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Arthroplasty for Cuff Arthropathy

Definition

  • Advanced G-H & A-C arthritis with complete cuff tear
  • Called Milwaukee Shoulder in 1981 (associated with HA deposition disease) then
  • Cuff Tear Arthropathy in 1983

Pathophysiology

  • Glenohumeral instability leads to advanced arthritis after cuff integrity lost
  • Rotator cuff prevents deltoid from elevating the head through compressive action
  • With Rotator Cuff loss, there is Progressive narrowing of the subacromial space with humeral head ascent
  • Coracoacromial arch is the secondary static stabiliser to humeral head migration

Pathogenesis

  • Initially loss of the cuff integrity through degeneration is tolerated
  • However as the superior forces exceed the medially directed forces the abrasive wear of cuff on acromion leads to buttonholing of head through the cuff
  • Articular surface of humerus abraded on undersurface of the acromion
  • The superiorly subluxed head has point contact on the superior glenoid
  • Particulate debris fills the joint with synovitis & effusion
  • subcutaneous fluid particularly superior to the AC joint
  • presence of cuff tear does not always indicate arthropathy if the force couples balanced across the humeral head

History

  • Unrelenting pain with referral to mid arm
  • Sharp pain with crepitus in overhead activities
  • Night pain significant

Examination

  • Effusion & SS / Deltoid atrophy common
  • Pain & crepitus with movement & loss of external rotation classical

Investigations

  • Xray
    • Osteopenia
    • Superior humeral head migration
    • Narrowing of AC interval
    • Severe erosions of the AC joint
    • Subchondral sclerosis
    • Cyst formation
    • Osteophytes
    • Loss of tuberosity prominence
    • “ Acetabularisation of glenoid “ & “ Femoralisation “ of the humeral head

Operative Treatment

Arthroplasty

Indications

  • Pain unresponsive to nonoperative care
  • Grade 4 deltoid power
  • The coracoacromial arch should be intact

Contraindications

  • Weakened or absent anterior deltoid
  • Active or suspected sepsis

Hemiarthroplasty with large head

  • Pollock compared TSR & Hemi in cuff arthropathy & found pain relief better with hemiarthroplasty
  • When the deltoid adequate & coacoacromial arch intact then procedure of choice
  • Use large head to limit migration & allow articulation with the coracoacromial arch

Total Shoulder Arthroplasty

  • Glenoid component loosening
    • high incidence of lucent lines
    • superior migration of head lead to eccentric forces at the glenoid margin & loosening
    • “Rocking-Horse“ Phenomena

Reverse Total Shoulder Replacement

  • good short term results
  • concerns regarding longevity
  • increasing popularity