Wednesday, January 2, 2013

Cuff tear arthropathy resurfacing

Treatment of severe cuff tear arthropathy with the humeral head resurfacing arthroplasty: two-year minimum follow-up

At a time when reverse total shoulder arthroplasty - the most expensive approach - is commonly used for the treatment of severe rotator cuff tear arthropathy (CTA), it is refreshing to see a report of a more conservative surgical approach, humeral head resurfacing without glenoid arthroplasty.

The authors present the results of 24 patients (6 men and 18 women, mean age of 71 years (range, 53-85 years)) with CTA who underwent resurfacing arthroplasty. The criteria for inclusion were (1) painful CTA with complete absence of the supraspinatus and infraspinatus tendons with retraction and fatty infiltration of the muscles, (2) superior migration of the humeral head with concave deformity of the acromion undersurface, and (3) at least 150" of passive flexion and abduction and 30" of passive external rotation. The exclusion criteria were (1) anterosuperior instability of the shoulder joint [we have corrected what seems to have been a misprint in this criterion], (2) rheumatoid or inflammatory arthritis, (3) CTA as a consequence of a previous fracture, (4) previous infection of the affected shoulder, and (5) neural injuries of the affected upper limb.

The Constant score improved from 21 points (range, 7-44 points) to 63 points (range, 23-89 points) at a mean of 38 months (range, 24-56 months). Patients with an intact or moderately atrophied teres minor muscle (n = 16) showed a significantly better Constant score (P = .011) and greater active external rotation (P = .034) than patients with severe atrophy. The type of glenoid erosion did not have an effect on the clinical or functional outcome. Patients with an intact subscapularis fared better than those with subscapularis deficieny. Three patients were revised to reverse total shoulders, all had limited active elevation and one had anterior instability.

We offer humeral hemiarthroplasty with aCTA arthroplasty for selected individuals an intact subscapularis, no anteriorsuperior instability, and active elevation of >90 degrees, especially if the individual desires activities that will load the arm (skiing, golf, weights, crutch use) or if they are at risk for falling (which is a hazard for individuals with a reverse total shoulder). A good example is shown here. Key elements in this surgery are (a) assuring that the prosthetic head diameter matches that of the resected head so that it fits within the 'acetabularized' coracoacromialglenoid concavity, (b) preserving the coracoacromial arch and upper clavipectoral fascia for stability, (c) assuring a robust subscapularis reconstruction, and (d) removing any prominent tuberosity bone lateral to the prosthesis.

There authors point out that a resurfacing prosthesis does not allow a distal shift in the center of rotation, retensioning the deltoid. We find that CTA arthroplasty does allow the desired retensioning if a prosthetic head is used that is thicker than the amount of bone removed. Two examples are shown here. Both had stable shoulders without anteriorsuperior escape, intact subscapularis tendons and active elevation >90 degrees. Note that in addition to the distal displacement of the humerus, it is also moved laterally, so that the tension in residual external rotators is optimized (rather than the slackening of these muscles seen with reverse total shoulders in which the humerus is medialized).

We offer the reverse total shoulder for individuals lacking 90 degrees of active elevation and for those with anterosuperior or intractable posterior instability. as long as the individual recognizes the risks of this procedure. 


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