Cuff arthropathy – indication for reverse total shoulder arthroplasty

Authors: F Gohlke

References: SECEC, Rome 205

Constrained and reverse arthroplasty was tried from the early 70s for many indications with high rate of loosening and mechanical complications (Copeland 1978, Wretenberg et al. 1987).  Paul Grammont reported first his experience with the “Delta shoulder prosthesis” (Grammont and Baulot 1993) which was used mostly in cases with cuff tear arthropathy.  Within the last 5 years the number of cases operated on increased gradually in Europe.
The main indication for the reverse endoprosthesis is still the painful, pseudoparetic shoulder in elderly patients with rotator cuff insufficiency of different aetiology.  The highest percentage includes osteoarthritis caused by massive, irreparable rotator cuff tears, widely described as “cuff tear arthropathy”.  However, this disability can be the result of different entities: proximal humerus fractures, rheumatoid arthritis and, neurogenic disorders.
The value of reverse arthroplasty is proven for cuff arthropathy.  For all other indications it remains unclear, because limited experience is available.  With the exception of cuff tear arthropathy the number of cases published in literature is still small and the follow-up time short.

Reverse shoulder arthroplasty in cuff tear arthropathy seems to be a safe procedure, which provides good clinical results in the mid- to long-term follow-up (De Buttet et al. 1997, Valenti et al. 2001, Sirveaux et al. 2001, Werner et al. 2005).  Especially in case of type E-2 glenoid wear (Classification acc. Huguet et al. 2001) prospective studies (Favard et al. 2001) have demonstrated in the midterm follow up significant better results than hemiarthroplasty, especially the fixed fulcrum and the shift of the rotation centre towards the medial and inferior which provides an improved preload of the deltoid muscle.  The functional results reported in literature (age related CS between 76-94%) depend on the preoperative diagnosis.  The complication rate has proven to be comparable to hemiarthroplasty and varies between 5-33% depending on the percentage of revision cases.
The success of reverse TSR depends less on the status of the Subscapularis and teres minor muscle, the latter important for a gain in active external rotation.  Internal rotation is mostly reduced.  Special problems may occur in the long-term follow up regarding progressive glenoid loosening due to the so called “inferior notching” (classification acc. to Nerot), which is supposed to be a result of an impingement at the inferior glenoid rim followed by increased polyethylene wear and progressive Osteolysis.
When wear of the coracoacromial arch or a mobile os acromiale is present inferior displacement of the fragments or a fatigue fracture of the acromion can be occur, which can be prevented by primarily bone grafting (using the resected humeral head) and a cerclage.
Successful revision after failed delta-flap reconstruction is described and may work in case of less extensive muscle damage.

Osteoarthritis and irreversible cuff dysfunction after proximal humerus fracture (pseudoarthrosis, loss or dislocation of the tuberosities).  Many centres actually use reverse arthroplasty in case of type 3 and 4 fracture sequela (classification acc. to Boileau) because the results of hemiarthroplasty have proven to be less favourable and not predictable. 
The functional results of reverse arthroplasty seem to be acceptable but less excellent than cases with cuff tear arthropathy.  The higher percentage of stiffness, instability and loss of active external rotation and elevation may be due to scarring and lesions of the deltoid muscle. 
Cuff tear arthropathy in rheumatoid arthritis.  In rheumatoid patients at the late stage of the disease often-severe osteoporosis and loss of bone stock of the glenoid limits the use of reverse arthroplasty.  Bone grafting may be necessary and the risk of instability especially in case of excessive wear of the glenoid and medialization of the rotational centre high.  Nevertheless Rittmeister & Kerschbaumer (2001) have shown in a small series of patients with irreparable cuff tears acceptable results.  Later on Woodruff et al. reported in the long-term follow-up a high rate of progressive radiolucencies and moderate gain of function with a CS of 59.
In some cases with excessive wear of the glenoid hemi or bipolar arthroplasty may be less hazardous than reverse arthroplasty.  In young patients (less than 50 years) reverse arthroplasty should be avoided.  In young patients with early onset of rheumatoid destruction cup resurfacement may be the preferable way providing further options.
Chronic, unreduced dislocation and irreparable massive cuff tears.  Especially in old anterior dislocations of more than 3 months standard hemiarthroplasty cannot ensure predictable clinical results.  Reverse endoprothesis may be considered, however, failure with early loosening or instability may occur. 
Cuff arthropathy in neurological disorders.  Complete palsy of the brachial plexus or axillary nerve should be regarded as contraindication.  The benefit in other neurological diseases like syringomyelia or muscle atrophy is not documented.  The author has successfully used reverse arthroplasty in rare case of spontaneous antero-superior dislocation and fatigue fracture of the scapular spina in severe Parkinson’s disease but the midterm follow-up shows early progressive inferior notching and Osteolysis.
Rotator cuff insufficiency after deep infection.  In case of osteoarthritis following deep shoulder infection and joint destruction with irreparable cuff tears the author has successfully used reverse arthroplasty as a second stage procedure after implantation of an anatomic spacer loaded with antibiotics.  In literature little is reported about the benefit of this procedure.

Reverse shoulder arthroplasty can be advocated for elderly patients with pseudoparectic painful shoulders, because it provides superior functional results compared to standard shoulder arthroplasty in the mid-term follow-up.  At present it gets proven for cases with osteoarthritis and rotator cuff insufficiency of different aetiology.
Caution is appropriate in case of:
- Gross destruction of the glenoid or severe osteoporosis
- Severe damage of deltoid muscle (more than 30%), asymmetric muscle defects and stiff, unbalanced shoulders
- Younger patients (less than 60 years)

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