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Rotator Cuff Arthropathy
Posted: Jan 31 2022 #(C101976)
A

Rotator Cuff Arthropathy in 63F

HPI

A 63-year-old female presents with right shoulder pain, worsening over the past 6 months. She has a history of rotator cuff repair in 2015 and revision cuff repair in 2016. Did well until 2020, then had atraumatic gradual onset of pain. She has undergone cortisone injection and attempted PT without relief. She now has difficulty reaching arm to shoulder height and above. Denies any numbness/tingling in the arm. VAS Pain score: 2/10 ASES: 83 Subjective Shoulder Value: 30% Constant: 56

PMH

None

PE

Focused physical examination of the right shoulder reveals well-healed arthroscopic portals without open wounds or abrasions. There is moderate infraspinatus muscle atrophy and mild scapular dyskinesia with repetitive forward flexion in the scapular plane. There is tenderness to palpation over the biceps grove and coracoid. Her ROM is as follows: Range of Motion (Active/Passive): Right Shoulder Forward Flexion (FF) 90/135 degrees External Rotation (ER) 5/10 degrees Internal Rotation (IR) T12 Abduction (ABD) 85/110 degrees Range of Motion (Active/Passive): Left Shoulder Forward Flexion (FF) 160/165 degrees External Rotation (ER) 45/50 degrees Internal Rotation (IR) T7 Abduction (ABD) 155/160 degrees   Strength Testing of the right shoulder reveals weakness of the supraspinatus (3+/5) and a 10-degree external rotation lag. There is 5/5 strength on belly press and bear hug.

Poll
1 of 12
1. In addition to the plain radiographs above, would you obtain any additional imaging to guide treatment?
No - plain radiographs are sufficient
7%
36/473
Yes - additional radiographic views (aXR)
0%
2/473
Yes - CT scan of the shoulder (CT)
28%
134/473
Yes - MRI scan of the shoulder (MRI)
27%
128/473
Yes - aXR + CT
0%
3/473
Yes - aXR + MRI
1%
9/473
Yes - CT + MRI
26%
124/473
Yes - aXR + CT + MRI
5%
27/473
Outside my area of expertise - best if I don't vote
2%
10/473
2. Would you use a classification system to guide your management of this patient?
No - a classification system would not help me
41%
191/457
Yes - Goutallier
13%
60/457
Yes - Hamada
19%
88/457
Yes - Seebauer
2%
10/457
Yes - Sirveaux
0%
3/457
Yes - a combination of those named above
11%
51/457
Yes - other described Classification
0%
4/457
Outside of my area of expertise - best I don't answer
10%
50/457
3. If you would use the Hamada Classification, what grade would you give this patient?
I would not use the Hamada Classification
30%
129/425
1
0%
3/425
2
2%
11/425
3
14%
60/425
4A
12%
51/425
4B
13%
56/425
5
7%
31/425
Outside of my area of expertise - best I don't answer
19%
84/425
4. If concerned for an infection, how would you work up the patient?
I am not concerned for an infection and would not work up.
24%
110/456
Labs alone (i.e ESR, CRP, CBC)
23%
105/456
Aspiration alone
0%
0/456
Arthroscopic biopsy alone
0%
2/456
Labs + Aspiration
31%
143/456
Labs + Arthroscopic biopsy
7%
33/456
Aspiration + Arthroscopic biopsy
0%
3/456
Labs + Aspiration + Arthroscopic biopsy
11%
52/456
Outside my area of expertise - best I don't answer
1%
8/456
5. How would you definitively manage this patient?
Nonoperative
4%
19/440
Operative
92%
408/440
Outside my area of expertise - best if I don't vote
2%
13/440
6. If you choose Operative treatment and the patient received a corticosteroid injection last week, how long would you wait to perform surgery?
I would not choose Operative treatment
0%
3/447
< 1 month
9%
41/447
1-2 months
18%
84/447
2-3 months
25%
116/447
3-4 months
32%
146/447
4-6 months
6%
29/447
> 6 months
3%
17/447
Outside my area of expertise - best if I don't vote
2%
11/447
7. If you choose Operative treatment, what would you recommend?
I would not choose Operative treatment
0%
3/436
Arthroscopic debridement (i.e. CAM procedure)
4%
21/436
Subacromial balloon spacer
1%
6/436
Superior capsular reconstruction (SCR)
3%
15/436
Tendon Transfer
0%
3/436
Arthroplasty
85%
374/436
Arthrodesis
0%
1/436
Outside my area of expertise - best if I don't vote
2%
13/436
8. If you choose Arthroplasty, what procedure would you perform?
I would not choose Arthroplasty
0%
2/433
Hemiarthroplasty (HA)
0%
1/433
Ream and Run (non-prosthetic glenoid)
0%
1/433
Anatomic total shoulder arthroplasty (TSA)
4%
18/433
Reverse total shoulder arthroplasty (RSA)
91%
395/433
Other
0%
0/433
Outside my area of expertise - best if I don't vote
3%
16/433
9. If you choose Reverse Total Shoulder Arthroplasty (RSA), how would you manage the glenoid?
I would not choose RSA
1%
5/425
Maintain current glenoid version
31%
133/425
Eccentric reaming
19%
84/425
Bone grafting
11%
47/425
Augment base plate
24%
103/425
Other
0%
2/425
Outside my area of expertise - best if I don't vote
12%
51/425
10. If you choose Reverse Total Shoulder Arthroplasty (RSA), would you repair the subscapularis?
I would not choose RSA
1%
5/413
No
26%
110/413
Yes
64%
268/413
Outside my area of expertise - best if I don't vote
7%
30/413
11. If you choose Reverse Total Shoulder Arthroplasty (RSA) with subscapularis repair, what would be your immediate postoperative motion restrictions?
I would not choose RSA
0%
3/401
I would not have repaired the subscapularis
8%
34/401
No restriction
2%
9/401
Pendulums only
25%
104/401
Passive/active-assisted range of motion without limitations
4%
18/401
Passive/active-assisted range of motion without any external rotation passed neutral
37%
150/401
Sling on at all times (no active/passive shoulder ROM)
14%
57/401
Other
0%
3/401
Outside my area of expertise - best if I don't vote
5%
23/401
12. If you choose Reverse Total Shoulder Arthroplasty (RSA) with a subscapularis repair, what would your immediate postoperative weight-bearing status be?
I would not choose RSA
1%
5/396
Non-weightbearing (NWB)
50%
199/396
Partial-weight bearing (< 5 lbs, PWB)
29%
117/396
Weight-bearing as tolerated (WBAT)
14%
56/396
Outside my area of expertise - best if I don't vote
4%
19/396
PROCEDURE #1 DOP: 7/2/2021

Right shoulder arthroscopic debridement with soft tissue and bone biopsies; 5 biopsies obtained from different locations, all negative for infection

PROCEDURE #2 DOP: 9/9/2021

Right Reverse Total Shoulder Arthroplasty; Wedged augment utilized to correct the superior inclination back to neutral

icon
OUTCOMES
Post-procedure P2
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