a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
The first author to describe the clinical findings from arthropa-thy of the rotator cuff was Robert Adams, in 1857. In 1981,Halverson et al.1described the "Milwaukee shoulder", inwhich crystals of calcium phosphate such as hydroxyapatitewere involved in a cellular reaction with release of collage-nases and joint destruction. However, Neer was the first touse the term "arthropathy of the rotator cuff", in 1977, in astudy published in 1983.2Neer believed that extensive injuryto the rotator cuff was the cause of the arthropathy and pre-sented the hypothesis that this pathological condition mightbe the result of mechanical factors such as anterosuperiorinstability, and nutritional factors such as loss of the closedjoint space, with impairment of nutrient diffusion to the jointsurface. Interruption of the bone circulation that is providedby the rotator cuff also contributes toward the metabolic lossat the humeral head. The final result from these mechani-cal and metabolic alterations, in association with osteopeniathrough disuse of the glenohumeral joint due to pain, consistsof collapse of the glenohumeral joint.
More recently, in 1997, Collins and Harryman5produced asynthesis from the two theories and formulated the hypothe-sis that cranial migration of the humeral head, resulting fromloss of the stability that the rotator cuff provides, leads toabnormal glenohumeral contact and formation of debris in thejoint. Thus, an inflammatory cascade caused by the calciumphosphate crystals that are released is developed.
The incidence of rotator cuff injuries increases with age.They are relatively rare before the age of 40 years, becomemore frequent in the fifth and sixth decades of life and con-tinue to increase in the seventh decade and beyond. Manycases do not present symptoms and approximately 50% of allindividuals over the age of 80 years may have asymptomaticrotator cuff injuries.
Arthropathy of the rotator cuff mainly affects elderlywomen on their dominant side and it triggers chronic symp-toms such as progressive pain, which worsens at night andwith activities that require use of the shoulder. Other symp-toms include weakness and difficulty in raining the arm, andthese give rise to functional limitation. Physical examinationreveals signs of extensive injury to the rotator cuff, such asatrophy of the supraspinatus and infraspinatus muscles.
Radiographs show glenohumeral arthrosis, with cranialdisplacement of the humeral head, which may give rise toabnormal contact between this and the coracoacromial archand thus lead to "rounding" of the greater tubercle ("femor-alization") and to concave erosion of the coracoacromialarch ("acetabulization"). Using radiographs in anteroposterior(AP) view, Hamada et al.11described the natural evolutionof extensive rotator cuff injuries, with the development of degenerative arthropathy, and proposed a classification sys-tem consisting of five evolutionary stages. However, these donot guide the therapy.
Seebauer12developed a biomechanical, functional andmorphological classification system that presents therapeuticrelevance and assesses the integrity of the anterior stabili-zers of the shoulder and coracoacromial arch, the presenceof dynamic stability and the upward migration of the humeralhead. Additional examinations, such as computed tomogra-phy and magnetic resonance imaging, are not necessary fordiagnosing arthropathy of the rotator cuff, but they helpin making preoperative assessments to analyze the bonestock and the conditions of the rotator cuff, such as fattydegeneration.
Treatments for arthropathy of the rotator cuff should bestarted using non-surgical methods, such as modification ofactivities, use of analgesic and/or anti-inflammatory medica-tions and use of subacromial corticosteroid infiltration.
Surgical treatment is indicated for patients who donot respond to conservative treatment. Procedures such asarthroplasty to resect the humeral head and glenohumeralarthrodesis are considered to be salvage methods, to be used inpatients presenting multiple surgical failures, deficiency of thedeltoid muscle and infection. Arthroscopy for debridement,tenotomy of the biceps and tuberculoplasty can be performed,particularly in elderly patients and those with low functionaldemands. Conventional total arthroplasty of the shoulder isnow contraindicated in patients presenting arthropathy of therotator cuff because of the high rate of loosening of the glenoidcomponent. The current alternative arthroplasty options forarthroplasty of the rotator cuff are non-conventional (CTA®)partial arthroplasty and use of a reverse prosthesis.
CTA®partial arthroplasty presents greater lateral extentwith coverage of the tubercle and produces better contactand connection with the coracoacromial arch (Figs. 1 and 2).Reverse prostheses are based on the concepts of Gramontet al.,19involving moving the center of rotation medially anddistally, with gains in deltoid muscle function. This principle
improved the stability of the implant and the range of motion.Nonetheless, despite the good results from reverse prostheses,this is a technically more complex procedure with higher com-plication rates (5% to 33%). CTA®hemiarthroplasty presentsgood results in selected patients, with lower incidence of com-plications than that of reverse prostheses.
Patients who are candidates for CTA®hemiarthroplastyneed to be free from pseudoparalysis, present a coracoacro-mial arch that maintains the relative kinematics of theshoulder joint, without anterosuperior escape (Seebauer typesIA, IB and IIA), absence of previous surgery involving resectionof the coracoacromial arch, functioning motor (intact deltoid)and sufficient subscapular muscle.
The objective of this study was to evaluate the evolution ofthe functional results from CTA®partial arthroplasty for sur-gically treating degenerative arthropathy of the rotator cuff,after a mean follow-up of 5.4 years.
Methods
Between December 2006 and June 2009, 23 shoulders of23 patients underwent CTA®partial arthroplasty to treatarthropathy of the rotator cuff. During a mean follow-up of 1.6years, there were improvements in the clinical parameters andUCLA score, as described in the paper by Brasil Filho et al.14These patients were evaluated prospectively in the presentstudy after a mean follow-up of 5.4 years.
Among the 23 patients who were included in the first study,three were excluded from the present study because they haddied in the meantime and two because they were lost from thefollow-up. Thus, 18 patients remained in the study (Table 1).Among these, there was one patient who evolved with latepostoperative infection and required surgery to remove theprosthesis.
All the patients were operated by the same surgical team(from the Shoulder and Elbow Group of the State of São Paulo
Public Servants' Hospital). A deltopectoral access route wasused.
The length of postoperative follow-up ranged from 4.6 to6.7 years, with a mean of 5.4. The mean age was 78 years. Thedominant limb was affected in 13 patients (72.2%).
The Seebauer classification was used.12In stage IA, thehead is centered in the glenoid; in IB, the head migrates medi-ally and the glenohumeral space becomes pinched; in IIA, thehumeral head migrates superiorly, but is stabilized by the cora-coacromial arch, which remains intact; and in IIB, the humeralhead migrates anterosuperiorly, due to insufficiency of thecoracoacromial arch.
Among the 18 patients included in this study, three wereclassified before the operation as Seebauer lA, seven as lB andeight as llA.
The inclusion criteria were that the patients needed to besymptomatic and classified as Seebauer lA, lB and llA, who didnot improve with conservative treatment over a minimum ofsix months. The exclusion criteria were situations in whichthe patients improved through clinical treatment or presentedprevious surgery or neurological lesions in the limb affected,arthropathy classified as Seebauer llB or insufficiency of thedeltoid muscle and subscapularis muscle.
In evaluating the results, the functional scale of the Univer-sity of California in Los Angeles (UCLA) was used, as modifiedby Ellman and Kay.29To evaluate satisfaction, the Neer crite-ria were used. To measure the range of motion, the methodof the American Academy of Orthopedic Surgeons was used.To compare the UCLA score and range-of-motion results, thenonparametric Friedman test was used.
The statistical significance of the differences in meansbetween the quantitative variables was ascertained by meansof the paired Student's t test and the differences in vari-ance were ascertained by means of analysis of variance(ANOVA). The normality of the variables was tests using theShapiro-Wilk test. All of the analyses were performed using a significance level of 5%. Results with p-values < 0.05 wereconsidered to be statistically significant. Two-tailed optionalhypotheses were always envisaged.
The information gathered formed a database that wasdeveloped using the Excel®software for Windows and the sta-tistical analysis was performed using the Stata®11 SE andSPSS®16.0 software.
Results
After a mean follow-up of 5.4 years, 14 patients consideredthat they were satisfied with the surgery (78%). Among thefour who were dissatisfied, three complained about their lackof gain in range of motion, although they reported havingachieved an improvement in pain in relation to before theoperation. For one patient, the dissatisfaction was due mainlyto pain (Fig. 3).
In relation to the range of motion after a mean follow-up of5.4 years, there was an improvement in the mean active ele-vation, which went from 55.8?before the operation to 82?afterthe operation. The mean external rotation improved from18.9?before the operation to 27.3?after the operation (Fig. 4).The mean medial rotation remained at the level of the thirdlumbar vertebra.
The mean UCLA score after the mean follow-up of 5.4 yearswas 23.94 and this was a significant improvement in compar-ison with the preoperative mean of nine (p < 0.001). A smallimprovement was observed in relation to the mean after thefirst postoperative year (22.39), but without statistical signifi-cance. The mean pain level was 7.67, with a range from 2 to10; function was 6.11, ranging from 4 to 10; active flexion was3.06, ranging from 0 to 5; anterior flexion force was 3.22, ran-ging from 2 to 4; and satisfaction was 3.89, ranging from zeroto 5. There were statistically significant improvements in allthe criteria for assessing the UCLA score (Table 2 and Fig. 5).
There were significant improvements between the pre andpostoperative evaluations, both at one year after the opera-tion and at the end of the follow-up. However, there was nostatistically significant change between the two postoperativeevaluations, performed at means of one and 5.4 years after theoperation (Table 3).
Discussion
CTA®partial arthroplasty for treating arthropathy of the rota-tor cuff is a relatively recent procedure, with few studies
available in the literature, especially with long-term follow-ups.
Vitotsky et al.13conducted a study with a mean follow-upof 32 months and minimum of two years, on 60 patients whounderwent CTA®partial arthroplasty, including Seebauer IA,IB and IIA patients. They obtained satisfactory results in 89% ofthe cases, with mean improvements of 22?in external rotationand 60?in flexion. In our sample, after a minimum follow-upof 4.6 years and mean of 5.4 years, among 18 CTA®partialarthroplasty procedures in 18 patients, the mean satisfactionrate obtained was 78%, with a mean improvement in elevationfrom 55.8?to 82?and in external rotation from 18.9?to 27.3?.Just as in our study, Vitotsky et al.13did not include SeebauerIIB patients.
Over a mean follow-up of 3.7 years, Goldberg et al.18obtained a satisfaction rate of 78%, with mean improvementsof 33?in elevation and 23?in external rotation through usingconventional hemiarthroplasty. The patients with a minimumelevation of 90?achieved the best results. In our study, patientswith elevations of less than 90?were excluded.
In a study with a mean follow-up of 28.2 months on 15cases of hemiarthroplasty, Zuckerman et al.26obtained meanimprovements of 17?in elevation and 14?in lateral rotation.
The satisfaction rate among the patients was 87% and theUCLA score improved from 11 to 22 points.
Checchia et al.33followed up 11 patients who underwenthemiarthroplasty to treat arthropathy of the rotator cuff, fora mean of 69 months. They obtained a pain improvementrate of 81.8%, satisfactory results in 54% and a mean UCLAscore of 22.7 points. These authors observed that certain fac-tors were associated with unsatisfactory evolution, such asprevious surgery on the shoulder with impairment of the cora-coacromial arch and previous injury of the deltoid muscle. Inour sample, patients with previous shoulder surgery and thoseclassified as Seebauer IIB were excluded.
In our study, patients whose main preoperative symp-tom was limitation of movements presented unsatisfactoryresults after the surgery, such that three of the four dissatisfiedpatients reported this complaint. This finding is in conformitywith the study by Nam et al.
The UCLA functional score, which assesses pain, func-tion, active flexion, anterior flexion force and satisfaction,improved from poor (mean of nine points) before the oper-ation, to reasonable after follow-ups of one year and 5.4 years(means of 22.39 and 23.94 points, respectively), which con-firmed that hemiarthroplasty was a good option for surgicallytreating arthropathy of the rotator cuff in selected patients.There was a statistically significant improvement in UCLA, inrelation to before the operation, while the difference betweenthe mean postoperative times of one year and 5.4 years wassmall and non-significant. This can be understood as main-tenance of the positive results from the prosthesis over thispostoperative period.
Since this is a surgical procedure indicated for elderlypatients, one of the factors that caused difficulty in carry-ing out the present study was in relation to making long-termreevaluations on all the patients, because of deaths and lossof follow-up.
Conclusion
The functional results from non-conventional CTA®partialarthroplasty for treating arthropathy of the rotator cuff inselected patients remained satisfactory after a mean follow-up of 5.4 years.
Conflicts of interest
The authors declare no conflicts of interest.
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