Review Question - QID 216837

The patient in question has a rotator cuff tear and subsequent superior escape of her prior shoulder hemiarthroplasty as evident on the plain radiograph.

The indications for shoulder hemiarthroplasty (HA) have narrowed over time, although HA may still be useful in the setting of proximal humerus fracture, humeral head osteonecrosis, and in rare cases for primary arthritis. Competency of the rotator cuff is important to ensure a successful outcome, as the HA implant relies on the compressive forces of the rotator cuff to maintain motion and strength. When the rotator cuff and the coracoacromial arch become deficient, the humeral head prosthesis can escape superiorly, leading to pain and a loss of strength and function. In these cases, conversion to reverse total shoulder arthroplasty (RTSA) may be indicated to manage the lack of rotator cuff integrity. There are varying degrees of humeral stem modularity that may make this conversion easier.

Leung et al. compared the outcomes of patients with rotator cuff arthropathy treated with HA and RTSA. They found long-term outcome scores were much better in the RTSA group, as was the range of motion in elevation. They concluded that while HA was previously used to treat cuff tear arthropathy, RTSA may now be a more appropriate choice as it performs better in improving pain and function.

Young et al. performed a matched-pair analysis of functional outcomes of RTSA and HA in the management of rotator cuff tear arthropathy. They note that after controlling for all variables, RTSA resulted in a better functional outcome than HA for this group of patients. They concluded that this data supports the recent trend of using RTSA rather than HA for this population.

Figure A demonstrates a right shoulder AP radiograph with a well-fixed hemiarthroplasty and superior escape of the implant, such that the prosthetic head is articulating with the acromion.

Incorrect Answers:
Answer 1: Conversion to anatomic total shoulder arthroplasty would not be the best answer choice, as this implant still relies on a functional rotator cuff to function appropriately. There would be no change in function with conversion to TSA.
Answer 3: Maintenance of the hemiarthroplasty implant and rotator cuff repair is not the most reliable method of treatment in this patient, as there would be a high likelihood of failure.
Answer 4: Revision HA would be less likely to provide an improved functional outcome and quality of life improvement compared to RTSA.
Answer 5: Physical therapy would not address the mechanical failure of the rotator cuff. While therapy may be able to improve her passive range of motion, it would not be the best option to improve her function and quality of life.