Rean and Run Diary - 5 months

Check out our patient's five month update to the diary. A real testimony to 'attitude is everything'.

--

Use the "Search the Blog" 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.

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

Chondrolysis and Pain Pumps - more recent cases

Recently we cared for two individuals under the age of 40 with chondrolysis after the use of pain pumps for the intra-articular infusion of local anesthetics.

The first had a cuff repair and subacromial decompression with a pain pump a decade ago followed by progressive loss of comfort and function. X-rays showed joint space loss.

In spite of the patient's young age, we recommended a total shoulder because of our observation that individuals with chondrolysis have a difficult time rehabilitating a ream and run procedure.

At the time of surgery, the cartilage over the humeral head was gone.

We hope that some comfort and function will be restored after the total shoulder.

The second patient had had arthroscopic surgery with a pain pump over 6 years ago. Two years later the patient's surgeon performed a hemiarthroplasty for chondrolysis.

Because of persistent pain and loss of function, the patient presented to us for complex conversion to a total shoulder.

--

Use the "Search the Blog" 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.

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

Shoulders and fly fishing anglers

Practicing shoulder surgery in the Pacific Northwest, we get the chance to meet a wonderful variety of outdoors people who become limited in their ability to enjoy climbing, skiing, kayaking, diving, windsurfing, sailing and, of course, fly fishing. 

On the drive over to the Yakima for a wonderful day of dry fly fishing, I had the chance to reflect on some recent encounters with avid devotees of this remarkable activity. Before I tell you their stories, there are some common features to be recognized:

(1) These individuals are steadfastly dedicated to fly fishing, and would rather stand in a river waiving a rod than eat

(2) These individuals are in the prime of life (i.e. they are all 60 and over) 

(3) They came into the office because their shoulders limited their ability to cast and/or land fish.

STIFFNESS

The important fact is that the shoulders of folks in this age group are at risk for shoulder stiffness, weakness, pain and loss of function from two principal causes: osteoarthritis and rotator cuff wear. Fortunately, limitations from these conditions can often be reduced by gentle range of motion exercises. Just as the use of barbless hooks and avoiding handling of the fish can prevent attrition of trout and steelhead in our rivers, gently stretching the shoulder before and during a day of fly casting is a great way to keep the joint limber and comfortable and to prevent shoulder problems.

Meet Angler A,  70 year old adventure guide for fishing and diving around the world. The problem here was mild arthritis and stiffness. The symptoms greatly improved with a minor smoothing procedure and lots of mobilization exercises.

ROTATOR CUFF 

While folks under the age of 60 may tear their cuff tendons with a fall, those of us more senior than that can wear, thin or tear the rotator cuff tendons with lifting an anchor over the side of the boat or in getting the canoe off the car top carrier. Keeping the shoulder flexible, being thoughtful about lifting, and getting help with heavy things can be useful preventative strategies. 

When the rotator cuff tendon is acutely torn from a sudden injury, surgical repair is a strong consideration. However, when the cuff fails progressively over time without a definite injury, stretching exercises may help resolve the symptoms. If the shoulder remains painful, a 'smooth and move' procedure often makes the shoulder more comfortable and functional without the long rehabilitation from a rotator cuff repair. Not infrequently we meet anglers over the age of 60 who have had a surgical attempt at rotator cuff repair, only to learn that the rotator cuff tendon tissue was not good enough for a solid repair and to fail to improve after surgery. Perhaps surprisingly, a smooth and move procedure can often restore substantial comfort and function, even though the integrity of the rotator cuff is not restored.

Meet Angler B, a 69 year old avid spring creek fly fisher and author from Montana having had two previous attempts at rotator cuff repair with a painful clicking and weak shoulder. The MRI (shown below) shows lack of tendon healing. If the shoulder does not improve with range of motion exercises, a smooth and move procedure will help get the shoulder ready for the planned angling trip to South America.

ARTHRITIS

Individuals over 60 not uncommonly have lost some of the cartilage that normally provides a smooth bearing surface for the shoulder joint. This 'wear and tear' arthritis can cause stiffness, pain and loss of function. Once again, gentle home exercises can often temper the symptoms and prevent progression of the condition.

If symptoms become severely limiting of the quality of living, surgical reconstruction in the form of a ream and run or a total shoulder can be considered.

Meet Angler C, a 68 year old steelhead guide, who lives on the bank of one of Oregon's most famous rivers. Arthritis of the shoulder took the enjoyment out of spey casting (see the loss of joint space in the joint on the x-rays below. Alongside the shoulder is a pacemaker, keeping his ticker ticking).

Exercises improved his condition, but not enough, so he proceeded with a ream and run procedure (shown below) which has him back on the river.

Let us end with a perspective provided by Robert Fulghum in It Was on Fire When I Lay Down on It

"The River-Runner's Maxim, taught to me when I was learning white-water canoeing from friend Baz, a maximum pro: "Sitting still is essential to the journey." When heading off downriver, pull over to the bank from time to time and sit quietly and look at the river and think about where you've been and where you're going and why and how. "

----

If you have suggestions for topics you'd like us to address in this blog, please send an email to

shoulderarthritis@uw.edu.

Use the "Search the Blog" 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.

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

Rotator cuff repair - does healing of the tendon matter in the clinical result?

Rotator cuff tear

The JBJS just published an article entitled Repair Integrity and Functional Outcomes After Arthroscopic Suture-Bridge Rotator Cuff Repair. The re-tear rate of the medium, large, and massive tears (as classified according to the anterior-to-posterior diameter of the tear) was 12%, 21%, and 22%, respectively. Once again it is of interest that "None of the functional outcomes in this study differed significantly between the healed and unhealed groups."  The discussion section of this paper contains this very interesting paragraph:

"Frank et al.did not find any significant difference between failed and intact repairs, except with regard to the UCLA scores. During postoperative clinical evaluations, Park et al.found no difference between failed and intact repairs except with regard to abduction power at the six-month follow-up assessment. In the study by Voigt et al, neither patient satisfaction nor the Constant-Murley score, nor any subcategory, differed significantly between the unhealed/re-torn group and the group with an intact supraspinatus tendon. Sethi et al. did not find a significant difference between healed and unhealed tears with respect to outcome scores, with the exception of the strength component of the ASES."

So once again, we must wonder about the importance of cuff integrity in the improvement experienced by the patient after rotator cuff surgery.

--

Use the "Search the Blog" 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.

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

Reverse total shoulder mechanics

Reverse shoulder
Reverse total shoulder

JSES recently published an in vitro study of the effect of deltoid tension and humeral version in reverse total shoulder arthroplasty.

In this cadavaric study, the authors examined the effect of increased deltoid tension (achieved by increasing implant thickness) and humeral version on the in vitro mechanics of the shoulder. They found that the force necessary for dislocation was not significantly affected by implant thickness or version.

In a previous posts we discussed the relationship between increased humeral length and acromion/spine fractures and nerve injuries, suggesting that maximizing deltoid tension may not be the safest way to achieve stability in a reverse total shoulder.

The authors mention briefly the issue of 'inferior impingement' as a mechanism for instability of reverse total shoulders (this is the same mechanism that results in notching as discussed before).  In this study, the authors used the Tornier Aequalis Reverse prosthesis. With respect to 'inferior impingement' it is of interest to examine the radiograph on the prosthesis website, reproduced below, which shows a slightly abducted arm with the prosthesis in place. We've added an arrow to show the 'inferior impingement'. It seems possible that this 'inferior impingement' may have at least three undesirable effects: (1) limitation of adduction, (2) notching and (3) instability due to levering apart of the two joint surfaces with adduction.

--

Use the "Search the Blog" 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.

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

Long-term follow-up of cases of rotator cuff tear treated conservatively JSES

Rotator cuff tear

JSES published a study on the Long-term follow-up of cases of rotator cuff tear treated conservatively. Between 1996 and 1999, the authors offered non-operative treatment to 104 consecutive patients (107 shoulders) diagnosed by MRI or arthrogram as having rotator cuff tears. Patients were informed that they could have surgery if their symptoms continued. Non-operative management included injections, medications and physical therapy continued until the patient was satisfied. Three patients had cuff repair for persistent limiting symptoms. Long term followup was available in 2009 on 43 shoulders, of which 56% had no pain, 33% had slight pain, and 12% had pain during activities of daily living. Patients with poorer results tended to be younger than those with better results.

This article was highlighted in a recent email from an orthopaedic surgeon colleague: "As you may recall, I have a irreparable rotator cuff tear (RCT). I followed your advice and now my right shoulder is essentially asymptomatic. Yesterday I skied 19000 vertical feet—19 Xs up and down XXX —with no shoulder probs. Several months ago J. Shoulder Elbow had a commentary on Dr. Codman, publishing his first 2 rotator cuff repair op. reports. I was fascinated to read that Codman concluded that the massive tears he found in the hod carrier and Irish washerwoman had been present for years without significant functional impairment. A recent article from Japan (J. Shoulder Elbow (2012), 491-494 indicates that the great majority of pts they followed had no significant sx or impairment with unrepaired RCTs. I have done lots of Independent Medical Evaluations on workers who had rotator cuff tears of various severity who had open or arthroscopic repairs—the result is usually the same—some residual pain which limits them with overhead work and a ratable impairment in the range of 10% to 25% of the upper extremity due to postoperative stiffness. My question is why, especially in the worker’s comp setting, does a MRA showing a tear automatically result in an attempted surgical repair? Am I missing something? Are there good reasons to repair RCTs surgically? What are the indications other than a positive MRA?"

The principal value of this article is that it demonstrates that rotator cuff tear in and of itself need not be an indication for surgery. While the Journal listed this as a Level II prognostic study, we really don't have enough data to use the data prognostically. What would have been most helpful would be to know more about the size and acuity of the cuff tears as well as the shoulder function at the time they presented. It would also be important to know more about the fate of the 50+ shoulders that were not included in the follow-up for a variety of reasons. 

It seems important that several elements need to be included in any study of rotator cuff treatment:

(1) patient age

(2) whether the tear is acute or chronic

(3) the comfort and function of the shoulder

As we've posted before, other factors are important in determining if the rotator cuff is repairable.

Whether or not the patient should have a repair depends not only on the repairability of the tear, but also on the nature and severity of the problems the patient is having with their shoulder. In many cases, when non-operative management of chronic cuff tears is insufficiently effective, we have found that a 'smooth and move procedure' is helpful, without the need for the extensive recovery perior necessary to protect a repaired cuff tear.

In summary, we encourage young, non-smoking individuals with symptomatic, repairable acute rotator cuff tears to consider a prompt cuff repair so that they have the optimal chance of regaining their strength. Individuals with chronic tears have time to try non-operative management, including stretching, strengthening of the deltoid and residual cuff muscles, and mild anti-inflammatory analgesics. If this non-operative program fails to give the desired improvement, the pros and cons of repair vs. smooth and move are reviewed with the patient.

--

Use the "Search the Blog" 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.

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

Total Shoulder Arthroplasty: Relationship of glenohumeral curvature mismatch to stability and interface motion.

JSES recently published "Interface micromotions increase with less-conforming cementless glenoid components."
Readers my want to view this study in view of the concept of concavity compression. You should surely treat yourself to the video on this topic prepared by my late partner, Doug Harryman. as well as his article "The effect of articular conformity and the size of the humeral head component on laxity and motion after glenohumeral arthroplasty. " It is important to recognize that normal glenohumeral kinematics include translation of the humeral head on the glenoid surface. Also, you should be aware of the work of David Collins, who did a very similar study many years ago.

A note of caution about nomenclature. Different prosthesis systems use different ways of describing the components. In this study, the authors describe the surface in terms of the RADIUS of curvature. They used a consistent head radius of 20 mm and examined glenoid surfaces ranging from 20 to 26. Some systems, including the one we use here, describe the head curvature in terms of the DIAMETER, 40 mm to 56 mm for example. In the system we use, the glenoid components are all 6 mm in DIAMETER greater than the humeral head: a 6 mm diametric mismatch or a 3 mm radial mismatch. In contrast, Neer's original total shoulder system had no mismatch in diameter between the glenoid and humeral components.

The premise of this article seems to be that cementless bone ingrowth fixation is desirable for glenoid components and that, for that reason, motion at the prosthesis bone-prosthesis interface is to be avoided. We can agree with the second part of this assertion, although evidence for the first part is lacking.

This study shows that the greater the mismatch between the curvature of the humeral head and the glenoid, the more translation allowed when a displacing force is applied to it. Once one understands the concept of concavity compression, it is intuitive that a greater degree of mismatch between the curvatures would allow for more translation per unit applied displacing force. This is exactly what the authors of the JSES paper found.

Much of the remainder of this article attempts to relate glenohumeral diameter mismatch to glenoid-bone micromotions. The problem is that so many variables we encounter clinically - direction of load, magnitude of load, quality of bone, type of fixation, seating of the component, compliance of the glenoid component, etc -  are not emulated in this in vitro study using 'bone substitute'. To appreciate the complexity of the clinical situation, you may like to read "The influence of glenohumeral prosthetic mismatch on glenoid radiolucent lines: results of a multicenter study."

As we pointed out in our book, The Shoulder is A Balance of Mobility and Stability.  In shoulder arthroplasty, many factors need to be considered in achieving this balance. While glenoid component loosening is the major complication of total shoulder arthroplasty, the geometry of the glenoid and humeral joint surfaces are only one of the many variables that need to be considered.

--

Use the "Search the Blog" 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.

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

Postoperative pain strongly correlated with preoperative pain

JSES recently published an article "Postoperative pain associated with orthopedic shoulder and elbow surgery: a prospective study". In this important prospective Level I study, the authors assessed (1) preoperative pain and (2) anticipated postoperative pain using standardized questionnaires before a variety of shoulder and elbow procedures and then correlated these measurements with the pain after surgery.

The pain experience by the patient at 3 days after surgery was highly correlated with the preoperative pain score (p .006) and the anticipated postoperative pain score (p<.001). 

In that pain is one of the important measures of surgical outcome, it is important to recognize that the amount of pain patients have going into the procedure and their anticipation of the amount of pain they will after afterwards can inform preoperative surgeon-patient discussions and allow for the customization of postoperative pain management strategies.

--

Use the "Search the Blog" 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.

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

Platelet Rich Fibrin Matrix (PRFM) has little effect on healing when applied during rotator cuff repair

PRFM has little effect on healing when applied during rotator cuff repair. This was the conclusion of a recent report that randomized patients having rotator cuff repairs to receive or not receive PRFM.There were no differences in tendon-to-bone healing between the two groups by ultrasound and no difference in clinical outcomes, including strength between groups. In fact, the use of PRFM was associated with a statistically higher chance of a residual cuff defect at 12 weeks after surgery.

--

Use the "Search the Blog" 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.

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

Predictors of Outcome in Joint Replacement

Much of this work as been done with respect to total knees, but there's every reason to believe that the same predictors would apply to shoulder surgery.

These factors include

Body Mass Index (BMI) - disproportionately heavy individuals had poorer outcomes

Provider Volume, age, and associated medical conditions - Higher revision rates were associated with lower patient age and low hospital volume. Complications during admission were associated with increased patient age and comorbidity, and higher hospital volume.

Catastrophizing and depressive symptoms - depressive symptoms were predictors of greater global pain complaints, while catastrophizing was a specific predictor of elevated nighttime pain.

Preoperative pain and function. - the strongest determinant of outcome was pre-operative pain and function (less severe patients had the best outcomes)

Poor preoperative comfort, function, and mental health -  the most significant preoperative predictors of worse preoperative scores on the pain,  physical functioning and mental health.

These results are important in that they suggest that the route to better results may lie more in understanding and managing these risk factors than in improvement in prosthetic design.  They surely need to be covered in preoperative discussions with patients with such findings.

--

Use the "Search the Blog" 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.

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

Chondrolysis and pain pumps, the cases keep coming

I continue to receive emails from individuals around the country with the situation described below:

"I am a physical therapist in XXXX and have a patient (now 25 years old) who has a failed hemiarthroplasty. See had an initial decompression surgery at 16 then experienced bouts of instability. She then underwent stabilization surgery and did well from 2006 to 2008 then experienced gradual onset of shoulder pain. She returned to the surgeon who informed her she had glenohumeral chondrolysis secondary to a pain pump post surgically. She had a hemiarthroplasty in 2009 and her shoulder is a mess. She struggles daily with pain and basically inability to function at shoulder level. She's exhausted everybody in XXXXX and has had shoulder fusion offered as the only option. She traveled at her expense to see XXXX who also recommended fusion. Up to her first surgery she was a student at the University of XXXX, now she spends each day wondering how to endure the pain. She has been to numerous physiatrists and pain specialists who are unable to adequately control her pain. I see her struggle and googled "failed shoulder hemiarthroplasties" to se if anyone was addressing this. Please email me back if there is any information I can pass onto my patient. Thanks you for your consideration"

--

Use the "Search the Blog" 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.

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

Colin Porter Husky Offensive Lineman Degenerative Arthritis of the Shoulders

This morning's Seattle Times carried the Headline "Colin Porter's career over". The article states that he has 'degenerative arthritis' of his shoulders perhaps resulting from repeated injuries starting in highschool.

Degenerative arthritis is a condition in which the cartilage and the natural roundness of the joint surfaces are lost. It is most easily diagnosed by x-rays.

Specific exercises may help shoulders with arthritis.

In severe cases, a ream and run procedure or a total shoulder replacement may be considered.

--

Use the "Search the Blog" 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.

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

Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear

JSES published a recent article on Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear.

This article points to the scarcity of data on the different factors potentially influencing the risk of glenoid component failure, one of the most important causes of unsatisfactory results from a total shoulder arthroplasty. They reviewed concepts in glenoid component design, metal glenoid components, polyethylene glenoid components, pegs vs keels, glenohumeral component mismatch, glenoid version and bone stock and observed the lack of high quality evidence supporting any particular approach to prosthetic glenoid resurfacing. They also pointed to the potentially serious problems of glenoid bone deficiency after glenoid component failure making revision difficult and less satisfactory than primary arthroplasty.

Hopefully the future will see higher quality studies that can inform better surgical techniques and component designs. 

It is of interest that the figure below showing to radiographs of the same shoulder only 6 months apart is reminiscent of the problem of secondary cuff dysfunction discussed in a previous post.

--

Use the "Search the Blog" 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.

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

Radiographic analysis of the effects of glenosphere position on scapular notching following reverse total shoulder arthroplasty JSES

A study on  the Radiographic analysis of the effects of glenosphere position on scapular notching following reverse total shoulder arthroplasty was recently published in JSES.

Scapular notching results when the medial aspect of the humeral cup contacts the lateral scapular margin.

An example is shown here in the area marked by the dark line. Note that the scapular bone in this area has been completely reabsorbed, leaving the glenoid component relatively unsupported. Notching has been associated with damage to the polyethylene of the humeral cup, with instability and with inferior clinical outcomes.

The authors hypothesized that inferiorly tilting the glenosphere (as shown below) would decrease the grade of notching. It is of interest that notching was present in 70% of their 71 cases at a minimum of 12 months after surgery. There was no statistically significant different in the notching rate or severity between those shoulders with inferior tilt and those with neutral tilt.  

The shoulders in this study were not randomized and were not controlled for the different types of prostheses used.  The clinical outcomes are not presented. 

Many factors can affect notching, including the design of the component (especially with respect to the offset of the glenosphere from the scapula) and the superior-inferior position of the glenoid. 

Inferior tilt would appear to have the disadvantage of moving the center of rotation and, therefore, the humeral component medially - in closer proximity to the scapula - as suggested by the diagrams above from this article. Inferior tilt also has the disadvantage of require sacrifice of bone at the inferior glenoid - glenoid bone stock is precious in the elderly individuals requiring this procedure. 

====

Use the "Search the Blog" 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.

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

Outcomes of arthroscopic rotator cuff repairs in obese patients JSES

Outcomes of arthroscopic rotator cuff repairs in obese patients were investigated in a recent JSES article.
The patients were classified as normal weight (body mass index <25), overweight (BMI 25-30), and obese (BMI>30). The sizes of the cuff tears did not differ significantly between obese and non obese patients. Operative times were on average 21 minutes longer (p .013) for the obese patients. Patients had an arthroscopic 'double row equivalent' repair with PT started at 6 weeks.  ASES and PENN scores were statistically significantly worse for the obese patients at an average of 16 months after surgery.  83% of the non-obese patients had 'successful' outcomes while only 71% of the obese patients had successful outcomes. 23 of the 59 obese patients were kept overnight to monitor for sleep apnea.  5 of 59 repairs in obese patients had revision surgery while 5 of 90 repairs in non obese patients had revisions. The structural outcomes of the cuff repairs are not otherwise presented; reliable information on cuff integrity is not available.

This information on obesity as a risk factor is of interest. We do not know, however, the degree to which obesity is a risk factor for structural healing of the repaired cuff.

==

Use the "Search the Blog" 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.

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

Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment: AAOS Exhibit

Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment was the topic of a recent AAOS exhibit. The authors define this condition as the combination of rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeral head.

When the rotator cuff is deficient, the concavity compression mechanism of shoulder stability is compromised. This leads to a complex combination of weakness, arthritis and instability known as cuff tear arthropathy. In this condition contraction of the deltoid presses the humeral head upwards against the coracoacromial arch rather than flexing or abducting the arm. In some cases the shoulder can compensate for this pathoanatomy, but in other cases the arm becomes dysfunctional or 'pseudoparalytic'. A practical definition of pseudoparalysis is the inability to elevate the arm to 90 degrees in spite of rehabilitation of the residual muscles. Pseudoparalysis can be particularly severe if the shoulder has had a prior acromioplasty, which compromises the stabilizing effect of the coracoacromial arch. This can compound the problem by giving rise to anterosuperior escape.

When the head is superiorly displaced, but the shoulder remains stable and is capable of 90 degrees of active elevation, a CTA prosthesis is an option that avoids some of the risks of a reverse total shoulder.

When the humeral head is superiorly displaced on the glenoid and when there is anterosuperior escape, the situation cannot be managed with a conventional shoulder arthroplasty in that this procedure does not increase the stability of the joint. For informed patients with major loss of comfort and function of the shoulder resulting from cuff tear arthropathy, a reverse total shoulder can be considered.

The authors conclude:  "the initial management of rotator cuff arthropathy should begin with conservative measures, surgical intervention is often required. Promising results following reverse total shoulder arthroplasty have led to an increase in the utilization of this procedure. However, complication rates remain high, demonstrating the importance of strict patient  selection and careful operative technique as well as the necessity of future design modifications."

--

Use the "Search the Blog" 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.

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

Discordance between anatomical and clinical results in rotator cuff repair

Articles in JSES on the Prospective evaluation of arthroscopic cuff repairs at five years demonstrate that healing as evidenced by ultrasound 'did not correspond to clinical outcomes'. Larger tears in older patients who had concomitant procedures, such as biceps or AC joint procedures, were more likely to have defects by ultrasound at five years, but no preoperative or intra-operative factors were found to be predictive of an excellent functional result at five years.

These results are consistent with previous work indicating that the outcome of cuff surgery depends on many factors and that patients having cuff surgery may have good functional outcomes, even if the cuff does not remain intact.

--

Use the "Search the Blog" 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.

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