REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY

Reverse Shoulder Arthroplasty for Rotator cuff arthropathy

J. Mohan Kumar¹, Vijay Kulkarni², Chandrakanth³

Senior Consultant Orthopaedics and Shoulder Specialist, Kauvery Hospital, Electronic City, Bangalore

Consultant Orthopaedician, Kauvery Hospital, Electronic City, Bangalore

Abstract

Reverse shoulder arthroplasty (RSA) is increasingly gaining popularity worldwide in treating various traumatic and degenerative disorders of shoulder joint. Reverse shoulder arthroplasty (RSA) for cuff tear arthropathy improves shoulder function and reduces pain. Implant position and soft tissue balancing are important factors to optimize outcome. The anatomical shoulder arthroplasty consists of a concave glenoid socket and proximal humeral ball prosthesis. While in the reverse shoulder arthroplasty, the anatomy is reversed to a glenoid ball (glenosphere) and concave proximal humerus component. We present a case of rotator cuff arthropathy treated with reverse shoulder arthroplasty.

Keywords:

RSA (Reverse shoulder Arthroplasty), Rotator cuff arthropathy

Background

Glenohumeral (shoulder) joint is a synovial multiaxial ball and socket articulation between the humeral head and the bony glenoid that permits a wide range of motion (Fig. 1).

[1]

Glenohumeral stability is achieved by dynamic and static stabilizers.

Fig. 1.

Shoulder joint anatomy.

The rotator cuff muscles are subscapularis muscle, supraspinatus muscle, infraspinatus, and teres minor muscles (Fig. 2). The dynamic Glenohumeral stabilizers function to keep the humeral head in a central position in the glenoid fossa during the shoulder movements. Rotator cuff arthropathy term was coined by Neer, defined as a massive rotator cuff tear with superior migration and diminished acromiohumeral distance with erosion of the tuberosities (‘femoralization’) of the proximal humerus and other arthritic changes in the glenohumeral joint [2]. In the RSA, the shoulder center of rotation is displaced inferiorly and medially. This modification in the center of rotation allows the deltoid muscle to work on a longer lever arm. This mechanical advantage allows more deltoid muscle fibers to act on shoulder abduction. Also, the downward humerus displacement increases the deltoid muscle tension.[3] The RSA transforms the shear forces around the shoulder into compressive forces creating a rotational moment that allows the deltoid muscle to start arm abduction.[4]

Fig. 2.

Rotator cuff muscles.

RSA is gaining popularity around the world to treat different shoulder pathological conditions in adult populations. RTSA is mainly used to treat patients who suffer from deficient rotator cuff function with or without glenohumeral arthritis.

Case Details

A 70-years-aged female presented to our clinic with pain and disability of right shoulder for 3 years. She was treated at various centers conservatively with no relief of symptoms. Clinical examination revealed restricted range of movements and very painful shoulder joint. Radiographs revealed proximal migration of humeral head <5 mm with early arthritis of shoulder (Hamada stage 4) (Figs. 3 and 4). MRI showed massive retracted rotator cuff tear with muscle atrophy (Goutallier stage 3) (Figs. 5 and 6). Given the age of the patient , clinical and radiological findings it was decided to perform a reverse shoulder arthroplasty. Using a Arthrex Universe reverse shoulder system, reverse shoulder arthroplasty was performed (Fig. 7). Post operative period was uneventful. Rehabilitation was started from day one and patient recovered well. Pain was relieved of pain and functional range of movements achieved.

Fig. 3

Pre operative radiograph.

Fig. 4.

Hamada classification of Cuff arthropathy.

Fig. 5

MRI showing Cuff muscle atrophy.

Fig. 6.

Goutallier classification of Cuff atrophy

Fig. 7.

Post Operative radiograph.

Discussion

The reverse total shoulder arthroplasty was introduced to treat the rotator cuff-deficient shoulder. Since its introduction, an improved understanding of the biomechanics of rotator cuff deficiency and reverse shoulder arthroplasty has facilitated the development of modern reverse arthroplasty designs.

The RSA effectively relieves symptoms and restores function for patients with irreparable rotator cuff tears [

,6]. Although the RSA has improved treatment options for various problems associated with the rotator cuff, its use is not without problems. Complication rates have been reported from 10% to 47% [6] and the dislocation rate is reportedly 0% to 9% [6]. The dislocation rate is nearly doubled in patients without a subscapularis tendon. Scapular notching can be frequent with RSA, although in most instances it does not appear to cause any clinical problems and at least one series has reported no incidence of notching at two years after surgery [6]. For these reasons surgeons should remain cognizant of limitations and potential problems of the RSA prior to recommending its use.

Conclusion

Reverse shoulder arthroplasty has revolutionized treatment of the rotator cuff deficient shoulder, but its use must be for the appropriate patient. Complication rates are high and potentially devastating for the patient. Even seemingly trivial complications such as a dislocation can ultimately lead to a resection arthroplasty. With proper patient selection however, the function can be excellent and life changing for the patient.

References

Chang LR, Anand P, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2022. Anatomy, Shoulder and Upper Limb, Glenohumeral Joint.
Neer CS, 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am. 1983;65:1232-1244.
Grammont PM, Baulot E. The classic: Delta shoulder prosthesis for rotator cuff rupture. 1993. Clin Orthop Relat Res. 2011;469(9):2424.
Cheung E, et al. Complications in reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2011;19(7):439-49.
Boileau P, et al. Neer Award 2005: The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527-540.
Cuff D, et al. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am. 2008;90:1244-1251.

Dr. J. Mohan Kumar

Senior Consultant – Orthopaedic

Dr. Vijay A Kulkarni

Consultant – Orthopaedics

Dr. Chandrakanth

Junior Consultant – Orthopaedics

REVERSE SHOULDER ARTHROPLASTY FOR ROTATOR CUFF ARTHROPATHY