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

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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). 

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).

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

A 60 year old physically active electrician sustained a traumatic cuff tear in the right shoulder, which was repaired 16 years prior to presentation. The function of the shoulder deteriorated progressively to the point that he was unable to return to work or his other activities.  A series of PRP injections appeared to worsen his symptoms. Another surgeon offered a reverse total shoulder but the patient declined out of concern for complications and failure of the polyethylene liner with his hobbies of chopping wood and bee keeping.

At the time of presentation he had a painful crepitant shoulder with only 70 degrees of active elevation and 140 degrees of passive motion. He had weakness of elevation and external rotation, but strong internal rotation.  

His radiographs showed glenohumeral arthritis and retained suture anchors.

 

After a discussion of the alternatives, he desired to proceed with a CTA hemiarthroplasty (see this link). At surgery his supraspinatus and infraspinatus were torn and irreparable. His subscapularis was intact.

His postoperative radiograph is shown below.

Three months after surgery he returned to work as an electrician with a comfortable functional shoulder. His active elevation at 3 months is shown below

He had no limitation of active internal rotation (which can be a problem after reverse total shoulder arthroplasty).

Comment: While this man did not meet the usual criteria for a cuff tear arthropathy hemiarthroplasty (preoperative active elevation >90 degrees with good passive elevation), his strong rehabilitation efforts enabled him to regain the function he needed for work

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 that can be associated with reverse total shoulder arthroplasty (e.g. dislocation, notching, acromial/spine fracture).

See these related posts:

Reverse total shoulder for everything? How about for cuff tear arthropathy?

Managing cuff tear arthropathy in the active woman rancher

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

Cuff tear arthropathy: CTA prosthesis or reverse total shoulder

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

Treating cuff tear arthropathy in the active patient - the CTA prosthesis

Mechanical failure of reverse shoulder arthroplasty

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).

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).

Management of cuff tear arthropathy in an active patient - less is more

An active, muscular man in his early 60s presented with pain on use of his right shoulder after a number of failed attempts at rotator cuff repair. His radiographs are shown below.

He had a stable shoulder with retained active elevation in spite of having irreparable subscapularis, supraspinatus and infraspinatus tendons.

Because of his active life, he did not want to have a reverse total shoulder, electing instead a CTA hemiarthroplasty. At surgery the irreparability of his cuff and subscapularis was confirmed.

One year after surgery, he returned with a comfortable shoulder with full active motion and progressively improving strength. He reported no problems with shoulder instability.

His x-rays at that time show an impaction-grafted, smooth, standard length stem and an extended head prosthesis articulating with the undersurface of the acromion and centered in the glenoid socket.

Comment: In selected patients with cuff tear arthropathy who have preserved active elevation, the CTA hemiarthroplasty can restore shoulder comfort and function, avoiding the risks of dislocation, acromial/spine fractures, and scapular notching that are associated with a reverse total shoulder.

Our technique for this procedure is shown in this link.

You may be interested in these related posts:

Treating cuff tear arthropathy in the active patient - the CTA hemiarthroplasty.

CTA hemiarthroplastly or reverse total shoulder for cuff tear arthropathy? It depends.

Rotator cuff tear arthropathy and the CTA hemiarthroplasty

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

To add this blog to your reading list in Google Chrome, click on the reading list icon

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).