“In an older person with good glenoid bone a reverse is the best option for cuff tear arthropathy, ” states Lynn Crosby. Ed McFarland counters, “No. These patients need to suck it up and try nonoperative treatment first.”
This week’s Orthopaedic Crossfire® debate is “This Cuff Tear Arthropathy Is Best Treated Wjith a Reverse Shoulder.” For the proposition is Lynn A. Crosby, M.D. of the Medical College of Georgia; against the proposition is Edward G. McFarland, M.D. from The Johns Hopkins University. Moderating is Thomas S. Thornhill, M.D. from Harvard Medical School in Boston.
Dr. Crosby: “Cuff tear arthropathy is the arthritic eroded collapse of the glenohumeral joint, with superior migration of the humeral head after a massive rotator cuff (RC) tear. This was first described by Charles Neer and Ed Craig in 1972. The acromial humeral distance we get on a normal X-ray is 7-14 mm; if we look at the sagittal view on an MRI, the supraspinatous should fill that entire fossa. If the acromial humeral distance is decreased less than seven, but is five or less, the supraspinatous is usually retracted and the humeral head on a plain X-ray shows us that the acromial humeral distance is decreased. And in the sagittal MRI fatty atrophy is noted in the fossa.”
“If it goes on longer and the acromial humeral distance is less than 5mm on the plain X-ray, then this is a massive tear, including the infraspinatous. If you do get an MRI you’ll see that usually on the axial view the infraspinatous is usually retracted and gone. Coronal view: if you look at certain cases on an MRI you would say there is a massive tear that’s irreparable with the supraspinatous retracted up over the head…but the head is still located and the acromial humeral distance is still relatively normal. On the MRI, if the fatty atrophy has not decreased the muscle mass, and it’s at or below the line of the acromion corocoid line then this is still a repairable situation. But if it’s less than 5mm conservative care would be recommended, namely injections and deltoid rehab.”
“If that fails you can think about an arthroscopic debridement if they are male, the ROM [range of motion] is above 100 degrees, and they have good deltoid tone. But most of the time in these patients if they’ve failed that we discuss arthroplasty.”
“If we look at the old classification for these, this helps make the decision. We used to have Type 1A and Type 1B, and you could do a hemi. In Type 1A the head is still centered and there is still motion, and it’s using the whole undersurface of the acromion as the new joint. Type 1B is still centered, but the erosion has occurred more medially, but there’s still active elevation because they are still using this space to elevate off of.”
“If you just replace the head the patient will get some pain relief, but the wear is going to be in the same place and it will continue. If you just replace the head, it’s still rotating under the acromion and the superior aspect of the glenoid continues to wear. When this happens, and that fails and you have to reconstruct the hemiarthroplasty, you have less bone to deal with.”
“If you have to do a reconstruction with a reverse you may have to use augments because you want this inferior tilt. If you put a glenoid in an eroded superior glenoid your forces are superior and you’re going to get a shear force.”
“In the patient with Grade IV fatty infiltration who is 69, retired, a previous tennis player, has pain with or without activity, and he still has well preserved glenoid bone. In this case I think there is only one option…a reverse.”
Dr. McFarland: “There are many things short of a reverse, including non-operative treatment, arthroscopic debridement, cup arthroplasty, etc. It depends a lot on patient characteristics. This is a very heterogeneous group; many patients have full range of motion and fairly decent function. I tell my residents and fellows that these lesions are attached to a person, so what’s important are the demographics and the radiographs. How much arthritis is there? How much pain, loss of motion, and loss of function?”
“Other variables to consider in making a treatment plan are their age, whether it’s their dominant arm, other medical conditions, their activity level, and the surgeon’s expertise. I tell patients that come in with RC tears that have arthritis that this is not heart disease, and that they have time to make a decision. There is nothing in the literature indicating that a patient with cuff tear arthropathy is doomed to shoulder purgatory. There is no compelling reason in this patient to have surgery based on the information that we’ve been given.”
“So I begin with nonoperative treatment. If the patient wants to play sports and be active then the best thing is that he or she not have surgery. The goal of nonoperative treatment is to maintain ROM (these patients often have pain when they get stiff); we work hard to get them pain relief; we have them avoid lifting overhead and away from their body. They can use non-steroidals if there are no contraindications, chondroitin sulfate, cortisone dose packs, glenohumeral joint injections (sometimes helps, depending on the degree of arthritis), hyaluronic acid injections.”
“As for surgery, only about 80% of people get pain relief, and by five years most will have an arthroplasty. I tell patients, particularly the older ones, that it’s not going to buy them much time. Regarding the indications for tendon transfers, it should be a younger patient…but the results aren’t as predictable as we would like them to be. They are better for regaining external rotation as opposed to pain relief. But all you have to do is get an infected one and you will change your mind. I don’t do them anymore.”
“As far as humeral resurfacing, this is for a younger, active patient who is not ready for joint replacement. The resurfacing options are cup arthroplasty, cuff tear arthroscopy head, or hemiarthroplasty. The results are unpredictable. But for patients who want to stay active they are probably a better choice than a reverse. With humeral resurfacing of any type you want to put them in patients who are going to do sports where they’re not going to break things.”
“A great study by Lawrence et al. from Mayo found that the most common activities after a reverse total shoulder arthroplasty were cooking, baking, and driving. The most high demand things were snow shoveling, wheelbarrow use, and dirt shoveling. Maybe at Mayo—where I trained—that’s all you have to do up there. But you don’t want to put a reverse total shoulder arthroplasty in someone who wants to be at all athletic.”
“So the reservations about reverse now are that there are no results beyond 10 years and that the effect of notching is not known. Also, could it some day be the equivalent of metal on metal hip? Maybe 20 years from now if these things are all falling out—hopefully I will be retired—but there will be plenty of attorneys ready to take us on.”
“So if these patients do get a resurfacing it should be a procedure that is convertible to a reverse. Dr. Crosby needs to admit defeat.”
Moderator Thornhill: “Lynn, Ed says that he is going to do a conservative therapy and when that doesn’t work he’ll do a resurfacing that could be converted to a reverse. Your response?”
Dr. Crosby: “Those are all good options. It depends on what he wants. If he wants a procedure that’s going to give consistent pain relief, early results show that 10 years isn’t unreasonable if it is put in correctly and watched. Contrast this with a surface replacement or a hemiarthroplasty you’re probably going to get it converted at some point. Ed made a good point: if you use a system that is convertible that would be much easier and you wouldn’t have to remove the stem. But still, in a patient who is nearly 70, you’d probably do better with a reverse.”
Moderator Thornhill: “Ed, now they have these convertible implants. What are issues of converting a failed hemiarthroplasty with this stem?”
Dr. McFarland: “If you’re going to convert them, unfortunately every time you operate on the shoulder the results get a bit worse. One of the problems with converting a hemi to a total is that the subscapularis becomes dysfunctional in a large percentage of those patients. The reverse has allowed us to convert a hemi to a functional arthroplasty. In the past it was totally unpredictable in terms of results. It also deals with bone loss better than a conventional total shoulder. So revising these hemis to a reverse is not that big of an operation. In a patient who wants to stay active they can go with a hemi first. But as Lynn said the pain relief is still a bit unpredictable with hemis.”
Moderator Thornhill: “Lynn, what is it that makes a shoulder that’s a 1A or even a 1B progress? Some of them don’t necessarily progress to get out of the glenoid. Is there any predictability about this?”
Dr. Crosby: “I don’t think there’s any information on that, but activity level is important. Are they loading that area? Are they trying to use it with resistance over time? I think the more active individual that is lifting is likely to progress faster than someone who is sedentary.”
Dr. McFarland: “I think the thing that determines how much pain someone has is how they use their shoulder.”
Moderator Thornhill: “Ed, if your other shoulder is normal are you less likely to proceed with a more aggressive procedure?”
Dr. McFarland: “We see a lot of patients with bilateral disease, and it’s not uncommon to replace one of them and have them able to just tolerate the other one. We have a conversation with them as far as what their priorities are. The only time I’ve had to worry about dominance or non dominance is with patients who have had strokes or those who are very dependent on their arms for gait (such as patients with wheelchairs). Most of the time we address the one that hurts the most and go from there.”
Moderator Thornhill: “Lynn, what about the CTAs…the implants that will hinge off the subacromial area?”
Dr. Crosby: “We toyed with a lot of different options before the reverse was allowed back into the U.S. For me the procedure that worked the best was Buz Burkhead’s Achilles tendon allograft. Patients were satisfied, their activity level was high…and I think the reason that worked so well was that you took the pressure off the bone superiorly. So if I still had to use a procedure I would use a hemiarthroplasty with an Achilles tendon allograft. As far as the hooded ones, the reason those were semi-successful is that they didn’t catch as they rotated.”
Moderator Thornhill: “Thank you both.”
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