Cuff tear arthropathy - current considerations

Rotator cuff tear arthropathy is a common indication for shoulder arthroplasty. The most common type of arthroplasty applied to this diagnosis is the reverse total shoulder.

As pointed out in Range of motion after reverse total shoulder - how important is it and what affects it? Lets look at 35 recent publications, patient satisfaction and range of motion appears to be optimized by lateralizing the glenoid center of rotation.

However, as pointed out in Acromial fractures after reverse total shoulder - current thoughts, acromial and spine stress fractures are one of the most common and most disabling of complications in patients with cuff tear arthropathy treated with reverse total shoulder, especially in female patients with poor bone quality. The role of component position in the causation of these fractures is less well defined, but lateralizing the glenoid center of rotation appears to be associated with increased risk.

So it seems that there is a tradeoff between optimizing function and reducing fracture risk.

Here's an illustrative example of an 82 year old lady with cuff tear arthroplasty who had an excellent functional outcome after her reverse total shoulder with a somewhat lateralized glenopshere. 

However, four months after her RSA, she developed disabling pain in the back of her shoulder and a CT scan showing an acromial fracture. In that the fracture is minimally displaced, it is anticipated that it will heal uneventfully with return of comfort and function.

It is difficult to know whether less glenosphere lateralization would have yielded the same level of function with less risk of fracture in this shoulder that has the well-established and unmodifiably dominant fracture risk factors of female sex, osteopenia, and cuff tear arthropathy.

There is an alternative approach to the surgical management of cuff tear arthropathy in patients at high risk for acromial/spine fractures: the CTA hemiarthroplasty.

Which can yield impressive levels of function without risk of acromial/scapular spine fractures.

Here is the two year postoperative function of the patient whose x-rays are shown above.

Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty presents this surgical option in further detail.

Unfortunately, the company that made this prosthesis, (DePuy, J&J) is no longer making this implant and no other company has taken it on, apparently for "business reasons".

It is my hope that readers of this post, which include representatives from many implant companies, will join me in advocating for the production of the extended humeral head component for the management of cuff tear arthropathy. Patient care should be our "business".

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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).