Saturday, March 1, 2014

Rotator cuff repair along with anatomic total shoulder

Anatomical total shoulder replacement with rotator cuff repair for osteoarthritis of the shoulder

Between 1996 and 2010, these authors performed 932 total shoulder arthroplasty for osteoarthritis. 45 of these (4.8%) underwent concurrent rotator cuff repair.
The final study group comprised 73% of these (33 patients) with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). The improvement in elevation was greater in those with a small tear. Radiographic evidence of instability developed in six patients with medium or large tears. In all, six glenoid components (18%) were radiologically at risk of loosening. Complications were noted in five patients (15%), all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture.
In sum, complications were more frequent and clinical scores were worse in those with larger cuff tears found at surgery. We do not have information on cuff tears identified at surgery that were not repaired.

Comment: These authors did not have the opportunity to evaluate the healing of the cuff repairs. We know from previous posts that cuff integrity does not correlate well with the clinical outcome of cuff repairs, thus we cannot conclude that the patients who did well had intact cuffs at followup.

Apparently these cuff tears were not identified preoperatively, probably because it may be difficult to sort out this diagnosis in the face of arthritis. So the question becomes how does one anticipate this problem and what happens if one unexpectedly finds a cuff tear.

Our approach is to check for strength of internal and external rotation (it may be difficult to check for supraspinatus strength in the arthritic shoulder) and for upwards displacement of the humeral head on the glenoid. Lack of rotator strength and superior head positioning suggest that major cuff pathology is likely. In that the tears encountered in this context are likely to be chronic and that the bone available for reattachment may be compromised and that we do not want to retard the rehabilitation of a shoulder arthroplasty while waiting for a cuff repair to heal, we discuss the option of a cuff tear arthropathy prosthesis with the patient before surgery.
In patients with pseudo paralysis, anterosuperior escape, prior acromioplasty, anterior or posterior instability discovered on the preoperative examination, we discuss the option of a reverse total shoulder with the patient prior to surgery.

If a small cuff tear is found at surgery unexpectedly and if a sufficiently robust repair can be achieved that does not require modification of the normal post-arthroplasty rehabilitation it is repaired.

Consultation for those who live a distance away from Seattle.

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