Wednesday, August 2, 2017

Is it necessary to image the rotator cuff prior to total shoulder arthroplasty?

The incidence and effect of fatty atrophy, positive tangent sign, and rotator cuff tears on outcomes after total shoulder arthroplasty

These authors conducted a retrospective review of the prevalence and effect of preoperative partial-thickness cuff tears and muscular degenerative changes on postoperative outcomes in their patients having total shoulder arthroplasty (TSA). Patients with full-thickness cuff tears (RCT) on preoperative magnetic resonance imaging were excluded from this study.

The review found 45 of 73 (62%) of patients could be included in their study (had a full complement of advanced imaging, minimum 2-year outcome measures, and available records data). The remainder of the patients lacked 2-year outcome data or were lost to follow-up. There were 12 men and 33 women with an average age of 65 ± 10 years. Final mean follow-up was 43 months (range, 24-73 months). Forty percent (18 of 45) of patients undergoing TSA had a significant (> 50% thickness) partial supraspinatus tendon tear. 
Grade 3 to 4 Goutallier changes were noted in 22% of all patients, and 13% demonstrated grade 3 to 4 changes in the context of no tear. Positive tangent sign was present in 7% of all patients. The remainder had no appreciable tear or minimal increased signal consistent with low-grade tearing on imaging.

Rotator cuff pathology, including tear status, Goutallier grade, and the presence of a tangent sign, did not correlate with postoperative functional outcome scores.

Comment: While the article suggests that  rotator cuff disease is generally uncommon in this patient population, a recent study "Relationship Between Age and Rotator Cuff Retear: A Study of 1,600 Consecutive Rotator Cuff Repairs" (see this link), found that a cohort of 1,600 patients with cuff tears was normally distributed in terms of age, with a mean age of  59 with a range of 15 to 91 years, a range that is similar to that of patients having total shoulder arthroplasty.  Thus it is not surprising that cuff pathology and arthritis co-exist in a fair number of patients.

Perhaps the best question to ask is whether a pre-TSA MRI is a worthwhile expense in this era of escalating health care costs? 

In our practice, we do not usually obtain pre-TSA MRI's or CT scans, finding that we can get the information we need for informed consent and surgical planning from a good history, physical exam of the three key elements of the cuff and plain x-rays to look for superior decentering of the humeral head (which would indicate cuff deficiency). We advise all patients having anatomic shoulder arthroplasty of the need to care for their rotator cuffs after surgery and to recognize that cuff failure after arthroplasty is a recognized cause of failure. In those with clinical evidence of compromised cuff tendon integrity, we discuss alternate management strategies such as a CTA or a reverse shoulder arthroplasty. 

Most often if the patient has good external rotator strength and a centered humeral head preoperatively, they are well served by a standard total shoulder.
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