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Tear Arthropathy
Kier J. Ecklund, MD
Thay Q. Lee, PhD
James Tibone, MD
Ranjan Gupta, MD
340
Abstract
Rotator cuff tear arthropathy represents a spectrum of shoulder
pathology characterized by rotator cuff insufficiency, diminished
acromiohumeral distance with impingement syndromes, and
arthritic changes of the glenohumeral joint. Additional features
may include subdeltoid effusion, humeral head erosion, and
acetabularization of the acromion. Although the progression of
rotator cuff tears seems to play a role in the development of cuff
tear arthropathy, information is lacking regarding the natural
progression of rotator cuff tears to cuff tear arthropathy.
Controversy remains about the role of basic calcium phosphate
crystals in the development of cuff tear arthropathy. Nonsurgical
management is the first line of treatment in most patients.
Traditionally, surgical management of rotator cuff tear arthropathy
has been disappointing because of the development of
complications long-term and poor patient satisfaction with
functional outcomes. Recent studies, however, report promising
experience with reverse ball-and-socket arthroplasty.
Anatomy and
Biomechanics
The rotator cuff consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles and
fills a critical role in active stabilization of the glenohumeral joint.
Other active stabilizers include the
deltoid, pectoralis major, latissimus
dorsi, teres major, biceps brachii,
and scapulothoracic muscles.5,6 Passive stabilizers of the shoulder joint
Pathogenesis
In 1972, Neer8 described anterior
acromioplasty done for the treatment of impingement syndrome.
Anterior acromioplasty was undertaken in the belief that most rotator
cuff injuries result from mechanical
compression of the rotator cuff tendons under the coracoacromial arch.
More recent histologic studies challenged this hypothesis.9,10 These authors reported no evidence of pathologic change on the undersurface of
the acromion in shoulders with articular-sided, partial-thickness rotator cuff tears. The authors suggested
that a separate process caused by intrinsic changes within the tendon itself leads to tendon degeneration and
eventual tearing.9,10 Because of these
findings, surgical dbridement of the
involved tendon may be undertaken
before repair.
A hypothesis has emerged recently that the origin of rotator cuff disease is multifactorial, including both
extrinsic and intrinsic factors. Extrinsic factors include the anatoVolume 15, Number 6, June 2007
Figure 1
Table 1
Radiographic Findings in Cuff Tear
Arthropathy
Superior migration of the humeral
head resulting in decreased
acromiohumeral distance
Osteophytes
Joint space narrowing
Rounding of the greater tuberosity
of the proximal humerus
Acetabularization of the
undersurface of the acromion
Superior glenoid wear
Osteopenia of the acromion and
proximal humerus
Glenohumeral joint subluxation
A patient with rotator cuff tear arthropathy demonstrating a geyser sign, in which
the destruction of the rotator cuff allows a hemorrhagic shoulder effusion to escape
into the subcutaneous tissue.
posed that the tear begins in the supraspinatus as a chronic degenerative tear. Progression of this tear
eventually leads to superior subluxation of the humeral head. Impingement of the remaining cuff tissue
against the acromion occurs, resulting in humeral articular surface
wear. Cartilage fragmentation results in particulate debris, which
causes synovial thickening and effusion as well as the generation of calcium crystals, as described. The
enzymatic response to these crystals
furthers the damage to the remaining cuff tissue and articular
surfaces.4 Although this is the most
satisfying hypothesis on the development of cuff tear arthropathy, it
remains unclear why only a percentage of patients with massive rotator
cuff tears progress to cuff tear arthropathy.
Diagnosis
Rotator cuff tear arthropathy occurs
in women more than in men, and
the dominant side is more commonly affected.4 Clinical findings include
joint effusion, pain (often worse at
night and with activity), and loss of
Management
Despite a wide spectrum of treatment options available for patients
Volume 15, Number 6, June 2007
Figure 2
Table 2
Classification of Progression of Rotator Cuff Tear Arthropathy20
Type
I: Centered
IA: Stable
IB: Medialized
II: Decentered
IIA: Limited
stable
IIB: Unstable
Description
Minimal superior migration of the humeral head
Intact anterior restraints
Minimal superior migration
Dynamic joint stabilization
Acetabularization of coracoacromial arch and
femoralization of humeral head
Intact anterior restraints/force couple intact
Minimal superior migration
Compromised dynamic joint stabilization
Medial erosion of the glenoid
Severe superior migration of the humeral head
Compromised anterior restraints/compromised
force couple
Superior translation of humerus
Insufficient dynamic joint stabilization
Minimum stabilization by coracoacromial arch
Superomedial erosion of glenoid
Incompetent anterior structures
Anterior superior escape
Absent dynamic joint stabilization
No stabilization by coracoacromial arch
Figure 3
Figure 4
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-headed
arrow) 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 respect
to the anatomic shoulder, but to a lesser degree than occurs with the Delta III prosthesis (panel B). (Reprinted with permission
from Lewis E. Calver.)
der Prosthesis (RSP) by Encore (Austin, TX) has distinct design differences compared with the Delta III.
The glenosphere has a more lateral
offset, and the glenoid baseplate has
a central fixed-angle screw for more
stability at the bone-baseplate interface39 (Figure 5). Clinical results from
a group of 60 patients with rotator
cuff deficiency and glenohumeral arthritis at a minimum follow-up of 24
months (average, 33 months) have
shown improvements in functional
scores (from 2.7 to 6.0), pain scores
(from 6.3 to 2.2), forward flexion
(from 55 to 105), abduction (from
41 to 102), and external rotation
(from 12 to 41).39 The complication
rate was 17%, but no patients
showed radiographic evidence of
scapular notching.
Current recommendations and
requirements for the use of the reverse ball-and-socket arthroplasty
in patients with rotator cuff tear arthropathy are failed nonsurgical
management, retained deltoid muscle function, low functional demands in elderly persons, and the
absence of severe comorbidities that
would preclude surgery. Further
Volume 15, Number 6, June 2007
Summary
Although the progression of chronic
rotator cuff tears likely plays a role
in the development of rotator cuff
tear arthropathy, information regarding its pathogenesis is lacking. Controversy remains as to the role of basic calcium phosphate crystals in the
development of cuff tear arthropathy. Nonsurgical management is the
recommended first step in treatment. When nonsurgical management of cuff tear arthropathy fails,
traditional joint arthroplasty may
improve pain and function in appropriately selected patients. However,
long-term complications and patient
dissatisfaction with functional results have encouraged the search for
additional treatment options. Furthermore, patients who have undergone previous operations on the
rotator cuff, with loss of the coracoacromial arch and defects of the
deltoid muscle, have increased rates
of humeral head subluxation follow-
Additional Resources
Related clinical topics articles
available on Orthopaedic Knowledge Online: Glenohumeral Arthritis and the Rotator Cuff Deficient Shoulder, by Gregory P.
Nicholson, MD, and Guido Marra, MD.
Rotator Cuff Tears Pathophysiology, by Evan Flatow, MD, and
Leeza Galatz, MD. Offers three
video demonstrations on rotator
cuff repair.
CD-ROM: Reverse Shoulder Arthroplasty for Rotator Cuff Arthropathy, by Evan Flatow, MD,
Kenneth J. Accousti, MD, and
Bradford Parsons, MD. Demonstrates a reverse shoulder arthroplasty for rotator cuff tear that
uses variable angled locking
screws and a porous tantalum ingrowth glenoid baseplate.
Book: Advanced Reconstruction:
Shoulder, Joseph D. Zuckerman,
MD, Editor. Developed in collaboration with the American Shoulder and Elbow Surgeons (ASES).
Provides advice and approaches
for more than 70 shoulder conditions. Over 700 illustrations.
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References
Evidence-based Medicine: There are
no prospective, randomized level I or
level II studies reported. The references cited are primarily level III/IV
case-control cohort or personal experience studies on endoprosthesis, total shoulder prosthesis, or reverse
shoulder prosthesis. One prospective
longitudinal study on rotator cuff
tears (reference 14) is reported, along
with several expert opinions (references 18 and 29).
Citation numbers printed in bold
type indicate references published
within the past 5 years.
1.
348
11.
12.
13.
14.
tis of All the Joints, ed 2. London, England: John Churchill and Sons, 1873,
pp 91-175.
Smith RW: Observations upon chronic rheumatic arthritis of the shoulder
(Part II). Dublin Quarterly Journal of
Medical Science 1853;15:343-358.
Neer CS II, Craig EV, Fukuda H: Cufftear arthropathy. J Bone Joint Surg
Am 1983;65:1232-1244.
Jensen KL, Williams GR Jr, Russell IJ,
Rockwood CA Jr: Rotator cuff tear arthropathy. J Bone Joint Surg Am
1999;81:1312-1324.
Labriola JE, Lee TQ, Debski RE, McMahon PJ: Stability and instability of
the glenohumeral joint: The role of
shoulder muscles. J Shoulder Elbow
Surg 2005;14:32S-38S.
Lee SB, Kim K, ODriscoll SW, Morrey
BF, An KN: Dynamic glenohumeral
stability provided by the rotator cuff
muscles in the mid-range and endrange of motion: A study in cadavera.
J Bone Joint Surg Am 2000;82:849857.
Hsu HC, Luo ZP, Cofield RH, An KN:
Influence of rotator cuff tearing on
glenohumeral stability. J Shoulder
Elbow Surg 1997;6:413-422.
Neer CS II: Anterior acromioplasty for
the chronic impingement syndrome
in the shoulder: A preliminary report.
J Bone Joint Surg Am 1972;54:41-50.
Ogata S, Uhthoff HK: Acromial enthesopathy and rotator cuff tear: A radiologic and histologic postmortem investigation of the coracoacromial
arch. Clin Orthop Relat Res 1990;
254:39-48.
Ozaki J, Fujimoto S, Nakagawa Y, Masuhara K, Tamai S: Tears of the rotator
cuff of the shoulder associated with
pathological changes in the acromion:
A study in cadavera. J Bone Joint
Surg Am 1988;70:1224-1230.
Sher JS, Uribe JW, Posada A, Murphy
BJ, Zlatkin MB: Abnormal findings on
magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg
Am 1995;77:10-15.
Yamaguchi K, Tetro AM, Blam O,
Evanoff BA, Teefey SA, Middleton
WD: Natural history of asymptomatic
rotator cuff tears: A longitudinal analysis of asymptomatic tears detected
sonographically. J Shoulder Elbow
Surg 2001;10:199-203.
Milgrom C, Schaffler M, Gilbert S,
van Holsbeeck M: Rotator-cuff changes in asymptomatic adults: The effect
of age, hand dominance and gender.
J Bone Joint Surg Br 1995;77:296-298.
Galatz LM, Griggs S, Cameron BD,
Iannotti JP: Prospective longitudinal
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
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