Rotator Cuff Deficiency Research Articles

Evaluation of the Translation Distance of the Glenohumeral Joint and the Function of the Rotator Cuff on Its Translation: A Cadaveric Study

To evaluate the distance and position of humeral head translation during glenohumeral motion and to investigate the function of the rotator cuff in glenohumeral translation. Using 9 cadavers, glenohumeral translation during passive pendulum motion was tracked by an optical motion capture system. Tension was applied to 5 compartments of the rotator cuff muscles, and 7 different conditions of rotator cuff dysfunction were sequentially simulated. Three-dimensional glenohumeral structure was reconstructed from the computed tomography images of the specimens, and the distance and position of glenohumeral translation were compared among the conditions. The average radius of glenohumeral translation was 10.6 ± 4.3mm when static loading was applied to all rotator cuff muscles. The radius increased significantly in the models without traction force on the supraspinatus and total subscapularis tendons (P= .030). The position of the translation center did not change in the mediolateral direction (P=.587) and in the anteroposterior direction (P= .138), but it moved significantly superiorly in the models without supraspinatus and infraspinatus loading (P= .011) and in those without supraspinatus, infraspinatus, and teres minor loading (P < .001). The distance and position of humeral head translation during glenohumeral motion changed with rotator cuff deficiency. The present study indicated that the subscapularis plays an important role in maintaining the central position of the humeral head, and that the infraspinatus acts as a major depressor of the humeral head during shoulder motion. The results of this study suggest that extension of a tear into the subscapularis should be avoided to maintain the centering function of the glenohumeral joint in cases with rotator cuff tear.

Return to sports after reverse shoulder arthroplasty—the Swiss perspective

This patient survey evaluated the return to previous sports activities in Swiss patients up to fiveyears after reverse shoulder arthroplasty (RSA). We screened our local shoulder arthroplasty registry for patients registered with a unilateral RSA due to rotator cuff deficiency between May 2010 and May 2015. Revision cases and patients already known as unwilling or unable to complete a German language questionnaire were excluded. Eligible patients received a paper questionnaire asking about their past and current sports activities, return time point and level of activity. Of 305 patients, 89% responded at a mean post-operative follow-up of 2.9years (SD 1.1). The respondents had a mean age of 77.1years (SD 7.8) and included 62% females. The overall rate of patients returning to a previous sports activity was 77%. Sixty-one percent (166/271) participated in regular sports activities before the onset of their shoulder disorders. After RSA, 47% (127/271) participated in at least one sport type with the most frequent activities including hiking (66), swimming (53), cycling (45) and callisthenics (43). Most patients carried out their main sports activity after surgery with a moderate level of intensity (83%) and between one to three times per week (69%). Forty-two percent of the respondents indicated that returning to sports was among their key demands after RSA. Returning to previous sports activities is an important expectation of RSA patients, and the majority do. Patient expectations of post-operative sports activity need to be addressed when planning RSA.

Reverse Shoulder Arthroplasty for the Treatment of Rotator Cuff Deficiency: A Concise Follow-up, at a Minimum of 10 Years, of Previous Reports.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer in patients with deltoid paralysis

Management of shoulder arthritis associated with deltoid paralysis can be very challenging. The purpose of this study was to report the outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer to reconstruct the anterior deltoid in patients with symptomatic shoulder arthritis and a paralyzed deltoid. This study included 31 patients with an average age of 51 years (range, 27-73 years). All patients had chronic deltoid paralysis with significant loss of function due to progressive arthritis associated with rotator cuff deficiency. All patients underwent reverse shoulder arthroplasty with pedicled pectoralis muscle transfer. Additional transfers were performed in patients with no preoperative external rotation: 5 underwent latissimus transfer, and 3 underwent direct lower trapezius transfer to the infraspinatus. At an average follow-up of 37 months, 29 patients had significant improvements in pain; the shoulder subjective value; the Disabilities of the Arm, Shoulder and Hand score; and shoulder range of motion, mainly flexion of 83° and external rotation of 15°. Two patients sustained postoperative acromial fractures and had persistent pain after surgery with minimal improvement in shoulder flexion and external rotation. One of them had a failed attempt at open reduction-internal fixation of the acromion. Reverse shoulder arthroplasty with pedicled pectoralis transfer is a promising procedure that may lead to improved pain and function in patients with shoulder arthritis associated with deltoid paralysis.

Revision of failed shoulder hemiarthroplasty to reverse total arthroplasty: analysis of 157 revision implants

There remains a paucity of studies examining the conversion of failed hemiarthroplasty (HA) to reverse total shoulder arthroplasty (RTSA). Therefore, the purpose of this study was to examine a large series of revision HA to RTSA. A population of 157 patients who underwent conversion of a failed HA to a revision RTSA from 2006 through 2014 were included. The mean follow-up was 49 months (range, 24-121 months). The indications for revision surgery included instability with rotator cuff insufficiency (n = 127) and glenoid wear (n = 30); instability and glenoid wear were associated in 38 cases. Eight patients with infection underwent 2-stage reimplantation. Patients experienced significant improvements in their preoperative to postoperative pain and shoulder range of motion (P < .0001), with median American Shoulder and Elbow Surgeons and Simple Shoulder Test scores of 60 and 6 points, respectively. There were 11 (7%) repeated revision surgeries, secondary to glenoid component loosening (n = 3), instability (n = 3), humeral component disassembly (n = 2), humeral stem loosening (n = 1), and infection (n = 2). Implant survivorship was 95.5% at 2 years and 93.3% at 5 years. There were 4 reoperations including axillary nerve neurolysis (n = 2), heterotopic ossification removal (n = 1), and hardware removal for rupture of the metal cerclage for an acromial fracture (n = 1). At final follow-up, there were 5 "at-risk" glenoid components. Patients experience satisfactory pain relief and recovery of reasonable shoulder function after revision RTSA from a failed HA. There was a relatively low revision rate, with glenoid loosening and instability being the most common causes.

What Are the Complications, Survival, and Outcomes After Revision to Reverse Shoulder Arthroplasty in Patients Older Than 80 Years?

By the time patients with a failed shoulder arthroplasty require revision surgery, a substantial number are older than 80 years. The risk of complications of revision arthroplasty in this elderly population is largely unknown and needs to be considered when contemplating whether these patients are too frail for revision surgery. (1) What are the 90-day medical and surgical complications after revision to reverse shoulder arthroplasty (RSA) in patients older than 80 years? (2) What are the 2- and 5-year survival rates after revision? (3) Was there an improvement in pain at rest or with activity, range of motion (ROM), and strength after revision surgery? Between 2004 and 2013, 38 patients who were older than 80 years (84 ± 3 years) underwent revision surgery to a RSA. Of those, five were lost to followup before 2 years, and two had died within 2 years of revision surgery, leaving 31 for analysis of our survivorship, pain, ROM, and strength endpoints at a minimum of 2 years or until revision surgery had occurred (mean, 28 months; range, 1-77 months); all 38 patients were included for purposes of evaluating medical and surgical complications at 90 days. During the period in question, our general indication for using RSA included failure of previous shoulder arthroplasty because of instability, glenoid loosening with bone loss, or rotator cuff insufficiency. The indication for revision to RSA did not change during the study period. The index procedure (revision to RSA at the age of 80 years or older) was the first revision arthroplasty in 33 (87%) patients and the second in five (13%) patients. We tallied 90-day medical and surgical complications by performing a retrospective chart and institutional joint registry review. The cumulative incidence of implant loosening (implant migration or tilting, or complete radiolucent lines present) and revision surgery was calculated at 2 and 5 years using competing risk of death method. Pain levels at rest or with activity (rated in a 1 to 5 Likert-type scale) were collected through a retrospective chart review and values before and after surgery were compared. Medical complications occurred in three of 38 (8%) patients and surgical complications occurred in five of 38 (13%) patients. The 90-day mortality was 3% (one of 38 patients), and the total mortality was 26% (10 of 38 patients). The cumulative incidence of revision was 11% (95% CI, 0%-20%) at 2 years and 16% (95% CI, 1%-30%) at 5 years; the cumulative incidence of loosening was 8% (95% CI, 0%-20%) at 2 years and 16% (95% CI, 1%-30%) at 5 years. Pain at rest or with activity improved from pre- to postoperation (preoperative: median, 4 [range, 2-5]; postoperative: median, 1 [range, 1-4]; median difference: -2, 95% CI -3 to 0; p < 0.000). The active ROM improved during the preoperative compared with postoperative periods: mean ± SD forward flexion of 52° ± 40° to 109° ± 44°, respectively (mean difference: 56; 95% CI, 40-72; p < 0.000), and mean ± SD external rotation of 15° ± 22° to 31° ± 21°, respectively (mean difference: 16; 95% CI, 8-25; p < 0.000). Age should not be used as a reason to not consider revision surgery to RSA in patients older than 80 years. Further studies with a prospective design, larger sample size, investigating risk factors for complications or poor outcome, and incorporation of functional scores are required. Level IV, therapeutic study.

Reverse total shoulder replacement: approaches and current controversies

Reverse total shoulder arthroplasty (RTSA) is a well-accepted treatment option for a number of pathologies including glenohumeral arthropathy with severe rotator cuff deficiency, revision of anatomic arthroplasty, rheumatoid arthritis, reconstruction after tumor resection, and severe fractures in the elderly. Despite advances in RTSA, significant challenges persist and continue to inspire innovation in technique and design. This review outlines the pervasive challenges of RTSA and the strategies that have been developed for these challenges. The anterosuperior and deltopectoral approaches have both been used successfully for RTSA, with considerations that render each approach applicable in certain scenarios. Pertinent issues related to the glenoid component center around determining the ideal position for the center of rotation and the ideal degree of baseplate tilt. On the humeral component side, debate exists regarding the optimal humerosocket inclination and the role for humeral component lateralization. With conflicting or limited data pertaining to these topics, there remains room for continued research, improvement, and innovation.

The Role of Reverse Shoulder Arthroplasty in Management of Proximal Humerus Fractures with Fracture Sequelae: A Systematic Review of the Literature.

Fracture sequelae of the proximal humerus poses a complex management decision due to the frequent deformity and its consequences on the peri-articular soft tissues. These patients are frequently elderly with significant medical comorbidities. Due to the age of the patient there is frequently rotator cuff deficiency and therefore the reverse shoulder arthroplasty (RSA) becomes the arthroplasty of choice. We have performed a systematic review of the literature and report nine studies presenting RSA for the treatment of fracture sequelae of the proximal humerus. It is clear that RSA can improve the range of movement and function following proximal humerus fracture sequelae. However, there is a risk of significant complications including dislocation (16.7%), infection (6.7%), intra-operative fracture (3%) and neurological injury (2.6%). There is a need to invest in future prospective comparative studies and randomised trials to further test RSA in fracture sequelae patients. This will provide us with information regarding the longevity of different prosthesis, outcomes and cost-effectiveness of treatment.

Is reverse total shoulder arthroplasty a feasible treatment option for failed shoulder arthroplasty? A retrospective study of 44 cases with special regards to stemless and stemmed primary implants.

Due to humeral or glenoid bone-loss and rotator cuff insufficiency reverse total shoulder arthroplasty often means the only remaining treatment option in revision shoulder arthroplasty. This study investigates the clinical outcome of patients treated with a reverse total shoulder in revision cases with special regard to stemless and stemmed primary implants. From 2010 to 2012 60 failed shoulder arthroplasties were converted to reverse total shoulder arthroplasty. Forty-four patients were available for follow-up after a mean of 24months. Patients were assessed with X-rays, Constant- and ASES Score and a questionnaire about their subjective satisfaction. The total number of observed complications was seven (16%). Ninety-eight percent of the patients were satisfied with their clinical result. Patients achieved a mean normalized constant score of 70.2% and a mean ASES Score of 65.3. Patients with stemless primary implants achieved a higher normalized constant score than patients with stemmed primary implants (82 vs. 61.8%; p=0009). Reverse total shoulder arthroplasty provides satisfactory clinical results and a high patient satisfaction in revision shoulder arthroplasty. The complication rate needs to be considered and discussed with the patient prior to surgery. Presence or absence of a stem of revised shoulder arthroplasties interferes with the outcome. LEVEL OF EVIDENCE IV: (Retrospective study).

Revision Strategies in Reverse Total Shoulder Arthroplasty

Background While initially developed to improve function in patients with chronic rotator cuff deficiency, the success of reverse total shoulder arthroplasty (RTSA) has led to expanding indications including fracture sequelae and revision of failed hemi- or total shoulder arthroplasty. While primary RTSA carries complication and revision rates of up to 75% and 2%–10%, respectively, these rates are higher in RTSA performed in a revision setting. Methods The current literature on RTSA and revision RTSA was reviewed to determine the most common complications and treatment strategies to address these complications. Results The most common complications leading to revision of RTSA are instability, infection, humeral implant loosening, and glenoid implant loosening. Each of these presents unique technical challenges for the surgeon. Retention or replacement of a reverse prosthesis affords high patient satisfaction and better functional outcomes than resection, but may require several additional surgeries. In cases in which reverse components cannot be implanted, salvage options, including resection arthroplasty and conversion to hemiarthroplasty, provide satisfactory pain relief but limited function. Discussion As the number of RTSA performed increase, so will the number of revisions. In this article, current treatment strategies for addressing the challenges of revision reverse shoulder arthroplasty are discussed.

Classification of full-thickness rotator cuff lesions: a review.

Rotator cuff lesions (RCL) have considerable variability in location, tear pattern, functional impairment, and repairability.Historical classifications for differentiating these lesions have been based upon factors such as the size and shape of the tear, and the degree of atrophy and fatty infiltration. Additional recent descriptions include bipolar rotator cuff insufficiency, ‘Fosbury flop tears’, and musculotendinous lesions.Recommended treatment is based on the location of the lesion, patient factors and associated pathology, and often includes personal experience and data from case series. Development of a more comprehensive classification which integrates historical and newer descriptions of RCLs may help to guide treatment further.Cite this article: Lädermann A, Burkhart SS, Hoffmeyer P, et al. Classification of full thickness rotator cuff lesions: a review. EFORT Open Rev 2016;1:420-430. DOI: 10.1302/2058-5241.1.160005.

Early Outcomes Following Metal-on-Metal Reverse Total Shoulder Arthroplasty in Patients Younger Than 50 Years.

Reverse total shoulder arthroplasty (TSA) is a useful intervention for older patients with glenohumeral arthritis and a deficient rotator cuff. However, as a semiconstrained prosthesis, conventional reverse TSA implanted in a young patient could fail over time secondary to polyethylene wear and subsequent osteolysis. A metal-on-metal prosthesis may avoid this type of failure. The purpose of this study is to assess the outcomes in an initial cohort of young patients who underwent reverse TSA using a metal-on-metal prosthesis. Surgical indications included age younger than 50 years with a functioning deltoid and significant impairment of shoulder function with irreparable rotator cuff due to tumor resection, arthritis, or revision surgery. Nine patients with an average age of 37 years underwent implantation of a custom metal-on-metal reverse TSA prosthesis. All patients had a minimum 12-month follow-up or a failure of their procedure requiring revision surgery prior to 1 year. American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, and range of motion were recorded and analyzed pre- and postoperatively to assess improvement, and all complications were noted. Average ASES score improved from 47 points preoperatively to 73.4 points postoperatively (P=.013). Average Constant and adjusted Constant scores improved from 20.8 points and 16% preoperatively to 61.8 points and 67.3% postoperatively, respectively (P=.019 and P=.068). Mean postoperative active forward flexion and active external rotation were 119.4° and 10°, respectively. Complications included the following: 3 patients sustained a postoperative dislocation, 1 patient had a glenoid fracture and complete loss of fixation of the baseplate, and 1 patient experienced dissociation of the glenosphere from the base-plate. Although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high. [Orthopedics.2016; 39(5):e957-e961.].

ASSESMENT OF KEY PARAMETERS ON THE PERFORMANCE OF THE DELTOID MUSCLE IN REVERSE SHOULDER ARTHROPLASTY — A MODELING AND SIMULATION-BASED STUDY

Reverse shoulder arthroplasty (RSA), in which anatomic concavities of glenohumeral (GH) joint are inverted, is a popular treatment of arthritic shoulders with deficient rotator cuff. The correct positioning of the glenohumeral center of rotation and initial setting of the deltoid length (Deltoid Tension) plays an important role in the outcome of the RSA. A study of the key literature has shown that despite common use of RSA, its biomechanical characteristics during motion are not fully understood. This study investigates the influence of some of the key parameters on the intensity of the moment in a shoulder after RSA during abduction in scapular plane. The kinematics after RSA are then compared with the anatomic shoulder kinematics and differences are discussed. Mathematical models of both the anatomical and reverse shoulder (RS) were developed in MATLAB and in MSC ADAMS. The anatomical and RSA geometries were defined using measurements obtained from X-ray and magnetic resonance imaging (MRI) images of the shoulder girdle. The results show that in RSA, the intensity of the moment generated in the GH joint improves. However, this improvement does not show a constant trend and its intensity can dramatically decrease in higher GH joint abduction.

Irreparable Rotator Cuff Tears: Restoring Joint Kinematics by Tendon Transfers.

Background:Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes.Methods:A selective literature search was performed and personal surgical experiences are reported.Results:Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis.Conclusion:Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands.

Are the Current Size Options of Glenoid Baseplates for Reverse Shoulder Arthroplasty Sufficient for our Local Population?: 現有反置式人工肩關節置換術中盂底板組件的大小選項是否滿足我們本地人口的需要？

Background/PurposeReverse shoulder arthroplasty (RSA) is an effective treatment for patients who suffer from shoulder pain and dysfunction associated with a variety of shoulder pathologies including severe rotator cuff deficiency with or without glenohumeral arthritis. It has been widely used in European countries and the United States and is now gaining popularity in Asia, including Hong Kong. However, there are only limited size options available for glenoid baseplates, with 25 mm being the smallest size in some commonly used systems. The aim of our study is to perform computerized tomography (CT) measurements of the glenoid dimension in the Chinese population and to see if the current glenoid baseplate component size option is sufficient for our local population. MethodsA total of 70 CT scans of shoulder regions were analysed. Measurements included maximum superoinferior height and the anteroposterior height. ResultsThe glenoid dimensions were smaller compared to those from previous studies in Caucasian counterparts. Some 41% of female glenoids had widths measuring < 25 mm (25 mm being the smallest size available in some commonly used RSA systems). ConclusionAlthough there are only limited size options available for the glenoid baseplate in RSA, from our data, it should be able to cover most patients in our local population. However, surgeons should exercise special care when contemplating performing reverse shoulder replacement for small size females in our local population.

Accuracy of the Subchondral Smile and Surface Referencing Techniques in Reverse Shoulder Arthroplasty.

Inferior glenoid baseplate tilt relative to the coronal axis of the scapular body has been associated with improved results and fewer postoperative complications in reverse shoulder arthroplasty. However, the native glenoid surface is not always a reliable reference for the true scapular axis. Digital preoperative planning software and advanced imaging now allow surgeons to more precisely determine optimal glenoid placement. The purpose of this study was to evaluate the accuracy of the subchondral smile and cannulated surface guide techniques in achieving inferior glenoid baseplate tilt by using 3-dimensional preoperative planning software. Virtual glenoid baseplate preparation and implantation was performed using computed tomography scans of 16 shoulders with rotator cuff deficiency. Two techniques were used: a subchondral smile technique that preferentially reams the interior glenoid, resulting in the appearance of a smile, and a cannulated surface guide technique that references the native glenoid face to place the baseplate in 10° of inferior tilt. Using the subchondral smile technique, the glenoid baseplate was implanted at a mean of 8.9° of superior tilt relative to the transverse scapular axis. Using the surface guide technique, the glenoid baseplate was implanted at a mean of 2.8° of superior tilt. Neither the subchondral smile technique nor the 10° cannulated surface guide technique is a reliable method to produce inferior glenoid tilt relative to the transverse axis of the scapula. Three-dimensional preoperative planning software is a useful tool when attempting to achieve optimal glenoid baseplate positioning in reverse shoulder arthroplasty. [Orthopedics. 2016; 39(4):e615-e620.].

Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation

To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles. Patients with massive posterosuperior rotator cuff retears who underwent open revision rotator cuff repair with patch augmentation were identified from a surgical registry. Outcomes data collected included American Shoulder and Elbow Surgeons; Quick Disabilities of the Arm, Shoulder and Hand; Single Assessment Numeric Evaluation; and Short Form-12 Physical Component Summary scores along with postoperative patient satisfaction, and activity modification. There were 10 men and 2 women (13 shoulders, 1 bilateral) with a mean age of 57 years (range, 26 to 68 years). All patients had at least one prior arthroscopic rotator cuff repair. After patch augmentation, there were no complications, no adverse reactions to the patch, and no patients required further surgery. One patient (7.7%) with 4 prior cuff repairs had a documented posterosuperior retear on magnetic resonance imaging 2months after repair. Minimum 2-year outcome scores were available for 12 of 13 (92.3%) shoulders after a mean follow-up period of 2.5 years (range, 2.0 to 4.0 years). The ASES score improved by 21.5 points. Although the pain component of the ASES score and the total ASES score didnot improve significantly, the function component of the ASES score improved significantly when compared withtheirpreoperative baselines (P < .05). Median patient satisfaction at final follow-up was 9/10 (range, 2 to 10). Biologic patch augmentation with human acellular dermal allograft was a safe and effective treatment method for patients with massive rotator cuff retears with deficient posterosuperior rotator cuff tendons in the presence of healthy rotator cuff muscles. Level IV, therapeutic study.

Periprosthetic humeral fractures: Strategies and techniques of revision arthroplasty

The primary aims when performing revision arthroplasty of periprosthetic humeral fractures (PHF) are preservation of bone stock, achieving fracture healing and preserving a stable prosthesis with the focus on regaining the preoperative shoulder-arm function. The indications for revision arthroplasty are given in PHF in combination with loosening of the stem. In addition, further factors must be independently clarified in the case of an anatomical arthroplasty. In this context secondary glenoid erosion as well as rotator cuff insufficiency are potential factors for an extended revision procedure. For the performance of revision surgery modular revision sets including long stems, revision glenoid and metaglene components as well as plate and cerclage systems are obligatory besides the explantation instrumentation. Despite a loosened prosthesis, a transhumeral removal of the stem along with a subpectoral fenestration are often required. Length as well as bracing of revision stems need to bridge the fracture by at least twice the humeral diameter. Moreover, in many cases a combined procedure using an additional distal open reduction and internal fixation (ORIF) plus cable cerclages as well as biological augmentation might be needed. Assuming an adequate preparation, the experienced surgeon is able to achieve a high fracture union rate along with an acceptable or even good shoulder function and to avoid further complications.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study

Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem. Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions. Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3). The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

Large/Massive Tears, Fatty Infiltration, and Rotator Cuff Muscle Atrophy: A Review Article With Management Options Specific to These Types of Cuff Deficiencies

Context: There are many studies in the literature looking into factors affecting outcomes in rotator cuff surgery. The aetiology of rotator cuff deficiency is often multi-factorial and there are many facets towards successful management in this often debilitating condition. Evidence Acquisition: We performed a literature search of MEDLINE and Embase databases using the terms large rotator cuff tears, fatty infiltration rotator cuff, rotator cuff atrophy, rotator cuff augmentation, rotator cuff tendon transfers, allografts rotator cuff repair, xenograft rotator cuff repair and synthetic grafts rotator cuff repair. Results: In this article, we focus particularly on the aetiology, pathology and prognosis of large tears, fatty infiltration and muscle atrophy of the rotator cuff. An overview of the various treatment strategies and current/future concepts are also discussed in managing patients with these types of rotator cuff deficiencies. Conclusions: Large tears, fatty infiltration and muscle atrophy of the cuff are challenging. An in-depth understanding of these elements may prove vital for the practising orthopedician in determining the right course of management. Techniques in strengthening the repair construct using augmentation play an important role in the treatment of this condition.