Rotator Cuff Deficiency Research Articles

Shoulder Tendon Transfers for Rotator Cuff Deficiency

Tendon transfer surgery can be employed to improve function in a select group of patients with irreparable rotator cuff tears or used in combination with reverse geometry shoulder arthroplasty performed for rotator cuff deficiency and arthrosis. This review aims to aid shoulder surgeons in patient selection for surgery, including the indications and contra-indications to tendon transfer.

RESULTS OF PRIMARY AND REVISION REVERSE SHOULDER ARTHROPLASTY

There is a report of two clinical cases of reverse shoulder joint replacement. In the first case, reverse arthroplasty performed in post-traumatic avascular necrosis of the humeral head. In the second case, the arthroplasty with reverse prosthesis was performed because of insufficiency of rotator cuff, and due to this, dislocation of unipolar shoulder. In both cases we achieved good functional outcome.

Reverse shoulder arthroplasty in revision of failed shoulder arthroplasty—outcome and follow-up

The number of shoulder arthroplasties has increased over the last decade, which can partly be explained by the increasing use of the reverse total shoulder arthroplasty technique. However, the options for revision surgery after primary arthroplasty are limited in cases of irreparable rotator cuff deficiency, and tuberosity malunion, nonunion, or resorption. Often, conversion to a reverse design is the only suitable solution. We analysed the functional outcome, complication rate and patient satisfaction after the revision of primary shoulder arthroplasty using an inverse design. Over a ten-year period 57 patients underwent revision surgery for failed primary shoulder arthroplasty using a reverse design. Of the 57 patients, 50 (mean age, 64.2 years) were available after an average follow-up of 51 months. Clinical evaluation included the Constant Murley Score, the UCLA score, and the Simple Shoulder Test, whereas radiological evaluation included plain radiographs in standard projections. Patients were also requested to rate their subjective satisfaction of the final outcome as excellent, good, satisfied or dissatisfied. Compared to the preoperative status, the overall functional outcome measurements based on standardised outcome shoulder scores improved significantly at follow-up. The overall mean Constant Murley score improved from 18.5 to 49.3 points, the mean UCLA score improved from 7.1 to 21.6 points, and the mean simple shoulder test improved from 1.2 to 5.6 points. The average degree of abduction improved from 40 to 93° (p < 0.0001), and the average degree of anterior flexion improved from 47 to 98° (p < 0.0001). The median VAS pain score decreased from 7 to 1. Complications occurred in 12 cases (24 %).A total of 32 (64 %) patients rated their result as good or excellent, six (12 %) as satisfactory and 12 (24 %) as dissatisfied. In revision shoulder arthroplasty after failed primary shoulder arthroplasty an inverse design can improve the functional outcome, and patient satisfaction is usually high. However, the complication rate of this procedure is also high, and patient selection and other treatment options should be carefully considered.

Results of Cemented Total Shoulder Replacement with a Minimum Follow-up of Ten Years

The purpose of this study was to assess the clinical and radiographic long-term outcomes of patients treated with a third-generation cemented total shoulder replacement and followed for at least ten years. The results of thirty-nine arthroplasties were analyzed clinically with use of the Constant score and on radiographs in two projections, with special regard to glenoid component loosening, at a mean of eleven years (range, ten to fifteen years) postoperatively. The mean Constant score was 27 points (range, 11 to 54 points) preoperatively and 61 points (range, 21 to 86 points) postoperatively (p < 0.0001). Mean shoulder flexion increased from 84° (range, 40° to 150°) preoperatively to 133° (range, 40° to 180°) postoperatively; mean abduction, from 77° (range, 40° to 110°) to 123° (range, 40° to 180°); and mean external rotation, from 11° (range, -20° to 40°) to 35° (range, 0° to 60°). No humeral components but 36% of the glenoid components were radiographically loose at the time of follow-up. Kaplan-Meier survivorship of the glenoid component was 100% after thirteen years with revision as the end point, whereas survivorship with radiographic loosening as the end point was only 48% after thirteen years. We found no correlation between glenoid loosening on radiographs and clinical findings such as the Constant score. Cranial migration of the humerus was seen in 69% of the cases. With the implants, cementation, and surgical technique utilized in this group of patients with primary glenohumeral osteoarthritis, radiographic loosening of the glenoid component and rotator cuff deficiency were very common at the ten to fifteen-year review. The follow-up was not long enough to fully identify the clinical sequelae of these findings.

Reverse Shoulder Arthroplasty for the Treatment of Rotator Cuff Deficiency

We previously evaluated ninety-four patients (ninety-six shoulders) who underwent reverse shoulder arthroplasty with use of a central compressive screw along with 5.0-mm peripheral locking screws for baseplate fixation and a center of rotation lateral to the glenoid. The purpose of this study was to report updated results at a minimum follow-up of five years. Since the last report, an additional two patients underwent revision surgery: one for recurrent instability and one for resorption of a proximal humeral allograft. The patients continue to have improved outcome scores and range of motion. Survivorship with the end point being revision for any reason was 73.5 months, with 94% survival at sixty months. Radiographic follow-up showed that two (3%) of seventy-six patients included in the survivorship analysis had asymptomatic humeral loosening, seven (9%) had scapular notching, and no patient had glenoid baseplate loosening or baseplate failure. The patients have maintained their improved function with durable clinical and radiographic results at a minimum of five years. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Floating glenoid after reverse total shoulder arthroplasty: a case report

Reverse total shoulder arthroplasty (RTSA) continues to evolve with new implants and surgical techniques to treat shoulders with rotator cuff deficiencies. However, intraoperative and postoperative complication and revision rates are high.1,3-5,10,11,14 The most frequent complications are scapular notching, dislocation, and glenoid component complications.1,3,4,10,11,14 Stress fractures of the scapular spine and the acromion have been described after RTSA.1,3,5,14 Few reports in the literature describe the effects of scapular fractures on the outcome of the replacement, but they can be the source of continued pain after RTSA.

Reverse Shoulder Replacement for Patients With Inflammatory Arthritis

Patients with inflammatory arthritis frequently develop destructive shoulder arthritis and rotator cuff tearing. Reconstruction with anatomical shoulder replacement produces lesser results than for other etiologies such as osteoarthritis. We postulated that reconstruction with reverse shoulder prostheses would lead to early satisfactory results for these patients. We carried out a retrospective review of 19 shoulders treated with reverse shoulder prostheses at a mean follow-up of 37 months. We rated patients' pain using a visual analog pain scale (VAPS) and noted active range of motion in forward elevation, abduction, and external rotation. American Shoulder and Elbow Society and Simple Shoulder Test SST scores were available for 12 patients preoperatively and 16 postoperatively. We graded final results using the modified Neer scale. Preoperatively, the mean VAPS was 6.5, with average flexion of 68, abduction 66, and external rotation 23°. The American Shoulder and Elbow Society score averaged 27 and the SST 1. Postoperatively, the VAPS was 1 and flexion was 138°, abduction 134°, and external rotation 52°. The mean ASES score increased to 76 and the SST to 8. There were 12 excellent, 5 satisfactory, and 2 unsatisfactory results. Complications included 2 scapular spine fractures, 1 acromial fracture, 1 dislocation, and 1 ulnar neuropathy. We found scapular notching in 42% of the shoulders. Six shoulders had grade 1 notching, and 2 shoulders grade 2 notching. There was no evidence of glenoid loosening, but we saw complete bone-cement radiolucency around 2 cemented stems. At early follow-up, reverse shoulder arthroplasty for the shoulder damaged by inflammatory arthritis and with a deficient rotator cuff can provide noteworthy improvement for most patients.

Intraoperative Issues Dictated by Diagnosis: Cuff Deficiency: Allograft, Transfer, or Advance

A deficient rotator cuff in an arthritic shoulder is one of the most challenging problems that a surgeon faces in shoulder arthroplasty. Regardless of whether the cuff deficiency is identified preoperatively or intraoperatively, the reconstructive challenges—namely restoring static and dynamic balance to the shoulder, alleviating pain, and optimizing function—remain the same. The existing literature on the surgical treatment of this difficult problem has defined certain principles of management, but many questions remain. Patients with small rotator cuff tears can successfully undergo a total shoulder arthroplasty, provided a secure rotator cuff repair can be performed. Patients with larger irreparable tears should not undergo total shoulder arthroplasty, given a high rate of glenoid loosening. For patients with irreparable rotator cuff tears and glenohumeral arthropathy, the appropriate surgical procedure is indicated by age and functional level. Patients younger than 70 years old with preserved forward elevation >90° are best treated with humeral resurfacing arthroplasty; the role of tendon advancement in conjunction with humeral resurfacing is controversial. Patients older than 70 years old, with or without a pseudoparalytic shoulder, are best treated with reverse shoulder arthroplasty. Concomitant latissimus and teres major transfer with reverse shoulder arthroplasty may expand the indications for reverse shoulder arthroplasty in the future; however, caution must be exercised until more long-term outcome data are obtained. Given the dramatic failure of allograft augmentation in primary rotator cuff repair, there is little, if any, role for allograft augmentation in a cuff-deficient arthroplasty.

Rotator Cuff Tear Arthropathy: Evaluation, Diagnosis, and Treatment

Rotator cuff tear arthropathy encompasses a broad spectrum of pathology, but it involves at least three critical features: rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeral head. Although many patients possess altered biomechanics of the glenohumeral joint secondary to rotator cuff pathology, not all patients develop rotator cuff tear arthropathy, and thus the exact etiology of rotator cuff tear arthropathy remains unclear. The objectives of this manuscript are to (1) review the biomechanical properties of the rotator cuff and the glenohumeral joint, (2) discuss the proposed causes of rotator cuff tear arthropathy, (3) provide a brief review of the historically used surgical options to treat rotator cuff tear arthropathy, and (4) present a treatment algorithm for rotator cuff tear arthropathy based on a patient's clinical presentation, functional goals, and anatomic integrity.

Total shoulder arthroplasty for the treatment of failed hemiarthroplasty in patients with fracture of the proximal humerus

Little information is available for the outcomes of conversion to total shoulder arthroplasty (TSA) of failed hemiarthroplasty (HA) implanted for fractures or fracture-dislocations of the proximal humerus. We evaluated the clinical and radiographic results in 16 patients who underwent conversion of HA to TSA due to pain and shoulder disfunction. Patients were a mean age of 63 years at revision, which was occurred a mean of 3.3 years after the HA. The main prerequisites for conversion were forward flexion to at least 60°, no massive cuff tear, or severe resorption or nonunion of the tuberosities. In all cases, a modular prosthesis was used in the HA, uncemented in 14 and cemented in 2. The latest follow-up was a mean of 4.6 years after revision. The mean Constant score was 50.6 (range, 33-69), with an average increase of 11.9 points compared with the preoperative score (P = .001). In 75% of patients, the mean score was 54.6 (average increase, 15.1 points). The lowest scores occurred in patients with a cemented prosthesis that needed to be removed, and in 1 patient who had loosening of the implanted glenoid that was revised. Conversion of HA to TSA can improve the preoperative condition in most patients aged in their 50s or 60s in the absence of rotator cuff deficiency and severe bone loss of the proximal humerus.

Clinical results of revision shoulder arthroplasty using the reverse prosthesis

Success of revision shoulder arthroplasty using an unconstrained prosthesis depends on an intact rotator cuff and satisfactory bone quantity. However, the reverse shoulder arthroplasty can stabilize a glenohumeral joint even in patients with rotator cuff deficiency and bone deficits, resulting in improved outcomes. Thirty shoulders in 28 patients with a failed arthroplasty were investigated consecutively between 2005 and 2008. All shoulders had significant rotator cuff deficiency without glenoid bone loss. Revision arthroplasty using the reverse prosthesis was performed with a minimum of 2 years of follow-up. Concomitant glenoid reconstructions with tricortical iliac crest bone grafting were necessary in 12 shoulders. The average adjusted Constant score improved from 24% to 65% and the American Shoulder and Elbow Surgeons (ASES) score improved from 55 to 72 (P < .0001). Average active forward flexion increased from 42° to 106° (P < .0001). The average ASES pain score improved from 6.6 to 1.6 (P < .0001). The overall complication rate was 50%, and 7 patients (23%) required reoperation. Overall, 24 of 30 shoulders (80%) were very satisfied or satisfied. Reverse shoulder arthroplasty can be an efficacious salvage procedure in the management of failed arthroplasty due to rotator cuff-related instability or bone defects, or both. Structural bone grafting on the glenoid side is successful at managing large defects, producing similar or better clinical outcomes compared with patients without bone loss. Although the operation is associated with a considerable complication rate, 80% of patients were satisfied with the results of the procedure, and 29 of 30 shoulders had a stable prosthesis.

Evaluation and Management of Proximal Humerus Fractures

Proximal humerus fractures are common injuries, especially among older osteoporotic women. Restoration of function requires a thorough understanding of the neurovascular, musculotendinous, and bony anatomy. This paper addresses the relevant anatomy and highlights various management options, including indication for arthroplasty. In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. In the case of displaced fractures, when surgical intervention may be pursued, numerous constructs have been investigated. Of these, the proximal humerus locking plate is the most widely used. Arthroplasty is generally reserved for comminuted 4-part fractures, head-split fractures, or fractures with significant underlying arthritic changes. Reverse total shoulder arthroplasty is reserved for patients with a deficient rotator cuff, or highly comminuted tuberosities.

Shoulder function and pain level after revision of failed reverse shoulder replacement to hemiarthroplasty

Background:The reverse total shoulder replacement has become a popular treatment option for cuff tear arthropathy and other shoulder conditions requiring arthroplasty in the setting of a deficient rotator cuff. Despite a revision rate of as much as 10%, to date, there are few reports of reverse replacement conversion to hemiarthroplasty, and none specifically examining shoulder function.Materials and Methods:Six patients with a reverse replacement that was dislocated, infected or loose were revised an average of 9.2 months after the reverse replacement. Two of the three patients that were dislocated also had a known deep infection. Patients with known infection were treated with explant of the reverse prosthesis and conversion to a preformed antibiotic spacer hemiarthroplasty. In three cases with gross loosening of the glenosphere without infection, treatment was performed with removal of glenosphere only, bone grafting of glenoid with allograft and conversion of humeral stem to hemiarthroplasty. Patients were evaluated with outcome scores and physical examination an average of 26.5 months after removal of the reverse prosthesis.Results:The average range of motion postoperatively was forward elevation 42.5 degrees and external rotation 1.7 degrees. The VAS pain score was 2.42 (range 0–6); simple shoulder test was 3.17 (range 1–5); and ASES score was 52.1 ± 8.5. There were no reoperations to date, and five patients had anterosuperior escape.Conclusions:Safe removal of a reverse replacement and conversion to hemicement spacer or hemiarthroplasty can provide pain relief in those patients with a dislocated or infected reverse replacement. However, the shoulder will likely have very poor function and anterosuperior escape postoperatively. Further studies are needed to determine the optimal treatment for the failed reverse shoulder replacement.Level of Evidence:Therapeutic Level IV.

Shoulder muscle activation and coordination in patients with a massive rotator cuff tear: An electromyographic study

Adaptive muscle activation strategies following a massive rotator cuff tear (MRCT) are inadequately understood, and the relationship among muscles during everyday activities has not been considered. Thirteen healthy subjects comprised the control group, and 11 subjects with a MRCT the patient group. Upper limb function was assessed using the Functional Impairment test-hand, neck, shoulder, and arm (FIT-HaNSA). Electromyography (EMG) was recorded from 13 shoulder muscles, comprising five muscle groups, during a shelf-lifting task. Mean FIT-HaNSA scores were significantly lower in MRCT patients (p≤0.001), reflecting a severe functional deficit. In MRCT patients, EMG signal amplitude was significantly higher for the biceps brachii-brachioradialis (p < 0.001), upper trapezius-serratus anterior (p= 0.025), muscle groups and for the latissimus dorsi (p = 0.010), and teres major (p=0.007) muscles. No significant differences in the correlation among muscle groups were identified, pointing to an unchanged neuromuscular strategy following a tear. In MRCT patients, a reorganization of muscle activation strategy along the upper limb kinetic chain is aimed at reducing demand on the glenohumeral joint. Increased activation of the latissimus dorsi and teres major muscles is an attempt to compensate for the deficient rotator cuff. Re-education towards an alternate neuromuscular control strategy appears necessary to restore function.

Reverse Shoulder Arthroplasty in the Management of Irreparable Rotator Cuff Tears without Arthritis.

The ability to provide reliable outcomes in treatment of patients with degenerative rotator cuff tears has become increasingly complicated, as a result of more advanced disease and the increased array of treatment choices. Develop and communicate with a consistent team of interdisciplinary physicians both preoperatively and postoperatively; utilize advanced imaging modalities to evaluate muscle atrophy as well as glenoid and humeral bone stock. Place the patient in a beach-chair position, check the abdominal strap, and position yourself facing the axilla. Develop the subdeltoid and subacromial spaces and take care to avoid vigorous over-retraction of the deltoid. Perform the head cut utilizing the 135° resection guide, broach the humerus, and ream the humeral socket. Ream the inferior surface to bleeding subchondral bone; bleeding subchondral bone on the inferior 50% of the prepared glenoid surface indicates a sufficient depth. At final reaming, the edge of the reamer should sit flush with the cut surface of the humerus. Proper soft-tissue balance is frequently achieved by positioning the humeral component so that the rim of the socket lies just above the humeral osteotomy site at the anatomic neck. When cementing the humeral component, the socket should match the reamed proximal part of the humerus. Initially, reverse shoulder arthroplasty was primarily used to treat osteoarthritis of the glenohumeral joint resulting from chronic rotator cuff deficiency or for true rotator cuff tear arthropathy. Indications Contraindications Pitfalls & Challenges.

견관절 역행성 인공관절 치환술의 원칙

Purpose: The purpose of this article is to identify and understand the complications of RTSA and to review the current methods of preventing and treating this malady. Materials and Methods: Previous constrained prostheses (ball-and-socket or reverse ball-and-socket designs) have failed because their center of rotation remained lateral to the scapula, which has limited of the motion of the prostheses and produced excessive torque on the glenoid component, and this leads to early loosening. The Grammont reverse prosthesis imposes a new biomechanical environment for the deltoid muscle to act, thus allowing it to compensate for the deficient rotator cuff muscles. Results: The clinical experience does live up to the lofty biomechanical concept and expectations: the reverse prosthesis restores active elevation above 90。in patients with a cuff-deficient shoulder. However, external rotation often remains limited and particularly in patients with an absent or fat-infiltrated teres minor. Internal rotation is also rarely restored after a reverse prosthesis. Failure to restore sufficient tension in the deltoid may result in prosthetic instability. Conclusion: Finally, surgeons must be aware that the results are less predictable and the complication/ revision rates are higher in revision surgery than that in the first surgery. A standardized monitoring tool that has clear definitions and assessment instructions is surely needed to document and then prevent complications after revision surgery.

Glenoid component loosening due to deficient subscapularis: a case study of eccentric loading

Total shoulder arthroplasty is an effective means of treating pain and loss of function associated with glenohumeral arthritis. The most common complication of this procedure is failure of the glenoid component, accounting for up to 59% of the unsatisfactory total shoulder arthroplasty results. Multiple studies to identify the factors associated with glenoid component failure have led to improvements in component design, bony preparation, and cement technique. Late failure has been partially attributed to eccentric loading of the glenoid component. This results in a rockinghorse phenomenon of the component, with the loading of one edge of the component causing the opposite edge to lift off the glenoid bone. This cyclic stress can lead to failure of the component fixation. The causes for this eccentric loading can be multifactorial, including conformity of the joint surfaces, component malposition, glenoid version, and rotator cuff insufficiency. This phenomenon has beenwell documented in total shoulder arthroplasties with superior migration of the humeral component on the glenoid due to rotator cuff tears. There have been many studies of retrieved glenoid components as well as biomechanical studies of glenoid loading related to glenoid loosening. Although subscapularis deficiency and anterior eccentric loading would be expected to cause a similar problem, to our knowledge, no report has been published of a patient in whom the clinical, anatomic, and pathologic findings all support this mechanism of glenoid loosening due to

Principles of glenoid component design and strategies for managing glenoid bone loss in revision shoulder arthroplasty in the absence of infection and rotator cuff tear

The number of total shoulder arthroplasty (TSA) cases continues to grow each year. With the increasing number of procedures being performed, there, in turn, will exist a greater need for revision procedures. Failure of a shoulder arthroplasty can result from soft-tissue problems, bony deficiencies, infection, and component wear or loosening. Component loosening and osseous deficiencies may occur on the humeral and/or glenoid side. Multiple studies have identified glenoid component loosening as one of the more common causes necessitating revision after TSA. Glenohumeral joint instability in the setting of rotator cuff deficiency is also a common cause of glenoid loosening. Eccentric loading of the glenoid from proximal humeral migration leads to increased stress at the bonecement or bone-implant interface, commonly referred to as the ‘‘rocking horse phenomenon.’’ Eccentric loading, instability, and glenoid loosening may also result from incomplete glenoid seating, glenoid or humeral component malpositioning, or tuberosity malunion. The importance of glenoid implantation becomes evident when one considers

How Reverse Shoulder Arthroplasty Works

The reverse total shoulder arthroplasty was introduced to treat the rotator cuff-deficient shoulder. Since its introduction, an improved understanding of the biomechanics of rotator cuff deficiency and reverse shoulder arthroplasty has facilitated the development of modern reverse arthroplasty designs. We review (1) the basic biomechanical challenges associated with the rotator cuff-deficient shoulder; (2) the biomechanical rationale for newer reverse shoulder arthroplasty designs; (3) the current scientific evidence related to the function and performance of reverse shoulder arthroplasty; and (4) specific technical aspects of reverse shoulder arthroplasty. A PubMed search of the English language literature was conducted using the key words reverse shoulder arthroplasty, rotator cuff arthropathy, and biomechanics of reverse shoulder arthroplasty. Articles were excluded if the content fell outside of the biomechanics of these topics, leaving the 66 articles included in this review. Various implant design factors as well as various surgical implantation techniques affect stability of reverse shoulder arthroplasty and patient function. To understand the implications of individual design factors, one must understand the function of the normal and the cuff-deficient shoulder and coalesce this understanding with the pathology presented by each patient to choose the proper surgical technique for reconstruction. Several basic science and clinical studies improve our understanding of various design factors in reverse shoulder arthroplasty. However, much work remains to further elucidate the performance of newer designs and to evaluate patient outcomes using validated instruments such as the American Society for Elbow Surgery, simple shoulder test, and the Constant-Murley scores.

Scapula Fractures After Reverse Total Shoulder Arthroplasty: Classification and Treatment

Reverse total shoulder arthroplasty (RTSA) implants have been developed to treat patients with deficient rotator cuffs. The nature of this procedure's complications and how these complications should be managed continues to evolve. Fractures of the scapula after RTSA have been described, but the incidence and best methods of treatment are unclear. We therefore (1) determined the incidence and (2) developed a classification system intended to suggest the best choice of treatment. We reviewed the records of 400 patients treated with RTSA over 4.5 years and identified all patients with scapula fractures. We identified three discrete patterns: avulsion fractures of the anterior acromion (Type I); fractures of the acromion posterior to the acromioclavicular joint (Type II); and fractures of the scapular spine (Type III). Twenty-two patients (5.5%) had fractures. Eight (2.0%) had Type I fractures on the first followup radiographs; these patients were treated nonoperatively with resolution of symptoms. Ten (2.5%) had Type II fractures a mean of 10.8 months after RTSA; seven of the 10 were treated surgically with improvement in their clinical symptoms. Four (1%) had Type III fractures at a mean of 10.3 months; all four fractures were treated with surgical fixation with healing. Scapula fracture is a relatively common complication of RTSA. Our observations suggest Type I fractures can be observed with a likelihood of symptom relief. For Type II fractures, we recommend acromioclavicular joint resection if stable but open reduction internal fixation if unstable. We believe Type III fractures are best treated with open reduction internal fixation. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.