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Introduction
  • A specific pattern of shoulder degenerative joint disease that results from
    • rotator cuff tears lead to loss of joint congruence
    • results in abnormal glenohumeral wear 
    • leads to the specific pattern of degenerative joint disease
  • Rotator cuff arthropathy is characterized by the combination of
    • rotator cuff insufficiency
    • glenohumeral cartilage destruction
    • superior migration of the humeral head
    • subchondral osteoporosis
    • humeral head collapse
  • Epidemiology
    • demographics
      • females > males
      • 7th decade most common
    • location
      • more common in dominant shoulder
    • risk factors
      • rotator cuff tear
      • rheumatoid arthritis
      • crystalline-induced arthropathy
      • hemorrhagic shoulder (hemophiliacs and elderly on anticoagulants)
  • Pathophysiology  
    • cuff tear arthropathy
      • mechanical factors
        • loss of the concavity due to compression effect
        • decreased range of motion and shoulder function
        • humeral head migration
        • instability with possible recurrent dislocations
      • nutritional factors
        • loss of water tight joint space
        • decreased joint fluid
        • cartilage atrophy (decrease in water and glycosaminoglycan content) and subchondral collapse (disuse osteoporosis)
      • crystalline-induced arthropathy
        • degradation proteins in the synovium destroy the rotator cuff and cartilage
        • end-stage disease leads to calcium phosphate crystal deposits
Anatomy
  • Glenohumeral joint 
Classification
 
Seebauer Classification of Rotator Cuff Arthropathy  
Type IA
(centered, stable)
 • Intact anterior restraints
 • Minimal superior migration
 • Dynamic joint stabilization
 • Femoralization of the humeral head and acetabularization of coracoacromial arch
 
Type IB
(centered, medialized)
 • Intact or compensated anterior restraints
 • Minimal superior migration
 • Compromised joint stabilization
 • Medial erosion of the glenoid 
 
Type IIA
(decentered, limited stability)
 • Compromised anterior restraints
 • Superior translation
 • Minimum stabilization by coracoacromial arch

 
Type IIB
(decentered, unstable)
 • Incompetent anterior restraints
 • Anterosuperior escape
 • Nonexistent dynamic stabilization
 • No coracoacromial arch stabilization
 
Presentation
  • Symptoms
    • pain, including night-pain
    • subjective weakness
    • subjective stiffness
  • Physical exam
    • inspection & palpation
      • supraspinatus/infraspinatus atrophy
      • prominence of humeral head anteriorly (anterosuperior escape) with elevation of arm
      • subcutaneous effusion from loss of fluid from capsule
    • range of motion
      • limitations in active and passive ROM
      • crepitus in glenohumeral and/or subacromial joints with ROM
      • pseudoparalysis
        • inability to abduct shoulder
    • provocative tests
      • external rotation lag sign
        • inability to maintain passively externally rotated shoulder with elbow at 90 degrees
        • consistent with a massive infraspinatus tear
      • Hornblower sign
        • inability to externally rotate or maintain passive external rotation of a shoulder placed in 90 degrees of elbow flexion and 90 degrees of shoulder abduction
        • consistent with teres minor dysfunction
Imaging
  • Radiographs
    • recommended views
      • complete shoulder series; AP, axillary, Grashey (true AP)
    • findings
      • acromial acetabularization (true AP)
      • femoralization of humeral head (true AP)
      • asymmetric superior glenoid wear
      • lack of osteophytes
      • osteopenia
      • "snowcap sign" due to subchondral sclerosis
      • anterosuperior escape
  • MRI
    • indications
      • not necessary if humeral head is already showing anterosuperior escape on x-rays
    • findings
      • shows an irreparable rotator cuff tear with 
        • massive fatty infiltration
        • severe retraction
Treatment
  • Nonoperative
    • activity modification, subacromial steroid injection, physical therapy
      • indications
        • first line of treatment
      • technique
        • physical therapy with a scapular and rotator cuff strengthening program
        • non-steroidal anti-inflammatories
        • subacromial steroid injections
  • Operative
    • arthroscopic debridement
      • indications
        • controversial
      • outcomes
        • unpredictable results
        • must maintain coracoacromial arch without acromioplasty or release of CA ligament
    • hemiarthroplasty  q q
      • indications
        • anterior deltoid is preserved
        • coracoacromial arch intact
          • deficiency of the coracoacromial arch will lead to subcutaneous humeral escape
        • younger patients with active lifestyles
      • outcomes
        • will relieve pain but will not improve function (motion limited to 40-70 degrees of elevation)
    • reverse shoulder arthroplasty 
      • indications
        • pseudoparalytic cuff tear arthropathy
        • preferred in elderly (>70) with low activity level
        • anterosuperior escape
        • requires functioning deltoid (axillary nerve) and good bone stock
          • deltoid is used to assist glenohumeral joint to act like a fulcrum in elevation
      • outcomes (short and intermediate at this point)
        • has the potential to improve both function and pain
        • risk of inferior scapular notching with poor technique
    • latissimus dorsi transfer
      • indications
        • pseudoparesis with external rotation  
        • combination with reverse total shoulder arthroplasty
    • pectoralis transfer
      • indications
        • internal rotation deficiency and subscapularis insufficiency
      • techniques
        • upper portion or whole pectoralis tendon transferred near subscapularis insertion on lesser tuberosity
      • complications
        • musculocutaneous nerve injury 
    • resection arthroplasty
      • indications
        • salvage only (chronic osteomyelitis, infections, poor soft tissue coverage)
    • glenoid resurfacing
      • contraindicated
        • excess shear stress on superior glenoid leads to failure through loosening
    • TSA
      • contraindicated
Complications
  • Infection
  • Neurovascular injury
  • Deltoid dysfunction
  • Instability (more common after hemiarthroplasty, rare after RTSA)
 

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