Monday, May 20, 2013

Cuff tear arthropathy: CTA prosthesis or reverse total shoulder

Comparison of Functional Outcomes of Reverse Shoulder Arthroplasty with Those of Hemiarthroplasty in the Treatment of Cuff-Tear Arthropathy: A Matched-Pair Analysis

This is the preoperative x-ray of a 70+ year old avid skier, rock climber when we first saw him in a year and a half ago. He could perform only 5 of the 12 functions of the simple shoulder test. After we presented him with the pros and cons of a CTA arthroplasty and a reverse total shoulder, he chose the former because of his desire to continue to ski and climb.
Here is his x-ray from today
He stated he has been having no pain in his operated shoulder and has been actively pursuing his sports without problem and without pain. He has improved from 5/12 simple shoulder test functions to 12/12. He presented today because he wanted the same procedure performed on his right shoulder.

We present this case before starting our discussion of the paper above to emphasize that the decision between a CTA prosthesis and a reverse total shoulder is not made on 'which is better?', but rather 'which is better for the given shoulder in the individual patient?'

The authors compared the results of 102 primary hemiarthroplasties for rotator cuff-tear arthropathy were compared with those of 102 reverse shoulder arthroplasties identified from the New Zealand Joint Registry. The patients were matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford Shoulder Scores (OSS) collected at six months postoperatively as well as mortality and revision rates were compared between the two groups. Unfortunately the preoperative OSS scores were not available, so that the improvement from the two surgeries cannot be known. Furthermore, data on prior surgeries, the status of the coracoacromial arch and residual rotator cuff are lacking.

There were fifty-one men and fifty-one women in each group, with a mean age of 71.6 years in the hemiarthroplasty group and 72.6 years in the reverse shoulder arthroplasty group. One third and one fourth of the patients did not participate in the followup, respectively. The mean OSS at six months was 31.1 in the hemiarthroplasty group and 37.5 in the reverse shoulder arthroplasty group. 

No difference was seen in early revision rates, with four revisions performed in each group within twelve months after the surgery. At the time of follow-up, there had been nine revisions in the hemiarthroplasty group and five in the reverse shoulder arthroplasty group. However, the lengths of follow-up were different (6.8 years for the CTA and 4.8 for the reverse total shoulders. Thus the annualized rates of revision were 1% per year for both types of prostheses.  In the hemiarthroplasty group, two patients underwent a revision because of infection; one, because of dislocation; and six patients had a revision to a reverse shoulder arthroplasty because of ongoing pain. In the reverse shoulder arthroplasty group, two patients had a revision because of infection; two, because of glenoid component loosening; and one, because of dislocation.

While the authors conclude that "reverse shoulder arthroplasty resulted in a functional outcome that was superior to that of hemiarthroplasty", the difference is small. The choice between these two procedures needs to be individualized based on patient specifics, such as the preoperative comfort and function, the desired postoperative activity level, the status of the coracoacromial arch, the presence or absence of anterosuperior escape, the presence or absence of pseudo paralysis, the bone quality, the glenohumeral anatomy, and the risk of falling. The diagnostic term 'cuff tear arthropathy' offers insufficient information on which the choice of procedures can be based. In our practice a shoulder with cuff tear arthropathy and pseudoparalysis and anterosuperior escape would not be an optimal candidate for a CTA prosthesis; a shoulder in a physically active person with cuff tear arthropathy and an intact coracoacromial arch without pseudoparalysis, would not be an optimal candidate for a reverse total shoulder.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.