CTA hemiarthroplasty or reverse total shoulder for cuff tear arthopathy? It depends.

Shoulders with cuff tear arthropathy (CTA), 

can be successfully treated with CTA hemiarthroplasty (CTA-H, hemiarthroplasty with an extended humeral articular surface) provided that the shoulder has active glenohumeral elevation and an intact coracoacromial arch

or with a reverse total shoulder arthroplasty (RSA) 

The RSA is more expensive and has complications including, instability, acromial and scapular fractures, baseplate failure, and scapular notching that are not seen with the CTA-H (see Mechanical Failure of Reverse Total Shoulder). As stated by the authors of The modern use of the extended humeral head (cuff tear arthropathy) hemiarthroplasty, "Today, the treatment of osteoarthritis in the rotator cuff–deficient population is largely dominated by reverse shoulder arthroplasty (RSA). Despite the popularity of and increased familiarity with this procedure, the complication rate of RSA remains significant. An extended humeral head hemiarthroplasty may provide a less invasive alternative for select patients with cuff tear arthropathy (CTA) and preserved glenohumeral active elevation. With the indications for reverse arthroplasty expanding to younger patients, there are concerns about the longevity of this implant, as well as the associated revision burden. In the setting of failed RSA, the bone stock available for glenosphere

baseplate fixation can be inadequate for reimplantation."

The authors of Drivers of Inpatient Hospitalization Costs, Joint-Specific Patient-Reported Outcomes, and Health-Related Quality of Life in Shoulder Arthroplasty for Cuff Tear Arthropathy sought to assess the hospitalization costs and improvements in comfort, function and health related quality of life (HRQoL) for these two types of shoulder arthroplasty in the management of CTA. CTA-H was selected in patients with retained active elevation, an intact coracoacromial (CA) arch, and an intact subscapularis, while RSA was selected in patients with pseudoparalysis or glenohumeral instability. Seventy-two patients (39 CTA-H and 33 RSA) were treated during the study time period.

The Simple Shoulder Test (SST) was used as a joint-specific patient-reported outcome measure of comfort and function. Improvement in quality adjusted life years (QALYs) was measured using the Short-Form 36 (SF-36). 

Costs associated with inpatient care were collected from hospital financial records.

Significant improvements in SST and SF-36 physical component scores were seen in both groups. 

Inpatient hospitalization costs were significantly higher in the RSA group compared to the CTA-H group ($15,074 ± $1,614 vs. $10,389 ± $1,948, p<0.001) driven primarily by supplies including the cost of the prosthesis ($9,005 ± $2,521 vs. $4,715 ± $2,091, p<0.001). 

Both procedures led to significant improvements in HRQoL and joint-specific measures:

SST comparison at two years after surgery:

SF36 Physical Component Summary comparison at two years after surgery:

SF 36 Mental Component Summary comparison at two years after surgery:

The revision rate for RSAs was twice that of CTA-Hs: 12% of the RSAs and 5% of the CTA-H shoulders required revision.

The diagnosis of diabetes was an independent predictor of higher inpatient hospitalization costs for both groups. 

Comment: It is of note that this study did not compare the two types of arthroplasty in patients with similar preoperative characteristics. Instead it compared the outcomes of the more conservative, less expensive CTA-H in shoulders with retained active elevation, intact coracoacromial arch, and intact subscapularis to the outcomes of RSA in shoulders that did not meet these indications for CTA-H.  

The results suggest that the cost-effectiveness of shoulder arthroplasty for cuff tear arthropathy may be optimized by reserving RSA for cases of CTA that do not meet the indications for the extended humeral head CTA-H arthroplasty. The cuff tear arthropathy arthroplasty technique is shown in this link.

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).

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

An active 60 year old man had a 7 anchor rotator cuff repair for a massive cuff tear four years prior to presentation. Three years later was climbing out of a truck and slipped off a stair and lost his left hand grip.  He held on by his right shoulder and felt like he pulled his arm out of the socket.  One year after this he presented with shoulder pain and weakness, but with active elevation to 100 degrees.

His AP radiograph showed superior displacement of an arthritic humeral head. 

His axillary truth view showed a centered humeral head centered on the glenoid with loss of the cartilage space

His MRI showed a full-thickness tear of the supraspinatus tendon. The torn tendon end was retracted to the level of the glenoid. There was severe thinning of the nearly absent infraspinatus tendon. There was a full-thickness tear of the subscapularis tendon. Thinned torn tendon end was retracted approximately 1 cm from the lesser tuberosity footprint. Fatty infiltration was seen in all cuff muscles.

Our colleague Philippe Collin requested some a saggital images. 

Here they are

After discussion of the alternatives, the patient declined a reverse total shoulder, electing instead to proceed with a CTA arthroplasty (see this link).

At the time of surgery complete irreparable tears of the subscapularis, supraspinatus and infraspinatus were verified along with an arthritic humeral head.

At six months after surgery he had a comfortable stable shoulder with 160 degrees of active elevation.

And these radiographs showing a humeral head supported superiorly by the coracoacromial arch

and centered on the axillary truth view.

Comment: This case is of interest because of the retained stability of the CTA arthroplasty in spite of the subscapularis deficiency.

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).