An active woman in her 60s with cuff tear arthropathy of the left shoulder after two failed rotator cuff repairs was referred for consideration of a reverse total shoulder arthroplasty. She has seronegative rheumatoid arthritis treated with prednisone, Avara and methotrexate. She had active, but painful elevation to 80 degrees. She had grade 4 internal and external rotation strength.

X-rays at presentation showed glenohumeral arthritis with contact between the humeral head and acromion

The axillary "truth' view showed posterior decentering of the humeral head on the arthritic glenoid.

Because of her active lifestyle and because she wished to avoid the limitations and risks of reverse total shoulder arthroplasty - such as instability, acromial/spine fractures, and baseplate failure - she elected a cuff tear arthropathy hemiarthroplasty (CTAH).

The procedure was performed without preoperative CT or 3D planning and without a brachial plexus block. The technique for this procedure is shown on this link.

At surgery her supraspinatus and the upper half her infraspinatus were absent. The subscapularis was intact. There was essentially complete loss of articular cartilage over the humeral head and glenoid. After debridement of the sutures and the graft that had been used in the prior cuff surgery, the arthritic humeral head was replaced with an extended articular surface hemiarthroplasty that matched the diameter of curvature of the native humeral head. Care was taken to preserve the coracoacromial ligament and the clavipectoral fascia. The smooth, standard length humeral stem was secured with impaction autografting. At the conclusion of the procedure the subscapularis peel was repaired to the lesser tuberosity with 6 #2 non-absorbable sutures. Assisted elevation was started on the day of surgery.

At 4.5 years after her CTAH procedure she reported that she had returned to her desired activities. Her shoulder was comfortable and able to perform 10 of the 12 functions of the Simple Shoulder Test, including the ability sleep on that side, to internally rotate the arm to tuck in her shirt behind her, to wash the back of the opposite shoulder, to lift eight pounds to shoulder level, as well as to toss and throw a ball. Her SANE score was 100. She could actively elevate her arm to 140 degrees.

Her x-rays at 4.5 after surgery showed secure fixation of her implant with the extended prothetic head articulating with the undersurface of the acromion and well centered in the glenoid socket in both views.

Comment: As shown here, the CTA hemiarthroplasty can be a cost-effective surgical procedure in patients with cuff tear arthropathy and retained active elevation of the arm. Of note the CTAH does not limit internal rotation, which can be a problem with reverse total shoulders (see Reverse total shoulder: how to get the "internal rotation" needed for function).

For additional information, see these links

CTAH or reverse for cuff tear arthropathy?.

Rotator cuff tear arthropathy and the CTA prosthesis

Treating cuff tear arthropathy in the active patient - the CTA prosthesis

The versatile, inexpensive and safe CTA hemiarthroplasty for patients with preserved active elevation

CTA arthroplasty rather than a reverse total shoulder for rotator cuff tear arthropathy

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