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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
 
 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  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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Questions (10)
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(OBQ12.19) Following open pectoralis major transfer to address chronic subscapularis insufficiency, which of the following movements would most likely show weakness if an iatrogenic nerve injury occurred during the pectoralis transfer? Review Topic

QID: 4379
1

Elbow flexion

62%

(2693/4353)

2

Elbow extension

2%

(74/4353)

3

Shoulder external rotation

4%

(180/4353)

4

Shoulder adduction

13%

(579/4353)

5

Shoulder abduction

18%

(790/4353)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ05.78) A 75-year-old retired carpenter has had 2 years of increasing left shoulder pain and intermittent swelling of the left shoulder as shown in Figure A. He is right-hand dominant and an avid bowler. He denies constitutional symptoms. Physical examination reveals 80 degrees of active forward flexion and 170 degrees of passive range of motion. Palpation of the left shoulder reveals subcutaneous fluid with no distinct mass. A radiograph is shown in Figure B. What is the next most appropriate step in management? Review Topic

QID: 964
FIGURES:
1

Biopsy and referral to orthopaedic oncologist

4%

(29/748)

2

Reverse total shoulder arthroplasty

74%

(550/748)

3

Arthrocentesis of the shoulder with aspirate submitted for cell count and differential

15%

(114/748)

4

Conventional unconstrained total shoulder arthroplasty

6%

(47/748)

5

Cervical spine MRI to evaluate for the presence of a syrinx

1%

(7/748)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ04.36) A 75-year-old, right-hand-dominant female has a chronic rotator cuff tear and shoulder pain for 10 years which has failed conservative treatment. A radiograph is shown in Figure A. Your examination and further imaging will help you to decide between which of the following pairs of surgical options for this patient? Review Topic

QID: 97
FIGURES:
1

hemiarthroplasty or total shoulder arthroplasty

2%

(28/1677)

2

reverse total shoulder or total shoulder arthroplasty

34%

(567/1677)

3

hemiarthroplasty or reverse total shoulder arthroplasty

63%

(1064/1677)

4

total shoulder arthroplasty or glenohumeral arthrodesis

1%

(11/1677)

5

total shoulder arthroplasty or scapulothoracic arthrodesis

0%

(0/1677)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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