Hemiarthroplasty for Cuff Tear Arthropathy

Jeremy Hall, M.D., FRCSC
Toronto, ON

Cuff Tear Arthropathy
Arthritis in association with rotator cuff tears was first observed and described in 1853 by Professor Adams of the University of Dublin1. Charles Neer later explained the clinical entity of cuff tear arthropathy and its pathomechanics in 19772. Patients with this condition are plagued with pain and limited function. Cuff tear arthopathy challenges our understanding of the shoulder and is often difficult to treat surgically with success (Figure 1).

Figure 1. (click on thumbnail for larger view)
X-ray typical of cuff tear arthropathy. Note severe glenohumeral arthritic change and superior migration of the joint.
hall_fig1.jpg

Cuff tear arthropathy generally occurs after a large or massive rotator cuff tear. Loss of the dynamic balance of the glenohumeral joint as a consequence of rotator cuff dysfunction leads not only to pathological changes of the joint, but complicates joint replacement. Without the stability afforded by an intact rotator cuff, ongoing shear forces at the glenohumeral interface lead to problems in glenoid fixation, such as early loosening and failure in both constrained and unconstrained total shoulder arthroplasty designs3.

Surgical Treatment
As a result, surgical treatment for this disorder has been fraught with difficulties. Recent advances in shoulder arthroplasty techniques and implants, such as the reverse total shoulder implant and the extended humeral head hemiarthroplasty, are improving surgical outcomes.

Hemiarthroplasty
Seebauer classified cuff tear arthropathy into four types (Figure 2)4. Current recommendations suggest that Type 1A and B (centered) and Type 2A (decentered, limited stable) are potentially amenable to treatment using hemiarthroplasty as the glenohumeral joint remains relatively supported superiorly and anteriorly by an intact coracoacromial arch. In this process, described as acetabularization and femoralization of the glenohumeral joint, the rotator cuff action is replaced by this arch, which provides a fixed fulcrum through which the deltoid can act to move the arm. Care must be taken to ensure stability of this articulation, while attempting to provide unrestricted range of motion. This balance is likely the most challenging aspect of this procedure.

Figure 2. (click on thumbnail for larger view)
Seebauer Classification of cuff tear arthropathy. (reproduced with permission)

hall_fig2.jpg
Reverse Total Shoulder
Reverse total shoulder designs also attempt to utilize the fixed fulcrum concept. The spherical glenoid lateralizes and depresses the humerus and aims to optimize the action of the deltoid both in maintaining stability of the articulation and movement of the arm. In order to provide joint stability, the deltoid must be under significant tension, which leads to greatly increased shear forces across the bone/prosthesis interface and potential catastrophic failure. For this reason, reverse total shoulder arthroplasty was originally recommended for sedentary elderly individuals, and in patients with Seebauer Type 2B cuff tear arthropathy or glenohumeral escape.

Hemiarthroplasty - A Gold Standard?
In general, the literature reports good but unpredictable results for hemiarthroplasty in cuff tear arthropathy5,6. Zuckerman described his series of 15 shoulder hemiarthroplasties in 13 patients for cuff tear arthropathy in 20005. He reported 11 patients with overall satisfaction with the implant, with an average active range of motion of 86o of forward elevation and 29o of external rotation.

Figure 3. (click on thumbnail for larger view)
X-ray of shoulderhemiarthroplasty using an extended humeral head prosthesis.
hall_fig3.jpg
 
Improved pain scores and postoperative range of motion have been reported with the extended humeral head design as the greater arc under the acromion provides for a more contiguous articulation with the acetabularized glenoid and acromion. Visotsky et al reported 89% successful outcomes after extended humeral head hemiarthroplasty for cuff tear arthropathy using "limited goal criteria"1. Postoperative range of motion improved to an average of 116o of active forward elevation and 30o of external rotation and postoperative pain scores improved 4-fold on a visual analog pain scale.


Conclusion
Cuff tear arthropathy is a difficult clinical problem. Surgical treatment can be challenging as results may be unpredictable. Hemiarthroplasty for cuff tear arthropathy can yield satisfactory and functional results in patients despite rotator cuff deficiency. Reverse total shoulder designs are dependant on extreme forces to maintain stability, and are best left for the treatment of sedentary elderly patients with glenohumeral escape.

References

  1. Visotsky J.L., Basmania C., Seebauer L., Rockwood C.A., Jensen K.L. Cuff tear arthroplathy: Pathogenesis, classification and algorithm for treatment. J Bone Joint Surg AM. 2004;86:35-40
  2. Neer C.S. 2nd, Craig E.V., Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65:1232-44.
  3. Franklin J.L., Barrett W.P., Jackins S.E., Matsen F.A. 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty 1988;3:39-46. 12.
  4. Seebauer L., Walter W., Keyl W. Reverse total shoulder arthroplasty for the treatment of defect arthropathy. Oper Orthop Traumatol. 2005;17:1-24.
  5. Zuckerman J.D., Scott A.J, Gallagher M.A. Hemiarthroplasty for cuff tear arthropathy. J Shoulder Elbow Surg. 2000;9:169-72.
  6. Sanchez-Sotelo J., Cofield R.H., Rowland C.M. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone JointSurg Am. 2001;83:1814-22.11.

Submit Community Content

If you have orthopedic information that you would like to share with the Orthogate Community, please register/login and submit your news, event, job, article, case or workshop from the Submit Content menu under the My Account area. Learn more!