Review Question - QID 219996

An elderly patient with radiographic evidence of glenohumeral arthritis and clinical exam findings suggestive of a rotator cuff tear should be managed operatively with reverse total shoulder arthroplasty (RTSA). A contraindication to performing this surgical procedure is global deltoid deficiency (Answer 3).

In the setting of a rotator cuff tear and glenohumeral arthritis, RTSA offers the advantage of altering the center of rotation of the shoulder in an inferior and medialized direction. This allows the deltoid muscle to act on a longer fulcrum providing a greater mechanical advantage to substitute for the deficient rotator cuff musculature and enhance shoulder abduction. Since the deltoid muscle is the primary mover of the shoulder joint in RTSA, global deltoid deficiency or permanent axillary nerve pathology is a contraindication to RTSA. Other contraindications include acromion deficiency, glenoid osteoporosis, and active infection.

Khazzam et al. provided The Management of Glenohumeral Joint Osteoarthritis Evidence-Based Clinical Practice Guideline summary. This guideline provides 13 evidence-based recommendations for treating glenohumeral osteoarthritis, excluding other etiologies such as rheumatoid or posttraumatic arthritis. Developed through a systematic review, the guideline aims to assist trained healthcare professionals in optimizing patient care. It emphasizes the need for improved research on total shoulder arthroplasty implant survivorship, the efficacy of nonsurgical treatments, advanced imaging modalities, and comparative outcomes of reverse versus anatomic shoulder arthroplasty in complex cases.

Jo et al. reviewed the implementation of RTSA in the setting of glenohumeral arthritis. The authors aim to detail the expanding role of RTSA in managing glenohumeral osteoarthritis, its theoretical foundations, and supporting literature. The authors note that anatomic total shoulder arthroplasty (TSA) has long been effective in treating glenohumeral osteoarthritis, offering excellent pain relief and functional outcomes. RTSA, initially developed for rotator cuff tear arthropathy, has demonstrated comparable outcomes to TSA even in cases with intact rotator cuffs. The authors conclude that RTSA is an effective surgical modality for glenohumeral arthritis and indications have broadened to include proximal humerus tumors, hemiarthroplasty revisions, and failed TSA revisions.

Figure A is an AP radiograph showing a left proximal humerus fracture. Figure B is a Grashey view radiograph also showing a left proximal humerus fracture.

Incorrect Answers:
Answer 1: Inflammatory arthropathies such as rheumatoid arthritis are not a contraindication to RTSA if glenoid bone stock is preserved.
Answer 2: Pseudoparalysis occurs secondary to irreparable rotator cuff tears in the setting of glenohumeral arthritis and is an indication for RTSA.
Answer 4: An incompetent coracoacromial arch can lead to the development of anterosuperior escape and is an indication for RTSA.
Answer 5: Advanced physiologic age (>70) is not a contraindication for RTSA.