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Updated: Jul 19 2023

Rotator Cuff Arthropathy

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  • summary
    • Rotator cuff arthropathy is a specific pattern of shoulder degenerative joint disease that results from a rotator cuff tear leading to abnormal glenohumeral wear and subsequent superior migration of the humeral head.
    • Diagnosis can be made primarily with shoulder radiographs showing glenohumeral arthritis with a decreased acromiohumeral interval.
    • Treatment for minimally symptomatic patients involves activity modification, subacromial steroid injections, and physical therapy. Shoulder arthroplasty (most commonly reverse total shoulder arthroplasty) is indicated for patients with progressive pain and deterioration of shoulder function. 
  • Epidemiology
    • Demographics
      • females > males
      • 7th decade most common
    • Anatomic location
      • more common in dominant shoulder
    • Risk factors
      • rotator cuff tear
      • rheumatoid arthritis
      • crystalline-induced arthropathy
      • hemorrhagic shoulder (hemophiliacs and elderly on anticoagulants)
  • Etiology
    • 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
    • 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
  • 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
      • Hamada Classification of Rotator Cuff Arthropathy
      • Grade 1
      • Acromiohumeral interval ≥ 6mm
      • Grade 2
      • Acromiohumeral interval≤ 5mm
      • Grade 3
      • Acromiohumeral interval ≤ 5mm, with acetabularization of acromion
      • Grade 4
      • 4A: Glenohumeral arthritis without acetabularization, AHI < 7mm
      • 4B: Glenohumeral arthritis with acetabularization, AHI ≤ 5mm
      • Grade 5
      • Humeral head collapse
  • 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
        • 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
          • 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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