Monday, March 19, 2018

Arthritis + a rotator cuff tear

Functional Outcomes and Predictors of Failure After Rotator Cuff Repair During Total Shoulder Arthroplasty

These authors point out that a well-functioning rotator cuff is necessary for the best results from an anatomic total shoulder arthroplasty (TSA).

They evaluated 45 of their patients who underwent concomitant TSA and rotator cuff repair (RCR): 22 had high-grade partial-thickness and 23 had full-thickness tears). 

Fourteen (31%) patients were labeled as having a poor result; 8 (18%) patients required reoperation. 

The indications for TSA were as follows: osteoarthritis (n=34), rheumatoid arthritis/inflammatory (n=7), posttraumatic (n=4), and avascular necrosis (n=1). Average follow-up was 4.7 years (range, 2.0-14.4 years) 

The mean AFE improved from 101° (range, 40°-160°) preoperatively to 139° (range, 30°-180°) postoperatively (P<.0001; 95% confidence interval, 26°- 50°). The mean AER improved from 20.0° (range, -20° to 40°) preoperatively to 40° (range, 0°-75°) postoperatively (P<.0001; 95% confidence interval, 14°-27°). 

There was a significant difference between the acromiohumeral interval preoperatively and immediately postoperatively (P=.013). However, at maximum radiographic follow-up, the acromiohumeral interval was not significantly different from preoperative values (P=.86). 

Patients with a preoperative acromiohumeral interval of less than 8 mm had an increased rate of cuff-related reoperation (P=.003). 

Comment: This report concerns a mixed group of pathologies: some with full thickness cuff tears, some with inflammatory arthropathy, and some with preoperative active elevation of 160 degrees. In our practice each of these characteristics would influence our shared surgeon-patient decision making. We rarely perform a cuff repair at the time of a shoulder arthroplasty because of the conflicting rehabilitation programs after these two procedures (protection for the first and motion for the second). Many patients with shoulder arthritis have "partial tears" that need not change the surgical approach as long as the shoulder has good active motion. Cuff repairs in individuals with inflammatory arthropathy have a high failure rate. Patients with shoulder arthritis and 160 degrees of preoperative motion may not need a cuff repair.

Our algorithm for patients with glenohumeral arthritis and cuff pathology is as follows:
(1) consider  total shoulder without cuff repair if there is no superior migration of the humeral head with respect to the scapula and if there is active elevation > 90 degrees
(2) consider CTA arthroplasty (see this link) without cuff repair if there is superior migration of the humeral head with respect to the scapula and if there is active elevation > 90 degrees
(3) consider reverse total shoulder if is active elevation is < 90 degrees.
(4) avoid concurrent arthroplasty and cuff repair
(5) avoid cuff repair in patients with inflammatory arthropathy
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