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The Journal of Bone and Joint Surgery 81:1312-24 (1999)
© 1999 The Journal of Bone and Joint Surgery, Inc.

Current Concepts Review

Current Concepts Review - Rotator Cuff Tear Arthropathy*

KIRK L. JENSEN, M.D.{dagger}, OAKLAND, CALIFORNIA, GERALD R. WILLIAMS, JR., M.D.{ddagger}, PHILADELPHIA, PENNSYLVANIA, I. J. RUSSELL, M.D.§ and CHARLES A. ROCKWOOD, JR., M.D.§, SAN ANTONIO, TEXAS


   Introduction
Top
 Introduction
Historical Review
 Etiology
 Diagnosis
 Treatment
 Overview
 References
 
The association between massive tears of rotator cuff tendons and severe glenohumeral degenerative arthritis is complex and poorly understood. The theories that have been proposed to account for rotator cuff tear arthropathy of the shoulder joint include severe, localized rheumatoid arthritis1,2; hemorrhagic arthritis27; microcrystalline-induced arthritis67; and arthritis due to chronic attrition, leading to a massive tear of the rotator cuff tendons19,75. The confusion concerning the etiology of rotator cuff tear arthropathy is in part due to the fact that different authors have described its clinical characteristics in general terms and have given it various names, such as l'arthropathie destructrice rapide de l'épaule58, apatite-associated destructive arthritis30, Milwaukee shoulder40,45,67, and cuff tear arthropathy75.


   Historical Review
Top
 Introduction
 Historical Review
Etiology
 Diagnosis
 Treatment
 Overview
 References
 
Adams1,2 and Smith90,91 provided the earliest description of the pathoanatomical features of rotator cuff tear arthropathy, in the nineteenth century. Adams, who was the Regius Professor of Surgery at the University of Dublin, described two types of chronic rheumatoid arthritis: a generalized form resembling rheumatoid arthritis and a localized form involving the shoulder, which had the morphological characteristics of what is now known as rotator cuff tear arthropathy2. In his 1934 monograph, Codman19 reported the case of a fifty-one-year-old woman who had what he termed a subacromial space hygroma. He described recurrent swelling of the shoulder, absence of the rotator cuff, cartilaginous bodies attached to the synovial tissue, and severe destructive glenohumeral arthritis. These clinical descriptions of the entity now known as rotator cuff tear arthropathy were made without the benefit of modern diagnostic tests, such as serological analysis or synovial crystal analysis.

L'épaule sénile hémorragique (the hemorrhagic shoulder of the elderly) was described by DeSeze27 in 1968. This clinical entity, which was seen in three elderly women who did not have a history of trauma, consisted of recurrent, blood-streaked effusions of the shoulder and radiographic findings of severe degenerative glenohumeral arthritis and a chronic tear of the rotator cuff. DeSeze also cited previous reports in the literature by Galmiche and Deshayes39, Burman et al.12, Banna and Hume6, Shepard89, and Snook92, which documented a total of thirty cases of spontaneous hemarthrosis of the glenohumeral joint in elderly patients.

Apart from a single case report by Bauduin and Famaey7 in 1969, the hemorrhagic shoulder of the elderly was not mentioned again in the literature until 197756. The report published at that time described nine elderly women who had painful spontaneous effusions of the glenohumeral joint and identified an association between rotator cuff tear arthropathy and arthritis of the knee joint.

The term Milwaukee shoulder was introduced in 1981 to describe the condition in four elderly women who had recurrent bilateral shoulder effusions, severe radiographic destructive changes of the glenohumeral joints, and massive tears of the rotator cuff40,45,67. In 1982, spontaneous large glenohumeral effusions, mild pain, and tears of the rotator cuff were reported in six elderly women, and the condition was described as l'arthropathie destructrice rapide de l'épaule (rapid destructive arthritis of the shoulder)58. Neer et al.75 introduced the term cuff tear arthropathy to describe glenohumeral degenerative arthritis and a rotator cuff tear in twenty-six patients who had a total shoulder replacement. Two other terms, apatite-associated destructive arthritis and idiopathic destructive arthritis14, were introduced by Dieppe et al.30 in 1984 to describe rotator cuff tear arthropathy of the shoulder.


   Etiology
Top
 Introduction
 Historical Review
 Etiology
Diagnosis
 Treatment
 Overview
 References
 

Crystalline-Induced Arthritis of the Shoulder
An association between rotator cuff tear arthropathy and the intra-articular presence of basic calcium-phosphate crystals was identified in 198140,45,67. These three reports on the Milwaukee shoulder included clinical aspects and studies of synovial fluid as well as morphological and biochemical studies of excised synovial tissue from four patients, three of whom had bilateral disease. McCarty et al.67 identified collagenolytic and neutral protease activity in synovial fluid with use of assays measuring the release of soluble enzymatic products. Electron microscopic analysis of synovial tissue from the glenohumeral joints of patients who had rotator cuff tear arthropathy revealed microspheroids of basic calcium-phosphate crystals, suggesting phagocytosis of these crystals by cells in the synovial tissue (Fig. 1). Histological study revealed foci of calcific deposits in synovial microvilli and the subsynovial layers.



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  		Fig. 1 Transmission electron photomicrograph showing basic calcium-phosphate crystals (black material) in the synovial tissue (x 26,000).

 
The theory that has been proposed to explain the Milwaukee shoulder begins with the concept that a hydroxyapatite-mineral phase develops in the altered capsule, synovial tissue, or degenerative articular cartilage and releases basic calcium-phosphate crystals into the synovial fluid. These crystals then are phagocytized by synovial cells, forming calcium-phosphate-crystal microspheroids, which induce the release of activated enzymes from these cells, causing destruction of the periarticular tissues and articular surfaces.

Basic calcium-phosphate crystal is a generic term used to identify a crystal that is composed of carbonate-substituted hydroxyapatite, octacalcium phosphate, or, more rarely, tricalcium phosphate68. These crystals are not birefringent; thus, polarized light microscopy is not useful for identification. Furthermore, the resolution power of light microscopy is inadequate to detect the individual crystals, which are needle-shaped and less than 0.1 millimicrometer long. Both scanning and transmission electron microscopy with energy-dispersive x-ray microanalysis have been used to identify basic calcium-phosphate crystals in synovial fluid pellets. Unfortunately, there is no simple, cost-effective, readily available method to detect basic calcium-phosphate crystals that is comparable with the use of polarized light microscopy for the detection of calcium-pyrophosphate-dihydrate and monosodium-urate-6monohydrate crystals.

Aggregates of basic calcium-phosphate crystals have been found in the synovial fluid of joints undergoing acute attacks of mixed crystal deposition disease28, calcific periarthritis, or acute arthritis. These aggregates also have been identified in the synovial fluid of patients who have erosive polyarticular disease88, osteoarthritis of the knee7,42,48, and rotator cuff tear arthropathy46. The response of synovial tissue to calcium-containing crystals, such as basic calcium-phosphate and calcium-pyrophosphate-dihydrate crystals, is low-grade inflammation with cellular proliferation. The cellular hyperplasia observed in the synovial tissue of patients who have rotator cuff tear arthropathy may be explained by the mitogenic properties of basic calcium-phosphate crystals, which have been shown to stimulate proliferation of human foreskin fibroblasts63,64.

Synovial fibroblasts and chondrocytes, in response to certain growth factors, cytokines, and other chemical agents, synthesize the enzymes collagenase and stromelysin. Collagenase is a proteolytic enzyme that degrades interstitial collagen. Stromelysin, a metalloprotease, degrades connective-tissue components and activates procollagenase. As already noted, McCarty et al.67, in 1981, initially identified collagenase activity in synovial fluid from patients who had rotator cuff tear arthropathy. However, this finding was not confirmed in subsequent reports31,47,50,100. Halverson et al.50 suggested that this inconsistency may have been due to the presence of a low-molecular-weight inhibitor of collagenase31, the avid binding of collagenase to collagen63, or an artifact resulting from poor handling of specimens in preparation for the enzyme assays.

Recent investigations have focused on identifying the induction of collagenase or stromelysin gene transcription by basic calcium-phosphate crystals to elucidate the loss of collagenous structures in patients who have rotator cuff tear arthropathy. Basic calcium-phosphate crystals were found to stimulate the proliferation of cultured adult porcine articular chondrocytes and to increase collagenase messenger RNA in a dose-responsive manner72. Human fibroblasts have been induced by basic calcium-phosphate crystals to accumulate collagenase as well as stromelysin mRNA and to secrete collagenase, stromelysin63,64, and ninety-two-kilodalton gelatinase66. It appears that basic calcium-phosphate crystals induce the synthesis of proteolytic enzymes that are responsible for the degradation of cartilage-matrix components16.

The aggregates of hydroxyapatite crystals that have been observed throughout articular cartilage53, but most commonly in the mid-zone41, also may directly cause mechanical wear of cartilage. Using knee joints obtained from cadavera, Clift et al.18 found that a higher deposition of basic calcium-phosphate crystals and an increase in the mean friction coefficient occurred in conjunction with severe fibrillation of articular cartilage. An in vitro investigation also suggested that crystals in synovial fluid have the potential to cause wear of articular cartilage52. As the presence of crystals increased, the concentration of wear debris and the size and shape of the crystals influenced the type of articular damage that was observed. The large crystal aggregates, which frequently are found in the mid-zone of articular cartilage, were studied with use of a linear elastic finite element model under short-term loading conditions18. The results indicated that these aggregates increase the shear stress and strain concentrations in the surrounding cartilage.

The exact origin of basic calcium-phosphate crystals remains unclear, and whether these crystals are the cause or the result of arthritis remains unanswered. It has been suggested that basic calcium-phosphate crystals are an epiphenomenon resulting from biochemical changes in the matrix of damaged cartilage and that the crystals then are shed into the synovial fluid49. Periarthropathies such as calcific rotator tendinitis or degenerative tears of the rotator tendon are conditions in which basic calcium-phosphate crystals are known to form95. Additional investigation is needed to fully elucidate the origin of the basic calcium-phosphate crystals and the effect that they elicit in individuals who have degenerative disease of the shoulder.

Cuff Tear Theory
In 1934, Codman19 described a condition in which a chronic tear of the rotator cuff may result in a hygroma of the shoulder and destruction of the glenohumeral joint. He attributed the pathological changes of rotator cuff arthropathy to neglect of the ruptured rotator cuff, as retraction of the torn rotator muscles left the humeral head freely exposed under the deltoid, resulting in chronic synovitis and effusion of the bursa or joint.

In 1983, Neer et al.75 postulated that certain chronic, massive tears would lead to a degenerated glenohumeral joint if left untreated. The mechanism of destruction of the articular cartilage was said to include mechanical and nutritional alterations in the shoulder with a rotator cuff tear. The mechanical factors that were mentioned included anteroposterior instability of the humeral head, resulting from a massive tear of the rotator cuff, and rupture or dislocation of the long head of the biceps, leading to proximal migration of the humeral head and acromial impingement. Glenohumeral articular wear was thought to occur as a result of repetitive trauma from the altered biomechanics associated with the loss of primary and secondary stabilizers of the glenohumeral joint. The nutritional status of the articular cartilage in a shoulder with a torn rotator cuff would be altered by the loss of a closed joint space and of normal glenohumeral motion. Changes in the composition of the articular cartilage then would occur because of inadequate diffusion of nutrients as the loss of a watertight joint space diminished the quantity of synovial fluid. In addition, disuse osteoporosis of the proximal part of the humerus would decrease the density of the subchondral bone in the humeral head and contribute to atrophy of the articular cartilage. Degenerative arthritis and subchondral collapse eventually would develop as a result of these changes in the articular cartilage.

This theory was based on the clinical observations and the intraoperative findings during arthroplasty in twenty-six shoulders75. Histological studies revealed three consistent findings: areas in the humeral head where the articular cartilage was atrophic and the subchondral bone was osteoporotic, fixed point contact between the glenoid and the humerus where the articular cartilage was denuded and the subchondral bone was sclerotic, and fragments of articular cartilage in the subsynovial layers. Normal chemical profiles of synovial fluid were obtained from twelve of the twenty-six shoulders; no other analysis of the synovial fluid, synovial tissue, or joint capsule was performed.

It is impossible to estimate accurately the number of shoulders with a rotator cuff tear that proceed to rotator cuff tear arthropathy, as several studies of cadavera have documented the age-related prevalence of rotator cuff tears21,26,43,69. Those studies did not show a relationship between the presence or size of the rotator cuff tear and symptoms or the prevalence of associated glenohumeral arthritis. Neer et al.75 estimated, on the basis of Neer's observation of approximately fifty-two cases of cuff tear arthropathy in the eight-year period of the study, that cuff tear arthropathy would develop in only 4 percent of patients who have a complete tear of the rotator cuff and suggested that, because of their small size, most tears of the cuff do not lead to arthropathy.

Several authors have performed longitudinal follow-up studies of patients who had a massive rotator cuff tear, with different results8,51,98. Hamada et al.51 reported the long-term radiographic results of nonoperative treatment of twenty-two patients with arthrographically proved massive rotator cuff tears. In five of the seven shoulders that were followed for more than eight years, degenerative changes had progressed radiographically. Those authors concluded that a massive tear of the cuff would progress to cuff tear arthropathy with progressive radiographic changes. In 1993, Bokor et al.8 reported that the functional results of nonoperative treatment of arthrographically proved rotator cuff tears did not deteriorate after an average follow-up period of seven to eight years. However, objective data, such as the size of the tear and the radiographic appearance of the shoulder, were not included, and only one patient later had symptoms of rotator cuff tear arthropathy.

Arthroscopic subacromial decompression without débridement of the tendon also has been performed for the treatment of full-thickness rotator cuff tears9,32-34,60; however, reports on that procedure have described only short-term results and have lacked radiographic follow-up. In a retrospective study of twenty-five patients who had had arthroscopic acromioplasty and débridement of a tear of the rotator cuff with six to nine years of follow-up, seven patients had clinical and radiographic features of rotator cuff tear arthropathy70. The tears in that series were classified according to size, and the integrity of the subscapularis tendon was not specifically reported.

Open4,85 and arthroscopic9,32-34,60,71 débridement of massive tears of the rotator cuff combined with acromioplasty has been reported in patients who did not have glenohumeral arthritis. Those studies provided more objective data regarding the size of the tear and the clinical outcome. Apoil and Augereau4 reported that rotator cuff tear arthropathy developed in more than one-fourth of fifty-six patients ten years after open débridement of a degenerative lesion of the rotator cuff. Rockwood et al.85 reported that none of fifty-three shoulders that had a chronic, massive, irreparable tear of the supraspinatus and infraspinatus tendons had progressive deterioration of the glenohumeral joint after open acromioplasty and débridement of the rotator cuff. That series was followed for an average of six and one-half years, and shoulders followed for less than five years were compared with those followed for at least five years. Neither deterioration in the functional results nor the appearance of radiographic degenerative changes could be associated with time. Twenty shoulders had superior migration of the humeral head, defined as an acromiohumeral distance of seven millimeters or less. The subscapularis and teres minor tendons were intact in all of these patients. Preoperatively and postoperatively, patients were started on a specific orthopaedic-surgeon-directed rehabilitation program. After passive range of motion was restored, the patients were instructed in a program for strengthening of the remaining rotator cuff muscles, the deltoid muscle, and the scapular stabilizing muscles. Even though the supraspinatus and the infraspinatus were absent, the compressive effect of the subscapularis, teres minor, and scapular stabilizing muscles allowed active use of the shoulder. The active forward elevation of the shoulder improved from an average of 105 degrees preoperatively to an average of 140 degrees postoperatively. The result, based on relief of pain, function, range of motion, strength, and patient satisfaction, was satisfactory in forty-four (83 percent) of the fifty-three patients and unsatisfactory in the remaining nine (17 percent)85.

The effect of a tear of the rotator cuff on the biomechanics of the shoulder has been investigated in radiographic and biomechanical studies. Inman et al.54 used the concept of force couples to develop a theoretical model that determined the force requirements necessary for function of the shoulder joint. The force couple in the coronal plane consisted of the superiorly directed force vector of the deltoid muscle and the inferiorly directed force vector of the short external rotators of the rotator cuff. Rotation or abduction of the shoulder joint occurred as the two oppositely directed forces acted on opposite sides of the center of rotation54. A weak or detached supraspinatus tendon would be unable to maintain centering of the humeral head on the glenoid, and a superiorly directed force vector would result from the unbalanced force couple62. This concept was supported by a radiographic study comparing patients who had an arthrographically proved tear of the supraspinatus with those who had a normal shoulder81. The authors of that study concluded that some patients who have a rotator cuff tear have superior translation of the humeral head on the glenoid as a result of the loss of the normal depressing effect of the supraspinatus81. Free-body analysis of the glenohumeral joint has shown that the resultant force vector is directed superiorly during the first 60 degrees of shoulder elevation, and it also has been used to explain superior migration of the humeral head in association with a tear of the rotator cuff82. Although these investigators provided insight into glenohumeral biomechanics, they disregarded the contributions of the other rotator cuff muscles in maintaining joint stability.

The presence and importance of the transverse-plane force couple (Fig. 2), in which the anterior aspect of the cuff (the subscapularis) is balanced against the posterior aspect (the infraspinatus and the teres minor), was first revealed in an electromyographic study87. In a subsequent study, fluoroscopic examination of patients who had a massive tear of the rotator cuff revealed varying degrees of glenohumeral instability that corresponded directly to the degree of involvement of the posterior portion of the rotator cuff and the subscapularis tendon10. A suspension-bridge model of the shoulder, in which the leading edge of the detached rotator cuff tendon behaves biomechanically like the cable of a suspension bridge, was used to explain the nonprogressive nature of some rotator cuff tears11. The tension that develops on the edge of the supraspinatus tendon during the contraction of the torn rotator cuff muscle was theorized to propagate along the cable of the bridge to its point of attachment on the greater tuberosity. This allows some patients who have a large or massive tear to maintain the transverse force couple and thus to retain the ability to actively elevate the shoulder. The location of the cable (tendon) attachments on the tuberosities results in either stable or unstable glenohumeral kinematics, depending on the presence of an intact transverse force couple10,11. This principle has been supported clinically; Nove-Josserand et al.78 reported that the size of the tear of the rotator cuff and the amount of degeneration of the infraspinatus muscle as seen on magnetic resonance imaging substantially affected superior migration of the humeral head.



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  		Fig. 2 Axillary view revealing the transverse force couple between the anteriorly located subscapularis muscle and the posteriorly located external rotators. These two medially directed forces are balanced and produce centering of the humeral head with compression of the head against the glenoid. S = subscapularis, I = infraspinatus, O = center of rotation, r = distance to force vector of subscapularis, and R = distance to force vector of infraspinatus.

 
Biomechanical studies to investigate the effect of a rotator cuff tear on the performance of the glenohumeral joint have been performed in cadavera. A dynamic shoulder-testing apparatus with preserved transverse force couples was used to investigate the effect of a torn supraspinatus tendon70. Full abduction was possible, and the glenohumeral kinematics were not markedly altered70. In another study with use of this testing apparatus, it was found that, if the transverse force couple remained functionally intact, there was sufficient compressive force to maintain concentric reduction of the humeral head and the ball-and-socket kinematics94. No association was found between the size of the tear and the geometry of the humeral head, disproving the concept that there is a critical ratio between the size of the rotator cuff tear and the size of the humeral head. The information from these cadaver studies is limited, however, as scapulothoracic motion was not included and the artificial environment does not take into account the attritional, degenerative changes that occur in the rotator cuff tendons.

Rotator cuff tear arthropathy is a clinical manifestation of instability of the glenohumeral joint and loss of articular cartilage. On the basis of the existing clinical and biomechanical data, it is apparent that, if the remaining balance of the rotator cuff in the coronal and transverse planes is sufficient to maintain glenohumeral stability, then the presence of a rotator cuff tear or degenerative defect may not alter the biomechanics of the glenohumeral joint. If stability cannot be maintained and repetitive abnormal excursions of the humeral head occur on the glenoid, both in the transverse and the coronal plane, then wear and loss of the glenohumeral cartilage will result. The combination of glenohumeral instability due to loss of the primary and secondary stabilizers and loss of normal articular cartilage results in the generation of basic calcium-phosphate crystals. These crystal aggregates, which may originate from the damage to the articular cartilage or from the degenerative changes in the rotator cuff tendons, accelerate additional degenerative changes through the induction of enzymatic activity.


   Diagnosis
Top
 Introduction
 Historical Review
 Etiology
 Diagnosis
Treatment
 Overview
 References
 

Clinical Presentation
Rotator cuff tear arthropathy is more common in women than in men (Table I). Patients typically are elderly women with shoulder symptoms of long duration. The dominant side is most commonly affected; however, bilateral involvement is seen in approximately 60 percent of patients, in our experience. The symptoms include relatively mild or moderate joint pain, a loss of motion, and recurrent swelling of the shoulder. The pain characteristically interferes with sleep and intensifies with activity.


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  		TABLE I SUMMARY OF THE CLINICAL FEATURES OF ROTATOR CUFF TEAR ARTHROPATHY OF THE SHOULDER JOINT

 
Although patients may report a history of having received multiple corticosteroid injections, no association has been found between the severity of the symptoms and the number of previous injections. Six of the twenty-one patients reported on by Rockwood et al.85 had a history of multiple corticosteroid injections, and one patient had had more than twenty injections over a three-and-a-half-year period. In another report, sixteen of twenty-six patients had received previous corticosteroid injections; seven of them had not received injections until radiographic changes had developed, and only six had had more than three injections74.

Physical examination usually reveals mild swelling of the shoulder involving the subacromial and glenohumeral joints (Fig. 3) and atrophy of the supraspinatus and infraspinatus muscles. Neer et al.75 noted that most of the twenty-six patients specifically reported on in their series had substantial recurrent swelling of the shoulder reminiscent of hygroma of the subacromial space, as described by Codman19, and that ecchymosis about the shoulder with blood-tinged effusions was present in five patients. Similarly, Williams and Rockwood99 reported recurrent massive glenohumeral effusions in three of their twenty-one patients.



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  		Fig. 3 Clinical photograph of a seventy-one-year-old woman who had rotator cuff tear arthropathy of the right shoulder. Swelling of the shoulder is apparent. At the time of the operation, 150 to 200 milliliters of blood-tinged fluid was evacuated.

 
The active and passive range of motion can be severely limited because of soft-tissue contractures or fixed glenohumeral subluxation. Active glenohumeral motion may be accompanied by palpable or audible crepitus and usually is painful. Weakness of the external rotators may be profound, as specifically noted in six of the twenty-one patients who had rotator cuff tear arthropathy in the report by Williams and Rockwood99. Neer et al.75 also described limitations of active glenohumeral motion in patients who had rotator cuff tear arthropathy; only two of the twenty-six patients in their series were able to actively elevate the shoulder above 90 degrees. In 1992, Pollock et al.80 reported on thirty shoulders (twenty-one patients) that had a tear of the rotator cuff; the average forward elevation was 67 degrees. Glenohumeral instability secondary to a rotator cuff tear also is common in severely affected shoulders.

An association between rotator cuff tear arthropathy and arthritis of the lateral compartment of the knee was reported by Halverson et al.50; sixteen of their thirty patients who had rotator cuff tear arthropathy had symptomatic arthritis of the knee. The prevalence of narrowing of the lateral compartment, rather than the medial compartment, was significantly higher in this series than it was in a report of fifty-six patients who had primary osteoarthritis (p < 0.01)48.

Radiographic Findings
Characteristic radiographic findings include superior migration of the humeral head with articulation with the overlying acromion, narrowing of the glenohumeral joint space, formation of osteophytes, and periarticular soft-tissue calcifications (Fig. 4-A). Occasionally, in severely affected shoulders, erosive changes are seen both in the glenohumeral joint and in adjacent structures such as the base of the coracoid process, the lateral end of the clavicle, and the anterior aspect of the acromion.



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  		Figs. 4-A and 4-B: Characteristic radiographic findings of rotator cuff tear arthropathy. Fig. 4-A: Preoperative anteroposterior radiograph revealing articulation between the humerus and the acromion, rounding of the greater tuberosity, and loss of articular cartilage from the glenohumeral joint.

 
Halverson et al.50, in a series of thirty shoulders with destructive shoulder arthropathy, identified superior subluxation of the humeral head in twenty-three shoulders and humeral head deformity in twenty. Neer et al.75 reported an area of collapse of the proximal aspect of the humeral articular surface in all twenty-six patients in their series; they considered this finding a requirement for the diagnosis of rotator cuff tear arthropathy. Rounding-off of the greater tuberosity, as described by McCarty et al.67, is produced by the superiorly migrated humeral head articulating chronically under the acromion. Adams2 and Neer et al.75, who both described thinning of the acromion and occasional acromial separation into anterior and posterior portions, thought that the acromial fragmentation was developmental in nature. An unfused acromial apophysis was noted in three of the twenty-six patients of Neer et al.75. Conversely, Dennis et al.25 reported an acromial stress fracture associated with rotator cuff tear arthropathy in three patients and attributed the fracture to the mechanical forces of the superiorly directed humeral head.

Anterior or posterior instability of the glenohumeral joint may be evident on the axillary lateral radiograph. If fixed subluxation occurs, additional radiographic investigation is warranted to delineate the architecture of the glenoid. Fixed subluxation typically leads to sclerosis and formation of osteophytes, and glenoid erosion may occur at the point of contact with the humeral head (Fig. 4-B). Computed tomography is used to detect erosion, deformity, or defects of the glenoid38,73. Glenoid wear also may occur medially, as evidenced by destruction of the coracoid process, which is best seen on a West Point axillary radiograph86.



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  		Fig. 4-B Preoperative axillary lateral radiograph revealing loss of the articular joint space, periarticular soft-tissue calcifications, posterior fragmentation of the glenoid, and flattening of the humeral head.

 
Although arthrography, ultrasonography, and magnetic resonance imaging are not necessary for diagnosis, each reveals characteristic findings of a chronic rupture of the rotator cuff. Arthrography often reveals an abnormal communication (the so-called geyser sign23) between the glenohumeral and acromioclavicular joints that is associated with pathological distention or formation of a pseudoganglion of the acromioclavicular joint.


   Treatment
Top
 Introduction
 Historical Review
 Etiology
 Diagnosis
 Treatment
Overview
 References
 
Options for the treatment of rotator cuff tear arthropathy include medical management of the symptoms, arthroscopic lavage15, arthroscopic débridement, humeral tuberoplasty35, arthrodesis5, constrained arthroplasty22,59,83,84, semiconstrained arthroplasty3,74, total shoulder arthroplasty75, bipolar total shoulder arthroplasty57,93,96,101, and hemiarthroplasty5,36,80,99. Patients who have little pain and limitation of activities of daily living should be managed with mild analgesics and gentle, function-maintaining exercises. Prostaglandins such as misoprostol have been shown in vitro to inhibit basic calcium-phosphate-crystal-induced mitogenesis in a dose-dependent manner; however, they remain under investigation65. Repeated intra-articular injections of corticosteroids are discouraged, as they have been shown to be ineffective99 and may cause iatrogenic infection.

Arthroscopic irrigation to remove activated enzymes and crystals has been reported only recently15 and offers only limited, short-term relief. Arthroscopic acromioplasty and tendon débridement was described in six patients who had rotator cuff tear arthropathy33. However, the results were not stratified according to the location of the tear, and this technique should be viewed with caution.

Elderly patients who have rotator cuff tear arthropathy may not accept glenohumeral arthrodesis or tolerate it well because of the cosmetic appearance, poor function, and the frequent bilaterality of the condition. Cofield and Briggs20 reported the results of glenohumeral arthrodesis in a series that included twelve patients in whom the indication for the procedure was degenerative arthritis and an irreparable rotator cuff tear. Two of the patients had a pseudarthrosis, and six needed repeat operative procedures. The osteoporotic bone in the scapula and the proximal part of the humerus of these elderly, usually female patients makes arthrodesis difficult. Therefore, this procedure should be reserved for patients who have a nonfunctioning deltoid muscle.

A primary indication for shoulder arthroplasty with insertion of a constrained prosthesis with cement has been a rotator cuff tear associated with arthritis of the glenohumeral joint. The fixed-fulcrum mechanics of these prostheses have resulted in high rates of mechanical failure and loosening of the glenoid component22,59,83,84. Loosening of the glenoid component was reported in ten of forty-nine shoulders that had been treated with a Stanmore prosthesis59, and major complications, including dislocation of the humeral component and a bent or broken humeral neck, occurred in twenty-nine of ninety-four shoulders treated with a Michael Reese prosthesis83,84. One-millimeter-wide radiolucent lines were identified about the screws and the central post of the glenoid component of 30 percent of the Michael Reese prostheses that had not been revised84. The use of constrained shoulder arthroplasty was discouraged by Neer76 because of the poor quality of the scapular bone, which precluded adequate fixation of the glenoid component.

Several modifications have been made to the glenoid component to provide superior mechanical coverage and to resist superior migration of the humeral component. Clayton et al.17 reported use of a subacromial polyethylene spacer as a means of constraint against superior subluxation of the humeral component in seven patients who had an irreparable rotator cuff tear and arthritic articular surfaces. No difference was detected between the results for the seven patients who had received the spacer and those for fifteen additional patients who had had a conventional hemiarthroplasty or a total shoulder arthroplasty with use of the Neer prosthesis; according to Neer76, the use of subacromial spacers has generally been discontinued.

Neer et al.74-76, Amstutz et al.3, and Gristina et al.44 reported use of a semiconstrained prosthesis in shoulder arthroplasty. Neer et al.74-76 used an enlarged glenoid component (one that was 200 or 600 percent larger than standard size) with a superior hood to resist superior subluxation of the humeral component in patients who had a rotator cuff tear. Use of the 600-percent-enlarged component was abandoned because of its interference with rotator cuff repair76. The Dana total shoulder system3 includes a glenoid component that has a posterior hood to resist superior subluxation, as well as extended anterior and posterior lips to prevent anterior and posterior subluxation. Gristina et al. also used a hooded glenoid component to resist posterior subluxation in patients who had a rotator cuff tear.

Experience with hooded glenoid components is limited compared with that with standard, unconstrained components. In addition, few reports of total shoulder replacement have presented the results of use of semiconstrained glenoid components separately from those of use of standard components. Neer76 noted a higher prevalence of radiolucent lines around semiconstrained glenoid components and suggested that the likelihood of loosening is greater as a result of increased stress imparted to the bone-cement interface by the added constraint. A biomechanical study performed by Orr et al.79 with use of finite element analysis of the natural glenoid as well as various designs of glenoid components supports Neer's hypothesis. Hooded components were associated with increased compressive stresses under their superior portion and increased tensile stresses under their inferior portion. Those authors concluded that the abnormal stresses encountered with the hooded components increased the tendency for the component to tip superiorly and could lead to early loosening. Currently, there is limited information regarding the survival of these glenoid components, and they therefore should be used with caution.

Interest in semiconstrained arthroplasty was initiated in Europe with the development of the Reverse Ball-and-Socket Delta III prosthesis. De Buttet et al.24 reported preliminary results, at an average of two years postoperatively, in seventy-one patients who had osteoarthritis and a massive rotator cuff tear. Forty-nine patients had a good or excellent result, and three had a revision because of early failure of the glenoid component. Survival analysis with prospective data collection will be necessary before this method can be recommended.

A direct association between superior migration of the humeral component due to a rotator cuff tear and loosening of the glenoid component was reported by Franklin et al.37 in 1988. Seven of fourteen patients who had a total shoulder arthroplasty for the treatment of glenohumeral arthritis and a rotator cuff tear had loosening of the glenoid component at an average of two and one-half years postoperatively, whereas none of sixteen patients who had an intact cuff had such loosening. Those authors theorized that the eccentric superior loading of the glenoid component resulted in increased compressive stresses on its superior rim, causing it to loosen and tilt superiorly. They referred to this phenomenon as the rocking-horse glenoid and credited Gristina with first recognizing that a shift of the instant center of rotation of a glenohumeral prosthesis could result in abnormal stress on the anchorage of the glenoid component to the bone. Hemiarthroplasty was recommended, as it improved comfort and function without the risk of future loosening of the glenoid component (Figs. 5-A and 5-B).



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  		Figs. 5-A and 5-B: Radiographs made after hemiarthroplasty. Fig. 5-A: Anteroposterior radiograph showing superior migration of the humeral head and acromial contact.

 


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  		Fig. 5-B Axillary lateral radiograph showing the humeral head replacement with contact of the head centered in the glenoid.

 
In general, the results of hemiarthroplasty performed for rotator cuff tear arthropathy have been included in reports of hemiarthroplasty in patients who have a rotator cuff tear. Arntz et al.5 reviewed the results of hemiarthroplasty in twelve patients who had both glenohumeral arthritis and an irreparable rotator cuff tear and diagnosed seven patients as having rotator cuff tear arthropathy. The results were not stratified according to diagnosis; however, no patient had substantial pain, and active flexion improved from an average of 71 degrees preoperatively to an average of 110 degrees postoperatively. Those authors concluded that humeral hemiarthroplasty is the procedure of choice for patients who have both glenohumeral arthritis and an irreparable rotator cuff tear.

Lohr et al.61 compared the results of hemiarthroplasty with those of unconstrained or semiconstrained total shoulder arthroplasty in twenty-two shoulders with rotator cuff tear arthropathy. Hemiprosthetic replacement gave the poorest results with regard to relief of pain, whereas the unconstrained and semiconstrained devices had a high prevalence of radiographic and clinical loosening of the glenoid component. However, details concerning attempts at rotator cuff repair, soft-tissue balancing, and glenoid congruency were not included. Those authors concluded that rotator cuff tear arthropathy remains "one of the most difficult entities to treat."

Neer at al.74,76 identified rotator cuff tear arthropathy as a difficult clinical syndrome to treat because of the inability to repair degenerative, nonfunctioning rotator cuff muscles. Patients with rotator cuff tear arthropathy who had a shoulder arthroplasty were placed in the limited-goals category74, and postoperative management was aimed at achieving 20 degrees of external rotation and 90 degrees of forward elevation. A satisfactory result was obtained, with use of the limited-goals criteria, when the patient had no pain or only mild discomfort and was satisfied with the outcome.

Williams and Rockwood99 reviewed the results of hemiarthroplasty in twenty-one shoulders with degenerative arthritis and an irreparable tear of the rotator cuff. Emphasis was placed on operative technique, which included débridement of the retracted degenerative cuff defect without an attempt to repair and balance the remaining rotator cuff tendons by altering the size of the humeral head. The correct humeral head size allows the arm to lie freely across the abdomen, the humeral head to translate 50 percent posteriorly on the glenoid surface, and the subscapularis tendon to be reattached to the cut surface of the humeral neck without bow-stringing of the tendon on the rim of the humeral head. Those authors reported a satisfactory result for eighteen of twenty-one patients with use of the limited-goals criteria of Neer et al.74. All patients had lower pain scores after the hemiarthroplasty, and there were no instances of postoperative instability. The average active forward elevation improved from 70 degrees preoperatively to 120 degrees postoperatively, and the average external rotation improved from 27 to 46 degrees. Williams and Rockwood concluded that humeral hemiarthroplasty provided reliable relief of pain and restored the ability to perform activities of daily living.

Pollock et al.80 compared the results of total shoulder replacement with those of humeral hemiarthroplasty in thirty shoulders that had a rotator cuff tear. At an average of forty-one months postoperatively, relief of pain was satisfactory in eighteen of the nineteen patients who had had a hemiarthroplasty and in nine of the ten patients who had had a total shoulder arthroplasty. Twelve patients (thirteen shoulder arthroplasties) had been identified as having rotator cuff tear arthropathy, and they reported mild or no pain and had an average increase in forward elevation of 44 degrees.

Recently, Field et al.36 reported the results of hemiarthroplasty in sixteen patients who had rotator cuff tear arthropathy; ten of twelve patients who had normal function of the anterior portion of the deltoid and an adequate coracoacromial arch were considered to have a successful result according to the limited-goals criteria of Neer et al.74. All four patients who had had a previous acromioplasty and coracoacromial release had an unsuccessful outcome. The size of the humeral head was determined by its capacity to articulate with the coracoacromial arch and to maintain the ability to translate on the glenoid approximately 50 percent of its width anteriorly, posteriorly, and inferiorly. Oversizing of the head was intentionally avoided, in order to prevent an anterior shift of the head on the glenoid and tightening of the soft tissues. The reported results of hemiarthroplasty performed specifically for painful rotator cuff tear arthropathy reveal a reliable improvement in the pain-scale rating; however, gains in active forward elevation have been inconsistent (Table II)36,80,99.


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  		TABLE II SUMMARY OF THE REPORTED RESULTS OF HEMIARTHROPLASTY IN PATIENTS WHO HAD ROTATOR CUFF TEAR ARTHROPATHY

 
Bipolar total shoulder arthroplasty was designed in 1975 by Swanson et al.93 for the treatment of advanced glenohumeral arthritis associated with superior migration of the humeral head and loss of function of the rotator cuff. Swanson et al. theorized that the oversized humeral head would increase the stability of the joint, increase the abductor lever arm and power, and prevent impingement of the tuberosities. The increased area of contact between the bipolar cup and the acromion and glenoid, combined with motion at two interfaces as a result of the bipolar design, was thought to decrease prosthetic contact forces and to provide relief of pain. Swanson et al.93 reported that, at an average of five years after this procedure, thirty-five shoulders (thirty-one patients) had excellent relief of pain. Patients who had rotator cuff tear arthropathy were not specifically reported on, and the size of the humeral head, which was thirty-six to fifty millimeters in diameter, was equivalent to that used in conventional hemiarthroplasty. A 30-point shoulder-scoring system, which allotted a maximum of 10 points to three clinical categories (relief of pain, ability to perform activities of daily living, and range of motion), was devised93.

Alterations to the original design have resulted in a lower-profile bipolar prosthesis that requires conventional resection of the humeral head, thus preserving the tuberosities. Worland et al.101 reported the results at an average of twenty-eight months after shoulder arthroplasty with use of the modified prosthesis in twenty-two patients. Although seven patients had had a previous attempt at repair of the rotator cuff, it was not reported if an acromioplasty or a release of the acromioclavicular ligament also had been performed. Twenty-one patients had a successful result according to the limited-goals criteria74 and an improvement in the shoulder score93. These results have not been duplicated by others, to our knowledge. Vrettos et al.96 used the same type of prosthesis in seven patients who had rotator cuff tear arthropathy and reported that all but one patient had moderate-to-severe pain and were unhappy with the result. In addition, radiographs of the shoulder in varying degrees of abduction revealed no motion at the glenoid-prosthesis interface or at the bipolar polyethylene liner-humeral head articulation. Concerns that have been raised regarding the modified bipolar prosthesis include potential overstuffing of the shoulder joint, rupture of the subscapularis tendon due to the vertical orientation of the component, and the effect of polyethylene wear13.


   Overview
Top
 Introduction
 Historical Review
 Etiology
 Diagnosis
 Treatment
 Overview
References
 
In summary, rotator cuff tear arthropathy of the glenohumeral joint is a clinical syndrome involving primarily the dominant extremity of elderly women and is frequently bilateral. On the basis of an extensive review of the literature, it is apparent that different authors have been describing the same clinical syndrome using different terms, which has created confusion. Rotator cuff tear arthropathy appears to be the end point in the continuum of severe degenerative changes in the glenohumeral joint. The degenerative changes that occur in the rotator cuff result in loss of the primary stabilizers of the glenohumeral joint and lead to articular wear and subsequent arthritis. As severe glenohumeral arthritis and instability develop, basic calcium-phosphate crystals are generated, inducing synovial hyperplasia and the secretion of collagenase and stromelysin enzymes. This response accounts for destruction of the collagen-containing structures45 and may lead to ecchymotic effusions through continued tearing of the rotator cuff. This complex interplay results in glenohumeral instability and rapid destruction of articular cartilage.

If rotator cuff tear arthropathy causes relatively mild symptoms, then treatment should consist of mild anti-inflammatory medication and gentle stretching exercises to maintain or to gain a functional range of motion. A strengthening program then should be initiated to improve the active use of the arm for activities of daily living. Medical treatment with use of prostaglandins to inhibit the effects of the basic calcium-phosphate crystals appears promising yet remains experimental. If nonoperative management fails in these patients, a humeral hemiarthroplasty is the procedure of choice as it provides reliable relief of pain and improvement in function. Both stability and the range of motion are maintained through careful soft-tissue balancing. Oversized humeral head components should be avoided. Patients who have had previous operations on the rotator cuff resulting in defects of the anterior portion of the deltoid, shortening of the acromion, and loss of the coracoacromial ligament are at risk for postoperative anterosuperior instability.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Peralta Orthopaedics, 3100 Telegraph Avenue, Suite 100, Oakland, California 94563.

{ddagger}Department of Orthopaedic Surgery, University of Pennsylvania, Silverstein Pavilion, Second Floor, 3400 Spruce Street, Philadelphia, Pennsylvania 19140.

§Departments of Medicine (I. J. R.) and Orthopaedic Surgery (C. A. R., Jr.), University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774.


   References
Top
 Introduction
 Historical Review
 Etiology
 Diagnosis
 Treatment
 Overview
 References
 

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