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Last updated Thursday, January 27, 2005
Stuffing and strength
The deltoid
The rotator cuff
The rotator cuff mechanism is in jeopardy in shoulder arthroplasty for several reasons. The suprascapular nerve, which supplies the supraspinatus and infraspinatus, is at risk during surgical releases as it courses medial to the coracoid and then down the back of the glenoid 1 cm medial to the glenoid lip. The cuff tendons are at risk during surgery because the humeral cut must come close to their insertion to the tuberosities superiorly and posteriorly. A humeral cut made in excessive retroversion is likely to detach the cuff posteriorly, and a cut made too low on the humerus is likely to detach the cuff superiorly. Overstuffing the joint places the cuff under tension when the arm is adducted or rotated. Most shoulder arthroplasties are performed for older individuals in whom the quality of the cuff tissue may be compromised not only from age-related changes, but also from disuse enforced by chronic glenohumeral roughness. Shoulder arthroplasty may quickly restore motion and smoothness to the joint, placing new and substantial demands on the disused cuff tissue. Thus the rehabilitation program and the patient's activities after arthroplasty must gradually increment the loads on the cuff, allowing the tissue the opportunity to toughen over time.
If a cuff defect exists at the time of the arthroplasty, a cuff repair to bone should be carried out, if the quantity and quality of the cuff tissue are sufficient to allow a durable repair under physiologic tension with the arm at the side. If the tuberosities are nonunited or if a tuberosity osteotomy is performed, secure fixation is required to restore cuff function. Under these circumstances the rehabilitation after arthroplasty is changed dramatically to allow for secure healing of the cuff mechanism to the humerus.
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