Shoulder and Elbow cases rotator cuff arthropathy

A 70-year-old, right-hand-dominant female presents to clinic complaining of 4 years of gradually worsening chronic right shoulder pain and stiffness. She says the pain is worse at night and with any range of motion, denies a history of trauma, pain in other extremities, or numbness or tingling of the right upper extremity. She notes that her mother suffered from rheumatoid arthritis that affected her shoulder. Physical examination reveals decreased muscle bulk over the right supra- and infraspinatus fossae compared to the contralateral side, limited active and passive ROM, marked weakness with external rotation, and 4+/5 strength with shoulder abduction. X-rays of the right shoulder are shown in Figures 2–58 and 2–59.

 

 

Figure 2–58

 

 

 

Figure 2–59

 

What is the most likely diagnosis?

1. Rheumatoid arthritis involving the right glenohumeral joint.

2. Frozen shoulder (adhesive capsulitis)

3. Rotator cuff tear arthropathy

4. Osteoarthritis involving the left glenohumeral joint

 

Discussion

The correct answer is (C). Rotator cuff tear arthropathy consists of a combination of rotator cuff insufficiency, glenohumeral joint degenerative changes, and superior humeral head migration. It is more common in women and also more often found on the dominant side. The patient’s clinical examination with weakened external

rotation and muscle atrophy signaling incompetent supra- and infraspinatus muscles point to rotator cuff insufficiency, and her plain films reveal narrowed glenohumeral joint space as well as superior migration of the humeral head. Choice D is incorrect because, while radiographs would show narrowing of the glenohumeral joint space, they would also likely show numerous osteophytes and posterior wear of the glenoid. Choice B is incorrect because, while adhesive capsulitis does present as decreased active and passive range of motion, the patient’s constellation of symptoms pointing towards rotator cuff insufficiency along with the radiographs make cuff tear arthropathy the more likely choice. Finally, Choice A is incorrect because even though she has a positive family history of rheumatoid arthritis, it is less likely to present only in a single joint. Also, rheumatoid arthritis on radiography appears more as an erosive process without the characteristic superior migration of the humeral head.

Which of the patient’s radiographic findings is most indicative of chronic rotator cuff insufficiency?

1. Superior migration of the humeral head

2. Narrowed glenohumeral joint space

3. Subchondral sclerosis

4. Osteopenia of the proximal humerus

 

Discussion

The correct answer is (A). Superior migration of the humeral head would be most indicative of chronic rotator cuff insufficiency associated with cuff tear arthropathy, as it is a direct result of the inability of the rotator cuff tendons to help maintain the humerus in its normal position. Acetabularization of the undersurface of the acromion is commonly associated with superior migration of the humeral head found in rotator cuff tear arthropathy, and can be assessed using the Hamada classification, which is based on measurements of the acromiohumeral interval on radiography (Table 2–8). Choices B and C are incorrect because, while narrowed glenohumeral joint space and subchondral sclerosis are associated with rotator cuff arthropathy on radiographs, they indicate degenerative joint changes rather than chronic rotator cuff insufficiency. Choice D is incorrect because it is not a specific sign of rotator cuff arthropathy.

 

Table 2–8 HAMADA CLASSIFICATION

 

Grade 1 Acromiohumeral interval >6 mm

 

Grade 2

Grade 3

Grade 4

Grade 5

Acromiohumeral interval ≤5 mm

Grade 2 plus acromial acetabularization

Grade 3 plus glenohumeral joint space narrowing Humeral head collapse

 

Kappe T, Cakir B, Reichel H, Elsharkawi M. Reliability of radiologic classification for cuff tear arthropathy. J Shoulder Elbow Surg. 2011;20:543–547.

 

What is the most appropriate treatment for the patient at this time?

1. Serial corticosteroid injections into the glenohumeral joint

2. Arthroscopic lavage of the glenohumeral joint

3. Arthroplasty of the glenohumeral joint

4. Physical therapy and PO nonsteroidal anti-inflammatories

 

Discussion

The correct answer is (D). First-line treatment for rotator cuff tear arthropathy is conservative management with physical therapy and NSAIDs. Glenohumeral steroid injections (Choice A) may partially relieve pain, but serial injections alone are not the most appropriate, initial course. Arthroscopic joint lavage (Choice B) has been tried in the past as treatment for rotator cuff tear arthropathy but it is not currently very common to perform and would definitely not be a first-line treatment. Choice C is incorrect because arthroplasty of the glenohumeral joint is a common treatment for rotator cuff tear arthropathy, it would only be indicated if the patient failed conservative management.

You send the patient to physical therapy and advise her to take ibuprofen as needed for pain. She returns to clinic in 3 months saying her pain and range of motion have not improved, and she would like to pursue operative treatment.

What is the preferred treatment for this patient?

1. Arthroscopic rotator cuff repair

2. Total shoulder arthroplasty with pectoralis tendon transfer

3. Reverse total shoulder arthroplasty with latissimus dorsi tendon transfer

4. Hemiarthroplasty of the glenohumeral joint

 

Discussion

The correct answer is (C). This patient has failed conservative management and continues to have pain and loss of function; therefore arthroplasty of the

glenohumeral joint is now indicated. Reverse total shoulder in particular (as opposed to total shoulder arthroplasty) is indicated for this patient because of her rotator cuff insufficiency. The reverse construct will help increase the efficiency of her deltoid muscle at glenohumeral abduction, since her supraspinatus and infraspinatus are clearly atrophied and nonfunctional. Latissimus transfer is also indicated due to the patient’s weakness with external rotation. Choice B is incorrect since total shoulder arthroplasty does not account for rotator cuff insufficiency and would likely lead to superior migration of the humeral prosthesis. Choice A is incorrect as the patient’s rotator cuff is likely irreparable by this time, and it would not address the degenerative changes of her glenohumeral joint. Hemiarthroplasty (Choice D) is incorrect because it is not as successful as a reverse total shoulder in improving range of motion and carries the risk of humeral head subluxation.

 

Objectives: Did you learn...?

 

 

Recognize the clinical presentation of a patient with rotator cuff arthropathy? Identify signs of rotator cuff arthropathy on imaging?

 

Treat a patient with rotator cuff arthropathy?