Rotator Cuff Tear Arthropathy

Epidemiology

  • Mean age 69 years
  • Female’s 3:1 males
  • Associated with Rheumatoid

Aetiology

  • Massive rotator cuff tear results in loss of fulcrum
    • Massive tear is generally 3-tendon involvement
  • Usually SS, IS, TM with SSc sparing
  • Humeral head migrates superiorly because of more vertical deltoid vector
  • Coracoacromial arch forms a new more supero-anterior fulcrum
  • CAL is generally last restraint to antero-superior escape
  • Pain results from:
    • LHB inflammation and impingement
    • Acromial erosion
    • Superior glenoid erosion
  • Not all patients with massive cuff tears develop symptomatic CTA
    • Estimated 5% with symptomatic massive cuff tear develop CTA
    • Therefore majority do not develop this problem

Clinical Diagnosis

History

  • Pain
  • Pseudoparalysis – pain & inability to elevate arm at all
  • Swelling
    • Fluid formation and large effusion is a common feature

Examination

  • Cuff weakness
  • Hornblower sign (TM)
  • External Rotation lag sign (IS)
  • Must assess deltoid function
  • Muscle wasting

Imaging

XR Features

  • Reduced Acromio-humeral distance (<7mm usually pathologic)
  • Acetabularisation of acromium
  • Femoralisation of humeral head – rounding off of GT
  • Sclerosis of acromium – snow cap sign
  • Glenohumeral degeneration – especially posterior superior

MRI Scan

  • Not usually necessary to make diagnosis

CT Scan

  • If there is a doubt regarding glenoid bone stock
  • Medial erosion to coracoid is not usually a feature of CTA

Management

Non-Operative

  • Analgesia
  • Activity limitation
  • Physiotherapy
    • Concentrate on what cuff is intact
    • Subscapularis for rotational control of humeral head
    • Anterior deltoid strengthening
    • Anterior deltoid centres humeral head and helps with forward elevation
  • Only has a role in the very low demand poor surgical candidate

Operative

Arthroscopic Debridement

  • May provide some pain relief
  • Use of electrocautery may denervate soft tissues in subacromial space
  • LHB tenotomy
  • Tuberoplasty of GT – rounding it off
  • No acromioplasty should be performed
  • Strictly avoid elevating or debriding CAL
    • Last restraint to anterior-Superior escape
  • Will not improve function
  • Improves but does not solves pain

Hemiarthroplasty

  • Either stemmed or resurfacing with an extended head
  • Principle is to remove pain generators by creating bone on metal articulation
  • Using a large head creates some articulation with the glenoid
  • A viable option if forward elevation is retained (>60 degrees)
    • i.e. no pseudoparalysis
  • Problems
    • Pain
    • Acromial erosion continues
    • Glenoid erosion continues
    • Poor function
    • Continued superior migration
    • No fulcrum restored
    • Anterior-superior escape once CAL becomes deficient

Reverse Geometry Shoulder Arthroplasty (RSA)

  • Indications
    • Pseudoparalysis (<60 degrees forward elevation)
    • Elderly Patient
    • Low demand patient
    • Failed cuff repair
    • Failed previous arthroplasty
    • Unreconstructable fracture with cuff deficit
  • Design Principles
    • Moves centre of rotation medially and inferiorly
    • Restores fulcrum
    • Tensions deltoid
    • Better results with intact Subscapularis – rotational control
      • Can be combined with Lat Dorsi Transfer if SSc deficient
  • Prerequisites
    • Functional Deltoid
    • Adequate glenoid bone stock for Glenosphere implantation
    • Older Patient
    • Lower demand patient
  • Complications
    • In general are higher than other forms of shoulder arthroplasty
    • Likely due to learning curve
      • Infection
      • Inferior Scapula Notching
      • Glenoid Loosening – main cause of revision
      • Fracture – acromial or humeral
      • Nerve Injury – extensive inferior exposure required
  • Outcomes
    • Better pain relief and function than any other operation for CTA
    • But,
    • Higher complication rate
    • Bigger surgery
    • No good bail out operation
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