Review Question - QID 216349

This patient has an acutely decompensated chronic rotator cuff tear, or cuff tear arthropathy (CTA). Of the above, the only proven surgical option is a reverse total shoulder arthroplasty.

The presentation of cuff tear arthropathy can vary. Most patients do not recall a specific injury where the rotator cuff tendons were initially torn and over time, the deltoid and scapular stabilizers are able to compensate for these abnormal mechanics. However, acute, low energy injuries will cause an abrupt decompensation with a significant degree of pain and disability and drive patients to see orthopedic consultation. Fortunately rest, physical therapy, and/or intra-articular injections will often alleviate this initial painful, inflammatory phase. If, however, the remaining musculature cannot compensate for the rotator cuff deficiency, surgical options including superior capsular reconstruction, tendon transfers, or reverse shoulder arthroplasty may be considered, each with specific indications and contraindications.

Feeley et al. reviewed arthroplasty options for cuff tear arthropathy. They noted that while hemiarthroplasty provided great pain relief, range of motion limitations remained. Anatomic total shoulder arthroplasty also provided great pain relief but rates of glenoid loosening due to the rocking-horse phenomenon restrict its use for CTA.

Matsen et al. described the design and rationale for RSA utility in the rotator cuff deficient shoulder. The reverse shoulder arthroplasty swaps the ball and socket components between the humerus and glenoid. It is a constrained prosthesis which limits translation of the humeral head and instead creates rotation. It also moves the center of rotation of the humeral head more inferior and medial which optimizes the function of the deltoid and makes it the primary driver of shoulder motion.

Werner et al. detailed a very early case series of 58 patients who underwent an RSA for painful pseudoparesis. They used the Grammont-style Delta III design for all patients and noted significant improvements in active forward elevation, Constant score and subjective shoulder values. However, they also reported an all-cause complication rate of 50% and reoperation rate of 33%.

Figures A-C are various MRI sequences showing a massive full-thickness, retracted suprapinatus tear with high grade fatty infiltration (and an upper border subscapularis tear).
Illustration A by Rebolledo et al. shows the change from the native shoulder to the RSA.

Incorrect Answers:
Answer 1- Rotator cuff repair would not likely be possible given the degree of muscle atrophy. A superior capsular reconstruction could be a better option, however one must consider age and ability to follow strict rehab protocols.
Answer 2- The Ream-and-run technique is considered for young laborers with glenohumeral arthritis and intact rotator cuff.
Answer 3- Hemiarthroplasty was previously the only arthroplasty option for cuff tear arthropathy, but has been pushed aside given the greater durability and longevity of RSA.
Answer 4- Anatomic TSA requires a functioning supraspinatus (and subscapularis). There is no role for this implant in cuff tear arthropathy.