Monday, April 2, 2012

Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment: AAOS Exhibit

Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment was the topic of a recent AAOS exhibit. The authors define this condition as the combination of rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeral head.

When the rotator cuff is deficient, the concavity compression mechanism of shoulder stability is compromised. This leads to a complex combination of weakness, arthritis and instability known as cuff tear arthropathy. In this condition contraction of the deltoid presses the humeral head upwards against the coracoacromial arch rather than flexing or abducting the arm. In some cases the shoulder can compensate for this pathoanatomy, but in other cases the arm becomes dysfunctional or 'pseudoparalytic'. A practical definition of pseudoparalysis is the inability to elevate the arm to 90 degrees in spite of rehabilitation of the residual muscles. Pseudoparalysis can be particularly severe if the shoulder has had a prior acromioplasty, which compromises the stabilizing effect of the coracoacromial arch. This can compound the problem by giving rise to anterosuperior escape.

When the head is superiorly displaced, but the shoulder remains stable and is capable of 90 degrees of active elevation, a CTA prosthesis is an option that avoids some of the risks of a reverse total shoulder.

When the humeral head is superiorly displaced on the glenoid and when there is anterosuperior escape, the situation cannot be managed with a conventional shoulder arthroplasty in that this procedure does not increase the stability of the joint. For informed patients with major loss of comfort and function of the shoulder resulting from cuff tear arthropathy, a reverse total shoulder can be considered.

The authors conclude:  "the initial management of rotator cuff arthropathy should begin with conservative measures, surgical intervention is often required. Promising results following reverse total shoulder arthroplasty have led to an increase in the utilization of this procedure. However, complication rates remain high, demonstrating the importance of strict patient  selection and careful operative technique as well as the necessity of future design modifications."


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