Rotator Cuff Tear Arthropathy

Rotator CuffTear Arthropathy

AbstractRotator cuff tear arthropathy represents a spectrum of shoulderpathology characterized by rotator cuff insufficiency, diminishedacromiohumeral distance with impingement syndromes, andarthritic changes of the glenohumeral joint. Additional featuresmay include subdeltoid effusion, humeral head erosion, andacetabularization of the acromion. Although the progression ofrotator cuff tears seems to play a role in the development of cufftear arthropathy, information is lacking regarding the naturalprogression of rotator cuff tears to cuff tear arthropathy.Controversy remains about the role of basic calcium phosphatecrystals in the development of cuff tear arthropathy. Nonsurgicalmanagement is the first line of treatment in most patients.Traditionally, surgical management of rotator cuff tear arthropathyhas been disappointing because of the development ofcomplications long-term and poor patient satisfaction withfunctional outcomes. Recent studies, however, report promisingexperience with reverse ball-and-socket arthroplasty.

The clinical entity now known asrotator cuff tear arthropathywas first described in the 19th centu-ry in isolated case reports.1,2 Howev-er, the term cuff tear arthropathywas first reported in the literature byNeer et al3 in 1983. The authorsdescribed cuff tear arthropathy asa rare pathologic entity character-ized by rotator cuff insufficiency,degenerative changes of the glenohu-meral joint, a subcutaneous effusion,humeral head collapse, acetabular-ization of the acromion, diminishedacromiohumeral distance, and ero-sions of the skeletal architecture ofthe shoulder. Currently, cuff tear ar-thropathy represents a broad spec-trum of pathology in which, at leastto some degree, three critical fea-tures are present: rotator cuff insuf-

ficiency, degenerative changes of theglenohumeral joint, and superior mi-gration of the humeral head.4 Othercharacteristics that may be seen arehumeral head collapse, erosivechanges of the superior glenoid oracromion, and subdeltoid effusion.

Anatomy andBiomechanics

The rotator cuff consists of the su-praspinatus, infraspinatus, teres mi-nor, and subscapularis muscles andfills a critical role in active stabiliza-tion of the glenohumeral joint.Other active stabilizers include thedeltoid, pectoralis major, latissimusdorsi, teres major, biceps brachii,and scapulothoracic muscles.5,6 Pas-sive stabilizers of the shoulder joint

Kier J. Ecklund, MD

Thay Q. Lee, PhD

James Tibone, MD

Ranjan Gupta, MD

Dr. Ecklund is Chief Resident,Department of Orthopaedic Surgery,University of California, Irvine, Orange,CA. Dr. Lee is Professor and Vice Chair,Research, Department of OrthopaedicSurgery, University of California, Irvine.Dr. Tibone is Professor, Department ofOrthopaedic Surgery, University ofSouthern California School of Medicine,Los Angeles, CA. Dr. Gupta is Professorand Chair, Department of OrthopaedicSurgery, University of California, Irvine.

None of the following authors or thedepartments with which they areaffiliated has received anything of valuefrom or owns stock in a commercialcompany or institution related directly orindirectly to the subject of this article:Dr. Ecklund, Dr. Lee, Dr. Tibone, andDr. Gupta.

Reprint requests: Dr. Gupta,Department of Orthopaedic Surgery,University of California, Irvine, 101 TheCity Drive South, Orange, CA 92868.

J Am Acad Orthop Surg 2007;15:340-349

Copyright 2007 by the AmericanAcademy of Orthopaedic Surgeons.

340 Journal of the American Academy of Orthopaedic Surgeons

include the bony geometry of theglenoid and coracoacromial arch;the glenoid labrum; the joint cap-sule, with associated glenohumeralligaments; and the coracohumeralligament.

The rotator cuff muscles com-press the humeral head against theconcave surface of the glenoid andlabrum, thereby allowing concentricrotation of the humeral head. Thisconcept, termed concavity-com-pression, is thought to be importantat both the mid range and end rangeof glenohumeral motion.5 Alter-ations in the compressive force gen-erated by the rotator cuff ultimatelyresult in instability and translationof the humeral head. Furthermore,biomechanical studies have demon-strated the importance of shoulderforce-couples as generated by a bal-anced rotator cuff to maintain cen-tering of the humeral head withinthe glenoid.6,7

Pathogenesis

In 1972, Neer8 described anterioracromioplasty done for the treat-ment of impingement syndrome.Anterior acromioplasty was under-taken in the belief that most rotatorcuff injuries result from mechanicalcompression of the rotator cuff ten-dons under the coracoacromial arch.More recent histologic studies chal-lenged this hypothesis.9,10 These au-thors reported no evidence of patho-logic change on the undersurface ofthe acromion in shoulders with ar-ticular-sided, partial-thickness rota-tor cuff tears. The authors suggestedthat a separate process caused by in-trinsic changes within the tendon it-self leads to tendon degeneration andeventual tearing.9,10 Because of thesefindings, surgical dbridement of theinvolved tendon may be undertakenbefore repair.

A hypothesis has emerged recent-ly that the origin of rotator cuff dis-ease is multifactorial, including bothextrinsic and intrinsic factors. Ex-trinsic factors include the anato-

my of the coracoacromial arch, ten-sile overload of the tendon, andrepetitive-use phenomena; intrinsicfactors include age-related degenera-tion, tendon vascular supply, region-al variation in the material proper-ties of the tendon, and structuralabnormalities of collagen fiber orien-tation.11,12

Given this hypothesis of the etiol-ogy of rotator cuff disease, little isknown about the natural history ofcuff tears. Yamaguchi et al12 re-viewed 45 patients with unilateralsymptoms who, at a mean follow-up of 5.5 years, had contralateralasymptomatic rotator cuff tears de-tected with ultrasound. Over an av-erage of 2.8 years, 23 of the patientsdeveloped symptoms, with corre-sponding decreases in the average ac-tivities of daily living score and in-creases in the mean visual analogpain score.

Two additional prospective stud-ies on asymptomatic tears havedemonstrated an age-related in-crease in prevalence. Using mag-netic resonance imaging, Sher et al11

found a 28% prevalence of full-thickness tears in patients aged>60 years compared with a 4% prev-alence in those aged between 40 and60 years. Using ultrasound, Mil-grom et al13 reported a 50% preva-lence of partial- or full-thicknesstears in patients aged >70 years. Nei-ther study found any correlation be-tween activity level and prevalenceof cuff tears.

Although the natural history ofsymptomatic rotator cuff tears is notwell documented, many authorshave reported on the outcome of sur-gical intervention. Galatz et al14

conducted a prospective cohortstudy of 33 patients, with standard-ized outcome measurements at2 and 10 years. At 10 years, the au-thors reported no change in the Con-stant score or patients subjective as-sessment of the surgery relative tothe outcomes at the 2-year follow-up. These outcomes provide evi-dence that the results for open rota-

tor cuff repairs do not deterioratewith time.

Although the underlying factorsthat may cause small or single ten-don rotator cuff tears to progress tomassive, multi-tendon rotator cufftears are poorly understood, hypoth-eses have been offered to explain thedevelopment of cuff tear arthropa-thy. In the rheumatology literature,the term Milwaukee shoulder wasintroduced to describe the conditionin four elderly women who had bi-lateral massive tears of the rotatorcuff, destructive glenohumeral ar-thritis, and recurrent shoulder effu-sion (ie, geyser sign)15 (Figure 1).

In the original three reports on theMilwaukee shoulder,15-17 an associa-tion was identified between the pres-ence of calcium phosphate crystalswithin the shoulder joint and cufftear arthropathy. The hypothesisthat was developed from these re-ports suggests that hydroxyapatitecrystals accumulate within the al-tered capsule, synovium, and carti-lage of shoulders with massive cufftears. These crystals are released intothe synovial fluid as basic calciumphosphate crystals (octacalciumphosphate or carbonate-substitutedhydroxyapatite). These crystals arephagocytosed by cells within thesynovium, which accumulate theminto microspheroids, stimulating therelease of proteolytic enzymes, in-cluding collagenase and protease.These enzymes lead to articular, cap-sular, and cuff destruction. Essen-tially, the response is a form of low-grade inflammation and synovialhyperplasia with the degradation ofcartilage-matrix components.

The hypothesis of Neer et al3 wasbased on a series of 26 patients whounderwent total shoulder arthro-plasty (TSA) for cuff tear arthropathy.Ages ranged from 50 to 87 years(average, 69 years); 20 patients werewomen and 6, men. These patientshad long-standing, progressive shoul-der pain that was worse at night andappeared to be the result of impinge-ment rather than trauma. The pa-

Kier J. Ecklund, MD, et al

Volume 15, Number 6, June 2007 341

tients had shoulder swelling, tears ofthe supraspinatus and infraspinatusmuscles, and, in 21 of 26 patients,rupture of the long head of the bi-ceps. Based on findings at surgery inthis group of patients, Neer et al3

presented a hypothesis that relied onmechanical and nutritional changesthat occur in these patients. Hestated that the massive rotator cufftear and the rupture of the long headof the biceps in these patients led toproximal migration of the humeralhead and subsequent acromial im-pingement. The loss of these dy-namic stabilizers of the glenohu-meral joint leads to repetitivetrauma of the articular surface; therepetitive trauma in turn causes lossof cartilage. Furthermore, the loss ofan enclosed joint space leads to poordiffusion of nutrients to the articularcartilage, thereby compounding thedamage. Secondary to disuse of theshoulder, the subchondral bone be-comes more osteoporotic, resultingin humeral head erosion. As the jointsurfaces erode, the passive stabilitythey afford is compromised.3

Collins and Harryman18 describedthe pathogenesis as a combination ofthese two hypotheses. They pro-

posed that the tear begins in the su-praspinatus as a chronic degenera-tive tear. Progression of this teareventually leads to superior sublux-ation of the humeral head. Impinge-ment of the remaining cuff tissueagainst the acromion occurs, result-ing in humeral articular surfacewear. Cartilage fragmentation re-sults in particulate debris, whichcauses synovial thickening and effu-sion as well as the generation of cal-cium crystals, as described. Theenzymatic response to these crystalsfurthers the damage to the remain-ing cuff tissue and articularsurfaces.4 Although this is the mostsatisfying hypothesis on the devel-opment of cuff tear arthropathy, itremains unclear why only a percent-age of patients with massive rotatorcuff tears progress to cuff tear ar-thropathy.

Diagnosis

Rotator cuff tear arthropathy occursin women more than in men, andthe dominant side is more common-ly affected.4 Clinical findings includejoint effusion, pain (often worse atnight and with activity), and loss of

motion.18 In the original descriptionof Neer et al,3 patients had a long-standing history of pain, from 2 to 20years (average, 9.8 years).

Physical examination demon-strates weakness suggestive of amassive tear of the rotator cuff com-bined with superior translation andincongruity of the glenohumeraljoint. Synovial fluid is free to com-municate between the glenohumeraljoint and subacromial bursa. Thereis marked atrophy of the shouldermusculature, especially the su-praspinatus and infraspinatus mus-cles, combined with weakness in ex-ternal rotation.19 As noted, Neer etal3 reported that the tendon of thelong head of the biceps was rupturedor dislocated in 21 of 26 patients inthe original series; however, the roleof the long head of the biceps to pre-vent superior translation of the hu-meral head is currently debated.Both passive and active ranges ofmotion of the shoulder are often se-verely limited, as are associated soft-tissue contractures. In this series,only 2 of 26 patients could activelyelevate the shoulder above 90.3

Radiographs demonstrate a spec-trum of characteristic findings in pa-tients with cuff tear arthropathy (Ta-ble 1). Superior migration of thehumeral head to varying degrees andsubsequent articulation with the un-

Figure 1

A patient with rotator cuff tear arthropathy demonstrating a geyser sign, in whichthe destruction of the rotator cuff allows a hemorrhagic shoulder effusion to escapeinto the subcutaneous tissue.

Table 1

Radiographic Findings in Cuff TearArthropathy

Superior migration of the humeralhead resulting in decreasedacromiohumeral distance

OsteophytesJoint space narrowingRounding of the greater tuberosity

of the proximal humerusAcetabularization of the

undersurface of the acromionSuperior glenoid wearOsteopenia of the acromion and

proximal humerusGlenohumeral joint subluxation

Rotator Cuff Tear Arthropathy


dersurface of the acromion resultfrom the massive rotator cuff tear.These findings manifest on radio-graphs as decreased acromiohumeraldistance (Figure 2). Additional radio-graphic findings with rotator cuff ar-thropathy include rounding of thegreater tuberosity of the proximalhumerus, erosion/acetabularizationof the undersurface of the acromion,superior wear of the glenoid, os-teopenia of the proximal humerusand acromion, and translation of theglenohumeral joint. These findingsare in contrast with those of primarydegenerative joint disease, in whichthere are osteophytes inferiorly andmedially on the humeral head, alongwith posterior glenoid wear.

Visotsky et al20 developed a clas-sification scheme for the progressionof cuff tear arthropathy based onclinical and radiographic parameters.The scheme posits two types: cen-tered (type I) and decentered (type II),with two subdivisions in each type(Table 2). Radiographically, type Idemonstrates minimal superior mi-gration of the humeral head. SubtypeIA shows early femoralization(rounding of the tuberosities) of thehumeral head and acetabulariza-tion (concave erosive change of theundersurface of acromion) of the acro-mion. Subtype IB shows additionalmedial erosion of the glenoid. Type IIshows more severe superior migra-tion of the humeral head, resultingin anterosuperior escape of the headin subtype IIB. In patients with se-vere glenoid erosion, the coracoidprocess also demonstrates erosion.

Arthrography, magnetic resonanceimaging, ultrasound, and computedtomography also reveal findings con-sistent with the severe rotator cuffdeficiency and the bony changes vis-ible on plain radiographs. Althoughconfirmatory, these studies are notnecessary for diagnosis.

Management

Despite a wide spectrum of treat-ment options available for patients

with cuff tear arthropathy, there areno prospective evidence-based datato support a consensus for treat-ment. The published literature large-ly consists of selected retrospectivecases series, which provide the im-petus for treatment regimens.

Nonsurgical management re-mains the first line of treatment inmost patients. It consists of nonste-roidal anti-inflammatory medica-tion and rehabilitation. Many sur-geons do not recommend repeatedinjection of corticosteroid, given therisk of infection and the lack of effi-cacy in rotator cuff tear arthropa-thy.4 Surgical treatment options in-clude arthroscopic lavage, humeraltuberoplasty, shoulder arthrodesis,and shoulder replacement with pros-thesis.4 However, many of these op-tions have been discarded because ofpoor outcomes; their interest lies intheir historical importance.

Historical MethodsCofield and Briggs21 reported on

the long-term outcome of shoulderarthrodesis undertaken for cuff teararthropathy in 12 patients (average

age, 50 years). Six required a secondsurgical procedure; two others devel-oped a pseudarthrosis. The poorbone quality in patients with cufftear arthropathy likely influencedthese results. Furthermore, these pa-tients did not compensate well forcomplete loss of motion in oneshoulder.

Humeral tuberoplasty has beendescribed as a procedure for patientswith massive rotator cuff tearsrather than for those with cuff teararthropathy. The procedure in-volves reshaping of the humeral tu-berosities with a high-speed burr tocontour them for articulation withthe undersurface of the acromion.Fenlin et al22 reported the short-term results (minimum, 27 months)in 19 patients with irreparable, mas-sive rotator cuff tears. The authorsreported excellent improvement inpain scores and increased scores inthe modified University of Califor-nia Los Angeles Shoulder RatingScale. Thirteen of the 19 patientswere pain free at follow-up; by com-parison, all had intractable pain pre-operatively. Others also have sug-

Figure 2

A, Anteroposterior radiograph of a shoulder with cuff tear arthropathy. Superiormigration of the humeral head with degenerative changes in the glenohumeral joint,glenoid erosion, acromial erosion, and femoralization of the humeral head areapparent. B, A scapular Y radiograph of a shoulder with cuff tear arthropathy,demonstrating superior migration of the humeral head and diffuse osteopenia.



gested that humeral tuberoplastymay be useful in patients with cufftear arthropathy.4

Indications for joint arthroplastysurgery are intractable pain that isunresponsive to nonsurgical care, afunctional deltoid, and an intact cor-acoacromial arch.18 In a review ofsemiconstrained shoulder arthro-plasties for cuff tear arthropathy,Nwakama et al23 recommended non-surgical treatment of patients when-ever possible because of the com-plications associated with thesedevices. These authors listed se-vere pain, recurrent hemorrhage,and large cyst formation as indica-tions for surgical intervention.Others4,18,24-26 have stressed the im-portance of adequate deltoid func-tion and an intact coracoacromialarch as prerequisites for any type ofshoulder arthroplasty in patientswith rotator cuff tear arthropathy.

Many prosthetic designs havebeen proposed for the treatment ofcuff tear arthropathy. One of the firstwas the constrained total shoulderarthroplasty (TSA). Although varie-

ties exist, all exhibit fixed-fulcrummechanics. That is, the humeralcomponent is allowed to movewithin the glenoid component butcannot dissociate from it unless theglenoid component is broken. Orig-inally, it was thought that a con-strained prosthesis would improvefunction in rotator cuffdeficientshoulders by stabilizing the center ofrotation, thereby allowing motion.However, constrained shoulder ar-throplasty has been abandoned in theUnited States because of high ratesof revision surgery for complications,including implant loosening, im-plant failure, and instability.27

Traditional, nonconstrained TSAhas been used to treat multipleshoulderdiseases, includingosteoar-thritis, rheumatoid arthritis, osteo-necrosis, and posttraumatic arthri-tis. It was introduced by Neer et al3

as an addition to hemiarthroplastyto prevent excessive excursion of theprosthetic head. Many investigatorsreported on the early use of the non-constrained TSA for these condi-tions. Franklin et al28 reported a ret-

rospective analysis of TSA inpatients with rotator cuff deficiency.Patients with cuff deficiency demon-strated significantly greater superiormigration of the humeral prosthesison the glenoid component comparedwith patients with no rotator cuffdeficiency. The investigators sug-gested that this superior displace-ment of the humeral head on the gle-noid led to loosening of the glenoidcomponent and a rocking horsephenomenon of glenoid loosening.Gristina et al29 recognized that thechange in the center of rotation onthe glenoid could lead to glenoidloosening. Poor glenoid bone stockmakes secure glenoid componentfixation more difficult in patientswith cuff tear arthropathy.

Another solution to the problemof superior humeral head migrationin patients with cuff tear arthropathyhas been to use a semiconstrainedglenoid component in which migra-tion is blocked by a hood or subacro-mial spacer. Neer et al30 reported onthe use of an enlarged glenoid com-ponent that possessed a superiorhood to resist humeral componentsuperior migration. A higher preva-lence of radiolucency was foundaround these semiconstrained gle-noid components compared withstandard components. Amstutz etal31 used a different hooded totalshoulder system to prevent superiorsubluxation and noted results simi-lar to those of Neer et al.30 Finite el-ement analysis of different glenoiddesigns by Orr et al32 supports thefindings of both Neer et al30 and Am-stutz et al.31 Orr et al32 found thathooded glenoid component designshad increased tensile stresses at theinferior portion of the glenoid com-ponentbone interface, with in-creased compressive stresses at thesuperior portion. These stresses, inturn, may lead to the rockinghorse phenomenon described byFranklin et al.28

More recently, Nwakama et al23

found evidence of radiographic gle-noid loosening in three of seven

Table 2

Classification of Progression of Rotator Cuff Tear Arthropathy20

Type Description

I: Centered Minimal superior migration of the humeral headIA: Stable Intact anterior restraints

Minimal superior migrationDynamic joint stabilizationAcetabularization of coracoacromial arch and

femoralization of humeral headIB: Medialized Intact anterior restraints/force couple intact

Minimal superior migrationCompromised dynamic joint stabilizationMedial erosion of the glenoid

II: Decentered Severe superior migration of the humeral headIIA: Limited

stableCompromised anterior restraints/compromised

force coupleSuperior translation of humerusInsufficient dynamic joint stabilizationMinimum stabilization by coracoacromial archSuperomedial erosion of glenoid

IIB: Unstable Incompetent anterior structuresAnterior superior escapeAbsent dynamic joint stabilizationNo stabilization by coracoacromial arch



semiconstrained implants, glenoidtranslation in one of seven, and an-terosuperior subluxation in five ofseven. Furthermore, range of motionin semiconstrained designs has beenless than satisfactory.23

Swanson et al33 developed a bipo-lar hemiarthroplasty for the treat-ment of severe arthritis associatedwith rotator cuff deficiency. The pro-posed advantage involved a large hu-meral head, which would increasethe stability of the articulationwhile decreasing impingement ofthe tuberosities during abduction. Afinal effect of the larger head was in-creased glenoid and coracoacromialcontact, which would distribute thepressure over a larger area thanwould a smaller head. With two sep-arate articulations, the bipolar de-sign was thought to decrease pros-thetic contact forces, which wouldresult in better motion with lesspain. Swanson et al33 originally re-ported excellent pain relief at an av-erage of 5 years after surgery. How-ever, the authors did not specificallyreport on patients with cuff tear ar-thropathy. Although the authors re-ported excellent improvements inpain, activity level, and shouldermotion, they also noted that thehead of the prosthesis migrated su-periorly an average of 8.7 mm at2 years after surgery.

A study by Worland et al34 report-ed the use of bipolar hemiarthro-plasty in 22 patients with rotatorcuff tear arthropathy (averagefollow-up, 28 months). According tothe limited goals criteria proposedby Neer et al,30 21 of 22 patients hada successful result as well as im-provement in shoulder score.

Currently, bipolar hemiarthro-plasty plays a limited role in thetreatment of rotator cuff arthropa-thy, secondary to issues of overstuff-ing the glenohumeral joint and theeffects of polyethylene wear debristhat accumulates with the bipolardesign. There has been no demon-strated advantage of the bipolar de-sign over traditional hemiarthro-

plasty.4,19,24,34 Although previousrecommendations included the useof larger humeral heads, present rec-ommendations for hemiarthroplastyare for either an anatomic replace-ment of the humeral head or small-er head sizes that, instead of over-stuffing the joint, tend to medializethe center of rotation relative to theline of pull of the deltoid.

Current MethodsPresently, surgical management

of cuff tear arthropathy relies onjoint arthroplasty from two distinctcategories: hemiarthroplasty and re-verse ball-and-socket arthroplasty.Humeral head arthroplasty remainsthe procedure of choice in theUnited States for patients aged 90 and have an intact coracoacro-mial arch and anterior deltoid mus-cle. The reverse ball-and-socket ar-throplasty is the procedure of choicefor patients aged 70 years or thosewho have no active shoulder eleva-tion available, that is, those withpseudoparalysis.

HemiarthroplastyHistorically, hemiarthroplasty has

been used to manage all shoulderconditions that involve joint degen-eration. Many early studies did notdifferentiate patients with rotatorcuff tear arthropathy from thosewith retained cuff function. Wil-liams and Rockwood19 focused onthe use of hemiarthroplasty in pa-tients with arthropathy. Theystressed dbridement of the rotatorcuff defect; correct choice of the hu-meral head size, as determined bythe amount of translation; and ap-propriate repair of the remainingsubscapularis tendon. Eighteen oftheir 22 patients had a satisfactoryresult,19 according to the limitedgoals criteria of Neer et al.30 All pa-tients had decreased pain scores.Mean active forward elevation im-proved from 70 to 120. Average ex-ternal rotation improved from 27 to46. The authors concluded that

hemiarthroplasty, when performedproperly, is useful for pain relief andrestores shoulder function for activ-ities of daily living.19

A variation of the hemiarthro-plasty is the cuff tear arthropathy hu-meral head, the Global AdvantageCTA Humeral Head (DePuy, Warsaw,IN). This implant provides an arc ofsurface area >180 to allow articula-tion with the lateral aspect of thehumeral head against the acromion.

Recent studies have demonstrat-ed results similar to those of Wil-liams and Rockwood19 and also havestressed the importance of a compe-tent coracoacromial arch in patientswith cuff tear arthropathy. In agroup of 16 patients treated withhemiarthroplasty for rotator cufftear arthropathy, Field et al25 foundthat 4 of 6 patients with unsuccess-ful results had undergone prior acro-mioplasty with coracoacromial liga-ment release. Three of these fourpatients had had anterosuperior sub-luxation of the humeral head afterthe earlier surgery; two of these fourhad had deficient deltoid musclefunction secondary to anterior del-toid detachment during the initialsurgery. Field et al25 concluded thatthe competency of the coraco-acromial arch and deltoid musclefunction were key components forstability of a hemiarthroplasty un-dertaken in the treatment of cufftear arthropathy.

Studies by Zuckerman et al24 andSanchez-Sotelo et al26 also have dem-onstrated moderate success withhemiarthroplasty. Zuckerman et al24

found a decrease in pain, an increasein mean active forward elevationfrom 69 to 86, and an increase inmean external rotation from 15 to29. Sanchez-Sotelo et al26 reported adecrease in the mean pain score andan increase in mean active elevationfrom 72 to 91. However, these au-thors noted anterosuperior instabil-ity in 7 of 30 patients and an associ-ation between instability and priorsubacromial decompression. Overall,the result of hemiarthroplasty was



graded as successful in 67% of shoul-ders at an average follow-up of5 years.26

Hemiarthroplasty can providegood pain relief and return to moder-ate function in patients with cufftear arthropathy. However, instabil-ity may be a long-term problem, es-pecially in the patient who under-went prior coracoacromial ligamentrelease or who is left with deltoidmuscle weakness.

Reverse Shoulder ArthroplastyReverse shoulder arthroplasty has

recently become available in theUnited States for patients with cufftear arthropathy. The concept of thesemiconstrained reverse ball-and-socket design was reintroduced byGrammont in 1985 as the Deltaprosthesis (DePuy).35 Earlier designsremained essentially experimental;only two case series were publishedin the English-language literature

pertaining to these first implants.Grammonts early design was two

thirds of a spherea metallic ballcemented to the glenoid (gleno-sphere). The humeral componentwas a polyethylene socket that wascemented into the medullary ca-nal.35 This prosthesis was used in alimited fashion and was modified byGrammont into the Delta III pros-thesis in 1991 (Figure 3). The DeltaIII was designed for cementlessscrew fixation of a glenoid baseplateto the glenoid. The glenosphere wasattached to the baseplate via a Morsetaper and a central screw. The hu-meral component became a three-part implant consisting of thehumeral cemented stem, humeralneck, and polyethylene cup.

The biomechanical concept of areverse ball-and-socket prosthesis isto increase the efficiency of the del-toid muscle for abduction by length-ening the lever arm upon which it

operates, thereby allowing it to gen-erate more torque for a given force.In the patient with cuff tear arthrop-athy, the absence of the supraspina-tus, infraspinatus, and (occasionally)parts of the subscapularis and teresminor muscles makes even limited-function abduction difficult. Essen-tially, the reverse ball-and-socket de-sign relies on the deltoid muscle tocompensate for the loss of rotatorcuff function. Furthermore, thesemiconstrained design of the deviceprevents the superior migration andinstability seen in other implantsused for arthropathy.

According to Boileau et al,35

Grammonts design affords the fol-lowing biomechanical advantages.(1) The large glenosphere allowsmore stability and a large range ofmotion. (2) The glenosphere makescontact with the glenoid surface,placing the center of rotation of theshoulder within the glenoid, therebyreducing the torque on the baseplate-bone interface. (3) The medializedcenter of rotation increases the num-ber of deltoid muscle fibers recruitedfor abduction. (4) Lowering of the hu-merus places increased tension onthe deltoid muscle.

Since its inception, the Delta IIIprosthesis has been used widely inEurope, with results published ofseveral clinical studies.35-38 Resultsindicate that the Delta III providesboth excellent pain relief and im-pressive improvement in active ab-duction in patients with cuff tear ar-thropathy. However, given the shortperiods of follow-up in these studies,the rate of revision surgery remainsrelatively high (4.2% to 13%).35-38

One problem noted is a predilectiontoward infraglenoid notching and in-ferior screw breakage secondary tohumeral component impingement.Although its significance remainsunclear, infraglenoid notching hasbeen seen in up to 65% in somestudies.38

A second reverse prosthesis wasrecently introduced in the UnitedStates (Figure 4). The Reverse Shoul-

Figure 3

Delta III prosthesis (DePuy, Warsaw,IN). The baseplate is shown with twofixed-angle locking screws and twoconventional screws.

Figure 4

Reverse Shoulder Prosthesis (Encore,Austin, TX). Note the central fixed-anglescrew on the glenoid baseplate, shownhere with four surrounding fixed-anglelocking screws.



der Prosthesis (RSP) by Encore (Aus-tin, TX) has distinct design differ-ences compared with the Delta III.The glenosphere has a more lateraloffset, and the glenoid baseplate hasa central fixed-angle screw for morestability at the bone-baseplate inter-face39 (Figure 5). Clinical results froma group of 60 patients with rotatorcuff deficiency and glenohumeral ar-thritis at a minimum follow-up of 24months (average, 33 months) haveshown improvements in functionalscores (from 2.7 to 6.0), pain scores(from 6.3 to 2.2), forward flexion(from 55 to 105), abduction (from41 to 102), and external rotation(from 12 to 41).39 The complicationrate was 17%, but no patientsshowed radiographic evidence ofscapular notching.

Current recommendations andrequirements for the use of the re-verse ball-and-socket arthroplastyin patients with rotator cuff tear ar-thropathy are failed nonsurgicalmanagement, retained deltoid mus-cle function, low functional de-mands in elderly persons, and theabsence of severe comorbidities thatwould preclude surgery. Further

studies are needed to determine thelongevity of these implants in pa-tients with cuff tear arthropathy.

Summary

Although the progression of chronicrotator cuff tears likely plays a rolein the development of rotator cufftear arthropathy, information regard-ing its pathogenesis is lacking. Con-troversy remains as to the role of ba-sic calcium phosphate crystals in thedevelopment of cuff tear arthropa-thy. Nonsurgical management is therecommended first step in treat-ment. When nonsurgical manage-ment of cuff tear arthropathy fails,traditional joint arthroplasty mayimprove pain and function in appro-priately selected patients. However,long-term complications and patientdissatisfaction with functional re-sults have encouraged the search foradditional treatment options. Fur-thermore, patients who have under-gone previous operations on therotator cuff, with loss of the cora-coacromial arch and defects of thedeltoid muscle, have increased ratesof humeral head subluxation follow-

ing hemiarthroplasty. Hemiarthro-plasty has demonstrated adequatepain relief but only modest improve-ment in functional range of motionin patients with cuff tear arthropa-thy.

Encouraging early results havebeen reported with reverse ball-and-socket arthroplasty. The ability ofthis implant to maintain the humer-al socket centrally on the gleno-sphere may restore normal glenohu-meral kinematics in the face of thecompromised primary and second-ary stabilizers of the glenohumeraljoint. Studies have demonstrated in-creased active range of motion at-tained with this implant, whichleads to improved function for pa-tients with cuff tear arthropathy.However, complication rates remainrelatively high (17%), and long-term follow-up and increased experi-ence with these implants are needed.Fortunately, our knowledge of rota-tor cuff tear arthropathy has in-creased greatly during the past twodecades, with surgical managementof this disease continuing to im-prove.

Figure 5

A, The shoulder, demonstrating the center of rotation and the lateral offset (double-headed arrow). B, The Delta III device(DePuy) implanted in a shoulder, demonstrating how it causes the center of rotation and offset to shift medially (single-headedarrow) with respect to the anatomic shoulder. C, The Reverse Shoulder Prosthesis (Encore) implanted in a shoulder,demonstrating how the device causes the center of rotation and lateral offset to shift medially (single-headed arrow) with respectto the anatomic shoulder, but to a lesser degree than occurs with the Delta III prosthesis (panel B). (Reprinted with permissionfrom Lewis E. Calver.)



References

Evidence-based Medicine: There areno prospective, randomized level I orlevel II studies reported. The refer-ences cited are primarily level III/IVcase-control cohort or personal expe-rience studies on endoprosthesis, to-tal shoulder prosthesis, or reverseshoulder prosthesis. One prospectivelongitudinal study on rotator cufftears (reference 14) is reported, alongwith several expert opinions (refer-ences 18 and 29).

Citation numbers printed in boldtype indicate references publishedwithin the past 5 years.

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analysis of postoperative shoulderfunction: A ten-year follow-up studyof full-thickness rotator cuff tears.J Bone Joint Surg Am 2001;83:1052-1056.

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22. Fenlin JM Jr, Chase JM, Rushton SA,Frieman BG: Tuberoplasty: Creationof an acromiohumeral articulation. Atreatment option for massive, irrepa-rable rotator cuff tears. J ShoulderElbow Surg 2002;11:136-142.

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Additional Resources

Related clinical topics articlesavailable on Orthopaedic Knowl-edge Online: Glenohumeral Ar-thritis and the Rotator Cuff Defi-cient Shoulder, by Gregory P.Nicholson, MD, and Guido Mar-ra, MD.

Rotator Cuff Tears Pathophysi-ology, by Evan Flatow, MD, andLeeza Galatz, MD. Offers threevideo demonstrations on rotatorcuff repair.

CD-ROM: Reverse Shoulder Ar-throplasty for Rotator Cuff Ar-thropathy, by Evan Flatow, MD,Kenneth J. Accousti, MD, andBradford Parsons, MD. Demon-strates a reverse shoulder arthro-plasty for rotator cuff tear thatuses variable angled lockingscrews and a porous tantalum in-growth glenoid baseplate.

Book: Advanced Reconstruction:Shoulder, Joseph D. Zuckerman,MD, Editor. Developed in collab-oration with the American Shoul-der and Elbow Surgeons (ASES).Provides advice and approachesfor more than 70 shoulder condi-tions. Over 700 illustrations.



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31. Amstutz HC, Thomas BJ, Kabo JM,Jinnah RH, Dorey FJ: The Dana totalshoulder arthroplasty. J Bone JointSurg Am 1988;70:1174-1182.

32. Orr TE, Carter DR, Schurman DJ:Stress analyses of glenoid componentdesigns. Clin Orthop Relat Res 1988;232:217-224.

33. Swanson AB, de Groot Swanson G,Sattel AB, Cendo RD, Hynes D, Jar-Ning W: Bipolar implant shoulder ar-throplasty: Long-term results. ClinOrthop Relat Res 1989;249:227-247.

34. Worland RL, Jessup DE, Arredondo J,Warburton KJ: Bipolar shoulder ar-throplasty for rotator cuff arthropa-thy. J Shoulder Elbow Surg 1997;6:512-515.

35. Boileau P, Watkinson DJ, HatzidakisAM, Balg F: Grammont reverse pros-thesis: Design, rationale, and biome-chanics. J Shoulder Elbow Surg 2005;14:147S-161S.

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Rotator Cuff Tear Arthropathy