Pseudoparalysis?

What is pseudoparalysis? An international group of 26 experienced shoulder surgeons tried to answer this question using a a modified Delphi process as reported in Defining Pseudoparalysis & Pseudoparesis - A Consensus Study. 

The term "pseudoparalysis " is often used to describe a shoulder with preserved passive motion but lacks the ability to actively elevate the arm.

In some cases, the diagnosis is apparent.

However,  in the above referenced article, there was lack of consensus about the thresholds of motion necessary to make the diagnosis of pseudoparalysis. This is particularly an issue in the stiff shoulder.

An imporant question is "why does all this matter"?  There seems to be at least two reasons: (1) the ranges of active and passive motion help determine treatment (e.g. anatomic vs reverse total shoulder) and (2) these ranges are important measures of the success of treatment.

Perhaps the most practical and least controversial approach is to simply document the range of passive humero-scapular flexion

and the range of active humero-scapular flexion

These two simple measures may be more helpful in guiding treatment and in documenting treatment effectiveness than wondering if the shoulder is pseuoparalytic or pseudoparetic.

Lord Kelvin 1824–1907: "When you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be"

It is of note that we measure humerothoracic not glenohumeral motion. Thus the motion of the scapula on the chest wall and the motion of the humerus with respect to the scapula are included.'

See also, what is pseudoparalysis anyway?

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link). 

Pseudoparalysis in massive irreparable rotator cuff tears: what is it and why is it so important?

Patients with massive irreparable rotator cuff tears have widely varying abilities to actively raise their arm. 

Some have quite functional active forward elevation. 

Others have pseudoparalysis, a condition in which the arm can only be passively elevated with assistance from the other arm.

but the arm cannot be actively raised by the patient above the horizontal without assistance.

Patients with massive irreparable rotator cuff tears and pseudoparalysis (as shown in the movie above) may consider reverse total shoulder arthroplasty.

On the other hand, patients without pseudoparalysis may consider simpler, less costly and safer procedures, such as a smooth and move if the shoulder is not arthritic (see this link) and a cuff tear arthropathy hemiarthroplasty if the shoulder is arthritic (see this link and this link).

Because of the clinical importance of pseudoparalysis, the question naturally arises, "are many patients on the borderline of being able to actively elevate their shoulders above the horizontal?", in other words is there a substantial percentage of patients with massive irreparable cuff tears who are "almost pseudoparalytic" or "just barely pseudoparalytic"?

This question can be addressed by data from Pseudoparesis and Pseudoparalysis in the Setting of Massive Irreparable Rotator Cuff Tear: Demographic, Anatomic, and Radiographic Risk Factors. The authors of this paper identified two groups of patients with massive irreparable rotator cuff tears:

The pseudoparalytic group: 79 patients having active forward elevation (AFE) <90 degrees with maintained passive range of motion. The mean (± standard deviation) active forward elevation for this group was 59± 26 degrees.

The non pseudoparalytic group: 50 patients with massive irreparable rotator cuff tears having active forward elevation (AFE) ≥90 degrees. The mean (± standard deviation) active forward elevation for this group was 151± 20 degrees. (p<0.001).

From these means and standard deviations the probable distributions of active forward flexion for the two groups can be determined. The important result is that there was very little overlap between the two groups (see chart below). In other words, most patients with massive irreparable rotator cuff tears were either obviously pseudoparalytic or obviously non pseudoparalytic.   

This bimodal result can be compared to the chart comparing the acromiohumeral distance for pseudoparalytic (4.8±2.7) and non pseudoparalytic (7.6±2.6, p<0.001) shoulders using data from the same study (see below). 

The minimal overlap in active flexion between the pseudoparalytic and non pseudoparalytic groups is striking by comparison to the overlap in acromiohumeral distance. 

  

Comment: This analysis points out that the clinical differentiation of pseudoparalytic and non pseudoparalytic shoulders is usually straightforward, simplifying decision making about the need for a reverse total shoulder arthroplasty (see for example, Reverse total shoulder for everything? How about for cuff tear arthropathy?).

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Superior capsular reconstruction with autograft: the importance of the subscapularis

Clinical outcomes and temporal changes in the range of motion following superior capsular reconstruction for irreparable rotator cuff tears: comparison based on the Hamada classification, presence or absence of shoulder pseudoparalysis, and status of the subscapularis tendon

These authors report their outcomes for 54 consecutive patients with irreparable rotator cuff tears or pseudoparalysis (PPS) who underwent superior capsular reconstruction (SCR) using autologous tensor fascia lata with an average graft thickness of 8.3 mm.

The inclusion criterion for SCR was an irreparable rotator cuff tear or PPS with failed conservative treatment, supervised by physiotherapists, for >6 months. In all patients, the Hamada classification was grade 2 in 11 patients and grade 3 in 43 patients.

Included shoulders had a Goutallier grade 3 or higher fatty infiltration of the tendon with the tendon retracted to the glenoid level as evaluated on magnetic resonance imaging and torn tendons that could not reach the original footprint after the release of soft tissues at the time of surgery.

Pseudoparalysis (PPS) was defined as

(1) moderate PPS (n=16), no shoulder stiffness, active shoulder elevation (both flexion and abduction) ≤ 90 degrees , and the ability of the patient to maintain  ≥ 90 degrees  of elevation once the shoulder was passively elevated; 

(2) severe PPS (n=16), comprising no shoulder stiffness, active shoulder elevation  ≤ 90 degrees, and the inability of the patient to maintain  ≥  90 degrees of elevation once the shoulder was elevated passively; and 

(3) non-PPS (n=22), comprising no shoulder stiffness and active shoulder elevation > 90 degrees. 

Lidocaine was routinely injected into the subacromial space preoperatively; patients whose ROM improved were considered to have a painful loss of elevation and were not considered as patients with PPS. 

Patients who could not elevate their shoulders even in the supine position were considered to have deltoid insufficiency and were excluded from this study.

The 32 PPS patients were divided into 3 groups: intact subscapularis (SSC) (11 patients), repairable SSC (16 patients), and irreparable SSC (5 patients). 

They found no significant differences in postoperative ASES scores and shoulder range of motion between the Hamada grade 2 and grade 3 groups or between the non-PPS, moderate PPS, and severe PPS groups.  PPS patients required a longer duration to achieve shoulder elevation > 130 degrees; nevertheless, the authors found no significant differences in final outcomes between the non-PPS and PPS groups. 

However, significant differences in postoperative ASES scores were observed between the intact SSC (final ASES =  91) and irreparable SSC groups (final ASES = 56) and between the repairable SSC (final ASES = 92) and irreparable SSC groups (final ASES = 56). There were significant differences in postoperative shoulder elevation (see graph below). The repairable SSC tear group tended to take longer to achieve improvement in shoulder elevation than the intact SSC group, although the final outcomes between the 2 groups did not show a significant difference. 

The patients noted to have anatomic failure of the SCR had excellent shoulder function and no or minimal pain as did patients with partial failure of the subscapularis repair.

The authors concluded that the status of the subscapularis, rather than the Hamada grade or the presence or absence of PPS, influenced the clinical outcomes in this series of SCRs.

Comment: This study demonstrates the importance of the subscapularis integrity in the functional outcomes of reconstruction for irreparable rotator cuff tears. It also demonstrates the potential for reversing pseudoparalysis using superior capsular reconstruction with autologous tensor fascia and the timeframe for recovery.

The application of superior capsular reconstruction, rather than reverse total shoulder, is interesting and requires further clinical investigation of indications, technique and outcomes.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Can a reverse total shoulder reverse pseudoparalysis?

Clinical Predictors for Optimal Forward Elevation in Primary Reverse Total Shoulder Arthroplasty

These authors investigated 286 shoulders after a reverse total shoulder. Indications for surgery included rotator cuff tear arthropathy, osteoarthritis with rotator cuff deficiency, irreparable rotator cuff tear, or proximal humerus fracture. Complications were documented in 16 (5.6%) of the 286 subjects in the first 12 months postoperatively. including 1 intraoperative humerus greater tuberosity fracture, 8 postoperative periprosthetic humerus fractures, 2 acromion fractures, 2 dislocations, 2 cases of glenoid baseplate aseptic loosening, and 1 infection.

The cases were stratified into 2 groups: group I included shoulders that had achieved at least 145 of active forward elevation 12 months postoperatively (90th percentile of active forward elevation, 29 shoulders) and group II for shoulders that never achieved at least 90 of active forward elevation 12 months postoperatively (10th percentile of active forward elevation, 28 shoulders).

The only independent predictor of improved postoperative forward elevation was preoperative active forward elevation: shoulders in group I had 106±30 degrees of active elevation preoperatively whereas shoulders in group II had only 56±27 degrees of preoperative active elevation (<.0001).

Comment: In this series 29 patients were able to raise their arm above 90 degrees at a year after reverse total shoulder (Group I), while 28 (almost half) were not (Group II).

The usual rationale for a reverse total shoulder is pseudoparalysis, commonly defined as the inability to raise the arm actively above the horizontal (active elevation < 90 degrees). The average patient in group I had more than 90 degrees of active elevation before surgery (i.e. did not have pseudo paralysis).  By contrast the patients in Group II appeared to have pseudo paralysis that was not resolved by the reverse total shoulder. The authors were unable to find an explanation for the failure of these patients to regain active elevation, i.e. to reverse their pseudo paralysis.

By contrast to these results, our experience is that a well done reverse total shoulder is very effective in restoring active elevation to those with pseudo paralysis. For patients with cuff tear athropathy and retained active elevation (i.e. no pseudo paralysis), we often use the cuff tear arthropathy prosthesis because of its low complication rate and the need for minimal activity restrictions after surgery. See below

Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy

Cuff tear arthropathy is a type of shoulder arthritis in which both rotator cuff and the cartilage normally covering the joint are both deficient.

When the patient is unable to elevate the arm above the horizontal, cuff tear arthropathy is often treated using a reverse total shoulder. 

However, when active elevation of the arm is present,  a humeral hemiarthroplasty with an extended humeral head (the CTA arthroplasty) can provide a safe, effective and less invasive alternative.  In this procedure the resurfaced humeral head articulates with the undersurface of the intact coracoacromial arch.

This surgical procedure requires matching of the diameter of curvature of the native humeral head

And preserving the stabilizing tissue covering the anterior aspect of the humeral head.

Appropriate sizing of the humeral head prosthesis can re-tension the deltoid.

This procedure cannot be used when the shoulder has been destabilized by a prior acromioplasty

More about this technique can be seen in this youtube (link).

Here is an example of a shoulder with cuff tear arthropathy before surgery. In spite of the destruction of the joint surface, the patient was able to actively elevate her arm.

She elected to have a CTA arthroplasty. At surgery she had complete and irreparable failure of her supraspinatus or infraspinatus.

Here is her shoulder shoulder nine years after the CTA arthroplasty, showing remodeling of her coracoacromial arch.

She generously granted permission for us to show her function nine years after surgery.

This paper analyzed the preoperative characteristics, surgical findings, and clinical outcomes for 42 patients selected for extended head hemiarthroplasty - the CTA arthroplasty.

At an average of 2-years after surgery, there were no complications or revisions. Specifically the complications that have been associated with a reverse total shoulder were avoided: no component dissociations, no baseplate failures, and no dislocations.

The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001).

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder for rotator cuff deficiency and pseudo paralysis

Longitudinal observational study of reverse total shoulder arthroplasty for irreparable rotator cuff dysfunction: results after 15 years

These authors investigated the hypothesis that functional outcomes remain significantly improved over the preoperative state beyond 15 years of reverse total shoulder arthroplasty (RTSA) for irreparable rotator cuff dysfunction. 

Between 1997 and 2001, 52 consecutive patients (23 men, 29 women) with a mean age of 71 years (range, 53-87 years) with an irreparable rotator cuff tear and secondary pseudoparalysis of active anterior elevation (AAE) were treated with the Delta III prosthesis. Rotator cuff tears were considered irreparable if pseudoparalysis was chronic (ie, >3 months), if the acromiohumeral distance was <7 mm on a plain anteroposterior radiograph, or if the fatty infiltration of the supraspinatus and infraspinatus or supraspinatus and subscapularis muscles was greater than stage 2 according to Goutallier. Pseudoparalysis was defined as active anterior elevation of <90° with preserved, free passive anterior elevation. 

22 shoulders included in the analysis had RTSA at a mean age of 68 (range, 54-77) years. Patients were reviewed clinically and radiographically at no less than 15 years (mean, 16.1; range, 15-19 years). The RTSA was a primary procedure in 7 procedures, and 15 patients had undergone at least 1 previous nonarthroplasty procedure.

The Constant and pain scores were significantly improved. Active anterior elevation (53° to 101°; P = .001), abduction (55° to 86°; P = .005). The mean scores did not significantly deteriorate over 15 years, but mean active abduction was significantly reduced over time (P = .018). 

One or more complications were recorded in 13 patients (59%), with 6 failed RTSAs (27%).

This early series of RTSA showed a substantial complication and failure rate. If, however, complications were treated without removal of the implants, the authors felt the outcome was not compromised.
Comment: This paper provides an important and encouraging longitudinal perspective on reverse total shoulder arthroplasties performed for pseudoparalysis in patients without prior arthroplasty or fracture.
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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

What is pseudoparalysis, anyway?

Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques

These authors systematically reviewed the MEDLINE database, Cochrane database, Physiotherapy Evidence Database, and Google Scholar database  for studies that defined a preoperative shoulder group as having "pseudoparalysis".

In 16 studies, the most consistent definition was a massive rotator cuff tear with active elevation less than 90°, but studies inconsistently included stiffness, external rotation loss, arthritic changes, neurologic status, and pain. 

They concluded that pseudoparalysis of the shoulder has a variable definition in the literature without consistent consideration of degree or substratification of other confounders such as the presence of arthritis or pain. 

Comment: This article emphasizes that the inability of a patient to elevate the arm above 90 degrees cannot be equated to "pseudoparalysis" without assuring that this inability is not caused by (1) stiffness or (2) pain. In the first instance, a stiff shoulder with passive and active elevation each limited to 80 degrees does not satisfy the definition. In the second instance, a shoulder that has good passive elevation, but sufficient pain that the patient cannot actively elevate the shoulder does not satisfy the definition either. The authors point out that in cases where pain appears to be the limiting factor, injection of local anesthetic may clarify the diagnosis.

Two other important observations are made here: 

(1) Apparent inability to elevate the arm in the presence of good passive motion may respond to analgesics and physical therapy. Most shoulder surgeons have seen patients referred for a reverse total shoulder because of "pseudoparalysis" who respond to non-operative measures. However, non-operative management appears to have a poor chance of restoring function to shoulders with less that 50 degrees of active elevation - see this link.

(2) Many of the cases of classic pseudoparalysis are caused by the anterosuperior escape that can result from performing an acromioplasty as shown in the video below.

This is discussed further in this post:

The effect of coracoacromial ligament excision and acromioplasty on the amount of rotator cuff force production necessary to restore intact glenohumeral biomechanics.

These authors point out that coracoacromial ligament (CAL) excision and acromioplasty increase superior and anterosuperior glenohumeral translation. They used a cadaver model to estimate how much of an increase in rotator cuff force is required to re-establish intact glenohumeral biomechanics after acromioplasty.

Nine cadaveric shoulders were subjected to loading in the superior and anterosuperior directions in the intact state after CAL excision, acromioplasty, and recording of the translations. The rotator cuff force was then increased to normalize glenohumeral biomechanics.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% was required to eliminate the increased translation resulting from CAL excision.

At 150 and 200 N of superior and anterosuperior loading, an increase in the rotator cuff force of 25% and 30%, respectively, was required to eliminate the increased translation resulting from acromioplasty and CAL excision.

The authors concluded that after subacromial decompression, the rotator cuff has to increase  its force production to maintain baseline glenohumeral mechanics. Under many circumstances, in vivo force requirements may be even greater after surgical attenuation of the coracoacromial arch.

Comment: As Codman pointed out in 1934 "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation." 

He recognized then, as we should today, that the coracoacromial arch provides an important stabilizing function resisting the superiorly directed force applied by the deltoid or when pushing up from a chair, bed, floor or bar. He pointed to the normal articulation between the superior aspect of the cuff and the undersurface of the coracoacromial arch. 

The center of curvature of the arch is the same as the center of curvature of the humeral head.

The stabilizing effect of the arch remains the same if there is ossification of part of the coracoacromial ligament.

We have previously demonstrated that the acromion is loaded when superiorly directed force is applied through the humeral head (whether or not the cuff is intact).

 When the superior cuff tissue is absent, superiorly directed loads applied to the humeral head produce superior translation of the head until it is stopped by the coracoacromial arch.

Sacrifice of the coracoacromial arch in the cuff deficient shoulder is a common cause of anterosuperior escape and pseudoparalysis.

Where does that leave the concept of 'impingement'? See this link.

See an interesting relevant letter to the editor via this link.

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To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

essentials'

Pseudoparalysis - what is it and how should it be treated?

Cost-Effectiveness of Arthroscopic Rotator Cuff Repair Versus Reverse Total Shoulder Arthroplastyfor the Treatment of Massive Rotator Cuff Tears in Patients With Pseudoparalysis and Nonarthritic Shoulders

These authors define pseudoparalysis as a condition of the shoulder with active elevation of less than 90 in association with full passive elevation. They performed a Markov decision model analysis for the cost effectiveness of treatment of shoulders with pseudoparalysis without osteoarthritis, in other words the patients in question did not have cuff tear arthropathy. They compared  arthroscopic rotator cuff repair (ARCR) to reverse total shoulder arthroplasty (RTSA).

They found that for the base-case scenario(60-year-old patient), ARCR with conversion to RTSA on potential failure was the most cost-effective strategy when they assumed equal utility for the ARCR and RTSA health states. Primary RTSA became cost-effective when the utility of RTSAexceeded that of ARCR by 0.04 quality-adjusted life-years per year. Age at decision did not substantially change this result. These results are shown in the table below.

Comment: This article is important because it challenges the common paradigm that reverse total shoulder is the indicated treatment for most cases of pseudo paralysis.

Instead, this article is based on the assertions that (1) pseudo paralysis can be reversed without a reverse total shoulder, (2) reverse total shoulders are more expensive than non-prothesthetic approaches to pseudoparalysis, and (3) reverse total shoulders can have more serious and more expensive complications than non-prosthetic approaches to pseudoparalysis.

With these assumptions, their model suggests that an arthroscopic attempt to improve the integrity of the rotator cuff followed by a period of rest and rehabilitation is a more cost-effective alternative than a primary reverse total shoulder.

In trying to understand Markov model formulations, it is important to consider the utilities of the two treatments. Here the health related quality of life (HRQoL) for each treatment experienced over time was accumulated into quality-adjusted life-years (QALYs).

In this case these utilities were gathered from a small number of studies. 

The 2 studies included for RTSA utility reported on largely female (approximately 75%) and elderly (mean age 75 years) samples and found a mean HRQoL of 0.68 after RTSA.

The 4 studies included for arthroscopic cuff repair reported on relatively younger (mean age 55 years) and predominantly male (approximately 43% female) undergoing ARCR to find an average HRQoL of 0.78. None of these studies evaluated the integrity of the cuff after repair, so although the authors state that they were 'clearly able to repair' massive cuff tears, the durability of these attempted reattachments of the tendons to their insertion site has not been determined. In one of these studies  (see this link), the pseudoparalysis was acute, having been present for a mean of 3.9 months before surgery and was traumatic in origin in 45 (80.4%) patients. 

Lacking a clear best estimate for utility after RTSA and ARCR in an equivalent patient set, the authors arbitrarily assumed an equal base case HRQoL of 0.788 for both RTSA and ARCR. It is left to the reader to determine whether this assignment is reasonable.

Here are some other elements of the model

These authors have created a model based on available data. We suspect that they will continue to refine the model as more data become apparent so that it can develop into useful practice guidelines.

Such studies need to be interpreted with care as shown in this link, which points out that the sophisticated mechanics of the Markov model cannot compensate for uncertain assumptions.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Total shoulder - tuberosity fracture and pseudoparalysis

We were recently referred a patient who had had a total shoulder for arthritis. It is of note on the preoperative film that the head was in slight varus with a cyst in the tuberosity.

A total shoulder was performed.

Close examination revealed a displaced fracture of the greater tuberosity.

Which seems to have resorbed with time - no possibility of reconstructing the cuff.

The humerus is now superiorly displaced because of the resulting supraspinatus deficiency.  The patient has pseudoparalysis. It appears that there may be some rocking horse loosening of the glenoid component.

A reverse total shoulder is being considered with the plan to leave the glenoid peg and cement in place to help fix the glenosphere.

This case is presented to show the relationship of preoperative anatomy to the challenges faced at surgery, especially if a prosthesis with a large stem is used.

Our preference is to use a small humeral stem with impaction grafting and a glenoid component inserted with minimal cement as shown below. Should a revision become necessary, plenty of secure bone stock remains on both sides of the articulation and the risk of stress shielding is minimized.

 

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.