Indications for reverse total shoulder arthroplasty in rotator cuff disease

Abstract

Background: Reverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA's approval in 2004, the appropriateness in patients with rotator cuff disease is unclear.

Questions/purposes: We review the use of RTSA in patients with rotator cuff disease to (1) describe classification of rotator cuff tear reparability and the concept of a balanced shoulder; (2) explore the theory behind RTSA design relative to rotator cuff arthropathy; (3) discuss the indications and contraindications for RTSA; and (4) review published outcomes of RTSA for rotator cuff arthropathy.

Methods: We performed a selective review of the literature on the use of RTSA in the treatment of rotator cuff disease.

Results: Modern RTSA designs restore deltoid tension and a functional fulcrum to the rotator cuff deficient shoulder, which allows recovery of active shoulder elevation and effectively restores function in short- and medium-term followup studies.

Conclusions: In short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA.

Clinical relevance: For properly selected patients who have symptomatic and disabling rotator cuff deficiency, RTSA can result in life-changing improvements in pain, motion, function, and patient satisfaction.

Level of evidence: Level V therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Fig. 1A–B

(A) Superior migration of the humerus associated with rotator cuff failure results in loss of deltoid tension; contraction of the deltoid produces superior translation of the humeral head rather than humeral elevation. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.) (B) The reverse prosthesis restores deltoid tension and creates an appropriate fulcrum for the deltoid to produce humeral elevation. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.)

Fig. 2

The Grammont reverse prosthesis design maintains the center of rotation within the glenoid vault, which creates an appropriate fulcrum for the deltoid to produce humeral elevation while reducing the risk of glenoid loosening observed with earlier reverse prosthesis designs. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.)

Fig. 3

Compromise of the anterosuperior rotator cuff results in static anterior subluxation (anterior escape) that is apparent on the axillary radiograph. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.)

Fig. 4

Compromise of the posterosuperior rotator cuff results in static superior subluxation that is apparent on the anteroposterior radiograph. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.)

Fig. 5

This anteroposterior radiograph of a patient with a massive cuff tear without glenohumeral arthritis shows no evidence of superior migration or subluxation of the humeral head. (This figure was published in Gartsman GM, Edwards TB. Shoulder Arthroplasty. Philadelphia, PA: ©Saunders; 2008:219–221.)

Fig. 6

This patient is attempting to raise both arms, demonstrating pseudoparalysis of the right shoulder with associated anterosuperior escape.