalvage procedure as well4.

Numerous arthroplasty options have been designed to treatrotator cuff tear arthropathy. Total shoulder arthroplasty shouldbe considered in patients with a functional deltoid muscle, pref-erably accompanied by an intact coracoacromial arch24. One of theearliest arthroplasty designs was the hinged, or fully constrained,total shoulder arthroplasty design. The rationale for this designwas the creation of a stable fulcrum of motion, located at the

Fig. 4

Anteroposterior (Fig. 4-A) and axillary (Fig. 4-B) radiographs of a shoulder with a prior rotator cuff repair demonstrating acetabulization, femoralization, and

superior migration of the humeral head.

e34(5)



glenoid, through which the deltoid muscle could move the hu-merus. This design is no longer used in the setting of rotatorcuff tear arthropathy because the fully constrained glenohumeralarticulation leads to excessive stresses at the interface betweenthe bone and the glenoid implant, leading to rapid implantloosening; complication rates have been reported to be as high as87.5%25. Semi-constrained total shoulder arthroplasties weredesigned to resist superior translation of the humerus throughthe use of an enlarged glenoid component. However, despite thedecrease in constraint relative to the hinged total shoulder ar-throplasty design, increased stress at the interface between thebone and the glenoid implant also predisposes this design toearly glenoid implant loosening and failure26–28.

Conventional total shoulder arthroplasty has also beenused in the setting of rotator cuff tear arthropathy, with initialreports (Table I) demonstrating improved outcomes comparedwith constrained and semi-constrained designs. Conventionaltotal shoulder arthroplasty can reduce pain and improve shoulder

motion, especially in patients with a reparable rotator cuff tear. In1982, Neer et al. reported the results of total shoulder arthroplastyin sixteen patients with rotator cuff tear arthropathy; 91% of theprocedures were successful, according to ‘‘limited goals’’ criteria,at a mean of thirty months postoperatively26. However, in 1988,Franklin et al. retrospectively reviewed the results of conventionaltotal shoulder arthroplasty in fourteen patients with rotator cufftear arthropathy and found that 50% had glenoid componentloosening at a mean of thirty-seven months postoperatively, with30% requiring a component revision. In addition, 46% of pa-tients had persistent pain and 15% had instability. Without thecompressive and inferiorly directed force vector of the rotatorcuff, the humeral head displaced superiorly with arm motion,leading to eccentric loading of the glenoid component (the‘‘rocking horse’’ phenomenon)29. More recently, Nwakama et al.found only a 14% success rate, according to ‘‘limited goals’’ cri-teria, in seven patients with rotator cuff tear arthropathy treatedwith conventional total shoulder arthroplasty30. Consequently,

Fig. 5

The Seebauer classification system is a biomechanical description of rotator cuff tear arthropathy based on clinical and radiographic parameters.

(Reproduced from: Visotsky JL, Basamania C, Seebauer L, Rockwood CA, Jensen KL. Cuff tear arthropathy: pathogenesis, classification, and algorithm for

treatment. J Bone Joint Surg Am. 2004;86[Suppl 2]:35-40.)

e34(6)



rotator cuff tear arthropathy is now considered a contraindicationto the performance of conventional total shoulder arthroplastybecause of the high rates of component failure and complications.

Hemiarthroplasty remains a viable option for the treat-ment of rotator cuff tear arthropathy, especially in patients whohave coped with the rotator cuff deficiency and maintained afunctional range of shoulder motion preoperatively. The risk ofglenoid component failure is avoided by replacing only thearticular surface of the humerus. In addition, the use of a larger,‘‘cuff tear arthropathy’’ humeral head designed to articulatewith both the glenoid and acromion has been shown to im-prove the stability of the implant. Williams and Rockwoodreported the results of hemiarthroplasty in twenty-one patientswith rotator cuff tear arthropathy; 86% of the patients had asuccessful result, according to ‘‘limited goals’’ criteria, at amean of forty-eight months postoperatively and none had re-quired revision arthroplasty20. Similarly, Zuckerman et al. as-sessed the results of hemiarthroplasty in fifteen patients withrotator cuff tear arthropathy and found that 87% were satisfiedwith the outcome at a mean of twenty-eight months postop-eratively31. However, the risk of resorption of the glenoid and

the acromion, along with the limited improvement in shouldermotion, remain concerns associated with the use of hemiar-throplasty in cases of rotator cuff tear arthropathy. In addition,humeral instability continues to be a long-term concern, es-pecially in patients with a prior acromioplasty or an incom-petent coracoacromial arch. Sanchez-Sotelo et al. reportedanterosuperior instability in seven of thirty patients with ro-tator cuff tear arthropathy treated with hemiarthroplasty, andonly 67% of the procedures were considered successful at amean of five years postoperatively32.

More recently, the popularity of reverse total shoulderarthroplasty for the management of rotator cuff tear arthrop-athy has increased. This design reverses the anatomy of thenative glenohumeral joint by placing the ‘‘ball’’ at the glenoidposition and the ‘‘socket’’ on the humerus (Fig. 6). Modernreverse total shoulder arthroplasty designs, based on modifi-cations made by Professor Grammont, have shown encourag-ing results. Biomechanical improvements, such as moving thecenter of rotation distally and medially to improve deltoidfunction, have led to improved implant stability and an in-crease in the range of shoulder motion prior to subacromial

TABLE I Reports of Clinical Outcomes Following Arthroplasty for the Treatment of Rotator Cuff Tear Arthropathy (CTA) �

Study NFollow-up

(mo) Subjective Outcome Functional Score*

Total shoulder arthroplasty‡Neer, 198226 16 30 91% successful§Franklin, 198829 14 37 46% pain, 15% instabilityNwakama, 200030 7 63 14% successful§

Hemiarthroplasty#Williams, 199620 21 48 86% successful§, 0% excellentField, 199740 16 33 63% successful§Zuckerman, 200031 15 28 87% satisfied UCLA, 22Sanchez-Sotelo, 200132 37 60 67% successful§Goldberg, 200841 34 44 76% successful§ ASES, 67

Reverse total shoulder arthroplasty**Sirveaux, 200435 80 44 96% no or

little painConstant, 65.6

Werner, 200539 58 38 Subjective ShoulderValue, 56%

Constant, 64

Boileau, 200642 21 40 95% satisfied or verysatisfied

Constant, 66

Frankle, 200543 60 33 68% good or excellent ASES, 68.2Wall, 200744 59 40 93% satisfied

or verysatisfied

Constant, 65.6

Young, 200936 33 38 89% good or excellent ASES, 70

*UCLA = University of California Los Angeles score, and ASES = American Shoulder and Elbow Surgeons score. †FF = forward flexion, ER =external rotation, RTSA = reverse total shoulder arthroplasty, and abd. = abduction. ‡Because of the high rate of component failure (loosening inup to 50%) and the complication rate of 50% to 71%, cuff tear arthropathy is considered a contraindication to performing a total shoulderarthroplasty. §Based on Neer’s ‘‘limited goals criteria.’’ #Hemiarthroplasty remains a viable option in the treatment of CTA, especially in patientswho have coped with the rotator cuff deficiency and maintain a functional range of motion preoperatively. **Promising results have beendemonstrated with the use of reverse TSA to treat CTA; however, complication rates remain high, demonstrating the importance of strict patientselection and surgeon experience.

e34(7)



RevisionRate (%) Component Failure Rate (%)

ComplicationRate (%)

InfectionRate (%) Other†

6% 30% radiolucencies Based on ‘‘limited goals’’ criteria (Neer)30% 50% glenoid loosening 50% Coined term ‘‘rocking horse glenoid’’29% 43% loosening, 14% gross position shift 71% 0% ‘‘Limited goals’’ criteria

0% No clinical failures 0% ‘‘Limited goals’’ criteria13% 0% 38% 0% ‘‘Limited goals’’ criteria

0% 0% 7% 0% FF 69� to 86�, ER 15� to 29�0% 0% 5% 0% FF 72� to 91�, ‘‘limited goals’’ criteria0% 0% 6% 0% FF 78� to 111�, ‘‘limited goals’’ criteria

4% 6% loosening, 9% dissociation 12% at 5 years,71% at 7 years

16% grade-3 or 4 notching

33% 7% loosening, 9% dislocation,2% dissociation

50% Revision RTSA had significantlyworse results

0% 0% loosening 24% 0% 11% grade-3 or 4 notching

12% 3% glenoid loosening 17% 3% FF 55� to 105�, abd. 41� to 102�27% revisionprocedures(54 cases)

8% dislocation 19% 4%

0% 0% 8% 0% 24% notching

TABLE I (continued)

Fig. 6

Anteroposterior radiograph of the left

shoulder demonstrating a hemiarthro-

plasty performed to treat a proximal hu-

meral fracture (left). The hemiarthroplasty

was later converted to a reverse total

shoulder arthroplasty, using the same

humeral stem, because of rotator cuff

deficiency (right).

e34(8)



impingement33–35. Sirveaux et al. presented the results of reversetotal shoulder arthroplasty in eighty patients with rotator cufftear arthropathy; the mean Constant score was 65.6 at a meanof forty-four months postoperatively, with 96% of patientshaving little or no pain35. Similarly, Young et al. noted 89% ofpatients to have good or excellent results at a mean of thirty-eight months postoperatively, with a mean American Shoulderand Elbow Surgeons (ASES) score of 70 points36. In a review ofsixty patients, Frankle et al. noted significant improvements inthe mean ASES score from 34.3 to 68.2 points, in forwardflexion from 55.0� to 105.1�, and in abduction from 41.4� to101.8� after reverse total shoulder arthroplasty37. However,despite these encouraging results, complications after reversetotal shoulder arthroplasty for rotator cuff tear arthropathyremain a concern, as reported complications include asepticloosening, instability, implant dissociation, infection, fracture,neurapraxia, and radiographic signs of scapular notch-ing11,33,35,38,39. Revision rates and overall complication rates havebeen reported to be as high as 26% and 71%, respectively, instudies with medium to long-term follow-up15,35,39. Thus, al-though reverse total shoulder arthroplasty has demonstratedpromising clinical results, it remains a technically difficultprocedure with a high risk of complications.

Proposed Treatment Algorithm

During the initial evaluation of a patient with rotator cufftear arthropathy, several key aspects of the patient’s pre-

sentation may guide the surgeon toward a specific treatmentplan. Although a unique decision analysis must be performedfor each patient, a simplified treatment algorithm is presented

in Figure 7. This algorithm begins with a patient with a massive,irreparable rotator cuff tear with or without glenohumeralarthritis. Thus, although only those patients with glenohu-meral arthritis are considered to have rotator cuff tear ar-thropathy, patients without glenohumeral arthritis are alsoincluded in this algorithm as patients in both groups maypresent with similar symptoms.

Two key aspects to consider when evaluating a patient arethe patient’s age and desired activity level. Certain patients mayhave a physiologic age that does not match their chronologicage, and some of these patients may wish to return to a higherlevel of activity and may expect a greater functional range ofshoulder motion postoperatively compared with other patientsof similar age. Such patients may be more satisfied with a re-verse total shoulder arthroplasty than with a hemiarthroplasty.In contrast, relatively sedentary patients may be seeking onlypain relief, and such patients may be better suited for a hemi-arthroplasty. It is helpful to distinguish whether a patient’sprimary complaint is pain or decreased shoulder motion.

Another key aspect to consider is the presence or absenceof pseudoparalysis of the glenohumeral joint. Patients withpseudoparalysis are often unable to cope functionally, in thesetting of glenohumeral arthritis; such patients often require areverse total shoulder arthroplasty to restore a functional rangeof motion. Although high complication rates have been re-ported following reverse total shoulder arthroplasty, this op-tion can be very effective in patients with both pseudoparalysisand glenohumeral arthritis. A concomitant latissimus dorsitransfer can be performed to further improve shoulder externalrotation. In contrast, hemiarthroplasty may be indicated for

Fig. 7

A proposed treatment algorithm for the management of a massive, irreparable rotator cuff tear. RTC = rotator cuff, GH = glenohumeral, RTSA = reverse total

shoulder arthroplasty, and CTA = cuff tear arthropathy.

e34(9)



patients with glenohumeral arthritis without pseudoparalysis,as this procedure can provide good results in patients withstable shoulder kinematics and a functional subscapularismuscle that prevents anterosuperior escape. Thus, assessing apatient’s physiologic age and functional goals and performinga thorough clinical and radiographic examination will help toguide the surgeon to the appropriate surgical treatment for apatient with rotator cuff tear arthropathy.

Summary

Adequate treatment of the pathologic process of rotator cufftear arthropathy remains a complicated problem. Nu-

merous pathways have been proposed as the cause of rotatorcuff tear arthropathy, but the exact etiology remains unclear, asdoes the reason that only some patients with massive rotatorcuff tears develop rotator cuff tear arthropathy. Characteristicclinical examination findings include superior migration of thehumeral head, pseudoparalysis with attempted elevation of theupper extremity at the shoulder, and a positive hornblower’ssign. Radiographs demonstrating ‘‘femoralization’’ of the hu-meral head and ‘‘acetabulization’’ of the coracoacromial arch incases of end-stage rotator cuff tear arthropathy can be diag-

nostic. Although the initial management of rotator cuff ar-thropathy should begin with conservative measures, surgicalintervention is often required. Promising results following re-verse total shoulder arthroplasty have led to an increase in theutilization of this procedure. However, complication rates re-main high, demonstrating the importance of strict patient se-lection and careful operative technique as well as the necessityof future design modifications. n

Denis Nam, MDTravis G. Maak, MDBradley S. Raphael, MDChristopher K. Kepler, MDMichael B. Cross, MDRussell F. Warren, MDSports Medicine and Shoulder Service,Department of Orthopaedic Surgery,Hospital for Special Surgery,535 East 70th Street,New York, NY 10021.E-mail address for D. Nam: [email protected]

References

1. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am.1983;65:1232-44.2. Jensen KL, Williams GR Jr, Russell IJ, Rockwood CA Jr. Rotator cuff tear ar-thropathy. J Bone Joint Surg Am. 1999;81:1312-24.3. Hurov J. Anatomy and mechanics of the shoulder: review of current concepts.J Hand Ther. 2009;22:328-42.4. Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkhead WZ Jr. The rotator cuff-deficient arthritic shoulder: diagnosis and surgical management. J Am Acad OrthopSurg. 1998;6:337-48.5. Lippitt S, Matsen F. Mechanisms of glenohumeral joint stability. Clin Orthop RelatRes. 1993;291:20-8.6. Burkhart SS. Fluoroscopic comparison of kinematic patterns in massiverotator cuff tears. A suspension bridge model. Clin Orthop Relat Res. 1992;284:144-52.7. Warner JJP. The gross anatomy of the joint surface, ligament, labrum and cap-sule. In: Matsen FA, Fu FH, Hawkins RJ, editors. The shoulder: a balance of mobilityand stability. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1993.p 7-28.8. Halder AM, Itoi E, An KN. Anatomy and biomechanics of the shoulder. Orthop ClinNorth Am. 2000;31:159-76.9. Itoi E, Morrey BF, An KN. Biomechanics of the shoulder. In: Rockwood CA, MatsenFA, Wirth MA, Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: W.B. Saunders;2009. p 213-50.10. Halverson PB, Cheung HS, McCarty DJ, Garancis J, Mandel N. ‘‘Milwaukeeshoulder’’—association of microspheroids containing hydroxyapatite crystals, ac-tive collagenase, and neutral protease with rotator cuff defects. II. Synovial fluidstudies. Arthritis Rheum. 1981;24:474-83.11. Gerber C, Pennington SD, Nyffeler RW. Reverse total shoulder arthroplasty. J AmAcad Orthop Surg. 2009;17:284-95.12. Roberts CC, Ekelund AL, Renfree KJ, Liu PT, Chew FS. Radiologic assessment ofreverse shoulder arthroplasty. Radiographics. 2007;27:223-35.13. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularismuscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991;73:389-94.14. Burkhart SS, Tehrany AM. Arthroscopic subscapularis tendon repair: techniqueand preliminary results. Arthroscopy. 2002;18:454-63.15. Walch G, Wall B, Mottier F. Complications and revision of the reverse pros-thesis, a multicenter study of 457 cases. In: Walch G, Boileau P, Mole D, Favard L,Levigne C, Sirveaux F, editors. Reverse shoulder arthroplasty: clinical results,complications, revision. Montpellier, France: Sauramps Medical; 2006.p 335-52.16. Ecklund KJ, Lee TQ, Tibone J, Gupta R. Rotator cuff tear arthropathy. J Am AcadOrthop Surg. 2007;15:340-9.

17. McFarland EG, Sanguanjit P, Tasaki A, Keyurapan E, Fishman EK, Fayad LM. Thereverse shoulder prosthesis: a review of imaging features and complications.Skeletal Radiol. 2006;35:488-96.18. Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings inmassive rotator cuff tears. A long-term observation. Clin Orthop Relat Res. 1990;254:92-6.19. Visotsky JL, Basamania C, Seebauer L, Rockwood CA, Jensen KL. Cuff teararthropathy: pathogenesis, classification, and algorithm for treatment. J Bone JointSurg Am. 2004;86 Suppl 2:35-40.20. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-deficientshoulders. J Shoulder Elbow Surg. 1996;5:362-7.21. Scalise JJ, Iannotti JP. Glenohumeral arthrodesis after failed prosthetic shoul-der arthroplasty. J Bone Joint Surg Am. 2008;90:70-7.22. Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-termfunctional results. J Bone Joint Surg Am. 1979;61:668-77.23. Arntz CT, Matsen FA 3rd, Jackins S. Surgical management of complex irrepa-rable rotator cuff deficiency. J Arthroplasty. 1991;6:363-70.24. Collins DN, Harryman DT 2nd. Arthroplasty for arthritis and rotator cuff defi-ciency. Orthop Clin North Am. 1997;28:225-39.25. Post M. Constrained arthroplasty of the shoulder. Orthop Clin North Am. 1987;18:455-62.26. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulderreplacement. J Bone Joint Surg Am. 1982;64:319-37.27. Orr TE, Carter DR, Schurman DJ. Stress analyses of glenoid component de-signs. Clin Orthop Relat Res. 1988;232:217-24.28. Amstutz HC, Thomas BJ, Kabo JM, Jinnah RH, Dorey FJ. The Dana total shoulderarthroplasty. J Bone Joint Surg Am. 1988;70:1174-82.29. Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in totalshoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3:39-46.30. Nwakama AC, Cofield RH, Kavanagh BF, Loehr JF. Semiconstrained totalshoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing.J Shoulder Elbow Surg. 2000;9:302-7.31. Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff tear arthrop-athy. J Shoulder Elbow Surg. 2000;9:169-72.32. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthroplasty for gle-nohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint SurgAm. 2001;83:1814-22.33. Boileau P, Watkinson D. Reverse total shoulder arthroplasty for cuff tear ar-thropathy. In: Zukerman J, editor. Advanced reconstruction shoulder. Rosemont, IL:AAOS; 2007. p 579-90.

e34(10)



34. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005:The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, frac-ture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.35. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont invertedtotal shoulder arthroplasty in the treatment of glenohumeral osteoarthritis withmassive rupture of the cuff. Results of a multicentre study of 80 shoulders. J BoneJoint Surg Br. 2004;86:388-95.36. Young SW, Everts NM, Ball CM, Astley TM, Poon PC. The SMR reverse shoulderprosthesis in the treatment of cuff-deficient shoulder conditions. J Shoulder ElbowSurg. 2009;18:622-6.37. Frankle M, Levy JC, Pupello D, Siegal S, Saleem A, Mighell M, Vasey M.The reverse shoulder prosthesis for glenohumeral arthritis associated with severerotator cuff deficiency. A minimum two-year follow-up study of sixty patients. Surgicaltechnique. J Bone Joint Surg Am. 2006;88 Suppl 1 Pt 2:178-90.38. Middernacht B, De Wilde L, Mole D, Favard L, Debeer P. Glenosphere disen-gagement: a potentially serious default in reverse shoulder surgery. Clin OrthopRelat Res. 2008;466:892-8.

39. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudo-paresis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87:1476-86.40. Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of the shoulderfor rotator cuff arthropathy. J Shoulder Elbow Surg. 1997;6:18-23.41. Goldberg SS, Bell JE, Kim HJ, Bak SF, Levine WN, Bigliani LU. Hemiarthro-plasty for the rotator cuff-deficient shoulder. J Bone Joint Surg Am. 2008;90:554-9.42. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverseshoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revisionarthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.43. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The reverseshoulder prosthesis for glenohumeral arthritis associated with severe rotator cuffdeficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint SurgAm. 2005;87:1697-705.44. Wall B, Nove-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse totalshoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am.2007;89:1476-85.

e34(11)



rotator cuff tear arthropathy: evaluation, diagnosis, and...

Documents