Rotator Cuff Arthropathy: What Is It?


Chapter 36

Rotator Cuff Arthropathy


What Is It?



Stefano Gumina, and Vittorio Candela

Definition and Historical Review


The term rotator cuff arthropathy was coined by Neer et al to indicate a nosologic condition characterized by arthritic degeneration of the glenohumeral joint consequent to the massive posterosuperior rotator cuff tear. About one century earlier, Adams, in his book on rheumatic gout, and Smith had described cases of shoulder arthropathy characterized by erosion of the upper portion of the humeral head, of the acromion, of the distal third of the clavicle and rotator cuff tear. Codman, in his monograph published in 1934, described a case of a 51-year-old woman whose shoulder underwent rotator cuff tear, glenohumeral arthropathy, loose bodies, and swelling for the abundant articular synovial fluid.

Further papers were not published until the end of the 1950s. Galmiche and Deshayes, Burman et al., Banna and Hume, Shephard, and Snook reported a total of 30 cases of shoulder arthropathy, some of them with the characteristics of cuff tear arthropathy.

In 1968, De Seze et al. described the hemorrhagic shoulder of three elderly women whose clinical (blood-streaked recurrent effusion, rotator cuff tear) and radiographic (severe degenerative glenohumeral humeral arthritis) characteristics suggesting a rotator cuff arthropathy. One year later, Bauduin and Famaey described an analogous case.

Jensen et al., in a prestigious publication in 1999, described the three main clinical and radiographic characteristics of the cuff arthropathy: (1) massive tear of the rotator cuff, associated with shoulder pain, supra- and infraspinatus atrophy, and loss of motion (Fig. 36.1AD); (2) degenerative changes of the glenohumeral joint (Fig. 36.2A,B); and (3) upward migration of the humeral head observable on anteroposterior view (Fig. 36.3A). Humeral head collapse (Fig. 36.3B), erosive changes of superior glenoid or acromion, periarticular soft-tissue calcifications, and subdeltoid effusion are other possible features that may be present.

Etiopathogenesis


Mechanical Theory


According to mechanical theory, loss of downward force performed by a healthy rotator cuff on the humeral head would result in a superior migration of the humerus. This might facilitate an erosion of the superior surface of the glenoid and of the anteroinferior aspect of the acromion. In addition, the upward migration of the humeral head could cause eccentric work of the humeral head and, consequently, premature wear of the articular cartilage in the areas of higher glenohumeral compression. Because 21 of the 26 patients had the rupture of the long head of the biceps tendon, Neer et al thought that this injury would help the upward migration of the humeral head.

Burkhart’s hypothesis seems to support this theory. Burkhart believes that the healthy inferior portion of the rotator cuff creates a moment that must balance the deltoid moment (force coupling). Furthermore, the subscapularis is anteriorly balanced against the infraspinatus and teres minor posteriorly. Uncoupling of the essential force couples results in anterosuperior translation of the humeral head with attempted elevation of the shoulder.

In 1997, Collins and Harryman hypothesized that cuff arthropathy was initially due to supraspinatus tear and later to the infraspinatus lesion; the complex tendon tear would cause the upward migration of the humeral head and, consequently, the contact of articular cartilage of the humeral head against the anteroinferior margin of the acromion. Cartilage fragmentation results in particulate debris, which causes synovial thickening and effusion as well as calcium phosphate crystal formation. The enzymatic response to the crystals furthers the damage of the articular surfaces.

A concavity compression mechanism, suggested by Hurov, further corroborates the mechanical theory: The healthy cuff compresses the convexity of the humeral head against the pseudo-concavity of the glenoid; therefore the cuff, with other scapular muscles, would act as an important dynamic stabilizer of the joint. This action may be even more important in the presence of severe laxity of the static stabilizers of the shoulder (capsule, labrum, and glenohumeral ligaments). Oh et al identified that critical tear sizes responsible for disrupted joint kinematics are those with full-thickness supraspinatus tears and 50% detachment of the infraspinatus.

Nutritional Theory



image
FIG. 36.1 (A–D) Decrease in range of motion in a 75-year-old female patient with right rotator cuff arthropathy.

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FIG. 36.2 Magnetic resonance imaging of a right shoulder of a 77-year-old male patient with Hamada grade 4B cuff tear arthropathy. (A) Coronal T2 fat-suppressed. (B) Axial proton density fat-suppressed. (C) Sagittal T2 fat-suppressed.

It is known that cytokine and catabolic enzyme concentrations increase in the early phases of osteoarthritis. Many studies have also proved that the rotator cuff tear leads to an increased production of interleukin-1β and tumor necrosis factor, which helps explain the presence of pain and inflammation. It was also noted that the production of many cartilage matrix–specific matrix metalloproteinases (MMPs) is increased, including MMP-1, MMP-2, MMP-3, MMP-8, and MMP-13. The presence of MMP-3 is important because it is implicated in the proteolytic activation of the other MMPs. Yoshihara et al. observed that there is a correlation between the concentration of these cytokines, collagenases, and aggrecanases and accelerated cartilage degeneration after a cuff tear.

These observations change the contours of the nutritional theory in the genesis of cuff tear arthropathy. In fact, with the evacuation of a part of the synovial fluid through the tendon lesion, inflammation factors and proteolytic enzymes should be removed, and thus the health status of articular cartilage should be preserved.

In 2012, Reuter et al. sonographically assessed the articular surface of the glenohumeral joint in rats with a rotator cuff tear and observed a thickness decrease in the cartilage. Kramer et al. histologically studied the glenohumeral cartilage of rats subjected, respectively, to detachment of the posterosuperior rotator cuff and to suprascapular nerve root transection passing through the trapezoid. (The joint capsule was kept intact.) The animals were killed 12 weeks after surgery. In the first case, if there had been degenerative changes of the cartilage, it would have been attributed, in accordance with Neer’s hypotheses, to the altered mechanical loading and to the nutritional theory; instead, in the second case, it would have been attributed only to the mechanical hypothesis. Surprisingly, the amount of cartilage degeneration was similar between the groups. This result suggests that aberrant mechanical forces are the primary cause of articular cartilage degeneration in the setting of cuff tear arthropathy.

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FIG. 36.3 True anteroposterior x-rays of a right shoulder. (A) Hamada grade 3 cuff tear arthropathy. (B) Hamada grade 5 cuff tear arthropathy: bony destruction and humeral head collapse after a cuff repair failure.

Crystalline-Induced Arthritis of the Shoulder Theory


In the orthopedic literature, almost simultaneously with Neer’s hypotheses, a nosologic entity similar to the cuff arthropathy was described: the “Milwaukee syndrome.” Although it is responsible for a clinical condition similar to that of the cuff arthropathy, this disease has been attributed to the presence in the synovial fluid of basic calcium phosphate crystals encapsulated into microspheroids without apparent inflammatory cell response. Indeed, an altered capsular degenerated cartilage and synovium, possibly with a macrophage response and subsequent release of collagenase and neutral proteases, is associated with this condition, resulting in the attack and subsequent destruction of the joint.

In 1985, Dieppe and Watt noted that basic calcium phosphate crystals could be found in arthritic and neuropathic joints and in apparently healthy joints of elderly subjects. In addition, the apatite crystals are found especially in the most destructive atrophic situations. Therefore the authors hypothesized that the crystals are produced by the processes that are secondary to joint degeneration. This hypothesis reshapes the inflammation theory and suggests that the syndrome is a form of cuff arthropathy.

Autoimmune Rheumatic Diseases



 


TABLE 36.1




























Beighton Criteria for Diagnosis of Joint Hypermobility
Major Criteria
A Beighton score (Table 36.2) of 4/9 or greater (either currently or historically)
Arthralgia for longer than 3 months in four or more joints
Minor Criteria
A Beighton score of 1, 2, or 3/9 (0, 1, 2, or 3 if aged 50+)  
Arthralgia (>3 months) in one to three joints or back pain (>3 months), spondylosis, spondylolysis/spondylolisthesis
Dislocation/subluxation   in more than one joint, or in one joint on more than one occasion.  
Soft tissue rheumatism, more than lesions (e.g., epicondylitis, tenosynovitis, bursitis)
Marfanoid habitus (tall, slim, span/height ratio >1.03, upper/lower segment ratio <0.89, arachnodactyly [positive Steinberg/wrist signs])  
Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring
Eye signs: drooping eyelids or myopia or antimongoloid slant
Varicose veins or hernia or uterine/rectal prolapse

Idiopathic Theory


It is possible that the cuff arthropathy is the result of a fortuitous coincidence between rotator cuff tear, frequently found in elderly patients, and idiopathic glenohumeral arthropathy. In other words, arthropathy would occur regardless of cuff tear.

Upward migration of the humeral head consequent to the cuff tear would only be responsible for the fast evolution of the arthritic process, and it would only cause a more precocious wear of the upper portion of the glenoid surface. If this hypothesis is correct, the cuff arthropathy should not have a clear preference for sex, and patients should have an average age similar to that of patients with concentric arthropathy; instead, the cuff arthropathy is found predominantly in females and in older patients.

Theory Related to Joint Laxity


Because cuff tear arthropathy and youth joint laxity are significantly more frequent in females, we hypothesized that these two conditions are associated with each other. If the rotator cuff tear occurs in patients who have/had joint laxity, it is possible that the involved shoulder could develop a severe static instability that might be responsible for a premature wear of the cartilage of the superior glenoid. This assumption justifies the evident difference in the prevalence of cuff arthropathy due to sex.

In order to verify the accuracy of this theory, we administered dedicated questionnaires to patients with cuff arthropathy in order to detect joint hypermobility. The questionnaire investigates, using major and minor criteria, a patient’s current and previous ability to perform uncommon activities, the presence of joint diseases, or the tendency to dislocation. After exclusion criteria, 193 (n = 133) patients with glenohumeral osteoarthritis (48 males, 85 females; mean age [SD], 72.32 7.05]) were divided into two groups: group I (patients with rotator cuff arthropathy) and group II (patients with concentric shoulder arthropathy), composed of 71 (22 males, 49 females) and 62 (26 males, 36 females) patients, respectively. The presence of hypermobility was assessed in all participants by using the Beighton criteria. The diagnosis was obtained in the presence of two major criteria, or of one major and two minor criteria, or of four minor criteria (Tables 36.1, 36.2).

Furthermore, patients were administered a five-item self-report questionnaire (Table 36.3) introduced by Hakim to detect current or previous joint hypermobility. This questionnaire was developed and approved to be used in both teenager and elderly subjects. Hypermobility is diagnosed in the presence of two or more affirmative answers.

Application of the Beighton criteria led to a diagnosis of joint hypermobility in 16 patients (22.5%; 7 with two major criteria, 5 with one major and two minor criteria, and 4 with four minor criteria) in group I and in 15 patients (24.2%; 7 with two major criteria, 7 with one major and two minor criteria, and 1 with four minor criteria) in group II. The affirmative responses in the five-item self-report questionnaire in Groups I and II were 2 in 8 (11.3%) and 3 (4.8%) participants, as 3 in 1 (1.5%) and 5 (8%) participants, and as 4 in 2 (2.9%) and 4 (6.5%) participants, respectively. We found no significant association between groups I and II and both the Beighton criteria [χ2(1) = 0.051; P = .82] and the five-item self-report questionnaire [χ2(1) = 0.67; P = .41]. In conclusion, our data exclude this possible correlation.

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on Rotator Cuff Arthropathy: What Is It?

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