Zeman (1998) — The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Zeman, Burkhead·Journal of the American Academy of Orthopaedic Surgeons·1998·54 citations·Shoulder & Elbow

This review addresses the symptomatic rotator cuff-deficient arthritic shoulder, a difficult problem with no consensus management. It proposes a three-category diagnostic framework to guide surgical decisions. It then reviews the surgical options and the technical principles behind each.

Key Findings

The cuff-deficient arthritic shoulder falls into three categories that guide treatment:
–Rotator cuff-tear arthropathy (RCTA)
–Rheumatoid arthritis with cuff deficiency
–Osteoarthritis with cuff deficiency
Only about 4% of full-thickness cuff tears progress to RCTA, so mechanical upward migration alone cannot explain the disease. Neer's model adds a nutritional pathway: a torn cuff breaks the watertight joint space, synovial nutrients leak out, and cartilage atrophies.
Glenoid loosening tracks directly with cuff deficiency. Franklin et al found 7 of 14 cuff-deficient patients had a loose glenoid versus 0 of 16 with intact cuffs. An absent cuff lets the head migrate up and eccentrically rock the component, which is why hemiarthroplasty is preferred over total shoulder replacement here.
With Neer's limited-goals rehabilitation, roughly 80% to 90% of hemiarthroplasty patients reach satisfactory results, though pain relief is far more predictable than restored motion or strength.
Preserving the coracoacromial arch is essential. In Field et al, 3 of 4 patients with prior acromioplasty and cuff repair developed anterosuperior subluxation after hemiarthroplasty, while 10 of 12 with an intact arch and good deltoid succeeded.
Pollock et al showed hemiarthroplasty with subscapularis transposition covered the cuff defect completely in 15 shoulders and gave satisfactory results in all RA patients and 11 of 13 RCTA patients.
Resection arthroplasty and constrained replacement are discouraged. Resection produces a flail, unstable shoulder, and constrained implants generate interface stresses that cause rapid loosening and implant fracture.

Board PearlIn the cuff-deficient arthritic shoulder, use hemiarthroplasty not total shoulder replacement — an absent cuff lets the head rock the glenoid, causing loosening.

Clinical Relevance

When you see arthritis plus an irreparable cuff, the reflex to place a glenoid component is a trap. An absent cuff lets the humeral head ride up and eccentrically load the glenoid, and the loosening rate climbs sharply (7 of 14 cuff-deficient shoulders loosened versus none of 16 with intact cuffs). Choose hemiarthroplasty to sidestep that failure mode.

Protect the coracoacromial arch at all costs, because it is the last restraint against anterosuperior escape once the cuff is gone. This is why a previous acromioplasty is a red flag that predicts subluxation and failure.

Counsel the patient before surgery: this operation reliably relieves pain but does not reliably restore strength or overhead motion. Under Neer's limited-goals rehabilitation, 80% to 90% are satisfied on those terms. Reserve arthrodesis for the deltoid-deficient or multiply-failed shoulder.

Supplemental

The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Zeman·Journal of the American Academy of Orthopaedic Surgeons·1998·54 citations·Shoulder & Elbow

The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Key Findings

Clinical Relevance

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The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Key Findings

Clinical Relevance

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The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Key Findings

Clinical Relevance

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The Rotator Cuff-Deficient Arthritic Shoulder: Diagnosis and Surgical Management

Key Findings

Clinical Relevance

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