Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

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Cuff tear arthropathy

About cuff tear arthropathy

Rotator cuff tear arthropathy (or shoulder arthritis with a large rotator cuff tear) is a severe and complex form of shoulder arthritis in which the shoulder has lost not only the cartilage that normally covers its joint surface, but also the tendons of the rotator cuff tear which help position and power the joint.

Normally, the tendons of the rotator cuff (large arrows) allow smooth motion of the upper end of the arm bone (humerus) beneath the overlying bones and muscles.

When the rotator cuff is degenerated, chronically torn or otherwise deficient, the normally smooth upper surface of the upper end of the arm bone (humeral head) is unprotected from rubbing with the undersurface of the bone and ligaments above.

In cuff tear arthropathy, the upper surface of the ball of the upper arm bone (humeral head) becomes roughened as it rubs against the overlying bone (the acromion). This condition results in shoulder pain, weakness, stiffness and grinding on movement.

Treatment options for cuff tear arthropathy include partial joint replacement with a cuff tear arthropathy (CTA) prosthesis. If severe instability of the joint complicates cuff tear arthropathy, a reversed (reverse Delta) prosthesis may be indicated.

In this condition resisted isometric contraction of the cuff muscles is weak; acromiohumeral and often glenohumeral movements produce crepitance; radiographs demonstrate superior translation of the head of the humerus with respect to the acromion, loss of the articular cartilage of the superior humeral head, direct articulation of the head with the coracoacromial arch, "femoralization" of the proximal humerus and "acetabularization" of the upper glenoid and coracoacromial arch (see figures 76-79).

The combination of glenohumeral joint surface destruction and massive cuff deficiency can be devastating. (Neer, Craig, 1983) Yet, each patient has an individual combination of pain and functional losses. Patients with mild pain are managed with mild analgesics and gentle, function-maintaining exercises.

When chronic cuff deficiency with upward displacement of the humeral head leads to repeated abrasive contact between the upper humerus and the coracoacromial arch and symptomatic destruction of the humeral articular cartilage, reconstructive options are seriously limited. Shoulder arthrodesis is unattractive because these patients are often older and the condition may be bilateral. (Neer, 1983) Constrained total shoulder arthroplasty is an option, but the failure rate is very high. Secure cuff reconstruction with unconstrained total shoulder arthroplasty is usually impossible owing to massive cuff tissue deficiency. (Franklin, Barrett, 1988) Unconstrained arthroplasty without a secure cuff repair carries a high incidence of eccentric loading and "rocking horse" loosening of the component (see figure 80). (Franklin, Barrett, 1988, Matsen, Lippitt, 1994)

In a 1986 report to the ASES, Brownlee and Cofield reported on 20 surgical procedures for cuff tear arthropathy. (Brownlee and Cofield, 1986) These included Neer-type total shoulder arthroplasty, total shoulder arthroplasty using a hooded glenoid, and proximal humeral replacement without a glenoid. Extensive mobilization of tendons was attempted for repair. Pain relief was substantial in each group. Active abduction was best in the group with proximal humeral replacement. Three of the glenoid components loosened.

Arntz et al (Arntz, Jackins, 1993) reported our results in 19 patients, 54 to 84 years of age who had disabling pain attributable to a massive tear of the rotator cuff, accompanied by loss of the surface of the glenohumeral joint. These patients were not considered candidates for total shoulder replacement because of the massive deficiency in the cuff and the fixed upward displacement of the humeral head (see figures 76-79). A prerequisite for hemiarthroplasty was a functionally intact coracoacromial arch to provide superior secondary stability for the prosthesis. One important aspect of the operative technique was the selection of a sufficiently small prosthetic head volume so that excessive tightness of the posterior aspect of the capsule could be avoided (see Chapter 16 for discussion of "overstuffing"). Eighteen shoulders in sixteen patients were available for follow-up, which ranged from twenty-five to 122 months. Pain decreased from marked or disabling in fourteen shoulders preoperatively to none or slight in ten and to pain only after unusual activity in four. Active forward elevation improved from an average of 66 degrees preoperatively to an average of 109 degrees postoperatively. One patient, who had had an excellent result, fell and sustained an acromial fracture, so the functional result changed to poor. Three patients had persistent, substantial pain in the shoulder that led to a revision. Neither infection nor prosthetic loosening developed in any shoulder.

In a separate report, Arntz et al (Arntz, Matsen III, 1991) reviewed 23 shoulders in 23 patients with disabling pain associated with irreparable tears of the musculotendinous cuff. 12 shoulders with preserved passive motion, normal deltoid function, loss of glenohumeral joint surfaces, and sculpturing of the coracoacromial arch received a reconstruction with a humeral hemiarthroplasty. In another 11 shoulders that failed to meet these prerequisites or that demanded heavy use after operation, glenohumeral arthrodesis was selected. Comfort level and overall function were improved in both groups. Active forward elevation improved an average of 44 degrees in the hemiarthroplasty group and an average of 15 degrees in the arthrodesis group. These results coupled with the problems of glenoid loosening reported when total shoulder arthroplasty (see figure 80) is performed in the presence of cuff deficiency with upward head displacement suggest that humeral hemiarthroplasty is the preferred method for managing complex irreparable tears of the rotator cuff in which the articular surface is destroyed, yet the deltoid muscle is functional (see figures 78, 81, and 82). Shoulder arthrodesis is reserved for those patients who have both irreparable tears of the rotator cuff and irreparable deficiencies of the deltoid muscle, or the younger patient with demands for substantial strength at low angles of flexion (see figure 83).

Authors' preferred method for cuff tear arthropathy

In the reconstruction for cuff tear arthropathy we attempt to make use of the "femoralization" of the proximal humerus (i.e. rounding so that the prominence of the tuberosities is lost) and the "acetabularization" of the gleno-coraco-acromial socket (i.e. erosion of the upper aspect of the glenoid and congruent concavity of the coracoacromial arch) (see figures 77-79). We have found that this adaptive ball and socket joint can be effectively and safely resurfaced using a humeral hemiarthroplasty (see figures 81 and 82). The goals of surgery are:

1. assuring a smooth coracoacromial arch (usually already created by the process itself), avoiding acromioplasty and coracoacromial ligament section, which would destroy the superior constraint of the humeral head;
2. debriding useless fragments of cuff and bursa;
3. anatomically resurfacing the destroyed humeral articular surface with a humeral endoprosthesis which will articulate with the coracoacromial arch and at all costs, preserving the deltoid. We do not advocate cuff repair in this context, nor the use of double cups, or oversized humeral head prostheses. Instead the goal is to maintain the normal capsular laxity allowing internal rotation of the abducted arm to approximately 60 degrees.

Postoperatively, the patient is started on continuous passive motion (see figure 84) and allowed activities as comfort permits.

Disclaimer

This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.

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