Rotator Cuff

Tear Arthropathy

Kier J. Ecklund, MD
Thay Q. Lee, PhD
James Tibone, MD
Ranjan Gupta, MD

Dr. Ecklund is Chief Resident,

Department of Orthopaedic Surgery,
University of California, Irvine, Orange,
CA. Dr. Lee is Professor and Vice Chair,
Research, Department of Orthopaedic
Surgery, University of California, Irvine.
Dr. Tibone is Professor, Department of
Orthopaedic Surgery, University of
Southern California School of Medicine,
Los Angeles, CA. Dr. Gupta is Professor
and Chair, Department of Orthopaedic
Surgery, University of California, Irvine.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Ecklund, Dr. Lee, Dr. Tibone, and
Dr. Gupta.
Reprint requests: Dr. Gupta,
Department of Orthopaedic Surgery,
University of California, Irvine, 101 The
City Drive South, Orange, CA 92868.
J Am Acad Orthop Surg 2007;15:340349
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.

340

Abstract
Rotator cuff tear arthropathy represents a spectrum of shoulder
pathology characterized by rotator cuff insufficiency, diminished
acromiohumeral distance with impingement syndromes, and
arthritic changes of the glenohumeral joint. Additional features
may include subdeltoid effusion, humeral head erosion, and
acetabularization of the acromion. Although the progression of
rotator cuff tears seems to play a role in the development of cuff
tear arthropathy, information is lacking regarding the natural
progression of rotator cuff tears to cuff tear arthropathy.
Controversy remains about the role of basic calcium phosphate
crystals in the development of cuff tear arthropathy. Nonsurgical
management is the first line of treatment in most patients.
Traditionally, surgical management of rotator cuff tear arthropathy
has been disappointing because of the development of
complications long-term and poor patient satisfaction with
functional outcomes. Recent studies, however, report promising
experience with reverse ball-and-socket arthroplasty.

he clinical entity now known as

rotator cuff tear arthropathy
was first described in the 19th century in isolated case reports.1,2 However, the term cuff tear arthropathy
was first reported in the literature by
Neer et al3 in 1983. The authors
described cuff tear arthropathy as
a rare pathologic entity characterized by rotator cuff insufficiency,
degenerative changes of the glenohumeral joint, a subcutaneous effusion,
humeral head collapse, acetabularization of the acromion, diminished
acromiohumeral distance, and erosions of the skeletal architecture of
the shoulder. Currently, cuff tear arthropathy represents a broad spectrum of pathology in which, at least
to some degree, three critical features are present: rotator cuff insuf-

ficiency, degenerative changes of the

glenohumeral joint, and superior migration of the humeral head.4 Other
characteristics that may be seen are
humeral head collapse, erosive
changes of the superior glenoid or
acromion, and subdeltoid effusion.

Anatomy and
Biomechanics
The rotator cuff consists of the supraspinatus, infraspinatus, teres minor, and subscapularis muscles and
fills a critical role in active stabilization of the glenohumeral joint.
Other active stabilizers include the
deltoid, pectoralis major, latissimus
dorsi, teres major, biceps brachii,
and scapulothoracic muscles.5,6 Passive stabilizers of the shoulder joint

Journal of the American Academy of Orthopaedic Surgeons

Kier J. Ecklund, MD, et al

include the bony geometry of the

glenoid and coracoacromial arch;
the glenoid labrum; the joint capsule, with associated glenohumeral
ligaments; and the coracohumeral
ligament.
The rotator cuff muscles compress the humeral head against the
concave surface of the glenoid and
labrum, thereby allowing concentric
rotation of the humeral head. This
concept, termed concavity-compression, is thought to be important
at both the mid range and end range
of glenohumeral motion.5 Alterations in the compressive force generated by the rotator cuff ultimately
result in instability and translation
of the humeral head. Furthermore,
biomechanical studies have demonstrated the importance of shoulder
force-couples as generated by a balanced rotator cuff to maintain centering of the humeral head within
the glenoid.6,7

Pathogenesis
In 1972, Neer8 described anterior
acromioplasty done for the treatment of impingement syndrome.
Anterior acromioplasty was undertaken in the belief that most rotator
cuff injuries result from mechanical
compression of the rotator cuff tendons under the coracoacromial arch.
More recent histologic studies challenged this hypothesis.9,10 These authors reported no evidence of pathologic change on the undersurface of
the acromion in shoulders with articular-sided, partial-thickness rotator cuff tears. The authors suggested
that a separate process caused by intrinsic changes within the tendon itself leads to tendon degeneration and
eventual tearing.9,10 Because of these
findings, surgical dbridement of the
involved tendon may be undertaken
before repair.
A hypothesis has emerged recently that the origin of rotator cuff disease is multifactorial, including both
extrinsic and intrinsic factors. Extrinsic factors include the anatoVolume 15, Number 6, June 2007

my of the coracoacromial arch, tensile overload of the tendon, and

repetitive-use phenomena; intrinsic
factors include age-related degeneration, tendon vascular supply, regional variation in the material properties of the tendon, and structural
abnormalities of collagen fiber orientation.11,12
Given this hypothesis of the etiology of rotator cuff disease, little is
known about the natural history of
cuff tears. Yamaguchi et al12 reviewed 45 patients with unilateral
symptoms who, at a mean followup of 5.5 years, had contralateral
asymptomatic rotator cuff tears detected with ultrasound. Over an average of 2.8 years, 23 of the patients
developed symptoms, with corresponding decreases in the average activities of daily living score and increases in the mean visual analog
pain score.
Two additional prospective studies on asymptomatic tears have
demonstrated an age-related increase in prevalence. Using magnetic resonance imaging, Sher et al11
found a 28% prevalence of fullthickness tears in patients aged
>60 years compared with a 4% prevalence in those aged between 40 and
60 years. Using ultrasound, Milgrom et al13 reported a 50% prevalence of partial- or full-thickness
tears in patients aged >70 years. Neither study found any correlation between activity level and prevalence
of cuff tears.
Although the natural history of
symptomatic rotator cuff tears is not
well documented, many authors
have reported on the outcome of surgical intervention. Galatz et al14
conducted a prospective cohort
study of 33 patients, with standardized outcome measurements at
2 and 10 years. At 10 years, the authors reported no change in the Constant score or patients subjective assessment of the surgery relative to
the outcomes at the 2-year followup. These outcomes provide evidence that the results for open rota-

tor cuff repairs do not deteriorate

with time.
Although the underlying factors
that may cause small or single tendon rotator cuff tears to progress to
massive, multi-tendon rotator cuff
tears are poorly understood, hypotheses have been offered to explain the
development of cuff tear arthropathy. In the rheumatology literature,
the term Milwaukee shoulder was
introduced to describe the condition
in four elderly women who had bilateral massive tears of the rotator
cuff, destructive glenohumeral arthritis, and recurrent shoulder effusion (ie, geyser sign)15 (Figure 1).
In the original three reports on the
Milwaukee shoulder,15-17 an association was identified between the presence of calcium phosphate crystals
within the shoulder joint and cuff
tear arthropathy. The hypothesis
that was developed from these reports suggests that hydroxyapatite
crystals accumulate within the altered capsule, synovium, and cartilage of shoulders with massive cuff
tears. These crystals are released into
the synovial fluid as basic calcium
phosphate crystals (octacalcium
phosphate or carbonate-substituted
hydroxyapatite). These crystals are
phagocytosed by cells within the
synovium, which accumulate them
into microspheroids, stimulating the
release of proteolytic enzymes, including collagenase and protease.
These enzymes lead to articular, capsular, and cuff destruction. Essentially, the response is a form of lowgrade inflammation and synovial
hyperplasia with the degradation of
cartilage-matrix components.
The hypothesis of Neer et al3 was
based on a series of 26 patients who
underwent total shoulder arthroplasty (TSA) for cuff tear arthropathy.
Ages ranged from 50 to 87 years
(average, 69 years); 20 patients were
women and 6, men. These patients
had long-standing, progressive shoulder pain that was worse at night and
appeared to be the result of impingement rather than trauma. The pa341

Rotator Cuff Tear Arthropathy

Figure 1

Table 1
Radiographic Findings in Cuff Tear
Arthropathy
Superior migration of the humeral
head resulting in decreased
acromiohumeral distance
Osteophytes
Joint space narrowing
Rounding of the greater tuberosity
of the proximal humerus
Acetabularization of the
undersurface of the acromion
Superior glenoid wear
Osteopenia of the acromion and
proximal humerus
Glenohumeral joint subluxation

A patient with rotator cuff tear arthropathy demonstrating a geyser sign, in which
the destruction of the rotator cuff allows a hemorrhagic shoulder effusion to escape
into the subcutaneous tissue.

tients had shoulder swelling, tears of

the supraspinatus and infraspinatus
muscles, and, in 21 of 26 patients,
rupture of the long head of the biceps. Based on findings at surgery in
this group of patients, Neer et al3
presented a hypothesis that relied on
mechanical and nutritional changes
that occur in these patients. He
stated that the massive rotator cuff
tear and the rupture of the long head
of the biceps in these patients led to
proximal migration of the humeral
head and subsequent acromial impingement. The loss of these dynamic stabilizers of the glenohumeral joint leads to repetitive
trauma of the articular surface; the
repetitive trauma in turn causes loss
of cartilage. Furthermore, the loss of
an enclosed joint space leads to poor
diffusion of nutrients to the articular
cartilage, thereby compounding the
damage. Secondary to disuse of the
shoulder, the subchondral bone becomes more osteoporotic, resulting
in humeral head erosion. As the joint
surfaces erode, the passive stability
they afford is compromised.3
Collins and Harryman18 described
the pathogenesis as a combination of
these two hypotheses. They pro342

posed that the tear begins in the supraspinatus as a chronic degenerative tear. Progression of this tear
eventually leads to superior subluxation of the humeral head. Impingement of the remaining cuff tissue
against the acromion occurs, resulting in humeral articular surface
wear. Cartilage fragmentation results in particulate debris, which
causes synovial thickening and effusion as well as the generation of calcium crystals, as described. The
enzymatic response to these crystals
furthers the damage to the remaining cuff tissue and articular
surfaces.4 Although this is the most
satisfying hypothesis on the development of cuff tear arthropathy, it
remains unclear why only a percentage of patients with massive rotator
cuff tears progress to cuff tear arthropathy.

Diagnosis
Rotator cuff tear arthropathy occurs
in women more than in men, and
the dominant side is more commonly affected.4 Clinical findings include
joint effusion, pain (often worse at
night and with activity), and loss of

motion.18 In the original description

of Neer et al,3 patients had a longstanding history of pain, from 2 to 20
years (average, 9.8 years).
Physical examination demonstrates weakness suggestive of a
massive tear of the rotator cuff combined with superior translation and
incongruity of the glenohumeral
joint. Synovial fluid is free to communicate between the glenohumeral
joint and subacromial bursa. There
is marked atrophy of the shoulder
musculature, especially the supraspinatus and infraspinatus muscles, combined with weakness in external rotation.19 As noted, Neer et
al3 reported that the tendon of the
long head of the biceps was ruptured
or dislocated in 21 of 26 patients in
the original series; however, the role
of the long head of the biceps to prevent superior translation of the humeral head is currently debated.
Both passive and active ranges of
motion of the shoulder are often severely limited, as are associated softtissue contractures. In this series,
only 2 of 26 patients could actively
elevate the shoulder above 90.3
Radiographs demonstrate a spectrum of characteristic findings in patients with cuff tear arthropathy (Table 1). Superior migration of the
humeral head to varying degrees and
subsequent articulation with the un-

Journal of the American Academy of Orthopaedic Surgeons

Kier J. Ecklund, MD, et al

dersurface of the acromion result

from the massive rotator cuff tear.
These findings manifest on radiographs as decreased acromiohumeral
distance (Figure 2). Additional radiographic findings with rotator cuff arthropathy include rounding of the
greater tuberosity of the proximal
humerus, erosion/acetabularization
of the undersurface of the acromion,
superior wear of the glenoid, osteopenia of the proximal humerus
and acromion, and translation of the
glenohumeral joint. These findings
are in contrast with those of primary
degenerative joint disease, in which
there are osteophytes inferiorly and
medially on the humeral head, along
with posterior glenoid wear.
Visotsky et al20 developed a classification scheme for the progression
of cuff tear arthropathy based on
clinical and radiographic parameters.
The scheme posits two types: centered (type I) and decentered (type II),
with two subdivisions in each type
(Table 2). Radiographically, type I
demonstrates minimal superior migration of the humeral head. Subtype
IA shows early femoralization
(rounding of the tuberosities) of the
humeral head and acetabularization (concave erosive change of the
undersurface of acromion) of the acromion. Subtype IB shows additional
medial erosion of the glenoid. Type II
shows more severe superior migration of the humeral head, resulting
in anterosuperior escape of the head
in subtype IIB. In patients with severe glenoid erosion, the coracoid
process also demonstrates erosion.
Arthrography, magnetic resonance
imaging, ultrasound, and computed
tomography also reveal findings consistent with the severe rotator cuff
deficiency and the bony changes visible on plain radiographs. Although
confirmatory, these studies are not
necessary for diagnosis.

Management
Despite a wide spectrum of treatment options available for patients
Volume 15, Number 6, June 2007

Figure 2

A, Anteroposterior radiograph of a shoulder with cuff tear arthropathy. Superior

migration of the humeral head with degenerative changes in the glenohumeral joint,
glenoid erosion, acromial erosion, and femoralization of the humeral head are
apparent. B, A scapular Y radiograph of a shoulder with cuff tear arthropathy,
demonstrating superior migration of the humeral head and diffuse osteopenia.

with cuff tear arthropathy, there are

no prospective evidence-based data
to support a consensus for treatment. The published literature largely consists of selected retrospective
cases series, which provide the impetus for treatment regimens.
Nonsurgical management remains the first line of treatment in
most patients. It consists of nonsteroidal anti-inflammatory medication and rehabilitation. Many surgeons do not recommend repeated
injection of corticosteroid, given the
risk of infection and the lack of efficacy in rotator cuff tear arthropathy.4 Surgical treatment options include arthroscopic lavage, humeral
tuberoplasty, shoulder arthrodesis,
and shoulder replacement with prosthesis.4 However, many of these options have been discarded because of
poor outcomes; their interest lies in
their historical importance.
Historical Methods
Cofield and Briggs21 reported on
the long-term outcome of shoulder
arthrodesis undertaken for cuff tear
arthropathy in 12 patients (average

age, 50 years). Six required a second

surgical procedure; two others developed a pseudarthrosis. The poor
bone quality in patients with cuff
tear arthropathy likely influenced
these results. Furthermore, these patients did not compensate well for
complete loss of motion in one
shoulder.
Humeral tuberoplasty has been
described as a procedure for patients
with massive rotator cuff tears
rather than for those with cuff tear
arthropathy. The procedure involves reshaping of the humeral tuberosities with a high-speed burr to
contour them for articulation with
the undersurface of the acromion.
Fenlin et al22 reported the shortterm results (minimum, 27 months)
in 19 patients with irreparable, massive rotator cuff tears. The authors
reported excellent improvement in
pain scores and increased scores in
the modified University of California Los Angeles Shoulder Rating
Scale. Thirteen of the 19 patients
were pain free at follow-up; by comparison, all had intractable pain preoperatively. Others also have sug343

Rotator Cuff Tear Arthropathy

Table 2
Classification of Progression of Rotator Cuff Tear Arthropathy20
Type
I: Centered
IA: Stable

IB: Medialized

II: Decentered
IIA: Limited
stable

IIB: Unstable

Description
Minimal superior migration of the humeral head
Intact anterior restraints
Minimal superior migration
Dynamic joint stabilization
Acetabularization of coracoacromial arch and
femoralization of humeral head
Intact anterior restraints/force couple intact
Minimal superior migration
Compromised dynamic joint stabilization
Medial erosion of the glenoid
Severe superior migration of the humeral head
Compromised anterior restraints/compromised
force couple
Superior translation of humerus
Insufficient dynamic joint stabilization
Minimum stabilization by coracoacromial arch
Superomedial erosion of glenoid
Incompetent anterior structures
Anterior superior escape
Absent dynamic joint stabilization
No stabilization by coracoacromial arch

gested that humeral tuberoplasty

may be useful in patients with cuff
tear arthropathy.4
Indications for joint arthroplasty
surgery are intractable pain that is
unresponsive to nonsurgical care, a
functional deltoid, and an intact coracoacromial arch.18 In a review of
semiconstrained shoulder arthroplasties for cuff tear arthropathy,
Nwakama et al23 recommended nonsurgical treatment of patients whenever possible because of the complications associated with these
devices. These authors listed severe pain, recurrent hemorrhage,
and large cyst formation as indications for surgical intervention.
Others4,18,24-26 have stressed the importance of adequate deltoid function and an intact coracoacromial
arch as prerequisites for any type of
shoulder arthroplasty in patients
with rotator cuff tear arthropathy.
Many prosthetic designs have
been proposed for the treatment of
cuff tear arthropathy. One of the first
was the constrained total shoulder
arthroplasty (TSA). Although varie344

ties exist, all exhibit fixed-fulcrum

mechanics. That is, the humeral
component is allowed to move
within the glenoid component but
cannot dissociate from it unless the
glenoid component is broken. Originally, it was thought that a constrained prosthesis would improve
function in rotator cuffdeficient
shoulders by stabilizing the center of
rotation, thereby allowing motion.
However, constrained shoulder arthroplasty has been abandoned in the
United States because of high rates
of revision surgery for complications,
including implant loosening, implant failure, and instability.27
Traditional, nonconstrained TSA
has been used to treat multiple
shoulder diseases, including osteoarthritis, rheumatoid arthritis, osteonecrosis, and posttraumatic arthritis. It was introduced by Neer et al3
as an addition to hemiarthroplasty
to prevent excessive excursion of the
prosthetic head. Many investigators
reported on the early use of the nonconstrained TSA for these conditions. Franklin et al28 reported a ret-

rospective analysis of TSA in

patients with rotator cuff deficiency.
Patients with cuff deficiency demonstrated significantly greater superior
migration of the humeral prosthesis
on the glenoid component compared
with patients with no rotator cuff
deficiency. The investigators suggested that this superior displacement of the humeral head on the glenoid led to loosening of the glenoid
component and a rocking horse
phenomenon of glenoid loosening.
Gristina et al29 recognized that the
change in the center of rotation on
the glenoid could lead to glenoid
loosening. Poor glenoid bone stock
makes secure glenoid component
fixation more difficult in patients
with cuff tear arthropathy.
Another solution to the problem
of superior humeral head migration
in patients with cuff tear arthropathy
has been to use a semiconstrained
glenoid component in which migration is blocked by a hood or subacromial spacer. Neer et al30 reported on
the use of an enlarged glenoid component that possessed a superior
hood to resist humeral component
superior migration. A higher prevalence of radiolucency was found
around these semiconstrained glenoid components compared with
standard components. Amstutz et
al31 used a different hooded total
shoulder system to prevent superior
subluxation and noted results similar to those of Neer et al.30 Finite element analysis of different glenoid
designs by Orr et al32 supports the
findings of both Neer et al30 and Amstutz et al.31 Orr et al32 found that
hooded glenoid component designs
had increased tensile stresses at the
inferior portion of the glenoid componentbone interface, with increased compressive stresses at the
superior portion. These stresses, in
turn, may lead to the rocking
horse phenomenon described by
Franklin et al.28
More recently, Nwakama et al23
found evidence of radiographic glenoid loosening in three of seven

Journal of the American Academy of Orthopaedic Surgeons

Kier J. Ecklund, MD, et al

semiconstrained implants, glenoid

translation in one of seven, and anterosuperior subluxation in five of
seven. Furthermore, range of motion
in semiconstrained designs has been
less than satisfactory.23
Swanson et al33 developed a bipolar hemiarthroplasty for the treatment of severe arthritis associated
with rotator cuff deficiency. The proposed advantage involved a large humeral head, which would increase
the stability of the articulation
while decreasing impingement of
the tuberosities during abduction. A
final effect of the larger head was increased glenoid and coracoacromial
contact, which would distribute the
pressure over a larger area than
would a smaller head. With two separate articulations, the bipolar design was thought to decrease prosthetic contact forces, which would
result in better motion with less
pain. Swanson et al33 originally reported excellent pain relief at an average of 5 years after surgery. However, the authors did not specifically
report on patients with cuff tear arthropathy. Although the authors reported excellent improvements in
pain, activity level, and shoulder
motion, they also noted that the
head of the prosthesis migrated superiorly an average of 8.7 mm at
2 years after surgery.
A study by Worland et al34 reported the use of bipolar hemiarthroplasty in 22 patients with rotator
cuff tear arthropathy (average
follow-up, 28 months). According to
the limited goals criteria proposed
by Neer et al,30 21 of 22 patients had
a successful result as well as improvement in shoulder score.
Currently, bipolar hemiarthroplasty plays a limited role in the
treatment of rotator cuff arthropathy, secondary to issues of overstuffing the glenohumeral joint and the
effects of polyethylene wear debris
that accumulates with the bipolar
design. There has been no demonstrated advantage of the bipolar design over traditional hemiarthroVolume 15, Number 6, June 2007

plasty.4,19,24,34 Although previous

recommendations included the use
of larger humeral heads, present recommendations for hemiarthroplasty
are for either an anatomic replacement of the humeral head or smaller head sizes that, instead of overstuffing the joint, tend to medialize
the center of rotation relative to the
line of pull of the deltoid.
Current Methods
Presently, surgical management
of cuff tear arthropathy relies on
joint arthroplasty from two distinct
categories: hemiarthroplasty and reverse ball-and-socket arthroplasty.
Humeral head arthroplasty remains
the procedure of choice in the
United States for patients aged <70
years who have active elevation
>90 and have an intact coracoacromial arch and anterior deltoid muscle. The reverse ball-and-socket arthroplasty is the procedure of choice
for patients aged 70 years or those
who have no active shoulder elevation available, that is, those with
pseudoparalysis.
Hemiarthroplasty

Historically, hemiarthroplasty has

been used to manage all shoulder
conditions that involve joint degeneration. Many early studies did not
differentiate patients with rotator
cuff tear arthropathy from those
with retained cuff function. Williams and Rockwood19 focused on
the use of hemiarthroplasty in patients with arthropathy. They
stressed dbridement of the rotator
cuff defect; correct choice of the humeral head size, as determined by
the amount of translation; and appropriate repair of the remaining
subscapularis tendon. Eighteen of
their 22 patients had a satisfactory
result,19 according to the limited
goals criteria of Neer et al.30 All patients had decreased pain scores.
Mean active forward elevation improved from 70 to 120. Average external rotation improved from 27 to
46. The authors concluded that

hemiarthroplasty, when performed

properly, is useful for pain relief and
restores shoulder function for activities of daily living.19
A variation of the hemiarthroplasty is the cuff tear arthropathy humeral head, the Global Advantage
CTA Humeral Head (DePuy, Warsaw,
IN). This implant provides an arc of
surface area >180 to allow articulation with the lateral aspect of the
humeral head against the acromion.
Recent studies have demonstrated results similar to those of Williams and Rockwood19 and also have
stressed the importance of a competent coracoacromial arch in patients
with cuff tear arthropathy. In a
group of 16 patients treated with
hemiarthroplasty for rotator cuff
tear arthropathy, Field et al25 found
that 4 of 6 patients with unsuccessful results had undergone prior acromioplasty with coracoacromial ligament release. Three of these four
patients had had anterosuperior subluxation of the humeral head after
the earlier surgery; two of these four
had had deficient deltoid muscle
function secondary to anterior deltoid detachment during the initial
surgery. Field et al25 concluded that
the competency of the coracoacromial arch and deltoid muscle
function were key components for
stability of a hemiarthroplasty undertaken in the treatment of cuff
tear arthropathy.
Studies by Zuckerman et al24 and
Sanchez-Sotelo et al26 also have demonstrated moderate success with
hemiarthroplasty. Zuckerman et al24
found a decrease in pain, an increase
in mean active forward elevation
from 69 to 86, and an increase in
mean external rotation from 15 to
29. Sanchez-Sotelo et al26 reported a
decrease in the mean pain score and
an increase in mean active elevation
from 72 to 91. However, these authors noted anterosuperior instability in 7 of 30 patients and an association between instability and prior
subacromial decompression. Overall,
the result of hemiarthroplasty was
345

Rotator Cuff Tear Arthropathy

Figure 3

Figure 4

Delta III prosthesis (DePuy, Warsaw,

IN). The baseplate is shown with two
fixed-angle locking screws and two
conventional screws.

Reverse Shoulder Prosthesis (Encore,

Austin, TX). Note the central fixed-angle
screw on the glenoid baseplate, shown
here with four surrounding fixed-angle
locking screws.

graded as successful in 67% of shoulders at an average follow-up of

5 years.26
Hemiarthroplasty can provide
good pain relief and return to moderate function in patients with cuff
tear arthropathy. However, instability may be a long-term problem, especially in the patient who underwent prior coracoacromial ligament
release or who is left with deltoid
muscle weakness.
Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty has

recently become available in the
United States for patients with cuff
tear arthropathy. The concept of the
semiconstrained reverse ball-andsocket design was reintroduced by
Grammont in 1985 as the Delta
prosthesis (DePuy).35 Earlier designs
remained essentially experimental;
only two case series were published
in the English-language literature
346

pertaining to these first implants.

Grammonts early design was two
thirds of a spherea metallic ball
cemented to the glenoid (glenosphere). The humeral component
was a polyethylene socket that was
cemented into the medullary canal.35 This prosthesis was used in a
limited fashion and was modified by
Grammont into the Delta III prosthesis in 1991 (Figure 3). The Delta
III was designed for cementless
screw fixation of a glenoid baseplate
to the glenoid. The glenosphere was
attached to the baseplate via a Morse
taper and a central screw. The humeral component became a threepart implant consisting of the
humeral cemented stem, humeral
neck, and polyethylene cup.
The biomechanical concept of a
reverse ball-and-socket prosthesis is
to increase the efficiency of the deltoid muscle for abduction by lengthening the lever arm upon which it

operates, thereby allowing it to generate more torque for a given force.

In the patient with cuff tear arthropathy, the absence of the supraspinatus, infraspinatus, and (occasionally)
parts of the subscapularis and teres
minor muscles makes even limitedfunction abduction difficult. Essentially, the reverse ball-and-socket design relies on the deltoid muscle to
compensate for the loss of rotator
cuff function. Furthermore, the
semiconstrained design of the device
prevents the superior migration and
instability seen in other implants
used for arthropathy.
According to Boileau et al,35
Grammonts design affords the following biomechanical advantages.
(1) The large glenosphere allows
more stability and a large range of
motion. (2) The glenosphere makes
contact with the glenoid surface,
placing the center of rotation of the
shoulder within the glenoid, thereby
reducing the torque on the baseplatebone interface. (3) The medialized
center of rotation increases the number of deltoid muscle fibers recruited
for abduction. (4) Lowering of the humerus places increased tension on
the deltoid muscle.
Since its inception, the Delta III
prosthesis has been used widely in
Europe, with results published of
several clinical studies.35-38 Results
indicate that the Delta III provides
both excellent pain relief and impressive improvement in active abduction in patients with cuff tear arthropathy. However, given the short
periods of follow-up in these studies,
the rate of revision surgery remains
relatively high (4.2% to 13%).35-38
One problem noted is a predilection
toward infraglenoid notching and inferior screw breakage secondary to
humeral component impingement.
Although its significance remains
unclear, infraglenoid notching has
been seen in up to 65% in some
studies.38
A second reverse prosthesis was
recently introduced in the United
States (Figure 4). The Reverse Shoul-

Journal of the American Academy of Orthopaedic Surgeons

Kier J. Ecklund, MD, et al

Figure 5

A, The shoulder, demonstrating the center of rotation and the lateral offset (double-headed arrow). B, The Delta III device
(DePuy) implanted in a shoulder, demonstrating how it causes the center of rotation and offset to shift medially (single-headed
arrow) with respect to the anatomic shoulder. C, The Reverse Shoulder Prosthesis (Encore) implanted in a shoulder,
demonstrating how the device causes the center of rotation and lateral offset to shift medially (single-headed arrow) with respect
to the anatomic shoulder, but to a lesser degree than occurs with the Delta III prosthesis (panel B). (Reprinted with permission
from Lewis E. Calver.)

der Prosthesis (RSP) by Encore (Austin, TX) has distinct design differences compared with the Delta III.
The glenosphere has a more lateral
offset, and the glenoid baseplate has
a central fixed-angle screw for more
stability at the bone-baseplate interface39 (Figure 5). Clinical results from
a group of 60 patients with rotator
cuff deficiency and glenohumeral arthritis at a minimum follow-up of 24
months (average, 33 months) have
shown improvements in functional
scores (from 2.7 to 6.0), pain scores
(from 6.3 to 2.2), forward flexion
(from 55 to 105), abduction (from
41 to 102), and external rotation
(from 12 to 41).39 The complication
rate was 17%, but no patients
showed radiographic evidence of
scapular notching.
Current recommendations and
requirements for the use of the reverse ball-and-socket arthroplasty
in patients with rotator cuff tear arthropathy are failed nonsurgical
management, retained deltoid muscle function, low functional demands in elderly persons, and the
absence of severe comorbidities that
would preclude surgery. Further
Volume 15, Number 6, June 2007

studies are needed to determine the

longevity of these implants in patients with cuff tear arthropathy.

Summary
Although the progression of chronic
rotator cuff tears likely plays a role
in the development of rotator cuff
tear arthropathy, information regarding its pathogenesis is lacking. Controversy remains as to the role of basic calcium phosphate crystals in the
development of cuff tear arthropathy. Nonsurgical management is the
recommended first step in treatment. When nonsurgical management of cuff tear arthropathy fails,
traditional joint arthroplasty may
improve pain and function in appropriately selected patients. However,
long-term complications and patient
dissatisfaction with functional results have encouraged the search for
additional treatment options. Furthermore, patients who have undergone previous operations on the
rotator cuff, with loss of the coracoacromial arch and defects of the
deltoid muscle, have increased rates
of humeral head subluxation follow-

ing hemiarthroplasty. Hemiarthroplasty has demonstrated adequate

pain relief but only modest improvement in functional range of motion
in patients with cuff tear arthropathy.
Encouraging early results have
been reported with reverse ball-andsocket arthroplasty. The ability of
this implant to maintain the humeral socket centrally on the glenosphere may restore normal glenohumeral kinematics in the face of the
compromised primary and secondary stabilizers of the glenohumeral
joint. Studies have demonstrated increased active range of motion attained with this implant, which
leads to improved function for patients with cuff tear arthropathy.
However, complication rates remain
relatively high (17%), and longterm follow-up and increased experience with these implants are needed.
Fortunately, our knowledge of rotator cuff tear arthropathy has increased greatly during the past two
decades, with surgical management
of this disease continuing to improve.
347

Rotator Cuff Tear Arthropathy

Additional Resources
Related clinical topics articles
available on Orthopaedic Knowledge Online: Glenohumeral Arthritis and the Rotator Cuff Deficient Shoulder, by Gregory P.
Nicholson, MD, and Guido Marra, MD.
Rotator Cuff Tears Pathophysiology, by Evan Flatow, MD, and
Leeza Galatz, MD. Offers three
video demonstrations on rotator
cuff repair.
CD-ROM: Reverse Shoulder Arthroplasty for Rotator Cuff Arthropathy, by Evan Flatow, MD,
Kenneth J. Accousti, MD, and
Bradford Parsons, MD. Demonstrates a reverse shoulder arthroplasty for rotator cuff tear that
uses variable angled locking
screws and a porous tantalum ingrowth glenoid baseplate.
Book: Advanced Reconstruction:
Shoulder, Joseph D. Zuckerman,
MD, Editor. Developed in collaboration with the American Shoulder and Elbow Surgeons (ASES).
Provides advice and approaches
for more than 70 shoulder conditions. Over 700 illustrations.

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