Massive Rotator Cuff Tears: Reverse Shoulder Arthroplasty  

Ryan T. Bicknell, M.D., MSc, FRCSC
Kingston, ON

Definition of a Massive Cuff Tear A massive rotator cuff tear (MCT) was defined by Cofield as a tear with a diameter of 5 cm or more1. Gerber defined a MCT as a tendon tear involving two or more tendons after debridement2. Hamada and Fukuda described a MCT radiographically, as a shoulder with humeral head elevation without glenohumeral arthritis3 (Figure 1). According to the first two definitions, a MCT does not necessarily mean an irreparable tear. However, the Hamada and Fukuda definition indicates that the tear is chronic with associated humeral head elevation and is, generally, considered irreparable. This is an important distinction, as a MCT can be either acute and reparable, or chronic and irreparable.
BICKNELLFig_1

Figure 1 - Hamada and Fukuda radiological classification of massive cuff tear3. Stage 1: Normal acromiohumeral space. Stage 2: Acromiohumeral space < 7mm. Stage 3: Acetabularization of the acromion. Stage 4: Glenohumeral arthritis (4a - without acetabulization, 4b - with acetabulization). Stage 5: Humeral head necrosis.

Clinical Presentations and Treatment Options
Patients with a MCT often present with some combination of pain and/or loss of function, usually loss of active anterior elevation (AAE), but patients may also have loss of active external rotation (AER). Patients with pain and preserved function are often adequately treated with physiotherapy, steroid injection, or procedures such as repair for a reparable tear, or debridement, biceps tenotomy or tenodesis, partial repair or tendon transfers for irreparable tears4. However, patients with loss of function are often not adequately treated by any of these methods4.

The Role of Reverse Shoulder Arthroplasty
Reverse total shoulder arthroplasty (RSA) was developed to provide a solution that addresses both pain reduction and improved AAE5. By creating a fixed, medialized centre-of-rotation through a semi-constrained bearing surface, patients are able to achieve significant improvements in AAE, pain control and function6,7,8 (Figure 2).

BICKNELLFig_2a BICKNELLFig_2b

Figure 2
A. Preoperative radiograph of a patient with a MCT and a pseudoparalyzed shoulder. B. Postoperative radiograph after a RSA.

The initially described, and still main indication for a RSA, is cuff tear arthropathy (CTA)9,10. A MCT (without glenohumeral arthritis) is usually not an indication for a RSA. However, a RSA may be indicated in a patient with a MCT (without glenohumeral arthritis) in several circumstances9

  1. A pseudo-paralyzed shoulder - when there is antero-superior escape of the humeral head when attempting to elevate the arm and an inability to maintain the arm at the horizontal level).
  2. Static glenohumeral instability - either anterior or posterior instability.
  3. Patients who have failed other procedures. 

Results of RSA
Overall results of RSA indicate effective pain relief and improved function, with an ability to restore AAE, but AER is often unchanged. However, survival decreases after approximately six years and long-term outcomes are not available. The procedure is also associated with a high rate of complications and reoperations. Furthermore, results are dependent on the initial indication, with CTA having the best results7,9,10,11.

The results of RSA for MCT are not as well described as for CTA but appear similar in several studies. Boileau et al reported on 457 shoulders in a multicentre study with a mean 44-month follow-up9. The results in MCT (compared with CTA) were a Constant score of 63 (vs. 65) and AAE of 133 degrees (vs. 135 degrees). It should also be noted that results were worse in those patients having had previous cuff surgery. Wall et al reported on 191 shoulders with a mean 40-month follow-up10. The results in MCT (compared with CTA) were an absolute Constant score of 63 (vs. 65) and AAE of 143 degrees (vs. 142 degrees).

Other Important Considerations
Surgeons must be aware that RSA is a difficult procedure with a high complication rate and a long learning curve7. Therefore, authors have stressed that RSA should only be performed by surgeons experienced with the procedure and management of complications7. Because long-term outcomes are unclear, RSA should be reserved only for informed elderly patients. Furthermore, important preoperative considerations include a high level of suspicion for infection from a previous procedure, as the results of an infected RSA are poor9. As well, particularly attention should be attended to glenoid bone deficiencies, as RSA requires adequate glenoid bone stock to be successful and avoid complications7.

Finally, the importance of AER to normal overhead function is becoming increasingly understood. In many cases of MCT, patients may demonstrate significant deficits of AER, which are often not addressed by using a RSA (some patients may even lose active rotation after a RSA)9. Several authors have reported on the combined use of a RSA and a latissimus dorsi/teres major transfer, which has shown promise in restoring both AAE and AER in order to permit more physiologic shoulder function, particularly in the absence of an intact teres minor12,13.

Conclusions
In summary, RSA can be a viable solution for the patient with an irreparable MCT. However, all others options (operative and nonoperative) should be considered first, as RSA is associated with a high complication rate and uncertain long-term outcomes. This procedure should only be performed in elderly patients and by an experienced surgeon.

References

  1. Cofield R.H. Rotator cuff disease of the shoulder. J Bone Joint Surg Am 1985;67:974-979.
  2. Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clin Orthop Relat Res 1992;275:152-160.
  3. Hamada K., Fukuda H., Mikasa M., Kobayashi Y. Roentgenographic findings in massive rotator cuff tears. A long-term observation. Clin Orthop Relat Res 1990;254:92-6.
  4.  Elhassan B., Endres N.K., Higgins L.D., Warner J.P. Massive irreparable tendon tears of the rotator cuff: salvage options. In: Instructional Course Lectures, Volume 57. Duwelius PJ, Azar FM (ed.) American Academy of Orthopaedic Surgeons. 2008;13:153-66.
  5.  Grammont P.M., Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics 1993;16:33-36.
  6.  Boileau P., Watkinson D., Hatzidakis A.M., Hovorka I. Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae and revision arthroplasty. J Shoulder Elbow Surg 2006;15:527-40.
  7.  Matsen F.A., Boileau P., Walch G., Gerber C., Bicknell R.T. The reverse total shoulder arthroplasty. In: Instructional Course Lectures, Volume 57. Duwelius PJ, Azar FM (ed.) American Academy of Orthopaedic Surgeons. 2008;14:167-74.
  8. Werner C.M.L., Steinmann P.A., Gilbart M., Gerber C. Treatment of painful pseudoparalysis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-86
  9. Boileau P., Bicknell R.T., Chuinard C. Reverse shoulder arthroplasty: indications and results of the French multicenter study. Presented at the 24th Annual Open Meeting of American Shoulder and Elbow Surgeons, San Francisco, California, 2008.
  10. Wall B., Nove-Josserand L., O'Connor D.P., Edwards T.B., Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am 2007;89:1476-85.
  11. Guery J., Favard L., Sirveaux F., Oudet D., Walch G. Reverse Total Shoulder Arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006;88:1742-47.
  12. Boileau P., Chuinard C., Roussanne Y., Bicknell R.T., Rochet N., Trojani C. Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transferfor shoulder pseudoparalysis associated with dropping arm. Clin Orthop Relat Res 2008;466:584-93.
  13. Gerber C., Pennington S.D., Lingenfelter E.J., Sukthankar A. Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report. J Bone Joint Surg Am 2007;89:940-7.

 

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