Sad news about the management of severe cuff tear arthropathy (E3, IIA, 4B) in a 71 year old man.

A 71 year old active man presented with pain, stiffness and weakness of the right shoulder after prior rotator cuff surgery. He had active and passive elevation of his right arm to 90 degrees. 

His radiographs are shown below 

that could be described as Favard E3, 

Seebauer IIA,

and Hamada 4B

No additional imaging was performed. 

It is likely that managing this shoulder with a reverse total shoulder would have required the use of either a bone graft or an augmented baseplate as shown in the example below.

After a discussion of the alternatives, the patient elected to proceed with a CTA hemiarthroplasty. This was performed under general anesthesia without a nerve block.

At surgery the supraspinatus and infraspinatus tendons were retracted. The subscapularis was detached but reparable.

Three months after surgery he returned to the office for followup. He reported no shoulder discomfort and full active range of motion including the ability to reach up his back.

His x-ray at 3 months is shown below showing the fit of the extended articular surface CTA hemiarthroplasty head in to his "acetabulum" and the smooth standard length stem into the canal with impaction autografting.

His active elevation is shown below.

This outcome is consistent with those of many other cases (to see some of them search this blog for "CTA hemiarthroplasty", using the search box to the right). These patients have not experienced the important complications that can be associated with reverse total shoulder, such as baseplate loosening, dislocation, and acromial/spine fractures. See Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty.

The sad news is that the company making this cost effective/safe implant consisting of a smooth, standard length humeral stem and an extended humeral articular surface is discontinuing its production. Rest in peace.

Comments welcome at shoulderarthritis@uw.edu

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). 

Treating rotator cuff tear arthropathy without risking acromial and spine stress fractures

 It is well recognized that female sex, osteopenia, rotator cuff tear arthropathy, inflammatory joint disease and thin acromial bone are risk factors for acromial and scapular spine fractures after reverse total shoulder arthroplasty. Unfortunately, these conditions are commonly encountered in shoulder surgery.

A 71 year old woman presented with all of these conditions, retained active elevation above 90 degrees, and answered "yes" to only 3 functions of the 12 Simple Shoulder Test questions.

Her right shoulder x-ray at the time of presentation is shown below, demonstrating a thinned acromion, osteopenia, and acromiohumeral contact.

After discussion of the surgical options, including a reverse total shoulder, she elected to proceed with a CTA hemiarthroplasty. At the time of surgery, her supraspinatus and infraspinatus were detached and irreparable. Her subscapularis was detached but reparable.

A thin humeral stem was inserted with impaction autografting to provide a small filling ratio.

Nine years later she returned for evaluation of her contralateral shoulder. 

Her CTA hemiarthroplasty shoulder had 140 degrees of comfortable active elevation.

Her nine year followup film is shown below, demonstrating an intact acromion and no evidence of component loosening.

Comment: In our experience patients selected for the CTA hemiarthroplasty have been free of acromial/scapular spine fractures, dislocations, and prosthetic loosening. See CTA hemiartroplasty or reverse total shoulder for cuff tear arthropathy.

Comments welcome at shoulderarthritis@uw.edu

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/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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). 

  

Managing cuff tear arthropathy in an active farmer / physician - the simple and safe approach, 11 year followup.

 A 77 year old muscular retired physician, active rancher from the opposite corner of the U.S. presented with pain and loss of function of the left shoulder, thirteen years after a prior rotator cuff procedure. 

His functional deficits at that time are shown on his Simple Shoulder Test 

His x-rays at presentation are shown below.

He did not want a reverse total shoulder because of his active lifestyle caring for his farm and farm animals, clearing fallen trees, and landscaping. Instead he elected a CTA hemiarthroplasty (see this The cuff tear arthropathy arthroplasty). The procedure was performed eleven years ago without preoperative CT or MRI scans, 3D planning or interscalene block. His supraspinatus and infraspinatus tendons were absent. His subscapularis was detached, but reconstructed at the end of the case.

Seven years after surgery he returned for routine followup with these x-rays

and this shoulder function,

Now eleven years after surgery at the age of 88 he reports a mild increase in shoulder discomfort with active use, but that he is still working on his farm, sometimes tripping over tree stumps or falling when stepping in hidden holes

His current x-rays (11 years after his arthroplasty) are show below.

Comment: The CTA hemiarthroplasty is a durable, cost-effective and safer alternative to a reverse total shoulder for patients who have cuff tear arthropathy and retained active elevation (see Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty).  

Managing cuff tear arthropathy in the active woman rancher

Cuff tear arthropathy in an active 72 year old woman - options?

What if the patient with an irreparable cuff tear and arthritis doesn't want a reverse total shoulder?

Cuff tear arthropathy in a young 60 year old woman managed with the CTA hemiarthroplasty

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

70 year old active woman with irreparable rotator cuff tear and arthritis

60 year old active man with massive irreparable rotator cuff tear and arthritis

Unfortunately, in spite of their value to the patient, these implants are becoming less and less available, perhaps related to the fact that their use generates less revenue for the surgeon and for the orthopaedic company vendor than the more complex reverse total shoulder

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

Follow on twitter: https://twitter.com/RickMatsen or 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).

Cuff tear arthropathy in an active 72 year old woman - options?

 What surgical treatments should be considered for a 72 year old woman with shoulder pain and stiffness and these radiographs? Her active flexion is to 100 degrees.

Of note she used to pitch softball and hardball, but hasn't been able to throw in 25 years. She single-handedly takes care of a 13 acre property. 

She wished to avoid the potential risks and limitations of a reverse total shoulder and opted for a cuff tear arthropathy hemiarthroplasty (see this link and this link). 

She returned a year after surgery with a comfortable shoulder that enabled her return to her desired activities. Her one year films are shown below. Note the load sharing between the humeral head on one hand and the glenoid and coracoacromial arch on the other.

She kindly allowed us to share images of her motion.

And her re-gained throwing ability.

    

Experience with the CTA hemiarthroplasty indicates that the risk of acromial fracture, instability, and implant failure are very low (see Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty). 

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

Follow on twitter: https://twitter.com/RickMatsen or 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).

Managing cuff tear arthropathy in the active woman rancher

An active woman rancher in her early 60's, presented with pain in her right shoulder that prevented her from carrying out the necessary activities on her ranch. She had retained active elevation to 120 degrees. Her AP radiograph showed cuff tear arthropathy.

Wishing to avoid the risks and activity limitations associated with a reverse total shoulder, she elected a hemiarthroplasty with an extended humeral articular surface that articulates with the undersurface of the acromion - the CTA hemiarthroplasty (see this link for the technique).

At surgery the proximal humerus was completely devoid of articular cartilage, the long head biceps tendon, subscapularis, supraspinatus and upper infraspinatus were detached and irreparable.


Her postoperative x-ray is shown below.

At two years after her CTA hemiarthroplasty, her active motion was comfortable and full as shown below (including reach up the back).

Fifteen years after her arthroplasty, she kindly shared this series of photos showing her activities on the ranch.

Notably, in spite of her high level of daily activities, she has not experienced instability or acromial/spine fracture.

The chart below shows the minimum two year followup data for 45 patients having CTA hemiarthroplasty for cuff tear arthropathy with retained active elevation.



None of these patients experienced the complications associated with reverse total shoulder arthroplasty.

For more information, see this related post;
Treating cuff tear arthropathy in the active patient - the CTA prosthesis

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).

Bilateral cuff tear arthropathy in a 70+ year old farmer/rancher

A 77 year old farmer/rancher managing 200 head of cattle and spending much of his day getting on and off a tractor presented with bilateral cuff tear arthropathy, active elevation to 130 degrees and these radiographs. On the left side he had a prior acromioplasty which was of no clinical benefit to him.





Because of his active lifestyle, chance of falls on the farm, preserved active elevation, and desire to avoid the risks associated with a reverse total shoulder (e.g. dislocation, baseplate failure, and acromial/spine fracture), he elected a CTA hemiarthroplasty for the left shoulder 9 years ago and for the right 7 years ago. At each surgery both the supraspinatus and infrasinatus tendons were torn and retracted. The subscapularis was reparable on both sides.

He recovered well with a return to farming/ranching. His x-rays from five years ago are shown below.




His current films from an outside hospital are shown below - 9 year followup on the left and 7 year followup on the right.




His retained active elevation at the most recent followup is shown below.





Comment: As explained in The versatile, inexpensive and safe CTA hemiarthroplasty for patients with preserved active elevation, the CTA hemiarthroplasty is an attractive surgical alternative for active individuals with CTA and preserved active elevation. (See also CTA hemiarthroplasty or reverse total shoulder for cuff tear arthopathy? It depends.)

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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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).

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

The cuff tear arthropathy (CTA) hemiarthroplasty - using an extended humeral articular surface that articulates with the coracoacromial arch - is a versatile, effective and inexpensive reconstructive procedure for shoulders with cuff deficiency, arthritis and active elevation beyond 90 degrees. See Treating cuff tear arthropathy in the active patient - the CTA prosthesis. The technical details for this procedure are shown in this link.  In contrast to the reverse total shoulder arthroplasty, the CTA hemiarthroplasty avoids the risks of dislocation, acromial and scapular spine fractures, notching, baseplate loosening, glenoid fracture, and dissociation of the glenosphere from the baseplate.

Yesterday, we saw three patients in followup after this procedure demonstrating its application for different shoulder pathologies.

Case 1.

A man in his sixties had a proximal humeral fracture treated previously with plate fixation. This was complicated by loss of fixation and avascular necrosis. Preoperatively he had active flexion >90 degrees and the x-rays shown below.

At surgery the supraspinatus and infraspinaturs were absent. The plate and humeral head were removed and a CTA hemiarthroplasty with reconstruction of his subscapularis was performed. Eight years after surgery he returned for routine followup. His x-rays at that time are shown below.

His shoulder comfort and function were good with active elevation of 150 degrees as shown below.

Case 2. 

A man in his seventies presented with pain and stiffness of the left shoulder after a failed rotator cuff repair. He had active elevation above 90 degrees. His preoperative images showed cuff tear arthropathy, heterotopic bone and retained suture anchors.

At surgery he was found to have no supraspinatus or infraspinatus. He had a CTA hemiarthroplasty with debridement of unwanted bone and suture anchors. His subscapularis was reconstructed.

He returned six weeks after surgery with good comfort of the shoulder and active elevation greater than 90 degrees at this early stage of his rehab. His x-ray at that time is shown below.

Case 3.

A man in his seventies presented with pain and loss of function in his right shoulder. He had active elevation greater than 90 degrees. His preoperative x-rays are shown below.

At surgery he had no supraspinatus or infraspinatus. His subscapularis was reconstructed.

Three years after surgery he returned for routine followup. His x-rays at that time are shown below.

He had comfortable active elevation of 160 degrees as shown below.

Comment: As reported by the authors of  Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy, the CTA hemiarthroplasty is a safe and effective treatment for patients with cuff tear arthropathy and retained active elevation. It is substantially less expensive than a reverse total shoulder and does not require preoperative CT scans or 3D planning.

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).