Sunday, May 1, 2016

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis: A systematic review

These authors conducted a systematic review of multiple databases for levels I-IV evidence clinical studies of patients with primary osteoarthritis with a minimum 2-year follow-up.

They found 15 studies with 1259 patients (1338 shoulders) were selected. 

Radiographic humeral head migration was the most commonly reported indication of rotator cuff failure. After 6.6 ± 3.1 years, 29.9 ± 20.7% of shoulders demonstrated superior humeral head migration and 17.9 ± 14.3% migrated a distance more than 25% of the head. This was associated with an 11.3 ± 7.9% incidence of postoperative superior cuff tears. 

The incidence of radiographic anterior humeral head migration was 11.9 ± 15.9%, corresponding to a 3.0 ± 13.6% rate of subscapularis tears. 

They found an overall 1.2 ± 4.5% rate of reoperation for cuff injury.

Comment:  Shoulder arthroplasty abruptly re-activates a rotator cuff that has been relatively inactive because of the reduced shoulder use imposed by the pre surgical arthritis. As a result, the cuff experiences loads to which it has not been recently exposed and becomes at risk for failure. The results of this study indicate that cuff dysfunction (as suggested by superior humeral head migration) is not uncommon six years after shoulder arthroplasty. it appears that this cuff dysfunction does not routinely lead to repeat surgery.

Being mindful of the risk of delayed cuff and subscapularis failure, we caution patients about their cuff-related activities after arthroplasty as shown in this link. It is of note that the average age of individuals having shoulder arthroplasty for arthritis is very similar to the average age of individuals with rotator cuff tears.
If the cuff deficiency leads to major functional loss, such as pseudo paralysis or anterosuperior escape as shown below

a reverse total shoulder can be considered (see this link). The reverse total shoulder does not depend on the rotator cuff for stability; instead its geometry enables the deltoid to function independent of the cuff.


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