Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience

10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience

Gilles Walch and Bryan Wall

In 1983, Neer 1 first described cuff tear arthropathy (CTA) as glenohumeral arthritis in the presence of a massive rotator cuff (RC) tear and collapse of the humeral head. It was thought that the massive tear preceded the onset of glenohumeral changes, and that the loss of containment of the articular fluid and loss of motion led to improper cartilage nutrition, which progresses to glenohumeral arthritis. In addition, the altered biomechanics of the shoulder resulted in progressive superior migration of the humeral head, which would eventually erode into the underside of the acromion. The end result of this process was acetabulization of the shoulder with collapse of the humeral head.

Hamada and colleagues² stratified the progression of massive cuff tears to CTA into a five-tiered system introduced in 1990. Grade 1 included those patients with massive cuff tears and >6 mm of acromiohumeral distance. Grade 2 indicated an acromiohumeral distance ≤6 mm. Severe erosion, or acetabulization, of the acromion occurred in grade 3. Grade 4 has since been subdivided into grade 4a, glenohumeral joint changes without acetabulization, and grade 4b, glenohumeral joint changes with acetabulization.³ The onset of humeral head collapse is indicated by grade 5.

Clinical Presentation

The patient with the cuff-deficient shoulder may recall an inciting traumatic event; however, the onset is frequently indolent. Immediately after the acute massive tear, pain and weakness are the most common presenting symptoms. As the pain subsides, patients frequently present with a loss of active motion while maintaining normal passive motion, what has been termed the pseudoparalytic shoulder.⁴

Active elevation is limited to that which can be achieved through the scapulothoracic junction and is typically <80 degrees. In addition to the loss of active elevation, the clinical examination will often show weakness or loss of active external rotation (ER). This may occur with the elbow either at the patient’s side (“dropping sign”) or in 90 degrees of abduction (“hornblower’s sign”). Prior to the onset of degenerative changes, patients may regain some active motion, but often remain painful and easily fatigable during prolonged or repetitive activity. In time, many will develop significant nocturnal pain with some degree of stiffness. With the onset of glenohumeral changes, pain and stiffness with loss of passive motion will become the dominant symptoms. At this point, there is significant disability and the functional use of the extremity is negligible. Massive RC tears or degeneration of the cuff muscle can also be seen in cases of primary glenohumeral arthritis.

Treatment

The sheer number of treatment options available indicates the difficulty this problem presents. Nonoperative treatment is generally reserved for those patients who are Hamada grades 1, 2, or 3, with a normal glenohumeral joint and before the onset of true CTA. Pain and loss of motion will be the most common complaints. Nonoperative modalities can consist of antiinflammatory medications, corticosteroid injections, and activity modification. A physical therapy program focused on stretching is often helpful to regain passive and some active range of motion (ROM).

Arthroscopic treatments that have been recommended for this condition include tuberoplasty, débridement with anterior acromioplasty, and biceps tenotomy. Fenlin et al⁵ described arthroscopic tuberoplasty for patients with Hamada grade 2 and 3 changes. The goal of the procedure is to create a congruent acromiohumeral articulation by reshaping the proximal humerus. No concomitant acromioplasty is performed, and the coracoacromial arch is maintained to capture the humeral head during active elevation. Good pain relief and functional restoration were reported, but all patients noted poor ER strength. The procedure is relatively low risk, and no complications were reported. The procedure is contraindicated in the presence of glenohumeral arthritis.

Rockwood and colleagues^6,⁷ have reported on the results of anterior acromioplasty and cuff débridement in association with an aggressive rehabilitation program for the treatment of massive cuff tears. Patients with a strong anterior deltoid and intact biceps did well with significant improvement in active elevation and pain relief; however, patients with a history of previous attempts at cuff repair showed little improvement.

Walch et al³ described release of the long head of the biceps. Significant improvement in pain score and activities of daily living were noted; however, radiographic signs of glenohumeral arthritis and humeral head migration continued to progress.

Tendon transfers of the latissimus dorsi and pectoralis major have been used with reasonable success in select patients.^8–12 Gerber et al⁹ noted good results in patients undergoing latissimus dorsi transfers so long as the subscapularis remained intact. In a similar report, Jost et al¹⁰ reported good results with pectoralis major transfer for subscapularis deficiency, but results were not as good in the presence of a concomitant irreparable supraspinatus tear.

Arthrodesis has been suggested as an open technique for the treatment of massive cuff tears with and without glenohumeral changes. However, the procedure may not be well tolerated by the older patient.11–17 The effectiveness of this modality may also be limited by the difficulty of obtaining a solid fusion, with pseudarthrosis rates as high as 20%.^12,^13–23 The possibility of bilateral shoulder involvement and relatively poor functional outcomes has led some to abandon this technique. The one place that arthrodesis may still be indicated is for the younger manual laborer who has failed prior attempts at cuff repair.¹¹

The results of total shoulder arthroplasty in patients with massive cuff tears and glenohumeral degenerative disease have been poor, secondary to early glenoid loosening.¹⁴ The “rocking horse glenoid,” as originally described by Franklin and Matsen, leads to excessive force on the superior edge of the glenoid, secondary to head migration.¹⁵ This eccentric loading compromises the glenoid fixation and results in early loosening.

Hemiarthroplasty with limited-goals rehabilitation has been suggested by numerous authors because it avoids the problem of glenoid loosening completely.^1,^16–28 Typically, this results in some alleviation of pain, but incomplete restoration of motion, particularly active anterior elevation. Progressive erosion of the undersurface of the acromion can still occur.

Bipolar hemiarthroplasty is a relatively new treatment modality. In theory, the bipolar head design allows better elevation as the head stabilizes the humerus for the deltoid to pull against. Functional results reported using this method have been disappointing and have not led to a dramatic improvement in results when compared with hemiarthroplasty.^16–31

Reverse total shoulder arthroplasty initially had poor results due to early glenoid loosening.^17,^18–39 Grammont reintroduced the concept in the early 1990s, using an improved prosthetic design.^19,²⁰ Early reports have shown good results in terms of both function and pain relief without the rates of glenoid loosening seen in the previous designs.^21–52

Indications for Treatment

Our choice of treatment is dictated by numerous factors. The clinical history, physical examination, radiographic findings, and patient expectations must all be taken into account prior to making treatment recommendations and decisions.

In the case of an acute traumatic tear, treatment decisions must be made and implemented rapidly to prevent chronic degenerative changes that may prevent later surgical repair. Partial or small full-thickness tears can be converted to massive tears by acute trauma, such as a fall. These patients may report a long history of minimal to moderate shoulder pain, but may not note significant disability until the traumatic event. In such a situation, an anteroposterior (AP) radiograph of the shoulder in neutral rotation is used to determine the acromiohumeral distance. An acromiohumeral distance of ≤6 mm is indicative of a long-standing, massive RC tear with fatty infiltration of the infraspinatus. Primary repair of the RC in this case is unlikely to be successful. If the acromiohumeral distance is ≥7 mm, immediate repair of the RC is indicated.

The patient’s willingness and ability to tolerate postoperative immobilization and rehabilitation should also be considered. Elderly patients may have difficulty complying with the normal postoperative treatment regimen after cuff repair. Because these patients are frequently not in pain after the pain subsides from the initial injury, non-operative treatment may be considered. Physiotherapy to maintain ROM and antiinflammatories are helpful. In the event of persistent pain, isolated biceps tenotomy is performed. If disability is an issue and the patient agrees to participate in rehabilitation, cuff repair is considered.

Alternately, a computed tomography (CT) scan or magnetic resonance imaging (MRI) can be used to determine the degree of fatty infiltration of the RC musculature and the reparability of the RC. Goutallier et al²² graded the fatty infiltration of the muscle using five groups. Stage 0 indicates normal muscle with no fatty changes. In stage 1, there are occasional fatty streaks present. Stage 2 denotes significant fatty infiltration, but there is more muscle than fat present. In stage 3, there is an equal amount of fat and muscle present, and in stage 4, there is more fat than muscle tissue remaining. Stage 3 and 4 changes have been associated with chronic RC tears and a significantly decreased rate of success of cuff repair.²²

In the case of the chronic RC-deficient shoulder, the functional demands of the patient must be assessed. The patient who uses the arm primarily with the elbow at the side and can compensate for the lack of active elevation by using the contralateral arm is considered to be low demand. Normally, this is the older patient with significant muscular wasting about the shoulder and decreased acromiohumeral distance. If the pain is tolerable, skillful neglect with intermittent physical therapy and medication is frequently the most prudent course of treatment.

Biceps tenotomy may be considered for select patients who have persistent pain and no glenohumeral changes. This works well for posterosuperior tears, but massive tears that also involve the subscapularis have poor results with this technique. This is most likely due to secondary anterior instability of the humeral head with impingement between the coracoid and the lesser tuberosity that can be painful. This procedure normally relieves pain at rest, night pain, and pain that occurs with activities of daily living. Pain that occurs with heavy activity or exercise is not improved. As would be expected, strength and ROM do not show any clinically significant improvement with this technique. Patients who have been able to compensate for the RC tear and regain full motion will maintain this motion after biceps release and do very well. Those who have poor active motion prior to biceps release will show little clinically significant improvement.

The older patient, who complains only of loss of motion, or the pseudoparalytic shoulder, presents different challenges. Palliative procedures, such as biceps tenotomy or cuff débridement are not likely to be successful, as these procedures do nothing to restore a functional cuff mechanism. When the RC tear is long-standing, as evidenced by decreased acromiohumeral distance and fatty infiltration, treatment options available are skillful neglect, muscle transfer, or reverse shoulder arthroplasty. We tend to reserve muscle transfer for those patients who are younger than 70 years old. Elderly patients are treated nonoperatively if they are able to cope with the functional limitations present. If use of the hand at or above the level of the head is required, we have used reverse shoulder arthroplasty with good results.

When the RC tear affects the posterior cuff (infraspinatus and teres minor), patients will present with a loss of ER. The physical examination will typically reveal a positive ER lag sign or dropping sign if the infraspinatus is affected. A positive hornblower’s sign will be present in the face of an infraspinatus and teres minor tear. Radiographic signs can be similar to other cuff tears, with long-standing pathology leading to superior migration of the humeral head and a decreased acromiohumeral distance. Once fatty infiltration of the cuff has progressed beyond stage 2, repair is no longer a reasonable option and muscle transfers are considered. If the tear involves both the infraspinatus and the teres minor, latissimus dorsi transfer is required. Again, elderly patients who have low functional demands are treated nonoperatively. Reverse shoulder arthroplasty is not performed in this group, as the prosthesis does nothing to restore ER.

When glenohumeral arthritis is associated with RC deficiency, treatment options are more limited. Glenohumeral changes are always present in the setting of true CTA and may also be seen in association with massive cuff tears and primary osteoarthritis. Nonoperative treatment is always considered as initial treatment. Patients will frequently have significant rest and night pain in addition to loss of function of the shoulder. Activity will only exacerbate these symptoms. Biceps tenotomy and muscle transfers will result in limited pain relief with little functional improvement and are not recommended in these cases. We have employed hemiarthroplasty in the past with acceptable pain relief, but only modest improvements in active motion. Our early experience with reverse shoulder arthroplasty has been extremely encouraging, and we now consider this the treatment of choice for the cuff-deficient shoulder with associated glenohumeral degenerative changes.

Given the short-term follow-up available and the advanced age of most patients reported in the literature, attempts are made to restrict the use of this prosthesis to an older patient population. Patients younger than 60 years of age are encouraged to continue nonoperative therapy, including physical therapy, antiinflammatories, and corticosteroid injections, for as long as possible before reverse arthroplasty.

Fortunately, chronic RC deficiency, with or without glenohumeral changes, is exceedingly rare in young, high-demand patients. If a patient requires use of the arm with the elbow away from the body or for manual labor, glenohumeral arthrodesis is a viable treatment. This is one of the rare indications for which we still routinely employ arthrodesis.

There are several special situations in which the reverse prosthesis is indicated in the younger patient. Revisions of previous hemiarthroplasty or total shoulder arthroplasty frequently result in a poorly functional RC mechanism as it may be damaged during the revision. In addition, severe loss of glenoid and humeral bone stock frequently complicates these already difficult cases. In these situations, the reverse prosthesis is indicated to address the bony and soft tissue deficiencies. Tumor reconstructions also result in significant tissue loss. As in revision surgery, a stable arthrodesis is difficult to obtain after resection of humeral and glenoid bone. This leaves reverse arthroplasty as the only option that may restore some degree of functionality to the shoulder.

Treatment

Cuff Débridement and Biceps Tendon Release

Patient Positioning

The patient is placed in the beach-chair position. We typically employ an operative table that has removable superolateral sections for easy access to the posterior aspect of the shoulder. In lieu of this, a small bump can be placed behind the affected scapula, and the patient can be positioned at the lateral edge of the bed. The arm is draped free, allowing easy positioning during the case.

Surgical Technique

A posterior portal is made approximately 1 cm inferior and 1 cm medial to the posterolateral corner of the acromion. This portal position should allow easy arthroscope placement into the subacromial space and access to the lateral cuff insertion.

Once the presence of a massive and irreparable cuff tear is confirmed, a standard anterolateral working portal is made. The biceps tendon is then sectioned using arthroscopic scissors at the insertion at the supraglenoid tubercle and superior labrum. The tendon is allowed to retract spontaneously out of the glenohumeral joint. In cases where the tendon does not retract, the remaining intraarticular stump is resected.

Synovectomy and bursectomy are performed only to the extent required to provide proper visualization. Acromioplasty is not typically performed.

Postoperative Care

The arm is placed in a simple sling. Passive ROM is allowed beginning on postoperative day one. Active motion is allowed as soon as patient comfort permits. After suture removal, hydrotherapy and a swimming program are begun. Strengthening exercises are avoided as they may result in pain and stiffness.

Reverse Total Shoulder Arthroplasty

Patient Positioning

The patient is placed in the beach-chair position, with the affected shoulder just lateral to the edge of the table. This position should allow hyperextension of the humerus and dislocation of the humeral head. This will permit excellent exposure for the humeral cut and canal preparation. The shoulder is draped so that there is access to the lateral half of the clavicle anteriorly and the lateral half of the scapula posteriorly.

Approach

We routinely use a deltopectoral approach for this procedure, but a superolateral approach can be used as well. We feel that there are several significant advantages to the deltopectoral approach. With this approach, there is no disruption of the deltoid fibers. Although those authors who routinely use the superior approach have not reported significant problems with deltoid function or dehiscence postoperatively, it may be an unnecessary risk when adequate exposure could be obtained through alternative means. Up to 20% of these patients have significant preoperative acromial pathology.23 In these patients, it would seem counterintuitive to jeopardize the deltoid mechanism further.

The deltopectoral approach is also the standard “workhorse” approach for most shoulder procedures. It is used routinely for anatomical shoulder arthroplasty and is very familiar to most surgeons. This approach affords excellent exposure of the glenoid when combined with an inferior capsular release from the humeral and, in particular, the glenoid sides. These releases are not necessary with a superior approach, but they, along with a partial release of the pectoralis major, are thought to help increase postoperative ROM in those cases of severe arthritis and stiffness.

The deltopectoral approach is an extensile approach, which allows easy access to the anterior humerus. This is especially useful in revision arthroplasty, where humeral osteotomy may be necessary for component extraction. Moreover, identification of the axillary nerve is desirable in these complex cases, and this is best performed through the deltopectoral approach.

Optimal glenoid component placement may be easier through a deltopectoral approach. Difficulties with scapular notching have led many authors to recommend slightly inferior placement of the glenoid component with an inferior tilt, and this is extremely difficult through a superior approach, with the soft tissues and humeral head pushing upward on the glenoid reamers.

The one significant advantage that might be attributed to the superior approach is a lower rate of dislocation.²⁴ This seems intuitive because the remaining subscapularis muscle is left intact anteriorly.

The deltopectoral incision is begun at the coracoid process and extended distally and laterally for 10 to 15 cm, toward the midpoint of the humerus. The interval is easiest to identify at the most superior and medial portion of the incision. The cephalic vein is left laterally, with the deltoid muscle. Once the interval is opened adequately, the arm is placed in abduction and ER and a Homan retractor is placed over the coracoid process. The arm is returned to full adduction and slight ER, and the pectoralis major insertion is identified and then released along the superior 1 to 2 cm. This exposes the underlying circumflex humeral vessels at the inferior border of the subscapularis, which are ligated using two absorbable sutures.

The coracoacromial ligament is identified and divided just lateral to the coracoid insertion. Release of the fascia from the lateral portion of the conjoined tendon and coracobrachialis muscle allows a small blunt retractor to be placed underneath to expose the underlying subscapularis muscle. The axillary nerve is identified by placing the arm in adduction, slight forward flexion and neutral rotation, and then by following the anterior surface of the subscapularis medially, underneath the conjoined tendon. The nerve is sometimes difficult to see in larger patients, or those with significant fatty tissue surrounding it. In these cases, a larger blunt hand-held retractor (such as a Richardson retractor) is temporarily placed underneath the conjoined tendon to permit location of the nerve. It is then exchanged for a smaller retractor to avoid potential neurovascular complications from prolonged aggressive retraction.

The arm is then placed in abduction and internal rotation (IR) to locate the biceps tendon, which delineates the lateral border of the subscapularis and should lay just medial and deep to the pectoralis major insertion. Dissection using a pair of scissors oriented perpendicular to the tendon usually allows easy entrance into the biceps sheath to identify the tendon if it is still intact. Keeping the arm in the same position, the superior border of the subscapularis is found just behind the tip of the coracoid process.

Once all four borders of the subscapularis have been identified, two stay sutures are placed and the tendon is divided ~1.5 cm medial to insertion on the lesser tuberosity, following the anatomical neck of the humerus.

A humeral head retractor is introduced into the joint to sublux the head posteriorly, and the subscapularis is then released by performing a juxtaglenoid capsulotomy. This is begun by identifying the superior, or semitubular, portion of the subscapularis tendon. Dissecting scissors are slid along the superior tendon edge, releasing any subcoracoid adhesions. The deep surface of the muscle is then bluntly dissected free from the underlying capsule and middle glenohumeral ligament. The capsule and middle glenohumeral ligament are then sectioned, working back inferiorly and medially to the glenoid rim. Next, the previously transected muscle fibers of the inferior subscapularis are found. Lying just posterior to these fibers, which are seen in cross-section, is the inferior glenohumeral ligament. The inferior glenohumeral ligament and capsule are dissected free and sectioned superiorly and medially back to the level of the glenoid. The excursion of the muscle is then tested, and if found to be adequate, the muscle is buried in the subscapularis fossa and protected with a small sponge. If tendon excursion is still inadequate, a blunt instrument can be used to palpate for remaining adhesions on the undersurface of the subscapularis. The muscle is then buried in the subscapularis fossa, and a Kölbel retractor is placed in the fossa to retract the medial structures including the subscapularis muscle, axillary nerve, and conjoined tendon.

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