Cuff Tear Arthropathy: A Conundrum of Choice

Cuff Tear Arthropathy: A Conundrum of Choice Ronald Hollis, MD, and Leesa Galatz, MD Many surgical treatment options exist for cuff tear arthropathy, but in our opinion, the most reliable options include the unconstrained hemiarthroplasty and the reverse total shoulder arthroplasty. Currently our indications for a hemiarthroplasty consist of a patient with a contained head, no superior migration (Seebauer 1A and 1B), no previous violation of the coracoacromial arch, reasonable preoperative range of motion, and younger age. On the other hand, we believe indications for a reverse total shoulder arthroplasty include the older patient with a pseudoparalytic shoulder, superior migration (Seebauer type 2A or 2B), and loss of the coracoacromial arch. Semin Arthro 19:36-41 © 2008 Elsevier Inc. All rights reserved. KEYWORDS cuff tear arthropathy, hemiarthroplasty, reverse total shoulder arthroplasty

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lthough cuff tear arthropathy has become a popular topic in the literature over the past few years, its origin began over a century ago. In 1853, Professor Adams at the University of Dublin published case reports describing the localized destruction of the glenohumeral joint in association with rotator cuff tears.1 Since that time many authors have similarly described this entity in the shoulder, but it was not until 1983 that the term rotator cuff arthropathy was published in the literature by Neer and coworkers.2 The original description included glenohumeral arthritis, superior migration of the humeral head, bony erosions, and osteopenia in the presence of a rotator cuff tear. Dr. Neer’s description remains as the modern definition of rotator cuff arthropathy.

Etiology The exact etiology of rotator cuff arthropathy is unknown but multiple theories have been postulated in the literature. The Milwaukee shoulder as described in the rheumatology literature by Halverson and coworkers3 in 1981 discusses a crystalline mediated arthritis of the shoulder in the presence of a rotator cuff tear. The basic premise behind this theory is shoulders with rotator cuff arthropathy are associated with the presence of basic calcium-phosphate crystals. The uptake of these crystals by cells within the joint cause a release of activated enzymes (ie, collagenase) that are responsible for

Department of Orthopaedics, Washington University School of Medicine, St. Louis, MO. Address reprint requests to Leesa Galatz, MD, Department of Orthopaedics, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, St. Louis, MO 63110-1093. E-mail: galatzl@ wudosis.wustl.edu.

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1045-4527/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2007.12.005

the destruction of the articular surface and surrounding tissue.3 A nutritional theory has also been proposed that focuses on the abnormal quality and containment of joint fluid within the shoulder that over time allows degeneration of the articular cartilage and bone.2 Inadequate diffusion of nutrients due to loss of synovial fluid containment leads to abnormal composition of cartilage matrix, which contributes to the degradation and ultimate destruction of the joint surface. Neer and coworkers2 further postulated a mechanical cause for joint destruction in the presence of massive cuff tears. According to this theory, a torn rotator cuff causes unbalanced forces and abnormal loading patterns on the glenohumeral joint. They further proposed the articular wear occurs as a result of repetitive trauma to the joint from altered biomechanics associated with the loss of dynamic and static stabilizers. The concept of altered biomechanics in the presence of rotator cuff tears initiated further research on force couples within the shoulder. A theoretical model was proposed by Inman and coworkers4 that examined the forces necessary for normal function of the glenohumeral joint. Their study showed that the main superior force vector in the coronal plane was the deltoid muscle and the inferior force vector comprised the muscles of the rotator cuff. In the presence of detachment of the supraspinatus tendon, there would be superior migration of the head due to the inability to counteract the superior force vector produced by the deltoid.4 This was taken a step further in two studies by Burkhart5,6 in which he examined the presence of the transverse-plane force couple as described by a suspension bridge model. In this model the anterior subscapularis is balanced against the posterior cuff muscles, infraspinatus and teres minor. His study showed

Cuff tear arthropathy varying degrees of glenohumeral migration, in the presence of a massive cuff tear, that correlated with the involvement of the anterior and posterior rotator cuff. Acting as the cables in a suspension bridge, superior instability could be decreased if the anterior and posterior cuff are intact.6 This model may help to explain the ability of some patients to maintain elevation and centering of the humeral head in the presence of a large rotator cuff tear as well as the lack of progression of some patients to cuff tear arthropathy.

Clinical Presentation The clinical presentation of cuff tear arthropathy often begins with complaints of shoulder pain in the setting of poor functional range of motion. Pain may be present with activity or at rest and often interrupts sleep. Women are more commonly affected than men and more often the dominant extremity is involved. History often reveals a long course of shoulder evaluations and treatments including physical therapy, injections, and possible prior rotator cuff repairs. Physical examination may reveal atrophy of the scapular musculature as well as swelling around the shoulder. Differing degrees of active range of motion may be seen, with some patients suffering severe loss of active motion. Passive range of motion may also be limited depending on the amount of glenohumeral joint destruction and subluxation. A thorough evaluation of strength testing is helpful in delineating specific deficiencies in the rotator cuff musculature. A tear in the suprapinatus will show weakness in abduction and forward flexion. Two tests commonly used to assess the integrity of the subscapularis are the abdominal compression test and lift off test. Inability of a patient to hold their arm in external rotation, a positive lag sign, shows deficiency in the posterior rotator cuff. A positive hornblower’s sign is both sensitive and specific to a tear of the teres minor.7

Radiographic Findings Radiographic studies to evaluate rotator cuff arthropathy should start with quality plain radiographs consisting of an anterior–posterior (AP), true AP, scapular Y, and axillary views. Characteristic findings on plain films include superior head migration, acetabularization of the acromion, femoralization of the humeral head, glenohumeral joint space loss, osteophytes, and erosive changes of bone in severe cases. More advanced studies, such as magnetic resonance imaging (MRI) and computed tomography, are often used as well in patient evaluation but also for preoperative planning. Computed tomography provides an excellent study to evaluate bony architecture especially in the setting of glenoid wear.8 Magnetic resonance imaging has become the study of choice, by many, because of its accuracy in identifying rotator cuff tears as well its effectiveness of grading muscle atrophy. Although not as good as computed tomography, MRI still allows for the assessment of glenoid version and depth. Our institution has also shown ultrasonography to be a useful tool in the work up of this patient population. With experienced technicians and radiologists this study provides a reliable,

37 accurate, and cost-effective means of evaluating the integrity of the rotator cuff with high levels of patient tolerance.9-11 As with many orthopedic conditions there remains a high degree of variability in the way groups of patients are stratified within a given diagnosis. Visotsky and coworkers12 in 2004 published a classification system of cuff tear arthropathy called the Seebauer classification (Fig 1). Analysis of cuff tear arthropathy biomechanics and outcomes of arthroplasty led to the formation of four distinct groups.12 These groups are distinguished by the degree of superior migration from the center of rotation and the amount of instability of the center of rotation that can be assessed during evaluation of the plain radiographs.12 Types 1A and 1B in general have a well-contained humeral head without superior migration where as types 2A and 2B show superior migration of the humeral head with disruption of the coracoacromial arch. The Seebauer classification may provide useful information when determining treatment options, goals of reconstruction, and outcomes for patients with rotator cuff arthropathy.

Treatment Treatment options are numerous and as with most shoulder disorders should begin with maximizing nonoperative management. Mild analgesics, judicious use of cortisone injections, and physical therapy often can provide symptomatic relief for patients. When nonoperative management has been exhausted, operative choices fall mainly into three categories: arthroscopic debridement, arthrodesis, and arthroplasty. Debridement traditionally has only provided short-term relief in the setting of cuff tear arthropathy but remains an option for patients not medically fit for surgery or as a first line treatment in younger patients. There may also be some benefit from a biceps tenotomy in patients with massive rotator cuff tears. Athrodesis is generally not well tolerated in elderly patients and poses a concern for higher failure rates due to poor bone stock. Cofield and Briggs13 published a report on glenohumeral arthrodesis in a small number of patients with rotator cuff tears and found 55% of patients still complained of pain and only 64% of patients had subjective improvement. Therefore, arthroplasty remains the best surgical option for patients with rotator cuff arthropathy. Recent years have witnessed a dramatic expansion of options in the area of shoulder arthroplasty. Specifically, choices include constrained arthroplasty, semicomstrained arthroplasty, total shoulder arthoplasty, bipolar arthroplasty, hemiarthroplasty, and reverse total shoulder arthroplasty. History has demonstrated high rates of glenoid loosening with constrained and semiconstrained designs; thus, they are not currently used.14,15 Glenoid failure secondary to loosening has also been a problem when total shoulder arthoplasty is used in the setting of a cuff-deficient shoulder. Matsen coined the phrase “rocking horse glenoid” in an article that showed a high incidence of glenoid loosening or translation in total shoulder arthroplasties performed in the presence of irreparable rotator cuff tears.16 The proposed mechanism is asymmetrical shear forces acting on the glenoid from a superiorly migrating

R. Hollis and L.M. Galatz

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Figure 1 Seebauer classification of cuff tear arthropathy. CA, corocoarcormial. Reprinted with permission.12 (Color version of figure is available online.)

head causing failure of the component. Bipolar implants are theorized to decrease prosthetic contact forces as well as provide motion at two interfaces but to our knowledge only one study in the literature has shown positive results.17 In general, bipolar designs have never gained widespread use. Recently, one prosthesis designed for use as a hemiarthroplasty in the cuff-deficient shoulder has gained some popularity. It has a CTA (Cuff Tear Arthropathy) head that is intended to increase the surface area of the prosthetic head without increasing the head size. The articular portion of the prosthesis extends laterally over the greater tuberosity to theoretically facilitate smooth motion between head, glenoid, and acromion. Vitosky and coworkers12 in 2004 studied the use of the CTA head in 60 patients with cuff tear arthropathy with a minimum of 2 years follow-up. Their results showed average forward elevation increased from 56 to 116°, average American Shoulder and Elbow Surgeons (ASES) score increased from 29 to 79, and a successful result was seen in 89% of patients according to “limited goal criteria.”12 Hemiarthroplasty, before the emergence of the reverse arthroplasty, served as the main implant choice for the cuff-deficient shoulder (Fig 2). In a review of five studies in the literature, this option has performed fairly well for pain relief, with an average of 75% of patients reporting no or mild pain, but functional results have been variable as demonstrated by an average increase of active elevation from 67 to 101°.18-22

Results have been particularly disappointing in patients with anterior superior instability, an iatrogenic condition characterized by loss of the coracoacromial arch and painful anterior superior subluxation with attempted elevation. SanchezSotelo and coworkers22 reported on 7 cases of anterior superior instability within a series of 33 patients with cuff tear arthropathy. All 7 had previous acromioplasties and violation of the coracoacromial arch. Another study by Field and coworkers20 found that 6 of 16 patients with poor outcomes after a hemiarthroplasty for cuff tear arthropathy had previous acromioplasty and release of the coracoacromial ligament. Clinically during active elevation the head subluxates through the defect previously contained by the coracoacromial arch and becomes present in the subcutaneous space. Therefore, a hemiarthroplasty for treatment of cuff tear arthropathy should only be considered in a patient with a contained head, no superior migration (Seebauer 1A and 1B), no previous violation of the coracoacromial arch, reasonable preoperative range of motion, and younger age. A reverse shoulder arthroplasty has become an excellent option for many individuals with rotator cuff arthropathy (Fig 3). The design enables relatively good shoulder function in the absence of a rotator cuff. Early designs had a high rate of failure because of excessive shear forces on the glenoid component.23 The original prosthesis lateralized the center of rotation, allowing catastrophic loosening. The current design

Cuff tear arthropathy

Figure 2 Hemiarthroplasty in a patient with rotator cuff arthropathy.

consists of a glenosphere attached to a glenoid base plate and a polyethylene humeral cup attached to the humeral neck and stem. There are multiple theoretical advantages to this design, starting with the glenosphere, which consists of a large head with no neck. The larger head, analogous to the hip, allows a greater potential arc of motion for the prosthesis and greater stability. The absence of a neck theoretically improves the prosthesis in two ways. First, it medializes the center of rotation and reduces the torque at the glenoid component/bone interface, decreasing rocking at the interface and reducing the rate of loosening.24 Second, by medializing the center of rotation, it allows more recruitment of anterior and posterior deltoid fibers for elevation and abduction. In addition, on the humeral side, most designs have a congruent polyethylene humeral cup, implanted with a nonanatomic, more horizontal inclination of 155°, which has the advantage of lowering the humerus. This places the deltoid muscle under tension to provide a stable and biomechanically stronger fulcrum essential for active elevation in a shoulder with an unbalanced rotator cuff.24 Indications for a reverse total shoulder arthroplasty include a pseudoparalytic shoulder, a Seebauer type 2a or 2b rotator cuff arthropathy, and anterior superior instability. These forementioned indications represent shoulders that have lost the appropriate fulcrum to allow active elevation as well as the structural support that would prevent anterosuperior migration of the humeral head. The theoretical advantages to the reverse shoulder arthroplasty design, as described above, address these deficiencies and provide an optimal setting for patients to maximize the potential for a good outcome. Recent literature has shown favorable results.25-28 A report by Frankle and coworkers29 evaluated 60 patients with rota-

39 tor cuff deficiency and glenohumeral arthritis who underwent a reverse shoulder prosthesis with a minimum of 2-year follow-up. The average age was 71 years. The mean total score on the ASES system improved from 34.3 to 68.2, forward flexion increased from 55 to 105°, and 41 patients rated their outcome as good or excellent. Wall and coworkers30 in 2007 followed 59 patients with rotator cuff arthropathy as part of a large group of patients receiving a reverse shoulder prosthesis. Within this subgroup of patients they found an average increase in Constant score from 21 points preoperatively to 65 points postoperatively as well as an average increase in elevation from 76 to 142°. Similarly, Werner and coworkers31 reported on a subgroup of patients with cuff tear arthropathy after reverse shoulder arthroplasty and found a doubling of the Constant score postoperatively, an increase in subjective shoulder value from 12 to 53%, and an increase in active anterior elevation from 43 to 103°. Complications of the reverse total shoulder continue to be an area of concern even with the most experienced of surgeons. A wide range of complications including dislocation, infection, and reoperation have been discussed in the literature with rates anywhere from 0 to 60% reported. Although these numbers are rather concerning, it is important to look closer at the published reports to detect which patients are at higher risk. A recent report by Wall and coworkers30 reviewed the results after reverse total shoulder arthroplasty according to etiology. Even though they found substantial clinical and functional improvement in all groups, patients with primary rotator cuff arthropathy, primary osteoarthritis

Figure 3 Reverse total shoulder arthroplasty in a patient with rotator cuff arthropathy.

40 with a rotator cuff tear, and a massive rotator cuff tear had better outcomes, on average, than patients who had posttraumatic arthritis and those managed with revision arthroplasty. They also found the risk of complication associated with revision surgery (36.7%) was significantly higher than the risk of complication associated with primary surgery (13.3%).30 Similarly, a report by Werner and coworkers31 found a higher reoperation rate in a group of patients that received a reverse total shoulder as part of a revision procedure (40%) compared with a group without any previous operation (18%). Longevity of the reverse total shoulder also continues to be a concern because of the lack of long-term follow-up studies reported in the literature. One such study done by Guery and coworkers32 in 2006 looked at survivorship among their early experience with implantation of the Delta reverse prosthesis. Using Kaplan–Meier curves they showed two breaks in survivorship. The first occurred on the reoperation curve between 1 and 3 years after surgery and was associated with patients with rheumatoid arthritis and implantation as a revision procedure. A second break was shown at around 6 years on the function and pain curve, with cuff tear arthropathy patients most involved.32 The authors were unsure of the etiology of this late failure. Based on this information, a reverse total shoulder is not indicated in the younger patient. Although no absolute age has been agreed on, many feel the reverse total shoulder prosthesis is best indicated for patients 70 years or older.

Summary In summary, cuff tear arthropathy remains a potentially debilitating problem for patients that will be encountered by orthopaedic surgeons who take care of shoulder disorders in their practice. As we have discussed, there are myriad choices for the surgical treatment of cuff tear arthropathy, but in our opinion, the most reliable options include the unconstrained hemiarthroplasty and the reverse total shoulder arthroplasty. Currently our indications for a hemiarthroplasty for treatment of cuff tear arthropathy consist of a patient with a contained head, no superior migration (Seebauer 1A and 1B), no previous violation of the coracoacromial arch, reasonable preoperative range of motion, and younger age. On the other hand, we feel indications for a reverse total shoulder arthroplasty include the older patient with a pseudoparalytic shoulder, superior migration (Seebauer type 2A or 2B), and loss of the coracoacromial arch.

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Cuff tear arthropathy 29. Frankle M, Siegal S, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 87:1697-1705, 2005 30. Wall B, Nove-Josserand L, O’Connor DP, et al: Reverse total shoulder arthroplasty: A review of results according to etiology. J Bone Joint Surg Am 89:1476-1485, 2007

41 31. Werner CML, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 87:1476-1486, 2005 32. Guery J, Favard L, Sirveaux F, et al: Reverse total shoulder arthroplasty: Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 88:1742-1747, 2006