The Rotator Cuff–Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Craig A. Zeman, MD, Michel A. Arcand, MD, Jeffery S. Cantrell, MD, John G. Skedros, MD, and Wayne Z. Burkhead, Jr, MD

Abstract

The symptomatic rotator cuffÐdeficient, arthritic glenohumeral joint poses a localized shoulder arthritis associ- complex problem for the orthopaedic surgeon. Surgical management can be facil- ated with a large swelling about itated by classifying the disorder in one of three diagnostic categories: (1) rotator the shoulder, rotator cuff tear, cuffÐtear arthropathy, (2) rheumatoid arthritic shoulder with cuff deficiency, or biceps tendon rupture, and erosion (3) degenerative arthritic (osteoarthritic) shoulder with cuff deficiency. If it is of the superior portion of the not possible to repair the cuff defect, surgical management may include prosthet- humeral head, acromion, and distal ic arthroplasty, with the recognition that only limited goals are attainable, par- clavicle. In his classic 1934 text, ticularly with respect to strength and active motion. Glenohumeral arthrodesis Codman described the case of a 51- is a salvage procedure when other surgical measures have failed. Arthrodesis is year-old woman who had sus- also indicated in patients with deltoid muscle deficiency. Humeral hemiarthro- tained a traumatic rotator cuff tear plasty avoids the complications of glenoid loosening and is an attractive alterna- 6 years prior to surgery. During tive to arthrodesis, resection arthroplasty, and total shoulder arthroplasty. The the operation he found, in addition functionally intact coracoacromial arch should be preserved to reduce the risk of to the large cuff defect, humeral anterosuperior subluxation. Care should be taken not to ÒoverstuffÓ the gleno- head roughening, glenoid oblitera- humeral joint with a prosthetic component. In cases of significant internal rota- tion, intra-articular loose bodies, tion contracture, subscapularis lengthening is necessary to restore anterior and severe atrophy of the surrounding posterior rotator cuff balance. If the less stringent criteria of NeerÕs Ólimited musculature, and a large fluid goalsÓ rehabilitation are followed, approximately 80% to 90% of patients treated accumulation. He believed that with humeral hemiarthroplasty can have satisfactory results. these changes were the final stages J Am Acad Orthop Surg 1998;6:337-348 of a chronically neglected large rotator cuff tear.

The patient with a symptomatic must also deal with osteopenic rotator cuffÐdeficient, arthritic bone, severe soft-tissue contrac- Dr. Zeman is in private practice in Oxnard, glenohumeral joint poses a complex tures, and atrophied muscles. It Calif. Dr. Arcand is in private practice in problem for the orthopaedic sur- may be impossible to repair the cuff Norman, Okla. Dr. Cantrell is in private prac- geon. Although this condition has defect. Consequently, many of the tice in Lewisville, Tex. Dr. Skedros is in private been recognized since the early 19th patients who come to surgery are practice in Ogden, Utah. Dr. Burkhead is century, there is no consensus on its treated with prosthetic arthroplasty Clinical Associate Professor of Orthopaedic Surgery, University of Texas Southwestern 1-8 management. One of the difficul- with the recognition that only limit- Medical School, Dallas; and is in private prac- ties is the diverse clinical presenta- ed goals are attainable, particularly tice with W. B. Carrell Memorial Clinic, tion of patients with this disorder: with respect to strength and active Dallas. some have rotator cuffÐtear arthrop- motion.1,7,9-11 athy (RCTA), as defined by Neer et Reprint requests: Dr. Zeman, W. B. Carrell al1; others have end-stage rheuma- Memorial Clinic, 2909 Lemmon Avenue, Dallas, TX 75204. toid arthritis (RA) or degenerative History arthritis with cuff tears. Different Copyright 1998 by the American Academy of surgical solutions may be required Between 1830 and 1860, Smith and Orthopaedic Surgeons. for each presentation.9 The surgeon Adams described several cases of

Vol 6, No 6, November/December 1998 337 Rotator Cuff–Deficient Arthritic Shoulder

More than a century later, Bur- of the following diagnostic cate- humeral joint.14 For example, the man and co-workers described gories: (1) RCTA, (2) degenerative glenohumeral joint is balanced cases of recurrent spontaneous hem- arthritic (osteoarthritic) shoulder anteriorly and posteriorly by the orrhage into the subdeltoid bursa in with cuff deficiency, and (3) rheu- subscapularis, infraspinatus, and elderly patients with supraspinatus matoid arthritic shoulder with cuff teres minor. Most large rotator cuff tendon tears and glenohumeral deficiency. Categorization is based tears extend posteriorly into the arthritis. In 1968, DeSeze called this on specific clinical, radiographic, infraspinatus and teres minor, leav- condition l'Žpaule sŽnile hŽmorragique and laboratory findings. These des- ing the subscapularis unbalanced. (Òhemorrhagic shoulder of the ignations help the surgeon antici- Due to unbalanced force couples, elderlyÓ). In 1977, Neer introduced pate the quality of tissues, the natural volitional attempts to elevate the term Òcuff-tear arthropathyÓ to history of the disease, and the ulti- and/or rotate the arm can produce describe findings associated with a mate surgical outcome. destructive forces in the gleno- chronic full-thickness rotator cuff humeral joint. A deficient cuff may tear, which include restricted shoul- Rotator Cuff–Tear Arthropathy allow excessive upward migration der motion, erosions of the osseous In a 1983 landmark review arti- of the humeral head, resulting in structures of the shoulder, and an cle, Neer et al1 expounded on NeerÕs abrasion and erosion of the superi- arthritic, osteopenic, and collapsed original description of RCTA. or glenoid, acromioclavicular joint, humeral head.1 In the early 1980s, Because RCTA was found not to be and acromion. Because only about Halverson et al12,13 described the associated with degenerative arthri- 4% of shoulders with full-thickness ÒMilwaukee shoulder syndrome,Ó tis in other joints, they suggested rotator cuff defects progress to which is in many ways similar to that a massive rotator cuff tear is the RCTA,1 mechanical factors do not RCTA. initial event in the pathogenesis. appear to be wholly responsible for They also described mechanical and the pathologic features of RCTA nutritional factors that may precipi- described by Neer. Types of Rotator Cuff tate development of RCTA (Fig. 1). Problems in Arthritic Nutritional Factors Shoulders Mechanical Factors As in other diarthrodial joints, The concept of Òforce couplesÓ the articular surfaces of the shoul- Surgical management of a rotator in the shoulder emphasizes the crit- der receive nutrition from synovial cuffÐdeficient arthritic shoulder can ical nature of mechanical factors in fluid. A full-thickness rotator cuff be facilitated by assigning it to one the dynamic stability of the gleno- tear violates the closed joint space,

Mechanical Factors Nutritional Factors

Massive cuff defect Massive cuff defect

Reduced motion and function Loss of “water-tight” joint space Head migrates upward Gross instability

Disuse osteoporosis and Loss of pressure and Wear into acromion, acromio- Recurrent dislocations via biochemical changes in diminished quantity of clavicular joint, and coracoid “posterior mechanism” water and glycosamino- glycan content of cartilage joint fluid

Cartilage atrophy Abnormal trauma and subchondral collapse

Cuff-tear arthropathy Cuff-tear arthropathy

Fig. 1 Mechanical factors (left) and nutritional factors (right) that contribute to joint destruction in RCTA, according to Neer et al.1 (Adapted with permission from Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy. J Bone Joint Surg Am 1983;65:1232-1244.)

338 Journal of the American Academy of Orthopaedic Surgeons Craig A. Zeman, MD, et al allowing synovial fluid, with its particular seem to occur in the increasing pain that is worse at nutrients and other biochemical more destructive atrophic situa- night and is intensified by gleno- constituents, to leak into the subdel- tions. Consequently, they speculat- humeral motion. They also report toid and subacromial spaces and ed that BCP crystals may be a prod- loss of active shoulder motion. The surrounding soft tissues. In addi- uct of articular surface wear, and observation by Neer et al1 that 10 tion, pain leads to shoulder inactivi- that the crystals are produced by of 26 patients with RCTA had not ty, which reduces the delivery of processes that are secondary to joint received antecedent corticosteroid synovial nutrients and produces destruction and are not the inciting injections diminishes their impor- disuse osteopenia and joint stiff- cause. They proposed crystal depo- tance as an etiologic factor. ness. All of these factors contribute sition as an opportunistic event in Patients with OA and rotator to articular cartilage destruction. OA, with the joint damage predis- cuff tears also relate a history of posing to deposition, and the de- progressive pain and stiffness. It is Inflammatory Factors posits in turn modifying the under- not uncommon for these patients to The rheumatology literature con- lying disease. If this interpretation relate an acute traumatic event fol- tains an abundance of clinical cases is correct, Milwaukee shoulder syn- lowed by increased shoulder weak- that appear grossly similar to drome may be a localized form of ness and symptoms. Patients with RCTA.12-17 However, explanations erosive OA.16,17 rotator cuff tears and RA generally of the etiology of these conditions have a long history of polyarthritis emphasize biochemical factors, dif- Osteoarthritic Shoulder With and medical treatment for their fering from NeerÕs emphasis on defi- Cuff Tear systemic disease. They may have cient cartilage nutrition and marked In patients with an osteoarthritic pain in other joints of the hands, glenohumeral instability. In many shoulder and a cuff tear, the pri- wrists, elbows, hips, or knees. of the cases reported by rheumatolo- mary diagnosis is OA, and the In patients with RCTA, atrophy gists, crystal-induced inflammation associated cuff tear is traumatic or of the supraspinatus and infraspina- is considered to be the cause of attritional.2,18 Occasionally, hyper- tus muscles and weakness of exter- destruction. Halverson and co- trophic arthritis develops after a nal rotation and abduction are typi- workers identified basic calcium cuff tear or repair or after a shoul- cal physical findings on clinical phosphate crystals (BCPs), such as der replacement. examination. Active and passive hydroxyapatite, in the synovial tis- attempts to move the shoulder sue and fluid of shoulders with Rheumatoid Arthritic Shoulder through a functional range are limit- apparent inflammatory arthrop- With Cuff Tear ed by weakness, pain, and stiffness. athy.12,13 They hypothesized that the Patients with RA in the shoulder This is most apparent in external crystals are formed in diseased syn- and a cuff tear typically have sys- rotation and abduction. A rupture ovium and articular cartilage and temic symptoms, physical signs, of the biceps tendon may be detect- then released into the synovial fluid. and radiographic and laboratory ed. A large shoulder swelling, or Subsequent phagocytosis of these findings consistent with RA. The Òfluid sign,Ó which results from crystals by macrophages induces a radiographic appearance is similar chronic, excessive fluid pressure in phlogistic response that destroys the to that of RCTA, albeit commonly the subacromial bursa, may also be rotator cuff tendon and articular car- with more destruction.18 Extensive noted (Fig. 2). Aspiration of the tilage. As the tissue is damaged, rotator cuff tearing is not usual in fluid, which may be bloody or additional crystals are released, the shoulder affected by RA.18 blood-streaked, followed by corti- resulting in a vicious circle. This sone injection, is an excellent tempo- interpretation implies that the cuff is rizing measure that can be under- not torn traumatically in RCTA but Diagnosis taken in an attempt to avoid sur- is severely degenerated and charac- gery; however, recurrence after terized by a 5-cm or larger defect.2 History and Physical aspiration is common. In 1985, Dieppe and Watt16 Examination Patients with either RA or OA reviewed the role of crystal deposi- Patients with cuff-deficient, can have mild swelling, but this is tion in the pathogenesis of osteo- arthritic shoulders are typically usually synovial-tissue thickening arthritis (OA). They noted that BCP elderly (seventh decade or older) rather than fluid that can be aspi- crystals have been found in osteo- and female. Most commonly, it is rated. These patients may also arthritic joints, neuropathic joints, the dominant extremity that is have physical findings involving and joint tissue of healthy elderly involved. Patients usually present other joints, such as deformity, con- patients and that apatite crystals in with a long history of progressively tractures, or instability.

Vol 6, No 6, November/December 1998 339 Rotator Cuff–Deficient Arthritic Shoulder

Patients with Charcot (neuro- pathic) joints and osteonecrosis Fig. 2 The fluid sign is usually have intact rotator cuffs. seen as a swelling (arrow) Clinical workup may ultimately on the anterior aspect of reveal an underlying cause, such as this patientÕs shoulder. This is caused by fluid corticosteroid use, alcohol abuse, bulging from the gleno- tabes dorsalis, or syringomyelia. humeral joint through a Patients with a history of hemo- large chronic cuff tear and into the enlarged subacro- philia and numerous hemarthroses mial bursa. Less common- may also have hemophilic arthrop- ly, fluid in the subdeltoid athy. Radiographs of shoulders bursa can be associated with primary bursal in- with advanced disease may resem- volvement in RA.18 ble those of shoulders with RA or, less commonly, OA. Dark pigmen- tation of the joint tissues is apparent on gross examination, and histolog- ic examination of joint cartilage Imaging motion loss). Because cuff tears may reveals chondrocytes with intracel- There are a number of character- have unexpected configurations and lular iron deposits. istic plain-radiographic findings of sizes and the cuff tissue may be of RCTA (Fig. 3). Erosion of the prox- poor quality, the surgeon must be imal humerus may be so extensive prepared to use alternative methods Indications for Surgery that the humeral head is worn (e.g., autografts, allografts, or tendon beyond the surgical neck. Axillary transfers) in reconstruction or repair. The main indication for surgical lateral radiographs may reveal a These intraoperative decisions are management is unremitting pain fixed anterior or posterior gleno- facilitated by preoperative knowl- that has proved resistant to a trial of humeral dislocation. edge gained with magnetic reso- nonoperative measures, including Radiographs of osteoarthritic nance imaging. shoulders typically show subchon- dral sclerosis, humeral head osteo- Differential Diagnosis phytes, glenoid osteophytes, and The radiographic appearance of posterior erosion of the glenoid.18 glenohumeral joints in patients In contrast to RA and RCTA, osteo- with metabolic arthritis resembles penia is not characteristic of con- that in patients with OA; however, ventional OA. Unlike osteoarthritic the rotator cuff is usually intact. In shoulders, rheumatoid shoulders some advanced cases, the radio- are characterized by relatively sym- graphic findings can be similar to metrical juxta-articular erosion and those seen with advanced RCTA. relatively minimal subchondral Blood and joint-fluid chemistries sclerosis and osteophytosis.18 and synovial biopsy can help con- Patients with cuff deficiency firm a diagnosis of gout, pseudo- require extra preoperative, intraop- gout, hemochromatosis, and other erative, and postoperative decision types of metabolic arthritides. making. Although magnetic reso- Patients with septic arthritis are nance imaging is not necessary for often debilitated due to a general- the routine preoperative workup of ized disease process such as RA.19 patients with straightforward OA In the absence of fever and an ele- and obvious clinical and radiologic vated white blood cell count, diag- Fig. 3 Anteroposterior radiograph shows RCTA in the right shoulder of a 77-year- findings indicative of a full-thickness nosis depends on a high level of old man. The shoulder is in maximum rotator cuff tear, it may be useful in suspicion and the findings from active abduction. In addition to humeral patients with physical findings that joint aspiration and culture. If an head collapse, findings include periarticu- lar osteopenia, reduced acromiohumeral are difficult to interpret (e.g., those effusion is present, it is warm, in distance, and erosions of the glenoid, who cannot do a lift-off or belly- contrast to the cool effusion of acromion, and acromioclavicular joint. press test because of pain and RCTA.

340 Journal of the American Academy of Orthopaedic Surgeons Craig A. Zeman, MD, et al rest, oral analgesics and nonsteroidal cuff-deficient arthritic shoulder. It by the US Food and Drug Admini- anti-inflammatory medications, cor- typically produces a flail shoulder stration, is not considered appropri- ticosteroid injections, fluid aspira- that leaves the patient even more ate treatment because the design tions, and gentle range-of-motion disabled because deltoid function produces excessive interface stress- exercises. Additional considera- is often deficient as well. Inferior es, which can lead to rapid loosen- tions, such as patient age, activity instability and brachial-plexus trac- ing, implant dissociation, and bone level, job requirements, and general tion neuritis are common and con- and implant fracture.6,18,22 health, are extremely important in tribute to the severely compro- individualizing a treatment plan. mised shoulder biomechanics. Shoulder Bipolar Arthroplasty The integrity of the contralateral Swanson and Swanson8 pio- rotator cuff should also be assessed, Constrained Shoulder neered the use of shoulder bipolar as this may be important in planning Replacement arthroplasty for treating arthritic postoperative rehabilitation. Pa- In 1991, Laurence21 reported on shoulders with loss of the force- tients who use canes or are confined the use of polyethylene cups and couple balance required to hold the to wheelchairs may, during the first large stainless-steel heads that humeral head in the glenoid dur- few postoperative months, apply snap-fit together to form a con- ing abduction. Theoretical advan- increased stresses to the contralateral strained construct. After resection tages provided by the large head of shoulder; a course of preoperative of the superior two thirds of the this arthroplasty include the fol- stretching before a prosthetic arthro- glenoid, screws and bone cement lowing factors: (1) smooth concen- plasty may improve postoperative are used to fix the cup into this tric total contact for the entire function.2 region and into the coracoid and shoulder joint cavity; (2) reduction acromion. Seventy-one shoulders of force concentration over any one in 66 patients were followed up for contact area and, therefore, de- Surgical Options an average of 6.8 years. All of the creased resistance to movement; (3) patients apparently had large rota- longer moment arm between the Shoulder Arthrodesis tor cuff defects. The remaining dis- fulcrum and the muscle insertion, Many patients with a cuff-defi- tal cuff tendons were surgically increasing the efficiency of muscle cient, arthritic shoulder have poor transected with the tuberosities pull; and (4) prevention of impinge- general health and are at increased and reattached more distally after ment by the greater tuberosity risk for major surgical complica- placement of the prosthetic compo- against the acromion. tions. Shoulder arthrodesis is an nents. There was complete relief of Lee and Niemann23 reported on extensive operation that, when com- pain in 22 patients, only minor dis- the results of shoulder bipolar bined with spica immobilization, comfort in 35, and moderate pain arthroplasties performed on 14 may not be well tolerated by these in 9. Two shoulders were consid- patients, 13 of whom had irrepara- individuals.10,19,20 In addition, be- ered surgical failures, and 3 re- ble large rotator cuff tears. Two cause of poor bone stock, these quired revision surgery for loosen- groups were studied: 7 patients patients may have a higher failure ing (2 after trauma). Active use of with RA who underwent a primary rate than younger individuals. the arm was regained by 56 pa- shoulder arthroplasty and 7 pa- However, with the use of internal tients (85%), and 26 (40%) returned tients who underwent a secondary fixation, autogenous and allogeneic to gainful employment. reconstructive procedure. No rota- bone graft material, and aggressive Once considered a solution for tor cuff reconstruction was per- medical management, glenohumer- the patient with a cuff-deficient formed. The patients with RA all al arthrodesis is a viable option, arthritic shoulder, constrained had good pain relief and reported especially in the patient with RCTA, shoulder replacement created a satisfaction with the results of an irreparable cuff defect, and a whole new set of complications.18 surgery. In contrast, the patients in deficient anterior deltoid who has A theoretical advantage of this sur- the secondary reconstruction group undergone multiple procedures.20 gical option is that it provides the had only fair pain relief, and only 4 However, it is infrequently the opti- deltoid with a stable fulcrum on of the 7 were satisfied with their mal surgical option in this set- which to move the humerus when results. The RA group had a nearly ting.19,20 there is impairment of the normal threefold greater increase in range force couple between the cuff and of motion than the secondary Resection Arthroplasty the deltoid due to cuff insufficiency. reconstruction group. The authors Resection arthroplasty is not rec- However, constrained shoulder concluded that bipolar arthroplasty ommended for the patient with a replacement, which is not approved was a good choice for treating

Vol 6, No 6, November/December 1998 341 Rotator Cuff–Deficient Arthritic Shoulder patients with RA and massive cuff had major tears. Four longitudinal- ther surgery. The authors theorized tears, but one disadvantage was ly torn supraspinatus tendons were that in some cases the superiorly the large amount of bone resection repaired by simple suturing. Of the subluxated humeral head eccentri- required. Fewer complications 9 shoulders with major rotator cuff cally loaded the glenoid compo- occurred when the subacromial tears, 6 were repaired by suturing nent, ultimately producing rocking arch was intact. If the cuff was tendon directly to the cancellous and progressive loosening of the reparable, the investigators per- bone of the proximal humerus. The glenoid component. formed a standard Neer-type hemi- major tears in the remaining 3 Franklin et al6 reported an asso- arthroplasty or total shoulder shoulders were repaired with fascia ciation between glenoid loosening arthroplasty (TSA). lata grafts. Five of the rotator cuff and rotator cuff deficiency with repairs had failed by the time of the proximal humeral migration. Of 14 Nonconstrained Total Shoulder last reported follow-up, and 1 patients with rotator cuff deficiency, Arthroplasty patient had severe pain. The 7 demonstrated glenoid component In 1982, Neer et al9 reported on amount of active abduction that loosening. None of the 16 patients the results of nonconstrained TSA was achieved postoperatively was with an intact cuff had a loose gle- in 194 shoulders in patients treated clearly related to the condition of noid component. The amount of for various diagnoses. Follow-up the rotator cuff at surgery. When superior migration of the humeral was from 24 to 99 months. Rotator no complications occurred, results component directly correlated with cuff-tear arthropathy was found in were predictably good. Cofield the degree of glenoid loosening. 16 shoulders. Two patients (3 concluded that these results were The authors emphasized that an shoulders) had OA and a cuff defect superior to those obtained with intact, functional rotator cuff can (size not reported); both patients shoulder fusion in patients with reduce eccentric glenoid loading by were paraplegic as a result of similar shoulder conditions.10,19 centering the humeral head on the poliomyelitis. Twelve patients had Hawkins et al5 reported the re- glenoid during dynamic shoulder large cuff tears and RA; 17 addition- sults in 65 patients treated with motion. al patients with RA had small cuff TSA for OA and RA who were fol- tears that were easy to repair. In lowed up for an average of 36 Humeral Hemiarthroplasty the RCTA group, all but 1 patient months. Twenty-one patients, Marmor11 reported the results of had a successful result with Òlimit- most in the RA group, had rotator humeral hemiarthroplasty in 12 ed goalsÓ rehabilitation. The 2 pa- cuff tears, and all but 1 patient had shoulders of 10 patients with RA fol- tients in the OA group were satis- satisfactory repair of the rotator lowed up for an average of 4.5 years. fied with their postsurgical results. cuff. The results were satisfactory Five of the 12 shoulders had a rota- Seven of the patients with RA and in 90% of the shoulders, with no tor cuff tear (size not specified). All massive cuff tears had successful difference being noted between OA patients eventually had good pain results on the basis of limited-goals and RA patients. relief. One patient with significant rehabilitation criteria. The remain- Barrett et al22 reported the results pain required an acromioplasty after ing 22 RA patients had satisfactory of TSA in 50 shoulders of 44 pa- the initial procedure. All but 1 pa- to excellent results with a full exer- tients who were followed up for an tient ultimately attained increased cise rehabilitation protocol. Al- average of 3.5 years. Nine shoul- motion. though lucent lines developed ders had a tear of the rotator cuff. Arntz et al used humeral hemi- around the glenoid component in Three tears were less than 5 cm and arthroplasty as an alternative to nearly 30% of each group, sympto- were repaired; repair and/or recon- glenohumeral arthrodesis for the matic loosening did not occur. struction was attempted in the oth- cuff-deficient arthritic shoulder. In In 1984, Cofield10 reported the ers, but all of the results were con- 1993 they reported the results in 18 results of 73 TSAs in 65 patients sidered suboptimal. Of the 6 shoulders in 16 patients followed who had RA, OA, or posttraumatic patients with painful shoulders at up for 25 to 122 months.24 Eleven arthritis and were followed up for follow-up, 4 had glenoid compo- patients had RCTA. A prerequisite an average of 3.8 years. Of the 31 nent loosening; at the time of the for surgery was a functionally shoulders with OA, 3 had ÒminorÓ original procedure, all 4 patients intact coracoacromial arch, provid- and 3 had ÒmajorÓ rotator cuff tears had had a massive tear of the rota- ing secondary stability across the (major tears were at least as long as tor cuff. Two of these patients anterosuperior aspect of the the breadth of the supraspinatus underwent revision with a hemi- humeral prosthesis. A smaller tendon). Of the 29 shoulders with arthroplasty, 1 had a resection prosthetic head was used to avoid RA, 1 had a minor cuff tear, and 6 arthroplasty, and 1 elected no fur- pain associated with excessive

342 Journal of the American Academy of Orthopaedic Surgeons Craig A. Zeman, MD, et al tightness of the posterior capsule. the surgeon often encounters an bone from the humeral head (Fig. 5), Excessive shoulder tightness was incompetent coracoacromial arch. so as to resist humeral head migra- also avoided by allowing 50% pos- Some authors have augmented the tion in the superior direction. Both terior subluxation of the humeral arch with bone graft. In 1991, this technique and that of Wiley component on the glenoid fossa Wiley26 reported on four patients in seek to reestablish a stable fulcrum. and 90 degrees of internal rotation whom severe superior humeral The technique of Engelbrecht and of the abducted humerus. In all head subluxation developed after Heinert seems to make better sense cases, the rotator cuff was not resection of the coracoacromial lig- biomechanically, as it reestablishes repaired because of poor tissue ament. Three of the patients also the fulcrum closer to the original quality. At the final reported follow- underwent repair of a large to mas- instant center of rotation. up, 3 shoulders were pain-free, 8 sive cuff tear. These four cases In 1997, Field et al28 reviewed shoulders were slightly painful, 4 were selected to illustrate the po- the data on 16 patients who had shoulders were painful after activi- tential complications of debriding undergone humeral hemiarthro- ties that the patients described as the cuff without repair and the plasty for RCTA. The surgical not typical of daily use, and 3 shoul- value of retaining the coracoacro- technique and component sizing ders were markedly painful and mial arch. Two patients had un- (with use of a small humeral head) had to undergo revision proce- dergone humeral head replacement were similar to those described by dures. Humeral component loos- arthroplasty. Subsequent treat- Arntz et al.24 All tears were mas- ening was not seen. ment of these patients included sive and were debrided without an In 1996, Williams and Rock- capsular release and bone grafting attempt at repair. The average age wood25 reported on the results of of the coracoacromial arch with a of the patients was 74 years (range, humeral hemiarthroplasty in 21 7.5-cm-long piece of iliac-crest bone 62 to 83 years), and follow-up shoulders of 20 patients with ir- (Fig. 4). Postoperatively, both averaged 33 months (range, 24 to reparable rotator cuff defects and patients had significant pain relief. 55 months). With the use of NeerÕs glenohumeral arthritis who were In contrast to this method, En- limited-goals criteria, the results in followed up for an average of 4 gelbrecht and Heinert27 described 10 patients were rated as success- years. During subscapularis repair, the concept of augmenting the su- ful; those in 6, as unsuccessful. Of they invariably achieved 30 degrees perior aspect of the glenoid with the 6 patients with unsuccessful of external rotation. To achieve this degree of motion in 6 shoulders, the subscapularis was removed subperi- osteally from the lesser tuberosity and reattached 1 to 2 cm more medially through holes drilled near the edge of the humeral osteotomy. In 2 patients with deficient sub- scapularis muscles, the upper 50% of the pectoralis major was trans- ferred to the lesser tuberosity. To prevent posterior instability in patients with posterior erosion of the glenoid, the osteotomy was made in only 10 to 15 degrees of retroversion. Twelve shoulders were not painful, 6 were mildly painful, and 3 were moderately painful. Patients with moderate pain who had undergone previous operations stated that the recent surgery ameliorated their pain.2 A B When performing hemiarthro- Fig. 4 Lateral-to-medial (A) and posteroanterior (B) views of a scapula showing an iliac- plasty on the cuff-deficient arthritic crest bone graft rigidly attached to the acromion and coracoid, serving to reconstitute a shoulder, especially in the setting deficient coracoacromial arch. of previously failed cuff surgery,

Vol 6, No 6, November/December 1998 343 Rotator Cuff–Deficient Arthritic Shoulder

the rotator cuff. In their study, non- constrained TSA yielded the best results. In 1992, Pollock et al7 reviewed the results in 30 shoulders in 25 patients treated with either TSA (11 shoulders) or humeral hemiarthro- plasty (19 shoulders) for gleno- humeral arthritis with rotator cuff deficiency. Follow-up averaged 41 months. Seventeen arthroplasties A B were for RA or inflammatory arth- ritis, and 13 were for RCTA. Trans- position of the subscapularis (Fig. 6) resulted in complete closure of superior rotator cuff defects in 15 shoulders and partial closure in 11. Four cuffs with massive defects could not be covered and were not reconstructed. Satisfactory results were achieved in all patients in the RA or inflammatory arthritis group and 11 of 13 in the RCTA group. All shoulders regained functional forward elevation and external rota- C D tion. Patient satisfaction was simi- Fig. 5 A, Use of humeral head bone for grafting of a deficient superior pole of the glenoid lar in the hemiarthroplasty and TSA serves to resist superior humeral migration. B, Placement of bone graft and fixation with groups, but the hemiarthroplasty screws. C, Topographic relationship of graft with prosthetic humeral head. D, group achieved greater postopera- Radiograph shows a graft in a 73-year-old man. Note the use of suture anchors for fixation into osteoporotic bone. tive range of motion. The authors concluded that hemiarthroplasty with attempted rotator cuff repair produced the best results in these results, 4 had undergone at least Humeral Hemiarthroplasty patients. one attempt at rotator cuff repair Versus Total Shoulder A patient with OA and a small, with acromioplasty before the Arthroplasty easy-to-repair rotator cuff tear index procedure, and 2 had defi- Lohr et al4 briefly reported the can usually be treated with a cient deltoid function after the results of RCTA in 22 shoulders in modular nonconstrained TSA. rotator cuff surgery as a result of 22 patients with RCTA who were Severe bone loss in osteopenic postoperative deltoid detachment. treated with either nonconstrained patients generally requires fixa- Also, 3 of these 4 patients who had TSA, semiconstrained (i.e., hooded tion with polymethylmethacry- previously undergone acromio- glenoid) TSA, or hemiarthroplasty. late. A deltopectoral approach is plasty subsequently had anterosu- The mean follow-up period was 4 used. Many of these shoulders perior subluxation after hemi- years 7 months. The hemiarthro- have osseous excrescences on the arthroplasty. However, of the 12 plasty group had the poorest results acromion and acromioclavicular patients with good deltoid func- for pain relief. However, the non- joint arthritis, which can be dealt tion and an adequate coracoacro- constrained and semiconstrained with in a standard fashion as long mial arch, 10 had a successful TSA groups had a high incidence of as the cuff is reparable. A slightly result. This study illustrates that radiologic and clinical loosening of smaller humeral head or a ten- formal acromioplasty done in com- the glenoid component. The au- dency toward varus angulation bination with repair of a torn rota- thors concluded that although during implantation will take tor cuff may jeopardize the subse- RCTA is one of the most difficult- pressure off the cuff repair. It is quent success of humeral hemi- to-treat shoulder entities, every essential that 30 to 40 degrees of arthroplasty. attempt should be made to repair external rotation can be obtained

344 Journal of the American Academy of Orthopaedic Surgeons Craig A. Zeman, MD, et al

A B C

Fig. 6 A, Preoperative anteroposterior (AP) view of a right shoulder with a cuff tear and severe glenohumeral arthrosis. The broken line drawn obliquely across the proximal humeral head represents the direction of an osteotomy performed when there is an intact rotator cuff. The dotted line drawn obliquely across the more distal humeral head represents the more aggressive osteotomy used when perform- ing an arthroplasty in shoulders with large, retracted rotator cuff tears. Postoperative AP (B) and oblique (superior-to-inferior) (C) views show use of a superiorly transposed subscapularis tendon to cover a large cuff defect; prosthetic humeral head has been recentered.

intraoperatively after repair of the tate exposure for mobilization of Intact Subscapularis subscapularis. Replacement of the subscapularis or the entire pec- Although many patients with an the glenoid is not recommended toralis major insertion if transfer is intact subscapularis have a negative for patients with superior humer- required.2 lift-off test, they may have marked al head migration, as this finding Neer et al1 have stated that in weakness with active forward flex- is associated with a high inci- rare cases a supplemental posterior ion and external rotation. For these dence of glenoid loosening. incision may be needed to ade- patients, a standard deltopectoral Some basic surgical principles quately mobilize the posterior rota- approach is appropriate. A more should be emphasized before tors. Various methods of sub- aggressive humeral osteotomy is addressing specific details of this scapularis lengthening may also be also performed, which removes type of management. Protection of necessary in these stiff shoulders. more bone than usual. The osteoto- the axillary nerve is paramount, as If the cuff tear is small and the sub- my follows a line extending laterally contractures and joint deformities scapularis tendon is of good quali- from approximately 1 cm above the make it susceptible to intraopera- ty, the tendon can be dissected sub- lateral flare of the greater tuberosity tive injury. The surgeon must have periosteally off the lesser tuberosity to a point medially where, with firm a thorough understanding of how as close as possible to the bicipital manual downward traction on the to release joint contractures and groove. This tissue can then be arm, the humeral neck meets the safely mobilize the rotator cuff.29 reattached to the anteromedial inferior aspect of the glenoid. This Mobilization may include (1) re- aspect of the anatomic neck with satisfies three objectives: (1) it leaves lease of bursal adhesions from the the use of suture and drill holes. an osseous margin to which the dis- subacromial and subdeltoid spaces, For patients with massive rotator tal ends of the supraspinatus, infra- (2) release of the subscapularis cuff tears, internal rotation contrac- spinatus, and subscapularis can be from the capsule, (3) release of the tures, and good-quality subscapu- repaired; (2) it shortens the distance contracted capsule from the gle- laris tendon, a coronal Z-lengthen- that the mobilized tendons must tra- noid labrum, (4) proximal mobi- ing procedure is utilized. The sub- verse; and (3) it centers the humeral lization of tendons,30 (5) release or scapularis is not routinely separat- head on the glenoid. Despite ag- resection of the coracohumeral lig- ed from the joint capsule. The sur- gressive capsular releases inferiorly, ament, (6) rotator interval slide,31 gical approach is determined on the humeral head cannot be cen- and/or (7) release of the upper 1 the basis of whether or not the sub- tered without this relatively large cm of the pectoralis major to facili- scapularis is intact.32 amount of bone resection.

Vol 6, No 6, November/December 1998 345 Rotator Cuff–Deficient Arthritic Shoulder

When there is marked superior Deficient Subscapularis and soft-tissue reconstruction are erosion of the glenoid, a burr is If the patient has a positive lift- fruitless if the anterior deltoid is used to selectively remove bone off test, the subscapularis is in- deficient due to detachment or de- from the inferior aspect of the gle- volved in the massive tear, and the nervation. In this case, glenohumeral noid until a superior shelf is creat- patient has marked weakness with fusion with the use of pelvic recon- ed. The effective length of the sub- almost all active movements of the struction plates, autogenous and/or scapularis is increased by medial- shoulder. In this situation, a supe- allogeneic bone graft, scalene block izing the joint line, mobilizing the rior approach, as described by anesthesia, and postoperative man- cuff, lowering the instant center of Kessel,34 is recommended; the acro- agement of medical problems or rotation, and using a smaller mial osteotomy facilitates increased metabolic bone disease make this an humeral head. These factors facili- exposure of the superior aspect of attractive alternative even for tate transposition of the subscapu- the glenohumeral joint. The acro- patients in their late 70s or 80s. laris for covering large defects in mion must be repaired accurately the retracted supraspinatus tendon and securely. With an aggressive (Fig. 6). Preservation of the cora- humeral osteotomy and reshaping Postoperative Management coacromial arch is extremely im- of the glenoid with a burr, the portant for limiting anterosuperior resulting medialization of the gle- Postoperative management begins migration. When the posterior gle- noid usually allows repair of the with preoperative education of the noid is not eroded, the prosthesis subscapularis back to the lesser patient and her or his family, should generally be retroverted tuberosity and repair of the infra- emphasizing that pain relief is the more than usual (45 to 60 degrees), spinatus back to the greater tuber- primary goal of surgery, and realis- placing the greater part of the osity; however, the superior defect tic expectations for range of motion prosthetic head under the acro- typically cannot be repaired. In and strength are typically limited.1 mion. This maneuver ensures that, our experience, use of humeral On the first or second postopera- at the very least, the shoulder has head bone to supplement the supe- tive day, patients are taught pas- captured-fulcrum mechanics14 rior aspect of the glenoid has sive exercises, which are continued (Fig. 7). Although not routinely resulted in keeping the head cen- for at least 6 weeks. These exer- obtained, a computed tomographic tered in 3 of 5 patients followed up cises may be delayed for 3 weeks if scan of both shoulders can be use- for more than 2 years (Fig. 5). subscapularis reattachment or ful for comparing glenoid version lengthening was performed. Be- in some patients33; this information Deficient Deltoid tween 6 and 9 weeks, depending helps the surgeon to anticipate Even if the cuff defect is repara- on the size of the cuff tear and tis- both the location and the amount ble or reconstructible, attempts at sue quality, gentle active motion is of bone removal or augmentation restoring motion or balancing force allowed in all planes. When the that will be needed. couples with prosthetic replacement rotator cuff repair is tenuous, an

A B C

Fig. 7 A, Preoperative radiograph of a 73-year-old woman with RCTA treated with humeral hemiarthroplasty, glenoid burring, and superior transposition of the subscapularis. Radiograph (B) and clinical photograph (C) obtained 10 months after the procedure illustrate improved abduction.

346 Journal of the American Academy of Orthopaedic Surgeons Craig A. Zeman, MD, et al abduction pillow can be used for with a relatively small head yield- constrained TSA, and semicon- the first 4 to 6 weeks. At approxi- ed the most reliable results. strained TSA. The coracoacromial mately 3 weeks, pulley and internal- arch should be preserved and func- external rotation exercises on the tionally intact to reduce the risk of pillow are started. When the bone Summary anterosuperior subluxation. Care graft across the superior aspect of should be taken not to ÒoverstuffÓ the glenoid has united, active range The patient must realize that surgery the glenohumeral joint with pros- of motion is initiated. Resisted will predictably provide pain relief, thetic components. When patients strengthening is begun between 9 but that improvements in motion report considerably reduced inter- and 12 weeks. and strength are less predictable. nal rotation because of soft-tissue In a small series compiled at our The functional result will depend on contracture, subscapularis lengthen- institution from 1987 to 1990, four the condition of the rotator cuff and ing or medialization or both are nec- types of surgical management were deltoid muscle. The results are near- essary to restore anterior and poste- used to improve results in this ly always inferior to those that can rior rotator cuff balance. With the less group of patients: (1) bipolar pros- be obtained with conventional pros- stringent criteria of NeerÕs limited- thesis without cuff repair; (2) large- thetic arthroplasty in shoulders with goals rehabilitation, approximately head hemiarthroplasty without functionally intact cuffs. 80% to 90% of patients treated with cuff repair, (3) small-head hemi- A concerted effort must be made humeral hemiarthroplasty can have arthroplasty with subscapularis to repair the rotator cuff defect, satisfactory results.3,8 transposition, and (4) noncon- resurface the arthritic humerus Glenohumeral arthrodesis is a strained TSA with cuff repair. The (hemiarthroplasty), and smooth the salvage procedure when other sur- results in 18 patients followed up arthritic glenoid with a burr. Hu- gical measures have failed. It is for at least 2 years suggested that meral hemiarthroplasty avoids the also a viable option for patients repair of large rotator cuff defects complications of glenoid loosening who have undergone multiple with subscapularis transposition and is an attractive alternative to operations and for patients with and humeral hemiarthroplasty arthrodesis, resection arthroplasty, deltoid muscle deficiency.

References

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348 Journal of the American Academy of Orthopaedic Surgeons