Rotator Cuff Deficiency of the Shoulder

Rotator Cuff Deficiency

of the Shoulder

Mark A. Frankle, MD
Chief
Shoulder and Elbow Sugery
Florida Orthopaedic Institute Research Foundation
Temple Terrace, Florida

Thieme
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Library of Congress Cataloging-in-Publication Data

Rotator cuff deficiency of the shoulder / [edited by] Mark A. Frankle.

p. ; cm.
Includes bibliographical references and index.
ISBN 978–1–58890–506–2 (tpn : alk. paper)
1. Shoulder joint—Rotator cuff—Diseases. I. Frankle, Mark A.
[DNLM: 1. Rotator Cuff—surgery. 2. Arthroscopy. 3. Joint Prosthesis. 4. Rotator Cuff—injuries. WE 810 R8417 2008]
RD557.5.R669 2008
617.4’720597—dc22
2007044534

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

1 Biomechanics of Pathophysiology and Repair of Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Kai-Nan An
2 Massive Irreparable Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Mark Mighell
3 Classification of Rotator Cuff–Tear Arthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Ludwig Seebauer
4 Arthroscopic Management of Massive Rotator Cuff Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
James C. Esch and Yuri M. Lewicky
5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear . . . . . . . . . . . . . . . . . . . . . . . . . 37
Robert C. Decker and Spero G. Karas
6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Jonathan Levy
7 Hemiarthroplasty for Rotator Cuff–Tear Arthropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Kamal I. Bohsali, Jeffrey L. Visotsky, Carl J. Basamania, Michael A. Wirth, and Charles A. Rockwood Jr.
8 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The American Experience . . . . . . . 76
Mark A. Frankle, Nazeem Virani, Derek Pupello, and Sergio Gutierrez
9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience . . . . . . . . 105
Pascal Boileau and Christopher Chuinard
10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience . . . . . . . . . . . . . . . . . . . . 120
Gilles Walch and Bryan Wall
11 Treating the Rotator Cuff–Deficient Shoulder: The Mayo Clinic Experience . . . . . . . . . . . . . . . . . . . . . 135
John W. Sperling and Robert H. Cofield
vi Contents

12 Treating the Rotator Cuff–Deficient Shoulder: The Columbia University Experience . . . . . . . . . . . . . . 138
John-Erik Bell, Sara L. Edwards, and Louis U. Bigliani
13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience . . . . . . 147
Mark A. Frankle, Derek Pupello, and Derek Cuff
14 Tissue Engineering for the Rotator Cuff–Deficient Shoulder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Joshua S. Dines, Daniel P. Grande, and David M. Dines

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Foreword
Rotator cuff problems are the most common source of
shoulder pain, and as such are thoughtfully included in the
diagnostic evaluation of patients presenting with shoulder
pain. A tremendous spectrum of injury and disease affects
the rotator cuff. The list of issues is almost too long to enu-
merate, including strain, inflammation, abrasion, partial
tearing with tear sizes extending from small to extra-large,
and acute or chronic full-thickness tearing. Related issues
involving the long-headed biceps, degenerative changes on
the acromion process or hypertrophic enlargement of the
acromioclavicular joint, stiffness or instability, and varying
degrees of associated arthritic involvement of the gleno-
humeral joint also affect the rotator cuff. One can spend
an entire professional career studying these various areas
and trying to reach conclusions about the best treatment
utilizing current knowledge.
Over the last several decades, a revolution has occurred.
The introduction of arthroscopy and the development of
arthroscopic surgical tools have created an entirely new
approach to dealing with rotator cuff problems. Magnetic
resonance imaging has allowed visualization of details of
the rotator cuff and its musculature that was heretofore
not possible. A new type of shoulder prosthesis has been
introduced to replace not only arthritic joint surfaces but
also a deficient rotator cuff. Earlier attempts at this had
been inconsistent with limited effectiveness. However,
now there is promise that a new implant, the reverse type
of shoulder prosthesis, will have the necessary consistency
and effectiveness to become a first-line treatment choice
for patients with concordant rotator cuff deficiency, sub-
stantial arthritis, and usually a lack of active motion away
from the side.
Dr. Mark A. Frankle, the editor of this book, is an ex-
tremely energetic champion to further the understanding
of the rotator cuff deficient shoulder and its treatment. He
has brought together a magnificent set of chapters by au-
thors with unparalleled scientific background and practical
experience. For example, Professor Kai-Nan An has authored
hundreds of peer-reviewed manuscripts on the biomechan-
ics of the upper extremity, and he codifies his understanding
of these concepts in the introductory chapter. Other schol-
arly authors bring to the book focused information on epide-
miology and natural history, conservative treatment, arthro-
scopic initiatives, muscle replacement, tendon replacement,
and the thoughtful reminder of the full spectrum of disease
that can occur within this area. The main subject, cuff tear
arthropathy, is introduced with a thorough discussion of
classification systems defining the various components of
this problem. In considering prosthetic replacement, the
tried-and-true role of hemiarthroplasty is presented with its
great benefits and its striking limitations as well. The coup
de grâce, though, is the magnificently expansive discussion
of the rational and mechanics for the reverse shoulder pros-
thesis. This is coupled with exposition of the clinical experi-
ence from four centers. These unaltered opinions side by
side allow the reader to compare and contrast viewpoints—
something that just cannot be done in scientific journals,
but only in a textbook setting.
We are all well schooled in the concepts of evolution
and the supposition that things slowly change over time.
In fact, the changes are uneven in magnitude and have no
set schedule. The quite dramatic, rapid changes that have
occurred in this area may have been completed in our pro-
fessional lifetimes. As we are unable to predict the future
with any degree of accuracy, I think we all must believe
that the material included in this text may endure for quite
some time. Congratulations to Dr. Frankle for developing
the concept for this book so wonderfully and to all the au-
thors for helping us to better understand rotator cuff de-
ficiencies and their myriad manifestations of presentation
and nuances for treatment.
Robert H. Cofield, MD
Caywood Professor of Orthopaedics
Mayo Clinic College of Medicine
Consultant in Orthopaedic Surgery
Mayo Clinic
Rochester, Minnesota
Preface
In the early 21st century, the diseases faced by developed
nations have begun to shift. The number of people who are
over 50 years of age will soon outnumber those under 50.
This demographic change will correspondingly increase
the disease burden in this segment of the aging popula-
tion. It is estimated that once a person reaches the age of
65, he or she has a 50% chance of developing a torn rotator
cuff. The millions of people already affected by rotator cuff
disease has accounted for billions of dollars in health-care
costs to diagnose and treat this problem. Additionally, the
economic impact of disabled workers due to rotator cuff
injuries cannot be overstated. Although the majority of
these patients are able to be treated conventionally for re-
pairable rotator cuff tears, there exists an ever-increasing
number of patients faced with an irreparable tear. Many
of these people are often given confusing information re-
garding their options and are offered treatments unlikely
to help. As a result, they may increase their pain and di-
minish their shoulder function.
This situation has evolved from a combination of factors
including our inability as physicians to recognize when
these tears are beyond repair with conventional methods
and our reluctance to recognize the increasing magnitude
of the problem, which suggests a course of benign neglect.
To stop this problem, we must identify nonoperative treat-
ments that compensate for the rotator cuff defect and
consider operative treatments such as reconstructive sur-
gery. To this end, I have recruited physicians from around
the world who have demonstrated their authority on the
successful treatment of patients with a rotator cuff–de-
ficient shoulder. The historical perspective, classification,
and nonoperative and operative management of rotator
cuff disease of various well-known institutions is shared
within several unique chapters. It is my hope that this book
will be helpful to orthopedic surgeons who focus on treat-
ing patients with shoulder problems by providing an array
of successful treatment methodologies.
Acknowledgment
For their efforts, I would like to acknowledge all the con-
tributing authors and the research group at the Florida
Orthopaedic Institute Research Foundation led by Derek
Pupello, whose help has been immeasurable.
Contributors

Kai-Nan An, PhD Pascal Boileau, MD

Professor
Mayo Clinic College of Medicine
Director, Biomechanics Laboratory
Division of Orthopaedic Research
Mayo Clinic
Rochester, Minnesota
Carl J. Basamania, MD
Chief of Shoulder Surgery
Division of Orthopaedic Surgery
Duke University Medical Center
Durham, North Carolina
John-Erik Bell, MD
Department of Orthopaedic Surgery
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Louis U. Bigliani, MD
Professor and Chairman
Department of Orthopaedic Surgery
Columbia College of Physicians and Surgeons
New York Presbyterian Hospital
Columbia University Medical Center
New York, New York
Professor and Chairman
Department of Orthopaedic Surgery and Sports
Traumatology
Hôpital de L’Archet–University of Nice
Nice, France
Christopher Chuinard, MD, MPH
Shoulder and Elbow Surgeon
Great Lakes Orthopaedic Center
Traverse City, Michigan
Robert H. Cofield, MD
Professor
Department of Orthopaedic Surgery
Mayo Clinic College of Medicine
Mayo Clinic
Rochester, Minnesota
Derek Cuff, MD
Florida Orthopaedic Institute Research Foundation
Temple Terrace, Florida
Robert C. Decker, MD
Fellow
Department of Orthopaedics
Emory University School of Medicine
Atlanta, Georgia

Kamal I. Bohsali, MD David M. Dines, MD

Attending Orthopaedic Surgeon
Shoulder and Elbow Reconstruction
Department of Orthopaedics
Memorial Hospital
University of Texas Health Science Center
San Antonio, Texas
Professor and Chairman
Department of Orthopaedics
Albert Einstein College of Medicine
Bronx, New York
Hospital for Special Surgery
Great Neck, New York
xii Contributors

Joshua S. Dines, MD Derek Pupello, MBA

Kerlan Jobe Orthopaedic Clinic Executive Director
Los Angeles, California Florida Orthopaedic Institute Research Foundation
Temple Terrace, Florida
Sara L. Edwards, MD
Oakland Bone and Joint Specialists Charles A. Rockwood Jr., MD
Oakland, California Professor and Chairman Emeritus
Department of Orthopaedics
James C. Esch, MD University of Texas Health Science Center
Assistant Clinical Professor San Antonio, Texas
Department of Orthopaedics
School of Medicine Ludwig Seebauer, MD
University of California–San Diego Chairman
Orthopaedic Specialists of North County Department of Orthopaedics, Sports Medicine and
Oceanside, California Traumatology
Director
Mark A. Frankle, MD Center for Orthopaedics and Trauma Surgery
Chief Munich, Germany
Shoulder and Elbow Surgery
Florida Orthopaedic Institute Research Foundation John W. Sperling, MD, MBA
Temple Terrace, Florida Associate Professor
Department of Orthopaedic Surgery
Daniel P. Grande, PhD Mayo Clinic College of Medicine
Research Director Mayo Clinic
Department of Orthopaedic Surgery Rochester, Minnesota
Long Island Jewish Medical Center
Orthopedic Research Laboratory Nazeem Virani, MD
North Shore University Hospital Florida Orthopaedic Institute Research Foundation
Manhasset, New York Temple Terrace, Florida

Sergio Gutierrez, MS Jeffrey L. Visotsky, MD

Florida Orthopaedic Institute Research Foundation Orthopaedic Surgeon
Temple Terrace, Florida Des Plaines, Illinois

Spero G. Karas, MD Gilles Walch, MD

Assistant Professor Department of Shoulder Surgery
Department of Orthopaedics Division of Orthopaedic Surgery
Emory University School of Medicine Clinique St. Anne-Lumière
Emory Orthopaedic and Spine Center Lyon, France
Atlanta, Georgia
Bryan Wall, MD
Jonathan Levy, MD Orthopaedic Surgeon
Florida Orthopaedic Institute Research Foundation Sun City, Arizona
Temple Terrace, Florida
Michael A. Wirth, MD
Yuri M. Lewicky, MD Professor
Northern Arizona Orthopaedics Department of Orthopaedics
Summit Center Sports Medicine Shoulder Service
Flagstaff, Arizona University of Texas Health Science Center
San Antonio, Texas
Mark Mighell, MD
Shoulder and Elbow Surgery
Florida Orthopaedic Institute Research Foundation
Temple Terrace, Florida
 1 Biomechanics of Pathophysiology and
Repair of Rotator Cuff Tears
Kai-Nan An
Rotator cuff (RC) muscles are an integral part of the shoul-
der. The RC provides the torque needed to move the joint
as well as the force to stabilize the joint. RC ruptures are
frequently associated with loss of strength and stability of
the shoulder. Biomechanical studies have been performed
to explore the potential etiology of the injury and to assess
various treatment modalities. In this chapter, I will discuss
the basic concepts that relate to the RC muscle function
and injury, along with the biomechanical considerations
for the treatment of shoulders with RC deficiency.
The Rotator Cuff as Joint Mover
The function of muscle as a joint mover depends on the
muscle’s physiology and its mechanical efficiency. The
physiological cross-sectional area represents the effective
size of the muscle, which determines the ability of the mus-
cle to generate force. The physiological cross-sectional area
is not simply the area of a given muscle cross-section, but
the cross-section of the muscle fibers as calculated by di-
viding the muscle volume with the fiber length. The physi-
ology
Tears
14530_C01.indd 1
ological cross-sectional area of the RC muscles has been
studied and reported in the literature.1,2 The physiological
cross-sectional areas for the subscapularis, supraspinatus,
infraspinatus and teres minor muscles combined are 16.30,
5.72, and 13.75 cm2, respectively. The combined RC muscles
contribute almost 35% of the physiological cross-sectional
area of all the muscles crossing the shoulder joint.1 Within
the RC, the contributions of each muscle are 53, 10, 22, and
14% for the subscapularis, teres minor, infraspinatus, and
supraspinatus muscles, respectively.2
In addition to the physiological cross-sectional area,
the potential muscle contractile force further depends on
muscle length at contraction. As illustrated in the muscle
length-tension relationship, the peak muscle force is gen-
erated when the sarcomere is near optimal length (Fig.
1–1). Excessive shortening of the sarcomere reduces the
force generation as indicated by the ascending limb of the
length-tension curve on the left. On the contrary, excessive
sarcomere lengthening reduces force generation, as shown
by the descending limb on the right. Such length-tension
relationship needs to be considered in RC tear repair. The
supraspinatus muscle normally operates in the range near
the plateau of the length-tension curve, where A represents
10.1055/978-1-58890-635-9c001_f001
Figure 1–1 Potential muscle contractile force depends on
muscle length. The supraspinatus muscle normally oper-
ates in the range near the plateau of the length-tension
curve, where A represents the muscle at elongated length
when the arm is in the dependent position, and B repre-
sents the shortened muscle length when the arm is in full
abduction. Stretch of the tendon will shift the physiologi-
cal range of operation to the right on the length-tension
curve between A´B´. On the other hand, the infraspina-
tus muscle normally operates in the ascending limb of the
length-tension curve.
1/31/08 11:08:11 AM
 2 Rotator Cuff Deficiency of the Shoulder
the muscle at elongated length when the arm is in the de-
pendent position, and B represents the shortened muscle
length when the arm is in full abduction. In the cuff repair,
stretching of the tendon and muscle is usually required to
reattach the muscle to the tuberosity. Such stretching will
shift the physiological range of operation to the right on
the length-tension curve between A´ B´. With such a shift,
the force generation potential with the arm at the depend-
ent position is, therefore, compromised. Such reduction in
force generation could be clinically critical because the RC
muscles are instrumental in initiating abduction motion.
To avoid such a stretching effect, a patch graft could be uti-
lized to maintain the proper length-tension relationship.
On the other hand, the infraspinatus muscle normally op-
erates in the ascending limb of the length-tension curve.
Therefore, any stretch of the tendon and muscle of infra-
spinatus in the repair of defect will shift the range of func-
tion from AB to A ´B´, which will not compromise the force
generation of the muscle.
The moment arm (MA) further determines the me-
chanical efficiency of the muscle force in generating
torque around a joint. In general, the MA about different
axes of rotation for a given joint varies with joint posture.
Geometrically, the MA is measured as the shortest distance
between the line of action of the muscle and the axis or
center of rotation of the joint. Experimentally, it is difficult
to have an accurate assessment of the MA in such meas-
urement due to the errors in defining the line of action
as well as the joint center of rotation. Alternatively, the
MA could be determined based on an intimate relationship
among these three parameters.3 The instantaneous MA (r)
or mechanical advantage of a tendon can be related to the
tendon excursion (E) and the joint rotation () as:
MA(r) = dE/d
This concept has been used extensively in the past for
accurately assessing the muscle and tendon MAs in physi-
ological and pathological conditions.
Based on the above principle, the MAs of infraspinatus
and subscapularis muscles were noted to contribute not
only to external rotation (ER) and internal rotation (IR),
respectively, but also to the elevation of the arm in the
plane of the scapula, a role for which these muscles has
been given little or no consideration.4 The contribution of
the infraspinatus muscle to abduction is enhanced with IR,
whereas that of the subscapularis muscle is enhanced with
ER. Thus elevation of the arm in the dysfunction of the
supraspinatus muscle could potentially be compensated
by the remaining RC muscle through proper rehabilitation
and strengthening.4 The subscapularis muscle is a more
important elevator in the scapular plane than either the
supraspinatus or infraspinatus muscle, especially in the
latter phases of motion.5
Axial humeral rotation is an important movement com-
monly performed during activities of daily living and is a
targeted motion of shoulder rehabilitation, particularly in
14530_C01.indd 2
those protocols emphasizing RC strengthening.6 With the
humerus in neutral or elevated positions, the infraspinatus
is the most powerful external rotator, followed by teres mi-
nor. The subscapularis muscle is the most effective internal
rotator in this position.
Effects of Injury and Repair of Rotator
Cuff Tears on Joint Torque
RC tears are frequently associated with loss of shoulder
strength. The tendon detachments, tendon defects, and
muscle retractions of supraspinatus and infraspinatus
disturb the force transmission to the humerus and torque
generation by the RC. In two studies, these effects on force
transmission and joint torque were measured in various
types of simulated defects using cadaver specimens.
Detachment or creation of a defect involving up to two
thirds of the supraspinatus tendon resulted in a minor re-
duction in the force transmitted by the RC. Creation of a
defect involving the whole supraspinatus tendon resulted
in a moderate reduction. However, a simulated muscle
retraction involving one-third and two-thirds of suprasp-
inatus tendon, as well as the whole supraspinatus tendon
resulted in losses of torque of 19, 36, and 58%, respectively.
These findings support the rotator cable concept that cor-
responds to the clinical observation that patients with a
small rupture of the RC might present without a loss of
shoulder strength. Muscle retraction is potentially an im-
portant factor responsible for the loss of shoulder strength
following large RC ruptures.7
RC ruptures that extend into the infraspinatus tendon
may cause dysfunction. One study was performed to deter-
mine whether a threshold size of infraspinatus defect exists,
beyond which abduction torque generation decreases sub-
stantially.8 It was found that the glenohumeral abduction
torque progressively decreased with greater infraspinatus
detachment. When detachment extended to three-fifths of
the infraspinatus, abduction torque reduced 52% of the in-
tact condition, which was a significantly larger reduction
compared to supraspinatus release alone. The inferior por-
tion of infraspinatus, which includes the rotator cable in-
sertion, plays a role in transmitting the compression forces
across the glenohumeral joint.8
In the repair of rotator cuff tears, the torn tendon cannot
always be freed adequately to permit reattachment at its
original anatomical insertion site. An option is to advance
the site of insertion medially and reattach the tendon to a
trough in the sulcus or to the humeral head. The biome-
chanical effects of such medial advancement on the MA of
the supraspinatus muscle during glenohumeral elevation
were studied using fresh-frozen shoulders from cadavera.9
Medial advancement of the site of insertion of the supra-
spinatus tendon was simulated by the placement of suture
anchors in the sulcus of the proximal part of the humerus
1/31/08 11:08:12 AM
 1 Biomechanics of Pathophysiology and Repair of Rotator Cuff Tears
at points 3, 10, and 17 mm medial to the junction of the
supraspinatus tendon and the bone. Three and 10 mm of
medial advancement of the tendon had a minimum effect
on the MA during elevation compared with the value deter-
mined for the intact condition. However, 17 mm of medial
advancement was found to reduce the MA significantly.
Superior transposition of the subscapularis tendon has
been recommended for surgical repair of massive tears of
the RC. Superior transposition of the subscapularis tendon
significantly increased its abduction MA.10 The effect was
optimal when the simulated insertion site was lateral rather
than medial and, to a lesser extent, anterior versus poste-
rior. The results provided a biomechanical rationale for
subscapularis tendon transposition in restoring the loss of
abduction strength of the shoulder in a massive cuff tear.
Repair of large defects for RC tears associated with
muscle retraction is sometimes impossible. Biological or
synthetic patch graft has been proposed for the coverage
and restoration of the anatomy for load transfer. In one
study, a simulated supraspinatus tendon defect and retrac-
tion, and patch repair was performed.11 A patch graft was
inserted into the defect and the effects of reattachment to
the greater tuberosity, narrowing of the defect by using
a smaller graft, and anterior graft attachment (rotator in-
terval tissue versus subscapularis) were investigated (Fig.
1–2). Compared with the torque generation after creation
of a supraspinatus defect, the abduction torque was re-
stored with a graft placed between the infraspinatus and
either the rotator interval (68% of normal) or the subscapu-
laris (80% of normal). The optimum grafting technique for
abduction torque restoration occurred with a reduced size
patch connected anteriorly to the subscapularis and su-
tured to the greater tuberosity (107% of normal). In addi-
tion to the restoration of muscle length-tension relation-
ship, the patch graft also redirected force transmission,
thereby providing a potential treatment option for other-
wise irreparable defects. The same technique of patch graft
M>Q@E

ISP 



MLPQBOFLO >KQBOFLO
14530_C01.indd 3
3
could also be applied when tendon transfers are used to
reconstruct large or massive cuff tears.
Material Properties of the Rotator Cuff
Material properties of various portions of the RC tendon
have been extensively measured under both tensile and
compressive loads. The tensile properties of the suprasp-
inatus tendon were investigated by dividing the tendon
into three longitudinal strips: anterior, middle, and poste-
rior. The posterior strip was thinner in cross section than
were the others. The ultimate strength or failure stress was
significantly greater in the anterior strip (16.5 ± 7.1 MPa)
than it was in the middle (6.0 ± 2.6 MPa) and posterior
(4.1 ± 1.3 MPa) strips. The modulus of elasticity also was
significantly greater in the anterior strip. The anterior por-
tion of the supraspinatus tendon is mechanically stronger
than the other portions, and it seems to perform the main
functional role of the tendon.12
In another study, the mechanical properties of suprasp-
inatus tendon were investigated based on the layers of the
tissue.13 In general, the bursal side and joint side of the su-
praspinatus tendon showed different loading curves. The
modulus of elasticity of the bursal side was slightly lower
than the joint side. In contrast, the strain to the yield point
(15 ± 4%) and ultimate strength (6.3 ± 1.1 MPa) of the bursal
side were twice those measured in the joint side. Within the
layer of bursal side, the average elongation was higher in the
middle portion compared with the proximal and distal por-
tions. However, the averaged elongations in the joint side
were almost the same. These biomechanical properties cor-
related well with the histological structures of the tissue.
The structural and mechanical properties of the infra-
spinatus tendon, including the midsubstance and insertion
regions were studied.14 The failure loads of the midsuperior
(676.5 ± 231.0 N) and the inferior portion (549.9 ± 284.6

10.1055/978-1-58890-635-9c001_f002
Figure 1–2 A patch graft was inserted into the defect
of rotator cuff for the coverage and restoration of the
anatomy for load transfer. Reattachment to the greater
tuberosity, narrowing of the defect by using a smaller
graft, and anterior graft attachment would affect the
outcome of force transmission and torque generation.
1/31/08 11:08:13 AM
 4 Rotator Cuff Deficiency of the Shoulder
N) were higher than those of the superior (462.8 ± 237.2
N) and the mid-inferior portions (315.3 ± 181.5 N). Similar
trends across the tendon strips were also found for stiff-
ness, ultimate stress, and elastic modulus. High stiffness in
midsuperior and inferior tendon sections might explain the
low incidence of posterior dislocations. The low ultimate
failure loads in the superior portions might correlate with
the frequent extension of RC ruptures into the infraspina-
tus tendon.14
The structure and mechanical properties of the subscapu-
laris tendon were also measured in four sections superiorly
to inferiorly.15 Arm position had a significant influence on
stiffness. The inferior region showed a higher stiffness in the
hanging-arm position than at 60 degrees of abduction; the
opposite was found for the superior portion. The stiffness
of the superior and midsuperior portions was significantly
higher than that of the inferior region in both arm positions.
The superior and midsuperior portions failed at signifi-
cantly higher loads (superior: 623 ± 198 and 478.2 ± 206.6 N
at 0 and 60 degrees of abduction, respectively; midsuperior:
706.2 ± 164.6 and 598.4 ± 268.4 N, respectively) than did the
inferior portion (75.1 ± 54.2 and 30.3 ± 13.0 N, respectively).
Higher stiffness and ultimate load in the superior tendon
region might explain the infrequent extension of RC tears
into the subscapularis tendon.15
Compressive loading is an important factor associated
with the cuff tear when considering that the supraspina-
tus tendon wraps around the humeral head and impinges
with the acromion during glenohumeral abduction. The
compressive properties at 15 locations on the bursal and
articular surfaces of the supraspinatus tendon were inves-
tigated using indentation tests. The overall stiffness on the
bursal and articular sides of the tendon was significantly
different. On the bursal side, the anterior third had a sig-
nificantly higher initial stiffness than the other thirds, on
average. The compressive stiffness of the supraspinatus
tendon was found to be nonhomogeneous throughout the
structure. On the articular side, initial stiffness at a location
10 mm proximal to the greater tuberosity was significantly
higher than the rest, on average. Nonhomogeneous com-
pressive stiffness of the supraspinatus tendon would affect
the load transmission within the tendon, which might be
associated with the potential mechanism of tear.16
The material properties of the RC tissue definitely will
be influenced by aging and other pathological conditions,
although the effect is difficult to study. In one study, the
dynamic modulus of the supraspinatus tendon under cy-
clic loading was found to decrease with age (<60 years of
age 21.2 MPa; >60 years of age 15.5 MPa).17
Mechanisms of Rotator Cuff Injury
Two mechanisms of the RC tearing process are generally
considered. The intrinsic mechanism is associated with
the tissue degeneration and the extrinsic mechanism is as-
14530_C01.indd 4
sociated with the subacromial impingement. Mechanical
factors have been implicated as the initiator of RC tears in
either of those two mechanisms. Information on the me-
chanical stress and strain state of the RC tendons along
with the material properties of the tissue would promote
our understanding of how different variables contribute to
the pathological condition. The RC tendon could rupture
when the stress exceeds the failure strength of the tissue
such as in sports or trauma. On the other hand, in normal
activities, even the subfailure stress encountered could
subject the tissue to fatigue failure if the micro-damage
could not be repaired properly. Furthermore, the stress in
the tissue could result in biological remodeling of the tis-
sue, which might alter the material properties of the tissue
and lead to damage as well.
The mechanical stress and strain environment en-
countered in the RC tendon has been investigated both
experimentally and analytically. In a study, the suprasp-
inatus tendon’s stress environment was explored using a
finite element model. In the absence of impingement, high
tensile stress concentration was observed on the articu-
lar side due to the asymmetric shape of the tendon and
bony insertion at high angles of arm elevation, as well as
the wrapping around the bony humeral head at low angles
of elevation. With subacromial impingement, high stress
concentrations were noted in and around the critical zone.
Importantly, the findings indicated that the high stress and
potential tears caused by impingement may occur on the
bursal side, the articular side, or within the tendon.18 In
a more refined study, the four zones of tendon insertion
including tendon proper, noncalcified fibrocartilage, calci-
fied fibrocartilage, and bone were examined. The area of
high tensile stress was noted on the articular side of the
supraspinatus tendon, which shifted toward the insertion
as the arm was abducted. High stress concentration on the
articular side of the supraspinatus tendon near its inser-
tion during arm elevation helped to explain the frequent
occurrence of RC tears at this site.19 In addition to the ten-
sile stress, high compressive stresses were also noted in
both studies on the articular side ~10 mm proximal to the
greater tuberosity. This correlated with the location where
high compressive stiffness was identified and might reflect
the result of tissue adaptation to the stress.16
Experimentally, regional variations of intratendinous RC
strain over a range of clinically relevant joint positions were
measured using a novel magnetic resonance imaging (MRI)-
based texture correlation technique. The intratendinous
strain varied across tendon regions; the strain was higher
in the superior region than in the inferior region. However,
joint position had a more pronounced effect where the in-
tratendinous strain increased with increasing joint angle;
the 60-degree strain was significantly greater than the 15-
degree strain across all tendon regions. This may suggest
that overhead activities could be more associated with ten-
don loading resulting in tissue failure.20 Furthermore, using
the same technology, it was noted that the articular-surface
1/31/08 11:08:14 AM
 1 Biomechanics of Pathophysiology and Repair of Rotator Cuff Tears
partial-thickness tear increased intratendinous strain for all
joint abduction positions except 15 degrees.21
The strains on the joint and bursal sides of the suprasp-
inatus tendon with increasing load and during glenohumeral
abduction were quantified using extensometers.22 Increasing
the tendon load increased the strains on the joint side sig-
nificantly more than on the bursal side. During glenohumeral
abduction, the strain of tissue on the joint side increased
progressively, but on the bursal side, it decreased beyond 60
degrees of elevation. It was speculated that the differential
strain may cause shearing between the layers of the suprasp-
inatus tendon, and thus be a causative factor in failure of the
supraspinatus tendon. Using the same experimental tech-
nique, the potential propagation of thickness tears was also
examined. With a simulated full-thickness tear of the tendon
midsubstance, the strain on the bursal side increased with
load and elevation angles. An intratendinous delamination
tear increased joint-side strain during abduction and bursal-
side strain with loading. Tear propagation was observed from
joint to bursal sides during abduction. Eventually, the tendon
failure occurred at the insertion.23
The strain in the model within the repaired RC tendon
decreased significantly with the arm elevated more than
30 degrees. The strain increased in IR and decreased in ER.
It was concluded that more than 30 degrees of elevation in
the coronal or scapular plane and rotation ranging from 0
degrees to 60 degrees of ER compose the safe range of mo-
tion (ROM) after repair of the RC.24
The Rotator Cuff as Joint Stabilizer
Even though the glenohumeral joint has a large ROM, it
is still stable. The joint consists of the intercalated joint
surfaces of the humeral head and glenoid, along with the
surrounding capsuloligamentous structures. Interaction
between the capsuloligamentous structures and the ar-
ticulating surfaces provides the basic static constraint of
Fm
Fm
Rr
Rn
Rn < Rr
14530_C01.indd 5
5
the joint. On the contrary, coordinated muscle contraction
provides the dynamic balance and stability of the joint.
The concavity of the glenoid surface provides constraint
to the joint under compressive force.25 Compression into
the glenoid labral concavity keeps the humeral head cen-
tered. The constraining mechanism of concavity-compres-
sion was quantified by translating the glenoid underneath
the humeral head in eight different directions.26 Relative
translations between the glenoid and the humeral head and
the forces resisting translation were recorded. The stabil-
ity ratio, defined as the peak translational force divided by
the applied compressive force, was calculated. The results
indicated that stability ratios were 56, 60, 32, and 37% in the
superior, inferior, anterior, and posterior directions, respec-
tively. Removal of the glenoid labrum resulted in an average
decrease in stability ratio of 9.6%. Even moderate compres-
sive forces generated by the RC are sufficient to provide sta-
bility through the concavity-compression mechanism.
Muscle acts three-dimensionally to the distal bony seg-
ment across the joint. All muscle force vectors can be re-
solved into compressive and shear components (Fig. 1–3).
For the RC muscle at the glenohumeral joint, the dominant
component of force was perpendicular to the glenoid sur-
face. This compressive force generated by each of the RC
muscles changed significantly with the axial humeral rota-
tion. In neutral rotation, the compressive force component
averaged 90, 85, 98, and 96% of the muscle force in the teres
minor, infraspinatus, subscapularis, and supraspinatus, re-
spectively. The compressive component of the muscle force
stabilizes the glenohumeral joint through the mechanism of
concavity-compression as described earlier.
The shear component of the muscle force could either
stabilize or destabilize the joint by direct pull. The direc-
tion and magnitude of the shear force in anterior, poste-
rior, superior, and inferior directions generated by each
RC muscle were relatively small compared with the com-
pressive component. They also changed significantly with
humeral rotation. Anterior shear force components by the
10.1055/978-1-58890-635-9c001_f003
Figure 1–3 Superior view of the shoulder. Muscle acts
three-dimensionally to the distal bony segment across the
joint. All muscle force vectors can be resolved into compres-
sive and shear components. The compressive component of
the muscle force stabilizes the glenohumeral joint through
the mechanism of concavity-compression. The shear com-
ponent of the muscle force could either stabilize or destabi-
lize the joint by direct pull.
1/31/08 11:08:14 AM
 6 Rotator Cuff Deficiency of the Shoulder
teres minor (19%) and infraspinatus (16%) in neutral ro-
tation changed to posterior shear forces (5 and 8%) in 90
degrees ER. The supraspinatus generated destabilizing an-
terior shear force as high as 31% of the applied force to the
muscle in 90 degrees ER, which was significantly different
from the other muscles in this position.
To facilitate the comparison of stabilizing/destabilizing
roles of RC muscles, the dynamic stability index was con-
sidered. This index was defined by considering both the
effects due to concavity-compression mechanism as well
as the shear force generated by the muscle. It represented
the percentage of the unit muscle force in constraining
the joint subluxation.27 The dynamic stability index in the
anterior direction, for example, was significantly different
when the humerus was in neutral rotation (13, 13 47, and
60% for teres minor, infraspinatus, supraspinatus, and sub-
scapularis, respectively) compared with the end-ROM at
90 degrees of ER (37, 41, 0, and 32% for teres minor, infrasp-
inatus, supraspinatus, and subscapularis, respectively).
Principles of Reversed Total Shoulder
Arthroplasty for Severe Rotator Cuff
Tear Arthropathy
The application of reversed total shoulder arthroplasty is
becoming popular in treating patients with severe cuff tear
arthropathy. The basic concept involved in such design is
related to the shift of the center of joint rotation so that the
lever arms of the remaining muscle, such as the deltoid,
could be more effectively functional. In general, the center
of joint rotation is located at the center of curvature of the
articular surface in spinning motion (Fig. 1–4). In the nor-
mal shoulder, the center of rotation is located in the center
of convex surface of the humeral head. In the reversed total
shoulder, the convex surface is placed on the glenoid side.
The center of curvature, and thus the center of rotation, is
located in the glenoid component, which is further away
from the deltoid muscle. Therefore, an increased lever arm
for more effective function of the muscle is expected.
The application of reversed total shoulder arthroplasty
has another advantage in terms of implant fixation. The
implant fixation for the glenoid component is usually more
critical and difficult compared with that in the humeral
head due to the inferior bony stock. In general, assuming
that the joint articular surface is frictionless, the joint con-
tact forces are perpendicular to the joint surface (Fig. 1–4)
and are directed to the center of curvature. In the normal
shoulder joint or arthroplasty, the joint contact force would
References
1. Bassett R, Browne A, Morrey B, An K. Glenohumeral muscle force
and moment mechanics in a position of shoulder instability. J Bio-
mech 1990;23(5):405–415
14530_C01.indd 6
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10.1055/978-1-58890-635-9c001_f004
Figure 1–4 The application of reversed total shoulder arthroplasty,
in treating severe cuff tear arthropathy, would shift the center of joint
rotation so that the lever arms of the remaining muscle could be more
effectively functional. In addition, the joint contact forces are perpen-
dicular to the joint surface and are directed to the center of curvature. In
the normal shoulder joint or arthroplasty, the joint contact force would
apply to the glenoid surface in an eccentric manner. In that condition,
the so-called rocking horse effect may be experienced. However, in the
reversed total shoulder arthroplasty, the contact force on the glenoid
component is more in the concentric manner pointing to the center of
curvature where the peg of fixation is located to resist the loading.
apply to the glenoid surface in an eccentric manner. In that
condition, the so-called rocking horse effect may be expe-
rienced and could lead to implant loosening. However, in
the reversed total shoulder arthroplasty, the contact force
on the glenoid component is more in the concentric man-
ner pointing to the center of curvature where the peg of
fixation is located to resist the loading. Therefore, the load-
ing in the glenoid component would be more favorable in
this reversed total shoulder replacement.
Conclusion
The rotator cuff muscles play an important role in moving
and stabilizing the glenohumeral joint. The line of action
and movement of the muscles are important biomechani-
cal factors that need to be considered in the treatment of
associated pathologies of rotator cuff tear.
2. Keating J, Waterworth P, Shaw-Dunn J, Corssan J. The relative
strengths of the rotator cuff muscles. A cadaver study. J Bone Joint
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and moment arm of index finger muscles. J Biomech 1983;16:419–
425
4. Otis J, Jiang C, Wickiewicz T, Peterson M, Warren R, Santner
TJ. Changes in the moment arms of the rotator cuff and del-
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5. Kuechle D, Newman S, Itoi E, Morrey B, An K. Shoulder muscle
moment arms during horizontal flexion and elevation. J Shoulder
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mech (Bristol, Avon) 2000;15(5):322–329
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effects of supraspinatus tendon detachments, tendon defects, and
muscle retractions. J Bone Joint Surg Am 2002;84-A(5):780–785
8. Mura N, O'Driscoll S, Zobitz M, et al. The effect of infraspinatus
disruption on glenohumeral torque and superior migration of
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9. Liu J, Hughes R, O'Driscoll S, An K. Biomechanical effect of medial
advancement of the supraspinatus tendon. J Bone Joint Surg Am
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10. Nakajima T, Lee S, Hughes R, O'Driscoll S, An K. Abduction moment
arm of transposed subscapularis tendon. Clin Biomech (Bristol,
Avon) 1999;14(4):265–270
11. Mura N, O'Driscoll S, Zobitz M, Heers G, An K. Biomechanical effect
of a patch graft for large rotator cuff tears: a cadaver study. Clin
Orthop Relat Res 2003;415:131–138
12. Itoi E, Berglund L, Grabowski J, et al. Tensile properties of the su-
praspinatus tendon. J Orthop Res 1995;13(4):578–584
13. Nakajima T, Rokuuma N, Hamada K, Tomatsu T, Fukuda H. His-
tologic and biomechanical characteristics of the supraspinatus
tendon: Reference to rotator cuff tearing. J Shoulder Elbow Surg
1994;3:79–87
14. Halder A, Zobitz M, Schultz F, An K. Mechanical properties of the pos-
terior rotator cuff. Clin Biomech (Bristol, Avon) 2000;15:456–462
15. Halder A, Zobitz M, Schultz F, An K. Structural properties of the
subscapularis tendon. J Orthop Res 2000;18(5):829–834
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16. Lee S, Nakajima T, Luo Z, Zobitz M , Chang Y, An K . The bursal and
articular sides of the supraspinatus tendon have a different com-
pressive stiffness. Clin Biomech (Bristol, Avon) 2000;15(4):241–247
17. Nightingale E, Allen C, Sonnabend D, Goldberg J, Walksh W. Me-
chanical properties of the rotator cuff: response to cyclic loading
at varying abduction angles. Knee Surg Sports Traumatol Arthrosc
2003;11(6):389–392
18. Luo Z, Hsu H, Grabowski J, Morrey B, An K. Mechanical environ-
ment associated with rotator cuff tears. J Shoulder Elbow Surg
1998;7(6):616–620
19. Wakabayashi I, Itoi E, Sano H, et al. Mechanical environment of the
supraspinatus tendon: a two-dimensional finite element model
analysis. J Shoulder Elbow Surg 2003;12(6):612–617
20. Bey M, Song HK, Wehrli F, Soslowsky L. Intratendinous strain fields
of the intact supraspinatus tendon: The effect of glenohumeral joint
position and tendon region. J Orthop Res 2002;20(4):869–874
21. Bey M, Ramsey M, Soslowsky L. Intratendinous strain fields of the
supraspinatus tendon: effect of a surgically created articular-sur-
face rotator cuff tear. J Shoulder Elbow Surg 2002;11(6):562–569
22. Reilly P, Amis A, Wallace A, Emery R. Mechanical factors in the ini-
tiation and propagation of tears of the rotator cuff. Quantification
of strains of the supraspinatus tendon in vitro. J Bone Joint Surg Br
2003;85-B(4):594–599
23. Reilly P, Amis A, Wallace A, Emery R. Supraspinatus tears: propagation
and strain alteration. J Shoulder Elbow Surg 2003;12(2):134–138
24. Hatakeyama Y, Itoi E, Pradhan R, Urayama M, Sato K. Effect of arm
elevation and rotation on the strain in the repaired rotator cuff
tendon. A cadaveric study. Am J Sports Med 2001;29(6):788–794
25. Lazarus M, Sidles J, Harryman D, Matsen F. Effect of a chondral-
labral defect on glenoid concavity and glenohumeral stability. A
cadaveric model. J Bone Joint Surg Am 1996;78:94–102.
26. Halder A, Kuhl S, Zobitz M, Larson D, An K. Effects of the glenoid
labrum and glenohumeral abduction on stability of the shoulder
joint through concavity-compression: an in vitro study. J Bone
Joint Surg Am 2001;83:1062–1069
27. Lee S, Kim K, O'Driscoll S, Morrey B, An K. Dynamic glenohumeral
stability provided by the rotator cuff muscles in the mid-range and
end-range of motion. J Bone Joint Surg Am 2000;82:849–857
1/31/08 11:08:15 AM
 2 Massive Irreparable Rotator Cuff Tears
Mark Mighell

The etiology of massive rotator cuff tears is multifactorial

and continues to be a researched topic. To understand this
topic requires a basic knowledge of rotator cuff (RC) his-
topathology.

Anatomy of the Rotator Cuff

A clear understanding of the normal anatomy of the RC will
aid in the treatment of the diseased cuff. Clark and Har-
ryman1 have described the RC in detail. From their work,
we know that as the tendons of the posterior cuff approach
their site of insertion, they are confluent and not easily sep-
arated. Their studies have shown that the RC is made up of
multiple, confluent tissue layers functioning in concert.
Histological sections through the supraspinatus and in-
fraspinatus reveal five distinct layers (Fig. 2–1). The most
superficial layer contains large arterioles and comprises
fibers from the coracohumeral ligament. A sheet of fibrous
tissue from the coracohumeral ligament’s origin extends
posterolaterally to form a sheet over the supraspinatus and
Tears infraspinatus. This layer is 1 mm in thickness and the tissue 10.1055/978-1-58890-635-9c002_f001
Figure 2–1 Vertical, transverse section through the supraspinatus
fibers are oriented obliquely to the long axis of the muscle
tendon and capsule near the tendon insertion. Layer 1 is composed
bellies. Layer 2 is 3- to 5-mm thick and represents the direct of fibers of the coracohumeral ligament obliquely oriented with re-
tendinous insertion into the tuberosities. Large bundles of spect to the axis of each muscle. Large arterioles are present. Layer
densely packed parallel tendon fibers compose this layer. 2 is composed of closely packed parallel tendon fibers grouped in
Layer 3 is ~3-mm thick and comprises smaller bundles of large bundles. Layer 3 has smaller fascicles and these fascicles lack a
collagen with a less uniform organization. Fibers within this uniform orientation. Blood vessels are also present in this layer, but
layer travel at 45-degree angles to one another to form an are smaller than those in layers 1 and 2. Layer 4 is composed of loose
interdigitating meshwork that contributes to the fusion of connective tissue in which there are thick bands of collagen fibers.
The only blood vessels in this layer are capillaries, found adjacent to
the cuff tendon insertion. Layer 4 comprises loose connec-
the extraarticular surface of the capsule of the shoulder. Layer 5 is a
tive tissue and thick collagen bands that merge with the
thin, continuous sheet of interwoven collagen fibrils, which usually
coracohumeral ligament at the most anterior border of the insert on the humerus as Sharpey’s fibers within the bone.
supraspinatus. Layer 5 (2-mm thick) represents the shoulder
capsule. With respect to the blood supply, the arterioles are
larger and the vessels more prevalent on the bursal surface ing type I and type II collagen, chondroitan-4-sulfate, and
of the cuff and branch between layers 2 and 3.1 The articular chondroitan-6-sulfate.4
side of the RC is relatively hypovascular when compared
with the rich blood flow on the bursal side of the cuff.2
Histologically, tendon regions subject almost exclu- Prevalence
sively to tension differ from those exposed to high levels
of compression as well as tension.3 Tendons not subject Degeneration of the RC is a common source of shoulder
to compression consist primarily of spindle-shaped fi- dysfunction. It has been demonstrated that the presence
broblasts surrounded by densely packed, longitudinally of RC pathology was highly predictive of impaired physical
oriented collagen fibers principally made up of type I col- health and quality of life.5–7 In fact, the size of this impact
lagen. In contrast, tendons exposed to compression have is comparable to the effects of conditions such as diabetes
a fibrocartilaginous structure and a composition charac- mellitus, myocardial infarction, congestive heart failure,
terized by rounded cells surrounded by a matrix contain- hypertension, and clinical depression.6

14530_C02.indd 8 1/31/08 11:06:03 AM


Patients with massive RC tears generally present with
complaints of pain and weakness. Large tears increase the
likelihood of functional loss. Recent studies have shown that
weakness of >50%, relative to the contralateral side in shoul-
der abduction at 10% of abduction, was indicative of a large or
massive RC tear.7 MacDermid et al8 have demonstrated that
patients with RC pathology were weaker than the control
group of subjects who displayed no shoulder problems.
Patients often complain of pain with activity, as well as
night pain. Physical pain is the result of the inflammatory
nature of the subacromial bursa in RC disease. The expres-
sion of inflammatory mediators known to be involved in the
catabolic degenerative processes in the subacromial bursa
was studied and quantified in bursal specimens in patients
with RC disease. The data clearly show increased inflamma-
tion in the subacromial bursa in patients with RC disease
when compared with control patients. All of the cytokines,
proteases, and cyclooxygenase enzymes that were tested
showed significantly increased expression in the RC group
than in the control group.9 These enzymes may play an im-
portant role in the ultimate failure of the RC.
Natural History
Chronic massive tears have associated osteopenic bone,
poor-quality tendons, and inelastic muscles due to fatty in-
filtration and fibrosis.10 In fact, the weakest link in the aged
may be the osteoporotic bone. Bone density is higher be-
low the articular than in the greater tuberosity, and tendon
tears are associated with a reduction of cancellous bone
density of greater than 50%.11 In addition to bone quality,
age also plays a role when analyzing the results of tendon
repair. In patients with isolated supraspinatus tears who
underwent arthroscopic repair, age was clearly one of the
most important variables for tendon healing. In a study by
Boileau et al, 12 only 10 of 23 patients (43%) over the age of
65 had completely healed tendons. Established full-thickness
tears of the RC do not heal.13 Most tendon-to-bone healing
models document that contact between the bone and the
residual stump of the torn tendon is necessary for heal-
ing to occur.14 Tendon healing can occur if marrow-derived
bone cells come into maintained contact with the bursal
layer of the cuff. This layer is rich in arterioles and may
facilitate healing. In chronic cases, soft tissue interposition
on the insertion site, footprint, or RC prevents access to
the bone-derived marrow cells and tendon bone contact.
The environment for tendon healing is further compro-
mised when large gaps exist between the retracted tendon
and bone. It is unlikely that tendon or scar tissue can form
under these conditions in a region with an inherent low
metabolic activity. Studies have shown that tendon tears
are followed by loss of muscle mass, fibrosis, and fatty in-
filtration of the muscle. The chronically detached muscle
is not merely a smaller version of the original muscle, but
rather a different muscle altogether. The detached muscle
14530_C02.indd 9
2 Massive Irreparable Rotator Cuff Tears 9
becomes stiffer, and the passive loads required to repair it
become excessive.15
An initial decrease in sarcomere length and subsequent sar-
comere number is believed to be responsible for the observed
reduction in muscle volume. The reduction in sarcomere
number may represent a remodeling response of the muscle
to maximize function of the remaining sarcomeres. In chronic
tears, the tendon is often scarred down to the joint capsule
and may remain linked to the adjoining soft tissue structures.
These attachments act as tethers that allow for loading of the
remaining muscle fibers. This reapplication of tension has
been shown to decrease muscle atrophy.16,17 Retraction of the
myotendinous unit leads to a reduction in muscle volume,
fatty changes, and fibrotic infiltration. The cumulative effect of
these changes is a loss of elasticity and an architecturally dif-
ferent muscle.10 Repair of a significantly retracted muscle to its
original site requires the muscle to be lengthened. The passive
loads placed on the muscle could reach at least 70 N or a force
that could precipitate repair failure.12 Furthermore, extreme
lengthening of individual muscle fibers may cause irreversible
damage to the muscle, and despite the possibility of tendon
repair, the muscle itself remains nonfunctional. In this setting,
the repaired tendon acts as a static restraint.18
Nonoperative Treatment
Drug Treatment
In this section, I will outline general guidelines for con-
servative treatment for massive irreparable RC tears. At-
tempts at surgical repair of massive cuff tears often re-
sult in pain relief and improved function, but the ability
to achieve tendon to bone healing is poor.19 Proponents of
conservative treatment argue that a degeneration of the
RC occurs with aging.20 Conservative treatment should in-
clude various combinations of activity modification, oral
antiinflammatory agents, and local injection of steroid and
or hyaluronic acid preparations. Current clinical recom-
mendations are for no more than two or three steroid in-
jections per year, spaced 3 months apart.21,22 The concern
surrounding corticosteroids stems largely from potential
side effects. However, few studies have looked at the spe-
cific effects of corticosteroids on RC tendons. One recent
study found that a single dose of methylprednisolone had
no lasting effect on the collagen expression of either in-
jured or uninjured rat RC tendons 5 weeks after the injec-
tion. However, the authors did find that the collagen com-
position may be acutely altered after the injection with a
dramatic increase in the type III to type I collagen ratio.
This ratio can have an appreciable effect on the biome-
chanical properties of RC tendons if the same proportions
of collagen type are translated to the protein level. Based
on these findings, the authors recommend that therapy
and activity level should be modified to avoid aggressive
1/31/08 11:06:05 AM
 10 Rotator Cuff Deficiency of the Shoulder

shoulder motion and strengthening within the first 2 to 3

weeks following subacromial injection.23
Recently, there has been interest in the use of hyaluronan
supplementation in the treatment of patients with RC tear.24
Hyaluronans are polysaccharide molecules that occur natu-
rally in synovial fluid. Beneficial biologic activities of hyaluro-
nans may contribute toward symptom or disease modifica-
tions include the following: enhanced synthesis and decreased
degradation of synovial components of articular cartilage, di-
rect analgesic effects, and inhibition of inflammation.25
Results of hyaluronan therapy have been promising in
patients with periarthritis of the shoulder (subacromial bur-
sitis, tendonitis, and capsulitis). Yamamoto et al26 found that
periarticular injection of hyaluronan led to significant pain
relief in patients treated (69 to 70%) when compared with
control treatment with placebo (36 to 39%). In another ran-
domized study,27 outcomes of sodium hyaluronate injection
for RC tears were compared with steroid injection. Although
the therapeutic efficacy in the sodium hyaluronate group
was equivalent to that in the steroid group, both groups only
improved satisfaction in 35 to 39% of patients. No adverse 10.1055/978-1-58890-635-9c002_f002
Figure 2–2 A system of forces that exerts a resultant moment, but
reaction to either treatment was observed.
no resultant force, is called a force couple. A force couple is a system
that allows for a body to be rotated but not translated. The simplest
example of a force couple in the shoulder consists of two equal and
Physical Therapy opposite forces acting some distance apart. In this diagram, an axial
plane force couple is illustrated. It is assumed that the force of the
The therapy program that best suits the patient with a subscapularis (FS) is equal and opposite to that of the infraspinatus
deficient cuff is one that places emphasis on the deltoid. (FI). If this axial plane force couple is disrupted, then a translational
force is introduced and instability of the shoulder occurs.
Better function can be achieved in some patients who are
able to reeducate the deltoid muscle. This is best achieved
with a graduated home exercise program. My group has
included one protocol that has been proposed by Cope-
land and Levy28 that is both simple and straightforward. gained. In a study by Itoi and Tabata,30 the authors found
The program involves strengthening the deltoid muscle that the results of conservative treatment were best when
and improving range of motion with gentle, gravitational a treatment program was instituted within one year of the
exercises that should be performed 3 to 5 times a day for onset of symptoms. In addition, initial improvements dete-
at least 12 weeks. We feel that this program is suitable for riorated when patients were observed over several years.
most patients with massive tears of the RC in whom there The relationship between the follow-up period and the
still exists a balanced force couple, or in those patients results showed that the patients observed for 6 years or
who do not have anterior superior escape. more showed significantly lower scores than those with
Patients who have balanced fulcrum mechanics are the shorter follow-up periods. The authors also found that bet-
best candidates for physical therapy. In many instances, if ter results can be anticipated in patients with preserved
there is an intact transverse plane force couple, the shoul- range of motion and strength.
der can be adequately rehabilitated (Fig. 2–2). A functional Similarly, Boker et al31 treated 53 patients with con-
RC tear, as described by Burkhart et al,29 must possess five servative treatments, including nonsteroidal antiinflam-
biomechanical criteria: (1) intact coronal and traverse matory medication, stretching, and strengthening exer-
plane force couples, (2) a stable-fulcrum kinematic pat- cises. Patients were followed for an average of 7 years, and
tern, (3) an intact “suspension bridge” of the affected 75 to 80% reported satisfactory pain relief. However, these
shoulder, (4) occurrence through a minimal surface area, patients displayed negligible loss of function.
and (5) edge stability. After reviewing the results of studies implementing
conservative treatments for full RC tears, many of which
are detailed by Wirth et al,32 it appears that nonoperative
Results treatments are viable options to surgery in many cases.
These treatments show predictable pain relief, although
Nonoperative treatment seems to afford patients pain re- function may deteriorate over time, or it may not be re-
lief and improved strength, but function may not be re- gained at all.

14530_C02.indd 10 1/31/08 11:06:05 AM


References
1. Clark JM, Harryman DT II. Tendons, ligaments, and capsule of the
rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am
1992;74(5):713–725
2. Lohr JF, Uhthoff HK. The microvascular pattern of the supraspina-
tus tendon. Clin Orthop Relat Res 1990;254:35–38
3. Berenson MC, Blevins FT, Plaas AH, Vogel KG. Proteoglycans of hu-
man rotator cuff tendons. J Orthop Res 1996;14:518–525
4. Mehr D, Pardubsky PD, Martin JA, Buckwalter JA. Tenascin-C in ten-
don regions subject to compression. J Orthop Res 2000;18:537–545
5. Chipchase LS, O’Connor DA, Costi JJ, Krishnan J. Shoulder impinge-
ment syndrome: preoperative health status. J Shoulder Elbow Surg
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6. Ware JE, Kosinski M, Keller SD. SF-36 Physical and Mental Health
Summary Scales: A User’s Manual. Boston, MA: The Health Insti-
tute, New England Medical Center; 1994: 1.1–10.12
7. McCabe RA, Nicholas SJ, Montgomery KD, Finneran JJ, McHugh MP.
The effect of rotator cuff tear size on shoulder strength and range
of motion. J Orthop Sports Phys Ther 2005;35(3):130–135
8. MacDermid JC, Ramos J, Drosdowech D, Faber K, Patterson S.
The impact of rotator cuff pathology on isometric and isokinetic
strength, function, and quality of life. J Shoulder Elbow Surg
2004;13(6):593–598
9. Voloshin I, Gelinas J, Maloney MD, O’Keefe RJ, Bigliani LU, Blaine TA.
Proinflammatory cytokines and metalloproteases are expressed in
the subacromial bursa in patients with rotator cuff disease. Ar-
throscopy 2005;21(9):1076.e1–1076.e9
10. Meyer DC, Hoppeler H, von Rechenberg B, Gerber C. A pathome-
chanical concept explains muscle loss and fatty muscular changes
following surgical tendon release. J Orthop Res 2004;22(5):1004–
1007
11. Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteo-
penia of the humeral head with full thickness rotator cuff tears. J
Shoulder Elbow Surg 2004;13:333–337
12. Boileau P, Brassart N, Duncan WJ, Carles M, Hatzidakis AM,
Krishnan SG. Arthroscopic repair of full-thickness tears of the su-
praspinatus: does the tendon really heal? J Bone Joint Surg Am
2005;87(6):1229–1240
13. Galatz LM, Sandell LJ, Rothermich SY, et al. Characteristics of the rat
supraspinatus tendon during tendon to bone healing after acute
injury. J Orthop Res 2006;24(3):541–550
14. Gerber C, Schneeberger AG, Perren SM, Nyffler RW. Experimen-
tal rotator cuff repair: a preliminary study. J Bone Joint Surg Am
2004;86(9):1973–1982
15. Safran O, Derwin KA, Powell K, Ianotti JP. Changes in rotator cuff
muscle volume, fat content, and passive mechanics after chronic
detachment in a canine model. J Bone Joint Surg Am 2005;87-A:
2662–2669
16. Jamali AA, Afshar P, Abrams RA, Lieber RL. Skeletal muscle response
to tenotomy. Muscle Nerve 2000;23:851–862
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2 Massive Irreparable Rotator Cuff Tears 11
17. Baker JH, Hall-Craggs EC. Changes in sarcomere length following
tenotomy in the rat. Muscle Nerve 1980;3:413–416
18. Matano T, Tamai K, Kurokawa T. Adaptation of skeletal muscle in
limb lengthening: a light diffraction study on sarcomere length in
situ. J Orthop Res 1994;12(2):193–196
19. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The
outcome and repair integrity of completely arthroscopically re-
paired large and massive rotator cuff tears. J Bone Joint Surg Am
2004;86:219–224
20. Brewer BJ. Aging of the rotator cuff. Am J Sports Med 1979;7:102–
110
21. Lashgari CJ, Yamaguchi K. Natural history and nonsurgical treat-
ment of rotator cuff disorders. In: Norris TR, ed. Orthopaedic
Knowledge Update. Shoulder and Elbow. 2nd ed. Rosemont IL:
American Academy of Orthopedic Surgery; 2002:155–162
22. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of
injections of corticosteroids for subacromial impingment syn-
drome. J Bone Joint Surg Am 1996;78:1685–1689
23. Wei AS, Callaci JJ, Juknelis D, et al. The effect of corticosteroid on
collagen expression in injured rotator cuff tendon. J Bone Joint
Surg Am 2006;88(6):1331–1338
24. Shibata Y, Midorikawa K, Emoto G, Naito M. Clinical evaluation of
sodium hyaluronate for the treatment of patients with rotator cuff
tear. J Shoulder Elbow Surg 2001;10(3):209–216
25. Punzi L. The complexity of the mechanisms of action of hyaluronan
in joint diseases. Clin Exp Rheumatol 2001;19:242–246
26. Yamamoto R, Namiki O, Iwata H, et al. Randomized comparative
study of sodium hyaluronate (SPH) on periarthritis of the shoulder.
Jpn J Clin Pharmacol Ther 1988;19:717–733
27. Shibata Y, Midorikawa K, Emoto G, Naito M. Clinical evaluation of
sodium hyaluronate for the treatment of patients with rotator cuff
tear. J Shoulder Elbow Surg 2001;10(3):209–216
28. Copeland, SA, Levy O. "Anterior Deltoid Muscle Rehabilitation for
Massive Rotator Cuff Tear" (an advisory released by the Reading
Shoulder Surgery Unit, Capio Reading Hospital, Royal Berkhire
Hospital, and BUPA Dunedin Hospital, 2003)
29. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli
A. Partial repair of irreparable rotator cuff tears. Arthroscopy
1994;10(4):363–370
30. Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin
Orthop Relat Res 1992;275:165–173
31. Boker DJ, Hawkins RJ, Huckell GH, et al. Results of nonoperative
management of full-thickness tears of the rotator cuff. Clin Orthop
Relat Res 1993;294:103–110
32. Wirth MA, Basamania C, Rockwood CA. Nonoperative management
of full-thickness tears of the rotator cuff. Orthop Clin North Am
1997;28(1):59–67
1/31/08 11:06:07 AM
 3 Classification of Rotator Cuff–
Tear Arthropathy
Ludwig Seebauer
Cuff tear arthropathy (CTA) is not a unique pathologic entity.
It is the common end stage result of several disease processes
such as rheumatoid arthritis, rotator cuff (RC) tear arthropathy,
or Milwaukee shoulder syndrome. The characteristic clinical
and functional appearance of the common end stage of several
disease processes is characterized as a painful arthritic shoul-
der with nonfunctional, irreparable cuff. By developing a sub-
stantial defect in the RC tendons, these disease processes lead
to destabilization of the glenohumeral joint with subsequent
superior migration of the humeral head and secondary severe
damage to both the intraarticular and extraarticular elements.
Massive RC defects lead to a loss of static or dynamic gleno-
humeral stabilization and to an anterosuperior displacement
of the humeral head. The extent of displacement depends on
the number and locations of tendons affected1–3 and their de-
gree of involvement, the extent of atrophy of the muscles,2,3
the structural integrity of the coracoacromial arch, and the ex-
tent and direction of the accompanying glenoid destruction.
The consecutive anterosuperior displacement and instability
of the humerus and the change in the center of rotation cause
ator Cuff an insufficiency of the deltoid muscle.4 Biomechanical investi-
gations done by Grammont5 and De Wilde6 have shown that a
caudal and medial displacement of the glenohumeral center
er
of rotation causes a significant increase in the moment of ro-
tation of the deltoid muscle. Conversely, it could be assumed
that the superior and lateral displacement of the center of ro-
tation deteriorates the biomechanics of the deltoid. The previ-
ous classifications of Hamada and Fukuda18 or Favard19 did not
have any therapeutic impact. They purely describe the natural
course and explain the pathomorphologic consequences of
large and massive cuff tears. Therefore, my group established
a more functional and biomechanical classification of cuff tear
arthropathies into four types focusing on the position and sta-
bility of the center of rotation on static (normal x-ray) and dy-
namic (fluoroscopy) radiologic investigation. We intended to
develop a classification based upon treatment guidelines, and
one based on, yet independent from, the underlying etiology.
Biomechanics of Pathophysiology of
Rotator Cuff Tears
The RC tendons provide a major contribution to the dy-
namic stabilization of the glenohumeral joint by increas-
14530_C03.indd 12
ing the concavity-compression force in the joint.7,8 By their
synchronous action, they oppose the displacing effect
of the strong deltoid muscle, keeping the humeral head
centered in the glenoid fossa throughout its movement.9
The coupled work of the infraspinatus and subscapularis
tendons has been shown to be a major factor in superior
glenohumeral stability, whereas the contribution of su-
praspinatus tendon is less significant.10–13 A massive tear,
consisting of the supraspinatus tendon and at least one
of the other RC tendons (in most cases the infraspinatus)
makes the RC’s anterior and posterior force couple ineffec-
tive in both the vertical and the transverse planes. The re-
sult is a diminution of joint reaction force and a destabili-
zation of the glenohumeral joint.11 In cases where the long
head of biceps is still functional, it may oppose, to some
extent, the superior migration of the humeral head.12
Nové-Josserand and colleagues1 demonstrated in a ret-
rospective analysis on numerous (n = 246) patients with
large and massive cuff tears that the additional involve-
ment of the subscapularis tendon leads to a significant
decrease of the acromiohumeral distance (an indicator of
the superior migration of the center of rotation) in com-
parison to nonsubscapularis-involved two-tendon tears of
the supraspinatus and infraspinatus tendons. The location
of the defect, whether it is more a posterosuperior or an
anterosuperior large or massive defect, is also important
in relation to the amount of superior displacement. Pos-
terosuperior defects have a bony buttress by the osseous
arch of the acromion; therefore, the superior displacement
has structural barriers and limits. Gagey36 described a
biomechanically important tight fibrous frame consisting
of collagen fiber bundles in the anterior part of the supra-
spinatus and in the superior part of the subscapularis, the
biceps tendon and the coracohumeral ligament, which acts
as a passive restraint against anterosuperior translation.
Therefore, RC defects of the same size located in the an-
terosuperior section of the cuff leads to a greater amount
of superior translation than posterosuperior defects.
If the proximal pull of the deltoid is left unopposed,
the humeral head migrates superiorly toward the coraco-
acromial arch. The deltoid, which has lost its fulcrum, is
left with a smaller mechanical advantage and therefore
must generate more force to perform its function. The hu-
meral head then articulates with the coracoacromial arch
superiorly and the superior glenoid rim inferiorly, leading
1/31/08 11:03:23 AM

to flattening of the superior part of the humeral head and
tuberosities (“femoralization”), rounding and thinning of
the coracoacromial arch (“acetabularization”) and destruc-
tion of the superior glenoid region (Fig. 3–1). The result is
an incongruous, unstable joint with a higher joint friction
and superiorly malpositioned center of rotation. The oc-
currence, expression, and presentation of the single mor-
phologic features are multifactorial and mainly dependent
of the underlying pathology and the pathomechanics of
the RC tear. Otherwise, the pathomechanics of the RC tear
is highly dependent on the size and location of the tear,
the number of tendons involved, the integrity of the coraco-
acromial arch and the bony geometry of the glenoid.
In contrast to the negative biomechanical effect of the
superior migration of the center of rotation of the gleno-
humeral joint for the deltoid Grammont disclosed, 1 cm
caudalization or medialization improves the deltoid-torque
by 20 to 30%. In a recent study, De Wilde et al6 demon-
strated in a computer model, that a simulated elongation
of the deltoid along the humeral axis of ~10% with a stable
center of rotation significantly improves the delta force es-
pecially in the critical 90-degree-abduction position.
Characteristics of Different Etiologies
of Rotator Cuff Arthropathy
Although sharing a common functional result, it is impor-
tant to recognize the various disease processes leading to
CTA. The specific and characteristic parameters of the vari-
ous processes greatly affect the time and aggressiveness of
occurrence and the morphologic phenotypes of presenta-
Figure 3–1 Typical x-ray of rotator cuff tear arthropathy showing
superior migration, acetabularization, and superior glenoid erosion.
10.1055/978-1-58890-635-9c003_f001
14530_C03.indd 13
3 Classification of Rotator Cuff–Tear Arthropathy 13
tion of CTA. The different etiologies have a decisive influ-
ence on treatment and outcome.13
The most important etiopathologies are
• Primary rotator cuff tear arthropathy14
• Post–rotator cuff–repair arthropathy
• Inflammatory arthritis with extensive rotator cuff defect
• Crystalline-induced arthritis arthropathy (Milwaukee
shoulder)15
• Destructive arthritis
• Primary osteoarthritis with extensive rotator cuff defect
The characteristics of each etiopathology are discussed
below.
Primary Rotator Cuff Tear and Post–
Rotator Cuff–Repair Arthropathy
CTA could be the result of a massive RC tear. The term in-
troduced by Neer in 198314 refers to a primary massive RC
tear that by virtue of mechanical superior instability and
nutritional effects leads to a secondary glenohumeral joint
destruction. The percentage of massive cuff tears that will
end up as CTA is estimated to be between 0 to 25%, but it
is very difficult to predict which massive tear will result in
CTA.16 Post-CTA has similar pathoetiology and behavior as
primary CTA.
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is one of the most common
causes of CTA. Between 48 to 65% of RA patients have sig-
nificant glenohumeral joint involvement. About 24% of
those having glenohumeral arthritis will have a simultane-
ous RC tear. The acromioclavicular joint is also frequently
involved in the process, joining its cavity with that of the
now joined synovial intraarticular and subacromial bur-
sae spaces. Additionally, there are often severe osteopenia,
erosions of the entire glenoid without osteophyte forma-
tion, and medialization of the glenohumeral joint.17
Crystalline-Induced Arthritis
Arthropathy (Milwaukee Shoulder)
The Milwaukee shoulder syndrome was originally de-
scribed by McCarty in 1981.15 This is an uncommon en-
tity affecting shoulders of elderly people, predominantly
women. It consists of a massive RC tear, joint instability,
bony destruction, and large bloodstained joint effusion
containing basic calcium phosphate crystals, detectable
protease activity, and minimal inflammatory elements. Its
relation to RC arthropathy is not clear and it might rep-
resent one spectrum of the above. The role of the basic
1/31/08 11:03:23 AM
 14 Rotator Cuff Deficiency of the Shoulder
calcium phosphate crystals in creating this syndrome is
still controversial. Whether it is the cause of the articular
damage through macrophage released proteases, or just
the result of the osteoarthritic process is still unknown.
Primary Osteoarthritis with Extensive
Rotator Cuff Defect
Primary glenohumeral osteoarthritis is the most common
reason for shoulder joint replacement; however, it is as-
sociated with RC tear in only 5% of patients, most of which
are reparable. It is therefore uncommon for primary oste-
oarthritis to end up as CTA.
Classifications of Rotator Cuff
Arthropathy
Hamada–Fukuda Classification
The Hamada–Fukuda Classification18 is more or less a mor-
phologic description of the natural course of massive RC
tear and therefore only focusing on the group of (primary)
CTA according to Neer.14 Under the arthrographic proofing
of a massive cuff tear, they defined five types: Type 1 is
characterized by a normal joint morphology and an ac-
romiohumeral distance of more than 6 mm. In type 2, the
acromiohumeral distance was 5 mm or less. In type 3, ad-
ditional acetabularization could be observed. Acetabulari-
zation is defined as a concave deformity of the acromion
undersurface and distinguished into two subtypes. In type
4, narrowing of the glenohumeral joint is added and in type
5, collapses of the humeral head are seen. Despite this very
A B
14530_C03.indd 14
comprehensive description of the occurrence of the mor-
phologic features of primary CTA at the different phases of
this disease, there is no literature, which showing any rec-
ommendation or results of a specific type adapted therapy
of the five different groups.
Farvard Classification
Farvard and colleagues19 described three different types.
Type 1 is characterized by superior glenohumeral wear with
upward migration and acromion modifications; type II shows
central narrowing with little alteration of the acromion shape;
finally, type III represents the lysis of the head or acromion.
Similar to the previous described classification, this classifi-
cation is merely a pathophysiologic and pathogenic explana-
tion for CTA, but without any therapeutic impact. Type I is
developing slowly out of old tears (CTA according to Neer)
—some coming to a destructive type of arthropathy. Type II is
estimated as an osteoarthritic shoulder with secondary mas-
sive cuff tear. Type III is seen for “rheumatoid shoulders” with
a concomitant cuff tear or short prior to bony destruction.
Burkhart Classification
Burkhart20 developed a classification of cuff tears based on
their biomechanical behavior. Under dynamic radiologic
examination (fluoroscopy), Burkhart found three different
biomechanically different types of RC tears: His investiga-
tions are focused on the position of the fulcrum of the gleno-
humeral joint. The fulcrum of the glenohumeral joint could
be stable, unstable, or captured (Fig. 3–2). He assumed that
the pathomechanics of RC tears are highly dependent on the
10.1055/978-1-58890-635-9c003_f002
Figure 3–2 Burkhart classification of ro-
tator cuff tears: (A) stable center type,
and (B) captured center type.
1/31/08 11:03:25 AM

Figure 3–3 Typical x-rays of the four types of rotator cuff tear arthropathy according to the author’s classification (Bar: lever of the deltoid)
10.1055/978-1-58890-635-9c003_f003
balance of the force couple of the subscapularis in the front
and the infraspinatus in the back as counterpart of the supe-
rior displacing effect of the strong deltoid muscle (Fig. 3–2).
Author's Classification System
The specific problems and features of single etiologies are
extensively described in the previous chapter. Besides the
specific problems, there is a common feature for all patholo-
gies that is characterized by a progressive soft tissue and
bone defect, which causes superior migration and instability
of the humeral head. Because of this, we developed a more
biomechanical, functional, and morphologic classification,
which focuses on the position and stability of the center of
rotation of the glenohumeral joint (Fig. 3–3).21,22
In developing our classification as a tool in decision making
for prosthetic therapy of CTA, our criteria were as follows:
–Not a simple pathomorphologic description
–Biomechanically oriented
–Description amount of static and dynamic anterosu-
perior instability
–Position and stability of center of rotation as decisive
parameters
–Therapeutically oriented
–Independent from underlying pathology
–Additional tool for decision making in prosthetic treat-
ment beside the clinical parameters
Table 3–1 Pathomechanics and Pathomorphologic Classification of Cuff Tear Arthropathy
Type Ia Type Ib
Centered, stable Centered, medialized
No superior migration No superior migration
Acetabularization of Medial erosion of the glenoid
coracoacromial arch;
femoralization of humeral
head
14530_C03.indd 15
3 Classification of Rotator Cuff–Tear Arthropathy 15
Therefore, we established a mainly functional and bio-
mechanical classification of CTAs into four types focusing
on the position and stability of the center of rotation on
static (normal x-ray) and dynamic (fluoroscopy) radiologic
investigations. In types Ia and Ib, the center of rotation is
not displaced, whereas in types IIa and IIb it is significantly
cranially displaced. Type IIb is characterized by a complete
static or dynamic anterosuperior instability (Table 3–1).
Sometimes it is difficult to distinguish between types
IIa and IIb on a simple static anteroposterior x-ray. To
distinguish between both types the clinical aspect under
loaded conditions (active abduction or elevation against
resistance) shows an increased superior displacement in
type IIb patients. This could be also proved by a radiologic
investigation under fluoroscopy (Fig. 3–4).
The four types are markedly different in respect to pre-
operative function after elimination of pain and to the re-
sults after conventional shoulder hemiarthroplasty.23
Treatment of Rotator Cuff Tear
Arthropathy by Shoulder Arthroplasty
Current Options
Different approaches to the treatment of defect arthropa-
thies (osteoarthritis with irreparable cuff defects) are de-
10.1055/978-1-58890-635-9c003_t001
Type IIa Type IIb
Decentered, limited stability Decentered, unstable
Superior translation Anterosuperior dislocation
Minimum stabilization by No stabilization by coracoacromial arch
coracoacromial arch
1/31/08 11:03:25 AM
 16 Rotator Cuff Deficiency of the Shoulder
A B
scribed in the literature. The use of conventional anatomical
prostheses leads at best to an alleviation of pain. Functional
results to be expected have already been described by Neer
as “limited goal rehabilitation.”24 The often contradictory
results of hemiarthroplasty have been analyzed prospec-
tively by Wirth et al.25 Poor functional results can be ex-
pected if the cuff is not reconstructed, is irreparable, or if the
restraint of the coracoacromial arch is lacking. Even with
the use of big or oversized humeral heads in special cases,
the results are at best satisfactory.26,27 Constraint prostheses
introduced at the end of the 1970s and the beginning of
the 1980s have been abandoned because of early loosen-
ing.28 In addition, the functional results of the bipolar pros-
theses are definitively less uniform and reach, at best, the
outcome of the reversed prosthesis in their lower quarter
results (in general, multiply-operated patients with often-
damaged deltoid muscles).29,30 With the exception of the
constraint prosthesis, the reason for these poor results of
hemiarthroplasties and bipolar prostheses is that the center
of rotation is not brought sufficiently caudal and medial.
This is necessary to optimize the function of the deltoid.
Figure 3–5 Acceptable clinical result with an anatomic hemiarthroplasty for a type Ib defect.
14530_C03.indd 16
10.1055/978-1-58890-635-9c003_f004
Figure 3–4 Anteroposterior x-ray, static
and dynamic with fluoroscopy: (A) supe-
rior displacement with the arm resting at
the side, and (B) superior dislocation with
the arm under resisted abduction.
Even if the normal center of rotation has been restored, the
functional results are not as good as those with the reverse
prosthesis (Fig. 3–5). For this reason, the aforementioned
prosthesis can be used for type I defect arthropathies ac-
companied by significant medial glenoid erosion (type Ib of
our classification). The use of oversized humeral heads dur-
ing hemiarthroplasty leads more to a lateralization than to a
lowering of the center of rotation and that deteriorates the
moment of rotation of the deltoid muscle. Reports dealing
with hemiarthroplasties or bipolar prostheses list their re-
sults as excellent and good, even when the maximal eleva-
tion and abduction do not exceed 110 degrees.25–31
Outcome Depending on Our
Classification
To evaluate the practicability and usefulness of our classi-
fication, we did a retrospective analysis on 37 (10 men, 27
women) patients with large and massive cuff tears (mini-
mally involved two tendons) and concomitant degenera-
10.1055/978-1-58890-635-9c003_f005
1/31/08 11:03:26 AM

10.1055/978-1-58890-635-9c003_f006
Figure 3–6 Retrospective study of result of rotator cuff tear ar-
thropathy treated with hemiarthroplasty versus reversed shoulder
arthroplasty in correlation to the types of rotator cuff tear arthropa-
thy according to author’s classification. Clinical results are shown as
median of an age- and sex-corrected Constant Score.32
tive or inflammatory joint disease. Patients were operated
between 1993 and 1999. Fifteen patients were treated with
a modular hemiarthroplasty (Global Shoulder System,
DePuy Inc., Warsaw, IN), 5 of the 15 patients got an over-
sized extra-large head. Twenty-two patients did receive a
reverse shoulder arthroplasty (Delta III, Global Shoulder
System, DePuy Inc., Warsaw, IN). The mean age of the pa-
tients was 70 years. The clinical result after a minimum
of 2-year follow-up was documented in an age- and sex-
corrected Constant Score32 (CS%). There was a significant
Figure 3–7 Typical radiological outcome pictures of hemiarthroplasty according to the author’s classification. 10.1055/978-1-58890-635-9c003_f007
14530_C03.indd 17
3 Classification of Rotator Cuff–Tear Arthropathy 17
correlation of the Constant Score in the hemiarthroplasty
group with the type of cuff-tear arthropathy graded to our
classification system. In the patient group treated with
the reverse shoulder arthroplasty, no outcome difference
could be found between the different types of CTA (Fig.
3–6). In the type IIa and IIb groups, we treated 5 of the
15 hemiarthroplasty patients with an extra-large modular
head. This subgroup did not have a better clinical outcome.
The estimated biomechanical advantage of the large heads
was not seen and clinically, the results tended to be worse
than with anatomically sized heads due to overstuffing of
the soft tissue envelope (Fig. 3–7).
To prove our results, we did a prospective study on 63
patients with massive and irreparable RC tear and degen-
erative or inflammatory changes of the glenohumeral joint.
Due to the bad results in the retrospective study, type IIb
patients only were treated with reversed shoulder arthro-
plasty (Fig. 3–8). Because of the poor glenoid bone stock
type, type Ib patients never were treated with reversed
shoulder prosthesis (Fig. 3–5). The patients were operated
on between January 2000 and June 2002. Twelve patients
received a modular conventional hemiarthroplasty (Global
Shoulder System) with a “size-adapted” 5-head or a CTA 7-
head. Six patients were treated with bipolar prostheses and
46 patients were treated with reversed prostheses Delta III.
The average age of 70 years and the sex distribution (male:
female = 1:3) were both the same as in the retrospective
study. After a mean follow-up of 14 months, the Constant
Score (age and sex corrected) was recorded. The results
(Table 3–2) were very similar to the retrospective study.
Similar to the retrospective study, significantly worse
results with conventional arthroplasty than with reversed
arthroplasty in the type IIa could be found. This is clearly
1/31/08 11:03:28 AM
 18 Rotator Cuff Deficiency of the Shoulder

Figure 3–8 Excellent clinical result with a reversed arthroplasty for a type IIb defect. 10.1055/978-1-58890-635-9c003_f008

related to the unfavorable biomechanical circumstances in
these patients. The fact of a high and unstable position of
the center of rotation weakens the deltoid as the mainly
functioning muscle around the joint. The best results were
found in the type IIb group treated with reversed arthro-
plasty (Fig. 3–8).
Conclusions
Despite favorable clinical short- and midterm clinical re-
sults33,34 with the current reverse shoulder prostheses,
recent studies have reported an increased percentage of
inferior glenoid erosion and higher rates of revision after
6 to 7 years of follow-up.35 Hence, the use of a reversed
shoulder arthroplasty for all patients with a pathological
glenohumeral joint and a concomitant large or massive
RC tear cannot be recommended. The age of the patients
is the most decisive parameter for differential indication
in arthroplasty for CTA. Until 10-year or longer follow-up
studies are known, the use of reversed shoulder arthro-
plasties in patients younger than 70 to 75 years old should
be discussed seriously.
Table 3–2 Prospective Comparative Study of Treatment of Cuff
Tear Arthropathy with Different Types of Shoulder Prostheses:
Clinical Results (Median Constant Score, Age- and Sex-
Corrected) Correlated with the Author’s Classification System
Prosthesis Type Ia Type Ib Type IIa Type IIb
Conventional prosthesis 80 80 70
(5) (4) (3)
Bipolar prosthesis 74 59
(3) (3)
Reversed prosthesis 91 92
(7) (16)
In addition to age, the clinical presentation is also a very
important factor in decision-making. If pain-related functional
impairment is excluded, a conventional shoulder hemiarthro-
plasty would be unsuccessful in the prosthetic treatment of
a highly pseudoparalytic shoulder—a shoulder with active
flexion or abduction significantly lower than 90 degrees with
the typical aspect of anterosuperior dislocation (Fig. 3–9). The
clinical outcome would be some pain relief at best, with a
highly unsatisfactory functional result. To offer these patients
a satisfactory functional outcome, the only choice of prosthetic
therapy is a reversed shoulder arthroplasty.
In younger patients, alternative therapies should be con-
sidered. Because of the extraanatomic design of the current
reverse shoulder systems, there are mechanical disadvan-
tages, mainly early glenoid component loosening or mid-
term inferior glenoid erosion, polyethylene-liner wear, and
secondary midterm loosening of glenoid component. There-
fore, younger patients with CTA should not be treated with
a reverse shoulder arthroplasty. A conventional hemiarthro-
plasty, perhaps with some soft tissue reconstruction, may
be considered. The decisive question in the preoperative
decision-making relates to the biomechanical competence
of the residual RC tear. This is determined by the RC’s func-
tional performance and by the radiological changes in the
position of the center of rotation of the glenohumeral joint.
Another decisive parameter is the quality and quantity of
morphologic changes of the joint. The occurrence and pres-
entation of the typical morphologic features of CTA is multi-
factorial and mainly dependent on the underlying pathology
and the pathomechanics of the RC tear. The pathomechanics
of the RC tear is highly dependent on the size and location of
the tear, the number of tendons involved, the integrity of the
coracoacromial arch, and the bony geometry of the glenoid.
Besides the clinical parameters (pseudoparalysis, lag
signs), our radiological classification focusing on the posi-
tion and stability of the center of rotation of the gleno-
90
humeral joint is a helpful tool in decision making for the
(23)
type of prosthesis in CTA—especially in younger patients.

14530_C03.indd 18 1/31/08 11:03:30 AM


A B
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3 Classification of Rotator Cuff–Tear Arthropathy 19
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Figure 3–9 Typical (A) clinical and (B) ra-
diologic appearance of a rotator cuff tear
arthropathy with a biomechanically de-
compensated massive rotator cuff tear.
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Surg Am 1983;65(9):1232–1244
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17. Lehtinen JT, Kaarela K, Belt EA, Kautiainen HJ, Kauppi MJ, Lehto M.
Relation of glenohumeral and acromioclavicular joint destruction
in rheumatoid shoulder. A 15 year follow up study. Ann Rheum Dis
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- Differentialindikation und Frühergebnisse. Z Orthop 2001;139
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surgery on the outcome of shoulder arthroplasty. Paper presented
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at: 8th International Congress on Surgery of the Shoulder, April
23–26,2001; Cape Town, South Africa
26. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff
deficient shoulders. J Shoulder Elbow Surg 1996;5:362–367
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thy. J Bone Joint Surg Am 1999;81:1312–1324
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term follow-up observations. Clin Orthop Relat Res 1983;173:109–
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29. De Buttet M, Bouchon Y, Capon D, Delfosse J. Grammont shoulder
arthroplasty for osteoarthritis with massive rotator cuff tears—re-
port of 71 cases. J Shoulder Elbow Surg 1997;6:197
30. Vrettos BC, Wallace WA, Neumann L. Bipolar hemiarthroplasty of
the shoulder for the elderly patient with rotator cuff arthropathy. J
Bone Joint Surg Br 1998; 80(Suppl 1):106
31. Worland RL, Jessup DE, Arredondo J, Warburton KJ. Bipolar shoul-
der arthroplasty for rotator cuff arthropathy. J Shoulder Elbow Surg
1997;6:512–515
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32. Constant CR, Murley AH. A clinical method of functional assess-
ment of the shoulder. Clin Orthop Relat Res 1987;214:160–164
33. Sirveaux F, Farvard L, Oudet D, et al. Grammont inverted total
shoulder arthroplasty in the treatment of glenohumeral oste-
oarthritis with massive rupture of the cuff. J Bone Joint Surg Br
2004;86:388–395
34. Frankle M, Siegal S, Pupello D, et al. The reverse shoulder prosthe-
sis for glenohumeral arthritis associated with severe rotator cuff
deficiency. A minimum two-year follow-up study of sixty patients.
J Bone Joint Surg Am 2005;87:1697–1705
35. Farvard L. Guery J, Bicknell R, et al. Survivorship of the reverse
prosthesis. In: Walch G, Boileau P, Mole D, et al., editors. Reverse
Shoulder Arthroplasty—clinical results—complications—revisions.
Montpelier, VT: Sauramps Medical, 2006;373–380
2
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1/31/08 11:03:32 AM
4 Arthroscopic Management of Massive
Rotator Cuff Tears
James C. Esch and Yuri M. Lewicky
Since Watanabe and the early days of arthroscopy, arthro-
scopists have been pushing the envelope to see just how
far minimally invasive techniques can go. The primary goal
has always remained the same, “To do the most good with
the least amount of harm to surrounding tissues.” With the
development of smaller instruments, better cameras, and
standard techniques, the evolution has progressed stead-
ily in the knee with the shoulder now just coming into its
own. Arthroscopic repair of small to large cuff tears has
been achieved, and now some massive tears are being ad-
dressed as well.1–6 Indications include patients that are able
to lift their arm overhead with some difficulty and have a
chief complaint of significant pain rather than weakness.
Treatment options range from less complex procedures
to state-of-the-art bioengineered implants. They include
débridement of the rotator cuff (RC) in isolation, biceps te-
notomy or tenodesis, partial repair of the RC tendons, cuff
mobilization by interval slides with subsequent repair, soft
tissue patch tenodesis, and soft tissue patch augmentation
for cuff deficiency.
The goal of treatment is to relieve pain and therefore
improve function. If there is significant muscle atrophy at
the time of initial evaluation, then permanent weakness is
to be expected irrespective of the treatment chosen. This
must be conveyed to the patient preoperatively so their
expectations before surgery are realistic. Repair may work
best in patients that have slight narrowing of the acromio-
humeral distance (Fig. 4–1). A contraindication to arthro-
scopic repair of massive cuff tears is the condition where
the acromiohumeral distance is significantly narrowed
10.1055/978-1-58890-635-9c004_f001 Figure 4–1 Narrowed rotator interval on the “push-up” radiographic view.
secondarily to arthritis. Cuff arthropathy (Fig. 4–2) should
be more properly addressed with a shoulder arthroplasty
and is beyond the scope of this chapter.
Definition of a Massive Rotator Cuff Tear
RC tears by definition are defined as small (<1 cm), me-
dium (1 to 3 cm), large (3 to 5 cm), and massive (>5 cm).2,3
Further classifications have considered massive tears as
any tear that involves two or more tendons (Fig. 4–3).4 The
authors consider massive tears as a tear of the suprasp-
inatus tendon that either then extends posteriorly into
the infraspinatus tendon or extends anteriorly traversing
the rotator interval and involving the subscapularis ten-
don insertion (Fig. 4–4). When the latter exists, the biceps
tendon is frequently partially torn or dislocated from the
intertubercular groove.
Patient Presentation
The patient with a massive tear of the RC usually presents
with complaints related to pain and loss of function. Pain
may vary from none to a significant amount. Night pain is
often seen when the patient lies on the unaffected side,
with some relief gained by lying on the affected arm. Co-
morbidities frequently exist with this patient population.
The patients tend to be older, have a high BMI, suffer from
heart disease, and frequently have a workmen’s compen-
22 Rotator Cuff Deficiency of the Shoulder

Figure 4–3 Arthroscopic intra-articular view upon introduction of

the scope from the posterior portal. 10.1055/978-1-58890-635-9c004_f003
Figure 4–2 Rotator cuff arthropathy, a contraindication for arthro-
scopic rotator cuff repair. 10.1055/978-1-58890-635-9c004_f002

sation claim pending. Other comorbidities include female
gender, long duration of symptoms (>3 years), and a poor
anesthetic classification (America Society of Anesthesiolo-
gists).5–12
On clinical examination stiffness may predominate with
radiographic evidence of superior humeral head migration
and arthritic changes. For patients that present primarily
with pain, they may have a full range of motion and be able
to lift their arm overhead even though they have weak-
ness with resisted external rotation as seen with a posi-
tive belly-off test.6–15 Overhead function can exist because
the remaining cuff muscles are able to center the humeral
head near the glenoid so that the deltoid and other mus-
cles can function satisfactorily to lift the arm overhead.
Some patients, preoperatively, can lift their arm overhead
by trapping the humerus under the acromion; this is the
so-called awning effect described by Burkhart.7,8
The surgeon needs to discuss with the patient the suc-
cess for pain relief and functional recovery to establish rea-
sonable postoperative expectations. If the surgical proce-
dure is able to center the humeral head within the glenoid,
even if the muscle is not intact, then recovery of overhead
function is a significant possibility.
A discussion with the patient about surgery should be-
gin with the concept that the arthroscope can be used to
evaluate the shoulder’s pathology and outline the overall
treatment plan. The discussion then involves the range of
treatment from simple débridement, to partial or complete

A B
Figure 4–4 (A) Arthroscopic view from the subacromial space with the scope in the lateral portal. Note the absence of infraspinatus and supra-
spinatus with tear extension into the rotator interval. (B) Shoulder magnetic resonance imaging scan of a patient with a massive rotator cuff tear.
10.1055/978-1-58890-635-9c004_f004
 4 Arthroscopic Management of Massive Rotator Cuff Tears 23

repair, to the use of tissue patches for repair augmenta-
tion.9 The patients are informed that pain relief is typically
achieved, but functional weakness can still persist. Addi-
tionally, the patients are informed that on postoperative
magnetic resonance imaging (MRI) or ultrasound there
generally is not complete evidence of cuff healing.10
visualization in preparation for repair. Of particular impor-
tance is the preservation of the coracoacromial ligament and
anterior bone of the acromion. The most severe complication
seen after aggressive release of the coracoacromial ligament
and resection of the anterior subacromial bone is a disastrous
migration superiorly of the humeral head followed by the
patient’s inability to lift his or her arm overhead.

Diagnostic Evaluation Arthroscopic Débridement with Biceps

MRI studies are useful in determining the size of a rotator
cuff tear and indicating whether it is partial or full thick-
ness (Fig. 4–4). Additionally, they aid in determining the
amount of fatty infiltration present within the involved
muscles. An MRI cannot predict ease of mobilization of the
torn tendons in preparation for repair nor can it predict
postoperative patient function.
The Goutallier scale provides a useful method for quan-
tifying the amount of fatty infiltration of the muscle. The
fatty infiltration can vary from 0 (no fat), 1 (some fat),
2 (more muscle than fat), 3 (muscle equal to fat), and 4
(less muscle than fat).11 The amount of fatty infiltration of
the muscle does not decrease with surgery; this has been
shown both in clinical studies as well as in animal mod-
els. Goutallier has created a global fatty regeneration index
(GFDI), which is the total amount of fat in the supraspina-
tus, infraspinatus, and subscapularis muscles combined.11
In Goutallier’s study, the percentage of recurrence after
open cuff repair was related to the amount of fat within
the muscle, where repaired cuffs were more likely to retear
if their preoperative fatty infiltration was high.
The suprascapular nerve with its sling affect under the
transverse scapular ligament is another factor involved in
cuff atrophy and its ultimate recovery. Some authors have
reported improvement after release of the suprascapular
nerve by documenting preoperative and postoperative de-
compression EMG studies.12 Release of the suprascapular
nerve may have a role in the future in the arthroscopic
treatment of rotator cuff tears.
Tenotomy
Cleaning–up of Large Rotator Cuff Tears
An 81-year-old man complained of pain with activity;
he was able to elevate his arm forward to 120 degrees. In
qualifying his distress, the patient stated that 80% of his
problem was pain and 20% was loss of function. An MRI
scan showed the humeral head to be superiorly migrated
on the glenoid with abutment against the undersurface of
the acromion (Fig. 4–5). His RC was retracted to the supe-
rior margin of the glenoid rim. There was significant at-
rophy of the supraspinatus and infraspinatus muscle. An
arthroscopy was performed and demonstrated a massive
RC tear with bare bone exposed on the humeral head (Fig.
4–6). His humeral head was congruent.
Treatment consisted solely of a biceps tenotomy with a
banana knife blade for his dislocated biceps (Fig. 4–7). Five
years later, the patient was satisfied with minimal pain and
an ability to lift his arm to 120 degrees of forward elevation.

Treatment
Arthroscopic Approach
Diagnostic arthroscopy of the glenohumeral joint and sub-
acromial space allows the surgeon to evaluate the RC and
make a decision as to whether débridement without repair13
or débridement with partial or complete repair can easily
be done, and whether or not advanced techniques such as
interval releases will be necessary. The biceps tendon can
be débrided and released (tenotomy) or tenodesed. The ar-
ticular cartilage and labrum can be débrided and any loose
bodies removed. A subacromial bursectomy with limited Figure 4–5 Shoulder magnetic resonance imaging scan of an 81-
subacromial decompression will allow for bursal-sided cuff year-old man with a chief complaint of pain.
10.1055/978-1-58890-635-9c004_f005
24 Rotator Cuff Deficiency of the Shoulder
Figure 4–6 Arthroscopic image of a massive tear with a dislocated
biceps tendon. 10.1055/978-1-58890-635-9c004_f006
Anterior Advancement of the Infraspinatus
Partial Repair of Large Rotator Cuff Tears
Patients in which a complete repair of a massive cuff tear
is not possible usually can lift their arm overhead to 150
degrees, preoperatively. They tend to have external rota-
tion weakness and pain as a chief complaint. Often the su-
praspinatus tendon is retracted well medial to the glenoid
rim and atrophy of the supraspinatus and infraspinatus
muscles is quite marked. In these patients, a partial repair
is usually feasible and quite satisfactory.14 An illustration of
this is a 75-year-old woman who enjoys daily swimming.
Clinically, she was able to elevate her arm 150 degrees,
with weak external rotation and marked pain. Her MRI re-
vealed an elevated humeral head with medial retraction of
the supraspinatus past the glenoid (Fig. 4–8). At surgery,
mobilization of the supraspinatus tendon laterally was un-
successful, but advancement of the infraspinatus tendon
Figure 4–7 Arthroscopic biceps tenotomy with a banana blade.
10.1055/978-1-58890-635-9c004_f007
Figure 4–8 Magnetic resonance imaging scan of a 75-year-old
woman with a chief complaint of pain.
10.1055/978-1-58890-635-9c004_f008
anteriorly into the supraspinatus footprint was achieved.
The infraspinatus was then successfully repaired with su-
ture anchors (Fig. 4–9). Burkhart has nicely illustrated this
concept of a partial repair of the infraspinatus, with ad-
vancement toward the anterior, in patients with a massive
tear that is complete and retracted (Fig. 4–10).15
Surgical Technique
Initial Arthroscopic Evaluation of the
Rotator Cuff
The initial arthroscopic evaluation of the RC begins
with the creation of a posterior lateral and anterior portal
Figure 4–9 Arthroscopic image of a partial repair of a three tendon
rotator cuff tear. 10.1055/978-1-58890-635-9c004_f009
 4 Arthroscopic Management of Massive Rotator Cuff Tears 25

A B

C D
Figure 4–10 (A) Arthroscopic image of a partial repair of the infraspinatus tendon into the supraspinatus footprint and (B) artist’s rendering,
(C) final appearance after knot tying and (D) artist’s rendering. 10.1055/978-1-58890-635-9c004_f010

followed by a lateral portal (Fig. 4–11). The anterior portal
is placed lateral to the coracoacromial ligament to allow
for easy scope movement and to preserve the coracoacro-
mial ligament. The shaver is used to excise the subdeltoid
bursa. The initial procedure begins with the scope poste-
rior and the shaver anterior to allow for débridement of
the bursa followed by the RC tendon and the cuff footprint
on the greater tuberosity (Fig. 4–12). The lateral border of
the greater tuberosity should be defined. Close inspection
for the medial extent of the supraspinatus tendon should
be performed. When found, its mobility should be deter-
mined with the use of an arthroscopic grasper (Fig. 4–13).
The aggressive excision of the coracoacromial arch with
its coracoacromial ligament strut should be avoided. In-
stead, a simple subacromial bursectomy with “smoothen-
ing” of the undersurface of the acromion can be employed
as described by Matsen.16 This allows for excellent cuff vis-
ualization, while preserving the function of the arch and
eliminating potential causes of impingement.
The arthroscope is then moved to the lateral portal and
débridement of the bursa from posterior, along the infra-
spinatus tendon, is performed. During this process, the
bursa can be traced laterally to the deltoid insertion and
the infraspinatus insertion on the greater tuberosity can
be defined (Fig. 4–14). The shaver can then be used on the
undersurface of the acromion further excising the bursa
and allowing for complete delineation of the supraspina-
tus muscle. The bony undersurface of the acromion is not
excised, but rather is cleaned and followed down to the
spine of the scapula, which will later be used to outline
26 Rotator Cuff Deficiency of the Shoulder
Figure 4–11 Three standard arthroscopic portals for cuff repair.
10.1055/978-1-58890-635-9c004_f011
“the posterior cuff interval” between the supraspinatus
and the infraspinatus tendons (Fig. 4–15). The shaver is
then placed in the anterior portal; while preserving the
coracoacromial ligament, the bursa is excised inferior to
the ligament down to the level of the coracoid. This allows
for exposure of the coracohumeral ligament (CHL).
The surgeon is now able, with a grasper, to grasp the
supraspinatus and infraspinatus tendons and determine
whether an anterior interval slide with mobilization of the
coracohumeral ligament should be considered. Many sur-
geons do this routinely on all cuff repairs. If mobility con-
tinues to be an issue after the anterior slide the surgeon
can consider a double-interval slide to further mobilize the
cuff in anticipation of repair.
The surgeon should be cautioned that mobilization of the
supraspinatus and infraspinatus tendons should be performed
A B
Figure 4–13 Arthroscopic image of mobilization of a cuff tear (A) without traction and (B) with traction applied by a grasper.
10.1055/978-1-58890-635-9c004_f013
Figure 4–12 Arthroscopic image showing bursal débridement prior
to repair of a massive cuff tear. 10.1055/978-1-58890-635-9c004_f012
in the proper direction to allow for the tendon to footprint
advancement and subsequent suture anchor repair. Marginal
convergence, or side-to-side, techniques tend to reduce ten-
sion on the bony repair, but in the case of a massive cuff tear,
these techniques are often better performed after the tendon
has been fixed to the bony footprint with suture anchors.
Interval Slides
The release of the coracohumeral ligament (anterior in-
terval slide) between the supraspinatus and the coracoid
process has been popularized by Tauro.17,18 As noted pre-
viously, this can be done while looking from the lateral
portal and using a shaver blade, basket forceps, or an elec-
trocautery from the anterior portal (Fig. 4–16).
The double-interval slide, popularized by Burkhart et al,
involves the release of the CHL anteriorly and the release
of the interval between the infraspinatus and supraspina-
tus tendons posteriorly (Fig. 4–17).19–30 The anterior release
 4 Arthroscopic Management of Massive Rotator Cuff Tears 27

Figure 4–14 Arthroscopic image of the subdeltoid bursa being de- Figure 4–15 Arthroscopic image of the infraspinatus and supra-
tached from the deltoid. 10.1055/978-1-58890-635-9c004_f014 spinatus interval; the spine of the scapula has been exposed.
10.1055/978-1-58890-635-9c004_f015

should be approached anteriorly and the posteriorly. With
the posterior interval release, the spine of the scapula is
cleaned with the shaver and the capsular side of the RC is
released. The interval is then released medially with an elec-
trocautery or a shaver blade until the fat of the suprascapu-
lar nerve is exposed at the spinoglenoid notch (Fig. 4–18).
Arthroscopic Suprascapular Nerve
Decompression
The mobility of a torn RC has significant importance when at-
tempting to repair it without undue tension. The suprascapu-
lar nerve has been shown to act as a cuff tether as it traverses
under the transverse scapular ligament in the suprascapular
notch (Fig. 4–19).20 Additionally, studies have shown that ten-
sion is placed on the nerve when cuff retraction is present.21
Some patients with massive RC tears have electromyogram
(EMG) evidence of muscle denervation of the supraspinatus
and infraspinatus muscles.22 Some surgeons release the su-
prascapular nerve at the time of cuff mobilization in antici-
pation of repair and the hope of improved nerve and muscle
recovery. The criteria for decompression include patients
with documented EMG evidence of muscle denervation from
suprascapular nerve compression.23
Arthroscopic suprascapular nerve decompression is per-
formed with the arthroscope inserted through a modified
posterolateral portal and a radiofrequency device from the

B
Figure 4–16 (A) Artist’s rendering, and (B) arthroscopic image of
the release of the coracohumeral ligament.
10.1055/978-1-58890-635-9c004_f016

A
28 Rotator Cuff Deficiency of the Shoulder
A B
D E
lateral portal.23,24 By following the CA ligament anteroin-
feriorly, identification of the coracoid base and the trans-
verse scapular ligament is facilitated.12 A modified Neviaser
portal is then utilized for probe placement and subsequent
transverse scapular ligament release. Release of the liga-
ment is more safely performed on the lateral side of the
suprascapular notch via subperiosteal elevation from the
coracoid base. This can be performed with a radiofrequency
device, beaver blade, or curved electrocautery (Fig. 4–20).23
Rotator Cuff Repair after Appropriate
Mobilization
Upon introduction of the scope into the subacromial space
proper delineation of the tear configuration must be per-
formed. This is facilitated by an adequate bursectomy and
placement of the scope in more than one portal to allow for
spatial awareness. Advancement of the RC to the properly
prepared bony footprint of the greater tuberosity should
be attempted with a grasper (Fig. 4–21A-C). Undue tension
on the repair should be avoided due to subsequent cuff fail-
C
Figure 4–17 Double interval slide tech-
nique. (A) Release of the coracohumeral
ligament, (B) posterior interval release,
(C) mobilization of the cuff tendons “the
slide,” (D) anchor repair, and (E) marginal
convergence of the massive cuff tear.
10.1055/978-1-58890-635-9c004_f017
ure occurring. If adequate lateralization of the cuff cannot
be done, then the footprint may be medialized 5 to 10 mm
(Fig. 4–21D).25 Additionally, advancement of the suprasp-
inatus and infraspinatus can be performed via interval
slides to enable proper repair. CR proceeds in a sequential
fashion starting with advancement of the infraspinatus an-
teriorly and laterally followed by “marginal convergence”
if necessary and completed with supraspinatus laterali-
zation. Marginal convergence involves the placement of
sutures between the supraspinatus and infraspinatus ten-
dons or between the supraspinatus and biceps tendon and
functions to reduce the tension on the tendon to footprint
reconstruction.26–39 The first double loaded suture anchor
is placed near the articular surface and the cuff is initially
secured with a mattress stitch. The second suture pair
from the anchor is then placed in a “T-type” mattress lock-
ing stitch (Fig. 4–22). Additional suture anchors are placed
in single file as needed along the articular margin. Recent
literature has focused on double-row suture anchor RC re-
pair.27–43 Studies have shown that greater surface area con-
tact with the footprint is achieved initially.28,29 Whether or
not this is important in repair healing has not been proven
 4 Arthroscopic Management of Massive Rotator Cuff Tears 29

A B

10.1055/978-1-58890-635-9c004_f018

Figure 4–18 Arthroscopic images of the double-interval slide. (A) Ini-

tial posterior interval release, (B) posterior interval release completed,
C and (C) anterior interval release.

Figure 4–20 Arthroscopic image of decompression of the supra-

Figure 4–19 Cadaveric suprascapular nerve release. scapular nerve. 10.1055/978-1-58890-635-9c004_f020
10.1055/978-1-58890-635-9c004_f019
30 Rotator Cuff Deficiency of the Shoulder
A B
C D
Figure 4–21 Arthroscopic image showing mobilization of the supra-
spinatus and infraspinatus tendons anterolaterally. (A) Before mobi-
lization, (B) mobilization with a grasper, (C) after mobilization with
clinically. If lateral uplifting of the repair occurs after me-
dial anchor placement, placement of a second suture an-
chor more laterally on the footprint or tuberosity serves to
reduce this tissue (Fig. 4–23A).
For massive cuff repairs, we prefer metal, dual-loaded
suture anchors (Smith & Nephew Twin-Fix; Smith &
Nephew, Inc., Andover, MA, or equivalent), high-strength
sutures (Smith & Nephew Ultra Braid or equivalent), and an
interlocking suture, such as the T-suture, mattress equiva-
lent.30,31 Newer anchors with improved bone holding and
high-strength sutures have now made the tendon suture
interface the weak link in the repair. The strongest bone for
suture anchor purchase is either just medial to the articu-
lar margin and under the articular surface or laterally on
the greater tuberosity. Typical patients with massive cuff
tears tend to have an osteoporotic lateral footprint; hence
they do not hold suture anchors well. Recessed suture eye-
lets with peripheral cortical purchase by the anchor may
suture placement, and (D) medialization of the rotator cuff footprint
to achieve a proper tension repair.
10.1055/978-1-58890-635-9c004_f021
very well solve this dilemma. For suture passage through
tendon, we prefer a direct suture passing technique (Smith
& Nephew E-pass), a retrograde pierce and grab technique
(Fig. 4–23B) (Smith & Nephew Arthro pierce), or suture
shuttle technique (Smith & Nephew Accupass).
Tissue Repair Enhancement
As science progresses, advancements in tissue repair en-
hancement abound. Techniques for enhancing a cuff repair
include bursal augmentation of the repair, growth factor
placement, and pulsed ultrasound. Uhthoff et al32 has writ-
ten extensively on the subacromial bursa as an important
source of pluripotent cells for repair. The bursal tissue,
in fact, does have an extensive vascular network and has
been referred to as the bursal epoetin. Whether or not
these cells are the actual initiators or enhancers of cuff tis-
 4 Arthroscopic Management of Massive Rotator Cuff Tears 31

sue repair is still to be proven. In our opinion, an attempt

should be made to preserve as much of the bursa as pos-
sible without sacrificing visibility for proper and complete
repair. Frequently, we will tack the remaining vascularized
bursal tissue down to the repair. Additionally, Montenegro
et al33 has shown by second-look arthroscopy, the impor-
tance of bursal augmentation of the repair (Fig. 4–24A,B).
We have used growth-factor enhancement at the time of
repair by inserting platelet-derived growth factor graft be-
tween the footprint and the tendon prior to suture tying
(Fig. 4–24C–E). Daily mechanical stimulation of the ten-
don, such as by pulsed ultrasound, has also been utilized to
enhance tendon to bone healing.34,35 Animal studies have
shown promise in this regard.

Figure 4–22 “T-type” mattress locking stitch.
10.1055/978-1-58890-635-9c004_f022
Postoperative Immobilization
Immobilization of the operative arm in a sling should be
done for at least 8 weeks to allow the tendon to heal to
bone. Some passive range of motion is allowed early on to
avoid joint capture. But it should be noted that even passive
motion places stress on the repair site.36–57 Animal studies
have shown that cuff to bone healing is a slow process.
The patient should be counseled that the cuff heals at a

10.1055/978-1-58890-635-9c004_f023

Figure 4–23 (A) Artist’s rendering of a double-row rotator cuff tear re-
B pair. (B) Pierce and grab technique for rotator cuff tear suture placement.
32 Rotator Cuff Deficiency of the Shoulder

A B

C D

E F
Figure 4–24 (A) Arthroscopic bursal augmentation of a rotator cuff place (note the probe is maintaining graft stability). (E) Completion
tear repair with (B) horizontal mattress, horizontal mattress absorb- of graft insertion between the native cuff and footprint. (F) Restore
able suture. (C) Introduction of the platelet-derived growth factor patch for massive cuff repair augmentation.
graft via an arthroscopic cannula. (D) Suturing of the growth factor in 10.1055/978-1-58890-635-9c004_f024
 4 Arthroscopic Management of Massive Rotator Cuff Tears 33

rate of 10% per month, and that complete healing may not
entirely occur until 10 months postoperatively. Generally,
early active assisted motion is allowed at 2 months post-
operatively, with the use of weights postponed until 6 to 9
months postoperatively. This tends to be a difficult concept
to communicate to patients; many feel that they are “fast
healers” and wish to return to weight lifting as soon as
possible. The mechanics of healing needs to be stressed to
these individuals.

Tissue Repair Augmentation

Frequently, a deficit in cuff tissue is noted after initial ar-
throscopic cuff débridement and mobilization. In these
instances augmentation of the planned repair can be per-
formed by using cells from the patient, innate growth fac-
tors, and or tissue scaffolds.37–63 Tissue scaffolds include
the use of porcine intestine (Restore Graft; DePuy Inc., War- A
saw, IN; Johnson & Johnson, Inc., New Brunswick, NJ) (Fig.
4–24F), freeze-dried dermal tissue (Graft Jacket; Wright
Medical Technology, Inc., Arlington, TN), and recently xe-
nografts, such as horse pericardium (Pegasus Biologics
OrthADAPT Bioimplant, Irvine, CA). The initial goal of the
scaffold is to create a tenodesis effect so that the humeral
head can be reasonably centered within the glenoid. This
combination leads to the restoration of the “force couples”
about the shoulder and thus allows for the larger muscle
groups to lift the arm overhead. Ideally, tissue penetration
by native host cells with graft incorporation, degradation,
and cuff restoration is the desired result. To date, this effect
has not been proven in the literature. Although the current
experience with these devices is limited, many patients
have had good pain relief with the humeral head coverage
that they afford. Unfortunately, there has been less than
excellent restoration of the tenodesis effect seen clinically
in these same patients. Postoperative MRI studies after the
use of these devices have shown either a very thin cuff or
a hypertrophic, thickened cuff (Fig. 4–25).38 The results B
of the Graft Jacket device are similar to those seen after Figure 4–25 Postoperative magnetic resonance imaging scan of a
arthroscopic repair of patients with a massive cuff tear and massive rotator cuff tear repaired with the (A) Restore Patch (note,
significant muscle atrophy. They include pain relief with the thin line of healing), and (B) the Graft Jacket (note, the thickened
moderate force couple restoration. area of healing. 10.1055/978-1-58890-635-9c004_f025

Complications Additional complications include anchor pullout with

The most severe complication seen with arthroscopic
treatment of massive RC tears is the superior migration of
the humeral head seen after aggressive removal of the un-
dersurface of the anterior and lateral acromion, including
resection of the coracoacromial ligament. Many surgeons
routinely aggressively remove these structures and inevi-
tably end up with this disastrous complication (Fig. 4–26).
For these patients, the only solution is a reverse total shoul-
der arthroplasty described elsewhere in this book.
repair failure, cuff to suture failure, stiffness, and contin-
ued pain.
Conclusions
Proper selection of patients with massive RC tears who
wish to undergo arthroscopic evaluation and repair can-
not be overly emphasized. Those individuals who present
with a cuff-arthropathy-type picture with a high-riding
34 Rotator Cuff Deficiency of the Shoulder
A A
B B
Figure 4–26 (A) A patient with superior migration of the humeral
head after failed massive rotator cuff repair with subacromial de-
compression. (B) Radiographs of the patient.
10.1055/978-1-58890-635-9c004_f026
humeral head should not be considered a candidate for ar-
throscopy; shoulder arthroplasty should be recommended
instead. Arthroscopic treatment of many patients with
massive RC tears is rewarding for the surgeon and satisfy-
ing for the patient. The patient typically has less pain and
better function, although weakness may still be present.
Healing seen on postoperative MRI scans in these patients
ranges from 40 to 50% and it is apparent that the muscle
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 5 Muscle Transfers for the Treatment of the
Irreparable Rotator Cuff Tear
Robert C. Decker and Spero G. Karas
The main goals in rotator cuff (RC) repair are to establish
continuity of the tendon, restore the soft tissue interface
with the overlying acromion, center the humeral head in
the glenoid, and relieve impingement.1 Failure of these
goals and failure to achieve repair of the RC is thought to
lead to the development of cuff tear arthropathy. A loss
of normal humeral head depression, which is supplied
by a balanced RC unit, results in the upward migration
of the humeral head. This, in turn, alters the force vector
across the glenohumeral joint, leading to early degenera-
tive changes. Additionally, with massive RC tear the hu-
meral head is not effectively stabilized in the anterior and
posterior direction, resulting in additional abnormal sheer
forces compounding the abnormal wear pattern.2
RC tear repair, in general, has demonstrated good long-
term results with clinical improvements.2–10 Outcomes of
repair correspond to the size or the RC tear, with massive
tears presenting the most difficult surgical challenge.6,10,11
able No universally agreed upon definition or treatment of a
massive RC tear has been established. Cofield3 defined
massive as any tear with a diameter >5 cm. Others have
defined a massive tear as those tears involving at least two
tendons.4 Intraoperatively, two findings are important in
determining if the massive RC tear is repairable: the elas-
ticity of the muscle and the assessment of the possibility
of direct tendon reinsertion into bone after excision of the
necrotic ends.5 Most large or massive RC tears are repair-
able; however, 5% of all RC tears are mechanically irrepa-
rable.6 Additionally, the repair of chronic, retracted tears
involving two or more tendons is technically difficult and
has been shown to be less successful.7–10
In those instances where mobilization and direct re-
pair of tendons is unattainable or has failed, an additional
procedure may be required. Adequate results have been
obtained from simple débridement and decompression
of massive RC tears and partial repairs.11,12 If débridement
proves unsuccessful, then transfer of local tissues may be
required to alleviate pain and improve function. Many ten-
don transfer techniques have been described for the man-
agement of massive, irreparable RC tear. These include mo-
bilization of the superior cuff and transposition of the long
head of the biceps tendon,11,13 supraspinatus muscle ad-
vancement,14–22 latissimus dorsi transfer,4,15–26 subscapu-
laris transfer,3,16 trapezius transfer,17–31 teres major trans-
fer,18–34 pectoralis major transfer,19 teres minor transfer,1
combined subscapularis and teres minor,20 and the deltoid
muscle flap.21,22 Although numerous techniques have been
illustrated, no gold standard exists yet. The multitude of
different transfers and the variability in the results of these
techniques demonstrates a general lack of consensus on
optimal treatment. Within this chapter, we will explore
the most commonly described tendon transfer techniques,
their indications, contraindications, and results.
It is important to understand the pathology present
within the shoulder prior to surgery. This information
should be sought preoperatively with plain radiographs
in orthogonal planes, magnetic resonance imaging (MRI),
and a thorough clinical exam. Muscle wasting in the su-
praspinatus fossa, weakness of external rotation (ER), and
abnormal scapulothoracic motion should alert the clini-
cian to the potential for a massive RC tear.23 Additionally,
it is important to know the main complaint of the patient,
their functional status, and expectations from reconstruc-
tive surgery. Armed with this information the surgeon can
best plan which reconstructive procedure to utilize.
Subscapularis Transfer
Subscapularis transfer is used for massive RC tears that
cannot be primarily repaired. Because this transfer has
been associated with diminished active elevation postop-
eratively, it is best performed on those unable to elevate
the extremity above their head or in whom overhead
function is markedly impaired.24 Additionally, the patient
should have a subscapularis amenable to mobilization.
Therefore, the ideal patient for subscapularis transfer has
a massive tear that is not amenable to primary fixation,
cannot elevate the arm, and has an adequate subscapularis
musculotendinous unit.
Surgical Technique
Cofield3 first described the subscapularis transfer in 1982
for patients with tendon deficiency preventing primary re-
pair. Through an anterior deltoid approach, the deltoid is
elevated from the anterior acromion with care to provide
a good sleeve for repair. An anterior acromioplasty is per-
formed with resection of the coracoacromial ligament and
38 Rotator Cuff Deficiency of the Shoulder
decompression of the subacromial space and supraspina-
tus outlet. A limited débridement is performed to obtain a
good vascular edge for healing. The upper half to two thirds
of the subscapularis is mobilized by incising the musculo-
tendinous junction in an oblique manner downward and
medially (Fig. 5–1). The subscapularis can be divided due
to its dual innervation from the superior and inferior sub-
scapular nerves. The distal half of the subscapularis is left
intact as an important passive and dynamic stabilizer of
the shoulder. Soft tissue attachments are detached, while
protecting both the axillary and musculocutaneous nerves.
The upper part of the subscapularis is advanced superiorly
and laterally to a cancellous trough medial to the greater
tuberosity. The free edge is secured into the cancellous
trough and the trimmed bleeding edges of the supra-
spinatus and infraspinatus are sewn to the transferred
subscapularis to close the defect (Fig. 5–2).
Finally, the shoulder is ranged to evaluate the repair
and ensure that the transfer is not overtensioned.24 Postop-
erative management requires closely supervised physical
therapy. Intraoperative ROM should guide postoperative
physical therapy. Passive ROM and pendulum exercises
are initiated immediately to prevent adhesions or con-
tractures. ER is avoided as the subscapularis is mobilized
superiorly and will be put under tension. Active ROM is
initiated at 6 weeks; ER is begun at 2 to 3 months.
In Cofield’s3 initial series of 29 patients, 10 underwent
subscapularis transfer for degenerative RC disease. Half
felt that they improved significantly, whereas the other
half felt they were only slightly improved and the aver-
age postoperative active elevation was 130 degrees. RJ and
TJ Neviaser36 found that transfer of the subscapularis and
teres minor was a good salvage procedure for a massive
Figure 5–1 The upper one half to two thirds of the subscapularis
is incised from its insertion on the lesser tuberosity. A bone trough
is prepared for insertion of the transferred tendon onto the greater
tuberosity. 10.1055/978-1-58890-635-9c005_f001
10.1055/978-1-58890-635-9c005_f002
Figure 5–2 Completed subscapularis transfer. The medial edge of
the transferred subscapularis tendon is sewed to the remnant lateral
edge of the supraspinatus. Laterally, the subscapularis is attached to
the greater tuberosity with suture anchors or transosseous sutures.
RC tear providing decreased pain and improved function
if the deltoid was intact. They found deltoid dysfunction
in three out of five failures. In 1983, Neer25 described use
of the upper 70% of the subscapularis for closure of large
superior defects. In a series of 33 patients followed for a
mean of 4.5 years, 16 had excellent results while 9 were
satisfied and 9 were unsatisfied. The unsatisfied group
primarily complained of decreased strength. Karas16 felt
caution should be utilized in selecting patients to undergo
subscapularis transfer due to the potential for loss of func-
tion. In a retrospective review of 20 patients who under-
went subscapularis transfer and subacromial decompres-
sion for massive, irreparable RC tears, Karas noted that 17
out of 20 patients were satisfied at a mean of 30 months.
Nineteen described a decrease in pain postoperatively; 9
patients still had weakness and pain with prolonged over-
head activities. Two patients lost active elevation despite
reduction in pain and felt that the operation made them
worse—possibly due to the loss of stabilization of the hu-
meral head.16,24 The transfer provides excellent pain relief,
but caution should be exercised in doing this transfer in
patients who have intact overhead function because this
has been shown to potentially deteriorate.16,24
Subscapularis transfer is not without potential compli-
cations. The subscapularis acts as a humeral head depres-
sor due to its insertional relationship into the lesser tuber-
osity. With transfer of the proximal half to two thirds of
the subscapularis, there might not be enough force to de-
press the head actively, while the deltoid elevates the arm.
With the subscapularis transferred superiorly, the anterior
force vector may not be able to balance the posterior force
vector. Additional potential complications include injury
to the musculocutaneous nerve and the axillary nerve as it
 5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear
crosses the subscapularis. An additional theoretical com-
plication is anterior instability resulting from transferring
the upper half to two thirds of the subscapularis superiorly
leaving only the lower third intact. While mobilizing the
subscapularis, it is important not to violate the anterior
capsule to protect against anterior instability.
Overall, subscapularis transfer is a useful procedure
when the RC cannot be closed by conventional methods.
However, the surgeon should be aware of the potential loss
of forward elevation after subscapularis transfer. Further-
more, subscapularis transfer violates what is often the only
intact, functioning, major muscle unit in patients with mas-
sive RC tear. Healing complications or rupture of the trans-
ferred muscle unit may result in no intact muscle group
about the glenohumeral joint. For this reason, subscapularis
transfer should likely not be the first choice in one’s arma-
mentarium for muscle transfer in massive RC tear.
Latissimus Dorsi
The latissimus dorsi transfer was conceived to allow clo-
sure of the RC defect with a vascularized, autogenous
tendon, while providing head depressor activity and res-
toration of ER.15 Originally a treatment for poliomyelitis
and brachial plexus injuries, the transfer was intended to
partially restore abduction as well as stabilization of the
glenohumeral fulcrum.26–45 The latissimus dorsi is a strong
extrinsic internal rotator and adductor of the humerus,
which receives its innervation from the thoracodorsal
nerve and its vascular supply through the thoracodorsal
pedicle lying on the anterolateral surface of the muscle.
Saha27 determined that the latissimus is active throughout
shoulder ROM, so synergy with a new function is attain-
able with proper muscle retraining and rehabilitation.
Zachary28 reported the first case of a latissimus dorsi trans-
fer in a child with brachial plexopathy. He transferred both the
latissimus and the teres major to the posterior humerus to
improve ER. In 1988, Gilbert et al29 and Gerber et al30 reported
on the technique of latissimus dorsi transfer for loss of ER and
superior humeral head migration in patients with massive RC
tears. A massive defect of the RC is biomechanically similar
to motor loss of the suprascapular nerve, thus a latissimus
dorsi transfer provides abduction, ER, and depressor forces to
the glenohumeral joint. The primary indication for latissimus
transfer is ER weakness due to loss of infraspinatus function.
Pain and forward elevation loss are relative indications for
latissimus transfer. Although not an absolute contraindica-
tion, Gerber et al noted that those patients with subscapularis
insufficiency fared less well after latissimus dorsi transfer.
Surgical Technique
The patient is draped in the lateral decubitus position and
a lateral incision across the axilla is utilized. The latissimus
39
dorsi is mobilized extensively along its superficial margins
and mobilized off the scapula. The neurovascular pedicle
is identified along the anteroinferior margin and protected
along its course. The insertion of the latissimus dorsi is
visualized by humeral abduction and internal rotation (IR).
The tendon is then resected at its bony insertion. Care must
be taken to avoid injuring the posterior humeral circumflex
artery at the superior edge of the tendon. The radial nerve
and axillary nerves are at risk during the tenotomy due to
their proximity.31–53 The tendon is mobilized to reach the
posterosuperior aspect of the RC with the shoulder in 60
degrees of abduction. Not infrequently, the tendon may
be short or thin, requiring augmentation with autogenous
fascia lata. The tendon must track medial to the instant
center of rotation of the shoulder joint throughout its arc
of motion (Fig. 5–3). To maintain this path, the inferior
enveloping fascia of the posterior deltoid may be used as a
pulley. This will prevent lateral subluxation of the tendon;
if it slips laterally it will become a primary adductor of the
humerus. The tendon can then be sutured to the existing
cuff tissue or used to close the defect as needed (Fig. 5–4).
ROM is protected in an abduction brace for 6 to 8 weeks
followed by gradual ROM and strengthening.
Gerber and colleagues30 have demonstrated encourag-
ing results with the latissimus dorsi transfer. They reported
on 69 massive RC tears treated with latissimus dorsi trans-
fer reviewed at an average of 53 months.30 They found a
significant improvement in pain, active flexion, active ab-
duction, and active ER. Abduction strength also improved
postoperatively. In this series, however, 13 patients with
subscapularis insufficiency had minimal improvement in
their postoperative outcome. The authors noted that the
10.1055/978-1-58890-635-9c005_f003
Figure 5–3 Passage of the transferred latissimus dorsi tendon deep
to the posterior deltoid. The fascia of the posterior deltoid may be
used as a “sling” to maintain a medial orientation of the tendon to
the glenohumeral joint’s instant center of rotation.
40 Rotator Cuff Deficiency of the Shoulder
10.1055/978-1-58890-635-9c005_f004
Figure 5–4 Attachment of the transferred latissimus dorsi tendon
to the humeral head. When possible, the distal edge of the tendon
should be attached to the superior aspect of the subscapularis ten-
don. Medially, the tendon is sewn to the remnant rotator cuff. Later-
ally, suture anchors or transosseous sutures are utilized to attach the
latissimus tendon to the greater tuberosity.
procedure may be of limited benefit to those patients with
a positive lift-off test preoperatively.
Aoki et al32 prospectively reported on 12 shoulders
that underwent latissimus dorsi transfer for irreparable
cuff defects. Good to excellent results were found in eight
cases, fair in one case, and poor in three cases. Function
and pain were significantly improved. The mean post-
operative active forward flexion was 135 degrees, which
represented a 36-degree improvement from mean preop-
erative measurements. Osteoarthritic changes appeared
in five shoulders and proximal migration of the humeral
head occurred in six. Aoki and colleagues theorized that
these changes occurred because the depressor action on
the humeral head might not have been fully restored due
to the latissimus dorsi not being fully active in the early
phase of elevation. Electromyography revealed that 75%
of transferred muscles showed synergistic action with the
supraspinatus. Nonsynergistic motion was evident in three
shoulders and was theorized to result from adhesions or
rupture. Nonsynergy was associated with poor results.
Risk factors for poor outcome were identified as multiple
previous surgeries, deltoid pathology, and involvement of
the subscapularis in the cuff defect.32
Miniacci and MacLeod33 retrospectively reviewed 17
patients who were treated with a latissimus dorsi trans-
fer for a massive RC tear. At a mean 51 months follow-up,
14 patients had significant pain relief and significant im-
provement in function for all activities except lifting more
than 15 pounds. Fourteen stated they would have the
operation again. Seven of 8 patients with a detached or
nonfunctional anterior portion of the deltoid also had im-
provement. Interestingly, the authors of this series noted
that insufficiency of the subscapularis did not adversely af-
fect postoperative outcome. There were three failures due
to ongoing pain and impaired function. These 3 patients
all had work-related injuries and viewed the operation as
a failure. Warner and Parsons34 evaluated the efficacy of
primary transfer of the latissimus dorsi versus transfer as
a salvage reconstruction for failed repairs. Salvage recon-
struction of a failed prior RC repair yielded inferior results
when compared with a primary latissimus dorsi transfer
for irreparable RC tear. Warner and Parsons reviewed 16
patients who underwent transfer as salvage after a failed
repair and 6 patients who underwent primary reconstruc-
tion. The salvage group had lower Constant scores (55 ver-
sus 70) and a higher rate of late rupture (44 versus 17%)
compared with the primary group. Postoperative active
forward flexion and ER were 122 degrees and 41 degrees
in the primary group, with 105 degrees and 40 degrees
in the salvage group, respectively. Inferior outcomes were
found in patients with poor quality tendon, severe fatty
degeneration, and deltoid detachment. Results of primary
transfers in Warner and Parson’s series were comparable
to Gerber et al’s series as 83% had good to excellent results.
Lower gains were realized when utilized as a salvage pro-
cedure with only 50% reporting good to excellent results
and 20% reporting poor outcomes. Warner and Parsons
concluded that a competent deltoid is mandatory for the
restoration of shoulder function once the tendon transfer
achieves humeral head coverage. Patient selection is criti-
cal to this outcome. The authors noted that results similar
to primary cases can be had with salvage only if the deltoid
is intact.
Based on the encouraging results obtained by Gerber
and others, the latissimus dorsi transfer has undergone
increasing acceptance for posterosuperior tear configura-
tions in patients that have limited ER and elevation with
an intact subscapularis.
Pectoralis Major Transfer
Subscapularis tendon tears are rare and account for 3.5
to 8% of RC tears.35,36 They are sometimes associated with
anterior shoulder instability and respond poorly to non-
operative management.35,37 Diagnosis is difficult and of-
ten causes a delay in treatment and a subsequently more-
complex repair.19,37–60 Gerber et al found that subscapularis
tendons repaired early had better results than those with a
delay to repair.38 If left untreated, the subscapularis might
not be amenable to repair due to retraction and atrophy.
Pain may be accompanied by instability and abnormal
glenohumeral kinematics.39 Various transfers have been
attempted for subscapularis tears, but the pectoralis major
has had the most attention.6,15,19,40–64
Wirth and Rockwood originally described transferring
the superior half of the pectoralis major tendon to the hu-
meral head for reconstruction of a massive RC tear.19 Resch
 5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear
et al41 modified this transfer to approximate the natural
course of the subscapularis more accurately.
Surgical Technique
Through a deltopectoral approach, the subscapularis, the
conjoined tendon, tendon of the pectoralis major, and the
anterior humeral head are all visualized. The long head of
the biceps is tenotomized and tenodesed in those where it
is dislocated anteriorly, and the superior half to two thirds
of the pectoralis major is detached from the humerus and
mobilized. Due to the segmental distribution of the thora-
coacromial artery and pectoral nerve after passing under
the clavicle, this does not compromise the neurovascular
status of the pectoralis.42 The musculocutaneous nerve
and its entrance into the coracobrachialis muscle is iden-
tified and the space posterior to the conjoined tendon is
developed. The pectoralis major tendon is then passed be-
hind the conjoined tendon and anterior to the musculo-
cutaneous nerve. Transosseous nonabsorbable sutures or
suture anchors are utilized to attach the transferred pec-
toralis major (Fig. 5–5). If a partial or complete rupture of
the supraspinatus is present, part of the pectoralis tendon
is mobilized to the greater tuberosity to fill the defect. At
the end of the procedure the musculocutaneous nerve is
visualized to ensure that it is not under tension. The re-
constructed shoulder is immobilized for 6 weeks. Passive
ROM exercises are initiated on the day after surgery; after
6 weeks, active ROM is begun and full loading is allowed
at 12 weeks.
Resch and colleagues41 described their experience with
12 patients who had irreparable tears of the subscapula-
Figure 5–5 Completed pectoralis major transfer. The musculotendi-
nous unit is mobilized and rerouted posterior to the conjoined ten-
don to reproduce the force vector of the subscapularis muscle. Care
must be taken to identify and protect the musculocutaneous nerve.
10.1055/978-1-58890-635-9c005_f005
41
ris tendon. They routed the transfer behind the conjoined
tendon to the lesser tuberosity to reproduce the anatomy
and biomechanics of the subscapularis. In their series, 8
patients had an isolated subscapularis tear; 4 patients had
concomitant lesions of the supraspinatus. After a mean of
28 months, 9 patients subjectively reported excellent or
good results, whereas 3 patients had fair results. No one
had a poor subjective outcome. Pain decreased in all pa-
tients and Constant scores improved from an average of
22.6 points preoperatively to an average of 54.4 postop-
eratively. There was an increase in forward flexion from 93
degrees to 129 degrees and abduction improved from 85
degrees to 113 degrees. Resch et al also noted improved IR
from the transfer; 3 patients with a preoperative positive
“lift-off” test were negative postoperatively. Furthermore,
5 of 6 patients with positive “belly-press” tests preopera-
tively were negative after transfer. Electromyographic ex-
amination of the pectoralis major tendon demonstrated
near symmetrical patterns of activity.41
Jost et al40 evaluated 30 consecutive pectoralis muscle
transfers for irreparable subscapularis tears with an aver-
age follow-up of 32 months. Unlike Resch and colleagues,
Jost et al altered the transfer technique by transferring the
entire pectoralis major muscle over the conjoined tendon.
The transfer was fixed to the medial aspect of the greater
tuberosity with bone anchors. Their technique was later
modified to transosseous suture fixation secondary to in-
sertion site pain in 11 of 18 shoulders. All 30 shoulders ob-
jectively were significantly improved. The Constant score
increased from 47% preoperatively to 70% postoperatively,
whereas shoulder subjective values improved from 23 to
55%. Pain, activities of daily living, forward flexion, and
abduction strength all improved. Subjectively, 25 patients
were either satisfied or very satisfied while 5 were either
disappointed or dissatisfied. Outcome was determined to
be less favorable when associated with an irreparable su-
praspinatus tear, and the transfer failed to restore full ac-
tive anterior elevation.
Combined Pectoralis Major and
Latissimus Dorsi Transfer
Building from earlier results on latissimus dorsi transfer for
massive posterior cuff tears and pectoralis major transfers
for anterior tears,6,19 Aldridge et al9 described a combined
transfer for massive RC deficiency. Both the pectoralis ma-
jor and latissimus dorsi were transferred to obtain a bal-
anced fulcrum between the anterior and posterior forces
of the cuff musculature.2 The importance of the pectoralis
transfer to the anterior defect was inferred from the results
of Gerber and colleagues’ earlier work on transferring the
latissimus dorsi for posterior tears.15,30,43 They found that
patients who underwent latissimus dorsi transfer with a
subscapularis tear failed to benefit from the transfer.30
42 Rotator Cuff Deficiency of the Shoulder

Indications for a combined transfer include a massive RC
deficiency, weakness, mild or no pain, and an inability to el-
evate the arm effectively at the GH joint. Patients with gleno-
humeral arthritis or a primary complaint of pain should, in
general, be deemed poor candidates for tendon transfer.
the long head of the triceps for reconstruction of massive
RC tears. The authors felt that the transfer provided a vas-
cularized space between the acromion and the humeral
head to help alleviate pain. The primary indication for the
triceps transfer was pain caused by supraspinatus and in-
fraspinatus tears not amenable to repair.

Surgical Technique
Surgical Technique
The procedure combines elements of both the Sever-
L’Episcopo procedure for brachial plexus birth palsies and The transfer procedure performed was originally described
the pectoralis major transfer for subscapularis defects.19,34,44 by Malkani and colleagues.47 If the RC was irreparable, the
Through a deltopectoral approach, the entire pectoralis muscular margins were débrided as necessary and transfer
major tendon and latissimus dorsi are removed from their of the long head of the triceps was performed. The long
insertions. The pectoralis major is transferred to the ante- head of the triceps was harvested through a long poste-
rolateral superior humeral head and sutured to the superior rior humeral incision. The long head’s tendon was divided
aspect of the subscapularis tendon. Through a posterolateral roughly 1.5 cm above the olecranon process and the mus-
incision the latissimus dorsi tendon is passed through the cle was isolated to the level of its main pedicle (Fig. 5–6).
quadrilateral space inferior to the axillary nerve and poste- The main pedicle was located roughly 2 to 3 cm distal to
rior circumflex artery. The latissimus tendon is then fixed the teres major tendon. A tunnel was prepared by blunt
to the posterolateral superior humeral head and sutured to dissection over the spine of the scapula to the subacromial
the remnants of the RC to close the posterior defect.9 The space. The long head was then passed through the subacro-
latissimus dorsi is transferred for function only and no at- mial space mimicking the course of the infraspinatus. The
tempt is made to cover the entire humeral head. Patients are transferred tendon was then attached to the humeral head
placed in an abduction brace for 6 weeks postoperatively, and the remaining RC musculature (Fig. 5–7). A standard-
followed by a standard sling for 3 weeks. Passive and active ized rehabilitation program progressing from passive ROM
assisted ROM and a strengthening program are instituted to strengthening was instituted postoperatively.
for a minimum of 3 months postoperatively.
Aldridge and colleagues retrospectively reviewed 11 pa-
tients with a combined transfer of the latissimus dorsi and
pectoralis major tendon for massive RC deficiency. Patients’
primary complaints were weakness and a decreased abil-
ity to elevate the affected arm. The primary preoperative
objective was to improve function. Mean active elevation
improved from 42 degrees preoperatively to 86 degrees
postoperatively with mean ER improving from 2.3 degrees
to 13 degrees. Overall, four patients made no improvement,
two were slightly improved, and five improved significantly.
The authors concluded that the combined procedure was an
effective salvage technique to improve active elevation and
ER in select patients with minimal pain who had failed both
nonoperative and operative management. Indications on
who would best benefit from this procedure are still being
elucidated; nevertheless, it does hold promise for providing
some patients with improved function.9

Triceps Transfer
Hartrampf et al45 developed the triceps musculocutane-
ous flap as an alternative to the latissimus dorsi flap for
chest wall reconstructions. Miller46 used the triceps flap to
cover large irreparable RC tears due to its ability to cover Figure 5–6 Area of mobilization for long head of triceps transfer.
long distances. Malkani et al47 investigated both the surgi- The tendon is taken down ~1.5 cm proximal to the olecranon proc-
cal anatomy of the long head of the triceps as well as pro- ess and mobilized to its main neurovascular pedicle ~3 cm distal to
spectively evaluated their clinical experience in utilizing the teres minor. 10.1055/978-1-58890-635-9c005_f006
 5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear
10.1055/978-1-58890-635-9c005_f007
Figure 5–7 Completed triceps transfer. The tendon is routed deep
to the posterior deltoid to replicate the course of the infraspinatus.
The transferred tendon is subsequently attached to the greater tu-
berosity and the remnant rotator cuff tendons.
Malkani et al prospectively studied the 2-year clini-
cal outcomes of triceps flap for coverage of irreparable RC
tears. Nineteen transfers of the long head of the triceps
transfer were evaluated in patients with massive, irrepa-
rable RC tears. All patients were subjectively satisfied with
their outcome and had improvement in their pain, qual-
ity of life, and function. UCLA shoulder scores improved
from 9.7 preoperatively to 28.8 postoperatively. Shoulder
ROM improved in lateral rotation, ER, and forward eleva-
tion, while no difference was noted in abduction. Malkani
and colleagues found no loss of elbow extension strength
postoperatively from removing the long head of the triceps
from the olecranon. This was consistent with Travill’s48
findings that the medial head of the triceps showed the
greatest amount of activity with elbow extension and the
long head the least amount of activity. Complications in
Malkani et al’s series included 1 patient who developed an
ulnar neuropraxia and 2 patients had decreased sensation
over the posterior arm postoperatively.49
In addition, Malkani and colleagues looked at 20 ca-
daver upper extremities to evaluate the surgical anatomy
involved with long head of the triceps transfer. Entry points
of neurovascular structures into the long head were meas-
ured from the distal margin of the teres major. An aver-
age of 3.2 important vascular pedicles was found, with the
largest branch consistently located within 2 to 3 cm of the
distal margin of the teres major tendon. Nerve branches
from the radial nerve followed the vascular pedicles. The
43
average length of the long head of the triceps muscle was
24.4 cm from the distal margin of the teres major to the
olecranon with an average width of 1.5 cm at its inser-
tion. The authors noted that there was sufficient triceps to
transfer to close a 5-cm defect in all cases.
Malkani et al felt that the triceps transfer did not suffer
from the limitations of other transfers. These limitations
include lack of sufficient flap to cover large defects, small
range of advancement, and donor site morbidity. Addition-
ally, the long head of the triceps flap is easily accessible in
the standard shoulder surgery position and can be easily
dissected without repositioning. The flap itself is extremely
versatile and can be applied to several different configura-
tions. Clinical results demonstrated decreased pain with
improved function and quality of life. Primary indications
should be for pain with massive defect and failure of repair
in patients with low functional demands.
Teres Minor Transfer
In 1934, L’Episcopo described the first technique to rebal-
ance the external and internal rotators in children with
brachial plexus injuries using the teres minor.44 A ten-
don to bone teres minor transfer had previously been de-
scribed for treatment of RC tears.1 Paavolainen modified
this transfer by utilizing a bone block stabilized by internal
fixation to provide increased fixation strength.1 Indications
for teres minor transfer are irreparable defects with badly
frayed, contracted RC tendons of poor quality. In addition,
as in most types of tendon transfer surgery, a cooperative
patient is necessary due to the demanding nature of the
long-term rehabilitation required.
Surgical Technique
The transfer is performed through an anterosuperior ap-
proach between the anterior and middle portions of the
deltoid. First, the RC tendons are mobilized and evaluated
for potential primary repair. Subacromial decompression
of the bursa and acromioplasty are also completed at this
time. If transfer is required, the arm is maximally inter-
nally rotated and the teres minor insertion is released with
a block of cortico-cancellous bone. The capsule is released
along the posterior glenoid rim to facilitate transfer of the
muscle, tendon, and the capsule en bloc. The tendon, along
with the bone block, is transferred anteriorly after removal
of a similar-sized segment of bone from the site of the RC’s
previous insertion. The teres minor bone block, once in po-
sition, is secured with a cancellous screw. The bare bone
block is then moved posteriorly and held in place by the
RC so that no fixation is required (Fig. 5–8). Paavolainen
felt a bone-to-bone interface allowed better healing ca-
pacity and longevity compared with previous tendon-to-
bone reconstructions. With the size of the tear reduced,
44 Rotator Cuff Deficiency of the Shoulder
10.1055/978-1-58890-635-9c005_f008
Figure 5–8 Teres minor tendon transfer. The teres minor is removed
from the greater tuberosity with a bone block. A second bone block
more anterior is removed to make room for the teres minor bone
block and to fill the defect left from the teres minor harvest. The teres
minor and its bone block are secured to the greater tuberosity with a
screw and washer or transosseous sutures.
the remaining edges are sewn together. If a gap remains,
an interval slide of the supraspinatus50 or an advancement
of the subscapularis20 is performed. Passive exercises are
initiated on the first postoperative day and continued for
6 weeks, at which time active exercises are begun. The
cancellous screw is removed under local anesthesia 3 to 6
months postoperatively to prevent chronic impingement.1
Paavolainen1 reported on 31 patients who underwent
teres minor transfer for irreparable, massive RC tears.
Night pain and activity-related pain improved in 93% of
cases. In addition, he found that function in daily activities
improved in 90% of patients. Although functional assess-
ment scores were decreased in 3 patients, all patients were
satisfied with relief of night pain.
In the setting of massive RC tear, glenohumeral force
coupling is disrupted. The supraspinatus supplies 14% and
the infraspinatus 22% of the force generation of the RC.49
If this force coupling cannot be reestablished to normal,
Paavolainen1 felt transferring the teres minor was justi-
fied to improve function and relieve pain. The teres minor
supplies 10% of the RC’s normal force. In contrast, Karas16
was reluctant to transfer the teres minor because of the
possible weakening of abduction and ER.51
Paavolainen1 felt that teres minor transfer was success-
ful in pain relief when performed for the proper patient
with a massive, irreparable RC defect. This transfer should
be reserved for the patient with a badly frayed, retracted
rupture and a retracted, poor quality tendon. Additionally,
the patient should be able to comply fully with a long pe-
riod of demanding rehabilitation. If these criteria are satis-
fied, teres minor transfer should provide pain relief and
functional improvement.
Biceps Transfer Interposition Grafting
In 1975, Bush 13 first described biceps transfer interposition
grafting (BTIG) as a means to close RC defects. He reported
on 14 patients with limited follow-up and demonstrated
good to excellent results in 75% of patients. The long head
of the biceps was transferred into the tear after maximum
mobilization of the RC to close down any residual defect.
Pain was the primary indication for BTIG transfer. Addi-
tional indications were massive, irreparable RC tears with
retraction and poor tissue; an intact long head of the bi-
ceps of good quality; a relatively normal glenohumeral
joint; and a motivated patient able comply with therapy.
Contraindications included paralysis of the remaining RC
muscles or the deltoid, and degenerative changes in the
glenohumeral joint.
Surgical Technique
Hansen52 describes a modified Gardner incision from the
anterolateral acromion to the lateral superior coracoid
process. Subcutaneous flaps are elevated and the deltoid
is split from the anterior acromion. Approximately 1 cm of
deltoid is raised from the anterior acromion laterally and
an anterior and inferior acromionectomy is performed.
Alternatively, the arthroscope can be utilized to evaluate
the RC tendon tear and the biceps tendon, decompress the
bursa, and perform an acromioplasty and distal clavicle
resection if necessary.
The anterior and posterior RC remnants are brought
together and tension is restored. Where the cuff is insuf-
ficient to allow complete closure, BTIG is utilized to close
the defect. The transverse ligament is incised and the bi-
ceps tendon is mobilized. A trough 1.5 cm posterior and
lateral to the bicipital groove is made and the biceps ten-
don is mobilized into the groove. The tendon must be sta-
ble in both internal and ER in the new groove to maintain
its normal function. The posterior RC remnant is then su-
tured to the posterior portion of the biceps and the ante-
rior portion of the RC is sutured to the anterior portion of
the biceps tendon. Remaining RC tissue is sutured to the
bone to reinforce the repair (Fig. 5–9). Patients are placed
in an abduction pillow postoperatively and pendulum ex-
ercises are instituted. A progressive rehabilitation program
is sequentially instituted as healing ensues.52
Hansen52 reported on 22 shoulders treated with BTIG
followed for a minimum of 2 years. The primary indication
for operative intervention was pain. Preoperatively, 19 of
the 22 shoulders had significant rest pain, all but one had
pain with use, and only one patient was able to sleep with-
out difficulty. The average preoperative active elevation in
 5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear
10.1055/978-1-58890-635-9c005_f009
Figure 5–9 Biceps tendon interposition graft. The biceps tendon is
mobilized and placed in an osseous trough 1.5 cm posterior to its
native course. The remnant supraspinatus and infraspinatus are then
mobilized and sewn to the biceps tendon. The repair is reinforced by
sewing the remnant rotator cuff tendon edge to bone.
his series was 97 degrees. Additionally, none was able to
perform all of the following activities of daily living: sleep,
raising the arm, lifting 10 pounds, combing hair, or reach-
ing the back pocket. Postoperatively, Hansen found that
all patients were sleeping comfortably at night, 19 of 22
shoulders did not have rest pain, and all but two patients
were able to perform all five aforementioned activities of
daily living. Subjectively, all but one patient was pleased
with their results and would have the procedure again. The
only complication noted was a long head of the biceps rup-
ture at 10 weeks postoperatively. The patient did not have
any pain and was able to continue to perform all activities
of daily living.52
Hansen stressed the importance of a complete and
thorough subacromial decompression, as it was likely as-
sociated with significant pain relief.53 The BTIG is not a
replacement for RC tissue, but simply a vascularized, an-
chored graft allowing the reestablishment of the yoke
mechanism between the anterior and posterior RC ten-
dons. Therefore, a net resultant inferior head depressor ef-
fect can be reestablished. In addition, the graft is believed
to help stabilize the humeral head and provide compres-
sion across the glenohumeral joint. Because the biceps is
not sutured into its new groove, it remains a gliding ten-
don and maintains its original function as a humeral head
stabilizer.54 Hansen concluded that biceps tendon transfer
does not result in additional harvest site morbidity and is
a suitable technique to achieve cuff closure when unable
to do so primarily. In those instances where standard tech-
niques failed to close a massive tear, BTIG proved reliable
and effective in improving function and relieving pain.
45
Deltoid Transfer
The deltoid muscular flap was described as a means to
cover an exposed humeral head secondary to a RC de-
fect. The transfer was initially described by Takagishi and
later modified by Augereau and provides several advan-
tages.20,55,56 First, the insertion of a thick piece of tissue
acts as a spacer between the humeral head and the ac-
romion. Second, the deltoid flap remains contractile and
vascularized. The contraction of the deltoid flap reinforces
the action of the intrinsic and extrinsic depressor muscles
of the humeral head, restoring scapulohumeral rhythm
while permitting full active anterior elevation. During the
first few degrees of active anterior elevation, the deltoid
flap contracts concurrently with the deltoid. As the me-
dial deltoid raises the humeral head, the contraction of the
flap exerts a downward force on the humeral head. This
will offset the elevating force of the deltoid during the first
60 degrees of active anterior elevation. The effectiveness
of the deltoid flap is dependent on the quality of deltoid
musculature. Therefore, a thin deltoid with signs of fatty
degeneration is a contraindication to transfer.21
Surgical Technique
Gazielly21 described an anterosuperior approach from the
lateral clavicle passing over the acromioclavicular (AC)
joint and finishing ~4 cm under the lateral edge of the acro-
mion. The anterior deltoid is incised vertically along the
axis of the AC joint to the junction between the middle
and anterior heads of the deltoid. The lateral aspect of the
anterior deltoid is then detached from the anterosuperior
edge of the acromion subperiosteally to allow a firm cuff
for repair. The anteromedial deltoid is left attached to the
clavicle. If necessary, acromioplasty and decompression
are performed if not previously performed during arthro-
scopic evaluation. The tear is then evaluated and resected
back to a vascularized edge amenable to repair. The width
of the flap needed depends on the width of the cuff tear in
its sagittal plane. The base of the flap must be at least 2 to
3 cm to maintain vascularization and innervation. The flap
is fashioned by cutting outward into the deltoid interval
laterally and the previous performed deltoid incision me-
dially (Fig. 5–10). Nonabsorbable sutures are passed first
through the posterior segment of the tear and then passed
through the leading edge of the deltoid flap. It is important
to incorporate the deep deltoid fascia as a means to pro-
vide strength to the repair (Fig. 5–11). The deltoid defect
is closed to help maintain shoulder contour and cosmesis
postoperatively. A 70-degree-abduction sling and post-
operative rehabilitation is started immediately. The two
goals of rehabilitation are to protect the flap against sub-
acromial compression and tensioning and to exercise the
flap to maintain its contractile property and avoid atrophy.
46 Rotator Cuff Deficiency of the Shoulder
Gazielly deemed postoperative exercise and therapy criti-
cal to success.21
Gazielly reviewed the outcomes of 20 patients treated
for massive cuff tears with deltoid flap. All patients had
failed a 6-month period of specific rehabilitation based on
strengthening the humeral head depressor muscles. Addi-
tionally, all patients had full passive ROM preoperatively, as
stiffness was a contraindication. All patients had pain and
muscle weakness. Postoperatively, 45% of patients were
free of pain and 55% had mild pain; postoperative level
of activity was satisfactory in 65% of patients. Improve-
ments were seen in active ROM, strength, and muscular
fatigue. Results of Gazielly’s series were similar to those
obtained by Saragaglia and Tourne.57 Results demonstrate
that deltoid flap repair helped with pain and postopera-
tive strength. Maximum strength was usually realized at
12 to 18 months postoperatively and patients were able to
return to work as fatigue pain was relieved.21
Augereau reported on 22 deltoid flaps evaluated by
MRI after 2.5 years and demonstrated 18 intact flaps. Re-
sults were better in those patients where the deltoid had
a homogeneous stroma with a thickness of >2 mm after
2.5 years. Augereau reported 37% of humeral heads were
centered postoperatively after deltoid transfer.55 Gazielly
followed his deltoid flaps with ultrasound and found 90%
were intact at one year. No signs of impingement were
found with intact transfers. Additionally, he found that
flaps that were between 5 and 9 mm had excellent and
good results, whereas flaps thinner than 4 mm did not do
as well with four poor and one fair result. These results re-
inforced the need for a good quality deltoid for satisfactory
transfer results.22
Deltoid transfer has been noted to be a reliable alter-
native for treating chronic, massive RC tears.21,22 Deltoid
transfer requires active, motivated adults with good del-
toid muscle quality who have near normal active ROM, but
suffer from pain and fatigue. Transfer is contraindicated in
Figure 5–10 Deltoid transfer. The transferred muscle unit is sewn to the residual medial cuff and to the leading edge of the remnant posterior
cuff. To ensure a strong construct, the deep fascia of the deltoid must be incorporated into the repair.
patients with signs of fatty muscular degeneration of the
deltoid, as they have poorer postoperative results.
Trapezius Transfer
Mikasa and Yamanaka transferred the trapezius for RC de-
fect coverage if the RC tendons could not be approximated
to the greater tuberosity at 90 degrees of abduction at pri-
mary repair.17–30,58 The trapezius is the largest of the sus-
pensory muscles of the shoulder girdle and is divided into
three parts: the upper, intermediate, and lower fibers. The
upper and intermediate fibers were utilized for transfer.
The upper fibers elevate the scapula along with the levator
scapulae and the intermediate fibers adduct the scapula.
Surgical Technique
The lateral decubitus position is typically used to perform
the trapezius transfer. A lateral incision is elongated to the
medial border of the scapula ~1 cm superior to the spine of
the scapula. The skin is mobilized to visualize the trapezius
of which ~10 cm is detached from the spine of the scapula
and 4 cm is detached from the distal clavicle. The acromial
insertion is left untouched. About 8 cm of the trapezius
is separated in parallel to its muscle fibers and the mus-
cle belly is elevated. The insertion of the trapezius at the
acromion is detached widely with a bone block. Next the
deltoid muscle is split and the acromion is osteotomized
at its midlateral point along the axis of the spine of the
scapula. The subacromial space is thus well visualized. The
shoulder is elevated to 90 degrees in the scapular plane
and a small bony groove is made in the tuberosity. The tra-
pezius is then passed beneath the osteotomized acromion
and the supraspinatus, infraspinatus, and subscapularis
are sutured to the trapezius flap as needed (Fig. 5–11).
10.1055/978-1-58890-635-9c005_f011
 5 Muscle Transfers for the Treatment of the Irreparable Rotator Cuff Tear
Figure 5–11 Trapezius transfer. The trapezius is harvested from the
lateral clavicle and the scapular spine with a small bone block. The sub-
acromial space is accessed via an acromial osteotomy, which is repaired
with a tension band technique.
10.1055/978-1-58890-635-9c005_f012
The acromial osteotomy is then fixed with a tension band
technique. Passive elevation and rotation are begun on the
fifth postoperative day with active exercises started at 4
weeks.59
Mikasa and Yamanaka performed seven trapezius
transfers for massive RC tears. Their primary indication for
transfer was pain at rest and night pain in patients where
primary RC repair could not be performed. Preoperatively
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49
71. Magermans DJ, Chadwick EK, Veeger HE, Rozing PM, Van der Helm
FC. Effectiveness of tendon transfers for massive rotator cuff tears:
a simulation study. Clin Biomech (Bristol, Avon) 2004;19(2):116–
122
72. Wang AA, Strauch RJ, Flatow EL, Bigliani LU, Rosenwasser MP. The
teres major muscle: an anatomic study of its use as a tendon trans-
fer. J Shoulder Elbow Surg 1999;8:334–338
73. Pagnotta A, Haerle M, Gilbert A. Long-term results on abduction
and external rotation of the shoulder after latissimus dorsi trans-
fer for sequelae of obstetric palsy. Clin Orthop Relat Res 2004;
426:199–205
74. Waters PM, Bae DS. Effect of tendon transfers and extra-articular
soft-tissue balancing on glenohumeral development in brachial
plexus birth palsy. J Bone Joint Surg Am 2005;87(2):320–325
75. Cleeman E, Hazrati Y, Auerbach JD, Shubin SK, Hausman M, Flatow
EL. Latissimus dorsi tendon transfer for massive rotator cuff tears:
a cadaveric study. J Shoulder Elbow Surg 2003;12(6):539–543
76. Pearle AD, Kelly BT, Voos JE, Chehab EL, Warren RF. Surgical tech-
nique and anatomic study of latissimus dorsi and teres major
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thoracodorsal artery within the latissimus dorsi muscle. Br J Plast
Surg 1986;39:206–209
78. Tobin GR, Schusterman M, Peterson GH, Nichols G, Bland KI. The in-
tramuscular neurovascular anatomy of the latissimus dorsi muscle:
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79. Gerber C, Krushell RJ. Isolated rupture of the tendon of the sub-
scapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br
1991;73(3):389–394
 6 The Spectrum of Disease in the Rotator
Cuff–Deficient Shoulder
Jonathan Levy
The understanding of the relationship between the rota-
tor cuff (RC) deficient shoulder and glenohumeral arthritis
continues to evolve. Early attempts at defining this pathol-
ogy resulted in a variety of nomenclature used to describe a
similar clinical presentation: Milwaukee shoulder, l’épaule
sénile hémorragique (the hemorrhagic shoulder of the eld-
erly), cuff tear arthropathy (CTA), apatite-associated de-
structive arthritis, and so on. These clinical descriptions
were focused on disease characteristics that typify what
has become known as CTA: severe glenohumeral arthri-
tis with joint collapse, a hemorrhagic-crystalline effusion,
and a massive RC tear. Classic CTA actually represents one
of several disease processes that can be present in the ro-
tator cuff deficient shoulder. In fact, a spectrum of disease
exists for the RC-deficient shoulder (Fig. 6–1).
Classic CTA, as originally described by Neer and col-
leagues,1 represents the patient with a massive RC tear
with severe glenohumeral arthritis that advances with
collapse of the articular surface. However, several other
manifestations within the spectrum of the RC-deficient
shoulder may result in a similar loss of function (Table
6–1). These include instability due to massive RC tears, RC
tears with minimal arthritis, RC deficiency with anterior
superior escape, and a variety of conditions that result in
proximal humeral bone loss and subsequent RC deficiency
(i.e., nonunion of greater tuberosity or tumor resection).
My goal in this chapter is to first review the established
knowledge on the disease. I will then focus on utilizing my
group’s experience in managing this population of patients
to establish key principles necessary to understand the pa-
thology, pathophysiology, and treatment of the RC-deficient
shoulder. By clearly defining the pathology present, one can
begin to understand how aspects of the pathology contrib-
ute to the pathophysiology of the disease. This introduction
will serve as a foundation for other chapters, as these prin-
cipals are paramount in the diagnosis and management of
the RC-deficient shoulder.
Historical Background
Although Neer et al1 first coined the term cuff tear arthropa-
thy, the description of such pathology was reported previ-
ously. In the 19th century, Adams and Smith described a pa-
tient with a localized form of rheumatoid arthritis involving
14530_C06.indd 51
the shoulder.2–5 In 1934, Codman reported a patient with a
subacromial space hygroma who had recurrent swelling, RC
deficiency, severe glenohumeral arthritis, and cartilaginous
bodies of the synovium.3 In 1981, McCarty coined the term
Milwaukee shoulder seen in 4 patients with identical clinical
presentations and joint fluid with active collagenase, neu-
tral proteinase, and hydroxyapatite crystals.4 In 1983, Neer
et al1 introduced the term cuff tear arthropathy to describe
the presentation of 26 patients with massive RC tears and
glenohumeral arthritis treated with a total shoulder re-
placement. Over the last century, several reports of similar
clinical presentations established various theories as to how
patients developed the condition.
Classic Cuff Tear Arthropathy
Several theories on the etiology of CTA have been discussed.
There exists no consensus among reports. The rheumato-
logic literature has emphasized the biochemical aspects of
the condition, whereas the orthopedic descriptions have
emphasized the mechanical factors.5–12
Reports of a hemorrhagic theory for CTA focused on the
presence of a hemarthrosis in patients with severe gleno-
humeral arthritis and massive RC tears. In 1967, DeSeze6 first
described this in 3 patients; however, later reports by Baudin5
in 1969 and Lamboley7 in 1977 noted similar presentations.
Another group of reports focused on the inflammatory
nature of the disease process. The Milwaukee shoulder
was introduced in the rheumatology literature by McCarty in
1981.4 This condition, reported mostly in women, consisted
of massive RC tear, glenohumeral arthritis, bony destruc-
tion, and joint instability. The hemarthrosis present con-
tained calcium phosphate crystals, active collagenase, pro-
tease activity, and inflammatory cells.4,8,9 The description
of the Milwaukee shoulder emphasized the central role of
calcium phosphate crystals. These crystals are phagocy-
tized by synovial cells activating the release of destructive
enzymes, which act on periarticular tissue and joint sur-
faces.4,8–17 Antoniou et al10 noted an association between
the apatite crystals, massive RC tears, and glenohumeral
arthritis. These crystals were seen with high levels of PGE2
in the synovial fluid of patients with CTA. The result is a
picture of severe degenerative arthritis with significant
bone loss and soft tissue destruction.
1/31/08 11:03:08 AM
 52 Rotator Cuff Deficiency of the Shoulder

The spectrum
of disease

Glenohumeral Massive
arthritis rotator cuff
tears

Classic
cuff tear
anthropathy
Osteoarthritis Massive cuff
with static tear with
anterior or Proximal
humeral bone antero-
posterior superior
subluxation loss
(i.e. Tumor, escape and
fracture sequelae, no arthritis
failed
Massive rotator hemiarthroplasty)
cuff tear with
severe arthritis
and centered
joint Failed cuff
repair with
early arthritis
Glenohumeral
arthritis

Massive 10.1055/978-1-58890-635-9c006_f001
Glenohumeral rotator cuff
Figure 6–1 (A) The spectrum of disease. (B) Clas-
B arthritis tears sic cuff tear arthroplasty.

The nutritional theory emphasizes the role of the RC
as a structural barrier. As noted by Neer and colleagues,1
extravasation of synovial fluid in the presence of massive
RC tears results in an inadequate diffusion of nutritional
components necessary for articular cartilage metabolism.
Additionally, by not using the joint, alterations in articu-
lar content (i.e., water content) and disuse osteopenia de-
velop. This results in cartilage atrophy, subchondral osteo-
penia, and collapse of the humeral head.
Perhaps the most significant role that the RC plays in
CTA is described in the mechanical theory. Neer et al1 was
the first to emphasize this role. The instability that results
from RC deficiency is the first step toward the develop-
ment of CTA. Loss of RC function results in a loss of the bal-
anced force couples needed to establish a stable fulcrum
for the glenohumeral joint.11 In this setting, the deltoid
moment results in glenohumeral instability with exces-
sive upward migration of the humeral head. Mechanical
factors of glenohumeral instability from RC dysfunction
and proximal migration of the humeral head to the point
of acromial impingement result in degenerative changes
seen on the humeral head, superior glenoid, and undersur-

14530_C06.indd 52 1/31/08 11:03:09 AM

 6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder
Table 6–1 Other Presentations of Cuff Deficient Shoulder
10.1055/978-1-58890-635-9c006_t001
Tendon loss
Massive rotator cuff tear with minimal arthritis
Massive rotator cuff tear with anterosuperior escape
Infection
Muscle loss
Infection
Severe glenohumeral arthritis with severe fatty infiltration of
intact rotator cuff
Bone loss
Fracture sequelae
Failed hemiarthroplasty for fracture
Failed hemiarthroplasty with rotator cuff tear
Failed hemiarthroplasty for cuff tear arthropathy
Failed bipolar hemiarthroplasty
Tumor resection
Infection
Nerve loss
Chronic Erb palsy
Suprascapular nerve palsy
Post-polio
face of the acromion. The end result is acetabularization of
the shoulder joint with severe joint destruction.
The connection between massive RC tears and the devel-
opment of classic CTA has not been clearly elucidated. Neer et
al1 estimated that 4% of patients with RC tears would develop
CTA. Hamada and colleagues,12 however, noted progressive
degenerative changes in 5 of 7 patients with massive RC
tears, suggesting that massive RC tears would ultimately lead
to progressive degenerative changes. In a cadaveric study,
Feeney et al13 showed a strong correlation between tears of
the RC and articular cartilage degenerative changes, as they
found articular cartilage damage in all 10 shoulders that had
RC tears. Nonetheless, Rockwood and colleagues14 noted no
progression of glenohumeral degeneration in patients with
massive RC tears 6.5 years after open acromioplasty and dé-
bridement of the RC. The mere presence of a massive RC tear
may not be enough to develop the progressive degenerative
changes seen in classic CTA; however, these massive tears
may result in severe functional loss. One would suspect that
as the aging population increases, the incidence of problems
related to the RC-deficient shoulder will surge.
Other Disease Presentations of the
Rotator Cuff Deficient Shoulder
Several conditions result in disability due to RC deficiency
(Table 6–1). The central role of the RC in providing shoul-
14530_C06.indd 53
53
der function is clear. RC deficiency results in variable de-
grees of weakness and instability that result in a signifi-
cant loss of function for the patient. Burkhart introduced
the concept of balanced force couples to distinguish func-
tional from dysfunctional massive RC tears.15 Once a bal-
anced force couple is lost, the RC becomes dysfunctional.
Whether the massive RC tear occurs with minimal ar-
thritis, severe arthritis (i.e., classic CTA), or isolated instabil-
ity (i.e., anterosuperior escape), the function of the RC will
ultimately determine the functional outcome. Reconstruc-
tive options must strongly consider the ability to restore a
functional RC for reliable improvements to be achieved.
In cases where the RC tendon is intact, severe muscular
atrophy of the RC may result in its dysfunction. This has been
recognized in patients with severe osteoarthritis and an in-
tact RC.16,17 In these patients when the arthritis is treated
with a total shoulder arthroplasty, instability results. It is
thought that the friction created by the severe arthritis cre-
ates a static stability. When this friction is replaced with a
smooth articulating surface, RC dysfunction results in joint
instability and failure of the joint replacement.
RC deficiency may also develop after failure of a RC
repair or subacromial decompression. This may be the
result of the natural history of the disease. However, the
important role of the coracoacromial arch in preventing
anterosuperior instability of the glenohumeral joint has
been described.18 In cases where both the RC and the cora-
coacromial arch are deficient, the resulting anterosuperior
instability results in significant disability and loss of shoul-
der function, often with pseudoparesis of the shoulder.
Several disease processes result in significant proximal
humeral bone loss. The importance of proximal humeral
bone is based on the RC insertion. As proximal humeral bone
loss becomes more severe, the loss of RC insertion becomes
greater. In severe cases of proximal humeral bone loss, sig-
nificant weakness and instability will result. This is seen in
cases of proximal humeral tuberosity malunion, nonunion,
or resorption, where the RC becomes dysfunctional due to
loss of its secure attachment. Similar findings are seen in
cases of failed hemiarthroplasty for proximal humerus frac-
ture, after tumor resection, and as a result of infection. In-
fections of the shoulder can be particularly devastating, as
loss of RC is coupled with significant joint destruction and
bone loss with limited reconstructive options.
Classification of Rotator Cuff Deficiency
To date, the only attempts at classifying RC deficiency have
been based on radiographic classifications. Two attempts
have been made to classify the RC-deficient shoulder into
distinct radiographic groups.19,20 It has been reported that
these radiographic distinctions may help to guide shoulder
surgeons in selection of appropriate treatment plan.20 Both
radiographic classification systems describe several grades
of degeneration, bone loss, and fixed instability.
1/31/08 11:03:09 AM
 54 Rotator Cuff Deficiency of the Shoulder
In 1990, Hameda et al19 proposed the first classifica-
tion of massive RC tears. The classification was based on a
series of 22 massive cuff tears that were treated nonopera-
tively. Five radiographic grades were described (Fig. 6–2).
They noted progression to CTA in one patient. They con-
cluded that patients with massive RC tears will ultimately
progress to CTA. Along the way, progressive radiographic
changes develop due to rupture of the long head of the
biceps, establishment of an abnormal fulcrum of the hu-
meral head against the acromion and the coracoacromial
ligament, and progressive weakness of external rotation.19
Seebauer et al20 was the first to emphasize the impor-
tance of joint stability. The Seebauer classification of CTA
(Fig. 6–3) has four radiographic stages with two types and
two subtypes. Patients with type 1 have centered joints
that are stable, whereas patients with type II have lost sta-
bility of the joint. Patients with type IA have developed
acetabularization of the coracoacromial arch with round-
ing of the humeral head. These patients have maintained
joint stability with intact anterior structures as noted by
the minimal amounts of superior migration of the humeral
head. Type IB differs in progressive loss of the anterior
restraints. These patients have compromised, but main-
A B
D E
14530_C06.indd 54
tained dynamic joint stabilization with minimal superior
migration of the humeral head. As the anterior structures
of the shoulder become compromised, progressive in-
stability results. Thus patients with type IIA and type IIB
show radiographic evidence of fixed instability. In type
IIA, superomedial erosion and extensive acetabularization
of the coracoacromial arch are seen. The humeral head is
superior translated. Instability is the hallmark of type IIB,
as the arthritic changes are minimal. The humeral head is
described in an anterosuperior position due to a deficient
coracoacromial arch.20
The Seebauer classification has been used to establish
algorithms for the management of CTA.20,21 Based on these
algorithms, patients with type IA can be successfully man-
aged using hemiarthroplasty, because the joint remains
centered. On the other hand, patients with radiographs
classified as type IIB should be managed with a reverse
prosthesis to treat the underlying joint instability.
The use of any radiographic classification system as
a treatment algorithm should be done so with caution.
Treatment of CTA requires a clear understanding of the
pathology present. Although aspects of this are seen on
radiographs (i.e., bone loss and loss of smooth articulat-
C
10.1055/978-1-58890-635-9c006_f002
Figure 6–2 (A–E) Hamada classification of
massive rotator cuff tears.
1/31/08 11:03:10 AM
 6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder 55

TYPE IA- TYPE IB- TYPE IIA- TYPE IIB-

centered centered decentered decentered
stable medialized limited stable unstable

• Intact anterior • Intact anterior • Compromised • Incompetent

restraints restraints anterior restraints— anterior structures
• Force couple compromised force
intact/compensated couple

• Minimal superior • Minimal superior • Superior translation • Anterior superior

migration migration escape

• Dynamic joint • Compromised • Insufficient dynamic • Absent dynamic

stabilization dynamic joint joint stabilization joint stabilization
stabilization

• Acetabularization • Medial erosion of the • Minimum stabilization • No stabilization by

of CA artch and glenoid, acetabulariza- by CA arch, superior- CA arch
femoralization of tion of CA arch, and medial erosion and • Deficient anterior
humeral head femoralization of extensive acetabulariza- structures
humeral head tion of CA arch and
femoralization of
humeral head

Figure 6–3 Seebauer classification of cuff tear arthropathy. CA, fication, and algorithm for treatment. J Bone Joint Surg Am 2004;
coracoacromial. From Visotsky JL, Basamania C, Seebauer L, Rock- 86:38. Adapted by permission.
10.1055/978-1-58890-635-9c006_f003
wood CA Jr., Jensen KL. Cuff tear arthropathy: pathogenesis, classi-

ing surfaces), much of the pathology is not seen. A clear
example is a patient with anterosuperior instability due to
RC and coracoacromial arch deficiency. This patient may
have seemingly normal radiographs (Fig. 6–4). This radio-
graph does not fit into any current classification system.
However, when a dynamic radiograph is performed in at-
tempted forward elevation, the dynamic instability clearly
becomes evident (Fig. 6–5).
Although radiographic classification systems may be
useful, they do not accurately represent the spectrum of
disease seen in the RC-deficient shoulder. To classify RC
deficiency accurately, a proper understanding of the pa-
thology present is necessary. A more reliable classifica-
tion system would grade each of the pathological changes
present and incorporate relevant radiographic findings.
Pathology
Identification and understanding the pathological changes
seen in the RC-deficient shoulder are essential for proper
diagnosis and management of the disease. The structures
that may undergo pathological change include the RC mus-
cle and tendon, articular surfaces of the glenohumeral joint,
bone support of the glenoid and humeral head, surround-
ing capsule, position of the glenohumeral joint, the deltoid

14530_C06.indd 55 1/31/08 11:03:11 AM

 56 Rotator Cuff Deficiency of the Shoulder
A B
Figure 6–4 Static anteroposterior (A), Y (B), and axillary (C) radiographs of 6-month follow-up after subacromial decompression and mini-open
rotator cuff repair. 10.1055/978-1-58890-635-9c006_f004
muscle, and the subdeltoid, subacromial, and subcoracoid
space (Table 6–2). Each of these pathological changes
plays significant roles in the disease process and may dra-
matically influence selection of treatment plan. Once the
extent of the pathology present in the involved shoulder
can be asserted, information from the clinical picture can
be integrated to form a logical treatment strategy.
Loss of Rotator Cuff Muscle and Tendon
The essential component of RC deficiency is directly related
to the amount of RC function lost. The size of the RC tendon
tear is the most obvious aspect of this pathology, because the
larger the RC tendon tear, the more the functional loss.22,23
However, the degree of muscle loss may be even more signifi-
A,B
14530_C06.indd 56
C
cant. Fatty infiltration of the RC muscle after RC tendon tears
has been previously described by Goutallier et al24 based on
computed tomography (CT) scans (Table 6–3). These muscu-
lar changes seen after RC tendon tears may be irreversible,
even after a successful tendon repair.25,26 A critical level of RC
muscle and tendon loss will result in significant functional
loss including weakness and joint instability.27
In patients with RC deficiency, the RC is unable to pro-
vide these important roles. Reconstructive efforts must
thus consider whether these functions can be reliably re-
stored, or whether efforts should be made to compensate
for the loss of strength and stability. Once instability has
developed from RC deficiency, the reliability of soft tissue
procedures at restoring stability becomes diminished. Pre-
operative magnetic resonance imaging (MRI) or CT scans
10.1055/978-1-58890-635-9c006_f006
Figure 6–5 Dynamic forward elevation antero-
posterior (A) and Y (B) radiographs demonstrat-
ing clear anterosuperior escape.
1/31/08 11:03:14 AM
 6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder 57
Table 6–2 Pathology Present in the Rotator Cuff Deficient are useful in predicting the size of the tendon tear and the
Shoulder 10.1055/978-1-58890-635-9c006_t002 degree of fatty infiltration present in the RC muscle.24 Ad-
ditionally, intraoperative decision making may be useful in
Rotator cuff deficiency
determining if the RC is salvageable.
Massive tear without loss of force couples It is clear that patients with RC loss will have some de-
Massive tear with loss of force couples gree of weakness due to loss of the muscle–tendon unit. The
Fatty infiltration greater the loss of the muscle–tendon unit, the more weak-
ness will be experienced by the patient. When other pathol-
Humeral head
ogies coexist with RC loss (i.e., superior glenoid wear with
Cartilage loss – complete, superior, eccentric, central change in joint position), patients may experience similar
Bone loss–eccentric, central amounts of weakness with less muscle–tendon loss. Rec-
Femoralization ognition of the additional pathologies present is therefore
critical in making appropriate treatment decisions.
Sclerosis
Peripheral osteophytes
Subchondral cysts
Loss of Glenoid Articular Surfaces
Glenoid Joint instability due to RC deficiency results in an eccen-
tric wear pattern that creates preferential glenoid articular
Cartilage loss – central, eccentric (anterior, superior, posterior,
anterosuperior) erosion. These wear patterns may be central, superior, an-
terior, anterosuperior, or posterosuperior. The direction of
Bone loss – central, eccentric (anterior, superior, posterior,
anterosuperior)
instability dictates the areas of glenoid wear.
Articular cartilage defects can produce both instability
Sclerosis
and stiffness depending on the type of cartilage loss present.
Peripheral osteophytes When defects are eccentrically placed, the concavity-com-
Subchondral cysts pression of the articular surface is lost and instability is
Joint position
enhanced. Thus patients with RC deficiency and eccentric
glenoid cartilage loss may have a greater degree of instabil-
Central
ity resulting in a clinical presentation of shoulder weakness
Static superior due to loss of the stable fulcrum. Management of these pa-
Static anterosuperior tients creates a challenge, because soft tissue reconstruction
Dynamic anterosuperior
may not be sufficient in preventing instability.
Conversely, patients with central cartilage loss develop
Static posterior
increased friction between the articulating surfaces. This
Capsule deficiency additional friction results in increased stiffness and en-
Enlarged hanced joint stability. Thus patients with RC deficiency
Contracted
and central glenoid cartilage loss may have worsened
symptoms of stiffness and pain without shoulder weak-
Thin
ness. If the cartilage surfaces are replaced with a smooth
Subdeltoid, subcoracoid, subacromial bursa articulation, and the joint instability from RC deficiency is
Inflammation not addressed, the instability may become more apparent.
Fibrosis
Although stiffness and pain may improve, patients may
note significant shoulder weakness due to loss of the sta-
Deltoid muscle
ble fulcrum.
Fibrosis
Deficiency
Loss of Humeral Articular Surface
Articular cartilage loss of the humeral head will develop
Table 6–3 Criteria for Grading Muscle Fatty Degeneration on in the cuff deficient shoulder. Variations of cartilage loss
Computed Tomography Scans 10.1055/978-1-58890-635-9c006_t003
include complete, superior, central, and eccentric. In the
Grade 0 No fatty deposits extreme example of classic CTA, complete articular carti-
lage loss was often associated with collapse of the humeral
Grade 1 Some fatty streaks
head.1 In other presentations of RC deficiency, localized
Grade 2 More muscle than fat areas of articular cartilage loss result may alter the clinical
Grade 3 As much muscle as fat presentation of the disease.
Grade 4 Less muscle than fat Eccentric superior humeral articular bone loss associated
with RC deficiency often presents once the joint position

14530_C06.indd 57 1/31/08 11:03:15 AM

 58 Rotator Cuff Deficiency of the Shoulder
has migrated superiorly. The humeral head begins to ar-
ticulate with the acromion, resulting in additional wear of
the acromion. In severe cases, this may result in acromion
fractures. Once the joint position has been altered, the
compression concavity mechanism of the shoulder is lost,
and the ability of the shoulder to establish a stable fulcrum
becomes compromised.28 This may be an independent rea-
son for complaints of pain. Thus superior humeral wear
not only represents loss of conforming articular surfaces,
but alludes to additional important pathological changes
that must be recognized in the shoulder.
Bone Loss
Bone loss in the cuff-deficient patient can be present on the
glenoid as well as the proximal humerus. Such bone loss
may be related to progressive bone erosion from asymmet-
ric wear patterns, fractures, previous surgery, or infections.
Glenoid Bone Loss
Glenoid bone loss may be mild, moderate, or severe. Bone
loss may be eccentric, as seen in chronic shoulder disloca-
tions, or central. In the most severe cases, a global loss of
glenoid bone stock may be present (Fig. 6–6). Thus, a CT
scan is essential in planning the appropriate treatment for
these patients.
Eccentric glenoid bone loss is often present in the RC-
deficient shoulder. In these cases, a greater degree of in-
stability is present. The concavity-compression of the
articular surface is lost along with the stable fulcrum of
Figure 6–6 Global severe glenoid bone loss. A computed tomogra-
phy scan showing severe global bone loss with erosion medial to the
base of the coracoid. 10.1055/978-1-58890-635-9c006_f006
14530_C06.indd 58
the shoulder. Additionally, progressive medialization of the
joint due to glenoid bone loss results in shortening of
the remaining muscle–tendon units about the shoulder.
This results in additional weakness. Successful treatment
strategies should not only focus on creating stability of the
glenohumeral joint, but also consider attempts at restoring
the shoulder back to the original center of rotation where
the length-tension curves of the muscles are more opti-
mal. This may be achieved through the use of glenoid bone
graft augmentation as well as utilizing devices that may
lateralize the center of rotation of the shoulder.
In some cases of centralized glenoid bone loss, in-
creased friction develops between the articulating sur-
faces. As the bone loss progresses, the joint may form an
arthrokatadysis resulting in increased friction between the
articulating surfaces. This additional friction may provide
increased stiffness and enhanced joint stability. In this set-
ting, patients present with greater complaints of pain and
loss of motion, than shoulder weakness.
The greatest challenge exists when the RC-deficient
shoulder develops severe glenoid bone loss. In addition to
the weakness from severe joint instability, these patients
have a medialized shoulder with loss of the length-tension
relationship of the remaining shoulder muscles. These pa-
tients thus have profound weakness that is difficult to re-
construct. Establishment of a stable glenohumeral joint is
the cornerstone of successful treatment of these patients.
In the setting of RC deficiency and severe glenoid
bone loss, stability of the glenohumeral joint can only be
achieved using a prosthetic device that can be anchored
to the glenoid. Long-term fixation of glenoid components,
however, is extremely challenging given the severe amount
of bone loss. Initially, adequate fixation must be achieved.
To obtain such fixation it is first necessary to clearly un-
derstand the remaining scapular bone available for sup-
port. CT scans may help this guide preoperative planning.
Often, the orientation of the device may need to change
such that it can be placed into the area of the scapula with
the greatest density of bone.29 Additionally, it is essential
to understand how the prosthetic device chosen is able to
achieve the necessary fixation. Those devices that provide
compression into the scapula will have the best chance
of obtaining bone ingrowth. This concept is similar to the
basic Academy of Orthopedics (AO) principals of fracture
fixation, where compression across the fracture site aids
in facilitating bone healing.30 Moreover, the method for
which the device is implanted may play a critical role in its
survivability. To achieve maximal fixation, perfect seating
of the glenoid prosthesis in the host bone is essential.31
Mismatches of this interface will result in increased mi-
cromotion of the device and the host bone due to eccentric
loads, favoring loosening of the component and mechani-
cal failure of the device.32
Once initial fixation is achieved, however, it is neces-
sary to understand how the forces of shoulder motion may
influence the maintenance of fixation. For example, as the
1/31/08 11:03:15 AM
 6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder
distance from the glenoid bone to the center of rotation of
the joint increases, additional force may be exerted on the
device-glenoid bone interface. Similarly, overtensioning of
the device by using a tight joint reduction or insufficient
soft tissue releases may result in increased amounts of
frictional torque across the device-glenoid bone interface.
In such cases of severe bone loss, it may be more important
to sacrifice optimal function and motion in favor of main-
taining fixation of the device. Thus selecting the appropri-
ate surgical technique and device will vary according to
the pathology present in each patient.
Proximal Humeral Bone Loss
The degree of proximal humeral bone loss directly influences
the amount of RC dysfunction. The more severe the proxi-
mal humeral bone loss, the greater is the loss of RC insertion.
Bone loss on the humeral side may result from fracture se-
quelae, failure of fracture healing (i.e., tuberosity nonunion,
malunion, or resorption), failure of tuberosity fixation after
hemiarthroplasty for proximal humerus fracture, tumor re-
section, infection, or from humeral prosthesis extraction dur-
ing revision procedures. In cases of severe proximal humeral
bone loss, complete loss of the RC insertion results in severe
joint instability. Reconstructive procedures must consider the
additional instability that is present in this cohort of patients
in selecting the appropriate treatment.
Management of severe proximal humeral bone loss
poses additional challenges. Without the rotational and
structural support of the proximal humerus, significant
force is transmitted to the humeral component. Cumula-
tively, these forces may result in humeral-sided compli-
cations such as aseptic loosening of the component30 or
mechanical failure. In severe cases of proximal humeral
bone loss, it is important to consider reconstruction of the
proximal humeral bone loss using allograft bone.
Joint Instability
The concavity-compression model emphasizes the role of
the RC in stability of the shoulder.28 The RC is a key dy-
namic stabilizer of the shoulder, and is necessary to es-
tablish a stable fulcrum for shoulder function.33 Cases
of shoulder dislocations after RC tears have been clearly
documented34–43; however, more subtle instability can be
difficult to identify.
In the RC-deficient shoulder, joint instability exists
at various levels of severity (Fig. 6–1), and may be static
or dynamic. Static instability is easily captured on radio-
graphs. Static deformities may be subtle subluxations as
described by Gerber and Nyffeler (Fig. 6–5),35 or more ob-
vious as seen in classic CTA (Fig. 6–7). Dramatic cases of
instability are seen in the cuff-deficient patient with loss
of the coracoacromial arch. These patients develop antero-
superior dynamic instability that occurs with attempted
shoulder elevation.
14530_C06.indd 59
59
Figure 6–7 Classic cuff tear arthropathy.
10.1055/978-1-58890-635-9c006_f007
Cases of mild instability are illustrated with static sub-
luxation seen on radiographs.35 Commonly, superior mi-
gration of the humeral head is seen in cases of massive
RC tears,36,37 Once the humeral head is no longer centered
on the glenoid, the mechanics of the joint have changed.
Progressive degeneration of the glenohumeral joint may
be seen.19
Cases of dramatic instability can be seen in patients with
anterosuperior escape. This type of instability is best cap-
tured on clinical examination, as static radiographs often
seem normal (Fig. 6–4). In attempted shoulder elevation, the
humeral head dislocates in an anterosuperior direction. Once
the shoulder develops such severe cases of instability, soft
tissue reconstructions become less reliable. Careful physical
examination of the RC-deficient patient is paramount.
Instability worsens with the presence of additional
pathological changes of the joint. As noted earlier, eccen-
tric glenoid articular loss or bone loss results in a loss of
the stable fulcrum needed for joint stability. Medializa-
tion of the joint disrupts the length-tension relationship
of the remaining muscles resulting in weakness of the
muscle units that aide in dynamic joint stability. Addition-
ally, pathological changes in the joint capsule may result
in unidirectional capsular deficiency or tightening which
potentiates the instability present.
Changes in the Capsule
Instability of the glenohumeral joint from a dysfunctional RC
may result in capsular stretching and deficiency. The capsule
is less able to act as a static stabilizer of the joint. Thus soft
tissue reconstructive procedures to tighten or augment the
capsular deficiency may be less reliable. The capsule may also
1/31/08 11:03:16 AM
 60 Rotator Cuff Deficiency of the Shoulder
be thickened. Thickened capsular tissue that is not properly
released may result in instability of the reconstructed joint,
because the joint hinges on the contracted tissue.
Changes in the Deltoid Muscle
Patients with RC deficiency develop pathological changes
in the deltoid muscle. Subdeltoid scaring and bursal thick-
ening may prevent normal muscle function. Deltoid mus-
cle atrophy is often present. Previous surgical approaches
often leave defects in a portion of the deltoid and can result
in axillary nerve injuries that may leave the deltoid atonic.
During reconstructive efforts, sufficient release of scar tis-
sue around the deltoid is necessary to provide the greatest
chance at deltoid function. In cases where prosthetic recon-
struction will rely predominantly on the deltoid function,
the amount of deltoid atrophy or deltoid muscle loss is
often a prognostic indicator of a successful reconstruction.
Careful preoperative characterization of the deltoid mus-
cle is thus key to predicting outcomes after reconstructive
efforts. One would not expect a patient with complete loss
of the anterior deltoid from a previous open RC repair to
have as good an outcome as someone with similar radio-
graphic findings, but no previous surgery.
Changes in the Subdeltoid, Subcoracoid,
and Subacromial Spaces
Patients with RC deficiency develop pathological changes of
the potential spaces about the shoulder. Thickening of the
bursa and scaring of the subdeltoid, subcoracoid, and sub-
acromial spaces result in joint stiffness. Complete releases
of these potential spaces are essential in the management
of the RC-deficient shoulder. Failure to perform proper soft
tissue release will not only increase the difficulty of expo-
sure, but also result in worse outcomes. Additionally, in-
adequate soft tissue releases may result in overtensioning
of prosthetic reconstruction. This may result in excessive
frictional torque across the articulation and early failures.
Surgical Treatment
With a clearer understanding of the pathology seen in the
cuff-deficient shoulder, it is possible to select the appropri-
ate treatment. To be successful, the treatment plan must
focus on addressing all aspects of the pathology.
A variety of surgical treatments has been described
based on the severity of the disease. Initially, when nonop-
erative measures fail, open or arthroscopic soft tissue pro-
cedures can be performed. When the arthritic changes are
severe, hemiarthroplasty has been considered the treat-
ment of choice.38–50 However, clinical series included vari-
able presentations of CTA, and the outcomes were unpre-
dictable. Patients noted consistent improvements in pain,
14530_C06.indd 60
but unreliable improvements in function.39 To achieve
reliable improvements in both pain and function, proper
identification of the severity of pathology in each patient is
necessary. For example, isolated treatment of joint incon-
gruity using a hemiarthroplasty in a patient with classic
CTA ignores the pathological instability present in these
patients. It is not surprising that reliable improvements
are not achieved.
Arthroscopic Procedures
Arthroscopy remains an important tool in the manage-
ment of the RC-deficient shoulder when arthritic changes
are minimal. Arthroscopic procedures allow for a clear
evaluation of the pathology present, and enable soft tissue
repairs and débridement that may improve pain and func-
tion in these patients. Arthroscopic lavage was initially de-
scribed as a treatment for the Milwaukee Shoulder.40 Since
then, several clinical studies have described the use of ar-
throscopy in the RC-deficient patient.
Arthroscopic débridement of massive RC tears may
provide significant improvement in pain relief. Using ar-
throscopic débridement of massive, irreparable RC tears,
Ellman et al41 found significant pain relief without im-
provement in strength or range of motion (ROM). Patients
must be informed that restoration in function, strength,
or ROM should not be expected. Reports have also noted
that results of débridement may deteriorate with time.42,43
Various factors have been described that may contribute
to the deterioration of results, including progression of de-
generative changes of the joint, progression in the size of
the RC tear with loss of the force couple balance, and loss
of passive stabilizers of the joint.42
Arthroscopic débridement may be augmented by biceps
tenotomy44 or tuberoplasty45 in attempt to eliminate pain
generators in the RC-deficient shoulder. Biceps tenotomy
has been popularized by Walch et al44 as a reliable way
to improve pain in patients with RC deficiency.44 Tubero-
plasty, originally described by Fenlin,46 allows for elimi-
nation of painful impingement without disruption of the
coracoacromial arch. Elimination of the pain generators
provides restoration of function and improvement in pain
for these patients. It is best suited for those patients with
RC deficiency that present with good motion and strength,
but are limited by pain and less concerned about func-
tion. These patients may have early glenohumeral arthritic
changes, but do not show evidence of instability on either
clinical examination or radiographs.
Arthroscopic partial repair was described by Burkhart
and colleagues47 as a way to restore normal mechanics
to the shoulder with a dysfunctional massive RC tear. By
repairing the margins of the tear, restoration of balanced
force couples allows for establishment of a functional RC
tear. This procedure is best suited for patients with RC defi-
ciency that present with pain and limitation strength who
1/31/08 11:03:17 AM
 6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder
are more concerned about function. These patients must
have preserved glenohumeral stability based on clinical
examination or radiographs. Failure to recognize instabil-
ity in these patients may result in treatment failure.
Open Soft Tissue Procedures
Reports of open anterior acromioplasty and débridement
for massive RC tears have shown reasonable improvements
in pain relief, but strength is not restored. Rockwood re-
ported satisfactory improvements in pain relief and ROM
in patients with a strong anterior deltoid and intact biceps.
Patients with a weak anterior deltoid or previous RC repair
had unsatisfactory outcomes.14,48 In a similar series, Garts-
man reported improvement in pain relief, ROM, and abil-
ity to perform activities of daily living in 79% of patients
(26/33); however, strength with elevation was decreased
after the operation.49
Tendon allografts, synthetic fibers, and biologic tis-
sue scaffolds have been used as interposition substrates
to augment or complete repairs of massive RC tears.50–63
Use of these soft tissue augmentations, however, has not
shown reliable and reproducible results.
Tendon transfers using the latissimus dorsi and pecto-
ralis major have been used to treat irreparable anterosupe-
rior and posterosuperior massive RC tears. Using the latis-
simus dorsi transfer, Gerber et al51 reported improvements
in pain relief, ROM, and strength in patients with postero-
superior massive RC tears not involving the subscapularis.
The use of the pectoralis major transfer for anterosuperior
massive RC tears has been less reliable, as the biomechan-
ics of the tendon transfer are not as optimal.52 Series by
Jost et al and Galatz et al have shown improvements in
pain relief and stability, with only reasonable improve-
ments in function.53,54
Arthrodesis
Arthrodesis can be used as a salvage procedure for the
RC-deficient shoulder.55,56 Consideration of this procedure
is best suited for patients with infection, severe deltoid
loss, or neurological injury to the shoulder, where alterna-
tive reconstruction measures would be unreliable. Young
manual laborers may consider arthrodesis as a suitable
option that would allow for return to work.55 Challenges
in obtaining successful arthrodesis include high rates of
nonunion,57–72 malposition, periarthrodesis fractures, and
prominent hardware.56–73
Arthroplasty
Attempts at total shoulder replacement for RC deficiency
have been met with early failures as eccentric loads placed
14530_C06.indd 61
61
on the glenoid result in loosening of the glenoid com-
ponent.58,59 This early loosening prompted surgeons to
choose humeral head hemiarthroplasty to manage these
patients. Despite becoming the treatment of choice for
these patients,60–81 variable gains in functional ROM and
inconsistent pain improvements (46 to 86% of patients)
have been observed.60–63 Additionally, the use of bipolar
hemiarthroplasty for the RC-deficient patient has not been
shown to be a reliable solution.64–84
The reverse shoulder replacement has gained popular-
ity for the treatment of the RC-deficient shoulder. Although
earlier reports using constrained reversed shoulder ar-
throplasties were plagued with difficulties related to gle-
noid failure and soon fell out of favor,65 recent reports of
modern designs have shown reliable improvements in pain
and functional recovery.21,66–89 Modern reverse shoulder
arthroplasty now utilizes a semiconstrained articulation
to establish stability of glenohumeral motion, allowing for
functional recovery of shoulder motion and reliable pain re-
lief. The reverse shoulder prosthesis is currently being used
to treat a variety of problems related to the cuff-deficient
shoulder. Each of these patient populations differs based
on the pathology present. Careful analysis of each patient
population will enhance our understanding of how the re-
verse can be used in treating each subset of patients. As our
understanding of patient pathology increases, new innova-
tions of surgical technique and prosthetic development will
allow for improved treatment of the RC-deficient shoulder.
Algorithm for Surgical Treatment of
the Rotator Cuff Deficient Shoulder
Our current recommendations for treatment of the RC-de-
ficient shoulder rests on careful identification of patient
pathology. Through a combination of careful history and
physical examination, radiographic studies, and intraop-
erative findings, the pathology present for each patient is
considered. A treatment plan is then constructed that is
able to address each aspect of the pathology present.
For example, treatment of a patient with classic CTA
requires careful characterization of the amount of glenoid
and humeral articular cartilage and bone loss, the amount
of RC muscle and tendon loss, the degree of joint instabil-
ity, degree of capsular contracture, the integrity of the del-
toid, and degree of scarring of the subacromial, subdeltoid,
and subcoracoid spaces. The design of the reverse shoulder
prosthesis allows for treatment of these pathologies, and
has thus become our standard treatment for this problem
(Fig. 6–8). Incongruent bone surfaces from loss of glenoid
and humeral articular cartilage and bone may be managed
by establishing a smooth, stable articulation. By restoring
the shoulder’s anatomical center of rotation and lateral
offset, the deltoid and residual RC muscles are placed in a
more optimal position to restore functional strength. Insta-
1/31/08 11:03:17 AM
 62 Rotator Cuff Deficiency of the Shoulder

bility is managed by substituting a semiconstrained device

with a glenosphere that is semicaptured by a conforming
humeral component. Finally, careful release of the sub-
acromial, subdeltoid, and subcoracoid spaces, as well as
the contracted capsule can be performed intraoperatively.
When glenoid bone loss becomes severe, however, it
may be difficult for the glenosphere of the reverse design
to achieve stable fixation. Hemiarthroplasty may be used
in this instance. However, because only a portion of the pa-
thology is being treated, one would expect a compromised
outcome for this patient.
An overview of the various aspects of a massive irrepa-
rable rotator cuff tear is presented in Fig. 6–9. An algo-
rithm for the treatment of the RC-deficient shoulder based
on the presenting pathology for each patient is given in
Table 6–4.

Figure 6–8 Design of the reverse shoulder prosthesis: standard

treatment option for a patient with classic cuff tear arthropathy sub-
deltoid. 10.1055/978-1-58890-635-9c006_f008

Massive
irreparable
rotator cuff tear
ity No I
abil nsta
Inst bilit
y

Reverse Arthritis
prosthesis re
Non
e to
Seve Min
• No arthritis with anterosup escape
• Min arthritis with poor motion Severe glenoid bone loss
poor post-op compliance Motion
Ye r Goo
Poo
No

s d
• Latissimus transfer
Reverse Hemiarthroplasty • Arthroscopic debridement,
Demand
biceps tenotomy and tuberoplasty
prosthesis • Partial repair Hi
• Reverse prosthesis gh
• Non-operative treatment Low
Exam findings
Arthroscopic
debridement, biceps
tenotomy, and
tuberoplasty Belly press ER Lag
al al
m
Se

i im
Se

in
ve

in
ve

M
re

M
re

Partial repair, Pectoralis Partial repair,

biceps tenotomy, Latissimus
transfer biceps tenotomy, transfer
tuberoplasty tuberoplasty

Figure 6–9 Chart explaining massive irreparable rotator cuff tear.

14530_C06.indd 62 1/31/08 11:03:17 AM

14530_C06.indd 63

Table 6–4 Treatments for Disease of Rotator Cuff Deficient Shoulder 10.1055/978-1-58890-635-9c006_t004

Rotator
Cuff Subacromial,
Muscle- Glenoid Humeral Subdeltoid,
Tendon Articular Glenoid Articular Humeral Joint Subcoracoid
Unit Surface Bone Surface Bone Instability Capsule Deltoid Space Treatment
Anterior Severe 0— 0— 0— 0—minimal Severe Patulent Anterior Variable RSP
Superior Escape minimal minimal minimal deficient amounts of
scar
Severe Arthritis, Severe Severe Severe Severe Severe +/− Severe (not Contracted Variable Dense scar Hemi versus RSP (with
Severe Glenoid collapse clinically glenoid augmentation)
Bone Loss apparent)
Severe Arthritis, Severe Severe Mild- Severe Mild- Severe (not Contracted Variable Dense scar RSP
Mild-Moderate Moderate moderate clinically
Glenoid Bone Loss apparent)
Minimal Arthritis, Severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Variable
Poor Motion, No minimal
Instability
PRIMARY

Minimal Arthritis, Mod -Severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Arthroscopic Debride-
Good Motion, Low minimal ment, Biceps tenotomy
Demand

6 The Spectrum of Disease in the Rotator Cuff–Deficient Shoulder

Minimal Arthritis, Mid—severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Pectoralis transfer
Good Motion, anteriorly minimal
High Demand,
Positive Belly
Press
Minimal Arthritis, Mid—severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Partial rotator cuff repair
Good Motion, anteriorly minimal + Biceps tenotomy
High Demand,
Minimal Belly
Press
Minimal Arthritis, Mid—severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Latismus dorsi transfer
Good Motion, posteriorly minimal
High Demand,
Positive ER Lag
Minimal Arthritis, Mid—severe Minimal 0— Minimal 0—minimal None Variable Variable Variable Partial Rotator Cuff
Good Motion, posteriorly minimal Repair + Biceps tenotomy
High Demand,
Minimal ER LAG
1/31/08 11:03:18 AM

63
 64 Rotator Cuff Deficiency of the Shoulder
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53. Jost B, Puskas GJ, Lustenberger A, Gerber C. Outcome of pectoralis
major transfer for the treatment of irreparable subscapularis tears.
J Bone Joint Surg Am 2003;85-A(10):1944–1951
54. Galatz LM, Connor PM, Calfee RP, Hsu JC, Yamaguchi K. Pectoralis
major transfer for anterior-superior subluxation in massive rotator
cuff insufficiency. J Shoulder Elbow Surg 2003;12(1):1–5
55. Arntz CT, Matsen FA III, Jackins S. Surgical management of complex
irreparable rotator cuff deficiency. J Arthroplasty 1991;6:363–370
56. Cofield RH, Briggs BT. Glenohumeral arthrodesis: operative and
long-term functional results. J Bone Joint Surg Am 1979;61:668–
677
57. Richards RR, Waddell JP, Hudson AR. Shoulder arthrodesis for
the treatment of brachial plexus palsy. Clin Orthop Relat Res
1985;198:250–258
58. Barrett WP, Franklin JL, Jackins SE, Wyss CR, Matsen FA III. Total
shoulder arthroplasty. J Bone Joint Surg Am 1987;69:865–872
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65
59. Franklin JL, Barrett WP, Jackins SE, Matsen FA III. Glenoid loosening
in total shoulder arthroplasty. Association with rotator cuff defi-
ciency. J Arthroplasty 1988;3:39–46
60. Arntz CT, Jackins S, Matsen FA III. Prosthetic replacement of the shoul-
der for the treatment of defects in the rotator cuff and the surface of
the glenohumeral joint. J Bone Joint Surg Am 1993;75:485–491
61. Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of
the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg
1997;6:18–23
62. Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff
tear arthropathy. J Shoulder Elbow Surg 2000;9:169–172
63. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthro-
plasty for glenohumeral arthritis associated with severe rotator
cuff deficiency. J Bone Joint Surg Am 2001;83-A(12):1814–1822
64. Lee DH, Niemann KM. Bipolar shoulder arthroplasty. Clin Orthop
Relat Res 1994;304:97–107
65. Brostrom LA, Wallensten R, Olsson E, Anderson D. The Kessel pros-
thesis in total shoulder arthroplasty. A five-year experience. Clin
Orthop Relat Res 1992;277:155–160
66. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse
prosthesis: design, rationale, and biomechanics. J Shoulder Elbow
Surg 2005;14:147S–161S
67. Adams R. A Treatise of Rheumatic Gout or Chronic Rheumatic Ar-
thritis of All the Joints. 2nd ed. London: John Churchill and Sons;
1873:91–175
68. Smith RW. Observations upon chronic rheumatic arthritis of the
shoulder. Part I. Dublin Quart J Med Sci 1853;15:1–16
69. Smith RW. Observations upon chronic rheumatic arthritis of the
shoulder. Part II. Dublin Quart J Med Sci 1853;15:343–358
70. Halverson PB, Carrera GF, McCarty DJ. Milwaukee shoulder syn-
drome. Arch Intern Med 1990;150:665–672
71. Newman JH, Chavin KD, Chavin IF. Milwaukee shoulder syndrome:
a new crystal-induced arthritis syndrome associated with hy-
droxyapatite crystals: a case report. Del Med J 1983;55:167–169
72. Rachow JW, Ryan LM, McCarty DJ, et al. Synovial fluid inorganic py-
rophosphate concentration and nucleotide pyrophosphohydrolase
activity in basic calcium phosphate deposition arthropathy and Mil-
waukee shoulder syndrome. Arthritis Rheum 1988;31:408–413
73. Jensen KL, Williams GR, Russel IJ, Rockwood CA. Current con-
cepts review—rotator cuff tear arthropathy. J Bone Joint Surg Am
1999;81:1312–1324
74. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the
shoulder and rotator cuff rupture. Clin Orthop Relat Res 1993;
291:103–106
75. Symeonides P. The significance of the subscapularis muscle in the
pathogenesis of recurrent anterior dislocation of the shoulder. J
Bone Joint Surg 1972;54B:476–482
76. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg 1996;5:362–367
77. Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff
tear arthropathy. J Shoulder Elbow Surg 2000;9:169–172
78. Ozaki J, Fujimoto S, Masuhara K, Tamia S, Yoshimoto S. Reconstruc-
tion of chronic massive rotator cuff tears with synthetic materials.
Clin Orthop Relat Res 1986;202:173–183
79. Sclamberg SG, Tibone JE, Itamura JM, Kasraeian S. Six-month mag-
netic resonance imaging follow-up of large and massive rotator
cuff repairs reinforced with porcine small intestinal submucosa. J
Shoulder Elbow Surg 2004;13(5):538–541
80. Wick M, Müller EJ, Ambacher T, Hebler U, Muhr G, Kutscha-
Lissberg F. Arthrodesis of the shoulder after septic arthritis: long-
term results. J Bone Joint Surg Br 2003;85:666–670
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 66 Rotator Cuff Deficiency of the Shoulder
81. Diaz JA, Cohen SB, Warren RF, Craig EV, Allen AA. Arthrodesis as a
salvage procedure for recurrent instability of the shoulder. J Shoul-
der Elbow Surg 2003;12:237–241
82. Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop
Surg 2006;14(3):145–153
83. Pollock RG, Deliz ED, McIlveen SJ, Flatow EL, Bigliani LU. Prosthetic
replacement in rotator cuff-deficient shoulders. J Shoulder Elbow
Surg 1992;1:173–186
84. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg 1996;5:362–367
85. Sarris IK, Papadimitriou NG, Sotereanos DG. Bipolar hemiarthro-
plasty for chronic rotator cuff tear arthropathy. J Arthroplasty
2003;18:169–173
86. Worland RL, Jessup DE, Arredondo J, Warburton KJ. Bipolar shoul-
der arthroplasty for rotator cuff arthropathy. J Shoulder Elbow Surg
1997;6:512–515
14530_C06.indd 66
87. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The
reverse shoulder prosthesis for glenohumeral arthritis associated
with severe rotator cuff deficiency. A minimum two-year follow-
up study of sixty patients. J Bone Joint Surg Am 2005;87(8):1697–
1705
88. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of pain-
ful pseudoparesis due to irreparable rotator cuff dysfunction with
the Delta III reverse-ball-and-socket total shoulder prosthesis. J
Bone Joint Surg Am 2005;87(7):1476–1486
89. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Gram-
mont inverted total shoulder arthroplasty in the treatment of
glenohumeral osteoarthritis with massive rupture of the cuff. Re-
sults of a multicentre study of 80 shoulders. J Bone Joint Surg Br
2004;86(3):388–395
1/31/08 11:03:18 AM
 7 Hemiarthroplasty for Rotator Cuff–
Tear Arthropathy
Kamal I. Bohsali, Jeffrey L. Visotsky, Carl J. Basamania, Michael A. Wirth, and Charles A. Rockwood Jr.
In 1853, Adams initially described rotator cuff arthropa-
thy (RCA), when he observed individuals with chronic ro-
tator cuff (RC) tears leading to severe arthritis.1,2 The term
cuff–tear arthropathy, however, was coined by Neer and col-
leagues in 1977 and formally described in 1983.3 Neer et
al reported on the pathoanatomical changes that occurred
with chronic massive RC tears, including structural changes
in the humeral head (atrophic cartilage, osteoporotic
subchondral bone), coracoacromial arch, and glenoid (ab-
sent cartilage and sclerosis at point of contact with humeral
head) surfaces. Superior displacement of the humerus into
the subacromial space resulted in erosion of the greater tu-
berosity (femoralization), and subsequent morphological
changes to the coracoacromial arch (acetabularization) (Fig.
7–1).3 Clinical manifestations included shoulder swelling,
supraspinatus and infraspinatus atrophy (weak abduction
Cuff and external rotation [ER]), as well as limited, incongruous
glenohumeral motion with debilitating (at times progres-
sive) pain. Based upon their clinical observations and intra-
operative examinations while performing 26 arthroplast-
ies, Neer and coauthors estimated that ~4% of patients with
massive RC tears would develop this pathological situation
if untreated.3 Neer et al hypothesized that the presence of
two interdependent mechanisms, mechanical and nutri-
Erosion and
Thin atrophic subacromial spur
cartilage
Rounding of
greater tuberosity
Ascent of
osteoporotic head
14530_C07.indd 67
tional, contributed to the cyclical process of RC destruction
and arthropathy. Radiographic (fluoroscopy, arthrography)
and electromyographic analyses of RC tears in patients have
provided information to support the force couple theory.4,5
An imbalance in transverse forces between the subscapu-
laris and posteroinferior cuff or coronal forces between the
deltoid and supraspinatus would result in displeasing kine-
matics. Unstable shoulder kinematics would lead to further
wear and accelerated disruption of transverse and coronal
plane force couples (Fig. 7–2).4,5
Classification
Because the outcomes from the treatment of massive RC
tears with glenohumeral arthritis are highly variable, at-
tempts have been made to categorize the severity of the
RCA. Seebauer and colleagues retrospectively analyzed all
institutional patients with RCA treated with conventional
hemiarthroplasty. Based upon functional outcomes and
radiographs, the authors proposed a biomechanical clas-
sification of the RC-deficient arthritic shoulder.6,7 The four
subtypes (Ia, Ib, IIa, IIb) were distinguished by degree of
superior migration from the center of humeral head ro-
10.1055/978-1-58890-635-9c007_f001
Figure 7–1 When pathological changes in cuff tear arthrop-
athy occur, the classic pattern of rotator cuff arthropathy
involves the superior migration of an osteoporotic humeral
head combined with erosion of the coracoacromial arch.
From Neer CS, Craig EV, Fukuda H. Cuff tear arthropathy. J
Bone Joint Surg Am 1983; 65: 1236. Adapted by permission.
1/31/08 11:06:53 AM
 68 Rotator Cuff Deficiency of the Shoulder

10.1055/978-1-58890-635-9c007_f002

Figure 7–2 The transverse force couple between the sub-

scapularis anteriorly and the external rotators (infraspina-
tus, teres minor) posteriorly are evident on an axillary
view diagram. These two forces balance and centralize
(in conjunction with the coronal forces of the deltoid and
supraspinatus) the humeral head to produce concavity
compression with the glenoid. From Jensen KL, Williams
GR, Russell IJ, Rockwood CA Jr. Current concepts review:
rotator cuff arthropathy. J Bone Joint Surg Am 1999; 81:
1316. Adapted by permission.

tation and the amount of instability of the center of ro- measures such as rest, nonsteroidal antiinflammatory
tation (see Chapter 6, Fig. 6–3). The proposed benefits of medications, corticosteroid injections, ROM exercises,
this classification include decision-making for appropriate fluid aspiration, and oral analgesics.8–10
implant selection, adjustment of reconstruction goals, and
assessment of patient functional outcomes.
Contraindications
A denervated or weakened anterior deltoid (less than an-
History and Physical Exam tigravity strength), incompetent coracoacromial arch, and
active or suspected sepsis all preclude implant arthroplasty
Patients with RCA are generally in their 7th decade or as a treatment option.9
older and are usually women.8 In general, a long history
of progressive pain, particularly at night is given by the
patient. The dominant upper extremity is more commonly Treatment Options
involved. Diminished active shoulder motion (abduction,
ER) with stiffness during passive range of motion (ROM) RCA, as a distinct endpoint along the continuum of gleno-
exercises is noted. Atrophy of the supraspinatus and infra- humeral degeneration, presents a unique operative chal-
spinatus muscles with variable degrees of abduction and lenge to the surgeon. The historical failure of total shoulder
ER weakness occur. Shoulder swelling may be present sec- arthroplasty with glenoid component loosening, second-
ondary to excessive fluid pressure in the subacromial bursa.
Aspiration of this fluid may be blood tinged or bloody in
appearance. Removal of this fluid combined with steroid
and anesthetic injections may provide temporary relief;
however, fluid reaccumulation is common.8–10

Imaging
True anteroposterior (AP) and axillary lateral views may
demonstrate the characteristic radiographic findings of
RCA (Fig. 7–3),8–10 Although not necessary, magnetic reso-
nance imaging (MRI) may be helpful in clinical scenarios
where physical exam findings are ambiguous or difficult to
interpret (i.e., secondary to pain).8

Surgical Treatment
Indications
The main impetus for surgical management of RCA is un-
remitting, progressive pain recalcitrant to nonoperative
Figure 7–3 An anteroposterior radiograph demonstrates superior hu-
meral head migration with rounding of the greater tuberosity (femo-
ralization) and erosion of the coracoacromial arch (acetabularization).
10.1055/978-1-58890-635-9c007_f003

14530_C07.indd 68 1/31/08 11:06:54 AM


ary to abnormal shoulder kinematics, precludes its use.
Previous alternative attempts at surgical correction for
improvements in pain relief, stability, and increased mo-
tion with constrained and semiconstrained devices have
provided marginal results with unacceptable complication
rates.8–10 Advances in implant design, instrumentation,
and surgical technique have propelled further interest in
the utilization of these devices, but long-term follow-up is
lacking. Short-term results, though promising, still present
unacceptable complication rates.10
The treatment goals of CTA are similar to those in stand-
ard degenerative (osteoarthritis) and inflammatory condi-
tions (rheumatoid arthritis): shoulder arthroplasty should
provide pain relief, restore glenohumeral stability, and im-
prove functional motion (i.e., for activities of daily living).
Based upon the severity of the arthropathy, the concept of
“limited-goals” surgery may be appropriate when evalu-
ating these patients.11 A current review of the literature
indicates that the unconstrained implant (i.e., hemiar-
throplasty) design has remained a viable alternative in the
treatment of RCA. Utilizing the standard deltopectoral ap-
proach, Arntz, Jackins, and Matsen12 reported their experi-
ence with the Neer II prosthesis in the treatment of 19 pa-
tients (21 shoulders) over a 9-year period (1978 to 1987).
Eighteen shoulders were available for review at a follow-up
range of 25 to 122 months. Notably, pain diminished from
“marked or disabling” in 14 shoulders to “none or slight”
in 10, and “pain with unusual activity” in 4. Active forward
elevation improved on average from 66 degrees preopera-
tively to 109 degrees postoperatively. Hemiarthroplasties
were performed only in those patients with a functionally
intact coracoacromial arch.12 Pollock et al13 in 1992 com-
pared hemiarthroplasty versus total shoulder arthroplasty
in 30 shoulders with RC tears. Thirteen shoulders at the
time of surgery demonstrated massive irreparable RC tears
and were subsequently treated with hemiarthroplasty and
cuff débridement. All 12 patients (13 shoulders) reported
little or no pain and displayed an average increase of 44
degrees of active forward elevation (average: 64 to 108 de-
grees) at 41 months postoperatively.
In 1996, Williams and Rockwood14 reported their results
in 20 patients (21 shoulders, average follow-up: 4 years) with
irreparable RC tears and glenohumeral arthritis treated with
humeral head replacement. Twelve shoulders demonstrated
no pain, six were mildly painful, and three were moderately
painful. The authors emphasized the need to preserve the
coracoacromial ligament if present, and to alter humeral head
size to obtain appropriate soft tissue balancing. In the pres-
ence of an incompetent coracoacromial arch, some authors
have advocated augmentation with iliac crest bone graft or
placement of bone from the resected humeral head in the
area of the superior glenoid. Such techniques have resulted
in noted improvements in pain relief.8 Recently, Hockman et
al15 underscored the importance of a competent coracoacro-
mial arch with their analysis of anterosuperior restraint in
cadaveric specimens with simulated massive RC tears, hu-
14530_C07.indd 69
7 Hemiarthroplasty for Rotator Cuff–Tear Arthropathy 69
meral head replacement, and coracoacromial ligament sta-
tus. Mean anterosuperior displacement of 3.4 mm occurred
in those specimens that underwent coracoacromial ligament
release, thus reinforcing its role as a secondary stabilizer to
anterosuperior migration in the RC-deficient shoulder. In
1997, Field and colleagues16 reviewed data on 16 patients
who underwent hemiarthroplasty for RCA. Similar to Arntz
et al,12 the surgical technique involved a modular humeral
head of appropriate size to allow for articulation with the
coracoacromial arch, but to also allow 50% translation on the
glenoid surface. The average age of the patient was 74 years
and follow-up was at 33 months. With the use of Neer’s lim-
ited goals criteria, 10 patients were rated as successful and
6 as unsuccessful. Of the six unsuccessful results, 4 patients
had previously undergone attempts at RC repair with acromi-
oplasty. Of these 4 patients, 3 demonstrated anterosuperior
subluxation after hemiarthroplasty. The authors emphasized
the need for good deltoid function, and attributed poor re-
sults to prior acromioplasty.16
Zuckerman et al17 performed a retrospective review of
15 shoulders with CTA. With an average patient age of 73
and mean follow-up of 28.2 months, 13 shoulders (13/15,
87%) demonstrated significant improvements in pain re-
lief, with average increases of active forward flexion from
69 to 86 degrees and ER from 15 to 29 degrees. UCLA rat-
ing scores improved from 11 to 22 postoperatively.18 The
authors concluded that favorable clinical results may be
obtained after hemiarthroplasty.
Sanchez-Sotelo and Cofield presented their review of
33 shoulders (30 patients) managed with hemiarthro-
plasty in the setting of glenohumeral arthritis with mas-
sive, irreparable RC tears.19 Clinical results were again
graded according to the limited-goals criteria of Neer et
al.11 The mean pain scores decreased from 4.2. to 2.2 at
most recent follow-up; however, nine shoulders (27%) dis-
played moderate pain at rest (5 shoulders) or pain with
activity (four shoulders). Mean active forward elevation
improved from 72 to 91 degrees. Twenty-two shoulders
(22/33, 67%) were graded as successful. Of note, anterosu-
perior instability occurred in seven shoulders associated
with a history of subacromial decompression (p < .04). The
authors concluded that hemiarthroplasty remains a viable
and durable option in the treatment of CTA with an intact
coracoacromial arch.19
Recently, Visotsky et al6 reported their results utilizing
a novel extended humeral head humeral prosthesis (Global
Advantage CTA, DePuy Orthopaedics, Inc., Warsaw, IN) for
the treatment of CTA.6 According to the Seebauer classifi-
cation, nine shoulders were type IA, 28 were type IB, and
23 were type IIA. Average age at the time of surgical inter-
vention was 70.4 years (range: 55 to 89). All patients un-
derwent a deltopectoral approach with preservation of the
coracoacromial arch and débridement of residual RC tissue.
Average duration of follow-up was 32.4 months (minimum
2 years). At reported follow-up,20 statistically significant (p
< 0.05) improvements were observed with Visual Analog
1/31/08 11:06:55 AM
 70 Rotator Cuff Deficiency of the Shoulder
Scale scores (9.3 to 1.9) for pain, average ER (8 to 30 degrees),
average forward flexion (56 to 116 degrees), and American
Shoulder and Elbow Surgeons (ASES) Scale22 scores (29 to
79). Despite the promising findings, the authors empha-
sized that historical results of hemiarthroplasty in CTA were
“good but not completely predictable.”
Surgical Technique
Here we detail our preferred patient positioning and surgi-
cal approach for CTA (DePuy Orthopaedics, Inc., Warsaw,
Indiana) hemiarthroplasty in patients with CTA. This ex-
tended humeral head prosthesis has a larger area of lat-
eral articulation in abduction and ER when compared with
standard humeral heads (Fig. 7–4). These steps should be
used as guidelines and adjusted to the specific patient. Prior
to surgical intervention, regional anesthesia (i.e., intersca-
lene block) may be performed to reduce intraoperative and
postoperative pain medication demand. Intravenous antibi-
otics are administered within 30 minutes of incision. Once
general anesthesia has successfully been obtained, the pa-
tient is placed in the semi-Fowler position (Fig. 7–5) with
the head anchored and protected with the McConnell head
device (McConnell Orthopedics Inc., Greenville, Texas).
Bony landmarks (clavicle, coracoid process, and humerus)
are identified. A standard deltopectoral approach is made
from the midclavicle medial to the coracoid process to the
midhumerus at the deltoid insertion (Fig. 7–6). The cephalic
vein is identified, protected, and mobilized laterally to main-
tain continuity with tributaries to the deltoid musculature.
10.1055/978-1-58890-635-9c007_f004
A B
Figure 7–4 In this Depuy CTA (cuff tear arthropathy; DePuy Ortho-
paedics, Inc., Warsaw, IN) humeral head implant, greater excursion
is noted in (A) abduction with an extended lateral humeral head sur-
14530_C07.indd 70
The clavipectoral fascia is incised, and divided from the
coracoacromial ligament inferiorly to the upper border of
the pectoralis major. A large effusion may be released. If
visualization and dislocation maneuvers prove difficult,
the upper 1 cm of the pectoralis major tendon may be in-
cised. With sharp and blunt dissection, the subdeltoid and
subacromial bursa may be removed. Do not perform an
acromioplasty or coracoacromial ligament release because
this may compromise postoperative implant stability. The
axillary nerve is palpated on the anteroinferior surface of
the subscapularis as it traverses posteriorly through the
quadrangular space. The biceps tendon may be absent, but
if present, is usually attenuated. If intact, we recommend
release and tenodesis at the conclusion of the procedure
prior to skin closure. The subscapularis is released directly
from its humeral insertion and tagged with a 1-mm cot-
tony Dacron suture for later repair through bone tunnels.
While protecting the axillary nerve with a Scofield retractor,
the anteroinferior capsule is released to approximately the 6
o’clock position. Posteriorly placed Darrach retractors (Spe-
cialty Surgical Instrumentation Inc., Huntsville, Alabama)
are combined with gentle arm extension to dislocate the
humeral head (Fig. 7–7). If further difficulty is encountered
with exposure, the posterior capsule may be released from
its glenoid insertion. RC remnants are excised. Remaining
posteroinferior cuff is protected with a modified curved
Crego (Wright Medical Inc., Huntsville, Alabama). If the hu-
meral head demonstrates significant collapse, preoperative
radiographs of the contralateral shoulder may aid in creat-
ing a template of the correct position of the humeral head
osteotomy. A special template is utilized to mark the angle
face when compared with (B) a standard humeral head implant. Im-
ages appear courtesy of DePuy Orthopaedics, Inc.
1/31/08 11:06:56 AM

of head resection. With the humerus parallel to the floor
and the arm externally rotated to 30 degrees, the humeral
osteotomy is performed with an oscillating saw on power.
This single cut removes the head at the appropriate angle
and retroversion. The resected head is measured with the
available templates and saved for possible bone grafting
with final stem implantation.
Axial reamers are introduced into the proximal hu-
merus at the most superolateral aspect of the osteotomy
site. Sequential reamers are utilized until cortical contact
is obtained. The appropriately sized broach is selected. It
Figure 7–6 Bony landmarks (clavicle, coracoid process, and hu-
merus) are identified, and a standard deltopectoral approach is
made from the midclavicle medial to the coracoid process to the
midhumerus at the deltoid insertion.10.1055/978-1-58890-635-9c007_f006
14530_C07.indd 71
7 Hemiarthroplasty for Rotator Cuff–Tear Arthropathy 71
10.1055/978-1-58890-635-9c007_f005
Figure 7–5 This patient is positioned in the
semi-Fowler (beach chair) position with the
head stabilized with a McConnell head holder
(McConnell Orthopedics Inc., Greenville, Texas),
thus allowing easy access to the shoulder region
and improved ability to dislocate the shoulder.
is imperative that the stem not be placed in varus because
this will place the humeral head prosthesis in a far medial
position, and may result in excessive greater tuberosity
resection. Standard trial heads are utilized to assess intra-
operative motion and corresponding soft tissue balancing.
Peripheral humeral neck osteophytes are removed with
an osteotome and rongeur. The humerus is then reduced
to assess ROM and stability. With the arm abducted to 90
degrees, internal rotation should be >70 degrees. Poste-
rior translation of the humeral head with the arm in neu-
tral rotation should approach 50% of the glenoid surface.
Figure 7–7 After the subscapularis and anteroinferior capsule have
been released, the arm is extended to facilitate dislocation of the hu-
meral head. Note the complete absence of the anterosuperior cuff.
10.1055/978-1-58890-635-9c007_f007
1/31/08 11:07:03 AM
 72 Rotator Cuff Deficiency of the Shoulder
A B
Figure 7–8 (A–C) In a humeral head resection, the side-specific, cuff tear arthropathy cutting guide is applied to the trial broach after soft tissue
balancing has been performed with a standard humeral head trial. 10.1055/978-1-58890-635-9c007_f008
If intraoperative motion is suboptimal, the humeral head
resection may be lowered in parallel with the original os-
teotomy with care taken to not violate the posterior cuff.
The posterior capsule may be incised to obtain appropriate
humeral head excursion. The humeral head is then redislo-
cated, and the trial head is replaced with the CTA head re-
section guide specific to the left or right humerus (Fig. 7–8).
An oscillating saw is used to remove bone from the greater
tuberosity (Fig. 7–9). The jig is removed; the transverse cut
is manually completed medially with a rongeur or bur to
meet the original oblique neck cut (Fig. 7–10). Care must
be taken to remove excess bone between the transverse
cut and the oblique cut; otherwise, stem orientation and
head placement may be affected. An appropriately sized
CTA trial head is seated on the trial stem (Fig. 7–11). The
shoulder is then reduced, and soft tissue balancing is as-
14530_C07.indd 72
C
sessed as previously described. The trial head and stem are
removed. Drill holes are made in the proximal humerus,
approximately one centimeter distal to the osteotomy site.
Pass sutures are threaded through these drill holes for
later subscapularis repair. If more ER is necessary, 1 cm of
medialization of the subscapularis repair will provide ~20
degrees of additional motion. The final implant is assem-
bled on the back table, while autogenous cancellous bone
harvested from the resected humeral head is introduced
into the proximal metaphyseal region to augment press fit
placement of the final implant. The final implant is placed
and the shoulder is reduced for subsequent subscapularis
repair (Fig. 7–12). The wound is thoroughly irrigated with
antibiotic solution, and soft tissues are infiltrated with local
anesthetic. Two inch drains are placed deep to the deltoid
and conjoint tendon. If an interscalene block is not used,
10.1055/978-1-58890-635-9c007_f009
Figure 7–9 In a humeral head resection, an oscil-
lating saw is used to remove bone from the greater
tuberosity, taking care not to alter the initial neck
osteotomy angle.
1/31/08 11:07:06 AM

Figure 7–10 In a humeral head resection, the cutting jig is removed,
and the transverse cut is completed manually with a rongeur or bur
to meet the original oblique neck cut.
10.1055/978-1-58890-635-9c007_f010
we recommend use of a commercially available indwelling
pain catheter-pump device placed in similar fashion to the
drain. The subcutaneous tissue is closed with 2–0 Vicryl
suture (Ethicon, Somerville, New Jersey). The skin is care-
fully reapproximated with a running subcuticular nylon
suture. Sterile dressing is applied; a sling and ice pack are
applied for comfort purposes. Prior to patient extubation,
intraoperative AP and axillary lateral radiographs are ob-
tained to confirm anatomic reconstruction and to exclude
periprosthetic fracture or shoulder dislocation (Fig. 7–13).
Figure 7–11 In this Depuy CTA (cuff tear arthropathy; DePuy Ortho-
paedics, Inc., Warsaw, Indiana) trial placement, an appropriately sized
CTA trial head is seated on the trial stem with reassessment of intraop-
erative motion. Image appears courtesy of DePuy Orthopaedics, Inc.
10.1055/978-1-58890-635-9c007_f011
14530_C07.indd 73
7 Hemiarthroplasty for Rotator Cuff–Tear Arthropathy 73
Figure 7–12 The final implant is placed and the shoulder is reduced
for subsequent subscapularis repair through bone tunnels.
10.1055/978-1-58890-635-9c007_f012
Postoperative Care and Rehabilitation
On the first postoperative day, instructions to the patient
are given regarding passive ROM exercises. Unrestricted
passive flexion is obtained with a patient-driven pulley
system. Passive ER is performed with a 3-ft stick within
limits deemed appropriate by the surgeon and is done
in conjunction with pendulum exercises. Patients should
perform these exercises 3 to 4 times a day, 7 days a week.
The patient is encouraged to use the hand and arm for ac-
tivities of daily living. Drains and pain pump catheters are
generally removed on postoperative day two during the
dressing change. Most patients are discharged on the third
postoperative day. Sutures are removed at 2 weeks. At 6
weeks, active and active assisted ROM exercises are per-
formed by the patient without restriction. At 3 months,
resistance exercises with Therabands (The Hygenic Corp.,
Akron, Ohio) are used by the patient to strengthen deltoid
and RC muscles. Patients should be informed that the re-
habilitation process is a lifelong commitment.
Results Analysis
Several of us (JLV, MAW, CAR) conducted a retrospective anal-
ysis on 53 (57 shoulders) cases of shoulder hemiarthroplasty
with the CTA humeral head prosthesis (DePuy Orthopaed-
ics, Inc., Warsaw, Indiana) performed from 1998 to 2004 for
RCA. A standard deltopectoral approach was utilized with ap-
propriate soft tissue balancing as previously described. All
patients began passive ROM exercises on postoperative day
one. At the time of surgical intervention, all shoulders dem-
onstrated advanced glenohumeral arthritis with complete
detachment of the supraspinatus and infraspinatus with
variable involvement of the teres minor and subscapularis.
1/31/08 11:07:07 AM
 74 Rotator Cuff Deficiency of the Shoulder
A B
Figure 7–13 Preoperative films (A) confirm cuff tear arthropathy in a patient with progressive shoulder pain refractory to nonoperative meas-
ures. Intraoperative x-rays (B) document anatomic reconstruction and exclude periprosthetic fracture or shoulder dislocation.
10.1055/978-1-58890-635-9c007_f013
The mean patient age was 69 years (range: 41 to 86), and av-
erage follow-up was 25 months (range: 2 to 66). ROM, pain
relief (Visual Analog Scale scores), Simple Shoulder Test21
(SST), and modified American Shoulder and Elbow Surgeons
(ASES) scores22 were assessed preoperatively and postop-
eratively. On average, active forward elevation increased
from 53 to 92 degrees, and active ER increased from 14 to
References
1. Adams R. Illustrations of the Effects of Rheumatic Gout or Chronic
Rheumatic Arthritis on All the Articulations. With Descriptive and
Explanatory Statements. London: John Churchill and Sons; 1857:
1–31
2. Adams R. A Treatise of Rheumatic Gout of Chronic Rheumatic Ar-
thritis of All the Joints. 2nd ed. London: John Churchill and Sons;
1873:91–175
3. Neer CS II, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint
Surg Am 1983;65:1232–1244
4. Burkhart SS. Fluoroscopic comparison of kinematic patterns in
massive rotator cuff tears. A suspension bridge model. Clin Orthop
Relat Res 1992;284:144–152
5. Saha AK. Dynamic stability of the glenohumeral joint. Acta Orthop
Scand 1971;42:491–505
6. Visotsky JL, Basamania C, Seebauer L, Rockwood CA Jr, Jensen KL.
Cuff tear arthropathy: pathogenesis, classification, and algorithm. J
Bone Joint Surg Am 2004;86:35–40
7. Seebauer L. Biomechanical classification of cuff tear arthropathy.
Abstract presented at: Global Shoulder Society Meeting; July 17–
19, 2003; Salt Lake City, UT
8. Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkead WZ Jr. The
rotator cuff-deficient arthritic shoulder: diagnosis and surgical
management. J Am Acad Orthop Surg 1998;6:337–348
9. Collins DN, Harryman DT II. Arthroplasty for arthritis and rotator
cuff deficiency. Orthop Clin North Am 1997;28:225–239
14530_C07.indd 74
40 degrees. Visual analog pain scores improved on aver-
age from 6.4 to 1.8 (10-point scale). SST and modified ASES
scores improved from 2.2 to 6 (out of a possible 12 points),
and 29.9 to 63.5 (out of a possible 100), respectively. Salient
findings from our study indicate that favorable clinical re-
sults may be obtained after hemiarthroplasty for CTA with
limited goals criteria.11
10. Bohsali KI, Wirth MA, Rockwood CA Jr. Current concepts review:
Complications of total shoulder arthroplasty. J Bone Joint Surg Am
2006;88:2279–2292
11. Neer CS II, Watson KC, Stanton FJ. Recent experience in total shoul-
der replacement. J Bone Joint Surg Am 1982;64:319–337
12. Arntz CT, Jackins S, Matsen FA III. Prosthetic replacement of the
shoulder for the treatment of defects in the rotator cuff and the sur-
face of the glenohumeral joint. J Bone Joint Surg Am 1993;75:485–
491
13. Pollock RG, Deliz ED, McIlveen SJ, Flatow EL, Bigliani LU. Prosthetic
replacement in rotator cuff-deficient shoulders. J Shoulder Elbow
Surg 1992;1:173–186
14. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg 1996;5:362–367
15. Hockman DE, Lucas GL, Roth CA. Role of the coracoacromial liga-
ment as restraint after shoulder hemiarthroplasty. Clin Orthop
Relat Res 2004;419:80–82
16. Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of
the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg
1997;6:18–23
17. Zuckerman JD, Scott AJ, Gallagher MA. Hemiarthroplasty for cuff
tear arthropathy. J Shoulder Elbow Surg 2000;9:169–172
18. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End result
study of factors influencing reconstruction. J Bone Joint Surg Am
1986;6:1136–1144
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19. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthro-
plasty for glenohumeral arthritis associated with severe rotator
cuff deficiency. J Bone Joint Surg Am 2001;83:1814–1822
20. Wirth MA, Tapscott RS, Southworth C, and Rockwood Jr. CA. Treat-
ment of glenohumeral arthritis with a hemiarthroplasty: A mini-
mum five-year follow-up study. J Bone Joint Surg Am 2006;88:964–
973
21. Lippitt SB, Harryman DT II, Matsen FA III. A practical tool for evalu-
ation of function: the Simple Shoulder Test. In: Matsen FA III, Fu
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7 Hemiarthroplasty for Rotator Cuff–Tear Arthropathy 75
FH, Hawkins RJ, eds. The Shoulder: A Balance of Mobility and Sta-
bility. Rosemont, IL:The American Academy of Orthopaedic Sur-
geons, 1993; 501–518
22. Richards RR, An KN, Bigliani LU, et al. A standardized method
for the assessment of shoulder function. J Shoulder Elbow Surg
1994;3:347–352
1/31/08 11:07:10 AM
 8 Rationale and Biomechanics of the
Reverse Shoulder Prosthesis:
The American Experience
Mark A. Frankle, Nazeem Virani, Derek Pupello, and Sergio Gutierrez

The design of reverse shoulder replacement has undergone
several modifications since its original inception. Early
versions of the reverse shoulder design (Fenlin, Gerard,
Kessel, Kölbel, Liverpool, Neer, and Avery II) likely failed
as a result of their inability to withstand the forces during
normal shoulder function.1–7 The two most widely used
reverse shoulder arthroplasty (RSA) designs today are the
Grammont design (manufactured by both DePuy Ortho-
paedics, Inc., Warsaw, IN, and Tornier, Inc., Eden Prairie,
MN) and the Reverse Shoulder Prosthesis (RSP; Encore
Medical Corp., Austin, TX).
hanics Grammont Reverse Shoulder Design
sis:
The initial version of the Grammont reverse shoulder de-
sign, released in 1985, utilized two cemented components.
Subsequently, modifications of this initial design have been
made based on clinical experience. The current Grammont
reverse design consists of a five-part system that utilizes a
medialized center of rotation (COR) (Fig. 8–1). The gleno-
sphere is a true hemisphere, with the COR directly in con-
tact with the glenoid surface.2 Although the Grammont de-
sign has shown improvement in patient outcomes, several
limitations have been reported.2–4 Four limitations noted
most commonly by having the COR medially to the glenoid
surface are
ylene to aggressive bone resorption probably occurs
when metal particles are released when the polyeth-
ylene liner is abraded and the metal liner is exposed.8,9
This process may be accelerated if a screw from the gle-
noid component is exposed from scapular bone loss and
abrades with the metal shell.
2. Limited Range of Motion Currently, several different
prosthetic designs of the reversed shoulder arthro-
plasties are available in a variety of geometries (nota-
bly, glenosphere size and COR). Differences in range of
motion (ROM), stability, security of fixation, and motor
function may vary greatly among the different implant
geometries; hence the selection of the appropriate
shoulder prosthesis requires a priori understanding of
the implant geometry. From a clinical standpoint, max-
imizing the potential ROM is a key element for func-
tional gains that may be achieved with reverse shoulder
prosthetic designs. Centers of rotation that are farther
away from the scapula allow the proximal humerus and
humeral socket more clearance before impinging on the

1. Scapula Notching Scapular notching has been docu-

mented by many patient series using the Grammont de-
sign and has ranged from 24.5 to 96% (Table 8–1).2,4–15
It is thought that notching is caused by impingement of
the medial aspect of the polyethylene socket on the in-
ferior portion of the scapular neck (Fig. 8–2).2 Although
the long-term clinical significance of scapular notching
remains a question, osteolysis and progressive erosion
of the inferior scapula have been documented.5–7 As
noted by Delloye et al, 3 progressive scapular notching
may be of considerable concern as it may result in late
glenoid-sided mechanical failures (Fig. 8–3). Osteoly-
sis in a joint with a well-fixed implant is a potentially
devastating problem due to the substantial bone loss
that may be associated with failure of that device. The Figure 8–1 The current Grammont reverse design consists of a five-
biologic reaction from mechanical abrasion of polyeth- part system that utilizes a medialized center of rotation.
10.1055/978-1-58890-635-9c008_f001

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14530_C08.indd 77

Table 8–1 Comprehensive Review of Data on Glenoid-Sided Complications in Reverse Shoulder Arthroplasty

10.1055/978-1-58890-635-9c008_t001 Glenoid
complication Glenoid
Average Glenoid rate loosening
follow- complication excluding with Glenoid
Author N Pathology up rate % screwing % migration % notching % Type of glenoid failure
45
Frankle, 2006 29 29 Failed hemiarthroplasties for 35 13.8 (4/29) 13.8 (4/29) 3.4 (1/29) 0 3 Glenoid loosening without
(ASES Biennial meeting) fracture migration
Glenoid loosening with migration
Mole, 2006 46 80 80 CTA 44.5 7.5 (6/80) 2/5 (2/80) 2/5% (2/80) 78 4 Glenoid unscrewing
(ASES Biennial 2 Glenoid loosening
meeting)
Walch, 200647 196 59 CTA 39.9 1.5 (3/196) 1.5 (3/196) 1.5 (3/196) 51 2 Glenoid loosening

8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
(AAOS meeting) 45 Failed 1 Glenoid fracture
Arthroplasty
34 Massive RCT
28 Post-traumatic
OA
25 Primary OA + RCT
2 Acute fracture
1 RA
2 Tumor
Seebauer, 20065 56 56 CTA 39 3.6 (2/56) 3.6 (2/56) 3.6 (2/56) 80.5 2 Loosening with migration
1 Loosening without migration
**19.5% note progressive
notching from grade 1–2 to
grade 3–4
Boileau et al, 20052 45 21 Primary CTA 40 40 (18/45) NA 0 74 1 Intraoperative glenoid fracture
5 Sequela of fracture 17 Glenoid radiolucency without
19 Failed loosening
hemiarthroplasties
De Wilde, 2005 4 4 Tumor 38 0 0 0 0
(CORR)48 reconstruction
Frankle et al, 200513 60 11 CTA with collapse 33 15 (9/60) 15 (9/60) 11.7 (7/60) 0 2 Glenoid loosening without
17 CTA without collapse migration
23 Failed RTC repair 7 Glenoid loosening with
7 Massive RTC tear migration
1 Posttraumatic
1 RA
Werner et al, 20054 58 17 Primary CTA 38 8.6 (5/58) 8.6 (5/58) 5.2 (3/58) 96 3 Glenoid loosening requiring
15 Failed hemiarthroplasties or revision
fracture 2 Glenoid radiolucency without
5 Failed TSA for fracture loosening
1 Failed
hemiarthroplasty for OA
17 Failed RTC repair
1/31/08 11:04:41 AM

2 Failed RTC debridement

1 Failed ORIF

77
14530_C08.indd 78

78
Rotator Cuff Deficiency of the Shoulder
Table 8–1 Continued

Glenoid
complication Glenoid
Average Glenoid rate loosening
follow- complication excluding with Glenoid
Author N Pathology up rate % screwing % migration % notching % Type of glenoid failure

Paladini, 200549 7 3 Failed hemiarthroplasties 30 0 0 0 14.3 (1/7)

(Chir Organi Mov) for OA
2 Failed hemiarthroplasties for
fracture
2 Failed hemiarthroplasties
for RA
Seebauer et al, 200530 57 57 CTA 18.2 1.8 (1/57) 1.8 (1/57) 0 24.5 1 Loosening of glenosphere
Seitz, 200550 12 12 Failed RTC repair 12 0 0 0 0
(Semin Arthroplasty)
De Wilde, 200451 13 13 Tumor reconstruction 36 15.4 (2/13) 15.4 (2/13) 0 26.6 (4/13) 2 Glenoid loosening without
(Acta Orthop Belg) migration
Katzer, 200452 21 11 Failed arthroplasty for OA 24 0 0 0 9.5 (2/21)
(Orthopedics) 7 Failed hemiarthroplasties for
fracture
2 Failed arthroplasty for RA
1 Failed total humerus
Sirveaux et al, 20046 80 80 OA with massive cuff rupture 44.5 39 (31/80) 31 (25/80) 6.25 (5/80) 63.6 (49/80) 6 Glenoid unscrewing
5 Glenoid loosening with
migration
20 Glenoid loosening without
migration
Vanhove & Beugnies, 32 32 CTA 31 3.1 (1/32) 3.1 (1/32) 3.1 (1/32) 50 migration 1 Glenoid loosening with
200440 migration
Woodruff, 200353 11 11 RA 87 45.5 (5/11) 45.5 (5/11) 0 NA 1 Peri-prosthetic glenoid fracture
(Int Orthop) 5 Glenoid loosening without
migration
Boulahia, 200254 18 6 Primary CTA 35 5.6% (1/18) 5.6% (1/18) 0% 40% ( ) 56% (10/18) 1 Glenoid loosening without
(Orthopedics) 5 7 OA with irreparable RTC 81 60 ( ) 40 ( ) NA revision
3 Posttraumatic arthritis with 1 Glenoid unscrewing
Delloye et al, 20023
large RTC tear 2 Glenoid loosening
4 Failed hemiarthroplasties
1 Primary CTA
Rittmeister, 200155 8 8 RA 54.3 25 (2/8) 25 (2/8) 25 (2/8) NA 1 Glenoid loosening with
(JSES) migration
1 Glenoid revised for aseptic
loosening
1/31/08 11:04:41 AM
14530_C08.indd 79

De Wilde, 200156 5 3 Failed hemiarthroplasties 30 0 0 0 60 ( )

(Acta Orthop Belg) for CTA
1 Failed hemiarthroplasty for
fracture
1 Failed hemiarthroplasty with
anterosuperior escape
Jacobs, 200157 7 7 CTA 26 NA NA NA NA
(Acta Orthop Belg)
Valenti et al, 200139 39 39 Severe arthritis with 84 10.3 (4/39) 2.6 (1/39) 2.6 (1/39) 56 (22/39) 3 Glenoid unscrewing
irreparable RTC tear 1 Glenoid loosening requiring
revision
Favard et al, 200110 80 80 Primary CTA 45.4 11.3 (9/80) 6.25 (5/80) NA 62.5 (50/80) 2 Intraoperative glenoid fractures
1 Unscrewed glenoid requiring

8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
revision
3 Glenoid loosening without
revision
3 Partial glenoid unscrewing
**3 revisions done (does not
specify if glenoid or humeral
failure)
Balot, 199958 12 8 AVN w/ RTC 0 0 0 0
(Acta Orthop Belg) 4 AVN w/o RTC
Baulot, 199559 16 16 CTA 27 3.7 (1/27) 3.7 (1/27) 0 0
(Acta Orthop Belg)
Grammont, 1993 60 14 24 0 0 0 NA
(Rhumatologie)

Abbreviations: AVN, avascular necrosis; CTA, cuff tear arthropathy; OA, osteoarthritis; ORIF, open reduction internal fixation; RA, rheumatoid arthritis; RTC, rotator cuff; TSA, total shoulder arthroplasty.
1/31/08 11:04:41 AM

79
 80 Rotator Cuff Deficiency of the Shoulder
Figure 8–2 Scapular notching caused by impingement of the infe-
rior glenoid on the medial portion of the humeral socket.
10.1055/978-1-58890-635-9c008_f002
acromion or superior glenoid, thus maximizing gleno-
humeral abduction. In adduction, a more lateral COR
ensures that the medial neck of the prosthesis does not
impinge on the inferior aspect of the scapula.
3. Loss of Rotational Strength As the glenohumeral joint
becomes more medialized, the length-tension relation-
ship of the shoulder muscles changes (Fig. 8-4). The ro-
tator cuff thus becomes relaxed, resulting in rotational
weakness. This has been demonstrated clinically in re-
ports using the Grammont design, because patients do
not recover external rotation strength.4,10
4. Loss of the Deltoid Contour As a direct result of medi-
alizing the COR, the Grammont design results in a loss
A B
Figure 8–3 (A,B) Glenoid-sided mechanical failure of Grammont design. 10.1055/978-1-58890-635-9c008_f003
14530_C08.indd 80
of the deltoid contour (Fig. 8–5). Aside from cosmetic
concerns, loss of the deltoid contour may be indica-
tive of significant effects on the deltoid function and
strength, as well as joint stability. As the glenohumeral
joint is medialized, the pulley effect of the deltoid is
lost,11 and the added stability created by compressive
forces of the deltoid on the joint becomes diminished.
The RSP was inspired by the Grammont design, but with the
advantages of keeping the COR lateral to the glenoid, as it is
in the normal shoulder.12 Similar to the Grammont design,
the RSP has also evolved since its initial use in 1998. The
first published clinical study using the RSP design revealed
significantly improved postoperative pain and functional
outcomes.13 This study utilized the earliest version of the
RSP, and some complications were thought to be related to
prosthetic design. To understand why these complications
occurred, biomechanical characteristics of the RSP were
studied. In this chapter, I summarize the findings related
to the biomechanics of the RSP and describe how these
findings have been used to make improvements in pros-
thetic design. Numerous relevant studies are presented in
abstract form with commentary throughout the chapter
to illustrate more fully the biomechanical issues related
to RSP.
Initial Reverse Shoulder Prosthesis
Design
When the RSP was first designed (Fig. 8–6), it consisted of
four parts with two glenosphere choices: a 32-mm neutral
glenosphere with a COR 10-mm outside the glenoid and
a 32 - 4 mm glenosphere with a COR 6-mm outside the
glenoid. The glenosphere was attached to the glenoid via
a baseplate that was fixed to the glenoid bone with a 6.5-
mm central cancellous bone screw and four peripheral,
1/31/08 11:04:41 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 81

10.1055/978-1-58890-635-9c008_f004
A B
Figure 8–4 (A) As the center of rotation becomes more medialized, the length-tension relationship of the rotator cuff muscles changes. (B) When
the center of rotation remains lateral to the glenoid, as it is anatomically, the length-tension relationship remains the same or is minimally affected.

variable angle, nonlocking, 3.5-mm diameter screws. On
the humeral side, a cemented titanium stem articulated
with the glenosphere via a conforming polyethylene com-
ponent. The polyethylene component was attached to a
Morse taper using a screw-in system and the Morse taper
was locked into the humeral stem. Complications that oc-
curred during the clinical use of the RSP prompted several
design changes that have modified this initial design into
what it is today. The primary reason for providing a choice
of two glenospheres with CORs outside the glenoid was to
minimize inferior scapular notching, which has been seen
in many patient series using reverse designs with a more
medial COR (Table 8–2).2,4–15 Other goals for placing the
COR more lateral in relation to the glenoid were to obtain a
more anatomic COR for the shoulder, to improve rotational
strength, maximize glenohumeral motion, and to restore
the deltoid contour. Nonetheless, many shoulder surgeons
have reservations about using a more lateral COR with the
reverse shoulder design. Past designs where the COR was
lateral to the glenoid failed because their design resulted
in excessive torque or shear forces on the glenoid component.2

Figure 8–6 Initial design of the Encore Reverse Shoulder Prosthesis

(Encore Medical Corp., Austin, TX) with the 32-mm neutral gleno-
Figure 8–5 As a direct result of medializing the center of rotation, sphere. The initial humeral socket was entirely polyethylene fixed to a
the Grammont design results in a loss of the deltoid contour. metal underside, which attached to the stem via a Morse taper.
10.1055/978-1-58890-635-9c008_f005 10.1055/978-1-58890-635-9c008_f006

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 82 Rotator Cuff Deficiency of the Shoulder

Table 8–2 Glenosphere Sizes, Distance from Glenoid to Center ing fixation), and (2) limiting the deforming forces at the
of Rotation of Glenosphere, and Micromotion interface (immobilizing the shoulder, avoiding overtension
Distance from of the reduction, or limiting the distance from the COR to
glenoid to center of the glenoid surface). Clinically, mechanical failures on the
Glenosphere rotation of glenoid side have been seen in both currently available re-
sizes glenosphere (mm) Micromotion (μm) verse shoulder designs (RSP and the Grammont design)
32-mm neutral 10 83.0 and range from 0 to 60% of patients (Table 8–3).
To provide adequate fixation, principles developed by
32 mm – 4 mm 6 73.8
the Association for the Study of Internal Fixation (ASIF) to
36-mm neutral 6 73.9 improve fracture healing were used in the development of
36 mm - 4 mm 2 64.8 the RSP. A key ASIF concept is that compression across a
40-mm neutral 4 69.7 fracture promotes successful bone healing. When applied
to prosthetic implants, compression between the pros-
40 mm – 4 mm 0 60.6
thetic surface and the prepared bone provides stability
10.1055/978-1-58890-635-9c008_t002 needed to allow bone ingrowth. To achieve compression,
the RSP design uses a 6.5-mm cancellous-type lag screw in
the center of the baseplate (Fig. 8–7). The thread provides
For example, the Kessel reverse shoulder design was de- substantial compressive forces between the bone and the
veloped to lateralize the COR deliberately in an attempt baseplate as the screw is driven into the bone. This differs
to increase the ROM so that the tuberosities could clear from the Grammont design which uses a central post that
the acromion during abduction. The problem was that the does not provide compression. It must be noted that a small
fixation method of the glenoid was insufficient to with- amount of compressive force is provided in the Grammont
stand the transmission of force through the bone–prosthetic design from the peripheral screws. This leads to our first
interface. This led to loosening on the glenoid side.14 The two studies described below, which compared a baseplate
constrained nature of early reverse shoulder designs also with central peg fixation to a baseplate with central screw
played a part in their failure and exit from the market. To fixation. The first study compared the compressive force
accommodate greater loads at the attachment site, the RSP present at the glenoid–baseplate interface and the second
improved fixation between the glenoid bone and baseplate. study compared the maximum load to failure.

Fixation Compressive Strength of Central Screw

Cementless fixation for prosthetic attachment to the bone Purpose
has been utilized to allow for osseous integration, which
provides for the secure long-term attachment between The purpose of this study was to determine the compres-
bone and prosthesis. However, the essential biomechanical sive force present at the glenoid–baseplate interface for
prerequisite for this process to successfully occur requires central screw fixation and central peg fixation.
a stable interface between the bone and the prosthetic de-
vice during initial healing while the tissue at the interface
between the prosthetic surface and bone is undergoing
maturation. A stable interface between a prosthesis and Table 8–3 The Load to Failure for Both the Reverse Shoulder
Prosthesis (RSP) and Grammont Design (Delta III)
adjacent bone allows for successful bone ingrowth. Excess
motion between the bone–prosthetic interface may result Low strength foam High strength foam
in failure of bone ingrowth and eventual mechanical fail- RSP Load Delta III RSP Load Delta III
ure of the device. The commonly accepted maximum mo- Trial (N) Load (N) (N) Load (N)
tion that allows effective bony ingrowth is 150 μm.15
1 1138 1320 1181 1030
Typical joint loads that occur after shoulder arthro-
plasty and during early recovery include up to one times 2 1029 1271 1250 1000
body weight (756 N). The ability to tolerate the application 3 1020 1000 — 1016
of such loads while successfully allowing bone to integrate 4 1030 — — —
into the prosthesis is dependent on how the applied load is
5 990 — — —
transferred to the interface between the prosthesis and the
bone, as well as the security of the attachment. Methods 6 1080 — — —
used to ensure proper attachment of prosthesis to bone in- Mean 1048 1197 1216 1015
clude (1) improving the attachment strength to withstand SD 53 172 — 15
the deforming loads transferred to the interface (improv-
10.1055/978-1-58890-635-9c008_t003

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 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
10.1055/978-1-58890-635-9c008_f007
Figure 8–7 To achieve compression, the reverse shoulder prosthe-
sis design uses a 6.5-mm cancellous type lag screw in the center of
the baseplate.
Methods
The compressive strength of the central component of
two different baseplates used to attach glenospheres to
the scapula were compared: the metaglene (baseplate) of
Grammont’s design and the RSP baseplate (Fig. 8–8). The
Grammont design uses a central post, wheras the RSP de-
sign utilizes a 6.5-mm cancellous central screw. Surface
preparation of each bone model was performed based on
the manufacturer’s technique manual with matched ream-
ers for the undersurface of each device. Force transducers
were attached to the underside of each baseplate in supe-
rior and inferior positions prior to implantation. The base-
plate of the Grammont design was impacted into the gle-
noid bone, while the RSP was screwed to 60 in lb of torque
(as measured by a surgeon using a torque wrench during
surgery). Both devices had all peripheral screws tightened
to 60 in/lb of torque. Repeated measurements for the force
at the interface between the baseplate undersurface and
prepared bone were obtained.
Results
It was found that the screw fixation system of the RSP
baseplate provided 2000 N of compressive force, whereas
A B
14530_C08.indd 83
83
the peg/peripheral screw system of the Grammont design
baseplate provided 200 N of compressive force (Fig. 8–9).
Maximum Load to Fixation Failure of
Central Screw
Purpose
The purpose of this study was to determine the maximum
load needed for failure of fixation for central screw fixation
compared with central peg fixation.
Methods
Glenoid baseplate components for the RSP and the Gram-
mont design were used. These baseplates were mounted
into rigid polyurethane foam with properties similar to
human glenoid cancellous bone. For the RSP baseplates,
a 25-mm diameter concave surface was created using a
hemispherical reamer and the baseplate was screwed into
the foam until it was fully seated against the concave sur-
face. For the Grammont baseplates, the central peg was
tapped into the pilot hole until the baseplate was fully
seated against the foam block. No additional peripheral
screws were used for fixation of either baseplate.
A shear load was applied to the rim of each baseplate us-
ing a flat plane indenter attached to a servo-hydraulics load
apparatus (model 8521, Instron Corp., Canton, MA) (Fig. 8–
10). The load acted parallel to the baseplate surface and the
displacement rate was 150 N/s. Load-displacement outputs
were monitored continuously and tests were continued un-
til a substantial drop in the load occurred with increasing
displacement. This indicated that the yield strength of the
foam substrate was exceeded and a failure of fixation be-
tween the foam and baseplate had occurred. The maximum
shear load endured by each of the two baseplate-foam con-
structs was determined from the load-displacement curve.
Three repetitions were completed for each baseplate.
10.1055/978-1-58890-635-9c008_f008
Figure 8–8 (A) The metaglene (baseplate)
of Grammont’s design, and (B) the Reverse
Shoulder Prosthesis baseplate.
1/31/08 11:04:46 AM
 84 Rotator Cuff Deficiency of the Shoulder

10.1055/978-1-58890-635-9c008_f009

Figure 8–9 (A) Diagram of compressive

forces present in the Grammont baseplate,
and (B) the Reverse Shoulder Prosthesis
A B baseplate.

Results Baseplate Micromotion Using 3.5-mm

The maximum load at failure of fixation for the RSP base- Peripheral Screws
plates with central screw fixation (631 N) was significantly
(p = 0.012) greater than the Grammont design baseplates Purpose
with central peg fixation (269 N). Baseplates with central
The hypothesis was that reverse shoulder baseplates with
screw fixation endured, on average, 2.3 times greater load
central screw fixation would have less motion during phys-
than baseplates with central peg fixation.
iologic loading than baseplates with central peg fixation.
Along with the central 6.5-mm cancellous screw, ini-
tial baseplate designs of the RSP employed four peripheral
3.5-mm diameter nonlocking, variable angle screws. These
Methods
screws provided resistance to rotation of the baseplate,
thus improving fixation and decreasing micromotion of The RSP and Grammont baseplates were mounted in rigid
the baseplate. Biomechanical testing was performed to un- polyurethane foam with properties similar to human gle-
derstand further the fixation of the baseplates of the two noid cancellous bone. For the RSP baseplates, a 25-mm di-
available reverse shoulder designs using their appropriate ameter concave surface was created using a hemispherical
peripheral screws. reamer and the baseplate was screwed into the foam un-

10.1055/978-1-58890-635-9c008_f010

Figure 8–10 A shear load was applied to the

rim of the (A) Grammont, and (B) Reverse
Shoulder Prosthesis baseplates using a flat
plane indenter attached to a servo-hydrau-
A B lics load apparatus.

14530_C08.indd 84 1/31/08 11:04:47 AM

 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 85

til it was fully seated against the concave surface. For the
Grammont baseplates, the central peg was tapped into the
hole until the baseplate was fully seated against the foam
block. Both baseplates were further secured with four pe-
ripheral screws, including two 3.5-mm diameter by 26-mm
long cortical screws and two 4.5-mm diameter by 24-mm
long cortical screws. The 3.5-mm screws were inserted at
a 90-degree angle and the 4.5-mm diameter screws were
inserted at a 60-degree angle relative to the baseplates.
Two of the peripheral holes on the Grammont baseplate
were threaded to mate with threads on the heads of the
4.5-mm screws. None of the peripheral holes on the RSP
baseplate were threaded.
A shear load of 756 N was applied to the rim of each
baseplate using a flat plate indenter attached to a servo-
hydraulic load apparatus (model 8521, Instron Corp., Can-
Figure 8–11 A servo-hydraulic machine articulating the socket com-
ton, MA). This load acted parallel to the baseplate surface ponent with the glenosphere.
with a displacement rate of 150 N/s. Baseplate motion was
measured using a digital displacement gauge (model 543–
683, Mitutoyo America Corp., Aurora, IL) with a resolution 10.1055/978-1-58890-635-9c008_f011
of 10 μm. Baseplate motion was defined as component dis-
placement from 0 N to 756 N loads. Three repetitions were Next, a study was conducted to evaluate the initial glenoid
completed for each baseplate. component fixation of the three different designs (RSP 32-
mm neutral, 32 - 4 mm, and the Grammont 36 mm). Com-
Results pressive and shear loads were applied to the glenoid com-
ponents to create eccentric loading conditions similar to the
Baseplate motion was significantly lower for the RSP base- rocking-horse loosening mechanism that has been observed
plates at 310 ± 20 μm than the Grammont baseplates at 367 in patients with rotator cuff deficiency treated with a total
± 23 μm (p = 0.016). Therefore, it was concluded that base- shoulder prosthesis.16 This study found that fixation of the
plate motion was significantly lower for reverse shoulder two available RSP glenospheres with 3.5-mm screws demon-
designs using a central cancellous screw and four peripheral strated increased baseplate micromotion compared with the
cortical screws compared with reverse shoulder designs us- Grammont design. However, micromotion for all devices was
ing a central peg and four peripheral cortical screws. below 150 μm, which is considered necessary for successful
The attachment of the glenosphere to the baseplate (col- bone ingrowth.15 The results of this study provided some vali-
lectively called the glenoid component) increases the forces dation toward the use of RSP glenospheres with more lateral
at the bone/baseplate junction. The choice of glenosphere CORs that were fixed with 3.5-mm nonlocking screws.
also plays a part, as increasing the distance between the gle- Based on the above tests, it was apparent that the RSP,
noid bone and the COR increases the forces seen at the bone/ despite having a lateral COR, had adequate glenoid fixation.
baseplate junction. As mentioned above, initial designs of Unfortunately, clinical use of RSP 32-mm neutral and 32 - 4-
the RSP were available with two glenosphere choices—the mm glenospheres with 3.5-mm nonlocking screws resulted
32-mm neutral glenosphere with a COR (COR) 10-mm in mechanical failure of the baseplate in some of the devices.
outside the glenoid and a 32 - 4 mm glenosphere with a In total, 267 shoulders were implanted with the RSP between
COR 6-mm outside the glenoid. To determine the baseplate 1998 and 2004 exclusively using the 3.5-mm peripheral
micromotion of the entire glenoid component (the gleno- screws. Out of these 267 patients, there were 21 baseplate
sphere and the baseplate) with all peripheral screws under failures (7.8%). Evaluation of two of the initial baseplate fail-
physiological loading and the maximum load at failure of ures was performed using scanning electron microscopy.
fixation, two tests were conducted to determine loads to
failure and micromotion during cyclic loading.
First, a servo-hydraulic machine was used to articulate Scanning Electron Microscopy of
the socket component with the glenosphere. A compres- Failed Baseplates17
sive and shear load was applied while load-displacement
output was continuously monitored (Fig. 8–11). The tests
were continued until a substantial drop in the shear load
Purpose
occurred with increasing displacement. The load to failure In an attempt to understand the failure mode of failed gle-
for both the RSP and the Grammont design was ~1000 N and noid fixation, a retrieval analysis of failed baseplates was
not significantly different from each other (Table 8–3). conducted.

14530_C08.indd 85 1/31/08 11:04:49 AM

 86 Rotator Cuff Deficiency of the Shoulder

A B
Figure 8–12 (A) Scanning electron microscope micrographs of the center screw, and (B) the baseplate undersurface.
10.1055/978-1-58890-635-9c008_f012

Methods type. The second experiment used an “offset gauge” device

A scanning electron microscope was used to determine if
bone ingrowth occurred and to analyze fatigue character-
istics at the center screw. Two baseplates were available
for analysis.
to compare baseplate motion within a range of lateral off-
set magnitudes, using two types of peripheral screws for
fixation. Lateral offset was defined as the distance from
the glenoid baseplate to the center of articular contact be-
tween the glenosphere and the polyethylene cup.

Results Methods: First Variation

Minimal bone ingrowth was observed on the porous coat- Two variations of the RSP glenosphere (32-mm neutral
ing on the undersurface of the baseplate. The striations and 32 - 4 mm) were tested in addition to a 36-mm gle-
of the central screw could be accurately characterized as noid component of the Grammont design. These devices
fatigue failure (Fig. 8–12). had varying lateral offsets, defined as the distance from

Conclusion
The findings of these analyses suggest that baseplate fail-
ure was a fatigue phenomenon, which resulted in failure
of bone ingrowth comparable to fixation failure occurring
in nonunions.
Once it was determined that the mode of mechanical
failure of the baseplate was fatigue fracture due to lack of
bone ingrowth, attempts were made to further improve
fixation of the baseplate. The idea of adding peripheral
locking screws to provide additional baseplate fixation
was conceived and the biomechanical study was repeated
using 5-mm locking and nonlocking screws (Fig. 8–13).

Screw Fixation of Glenoid

Components Using 5.0-mm Screws18
Purpose
This study was divided into two experiments. The first ex-
periment measured the baseplate micromotion after vary- Figure 8–13 (A) 3.5-mm-diameter nonlocking, (B) 5.0-mm-diam-
ing the screw diameter, screw type, and/or glenosphere eter nonlocking, or (C) 5.0-mm-diameter locking screws.
10.1055/978-1-58890-635-9c008_f013

14530_C08.indd 86 1/31/08 11:04:50 AM

 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
the glenoid baseplate to the center of articular contact be-
tween the glenosphere and the polyethylene cup. Baseplate
micromotion was used as an indirect measure of the ad-
equacy of fixation. The baseplate of the 36-mm Grammont
design glenosphere (COR at the glenoid) was implanted
with two captured 3.5-mm locking screws implanted at 90
degrees relative to the baseplate and 2 nonlocking screws
implanted at 60 degrees, following standard operating
procedure. The baseplates of the RSP 32-mm neutral and
32 - 4-mm glenospheres (COR 10 and 6-mm outside the
glenoid surface, respectively) were implanted with either
four 3.5-mm nonlocking screws, four 5.0-mm nonlock-
ing screws, or four 5.0-mm locking screws. Two 3.5-mm
nonlocking screws were implanted into RSP baseplates at
60 degrees and two 3.5-mm nonlocking screws were im-
planted at 90 degrees. All 5.0-mm screws were implanted
at 90 degrees with respect to the baseplate. All three gleno-
sphere/baseplate combinations were implanted into high-
strength polyurethane foam (Sawbones Solid Rigid Foam
1522–04, Pacific Research Laboratories, Vashon, WA) with
properties similar to excellent glenoid bone stock.
Compressive loads and shear loads of 756 N (one times
bodyweight) were applied to the glenoid components to cre-
ate eccentric loading conditions similar to the rocking-horse
loosening mechanism that has been observed in patients
with rotator cuff deficiency treated with a total shoulder
prosthesis.16 The polyethylene humeral components were
attached to the load apparatus and loads were applied at a
loading rate of 150 N/s and cycled in the superior and infe-
rior direction between +756 N and -756 N for 1,000 cycles.
Motion was defined as the difference in glenoid component
displacement at 0 N and 756 N loads measured after 1,000
cycles. At least 3 repetitions of each test were completed.
The calculated moment at the baseplate-foam interface was
12.1, 17.4, and 20.4 Nm for the Grammont design, RSP 32 - 4-
mm, and RSP 32-mm neutral components, respectively.
250
3.5 mm screws
5.0 mm non-locking screws
200
5.0 mm locking screws
* *
Motion (microns)
150
100
50 n=6 n=3 n=3 n=3
0 Figure 8–14 Graph comparing micromotion of
Delta III RSP-reduced
16 23
Offset Moment Arm (mm)
14530_C08.indd 87
87
Results: First Variation
The first experiment revealed that Grammont components
fixed with 3.5-mm screws had significantly less motion
than the RSP 32 - 4-mm (p = 0.017) and RSP 32-mm neu-
tral (p = 0.041) components fixed with 3.5-mm screws
and RSP 32 - 4-mm (p = 0.008) and 32-mm neutral (p =
0.006) components fixed with 5.0-mm nonlocking screws.
However, there were no significant differences (p = 0.151)
in component motion when the Grammont components
fixed with 3.5-mm screws were compared with the RSP
32-mm neutral and RSP 32 - 4-mm components fixed with
5.0-mm locking screws (Fig. 8–12). Baseplate motion for
Grammont components and RSP components fixed with
5.0-mm locking screws was below the 150 μm of motion
generally accepted as the threshold for bone ingrowth.15
Among the RSP components, baseplates fixed with the 5.0-
mm locking screws had less mean motion than did base-
plates fixed with the 5.0-mm nonlocking screws (p = 0.016)
or the 3.5-mm nonlocking screws (p = 0.067) (Fig. 8–14).
Methods: Second Variation
In the second experiment, an offset gauge device was
used to vary the lateral offset from 2- to 30-mm. Loads
were applied to the offset gauge by use of a flat-plane in-
denter attached to the load apparatus, and the shear load
was applied at seven different offset magnitudes. Fixation
was achieved via either four 3.5-mm non-locking screws
or four 5.0-mm locking screws implanted into RSP base-
plates. The loading rate was 150 N/s and cycled in the su-
perior and inferior direction between +756 N and -756 N
for 1000 cycles. Compressive loads and shear loads of 756
N (one times bodyweight) were applied to the glenoid
components to create eccentric loading conditions similar
to the rocking-horse loosening mechanism that has been
*
*
n=3 n=3 n=6
10.1055/978-1-58890-635-9c008_f014
RSP-neutral the different glenospheres under physiological
27 loading. RSP, Reverse Shoulder Prosthesis; Delta
III, a Grammont design.
1/31/08 11:04:51 AM
 88 Rotator Cuff Deficiency of the Shoulder
observed in patients with shoulder prostheses.16 Moments
at the baseplate-foam interface increased from 1.5 to 22.7
Nm as the offset magnitude was incremented from 2- to
30-mm on the offset gauge device. Motion was defined as
the baseplate displacement from 0 N to 756 N loads. One
repetition of each test was completed at each of the seven
offset increments.
Results: Second Variation
Results of the second experiment demonstrated a posi-
tive linear relationship between RSP baseplate motion and
lateral offset when either four 3.5-mm nonlocking screws
(linear regression, R2 = 0.98, p < 0.001) or four 5.0-mm
locking screws (linear regression, R2 = 0.78, p = 0.008) were
used for baseplate fixation (Fig. 8–15). Based on these lin-
ear relationships and loading conditions simulating 756
N (1 times body weight) of compressive and shear load,
RSP baseplates fixed with 5.0-mm locking screws had up
to 29% less motion than RSP baseplates fixed with 3.5-mm
nonlocking screws.
Conclusion
Overall, both lateral offset and peripheral screw type af-
fected the magnitude of baseplate motion. Additionally,
stable fixation was achieved for the RSP 32-mm neutral
components fixed with 5.0-mm locking screws despite a
substantially (69%) greater moment at the baseplate-foam
interface compared with the Grammont design. The results
of this study advocate the use of 5.0-mm locking screws
when implanting the glenoid component.
The study on 5.0-mm locking screws was initiated soon
after the first glenoid-sided mechanical failure was noticed.
Despite the above results suggesting improved baseplate
stability with 5.0-mm locking screws, the change in the
clinical implantation was delayed because the RSP device
had been entered into a Food & Drug Administration (FDA)
250
RSP-neutral (5.0 locking screws)
RSP-reduced (5.0 locking screws)
200
RSP-neutral (3.5 screws)
Motion (microns)
RSP-reduced (3.5 screws)
150 Delta III (3.5 mm screws)
100
50
0 baseplate motion and lateral offset when either four
0 5 10 15
Offset (mm)
14530_C08.indd 88
investigational device exemption study and any changes to
the device had to be approved by the FDA. In total, 267
devices were implanted without the use of locked screws.
Once the FDA approved the requested device changes, 5.0-
mm locking screws were immediately used in patients
(starting January 2004) and have become the standard. As
of June 2006, there have been no glenoid-sided mechanical
screw failures with the use of 5.0-locking screws for secure
peripheral RSP baseplate fixation (Table 8–4). Thus, because
at my institution the problem of glenoid-sided screw failure
was quickly recognized and addressed based on the clinical
and basic science investigations, glenoid-sided mechanical
failures have been limited since 2004, prior to the wide-
spread distribution of this device in May 2005.
Baseplate Position
Once the problem of screw fixation was addressed, the
patients that had glenoid-sided mechanical failures were
investigated further. In my practice, I had noted that in-
feriorly tilting the baseplate/glenosphere construct may
be an important factor in preventing failure. To study the
effect of baseplate position on glenoid-sided failure, radio-
graphic, biomechanical, and computer modeling studies
were performed.
Biomechanical Analysis of Baseplate
and Glenosphere Position19
Purpose
Failures of the baseplate were hypothesized to result from
increased shear stresses at the bone-device interface. To test
this hypothesis, a biomechanical study was devised to test a
32-mm neutral glenosphere at a 15-degree superior and 15-
degree inferior tilt, as well as at a neutral 0-degree tilt.
10.1055/978-1-58890-635-9c008_f015
Figure 8–15 Results demonstrating a positive linear
relationship between Reverse Shoulder Prosthesis
20 25 30 3.5-mm nonlocking screws or four 5.0-mm locking
screws were used for baseplate fixation.
1/31/08 11:04:53 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 89
Table 8–4 Comparison of the Number and Follow-up of RSP ripheral locking screws. Force transducers that measured
Baseplates Implanted Using the 3.5-mm Nonlocking Peripheral compression were attached to the undersurface of the
Screws Exclusively (Original Design) versus Using the 5.0-mm
baseplate at the superior and inferior positions. Higher
Locking Screws (Current Design)
positive forces indicated increasing compression; a nega-
RSPs: 3.5-mm nonlocking versus 5.0 mm locking tive force was indirectly indicative of tensile force (which
10.1055/978-1-58890-635-9c008_t004 3.5-mm 5.0-mm is considered a disruptive force due to the lifting of the
nonlocking locking baseplate off the bone). A linear voltage displacement
Total number RSPs implanted 267 257
transducer was placed with its tip at the base of the gleno-
sphere that measured micro displacement in the superior
Total number mechanical failures 21 0
and inferior directions. Eight different blocks were used for
Percentage 7.80% 0% each different baseplate angle (15-degree superior inclina-
Average time to failure 20 months N/A tion, 15-degree inferior inclination and 0-degree or normal
inclination) and 10 runs were performed per block at vari-
# >2 years from RSP surgery 267 53
ous abduction angles (10, 20, 30, 40, 50, and 60 degree).
# >20 months from RSP surgery 267 82 The following information was gathered: superior and in-
ferior forces between the baseplate and the foam, superior
Abbreviation: RSP, Reverse Shoulder Prosthesis.
and inferior displacement of the glenosphere, angle of hu-
meral abduction, and force at the origin of the cable.
Methods
An apparatus was developed to simulate abduction of
Results
the humerus through 60 degrees (Fig. 8–16). A movable All forces measured by the superior force transducer were
sled with a 500-pound load cell was connected via a cable compressive forces regardless of the tilt angle or the angle
through a series of pulleys to the distal portion of a steel of inclination (Fig. 8–17). Over the range of abduction an-
pipe used to simulate the humerus. The angle of abduction gles from 10 degrees to 60 degrees, the inferior force trans-
was measured using an electronic goniometer attached via ducer measured the greatest amount of compressive force
a ring that moved with the steel pipe. At approximately (more positive forces) with a 15-degree inferior tilt; the
half the distance between the glenohumeral joint and the greatest amount of tensile force, or less compressive force
cable attachment, a spring was attached (k = 18.67 lbf/in) (all negative forces), was measured at the 15-degree supe-
that gradually increased the compressive forces at the gle- rior tilt. This shows that compressive forces, which assist in
noid, simulating the forces present at the glenohumeral bone attachment to prosthesis, were most evenly distrib-
joint during humeral abduction. Silicone spray was used in uted when the baseplate/glenosphere was tilted inferiorly
the joint to simulate synovial fluid. at 15 degrees. The displacement data (Fig. 8–18) showed
The RSP baseplate was attached to a solid rigid poly- that the majority of movement was in the superior direc-
urethane block using a central attachment screw and pe- tion. It wasn’t until 50 degrees was reached in the 15-degree

10.1055/978-1-58890-635-9c008_f016

Figure 8–16 Apparatus used to analyze the effect of base-

plate position on the forces underneath and the displace-
ment of the glenosphere.

14530_C08.indd 89 1/31/08 11:04:55 AM

 90 Rotator Cuff Deficiency of the Shoulder
inferior inclination and 60 degrees was reached in the nor-
mal inclination that movement in the inferior direction was
noted. The magnitude of all displacement remained under
60 μm, which is well under the displacement of 150 μm
above which osteocytes cannot rebuild bone.20
Conclusion
Baseplates with 15 degrees of inferior tilt had the most uni-
form compressive forces and the least micromotion over
the range of abduction when compared with the neutral
and 15-degree superiorly tilted baseplates. These results
indicate that an inferior tilt of ~15 degrees will maximize
implant stability and minimize mechanical failure for the
glenosphere and baseplate component of the RSP.
Three-Dimensional Finite
Element Analysis of Baseplate
and Glenosphere Position21
Purpose
The effect of degree of inclination of the glenoid compo-
nent on micromotion of the baseplate for an RSP and the
Grammont design were studied. As with previous stud-
14530_C08.indd 90
10.1055/978-1-58890-635-9c008_f017
Figure 8–17 Graph showing force data under
the baseplate at different angles of abduction.
ies, baseplate inclination was hypothesized to effect shear
stresses at the device–bone interface.
Methods
A three-dimensional (3-D) finite element model was con-
structed to simulate a reverse shoulder prosthesis im-
planted on a cellular polyurethane foam block with the
humeral socket connected to the loading system. The foam
used had material properties similar to those of human
glenoid cancellous bone. The bottom surface of the foam
block was fixed. The loading system was comprised of a
spring element and a connector element (Fig. 8–19). Half
of the device was modeled due to the symmetry of the
loading and geometry (Fig. 8–20). For each of the two de-
signs, six inferior inclination angles (i.e., 0, 3, 6, 9, 12, and
15 degree) were tested.
Results
Numerical results indicated that the maximum bone/
base-plate relative motions along the x1 and x2 directions,
namely Max RM1 and Max RM2 (RM = relative motion),
are significantly larger for the Grammont design than for
the RSP. In addition, it was found that inferior tilting of the
baseplate with a sufficiently large inclination angle up to
10.1055/978-1-58890-635-9c008_f018
Figure 8–18 Graph showing displacement data
of glenosphere at different angles of abduction.
1/31/08 11:04:56 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 91

A 10.1055/978-1-58890-635-9c008_f019 B
Figure 8–19 Loading system of the three-dimensional finite element model for (A) the Grammont design, and (B) the Reverse Shoulder Prosthesis.

15 degrees reduces the bone/base-plate relative motions
for both the Grammont design and RSP (Fig. 8–21).
Radiographic Study of Baseplate and
Glenosphere Position22
Purpose
The working hypothesis for this study was that patients with
mechanical failure of their RSP baseplates were implanted
with a more superior tilt than those that did not fail.
Methods
A retrospective review was performed of 203 consecutive
patients with a minimum of 2-year follow-up, which were
treated with an RSP using the initial baseplate design uti-
lizing 3.5-mm peripheral nonlocking screws. There were
14 patients with mechanical failure of the baseplate (8
men, 6 women) and 189 patients without failure (55 men,
134 women) who were included in the study. To identify
the tilt of the baseplate relative to the scapula, the spino-
spheric angle was established for each patient (Fig. 8–22).
Results
The spinospheric angle averaged 72 degrees (Range = 50 to
96 degrees, SD = 8.6 degrees) for the 189 patients without
mechanical failure. In the 14 failures, mean spinospheric
angle was 80 degrees (Range = 71 to 84 degrees, SD = 5 de-
grees). A statistically significant difference in spinospheric
angle was observed between the failure and nonfailure
group (p = 0.0014).
The 84-month survival rate for the glenosphere/base-
plate construct was 98% in 101 out of 203 patients whose
spinospheric angle was 72 degrees or less (Group 1),
whereas the survival rate for the other 102 patients whose

10.1055/978-1-58890-635-9c008_f020

Figure 8–20 Finite Element Analysis coordinate

system for recording relative glenosphere motion.

14530_C08.indd 91 1/31/08 11:05:15 AM

 92 Rotator Cuff Deficiency of the Shoulder
Figure 8–21 Graph demonstrating that inferior tilting of the base-
plate with a sufficiently large inclination angle up to 15 degrees re-
duces the bone/baseplate relative motions for both the Grammont
design and the Reverse Shoulder Prosthesis.
10.1055/978-1-58890-635-9c008_f021
spinospheric angle was greater than 73 degrees (Group 2)
was 88% (Fig. 8–23).
Conclusion
Superior tilting of the glenosphere/baseplate construct
may increase the incidence of mechanical failure and lead
to a lower survivability of the implant.
Clearly, implantation of the baseplate in the proper position
is essential. Based on the radiographic, biomechanical, and
computer modeling studies, the current recommendation is to
implant the baseplate with an inferior tilt up to 15 degrees.
The biomechanical modeling and finite element mod-
eling described above were performed utilizing models
of good bone, with similar mechanical characteristics to a
14530_C08.indd 92
Figure 8–22 The spinospheric angle is defined as the arc subtended
by the baseplate and scapular spine in the coronal plane, as seen on
the anteroposterior view. 10.1055/978-1-58890-635-9c008_f022
normal scapula. However, when similar studies were per-
formed using a poor bone model, neither the Grammont nor
RSP design was able to minimize micromotion between the
prosthesis and the bone to below 150 μm. Concerns regard-
ing implantation of the RSP design in poor glenoid bone or
in situations where the purchase of the center screw was
suboptimal resulted in the addition of multiple glenosphere
options that could provide a more medial COR. In these sce-
narios, the improved RSP baseplate fixation could be used
in conjunction with a glenosphere with a COR as medial as
the glenoid surface. The medial COR would lessen the forces
at the bone/baseplate interface, but at the cost of decreased
potential ROM. Biomechanical modeling was used to fur-
ther evaluate these new glenosphere options.
10.1055/978-1-58890-635-9c008_f023
Figure 8–23 Kaplan–Meier survivorship of patients whose spino-
spheric angle was ≤72 degrees (group 1) and whose spinospheric
angle was >73 degrees (group 2).
1/31/08 11:05:18 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 93

10.1055/978-1-58890-635-9c008_f024

Figure 8–24 Diagram of the different glenospheres available for

the Reverse Shoulder Prosthesis. The different glenospheres offer
a range of centers of rotation from right at the glenoid (40 mm - 4
mm) to 10 mm lateral to the glenoid (32-mm neutral).

Effect of Changing the Distance
Between the Center of Rotation
and the Glenoid Surface on
Baseplate Fixation23,24
Purpose
Due to the increasing options available for RSP glenospheres,
a study was developed to quantify the biomechanical differ-
ences between them. It was hypothesized that by decreas-
ing the distance from the glenoid surface to the COR, forces
at the device–bone interface would decrease.
Methods
The effect of varying the COR on baseplate fixation was
evaluated using biomechanical, analytical, and fine ele-
ment analysis models. Six available RSP glenospheres (Fig.
8–24) were used along with the 36-mm Grammont gleno-
sphere. The distance from the glenoid to the COR ranged
from 0 mm to 10 mm (Table 8–5).
Biomechanical Model
A biomechanical testing apparatus similar to the one dis-
cussed above in the study on screw fixation of glenoid
components using 5.0-mm screws was used to test each
glenosphere implanted in bone models simulating ex-
cellent quality glenoid bone. All RSP glenospheres/base-
plate combinations were implanted using 5.0-mm locking
screws at 90-degree angles relative to the baseplate. The
Grammont glenosphere/baseplate combination was im-
planted with two nonlocking screws placed at 60 degrees
relative to the baseplate and two locked screws placed
at 90 degrees relative to the baseplate. The micromotion
between the baseplate and glenoid bone was measured
3-mm away from the bone/baseplate interface after an ap-
plication of 1000 cycles of shear loading at 756 N or one
times body weight.

Table 8–5 Differences in Dimensions for the Various Reverse Glenospheres Used in This Study

Glenosphere R (mm) h1 (mm) h2 (mm) h3 (mm) h0 (mm)

RSP (40 mm - 4 mm) 20 3 3 0 20
Grammont (36 mm) 18 2 3 1 19
RSP (36 mm - 4 mm) 18 1 3 2 20
RSP (40-mm neutral) 20 1 3 4 24
RSP (36-mm neutral 18 3 3 6 24
RSP (32 mm - 4 mm) 16 3 3 6 22
RSP (32-mm neutral) 16 7 3 10 26

Abbreviations: R, glenosphere radius; h0, distance between the glenoid and the tip of the glenosphere;
h1, distance between the top of the baseplate and the center of rotation; h2, height of the baseplate;
h3, distance between the glenoid and the center of rotation; RSP, Reverse Shoulder Prosthesis.
10.1055/978-1-58890-635-9c008_t005

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 94 Rotator Cuff Deficiency of the Shoulder
Finite Element Analysis
A 3-D axi-symmetric finite element model was created
to simulate the mechanical testing described above (Fig.
8–25). The finite element setup was modified to change
the coefficient of friction between the glenosphere and the
socket and to simulate the effect of misalignment between
the bone and baseplate.
Analytical Model
A mathematical equation was derived to help predict the
effect of changing the coefficient of friction and the distance
between the glenoid and the COR on the reaction moment
at the bone/baseplate interface at various abduction angles.
Results
The analytical, biomechanical and finite model had close
agreement (Table 8–6). In vitro mechanical testing indi-
cated that the average baseplate motion during 1000 load
cycles ranged from 90 μm to 120 μm for the seven different
glenosphere types (Table 8–7). Although there was a gen-
eral trend toward increased baseplate motion with increas-
ing distance from the glenoid to the COR, no significant dif-
ference was observed. Static equilibrium analysis found that
the reaction moment at the bottom of the baseplate rises
monotonically as the coefficient of friction of the articulat-
ing surfaces increases and as the distance from the glenoid
to the COR increases. Results from the finite element analysis
were strongly correlated (Spearman’s rank order correlation
s = 0.829 and p = 0.0423) with the in vitro mechanical test-
ing25 and confirmed that baseplate motion varied 30 μm or
less over the range of glenosphere component sizes tested
(Table 8–7). Additionally, the finite element analysis found
A B
14530_C08.indd 94
that a misalignment of 1 degree between the baseplate and
the bone axis can lead to micromotion as large as 310 μm
and that there is more baseplate motion with a frictional
articulating interface than with a smooth contact between
the glenosphere and the socket.
Conclusion
Evaluation of data from the mechanical analysis found that
despite large differences in distance between the glenoid
and the centers of rotation for various glenospheres (0 to 10
mm), the differences in baseplate micromotion from phys-
iological loads in healthy bone is insignificant provided
that adequate initial fixation is achieved. The presence of
increasing frictional torque increases baseplate micromo-
tion. Additionally, excessive baseplate motion occurs if
there is a mismatch between the glenoid and baseplate. It
must be noted that smaller reaction moments were seen in
the analytical model with centers of rotation closer to the
glenoid surface. Therefore, a medial COR may provide the
best scenario when confronted with bone deficiency of
the glenoid so that forces at the bone/baseplate junction
can be minimized.
The addition of locking screws combined with a selection
of glenospheres with varying distances from the COR to the
glenoid surface (0, 2, 4, 6, and 10 mm) have been used by
my practice since January 2004. Additional features of the
RSP baseplate aid in achieving stable fixation and promoting
bone ingrowth such as the concave baseplate and hydroxy-
apatite coating on the undersurface. After these changes and
up until the time this chapter was being finalized in late
2007, there had been no glenoid-sided mechanical failures.
In the setting of deficient glenoid bone, the current
recommendation for establishing stable baseplate fixa-
10.1055/978-1-58890-635-9c008_f025
Figure 8–25 Finite element models for (A) the
Reverse Shoulder Prosthesis 32-mm neutral, and
(B) the Grammont 36 mm.
1/31/08 11:05:33 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 95
Table 8–6 Comparison of Three Different Modes of Analysis Used in This Study 10.1055/978-1-58890-635-9c008_t006

Lowest to Highest Baseplate

Lowest to Highest Baseplate
Motion From Mechanical
Testing After 1000 cycles
of loading
Grammont
Increasing baseplate micromotion
Motion From Finite Element
Analysis at either of the 2 tested
coefficients of friction,
regardless of where the
measurement was taken or the
coverage area stimulated
Grammont
Lowest to Highest Reaction
Moment From Static
Equilibrium Analysis at ␮ > 0
and any abduction angle above
0 degrees
RSP 40 minus 4

(1) (1) (0)

RSP 40 neutral RSP 40 minus 4 Grammont
or reaction moment

(4) (0) (1)

Decreasing baseplate micromotion

RSP 40 minus 4 RSP 36 minus 4 RSP 36 minus 4
(0) (2) (3)

or reaction moment
RSP 36 minus 4 RSP 40 neutral RSP 40 neutral
(2) (4) (4)
RSP 32 minus 4 RSP 32 minus 4 RSP 32 minus 4
(6) (6) (6)
and RSP 32 neutral RSP 36 neutral RSP 36 neutral
(10) (6) (6)
RSP 36 neutral RSP 32 neutral RSP 32 neutral
(6) (10) (10)

2 = 0.829 2 = 0.964
p = 0.0423 p = 0.0182

2 = 0.757
p = 0.0638

*Distances between the simulated bone and the centers of rotation of the glenospheres in mm are given in parentheses. The Spearman rank-order cor-
relation coefficient (s), indicative of the strength of the correlation between the rankings, is given comparing the three analyses. Also, p-values give the
probability of the derived s values occurring by chance.
Abbreviation: RSP, Reverse Shoulder Prosthesis.

Table 8–7 Comparison of Baseplate Micromotion between the Finite Element (FE) Analysis and In-Vitro Mechanical Testing

10.1055/978-1-58890-635-9c008_t007 Baseplate Baseplate

micromotion micromotion
measured measured Baseplate
3 mm away 3 mm away micromotion
Distance from the from the from Difference
between simulated simulated mechanical between
simulated bone/baseplate bone/baseplate testing— FE analysis
glenoid and interface at interface at 1000 cycles at ␮ = 0.22 and
center of ␮ = 0 from ␮ = 0.22 from of repetitive mechanical
rotation (mm) FE analysis (␮m) FE analysis (␮m) shear load (␮m) testing

RSP (40 mm - 4 mm) 0 59 74 100 ± 10 26%

Delta-III 1 57 69 90 ± 24 23%

RSP (36 mm - 4 mm) 2 64 77 107 ± 15 28%

RSP (40 mm neutral) 4 69 84 97 ± 12 13%

RSP 36- mm neutral) 6 74 87 120 ± 10 28%

RSP (32 mm - 4 mm) 6 74 86 113 ± 12 24%

RSP (32- mm neutral) 10 84 96 113 ± 6 15%

Abbreviation: RSP, Reverse Shoulder Prosthesis.

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 96 Rotator Cuff Deficiency of the Shoulder

tion was developed from a clinical review of RSPs placed
in deficient glenoid bone stock. The placement of the cen-
tral screw in the bone at the junction of the spine of the
scapula and the body resulted in consistently strong screw
purchase. The bone at the base of the scapula spine was
robust, even in the most clinically dire circumstance. We
currently recommend placement of the baseplate into
this particular location, using 5.0-mm peripheral locking
screws, and a glenosphere with a more medial COR.
Humeral-Sided Complications
Initial concerns using the RSP centered on glenoid-sided
complications. Clinical experience coupled with basic science
research increased the understanding of how to avoid these
problems, and has helped to limit their incidence. We now
turn our attention to the humeral-sided complications.
The increased constraint of the reverse design places
greater force on the humeral side than is typically seen in a
conventional total shoulder arthroplasty. In a multicenter
study using the Grammont design, a 20% incidence of hu-
meral-sided complications was noted.26 Humeral compli-
cations included in this review were humeral fractures,
prosthetic dissociation, prosthetic subsidence, loosening,
and radiolucent lines.
The early experience using the RSP noted humeral com-
plications, which were identified during the early clinical
trials. Biomechanical models were thus created to gain
further understanding as to why these complications oc-
curred and develop solutions to limit these problems in
the future.
the load required to dissociate the polyethylene socket
from its metal underside when subjected to a cantilever
load. Nine different configurations of polyethylene/metal
underside combinations were tested (Fig. 8–26), two of
which had a screw that improved the fixation between
the metal underside and the polyethylene. In all cases, the
stem was assembled in a vise fixture. The poly socket and
metal backing were connected to the stem and the stem
was positioned and clamped into place. A load cell was
used to measure the force applied to the poly socket and
this load was applied to the polyethylene socket until the
polyethylene disassociated from the metal underside. This
test helped us determine that the best polyethylene/metal
backing combination to use in designs of the RSP should
include a screw to better secure the metal backing to the
polyethylene component.
Another test was done with the same nine configura-
tions of the socket to determine the number of cycles it
would take to cause failure. One humeral stem and one
glenoid head were used for all testing. Only the humeral
sockets were changed between tests because they were

Polyethylene Disassociation
The initial humeral design used an all polyethylene socket,
which was attached to a small metal button (similar to a
patellar metal insert in a total knee). The metal button pro-
vided a Morse taper attachment to the humeral stem, which
could then be cemented. Using this design, there were four
cases of polyethylene failure related to disassociation. All of
these failures occurred in the revision setting where proxi-
mal humeral bone support was deficient, allowing the poly-
ethylene to remain unsupported. The incidence of polyeth-
ylene disassociation in the revision setting was thus 3.5%
(4/115 revisions). This led to several experiments to test the
failure strength of this attachment site.

Mechanical Testing of Proximal

Polyethylene Inserts in the Encore
Reverse Shoulder Prosthesis
To determine the optimal configuration of the polyethyl-
ene component for the RSP, testing was done to determine
Figure 8–26 Diagram of the nine different configurations of
polyethylene/metal backing combinations that were tested.
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 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
the only components that were damaged from the fatigue
cycling. The fatigue load was applied to the center of the
glenoid head, and parallel to the humeral stem. A univer-
sal joint was at the bottom so that the humeral stem and
socket may deflect in any direction. Testing was continued
to failure or 5 million cycles, and then testing was stopped.
The failure mode of the humeral sockets was similar to
failure experienced when the ultrahigh molecular weight
polyethylene socket pulled away from the metal underside
at the back of the “U” channel.
After the above testing sequence, the most stable poly-
ethylene insert was selected and was used clinically from
2000 to 2004. Unfortunately, disassociation with the above
design still occurred, particularly when there was proxi-
mal humeral bone loss. Thus a metal shell encasing the
polyethylene socket was added to the design. The purpose
of the metal shell was to provide a more secure attach-
ment of the polyethylene socket to the humeral stem and
to allow an easy interchange between various sized modu-
lar inserts. With this new design, there was a possibility
of the polyethylene liner disassociating from the metal
shell. Three mechanical tests were performed to evaluate
the likelihood of component dissociation. They included
(1) the push-out strength of the polyethylene liner rela-
tive to the metal shell. This test determined the push-out
load required to cause movement between the poly liner
and metal shell of the RSP. (2) The torsional load required
to cause movement between the poly liner and metal
shell. This test was used to determine the force needed
to cause the antirotation tabs to shear. (3) The lever-out
load required to cause movement between the poly liner
and metal shell. This test was used to determine the force
needed to cause the poly insert to rock out of the shell.
Currently, the RSP is only available with the polyethyl-
ene humeral socket with the metal shell. The metal shell
is especially useful in cases with proximal humeral bone
loss. Additional investigation of how to provide the best
solution to restore proximal humeral bone loss is ongo-
ing. Clinical research suggests that restoration of this bone
with an allograft may provide fewer complications such
as dislocation and humeral loosening. Currently, biome-
chanical work is being performed to design an adaptable
prosthetic solution for proximal humeral bone loss, which
may be less technically challenging and more cost effective
than using a bone allograft.
Instability
Cases of dislocation have been reported using the reverse
designs, and is often considered the most frequent compli-
cation.27 Reports of the Grammont design note dislocation
rates of up to 30%.28 To further understand potential causes
of instability, a multidisciplinary team of scientists devel-
oped biomechanical models that could provide further in-
sight into instability of the reverse designs.
14530_C08.indd 97
97
Design factors inherent to each of the prostheses directly
influence the stability of the implant. These factors play an
important role in proper implant selection in cases where
stability is a concern. These factors also influence the degree
of soft tissue tensioning necessary to keep the device stable.
Previous studies on the stability of cadaveric shoulders and
total shoulder arthroplasty noted that stability is related to
the angle between the radius of curvature of the humeral
head and the radius of curvature of the glenoid cavity. As the
glenoid cavity becomes deeper and more constrained, the
force necessary to dislocate the humeral head increases.29–41
Based on this concept, glenospheres with different di-
ameters and sockets depths were developed. To discover
how much implant stability can be improved by these geo-
metric changes in prosthetic design, several biomechanical
experiments were performed.
Stability
Purpose
The purpose of this study62 was to quantify the stability
of six configurations of the RSP and the Grammont design
using experimental and analytical methods.
Methods
Each device was placed into a custom load fixture (Fig.
8–27). Two levels of normal force were applied to the hu-
meral component. The peak translational force required to
dislocate the glenosphere from the polyethylene socket was
measured. Analytical calculations were made to verify the
data generated in the experimental part of the experiment.
Results
Forces required for dislocation of the joint were higher for
devices with deeper sockets and larger diameter gleno-
spheres. The Grammont design, which has a shallower
(8.24 mm) socket, required 172 (±3.19) and 343 (±4.10) N
under 111 and 222 N of compressive force, respectively.
Under the same compressive forces, dislocation for the
40-mm semiconstrained, the deepest RSP (12.51 mm), re-
quired 344 (±10.9) and 532 (±9.25) N. Analytical data cor-
related well with experimental data, with errors ranging
from 2.2 to 25.9% for the 111 N compressive force and from
0.5 to 7.9% for the 222 N compressive force.
Conclusions
Based on the results of this study, an implant with a deeper
socket and a larger glenosphere diameter can provide im-
proved stability.
In cases of dislocation, it has been helpful to increase
the size of the glenosphere or to use a deeper, semicon-
1/31/08 11:05:34 AM
 98 Rotator Cuff Deficiency of the Shoulder
LVDT
Metal
Movable sled
fixture
Metal support on
bed of bearings
Load cell
Bearings
Movable sled
strained socket. The information from the above study has
since been used clinically to treat the 7 patients that devel-
oped instability after RSP. All 7 patients were revised to a
reverse prosthesis with a larger diameter glenosphere and
deeper socket. Six of the 7 patients have remained stable
after this revision, with one patient developing recurrent
instability even after reconstruction. Loss of motion was
felt to be related to earlier impingement that occurred
with larger glenospheres and deeper sockets. This balance
of stability versus mobility was the impetus for additional
biomechanical studies to determine the potential variation
in glenohumeral motion that occurs with design variations
between components.
Range of Motion
Currently, several different prosthetic designs of the reverse
shoulder arthroplasties are available in a variety of geometries.
Differences in ROM, stability, security of fixation, and motor
function may vary among the different implant geometries,
so selection of the appropriate shoulder prosthesis requires a
priori understanding of the implant geometry.
Few clinical or biomechanical studies have character-
ized glenohumeral motion associated with reverse shoul-
der prostheses. Utilizing dynamic radiographs, Seebauer
and associates studied isolated glenohumeral elevation
following Delta III reverse shoulder implant surgery, and
in a cohort of 35 primary and 22 revision patients found
active glenohumeral elevation was a maximum of 53 de-
grees.5,30 Utilizing a cadaver model, Nyffeler and associates
reported that significant improvements in glenohumeral
elevation (abduction ROM) could be obtained by altering
the position of the Delta III glenosphere more distally on
the glenoid.31 From a clinical standpoint, maximizing the
14530_C08.indd 98
10.1055/978-1-58890-635-9c008_f027
Motor Figure 8–27 Custom apparatus used to meas-
ure the force of dislocation of the various gleno-
sphere and socket combinations.
potential ROM is a key element for functional gains that
may be achieved with reverse shoulder prosthetic designs.
To further characterize the amount of glenohumeral mo-
tion that could be achieved with each design, a Sawbones
(Pacific Research Laboratories, Vashon, WA) shoulder
model was developed to test motion achieved after im-
plantation of each design.
Range of Motion of the Reverse
Shoulder Prosthesis
Purpose
The purpose of this study61 was to determine differences
in abduction ROM (ROM) of six configurations of the RSP.
The hypothesis is that the glenohumeral ROM (abduction)
is dependent on the COR offset of the glenosphere relative
to the glenoid.
Methods
An apparatus was developed to simulate abduction of the
humerus in the scapular plane. (Fig. 8–28) An orthopedic
surgeon implanted six configurations of the RSP into a
large left Sawbones scapula and humerus, and ROM data
was gathered.
Results
Results showed a positive linear correlation between ab-
duction ROM and COR offset relative to the glenoid. As the
COR is moved more lateral from the glenoid, abduction
ROM increases. The greatest total abduction ROM was 97
degrees (SD = 0.9) with an RSP glenosphere that has a COR
1/31/08 11:05:35 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
offset of 10 (SD = 0.4) mm from the glenoid and the small-
est abduction ROM was 67 degrees (SD = 1.8) with an RSP
glenosphere that has a COR offset of 0.5 (SD = 0.1) mm
from the glenoid surface.
Conclusions
Improvements in ROM were found to correlate statistically
with increased distance from the glenoid to the COR of the
glenosphere. CORs that are farther away from the scapula al-
low the proximal humerus and humeral socket more clear-
ance before impinging on the acromion or superior glenoid,
thus maximizing glenohumeral abduction (Fig. 8–29). In
adduction, a more lateral COR ensures that the medial neck
of the prosthesis does not impinge on the inferior aspect of
the scapula. This decreases the risk of inferior scapular ero-
sion, and improves overall abduction ROM. Because altered
glenohumeral geometry has been shown to affect shoulder
muscle forces during abduction,32 additional work is needed
to determine how changes in the COR offset relative to the
glenoid may influence shoulder muscle function.
Muscle Function
To understand how muscular function is affected by pros-
thetic geometric differences, several different biomechani-
cal studies were performed. As mentioned in Chapter 1,
the mechanical efficiency of the muscle in generating
torque around the joint is determined by the moment arm.
Using the direct method, moment arms may be calculated
for each joint position by measuring the shortest distance
from the action of the muscles to the COR of the joint. The
greater the moment arm for each muscle, the greater the
14530_C08.indd 99
99
10.1055/978-1-58890-635-9c008_f028
Figure 8–28 Apparatus used to simulate abduc-
tion of the humerus in the scapular plane. LVDT,
linear variable displacement transducer.
force generated. This approach was undertaken with the
various glenospheres described in the above studies, each
with a different COR and different radius of curvature. Mo-
ment arms were calculated for the deltoid, subscapularis,
and infraspinatus, to determine if certain prosthetic ge-
ometries are more effective in restoring different types of
motion (i.e., greater improvement in rotation than abduc-
tion in the scapular plane).
Deltoid Force Comparison Between
Glenospheres with Lateralized and
Medialized Center of Rotation–
Direct Method
Purpose
The purpose of this study was to determine the differences
in moment arms of the infraspinatus, subscapularis, and
deltoid muscles when different reverse shoulder implants
are used.
Methods
Six different configurations of the RSP and the 36-mm
Grammont were compared with a hemiarthroplasty. This
investigation employed two different procedures: (1) mo-
ment arms measured directly from digital video taken of
each of the specified muscles while undergoing 90 de-
grees of scapular abduction, and (2) using a mathematical
model to predict deltoid force necessary to abduct the arm
through 90 degrees of scapular plane abduction. This was
based on a free body diagram generated by biomechanical
video analysis.
1/31/08 11:05:35 AM
 100 Rotator Cuff Deficiency of the Shoulder
0 mm offset
10 mm offset
IG IG
IC IC
A GT A (ROM; A1 and B1) and abduction ROM (A2
GT
SC SC
SG SG
0 mm offset
10 mm offset
An apparatus was developed to simulate abduction of
the humerus through 90 degrees (Fig. 8–30). A movable
sled with a 500-pound load cell (Model LCH-500, OMEGA
Engineering Inc., Stamford, CT) was connected via a cable
to the attachment site of the deltoid on a simulated hu-
merus. The angle of abduction (± 0.01 degrees) was meas-
ured via an electronic goniometer (Greenleaf Medical, Palo
Alto, CA) attached via a ring that moves with the humerus.
Weights were used to apply a constant force of 60 N to
the subscapularis, infraspinatus and, where applicable, the
supraspinatus. A weight of 12 N was attached off the end
of the humerus to simulate the weight of the arm. Silicone
spray was used in the joint to simulate synovial fluid.
Seven different reverse shoulder glenospheres (32-mm
neutral, 32 – 4-mm), 36-mm neutral, 36 – 4-mm, 40-mm
neutral, and 40 – 4-mm and the 36-mm Grammont design
glenosphere were attached to a left Sawbones shoulder
model. A hemiarthroplasty was also used to simulate the
normal anatomic condition. All configurations were im-
planted by an orthopedic surgeon using appropriate sur-
gical techniques. Three different Sawbones models were
used for each different baseplate configuration and three
runs were performed per configuration. Data was collected
14530_C08.indd 100
10.1055/978-1-58890-635-9c008_f029
Figure 8–29 Schematic illustration show-
ing the concept of limitations to isolated
glenohumeral motion as a consequence of
impingement for adduction range of motion
and B2). Same size glenosphere diameter (32
mm) and different glenosphere COR offset
– 10 mm offset (A1 and A2) and 0 mm off-
set (B1 and B2) – are compared by ROM and
prosthetic impingement points. A, Acromion;
GT, greater tuberosity; SG, superior glenoid;
IG, inferior glenoid; SC, superior cup; IC, infe-
rior cup. ROM shown in illustration does not
include scapular motion. Note, for abduction,
impingement may occur on superior glenoid
(shown) or acromion. (Illustration does not
represent experimental data).
using a custom-made LABview (National Instruments, Aus-
tin, TX) graphical interface, and gathered information on
the angle of humeral abduction and force at the origin of
the cable. Statistical analysis was performed using a one-
way ANOVA and a Student’s t test.
Results
Results showed an antagonistic behavior (adductors) of
the infraspinatus and the subscapularis in the first 60 de-
grees of abduction (maximum adductor moment arms of
23.27 mm and 25.21 mm, respectively), then becoming
agonist (abductors) to the deltoid the remaining 30 de-
grees (maximum abductor moment arms of 4.64 mm and
5.87 mm, respectively). This is illustrated by decreasing
moment arms to 60 degrees as the line of action of the
muscle crosses the COR of the devices and then increasing
again as they pass the COR toward the end of 90 degrees
of abduction (Table 8–8). The trends in the mathematical
model correlated well with the biomechanical data and
may prove clinically useful for predicting optimal con-
figurations of offset and head size based on bone quality
and rotator cuff status.
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 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience 101

10.1055/978-1-58890-635-9c008_f030

Figure 8–30 Apparatus used to simulate abduction of the humerus through 90 degrees.

Conclusion Indirect Measure of Determining the

Deltoid moment arms are increased in glenospheres with Instantaneous Moment Arm
a lateralized COR. Results indicate a possible benefit in us-
ing a reduced lateral offset head RSP when deltoid function Purpose
is compromised.
This study was undertaken to determine differences in shoul-
Additionally, an indirect method of determining the in-
der muscle function in reverse implants of various designs
stantaneous moment arm for a given muscle or mechani-
when compared with the previously mentioned direct method.
cal advantage with a given glenosphere can be related to
the tendon excursion and the joint rotation.
Table 8–8 Moment Arms Calculated In Abduction Using the Methods
Origin-Insertion Method (Direct) 10.1055/978-1-58890-635-9c008_t008
Measurements were made using six different designs of the
Maximum moment arm RSP, a 36-mm Grammont design and a hemiarthroplasty
origin/insertion method when implanted into a left Sawbones humerus. The excur-
Infraspinatus Deltoid Subscapularis sion length of the infraspinatus, subscapularis, and mid-
32 Neutral 19.61 47.91 18.98 dle deltoid were measured while the humerus was rotated
through internal and external rotation, as well as elevated
32 mm - 4 mm 17.93 47.45 20.77
through abduction in the scapular plane. Videos were taken
36-mm neutral 23.27 48.99 24.17 of each muscle, and moment arms were measured from
36 mm - 4 mm 21.11 46.41 23.57 the videos using an image processing and analysis program
40-mm Neutral 19.48 43.03 22.91 (ImageJ, National Institutes of Health, Bethesda, Maryland).
normal
40 mm - 4 mm 20.56 47.34 23.31
Normal Results
40 mm Neutral 20.12 47.36 21.18 Deltoid moment arms increased throughout the range of ab-
reduced duction to a maximum of 49.7 ± 1.07 mm for the RSPs, 41.8
40 mm - 4 mm 21.17 47.19 23.27 ± 0.40 mm for the Grammont design and 26.7 ± 1.61 mm for
Reduced the hemiarthroplasty. When looking at muscle function dur-
ing abduction in the subscapularis and infraspinatus, their
Grammont 18.08 41.84 17.65
function changed from adductors to abductors when they

14530_C08.indd 101 1/31/08 11:05:38 AM

 102 Rotator Cuff Deficiency of the Shoulder
crossed the COR of the construct. The moment arms for the
subscapularis went from a maximum of 25.2 ± 0.42 mm in
adduction at 0 degrees to a maximum of 5.87 ± 1.01 mm in
abduction at 90 degrees for the RSPs, a maximum of 17.65 ±
1.35 mm in adduction at 0 degrees to a maximum of 3.2 ±
1.64 mm in abduction at 90 degrees for the Grammont design
and a maximum of 5 ± 0.35 mm in adduction at 40 degrees to
a maximum of 1.07 ± 0.62 mm in abduction at 90 degrees for
the hemiarthroplasty. The moment arms for the infraspina-
tus followed similar trends as the subscapularis: They went
from a maximum of 23.3 ± 0.33 mm in adduction at 0 degrees
to a maximum of 4.64 ± 0.34 mm in abduction at 90 degrees
for the RSPs, a maximum of 18.1 ± 0.26 mm in adduction at
0 degrees to a maximum of 1.65 ± 0.47 mm in abduction at
90 degrees for the Grammont design and a maximum of 5.53
± 0.98 mm in adduction at 0 degrees to a maximum of 3.2
± 0.72 mm in abduction at 90 degrees for the hemiarthro-
plasty. When looking at internal–external rotation, moment
arms were measured for the total angular rotation of the in-
fraspinatus and subscapularis. The maximum moment arms
were 36.1 ± 1.27 mm and 31.9 ± 0.43 mm, respectively, for the
RSPs, 24.3 ± 0.91 mm and 28.6 ± 1.81 mm, respectively, for the
Grammont design, and 23.5 ± 1.30 mm and 26.7 ± 1.38 mm,
respectively, for the hemiarthroplasty.
Conclusion
All reverse designs showed similar linear increases in
moment arms throughout the range of abduction. This
contrasted with the trends in the hemiarthroplasty. The
moment of the subscapularis and infraspinatus changes
from abduction to adduction as the arm elevates above the
prosthetic COR. The greater moment arms of the RSP in
internal and external rotation demonstrate a mechanical
advantage in having the COR lateral to the glenoid.
To validate these biomechanical studies, a clinical study
was established to characterize the functional improve-
ments seen after treatment with the reverse design. A Bio-
dex System 2 dynometer (Biodex Medical Systems, Shirley,
NY) study was undertaken to determine the range-specific
strength for a group of patients who received an RSP.
Range-Specific Strength after Reverse
Shoulder Prosthesis33
Purpose
Our goal in this study was to develop a standardized method
of measuring shoulder strength during various shoulder
motions before and after implantation of the RSP.
Methods
Beginning March 2004, a prospective analysis of shoulder
strength was performed in patients who underwent a RSP.
14530_C08.indd 102
We studied 28 patients who were available for a minimum
of 6-month Biodex follow-up. The average age of this study
group was 71 years (56 to 86) and included 6 men and 22
women. In terms of pathology, 21 out of 28 had a RSP for
primary cuff tear arthropathy and seven out of 28 had RSP
to replace a failed hemiarthroplasty done for fracture. Preop-
erative strength measurements were made using a Biodex
dynamometer (Biodex Medical Systems, Shirley, NY) in the
sitting position. Postoperative comparisons were made using
data at a minimum of 6-month follow-up. Maximum isomet-
ric shoulder flexion strength was assessed at four angles of
humeral forward elevation: 0, 30, 60, and 90 degrees. Maxi-
mum external and internal rotation strengths were also as-
sessed at 0 degrees of abduction and forward elevation.
Results
At 0 degrees of humeral elevation, maximal shoulder flex-
ion strength significantly improved from 7.9 J to 15.0 J (p =
0.0006). At 30 degrees of humeral elevation, maximal
shoulder flexion strength significantly improved from 3.5
J to 7.7 J (p = 0.042). At 60 degrees of humeral elevation,
maximal shoulder flexion strength improved from 3.2 J to
4.9 J, and at 90 degrees, maximal shoulder flexion strength
improved from 2.8 J to 4.4 J. Neither the improvements at
60 degrees or at 90 degrees were significant (p = 0.52 and
p = 0.57, respectively). Internal rotation strength signifi-
cantly improved from 10.5 J preoperatively to 14.9 J post-
operatively and external rotation strength significantly im-
proved from 7.4 preoperatively to 10.8 postoperatively (p =
0.031 and p = 0.007, respectively).
Conclusion
The RSP may significantly improve isometric forward
flexion strength at 0 and 30 degrees of humeral elevation.
Additionally, significant improvements of internal and
external rotation strength were seen. Further research
is necessary to understand the impact of prosthetic de-
sign on muscle strength and function following reverse
arthroplasty.
Conclusion
The RSP provides a viable option to restore motion and re-
lieve pain in patients with CTA who have few other options.
The design of the RSP was inspired by Grammont’s design,
but with the advantage of keeping the COR lateral to the
glenoid, as it is in the normal shoulder. The RSP design
provides the option of a lateral COR which can increase
potential ROM at the shoulder joint, improve rotational
strength, avoid scapula notching, and maintain deltoid
contour. The forces at the bone-baseplate junction may
increase; however, with adequate fixation, bone ingrowth
can be achieved. In cases of glenoid bone deficiency or
1/31/08 11:05:39 AM
 8 Rationale and Biomechanics of the Reverse Shoulder Prosthesis: The American Experience
suboptimal center screw purchase, a glenosphere with a
medial COR can be selected.
Complications on both the humeral and glenoid side
have occurred, many of which have been related to de-
sign features and technical errors in placement of the
prosthesis. Further biomechanical studies are needed
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1/31/08 11:05:40 AM
 9 Rationale and Biomechanics of the
Reversed Shoulder Prosthesis:
The French Experience
Pascal Boileau and Christopher Chuinard

The Problem
Treatment of the cuff-deficient shoulder has been a vexing
problem for many years. Although the rotator cuff provides
control of overhead rotation of the humerus and internal
and external rotation (ER) of the arm, its main function is
to stabilize the humeral head in the confines of the gle-
noid, thereby creating a stable fulcrum around which the
deltoid can act, providing forward flexion of the humerus.
When the rotator cuff is torn, the dynamic balance of
the shoulder can be lost; however, not every advanced cuff
tear (CT) leads to loss of forward flexion beyond 90 degrees
(i.e., pseudoparalysis). In fact, some patients can present
with complete tears of the posterior cuff, but maintain
forward flexion if there is a balance between internal and
external rotatory forces. An intact coracoacromial arch can
provide a stable articulation allowing the deltoid to work
s when there is a balance between the subscapularis and
teres minor. Figure 9–1 Previous reverse ball and socket prostheses tended to
If the dynamic balance of the joint is lost and arthropa- fail because their design resulted in excessive torque or shear forces
thy ensues, what options are available? Constrained ar- on the glenoid component (notice the small head and neck placing
throplasty seemed to provide great promise for restora- the center of rotation outside the scapula).
10.1055/978-1-58890-635-9c009_f001
tion of function because the humerus could be stabilized,
allowing the deltoid to work. Completely constrained ball
and socket designs, introduced in the 1970s, were adapted strained total shoulder arthroplasty for the cuff-deficient
from hip prostheses (Bickel, Macnab-English, Stanmore, shoulder was also unsatisfying as the “rocking-horse” ef-
Michael-Reese, Post).1,8 Subsequently, several prostheses fect led to early failure, and hemiarthroplasty became the
were introduced based on a reverse ball-and-socket design recommended treatment.3,4 Bipolar arthroplasty gained a
(Fenlin, Gerard, Kessel, Kölbel, Liverpool, Neer, and Avery brief following, and has remained the procedure of choice
ll).2,33 To achieve appropriate resting length and tension for a select few.5,6–19
on the deltoid, the original reverse ball and socket designs
lateralized the humeral component; concomitantly, the
center of rotation was lateralized. In fact, the instant center The Vision
of rotation was lateralized outside of the scapula, creating
a lever arm between the center of rotation and the bone/ Dissatisfied with the results of standard architecture ar-
implant interface. Because of the vectors involved with throplasty for the cuff-deficient shoulder, Professor Paul
humeral movement below 90 degrees (i.e., the initiation Grammont, a French orthopedic surgeon, designed a semi-
of abduction or humeral flexion), both torque and sheer constrained reverse prosthesis based on different, but
between the implant and the bone were created, resulting sound, biomechanical principles. To replicate the stability
in loosening (Fig. 9–1). of the intact cuff, a semiconstrained design was chosen to
Moreover, the constraint between the humeral and give the deltoid a stable fulcrum; to give mechanical ad-
the glenoid components meant that all of the forces were vantage to the deltoid, he increased its resting length and
transmitted to the glenoscapular interface. The failures recruited the posterior deltoid.
and poor results led to abandonment of both reverse archi- Prior to Grammont, constrained shoulder prostheses
tecture and constrained designs. Experience with uncon- tended to fail because their design resulted in excessive
106 Rotator Cuff Deficiency of the Shoulder
torque and shear forces at the glenoid component–bone
interface. Furthermore, although they usually allowed
some active elevation, this was, in most cases, less than 90
degrees and, primarily, scapulothoracic motion. Prosthetic
instability was also a concern. Many never went beyond
the experimental stage, and most are no longer commer-
cially available.
Grammont recognized that the lateral center of rota-
tion found in previous designs created a large lever arm
between the “ball” and its bone interface. By medializing
the center of rotation (so that it actually lies at the glenoid
bone–prosthesis interface), Grammont reduced the torque
on the glenoid component. Furthermore, with initiation of
abduction, the vector changed from parallel to the com-
ponent/scapula interface (i.e., shear) to perpendicular to
the glenoid component (i.e., compression), theoretically
increasing stability of the construct when it is most vul-
nerable (Fig. 9–2).
To power the “engine” of this new design, the deltoid,
Grammont sought to maximize the resting tension on the
deltoid while involving more of both the anterior and the
posterior fibers. To effect the changes in the deltoid, a com-
bined inferiorization and medialization of the humerus
relative to the acromion increases deltoid tension and rest-
ing length, recruiting more anterior and posterior deltoid
fibers and improving the force vectors (Fig. 9–3).
The realization of these principles involved two major
technological innovations: (1) on the glenoid side, use of a
large ball (36 or 42 mm in diameter) with no neck; (2) on
the humeral side, a small cup inclined to a non-anatomic
humeral inclination of 155 degrees with conforming—but
not fully constrained—articular surfaces. Both the large gle-
noid hemisphere and the small and conforming humeral
cup optimize the range of movement, minimize impinge-
ment between the components, and improve stability.
The first model of reverse prosthesis, designed by Paul
Grammont in 1985, had only two components (Fig. 9–4).
The glenoid component was either a metallic or a ceramic
ball, initially two thirds of a sphere and 42 mm in diam-
eter. It was designed to fit over the glenoid like a glove
and was fixed with cement. The humeral component was a
cemented polyethylene socket. Its concave surface was one
third of a sphere, and its stem was trumpet-shaped for ce-
menting into the humeral medullary canal. A bell saw was
used to prepare the glenoid, and two broaches were used
to prepare the different parts of the humerus—one for the
epiphysis and one for the diaphysis.
The preliminary results published (in French) in 1987
showed eight cases: three post-radiotherapy necrosis
cases, one inflammatory osteoarthritis case, and four revi-
sions of failed prostheses.9 The mean patient age was 70
years, and the cuff was absent or destroyed in all cases.
Mean follow-up was only 6 months. A transacromial ap-
proach (with osteotomy of the lateral acromion) was used
in all but one case. Revision osteosynthesis of an acromial
nonunion was required in three cases. All shoulders were
pain-free, but mobility was variable. In three cases, active
anterior elevation was 100 to 130 degrees, but in the other
three cases, it was less than 60 degrees.
The Realization
Unsatisfied with these results, Grammont made further
modifications, arriving at the current design. Because he
had several failures with the cemented glenoid compo-
nent, he decided to change the glenoid to an uncemented
system: a glenoid component fixed with a press-fit central
peg supported by screws of divergent direction that coun-
teract the initial shearing forces.2,9 He also changed the ra-
10.1055/978-1-58890-635-9c009_f002
Figure 9–2 By placing the center of rotation
medial, torsion and shear at the bone–gle-
noid interface are reduced; furthermore,
with the adduction, the force vector goes
from parallel to the articular surface (shear)
to perpendicular (compression).
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience
dius of the articular surface from two thirds of a sphere to
half of a sphere to place the center of rotation directly in
contact with the glenoid surface, decreasing lateral offset
Figure 9–4 The first model of the Grammont reversed prosthesis,
designed in 1985, had only two components: the humeral compo-
nent was all polyethylene and trumpet shaped; the glenoid compo-
nent was a metallic or ceramic ball, initially 2/3 of a sphere and 42 mm
in diameter. It was designed to fit over the glenoid like a glove and
was affixed with cement. 10.1055/978-1-58890-635-9c009_f004
107
10.1055/978-1-58890-635-9c009_f003
Figure 9–3 (A,B) The increased force of the
deltoid is gained from both the medializa-
tion of the center of rotation, which recruits
more deltoid fibers, and the lowering of the
humerus, which tensions the deltoid. (A) L =
increased length. The figure shows a shoulder
with a reverse prosthesis and compares the
center of rotation and humeral position to
a native glenohumeral joint (B). There is an
obvious increase in acromiohumeral distance
and an overall lengthening of the humerus.
at the glenohumeral articulation, thus decreasing shearing
forces. Grammont named this reverse prosthesis “Delta,”
as the concept was based solely on the deltoid for both
function and stability.
The second model, the Delta III reverse prosthesis (DePuy
Orthopaedics, Inc., Warsaw, Indiana), became available in
1991 and is still in use today. The glenoid is uncemented,
and either cemented or uncemented options are available
for the humerus. The Delta III has five parts: the glenoid
base plate (metaglenoid), the glenosphere, the polyethylene
humeral cup, the humeral neck, and the humeral stem (Fig.
9–5).
The glenoid component (metaglene) is a 29-mm disk,
with a rough surface and hydroxyapatite coating. Initial
fixation is ensured by a 29-mm-long central peg and four
peripheral, divergent screws (3.5 or 4.5 mm in diameter).
The aim is to place one screw in the base of the coracoid
and one screw into the inferior scapular pillar for maximum
hold. The pyramidal, divergent assembly of the screws has
been designed precisely to counteract the shearing forces
during initial abduction.
The glenosphere is a cobalt-chrome sphere, available in
two diameters: 36 and 42 mm, with a 19-mm offset. Ini-
tially, the fixation of the sphere on the metaglene was done
by use of peripheral threads, but this mechanism had a ten-
dency to unscrew, particularly in right shoulders. In 1996,
glenosphere-metaglene fixation was changed to a periph-
eral Morse taper and reinforced by a central countersunk
screw; the design change has almost completely eliminated
glenosphere dissociation except in trauma cases.
108 Rotator Cuff Deficiency of the Shoulder
10.1055/978-1-58890-635-9c009_f005
Figure 9–5 The Delta III reversed prosthesis has five parts: the glenoid
base plate (metaglenoid), the glenosphere, the polyethylene cup, the
humeral neck, and the humeral stem. A lateralized spacer, the rehausser
(not pictured), can provide greater deltoid tension if the polyethylene is
insufficient. Both a Delta I and a Delta II exist, but they are variations of a
conventional arthroplasty that utilize the same humeral stem.
The humeral stem is conical, and its surface is either
polished or hydroxyapatite-coated for cemented or un-
cemented fixation, respectively. It is available in three
lengths: 100 mm for the standard prosthesis and 150 and
180 mm for the revision prosthesis.
The humeral neck is screwed onto the humeral stem. It
has a fin to control rotation, and there are holes to allow tu-
berosity osteosynthesis. Like the stem, it is available with
a polished or a hydroxyapatite-coated surface. Three sizes
are available: 36–1 and 36–2 for a 36-mm-diameter cup
and 42–2 for a 42-mm-diameter cup. Initial unscrewing
between the neck and the stem resulted in the placement
of a polyethylene bushing between these components.
The humeral cup is made of polyethylene and has two di-
ameters conforming to the 36- and 42-mm glenospheres. It
is 6 mm thick and press-fitted onto the humeral neck com-
ponent. A 9-mm metallic extension may be screwed onto the
neck to increase the humeral offset. The humeral cup is also
available in a more constrained form with a deeper cup.
The Delta I and II prostheses are “standard” uncon-
strained versions of the Delta III prosthesis. All three pros-
theses share the same stem and humeral neck. The Delta I is
a hemiarthroplasty, which is easily converted from a Delta
III by fixing a metal head onto the humeral neck, whereas
the Delta II is a total shoulder prosthesis with a polyethyl-
ene glenoid component in place of the glenosphere.
A further evolution of Grammont’s designs occurred un-
der the direction of Dr. Gilles Walch and Prof. Pascal Boileau.
The Aequalis reverse prosthesis, available since 2002, fol-
lows the Grammont design, but incorporates prosthetic
changes designed to enhance both the ease of implantation
and survivability: improved instrumentation, variable angle
locking screws, and an array of polyethylene thicknesses.
The baseplate maintains the titanium HA design, but adds
the ability to vary the direction of the locking screws up to
30 degrees superiorly for the upper screw and 30 degrees
inferiorly for the lower screw; furthermore, they both can be
angled ±15 degrees in the anteroposterior (AP) direction.
For the humeral component, a polyethylene bushing
was added between the neck and the stem to minimize the
risk of disassembly. The cemented stem is rough-finished
cobalt chromium with scalloping to increase rotational sta-
bility; the noncemented stem is titanium with HA coating.
There are four stem lengths available—100 mm, 150 mm,
180 mm, and 210 mm. There are three polyethylene sizes
available: 6 mm, 9 mm, and 12 mm, plus an additional
9-mm titanium spacer. A humeral head adaptor to accom-
modate an Aequalis standard head is available should the
prosthesis need to be converted to a hemiarthroplasty.
The Deltoid and Grammont’s Design
This design confers mobility, increased deltoid torque, and
stability, while minimizing the unfavorable glenoid stresses,
which led to the failure of previous reverse prostheses. Ac-
cording to Grammont, the middle deltoid is most important
for abduction. This is particularly true in a normal shoulder
where parts of the anterior and posterior deltoid are at the
level of, or even medial to the center of rotation;8 therefore,
they either contribute very little to abduction or, in the case
of the more medial fibers, may even be adductors. However,
in patients with a reverse prosthesis, the medialized center
of rotation may allow some of these fibers to become more
effective abductors, thus augmenting the role of the ante-
rior and posterior deltoid and further increasing the force of
the deltoid overall (Fig. 9–6).
To effect the necessary changes to the deltoid, it must
be tensioned despite the medialization of the humerus.
Unfortunately, intraoperative determination of deltoid
tension is difficult and guided mostly by surgical experi-
ence; reduction should be as tight as possible, but allow
for full adduction. We also have found that the conjoint
tendon, exposed during a deltopectoral approach, should
feel taut after reduction with the arm at the side and the
elbow extended.
Biomechanics of the Grammont Design
Active elevation is restored by the fixed center of rotation,
the congruent joint surfaces, and the increased deltoid
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience
A B
C D
torque. Deltoid torque is augmented by both the increased
lever arm and the increased deltoid force (Torque = Lever
Arm x Force), as shown in Fig. 9–7. The elevation force
with a large ball is greater and proportional to the length
of the radius.8 Grammont conducted studies on a deltoid
simulator and calculated that
–A 10-mm medial displacement of the center of the
sphere on the glenoid increases the abduction moment
of the middle deltoid by 20% at 60 degrees of elevation.
–A 10-mm inferior displacement of the center of the
sphere on the glenoid increases the abduction moment of
the middle deltoid by 30% at 60 degrees of elevation.9,10
From a functional standpoint, according to Fick,11
Strasser,12 and Kapandi13 the deltoid can be divided into
seven parts (Fig. 9–6A,B):
109
10.1055/978-1-58890-635-9c009_f006
Figure 9–6 (A,B) The seven portions of the del-
toid; in a normal shoulder, only the middle del-
toid (portion III) and part of the anterior deltoid
(portion II) are lateral to the elevation axis, and
can participate to active elevation (C); in a shoul-
der with a reverse prosthesis the axis of elevation
is displaced medially which allows some of the
anterior and posterior deltoid fibres (portion I
and IV) to become more effective elevators (D).
–The anterior part, is inserted on the clavicula, and has
two portions: I and II
–The middle part is inserted on the acromion, and has
only one portion: III
–The posterior part is inserted on the spine of the scap-
ula, and has four portions: IV, V, VI, and VII
In a normal shoulder, if we consider that the axis of el-
evation is perpendicular to the plane of the scapula and is
located within the humeral head (at the level of the center
of rotation), we observe that only the middle deltoid (por-
tion III) and part of the anterior deltoid (portion II) are lateral
to this axis and can provide active elevation (Fig. 9–6C). The
other portions of the deltoid serve as adductors until humeral
elevation progresses to the point that these different portions
pass lateral to the sagittal axis and become elevators.
110 Rotator Cuff Deficiency of the Shoulder
In a shoulder with a reversed prosthesis, the axis of ele-
vation is medially displaced, located at the level of the gle-
noid surface (the center of rotation). In this situation, we
can observe that, in addition to the middle deltoid (portion
III), almost all the anterior (portions I, II), and even part of
the posterior deltoid (portion IV) become elevators from
the start of the movement (Fig. 9–6D).
Nevertheless, medializing the center of rotation also
medializes the humerus and the relative position of the
deltoid insertion. This means that the deltoid muscle le-
ver arm will be effectively decreased and weakened un-
less the upper arm is also lengthened, restoring tension.
Grammont even recommended overtensioning the del-
toid, slightly, to increase its force, as demonstrated by the
10.1055/978-1-58890-635-9c009_f007
Figure 9–7 The main principles of the Gram-
mont reverse prosthesis are (1) a fixed and
medialized center of rotation (C) reduces the
torque on the glenoid component; to increase
the deltoid lever arm (L), L2 is greater than L1;
and (2) a lowering of the humerus relative to the
glenoid to restores tension and augments del-
toid force (F2 > F1).
increased acromiohumeral distance after insertion of a re-
verse prosthesis (Fig. 9–7). In addition, as emphasized by
DeWilde et al,14 the elevation force is a function of the mo-
ment, a product of the muscle force and its lever arm, and
as little as a 10% increase in muscle length can improve the
moment; furthermore, the moment arm can be improved
by the relative increase in distance between the deltoid
line of action and the center of rotation.
Stability
Stability is provided by (1) the large prosthetic head (Fig. 9–8)
—dislocation requires displacement superior to the radius of
the head, as in a hip replacement where a large head is more
10.1055/978-1-58890-635-9c009_f008
Figure 9–8 Improved stability—as in the hip,
a large prosthetic head is more stable than a
small one. Improved stability is also provided
by the increased compressive forces (C) of
the anterior and posterior deltoid, as a result
of lowering the humerus.
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience
stable than a small 22-mm head;15 and (2) the increased com-
pressive force of the anterior and posterior deltoid as a result
of lowering the humerus (as described above). Grammont
calculated that with the Delta prosthesis, compressive forces
become superior to shearing forces beyond 45 degrees.9
Reduced Torque on the Glenoid
The torque on the glenoid components is dramatically re-
duced because the center of rotation actually lies at the
glenoid bone–prosthesis interface as seen in Fig. 9–2. Some
shear is inevitable during initial elevation of the shoulder,
but these forces rapidly become compressive as the move-
ment progresses.9,16,17
Limitations of the Grammont Design
Deficient or Absent External Rotation
As demonstrated in the literature, the Grammont reverse
prosthesis can effectively restore active elevation and ab-
duction above the horizontal. However, it does not restore
active ER. There are at least four major reasons that can
explain the limited and weak ER after a Delta reverse pros-
thesis. The first one is related to the design of the prosthe-
sis itself: the limited lateral offset of the glenosphere limits
the possibility of rotation of the humeral cup around it
with the arm at the side. However, there are patients who
maintain considerable ER.
The second reason for the limited and weak ER is related
to the medialization of both the center of rotation and of
the humeral shaft. The amount of posterior deltoid that
can be used to compensate for the absent external rotators
is decreased because of this humeral medialization. The
remaining external rotators (i.e., infraspinatus and teres
minor) may also be slackened and less efficient because of
this humeral medialization. However, the muscles’ inser-
tions are also lowered, which, in theory, maintains their
tension, but their vectors become more oblique than hori-
zontal, accounting for the loss of power.
The third reason for the lack of improvement in ER after
a Grammont reverse prosthesis is the status of the remain-
ing teres minor, as demonstrated in two previous studies.18,19
Our own study confirmed that active ER after a reverse pros-
thesis was significantly better if the teres minor were intact
than if it were absent or had fatty infiltration.20
Finally, the fourth reason for the weak ER may be re-
lated to technique, as mentioned recently by Nyffeler et
al:21 perforation of the posterior cortex of the scapula by
the drill or the posterior screw may damage the supra-
scapular nerve at the base of the scapular spine. Therefore,
if the infraspinatus is intact preoperatively, it should be
protected during surgery to preserve the patient’s active
ER: use a short (18-mm) posterior screw, directed inferi-
orly to avoid a lesion of the suprascapular nerve.
111
According to Grammont et al, there are three theoreti-
cal solutions to improve active ER when implanting a re-
verse prosthesis: (1) moving the deltoid V far forward, (2)
performing an external derotational osteotomy of the hu-
merus under the deltoid V, or (3) increasing retroversion
at the time of implantation of the humeral component.8,9
Obviously, only the latter could be used in daily surgical
practice, but it would have the potential disadvantage of
reducing internal rotation (IR), which may make it difficult
for patients to reach behind the back.
Our solution to restore active ER is to perform a latis-
simus dorsi and teres major transfer at the same time as
the reverse prosthesis. This is our procedure of choice for
patients with a pseudoparalyzed shoulder and no active
ER, manifest preoperatively by both lag and hornblower
signs with severe muscle fatty infiltration of infraspinatus
and teres minor (Fig. 9–9).22 We recommend this transfer
to all patients if they are unable to externally rotate to a
neutral position.
Deficient or Absent Internal Rotation
In our series, we have found that the Delta reverse prosthe-
sis rarely restores active IR, making it difficult for patients to
reach the back with the hand. Again, this is related to pros-
thetic design, which decreases lateral offset of the humerus
and medializes the center of rotation leading to (1) lim-
ited excursion of the cup around the ball in the horizontal
plane, and (2) a decreased ability of the anterior deltoid to
compensate for absent internal rotators. The efficacy of any
remaining subscapularis muscle may be decreased by the
obliquity of its new vector; however, this can be offset by
recruitment of the inferior muscular portion or by the use of
a superolateral approach, which has the advantage of pre-
serving the subscapularis insertion. We inform patients that
their maximal IR will be achieved at approximately one year
after the surgery, and we protect the subscapularis repair
for 6 weeks postoperatively. Furthermore, in some cases of
severe loss of IR, it may be necessary to perform a pectoralis
major transfer at the time of reverse arthroplasty, but a loss
of IR is better tolerated than a complete loss of ER.
The French Experience: Results and
Complications of the Multicenter
Study Group
Between January 1992 and April 2003, 457 reverse total
shoulder arthroplasties (RSAs) were performed in one of
five centers in France. The indications ranged from cuff tear
arthropathy (CTA) to revision arthroplasty (Table 9–1). Out
of the original 457, 68 were excluded. Twenty-three pa-
tients died before the minimum 2-year inclusion, 17 were
unavailable for follow-up, and 28 had incomplete data or
112 Rotator Cuff Deficiency of the Shoulder

A B

C D

E F
Figure 9–9 (A) Activities of daily living are affected, as dem- of the humerus. (D) This is facilitated by anterior dislocation of the
onstrated by the attempt to bring the hand to the mouth. (B) humerus. (E) The transferred tendons can be attached to the poste-
Schematic of modified latissimus dorsi (LD) and teres major (TM) rior aspect of the lesser tuberosity, or to the stump of the pectoralis
transfer, which takes two humeral internal rotators and transforms major. (F) The subscapularis is reattached to the humerus with non-
them into external rotators. (C) The pectoralis major is reflected to absorbable transosseous sutures that are placed prior to cementa-
reveal the insertion of the latissimus dorsi tendon; the two tendons tion of the humeral stem. Postoperative photographs demonstrate
are sutured together and the orientation is marked with different forward flexion, external rotation, and renewed ability to reach the
color sutures; the tendons are rerouted along the posterior access top of the head. 10.1055/978-1-58890-635-9c009_f009
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience
Table 9–1 Etiology for Reverse Shoulder Arthroplasty in the
Nice 2006 Review
Etiology Number in series
Fracture 15
Fracture sequelae 37
Cuff tear arthropathy/ massive rupture 175
Previous surgery 42
Osteoarthritis 22
Rheumatoid arthritis (PR) 8 with postoperative rehabilitation in this case.
Tumor 6 Our recent review of the 389 reverse shoulder arthro-
Chronic dislocation 5
Other 4 through a deltopectoral approach, and all were 36-mm
Revision total/hemiarthroplasty 80
Revision of reverse shoulder arthroplasty 5 cases were treated with simple closed reduction. Five
Total 399
inadequate follow-up. This represents an 87.3% inclusion
rate for the global series.
Three hundred eighty-nine shoulders were available for
complete clinical and radiographic follow-up at a minimum
of 24 months (range = 24 to 132 months). All patients were
prospectively followed, clinically and radiographically, on
a regular basis: 3, 6, 12 months, and then yearly after the
procedure. Functionally, the patients were assessed with
a ROM evaluation, Constant score, and subjective assess-
ment (very satisfied, satisfied, disappointed, or unhappy).23
Overall, the prosthesis was effective in restoring active
forward flexion, improving ER, and providing the majority
of patients with a shoulder that they described as very sat-
isfactory or satisfactory. Average absolute Constant score
improved from 22.5 to 57.7 for the series. Average forward
flexion increased from 68 to 124 degrees; ER improved
from 6 to 9.3 degrees. There was a 25% complication rate
for the whole series, and 30% of revision cases sustained at
least one complication, as detailed below.
Instability
Prosthetic instability may be related to insufficient tension of
the deltoid and medial impingement, which is facilitated by
medialization of the humerus and, consequently, the slacken-
ing of the remaining rotator cuff muscles. Although prosthetic
instability is not a frequent problem, almost all series report
some cases, and published rates of dislocation are between 0
and 30%.19,24–43 Prosthetic instability seems to be less frequent
when the prosthesis has been inserted through a superolateral
approach, probably because the remaining subscapularis is not
detached and the posterior cuff can be repaired.
Another potential reason for prosthetic instability is the
frequent formation of a hematoma in the dead space under
113
the acromion after a reverse prosthesis. In one case, we
observed that the liquid of the hematoma was interposed
between the humeral cup and the glenosphere, contribut-
ing to the prosthetic dislocation. We have termed this the
“piston mechanism” and recommend at least 24 hours of
closed suction drainage after implanting a reverse pros-
thesis. Finally, prosthetic instability after a reverse pros-
thesis is more frequent in revision surgery because of the
frequent atrophy or destruction of the anterior deltoid and
subscapularis muscle; one should be even more prudent
plasties demonstrated 22 cases of postoperative prosthetic
dislocation (5.7% incidence). All RSAs were performed
glenospheres. Sixteen occurred in the first 3 months. Five
shoulders required an open reduction; six shoulders un-
derwent open reduction with the addition of a humeral
component spacer or more constrained polyethylene in-
sert. Of greater concern was the fact that 5 patients noted
recurrent instability of the prosthesis at last follow-up.25
An additional six cases presented with instability more
than 3 months after surgery. Among these six late disloca-
tions, none were revised, and five were still unstable at the
last follow-up. The management of instability varies with
the timing and the severity of the instability.
It is of paramount importance to obtain a taught deltoid or
conjoined tendon at the time of surgery and the subscapula-
ris should be repaired. In cases of fracture, fracture sequelae,
revision, or tumor resection when the normal anatomic land-
marks are lost, it is necessary to restore the humeral length;
the incidence of instability was approximately double that of
CTA when the reverse prosthesis was used for those indica-
tions (4 versus 9 to 10%). Preoperative planning in cases with-
out normal anatomical landmarks therefore should include a
ruled x-ray of the contralateral humerus.
On the other hand, overtensioning the deltoid may lead
to a fracture of the acromion, especially in patients with
severe osteoporosis and eroded acromial bone often seen
in cuff tear arthritis or in patients with an os acromial. In
our series, we observed two acromial fatigue fractures that
appeared as incidental findings on the 3-month postoper-
ative radiographs. Neither patient could recall any trauma,
both were completely asymptomatic, and there did not ap-
pear to be any detrimental effect on function. Overtension-
ing the deltoid muscle may also result in a slight, perma-
nent abduction of the resting arm. The patients may be at
risk for a neuropraxia of the axillary nerve in these cases.
Humerus
Previously, the humerus has not been cited as a signifi-
cant source of complications in reverse arthroplasty. Our
multicenter review, however, demonstrates that humeral
114 Rotator Cuff Deficiency of the Shoulder
problems are more frequent than glenoid problems, with a
20% incidence. This includes fractures, radiolucencies and
loosening, and disassembly of the humeral components.
The periprosthetic fracture rate is 10% (this includes in-
traoperative and postoperative fractures). The majority of
postoperative fractures can be managed with conservative
treatment if the stem is not loose, but there will be a de-
crease in Constant score despite healing. In instances of
fractures that result in instability of the humeral stem, it
is necessary to treat the fracture with revision to a long-
stemmed component.26
When the reverse arthroplasty was used for revision
surgery, there was a 25% incidence of humeral fracture in-
traoperatively. Intraoperative fractures usually occur during
removal of the primary prosthesis or cement, and can occur
even if a humerotomy is performed because of the quality
of the host bone. Cerclage wiring or longer stems or both are
usually sufficient to treat the fracture, and they, along with
allograft material, should be available in revision surgery.
Disassembly of the humerus is rare. The two sites of
potential disassembly are the neck/stem junction and the
spacer (rehausser)/neck junction. Right arms were affected
by unscrewing of the neck/stem due to the counter-clock-
wise rotational forces during routine use of the upper limb.
The addition of a Morse taper and a setscrew between the
rehausser (lateralized spacer) and neck (metaphysis) and a
bushing between the neck and stem in the Tornier (Tornier,
Inc., Eden Prairie, Minnesota) design seems to have pre-
vented this complication in the large review.
There is a 5% rate of aseptic loosening of the humeral
stem. In addition to compressive forces, rotational forces
are present on the humeral side. One should keep in mind
that the Grammont prosthesis is a semiconstrained pros-
thesis, which means that there are added constraints and
torsional forces. If those constraints are potentially de-
creased on the glenoid side, then they may be increased on
the humeral side.
Possible reasons for such loosening are (1) the humeral
stem of the Delta prosthesis is round and offers very little
resistance to rotational torque; (2) the proximal epiphy-
sis and metaphysis are often missing in fracture sequelae
and revision cases (as a result of tuberosity migration and
lysis), thus giving little or no proximal bony support to
the prosthetic stem; (3) the cortical bone of the humeral
diaphysis is often very thin, particularly in revision and
fracture sequelae cases; and (4) occult infection may be
present if the patient had previous surgery.
Our recommendations to minimize loosening are (1)
the use of a cemented humeral stem or a hybrid humeral
component (proximal hydroxyapatite coating with distal
cement fixation); (2) the use of long stems in revision and
fracture sequelae cases; and (3) the performance of a two-
stage operation if there is any suspicion of infection (com-
plete ablation of previous surgical material, implantation
of a spacer with antibiotics, followed by implantation of
the prosthesis 6 weeks later).
Tuberosity migration was related to the etiology in six
cases (i.e., revision, fracture sequelae, acute fracture). There
were 30 cases of radiolucencies around the tuberosity re-
gion, likely due to stress shielding or to localized osteoly-
sis in cases of notching. The tuberosity lucencies appeared
early (<2 years) and were stable over time; they did not
affect the Constant score. In cases of frank tuberosity loss,
both range of motion and constant score were affected.
Glenoid
To date, the rate of glenoid component loosening in the
reverse prosthesis has been reported to be between 2 to
5%.14,15,17,24,27–29 The most common complication that has his-
torically been reported for Grammont’s design is scapular
notching; in fact, its presence was so common that it is now
regarded as a normal radiographic finding inherent to this
design. In all series, scapular notching has been observed in
more than 50% of cases (74% in our series), usually at early
follow-up.3,11,19,22,29–33 We have performed fluoroscopic ex-
aminations which showed that scapular notching is a result
of impingement of the medial aspect of the polyethylene
humeral cup on the scapular neck inferiorly with the arm
in the adducted position, but rotation may also play a role
because the notch is often posterior, the direct consequence
of the absence of a prosthetic neck on the glenoid side and
the lowering of the humerus (Fig. 9–10).
Impingement of the humeral cup on the scapular neck
is a cause for concern because some notching is more ex-
tensive than that caused by mechanical factors alone. Im-
pingement may be the initiating factor, with further oste-
olysis being triggered by polyethylene particles.34 Favard
et al have noted a negative effect of radiographic scapular
notching on the clinical outcome: if the notch was large
(extending beyond the inferior screw), the Constant score
was significantly lower and the risk for loosening was high
in their series.32 To try to minimize this problem of scapu-
lar impingement and notching, our current surgical prac-
tice is to place the glenoid component low (Fig. 9–11A).21
In the recent multicenter review, a notch was identified
in 60% of the cases with 22% graded 1, 18% graded 2, 12%
graded 3, and 8% graded 4 (according to the Sirveaux clas-
sification, Fig. 9–11B). Notching was more frequent with
superior erosion of the glenoid (type E2 according to the
classification of Favard, p = 0.001) and an anterosuperior
approach versus deltopectoral approach (p = 0.0007). Fur-
thermore, the notch was highly correlated with follow-up
as both the prevalence and the grade of notching increased
with time (p < 0.0001). Notching, however, was not corre-
lated with clinical outcome. There was also an association
between notches graded 2 to 3 to 4 and radiolucent lines
around the screws of the baseplate (p < 0.0001). Complete
loosening of the glenoid component was linked to a pro-
gressive notch in one case of the series. Radiolucent lines
around the inferior screw were present in 9.1% without
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience 115

A B
Figure 9–10 The scapular notching is a direct consequence of both reaches the inferior screw. (B) Retrieved glenoid component demon-
the absence of a prosthetic neck of the glenosphere and the hori- strates polyethylene wear resulting from impingement between the
zontal orientation of the humeral cup. (A) Example of notch, which cup and the scapula and, possibly, the glenoid screws.
10.1055/978-1-58890-635-9c009_f010

any clinical relevance. Glenoid loosening, when the lucent
lines reached the central peg, occurred in only seven cases
(1.5%) as an early complication (average delay: 20 months).
Disassembly of the glenosphere was seen in four cases.35
Infection
Infection represents the most severe complication in any
arthroplasty. This is particularly true for the reverse total
shoulder design. The recent multicenter review yielded an
infection rate of 2% (8/363) for primary arthroplasty and 7%
(7/94) for revisions. There were two infections categorized
as acute (<2 months), five as subacute (2 to 12 months), and
eight as chronic infections (>12 months). The most com-
mon pathogen was P. acnes in six cases (40%). At a mean
follow-up of 34 ± 19 months, there were 12 remissions
(80%) and three recurrent infections. One acute infection
was successfully treated with débridement and antibiotic
therapy.36 Ten patients required resection arthroplasty.
One patient received a two-stage revision. Débridement of
subacute infection resulted in recurrence. Overall, the 10
resections were in remission with 7 patients disappointed
and 3 satisfied, a mean Constant score of 31 ± 8 points, and
a mean active anterior elevation of 53 ± 15 degrees. The
two-stage exchange was in remission, but remained disap-

Inferior + Tilt = NO Notch Neutral = Notch

A
10.1055/978-1-58890-635-9c009_f011

Figure 9–11 Radiographs (A) comparing notch-

ing when the base plate is positioned at the level
of the inferior margin of the glenoid with 10 to
20 degrees of tilt (left) to the possible notching
when the base plate is centered on the glenoid
B without any tilt; (B) the Sirveaux classification.
116 Rotator Cuff Deficiency of the Shoulder
pointed with a Constant score of 27 points and an active
anterior elevation of 90 degrees.37
Conclusion
Shoulder arthroplasty in the arthritic, rotator cuff-defi-
cient shoulder is a difficult surgical problem. The concept
of the reverse prosthesis developed by Paul Grammont is
another step forward in the field of shoulder arthroplasty
thanks to two major innovations: (1) on the glenoid side,
a large metal hemisphere, and (2), on the humeral side,
a small polyethylene cup (covering less than half of the
hemisphere), oriented with a nonanatomic inclination of
155 degrees. This design provides a fixed and medialized
center of rotation, minimizing torque on the glenoid com-
ponent and improving the power of the anterior and pos-
terior deltoid for abduction. Furthermore, the humerus is
lowered relative to the acromion, restoring (and probably
increasing) tension of the deltoid fibers. This retensioning
of the deltoid, together with the improved lever arm for
abduction of the anterior and posterior deltoid, allows the
deltoid to compensate for the absent rotator cuff muscles
(Fig. 9–12).38
Our clinical experience is similar to that in the litera-
ture: the reverse prosthesis restores active elevation to
an average of 123 degrees (mean improvement of 41 de-
grees) and adjusted Constant score to 78% (mean increase
of 43) in patients with a cuff-deficient shoulder. However,
ER often remains limited, especially in those patients
with an absent or fat-infiltrated teres minor, manifest as
a hornblower’s sign.22 The same is true for IR, which is
not improved after a reverse prosthesis. Failure to restore
sufficient tension in the deltoid may result in prosthetic
instability. The design does appear to protect against early
loosening of the glenoid component, but impingement of
Figure 9–12 Radiographs and clinical photograph of a man with a hemiarthroplasty on the right and a reverse total shoulder arthroplasty on the left;
both were indicated for cuff tear arthropathy, but the right shoulder arthroplasty was performed prior to release of the Grammont prosthesis.
10.1055/978-1-58890-635-9c009_f012
the humeral cup on the scapular neck is a cause for con-
cern because of bone lysis and polyethylene wear. Fixation
of the humerus may be more of a concern than fixation of
the glenoid, especially in revision and fracture sequelae
cases, where the proximal epiphysis and metaphysis are
often missing.
We have observed a trend toward better results when
this prosthesis is used for its primary indication: CTA. Be-
cause of its unique ability to create a new biomechanical en-
vironment, it is now used for a wide variety of indications,
from acute fractures and fracture sequelae to chronic insta-
bility and revision arthroplasty.27,31,39,40 We feel that Gram-
mont’s design is not a panacea and recommend prudence
when extending the indications. What follows are the clini-
cal guidelines that we use for the management of the cuff-
deficient shoulder and the use of the reverse prosthesis.
In our institution, all patients with pain or functional
deficit of the shoulder related to a massive and irrepara-
ble CT undergo a detailed clinical and radiological exami-
nation of the shoulder. This includes an AP radiograph in
neutral rotation to measure the acromiohumeral distance
and to assess shoulder arthropathy according to Hamada
and Fukuda.41 We also include a computed tomography-
(CT-) arthrogram or magnetic resonance imaging (MRI) to
assess the fatty infiltration of the cuff muscles, the glenoid
bone stock and version, and the congruity of the shoulder
joint and the position of the humeral head. On physical
exam, it may be necessary to infiltrate the glenohumeral
joint with 10 to 20 cc of lidocaine to eliminate pain as the
source of dysfunction. Furthermore, the descente test, ask-
ing the patient to maintain >120 degrees of forward flexion
(after the arm is passively positioned by the examiner and
the support is removed), can rule out pain as the source of
pseudoparalysis.
Following this assessment, patients are divided into six
groups (Table 9–2):
 9 Rationale and Biomechanics of the Reversed Shoulder Prosthesis: The French Experience
Table 9–2 Groups and Treatment for Cuff Tear Arthropathy
Cuff deficient shoulder
Functional shoulder
PS PLE +ER
TLB/TO TLB/TO PPS
TLB+RSA
Abbreviations: PS, pseudoparalyzed; PLE, painful loss of elevation; TLB/TO, tenodesis of the long head of biceps/
tenotomy of biceps; ER, external rotation; PSS, painful stiff shoulder; ILER, isolated loss of external rotation; CLEER,
combined loss of elevation and external rotation; RSA, reverse shoulder arthroplasty.
Group 1 – Painful Shoulder Patients only complain of
pain; they have normal or near normal active elevation
and ER. They may have lost the last 20 or 30 degrees
of passive elevation because of entrapment of a hyper-
trophic biceps tendon (hourglass biceps).42 The acromio-
humeral distance (AHD) may be normal, but is usually
decreased (<7 mm) and there is minimal to no osteoar-
thritis (OA) or necrosis (Hamada and Fukuda stages 1, 2,
or 3). The infraspinatus, if present, has fatty infiltration
(Goutallier stage 3 or 4), but the teres minor is normal
or hypertrophic. These patients are best treated with an
arthroscopic biceps tenotomy or tenodesis. A partial cuff
repair may be associated. An acromioplasty is not rec-
ommended, but can be performed if the AHD is >7 mm.
Group 2 – Painful Loss of Elevation Patients complain
of both pain and loss of active elevation; they have nor-
mal or near normal active ER. Passive elevation is usu-
ally normal, and the patients can maintain elevation
above 90 degrees if the arm is assisted to this position
(the descent test). The loss of active elevation is linked
to the severity of the pain and can be improved with a
lidocaine injection. Again, the AHD is usually decreased
(<7 mm) but there is little or no OA or necrosis (Hamada
and Fukuda stages 1, 2, or 3). The infraspinatus is fatty
infiltrated (Goutallier stage 3 or 4) or torn, but the teres
minor is normal or hypertrophic. These patients are
also best treated with an arthroscopic biceps tenotomy
or tenodesis. A partial cuff repair may be associated.
An acromioplasty is not recommended, but can be per-
formed if the AHD is >7 mm.
Group 3 – Pseudoparalyzed Shoulder Patients com-
plain of loss of active elevation, but maintain normal
117
Non-functional shoulder
-ER
PSS ILER CLEER
TLB+RSA TLD TLB+RSA+
+L’Episcopo L’Episcopo
passive elevation; they have normal or near normal ac-
tive ER. There is anterosuperior escape of the humeral
head with attempted elevation of the arm (shrug). The
acromiohumeral is usually decreased (<7 mm). There
may be OA or necrosis (Hamada and Fukuda stage 3
or 4); however, some patients have a pseudoparalyzed
shoulder and no OA (Hamada stage 1, 2, 3). The infra-
spinatus, if present, is fatty infiltrated (Goutallier stage
3 or 4), but the teres minor is normal or hypertrophic.
The subscapularis is often torn or fatty infiltrated, and
the long head of the biceps is often dislocated. These
patients are best treated with a reverse prosthesis and
a biceps tenotomy or tenodesis.
Group 4 – Painful Stiff Shoulder Patients complain of
painful loss of active and passive elevation; they also
have limited active and passive ER (internal contrac-
ture). The AHD is usually decreased (<7 mm). There is
OA or necrosis (Hamada and Fukuda stage 3 or 4). The
infraspinatus may be fatty infiltrated or torn. These pa-
tients are best treated with a reverse prosthesis and a
biceps tenotomy or tenodesis.
Group 5 – Isolated Loss of ER Patients complain of
isolated loss of active ER, but active elevation is nor-
mal or near normal. Pain is usually present, but may
resolve if there is a spontaneous rupture of the biceps.
The impairment of active ER is demonstrated by the
presence of the hornblower sign, the drop sign, and
the ER lag sign (ERLS).22,43 The acromiohumeral is usu-
ally decreased (<7 mm), but there is little to no OA or
necrosis (Hamada stage 1, 2, 3). Both the infraspinatus
and teres minor are torn or completely fatty infiltrated
(Goutallier stage 3 or 4). The subscapularis is normal
118 Rotator Cuff Deficiency of the Shoulder
or partially torn. These patients are best treated with a
latissimus dorsi and teres major transfer and a biceps
tenotomy or tenodesis.
Group 6 – Combined Loss of Elevation and External Ro-
tation Patients complain of combined loss of active
elevation and active ER. They have normal passive el-
evation and rotation. There is anterosuperior escape of
the humeral head with attempted elevation of the arm
(shrug). The acromiohumeral is usually decreased (<7
mm). There may be OA or necrosis (Hamada and Fukuda
stage 3 or 4), but some patients have a combined loss of
elevation and ER without OA (Hamada stage 1, 2, 3). The
infraspinatus and teres minor are both completely fatty
infiltrated (Goutallier stage 3 or 4). The subscapularis is
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 10 Treating the Rotator Cuff–Deficient
Shoulder: The Lyon, France, Experience
Gilles Walch and Bryan Wall
In 1983, Neer1 first described cuff tear arthropathy (CTA)
as glenohumeral arthritis in the presence of a massive ro-
tator 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 car-
tilage nutrition, which progresses to glenohumeral arthri-
tis. 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 acetabuli-
zation 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 intro-
duced 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 ero-
sion, or acetabulization, of the acromion occurred in grade
3. Grade 4 has since been subdivided into grade 4a, gleno-
humeral joint changes without acetabulization, and grade
4b, glenohumeral joint changes with acetabulization.3 The
onset of humeral head collapse is indicated by grade 5.
cient
ence
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 el-
bow 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 fatiga-
ble 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 dis-
ability and the functional use of the extremity is negligible.
14530_C10.indd 120
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 modali-
ties can consist of antiinflammatory medications, corti-
costeroid 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 congru-
ent 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 compli-
cations were reported. The procedure is contraindicated in the
presence of glenohumeral arthritis.
Rockwood and colleagues6,7 have reported on the re-
sults 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 activi-
ties 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 pa-
tients.8–12 Gerber et al9 noted good results in patients un-
dergoing latissimus dorsi transfers so long as the subscapu-
laris remained intact. In a similar report, Jost et al10 reported
good results with pectoralis major transfer for subscapularis
1/31/08 11:04:21 AM
 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience
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 effective-
ness 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 in-
volvement and relatively poor functional outcomes has led
some to abandon this technique. The one place that ar-
throdesis 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 loosen-
ing.14 The “rocking horse glenoid,” as originally described
by Franklin and Matsen, leads to excessive force on the su-
perior 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 res-
toration 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 bet-
ter 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 im-
proved 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 de-
cisions must be made and implemented rapidly to pre-
vent 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
14530_C10.indd 121
121
disability until the traumatic event. In such a situation, an
anteroposterior (AP) radiograph of the shoulder in neu-
tral rotation is used to determine the acromiohumeral dis-
tance. 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 postop-
erative 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 per-
formed. If disability is an issue and the patient agrees to
participate in rehabilitation, cuff repair is considered.
Alternately, a computed tomography (CT) scan or mag-
netic 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 de-
notes 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 func-
tional demands of the patient must be assessed. The pa-
tient 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 de-
mand. Normally, this is the older patient with significant
muscular wasting about the shoulder and decreased acro-
miohumeral distance. If the pain is tolerable, skillful ne-
glect 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 liv-
ing. 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
1/31/08 11:04:21 AM
 122 Rotator Cuff Deficiency of the Shoulder
after biceps release and do very well. Those who have poor
active motion prior to biceps release will show little clini-
cally significant improvement.
The older patient, who complains only of loss of mo-
tion, 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 mecha-
nism. 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 re-
serve muscle transfer for those patients who are younger
than 70 years old. Elderly patients are treated nonopera-
tively if they are able to cope with the functional limita-
tions present. If use of the hand at or above the level of the
head is required, we have used reverse shoulder arthro-
plasty with good results.
When the RC tear affects the posterior cuff (infraspina-
tus and teres minor), patients will present with a loss of
ER. The physical examination will typically reveal a posi-
tive ER lag sign or dropping sign if the infraspinatus is af-
fected. 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, re-
pair 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 noth-
ing to restore ER.
When glenohumeral arthritis is associated with RC defi-
ciency, 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 symp-
toms. 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 ex-
tremely encouraging, and we now consider this the treat-
ment of choice for the cuff-deficient shoulder with associ-
ated 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 encour-
14530_C10.indd 122
aged 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 gleno-
humeral 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 ar-
throdesis is a viable treatment. This is one of the rare indica-
tions 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 dif-
ficult 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 typi-
cally employ an operative table that has removable supero-
lateral 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 posi-
tioned 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 por-
tal 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 re-
tract spontaneously out of the glenohumeral joint. In cases
where the tendon does not retract, the remaining intraar-
ticular stump is resected.
Synovectomy and bursectomy are performed only to
the extent required to provide proper visualization. Acro-
mioplasty is not typically performed.
1/31/08 11:04:22 AM
 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience
Postoperative Care
The arm is placed in a simple sling. Passive ROM is allowed
beginning on postoperative day one. Active motion is al-
lowed as soon as patient comfort permits. After suture re-
moval, 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 af-
fected shoulder just lateral to the edge of the table. This posi-
tion should allow hyperextension of the humerus and disloca-
tion 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 pro-
cedure, 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 au-
thors who routinely use the superior approach have not
reported significant problems with deltoid function or de-
hiscence postoperatively, it may be an unnecessary risk
when adequate exposure could be obtained through al-
ternative means. Up to 20% of these patients have signifi-
cant preoperative acromial pathology.23 In these patients,
it would seem counterintuitive to jeopardize the deltoid
mechanism further.
The deltopectoral approach is also the standard “work-
horse” 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 supe-
rior approach, but they, along with a partial release of the
pectoralis major, are thought to help increase postopera-
tive 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 scapu-
14530_C10.indd 123
123
lar notching have led many authors to recommend slightly
inferior placement of the glenoid component with an infe-
rior 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 mus-
cle is left intact anteriorly.
The deltopectoral incision is begun at the coracoid proc-
ess and extended distally and laterally for 10 to 15 cm, to-
ward 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 ad-
duction 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 fas-
cia from the lateral portion of the conjoined tendon and
coracobrachialis muscle allows a small blunt retractor
to be placed underneath to expose the underlying sub-
scapularis muscle. The axillary nerve is identified by plac-
ing the arm in adduction, slight forward flexion and neu-
tral 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 surround-
ing it. In these cases, a larger blunt hand-held retractor
(such as a Richardson retractor) is temporarily placed un-
derneath 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 posi-
tion, 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
1/31/08 11:04:22 AM
 124 Rotator Cuff Deficiency of the Shoulder
the subscapularis tendon. Dissecting scissors are slid along
the superior tendon edge, releasing any subcoracoid adhe-
sions. The deep surface of the muscle is then bluntly dis-
sected free from the underlying capsule and middle gleno-
humeral 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. Ly-
ing 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 subscapu-
laris fossa and protected with a small sponge. If tendon ex-
cursion 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 subscapu-
laris fossa, and a Kölbel retractor is placed in the fossa to
retract the medial structures including the subscapularis
muscle, axillary nerve, and conjoined tendon.
At this point, attention is turned to the anterior glenoid,
where any remaining labral tissue and subcoracoid bursa
is removed. Electrocautery is then used to release the infe-
rior glenoid capsular attachments, past the 6-o’clock posi-
tion, around to the 7-o’clock position in the right shoulder
or the 5-o’clock position in the left shoulder. The release
is done directly at the level of the bony attachment and
extends medial to the glenoid rim for 2 to 3 mm. This may
result in a small release of the triceps insertion, but this is
of no functional consequence. So long as the dissection is
performed at the bony insertion, there is no danger to the
axillary nerve, and in our experience, we have never in-
jured it using this technique. This step is absolutely critical
in allowing for proper posterior retraction of the humeral
head, and thereby for proper exposure and preparation of
the glenoid.
Humeral Preparation
The humeral head retractor is removed and the humeral
head is dislocated anteriorly. A sharp Homan retractor can
be used to retract any remaining cuff tendon. If the biceps
tendon is still intact, it is cut at the level of the glenoid
insertion. The intramedullary humeral head cutting guide
is then inserted using a starting point determined from
the preoperative radiographs. As there is frequently os-
teonecrosis and deformity of the head, this point can differ
from patient to patient, so it is best to simply choose the
starting point that gives the most direct in-line access to
the medullary canal.
There are two aspects of the cut that can be determined
by guide placement; the height and the retroversion. We
prefer a minimal head cut to preserve as much humeral
length as possible, allowing the prosthesis to be placed in
maximal tension. The appropriate retroversion of the cut is
14530_C10.indd 124
still a matter of considerable debate, and our current strat-
egy is to place the component such that the metaphyseal
portion of the prosthesis is contained within the bone of
the proximal humerus to the maximum extent possible.
This is done without specific regard for the retroversion of
the component. In this way, we tend to use the cutting jig
as a retroversion gauge rather than a retroversion guide.
Frequently, this technique yields retroversion of between
0 and 20 degrees.
Epiphyseal reaming is done using a hemispherical power
reamer. The back edge of the reamer is held parallel to the
plane of the humeral cut and advanced so that this rela-
tionship is maintained. Under normal conditions without
significant proximal humeral bone loss, the epiphysis is
reamed until the flat edge of the reamer is flush with the
surrounding bone.
Diaphyseal reaming is typically done with hand reamers,
and trial components are used to ensure proper humeral
preparation and fit. The trial components are then removed
to allow proper glenoid exposure and preparation.
Glenoid Preparation
Glenoid preparation begins by reinserting a humeral head
retractor into the joint, and retracting the head posteriorly.
The retractor will usually create a fracture of the thin an-
terior portion of the humeral metaphysis, what we have
termed a controlled fracture (Fig. 10–1). The fracture has
no effect on prosthetic implantation or fixation. This step
is only possible if the humeral trial has been removed, be-
cause the trial will block efforts to retract the head ad-
equately. An additional Homan retractor is placed superi-
orly, over the top edge of the glenoid.
The starting point for the peg-hole drill should be sev-
eral millimeters inferior to the center of the glenoid. Typi-
cally, the component is placed as far inferiorly as possible
without jeopardizing implant fixation, with an inferior tilt
of ~10 degrees.
Glenoid reaming is then performed using the appropri-
ately-sized reamers. Adequate posterior retraction of the
humeral head is critical at this point because the reamer
is the largest instrument used in glenoid preparation. A
selection of several different types of humeral head retrac-
tors is helpful if exposure proves difficult.
In osteoporotic bone, there is a tendency for the hu-
meral head to push the reamer anteriorly, causing the cen-
tral peg of the reamer to cut out of the pilot hole anteriorly.
This same effect can also result in excessive anteversion of
the glenoid component. In addition, the quality of glenoid
bone in these older patients is frequently poor, and care
must be taken to not fracture the glenoid while reaming.
If the reamer is compressed tightly against the bone first
and then started, a large amount of torque is created. If the
reamer is started and then gradually pressed against the
glenoid face, this torque is lessened, reducing the risk of
glenoid fracture.
1/31/08 11:04:22 AM
 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience
Figure 10–1 Photo showing the controlled fracture of the anterior
humeral metaphysis with humeral retractor in place.
10.1055/978-1-58890-635-9c010_f001
Glenoid Implantation
The glenoid baseplate is impacted using an insertion device
and fixed in place with screws. Several implants feature
fixed or multidirectional locking screws. When possible,
two normal compression screws are first placed anteriorly
and posteriorly, firmly securing the plate to the underlying
glenoid bone. These are followed by locking screws placed
superiorly and inferiorly. All screws are placed bicortically
when possible.
Care must be taken to be sure that no soft tissue inter-
feres with seating of the glenosphere. Additional posterior
or inferior retractors are added when necessary. Most sys-
tems include a Morse-taper locking mechanism, which is
supplemented with a countersunk safety screw.
Humeral Implantation
Once the glenosphere is in place, the humeral head retrac-
tor is removed and the head is dislocated. If there was any
remaining subscapularis, three transosseous nonabsorbable
sutures are passed to reattach the subscapularis later. The
humeral prosthesis is then placed using the retroversion
guide to replicate the version of the original humeral cut.
Although trial components are available to test implant
stability, they are typically not used. Because the prosthesis
14530_C10.indd 125
125
must be placed under significant tension, it is frequently
difficult to dislocate once reduced. This can make the re-
moval of trial liners extremely challenging. Instead, the de-
sired thickness of the polyethylene insert is impacted into
the metaphyseal component. The reduction is then per-
formed by pulling in-line traction on the arm and pushing
posteriorly on the humerus. If this is not possible due to
excessive deltoid tension, changing the position of the arm
is sometimes helpful. As the humeral component lies an-
terior to the glenoid, placing of the arm in IR will decrease
the profile of the humeral cup that the glenoid must clear
to reduce properly. In addition, we have noted that slight
forward flexion while pulling traction will sometimes
decrease deltoid tension and allow reduction. However,
care must be taken to avoid trying to lever the humerus
in place, which could result in a periprosthetic fracture. If
the reduction is still impossible, a wide, flat instrument,
such as an osteotome, can be used as a skid to reduce the
prosthesis. The instrument is placed between the glenoid
and the humeral cup. The humeral component is then slid
posteriorly, along the flat side of the instrument. Once the
cup has cleared the glenoid, the instrument is removed al-
lowing the prosthesis to reduce.
After the implant is reduced, the shoulder is taken
through a ROM to ensure that there is no significant im-
pingement, and then stability is checked by pulling lon-
gitudinal traction. If there is any noticeable pistoning, the
polyethylene liner is changed to a thicker size. If the thickest
linear is already in place, a modular spacer is placed and the
shoulder is reduced and retested. When using the deltopec-
toral approach, significant pistoning is not acceptable.
Providing that it does not unduly limit ER, the sub-
scapularis is closed using the transosseous sutures. The
wound is closed over a drain with absorbable deep and
skin sutures.
Postoperative Rehabilitation
Postoperative immobilization consists of a simple sling in
IR for one month. Passive ROM and pendulum exercises
are begun immediately. After one month, the sling is dis-
carded, and the patient is allowed activity as tolerated. Hy-
drotherapy is started as soon as possible (usually 2 weeks
postoperatively).
Treatment Results
Biceps Tenotomy
Spontaneous rupture of the long head of the biceps tendon
occurs frequently as part of the natural history of RC tears.25
This event is frequently associated with a decrease in pain.
Spontaneous ruptures are typically treated nonoperatively
with good results.25–61 Walch et al26 first proposed isolated
1/31/08 11:04:22 AM
 126 Rotator Cuff Deficiency of the Shoulder
biceps tenotomy for pain relief in massive cuff tears. Sub-
sequently, several investigators have also reported on this
technique.27–65 Scheilbel has reported good results in pa-
tients with minimal arthritic changes when the tenotomy
is combined with an arthroscopic tuberoplasty.28 Biceps
tenotomy has been used for the treatment of biceps tendo-
nitis and instability in the absence of cuff pathology with
good results.29
Biceps tenotomy has been criticized because of several
reports indicating that the tendon of the long head func-
tions as a humeral head depressor.30–71 It has also been
suggested that biceps tenotomy can result in increased sub-
acromial impingement.25,31 Rupture of the long head of the
biceps has also been associated with a 20% loss of forearm
supination strength and up to a 20% loss of elbow flexion
strength.32,33 Cosmetic deformity of the biceps muscle is
of concern; although some authors have documented its
presence, it does not seem to have a great effect on patient
satisfaction.3,34 Distal cramping is frequently seen in spon-
taneous ruptures or in younger, active, muscular patients;
however, this is infrequently noted in tenotomy patients
older than 60 years.27
Our experience with this technique began in 1988, when
the senior author began routinely using this procedure for
patients with an irreparable RC with associated upward mi-
gration of the humeral head and severe night pain or who
were unwilling to undergo the rehabilitation associated with
cuff repair. In 2005, the results of 307 patients treated with
biceps tenotomy were published with a mean follow-up of
almost 5 years.3 The average preoperative Constant score
improved 19.2 points from 48.4 to 67.6. Mean active ante-
rior elevation showed a small, but significant improvement
from 153.4 to 164.6 degrees, as most patients had already
regained nearly normal motion preoperatively. Eighty-six
percent of patients rated their subjective results as good or
excellent. Radiographic follow-up did reveal that the mean
acromiohumeral distance decreased from 6.6 mm preop-
eratively to 5.3 mm postoperatively. Furthermore, 24.8%
of patients progressed at least one grade on the Hamada
classification. Increasing duration of follow-up resulted in
progressive narrowing of the acromiohumeral interval and
progression of Hamada grade.3
Acromioplasty was performed in 110 of these cases. Pa-
tients with an acromiohumeral distance of 6 mm or less
showed slight decreases in both Constant score and active
anterior elevation. When the acromiohumeral distance
was greater than 6 mm, results were more favorable. The
acromioplasty had no effect on progression of arthritis.
Reverse Total Shoulder Arthroplasty
Functional Results
Because the reverse prosthesis has only been commer-
cially available since 1991, and saw limited usage until
14530_C10.indd 126
recently, the data reported in the current scientific liter-
ature is mostly short-term follow-up on relatively small
numbers of patients. However, these early reports seem
to be very promising. In one of the larger series to date,
Sirveaux and colleagues35 reported on 80 patients with
CTA, in a multicenter series at minimum 2-year follow-
up. Postoperative Constant scores showed an average in-
crease of 43 points, and active elevation improved 65 to
138 degrees at an average of 44 months postoperatively.
Although they noted a 15% complication rate with a 5% rate
of revision, 96% complained of little or no residual pain.
An intact teres minor was shown to be associated with a
better result. DeWilde et al36 had encouraging results in a
small series of 5 patients undergoing revision of an ana-
tomical prosthesis, and again in those patients requiring
reconstruction related to tumor resection.36–45 Rittmeister
and Kerschbaumer37 reported a high complication rate in
patients with rheumatoid arthritis, particularly related to
a superior approach using an acromial osteotomy. Delloye
et al38 reported on five cases with poor results, having sig-
nificant problems with loosening, scapular notching, and
poor overall outcome. Consequently, this investigator rec-
ommended a design change to the prosthesis to address
these concerns. In a longer termed investigation, Valenti et
al39 has reported good results in patients with CTA at more
than 5-years follow-up with no evidence of progressive
glenoid loosening or deterioration of results over time.
Our experience consists of 240 patients who have been
treated with Grammont reverse shoulder arthroplasty for
a variety of indications, including CTA, massive cuff tear
without glenohumeral arthritis, primary osteoarthritis,
posttraumatic arthritis, acute proximal humeral fracture,
tumor resection, rheumatoid arthritis, and revision of ana-
tomical total shoulder arthroplasty or hemiarthroplasty.40
Considering all patients, the average Constant score im-
proved from 22.7 to 59.8. All aspect of the Constant score
improved. The average score for pain improved from 3.5 to
12.3. The average score for activity improved from 5.6 to 15.3.
The average score for mobility improved from 12.2 to 24.9.
The average score for strength improved from 1.5 to 7.0. ROM
showed improvement with respect to active elevation and IR;
however, no statistically significant improvement was seen
for ER. Active elevation improved from a mean of 86 to 137
degrees. Active ER with the arm at the side decreased slightly
from a mean of 8 to 6 degrees. Mean IR improved by only one
level, from L5 to L4. Ninety-three percent (173) of the 186
patients reported being very satisfied or satisfied with the
overall results of their surgeries.
Results did not deteriorate with time. Of the 36 patients
with minimum 5-year follow-up included in this patient
group, the mean constant score was 59.5, and the mean
active elevation was 133.9 degrees. Mean active ER was 6.5
degrees. Mean IR was L3. All 36 patients reported that they
were very satisfied or satisfied with their overall results.
When the patients were divided according to reason for
reverse shoulder arthroplasty, the best overall results were
1/31/08 11:04:23 AM
 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience
seen in those patients with primary CTA or massive cuff
tears without arthritis. Posttraumatic arthritis and revision
cases were associated with worse results with respect to
both Constant score and ROM.40 Werner reported a similar
relationship, with patients having a history of prior shoul-
der surgery associated with significantly lower Constant
scores and pain relief.41
Radiological Results
The primary mode of failure of the first generation con-
strained and semiconstrained shoulder prosthesis was
loosening of the glenoid component. Grammont’s design
modifications to this concept have greatly reduced the in-
cidence of this complication in the short term. Sirveaux et
al35 reported the largest series to specifically address this
issue and noted an overall 6.25% rate of glenoid loosening.
Although this rate is certainly not trivial, this represents a
significant improvement over previous implants.
Glenoid loosening was seen twice in our patient group
(0.8%). Both cases were though to be secondary to surgical
error. In the first case, the superior approach was used, and
the glenoid was placed with a significant superior tilt (Fig.
10–2). The result was superior cutout and loosening of the
implant. A second case occurred in a patient with severe
superior glenoid wear. A structural iliac crest graft was used
to reconstruct the glenoid bone stock; however, the central
peg of the glenoid baseplate was not anchored in the na-
tive glenoid bone. This patient developed rapid loosening
of the graft and implant (Fig. 10–3). Both patients were
converted to hemiarthroplasties and reported good over-
all pain relief, but no functional improvement. Because of
these cases, we are now careful to always place the glenoid
A B
Figure 10–2 (A) Immediate postoperative film with severe superior tilt of the glenosphere. (B) Progressive superior cutout of the component.
10.1055/978-1-58890-635-9c010_f002
14530_C10.indd 127
127
component with a slight inferior tilt, and in revision cases,
we will use a component with an elongated central peg to
anchor the component in the native glenoid.
Patients with significant upward migration of the hu-
meral head will frequently have some degree of erosion or
fragmentation of the acromion preoperatively (Fig. 10–4).42
This is of obvious concern as the continued function of the
deltoid is paramount to the proper function of the reverse
prosthesis. Acromial problems are worrisome for those
surgeons who use a superior approach, especially if sup-
plemented with an acromial osteotomy for improved expo-
sure. Indeed, Rittmeister and Kerschbaumer37 reported an
exceedingly high rate of nonunion in rheumatoid arthritis
patients in which this technique was used. However, de-
spite the theoretical problems that severe fragmentation
of the acromion could create, very little has been written
on this issue. Werner et al41 reported four cases of acro-
mial or scapular spine fracture in a series of 58 cases, two
of which required reoperation. Frankle and colleagues43
also reported one scapular spine fracture and two acro-
mial fractures in a series of 60 cases. This problem has been
seen numerous times in our series.23 Preoperative acro-
mial pathology was noted in 21 cases (8.8%). Five of these
cases were classified as Hamada grade 3. Eleven cases were
grade 4b, and three cases were grade 5. An additional two
cases underwent reverse shoulder arthroplasty for the re-
vision of a failed hemiarthroplasty. No specific treatment
was used to address the acromial pathology. At last follow-
up, these patients averaged 142.7 degrees of active eleva-
tion with a Constant score of 64.9. These results were very
similar to results reported for patients without acromial
pathology. Postoperative radiographs displayed varying
degrees of inferior displacement of the lateral acromion
1/31/08 11:04:23 AM
 128 Rotator Cuff Deficiency of the Shoulder

A B
Figure 10–3 (A) Iliac crest graft was used to restore glenoid bone stock. Note that the central peg on the glenosphere is not anchored in the na-
tive glenoid bone. (B) Screw fracture with superior cutout of the component. 10.1055/978-1-58890-635-9c010_f003

in 87.5% of cases, which did not appear to have any effect
on overall function.23 We have seen two cases of postop-
erative stress fracture of the scapular spine, both of which
resulted in poor overall patient function and satisfaction.
Although we do not routinely do anything for preoperative
acromial pathology, we now recommend surgical stabili-
zation of postoperative scapular spine fractures.
Most other studies have shown little or no evidence of
loosening of either component; however, the incidence of
scapular notching has been a cause for concern. Reported
rates of notching have varied considerably in the literature
from 19 to 63%.35,36,39,44–46 Difficulty in obtaining standard
radiographic views may explain some of this discrepancy.
Because of the radio-opaque nature of the glenoid and the
tendency of the notch to form directly behind the glenoid
baseplate, small deviations in rotation can obscure the in-
ferior scapular neck. The metallic portion of the humeral
component may also obscure this area. Another problem
with comparing these studies is the absence of a reliable
definition and classification system of notching. The sys-

A B
Figure 10–4 (A) Preoperative radiograph showing fragmentation of the anterolateral acromion. (B) Preoperative computed tomography scan
confirming anterolateral fragmentation. 10.1055/978-1-58890-635-9c010_f004

14530_C10.indd 128 1/31/08 11:04:25 AM

 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience
Figure 10–5 Sirveaux classification of inferior notching. (From
Sirveaux F, Favard L, Oudet D, Huguet D, Walch G, Molé D. Gram-
mont inverted total shoulder arthroplasty in the treatment of gleno-
humeral osteoarthritis with massive rupture of the cuff. J Bone Joint
Surg Br 2004;86-B: 391. Reprinted by permission.)
10.1055/978-1-58890-635-9c010_f005
tem proposed by Sirveaux (Fig. 10–5) is applicable only
to those patients with inferior notching; it does not ac-
count for patients with posterior notching seen only on
the axillary view (Fig. 10–6).35 A similar system proposed
by Nerot has the same limitations.39 Both schemes rely
on radio-opaque metallic radiographic markers to stratify
notch severity, which means that considerable difficulty
can be encountered as one approaches the central peg and
superimposed screws. This makes the distinction between
more severe grades of notching (grades 3 and 4) difficult
or impossible.
Several theories for the origin of scapular notching have
been advanced. The most obvious reason for this phenom-
14530_C10.indd 129
129
Figure 10–6 Notching of the scapula neck can be seen extending
behind the posterior half of the glenoid baseplate.
10.1055/978-1-58890-635-9c010_f006
enon is the design of the Grammont prosthesis itself. By
medializing the center of rotation, the humerus and hu-
meral component are medialized, bringing them into close
proximity with the inferolateral border of the scapula. A
mechanical impingement can occur, which may result in
bone loss from the inferior glenoid neck (Fig. 10–7). In
support of this theory, severe wear of the medial portion
of the polyethylene liner (Fig. 10–8) or humeral metaphy-
sis has been seen at revision in some patients.38 However,
the size of the scapular notch is often larger than can be
explained by pure mechanical means, and the superior
border of the notch frequently extends above the inferior
locking screw, or even the central peg. It has been sug-
gested that an inflammatory reaction generated by poly-
ethylene particles or other stimuli may be responsible for
this additional resorption.39
Considerable debate surrounds the clinical significance
of scapular notching. Although many authors have ex-
pressed concern that severe notching may destabilize the
baseplate, to date, there is only one case in the scientific
10.1055/978-1-58890-635-9c010_f007
Figure 10–7 Inferior notching seen on modified
axillary view. Severe notching can be seen and
mechanical impingement between the humeral
component and glenoid component has resulted in
notching of an inferior glenoid screw.
1/31/08 11:04:26 AM
 130 Rotator Cuff Deficiency of the Shoulder
A B
Figure 10–8 (A,B) Metaphyseal portion and humeral cup of a humeral implant retrieved at time of revision surgery. Severe wear of the infero-
medial portion of the polyethylene liner is noted. 10.1055/978-1-58890-635-9c010_f008
literature that is directly attributed to notching.38 Sirveaux
et al35 noted that severe notching (grades 3 or 4) corre-
sponded with poor Constant score at minimum 2-year
follow-up. However, most series’ studies have not com-
mented on the effect of notching on short-term clinical
results. In addition, it remains to be seen if this problem
will be a progressive one, with patients developing more
severe notching with time.
In our current series, we noted an overall notching
rate of 50.7% at an average follow-up of 41.7 months.40 Of
those patients who demonstrated evidence of notching, 27
(43.5%) patients had grade 1 notching, 21 (33.9%) patients
had grade 2 notching, 5 (8.1%) patients had grade 3 notch-
ing, and 9 (14.5%) patients had grade 4 notching according
to the Sirveaux classification.35 An additional 15 patients
developed notching that could only be seen on an axillary
or modified axillary view and could not be classified us-
ing this scheme. Postoperative function, as measured by
Constant score or ROM, was not affected by the presence or
severity of the notching. In no case did notching progress
to glenoid loosening.
Several recommendations have been made to avoid
notching problems. Delloye and colleagues38 have sug-
gested that the prosthesis must be redesigned, noting that
the use of a hemispherical glenoid will, by necessity, lead
to impingement. VanHove and Beugnies47 have stated that
the use of a lateralized humeral cup of ≥6 mm will increase
the distance between the metallic portion of the humeral
metaphysis and the scapula. Placing the glenoid compo-
nent inferiorly on the glenoid face will also accomplish this.
In addition, they recommended avoidance of the larger,
42-mm-sized glenosphere. Positioning of the glenosphere
14530_C10.indd 130
with an inferior tilt is another suggested method to avoid
potential notching problems.
It should be noted that although there seems to be no
short-term deleterious effects of scapular notching, longer-
term follow-up is necessary before this question can be de-
finitively answered. In addition, although there are many
recommendations as to how to avoid notching, there is little
experimental evidence to support any one technique. We
currently recommend placing the glenoid component inferi-
orly and with an inferior tilt; however, we recognize that the
biologic and anatomical factors that lead to scapular notch-
ing remain incompletely understood. Therefore, scapular
notching is something that the surgeon and patient are will-
ing to accept prior to proceeding with this treatment.
Complications
Initial reports of complication rates have been somewhat
inconsistent. In those series that have discussed compli-
cations, rates reported have varied from 8 to 80%.36–46,48–51
Many early complications were related to the faulty lock-
ing mechanism between the glenoid baseplate and glenoid
sphere of the original Grammont design.21,35,39 Since a design
modification in 1996, this problem has not been reported.
In our series of 240 patients, dislocation and infection
were our most common complications.49 Postoperative
humeral fracture, scapular spine fracture, neuropraxia,
glenoid fracture, and prosthetic loosening were less com-
mon. The overall rate of complication was 18.6%.
Revision surgery significantly increased the risk of com-
plication to approximately 3 times that of primary surgery
1/31/08 11:04:27 AM
 10 Treating the Rotator Cuff–Deficient Shoulder: The Lyon, France, Experience 131
Table 10–1 Complications and Frequency among Primary and
Revision Reverse Total Shoulder Arthroplasty Patients

Primary Revision

Complication number % number %

Dislocation 8 5.2 7 14.3
Infection 5 3.2 3 6.1
Postoperative humeral 2 1.3 2 6.1
fracture
Transient neuropraxia 0 0.0 3 6.1
Scapular spine fracture 1 0.6 1 2.0

Glenoid loosening 2 1.3 0 0.0

Humeral loosening 1 0.6 1 2.0
Glenoid fracture 1 0.6 0 0.0
Humeral spacer 0 0.0 1 2.0
unscrewing
Total 20 12.8 18 38.6
10.1055/978-1-58890-635-9c010_t001 A
10.1055/978-1-58890-635-9c010_f009

(12.9 versus 36.7%). The rate of dislocation was nearly tri-

ple that of primary surgery (5.2 versus 14.3%). Humeral
fracture during humeral implant removal occurred in ap-
proximately one fourth of all revisions. Risk of infection
was also elevated in the revision population (Table 10–1).
Dislocation is of particular concern when discussing re-
verse shoulder arthroplasty. Several authors have previ-
ously reported dislocations, with rates varying from 0 to 31%.
B
DeWilde et al36 noted exceptionally high dislocation rates in
patients undergoing reconstruction after tumor resection
and for revision cases.37–45 Rates for those patients with less
complicated pathologies, such as CTA, have been significantly
lower. Sirveaux et al35 noted no instability in 80 patients with
CTA after 2 years. Valenti and colleagues had no instance of
dislocation in 39 patients with CTA followed for 5 years.39
Boulahia et al45 reported only one dislocation in 16 patients
with a broad spectrum of underlying diagnoses.
The initial treatment of dislocation is by closed reduc-
tion followed by a period of abduction bracing. In recurrent
cases or when the prosthesis cannot be closed reduced,
open reduction and possible implant revision is indicated.
The addition of length to the humeral prosthesis either by
increasing the thickness of the polyethylene humeral cup
or by using a metallic spacer increases the tension across
the joint, and thereby joint stability. In addition, some sys-
tems also include a more constrained cup design for these
cases (Fig. 10–9).

Conclusions
The RC-deficient shoulder is a complex entity that is dif-
ficult to treat. This is evidenced by the myriad of treatment
options that are available to the surgeon, ranging from
nonoperative modalities to arthroplasty and arthrodesis.
C
Figure 10–9 (A) Preoperative anteroposterior radiograph and (B)
computed tomography scan do not demonstrate evidence of scapu-
lar spine pathology. (C) Two-year follow-up clearly shows scapular
spine fracture with significant angulation of the entire acromion.

14530_C10.indd 131 1/31/08 11:04:29 AM

 132 Rotator Cuff Deficiency of the Shoulder
There is currently little consensus among shoulder sur-
geons regarding the uses and indications for these pro-
cedures. The relative rarity of this condition means that
there are few large studies in the literature, and that most
surgeons have little experience with these complications.
In our experience, treatments such as muscle transfers
and arthrodesis may be useful in a small subset of carefully
selected patients. However, their use is typically limited
to very young patients or younger patients with limited
active motion.
Biceps tenotomy is a good option for those older pa-
tients who have persistent pain, but have preserved active
motion, or for older patients who just desire relief of pain.
Although concern has been raised over possibly accelerat-
ing humeral head migration and progression to CTA, these
issues have not been clinically relevant. It is important to
remember that tenotomy will not increase motion in a pa-
tient who is already stiff; motion must be first regained by
judicious use of physical therapy.
The practice of reverse shoulder arthroplasty is still in
its infancy and indications are currently expanding. The
prosthesis was designed specifically for the cuff-deficient
shoulder, and it has had a dramatic impact on our cur-
rent treatment philosophy. There is sufficient evidence to
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68. Post M, Jablon M, Miller H, Singh M. Constrained total shoul-
der joint replacement: a critical review. Clin Orthop Relat Res
1979;144:135–150
69. Post M, Jablon M. Constrained total shoulder joint replace-
ment: long-term follow-up observations. Clin Orthop Relat Res
1983;173:109–116
70. Post M. Constrained arthroplasty of the shoulder. Orthop Clin
North Am 1987;18:455–462
71. De Wilde LF, Van Ovost E, Uyttendaele D, Verdonk R. Résultats
d’une prothèse d’épaule inversée après résection pour tumeur
de l’humérus proximal. Rev Chir Orthop Reparatrice Appar Mot
2002;88:373–378
72. McMaster PE. Tendon and muscle ruptures: clinical and experi-
mental studies on the causes and location of subcutaneous rup-
tures. J Bone Joint Surg Am 1933;15:705–722
14530_C10.indd 134
73. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the
biceps tendon. J Shoulder Elbow Surg 1999;8:644–654
74. Waugh RL, Hathcock TA, Elliot JL. Ruptures of muscles and tendons:
with particular reference to rupture (or elongation of long tendon)
of biceps brachii with report of fifty cases. Surgery 1949;25:370–
392
75. Kempf JF, Gleyze P, Bonnomet F, et al. A multicenter study of 210
rotator cuff tears treated by arthroscopic acromioplasty. Arthros-
copy 1999;15:56–66
76. Klinger HM, Spahn G, Baums MH, Stecke lH. Arthroscopic debride-
ment of irreparable massive rotator cuff tears: a comparison of de-
bridement alone and combined procedure with biceps tenotomy.
Acta Chir Belg 2005;105:297–301
77. Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilizing func-
tion of the biceps in stable and unstable shoulders. J Bone Joint
Surg Br 1993;75:546–550
78. Kumar VP, Satku K, Balasubramaniam P. The role of the long head
of biceps brachii in the stabilization of the long head of the hu-
merus. Clin Orthop Relat Res 1989;244:172–175
79. Rodosky MW, Harner CD, Fu FH. The role of the long head of the
biceps muscle and superior glenoid labrum in anterior stability of
the shoulder. Am J Sports Med 1994;22:121–130
1/31/08 11:04:31 AM
 11 Treating the Rotator Cuff–Deficient
Shoulder: The Mayo Clinic Experience
John W. Sperling and Robert H. Cofield
There has been an evolution in the treatment of rota-
tor cuff arthropathy (RCA) at the Mayo Clinic (Rochester,
MN). There was a brief experience with constrained and
semiconstrained designs in the 1970s and 1980s. However,
the predominant treatment for the last 25 years has been
hemiarthroplasty. Recently, there has been incorporation
of a reverse prosthesis design for the treatment of select
patients with cuff tear arthropathy (CTA). Our purpose in
this chapter is to discuss the Mayo Clinic experience in
treating RCA with shoulder arthroplasty. The results, risk
factors for an unsatisfactory outcome, and rates of failure
will be reviewed.
Hemiarthroplasty (Humeral Head
Replacement)
In the late 1970s, there was recognition of a group of pa-
tients who had destruction of glenohumeral cartilage in
association with severe RC tearing. This was often asso-
ciated with instability as well as some degree of bone loss.
Neer and coworkers1 have described a CTA to better char-
acterize this syndrome.
In 1986, Brownlee and Cofield reported on 20 shoulder
replacements performed for CTA between 1976 and 1982.2
or
Sixteen shoulder arthroplasties were available for review
Mayo at a mean of 4 years following surgery. A humeral head
replacement without a glenoid component was performed
in four shoulders. In these patients, there was a reduc-
tion of pain in all shoulders, but there was little change in
A B
Figure 11–1 (A) Preoperative radiograph demonstrates rotator cuff arthropathy with central glenoid erosion. The patient had active elevation
to 100 degrees and severe pain. (B) Postoperatively, the patient had mild pain and 110 degrees of elevation. 10.1055/978-1-58890-635-9c011_f001
14530_C11.indd 135
active motion. There were no reoperations among these
four shoulders. However, in the remaining 12 shoulders
that had placement of a glenoid component, revision was
needed for glenoid component problems in three shoul-
ders. This group was reviewed in 1991, and no substantive
changes had occurred over time.3
The results of shoulder hemiarthroplasty for RCA at the
Mayo Clinic in a series of 33 shoulders, followed for an av-
erage of 5 years, was recently reviewed by Sanchez-Sotelo
and colleagues.4 Eleven shoulders had undergone between
one and four previous procedures, including an acromio-
plasty in eight shoulders. Shoulder hemiarthroplasty was
associated with significant pain relief (Fig. 11–1 and Fig.
11–2). However, at the most recent follow-up, 9 patients
(27%) had moderate pain at rest or pain with activity. The
mean active elevation improved from 72 to 91 degrees (p =
0.008), mean internal rotation improved from L3 to L1 (p =
0.02), and mean active external rotation improved from 36
to 41 degrees (not significant). According to Neer’s limited
goals criteria, successful results were achieved in 22 cases
(67%). However, most patients were satisfied with the out-
come of the surgery and only four shoulders were subjec-
tively considered to be the same or worse than before the
operation. Two factors were associated with a less satisfac-
tory outcome: prior subacromial decompression and the
extent of proximal migration of the humeral head.
The experience with hemiarthroplasty for RCA revealed
that a less satisfactory outcome should be expected in pa-
tients with prior violation of the coracoacromial arch. The
use of either small humeral head sizes in an attempt to
1/31/08 11:02:44 AM
 136 Rotator Cuff Deficiency of the Shoulder

A B
Figure 11–2 (A) Patient with rheumatoid arthritis and massive rotator cuff tear. Preoperatively, she had severe pain and active elevation to 70
degrees. (B) One-year postoperative, she had no pain and active elevation to 90 degrees. 10.1055/978-1-58890-635-9c011_f002

facilitate reconstruction of the cuff or large sizes to maxi-

mize joint stability did not seem to be justified.

Constrained and Semi-constrained

Total Shoulder Arthroplasty
There was a strong initial interest in the design of total
shoulder prostheses that included a constrained or a ball-
in-socket design. Unfortunately, the frequency of compli-
cations was found to be extraordinarily high. In addition,
these complications were often quite serious and included
dislocations, component material failure, or component
loosening, most of which necessitated major revision sur-
gery. As an alternative to a completely captive ball-in-socket
arrangement, hooded or semiconstrained glenoid compo-
nents were designed as a part of a prosthetic system.
Early in our experience with total shoulder arthro-
plasty, we became involved to a limited extent with the
use of constrained total shoulder arthroplasties in patients
with various forms of glenohumeral arthritis. One of the Figure 11–3 The Neer hooded glenoid component.
early designs of a constrained total shoulder arthroplasty 10.1055/978-1-58890-635-9c011_f003
was developed by Dr. William Bickel5 at the Mayo Clinic.
The intent was to incorporate the low-friction concept of
Charnley and for the glenoid component to be entirely en-
cased within the glenoid process of the scapula to maxi-
mize the area of bone–cement contact.5 Unfortunately,
this experience was similar to the experience of others Table 11–1 Mayo Clinic’s Results Using Constrained Total
Shoulder Replacement 10.1055/978-1-58890-635-9c011_t001
and to our experience with the Stanmore shoulder pros-
thesis (Table 11–1). Significant complications were very Followup Active
common. Most notably, these included glenoid loosening
Prosthesis Years Shoulders Abduction Revision
and instability. Revision surgery was necessary in 12 of the
27 shoulders (44%). Our experience was better with the Bickel 12 12 95 8
Michael Reese design, but later failures occurred (largely Stanmore 9 9 93 4
glenoid loosening). This implant was subsequently re- Michael Reese 7 6 73 0
moved from the market.

14530_C11.indd 136 1/31/08 11:02:45 AM

 11 Treating the Rotator Cuff–Deficient Shoulder: The Mayo Clinic Experience
Fifteen shoulders did not have intervening revision
surgery and were available for analysis more than 2 years
after their initial surgical procedure. As in other series,
satisfactory pain relief usually occurred, but return of ac-
tive abduction was disappointing, averaging between one-
third and one-half normal. Using a rating system similar to
Neer's published criteria, there were no excellent results, 5
satisfactory results, and 22 unsatisfactory results.6
An additional design that was used at the Mayo Clinic
was the Neer hooded glenoid component. This glenoid
component was designed with a metal backed keel and
was oversized to compensate for superior subluxation as-
sociated with RCA. Nwakama and Cofield7 reviewed the
results of seven shoulders that underwent this procedure.
Six of the seven shoulders had an unsatisfactory outcome.
Two patients required revision surgery for subluxation or
glenoid loosening (Fig. 11–3).
Treatment Algorithm
The initial treatment for patients with RCA includes ac-
tivity modification, simple nonsteroidal antiinflammatory
medications, a gentle home physiotherapy program includ-
ing pain relieving measures, gentle stretching, and light
strengthening. In addition, corticosteroid injections may
be helpful. When patients have failed these nonoperative
measures, one can then consider operative intervention.
If there is considerable irregularity of movement, a form
of crepitus, and the arthritis is moderate, arthroscopic de-
bridement may be considered. However, this procedure is
References
1. Neer CS, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint
Surg Am 1983;65:1232–1244
2. Brownlee RC, Cofield RH. Shoulder replacement in cuff tear ar-
thropathy. Orthop Trans 1986;10:230
3. Lohr JF, Cofield RH, Uhthoff HK. Glenoid component loosening in
cuff tear arthropathy. J Bone Joint Surg Br 1991;73-B(Suppl):106
4. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthro-
plasty for glenohumeral arthritis associated with severe rotator
cuff deficiency. J Bone Joint Surg Am 2001;12:1814–1822
14530_C11.indd 137
137
not commonly needed. For those patients who might be
considered surgical candidates, the tendency is to perform
a hemiarthroplasty when the humeral head is stable be-
neath the acromial arch, when the glenoid erosion is sub-
stantial, or when there is active elevation to ≥60 or 70 de-
grees. In addition, among younger patients and those who
actively use their shoulders and arms, hemiarthroplasty is
typically performed.
The reverse prosthesis is used more frequently when
there is anterosuperior escape of the proximal humerus;
when the glenoid is intact, or relatively so; or when the pa-
tient has pseudoparalysis, barely being able to raise the arm
away from the side. The reverse prosthesis is most appropri-
ate for elderly patients and those who are sedentary.
Summary
Early experience with constrained or semi-constrained de-
signs for the treatment of RCA resulted in a high complica-
tion and failure rate. Humeral head replacement has been
found to have a moderate chance of good to excellent pain
relief, minimal improvement in motion, and a low rate of
mechanical failure. Risk factors for an unsatisfactory out-
come with hemiarthroplasty include a prior subacromial
decompression and significant superior subluxation. The re-
verse prosthesis has provided a new option to treat patients
with RCA, particularly those patients with anterosuperior
escape. The early experience with a reverse prosthesis has
been encouraging; however, longer follow-up will be neces-
sary to determine the durability of this prosthesis.
5. Cofield RH, Stauffer RN. The Bickel glenohumeral arthroplasty. In:
Morrey, BF (ed) Conference on Joint Replacement in the Upper Limb.
Bury St Edmunds, UK: Institute of Mechanical Engineering Publica-
tions; 1977:15–25
6. Cofield RH. Results and complications of shoulder arthroplasty. In:
BF Morrey, ed. Reconstructive Surgery of the Joints. 2nd ed. New
York, NY: Churchill Livingstone; 1996: 773–787
7. Nwakama AC, Cofield RH, Kavanagh BF, Loehr JF. Semiconstrained
total shoulder arthroplasty for glenohumeral arthritis and massive
rotator cuff tearing. J Shoulder Elbow Surg 2000;9(4):302–307
1/31/08 11:02:45 AM
 12 Treating the Rotator Cuff–Deficient
Shoulder: The Columbia University
Experience
John-Erik Bell, Sara L. Edwards, and Louis U. Bigliani
History
The Legacy of Harrison L. McLaughlin
The New York Orthopaedic Hospital, located within New
York Presbyterian Hospital, Columbia Campus, in upper
Manhattan, has supported the work of great leaders in
shoulder surgery throughout the 20th century, a privilege
that continues today. The pedigree of the Shoulder Service
is extensive; it has its roots within the renowned Fracture
Service, established by Dr. William Darrach. Harrison Lloyd
McLaughlin, M.D., F.A.C.S. (Fig. 12–1) began his medical
career on the Fracture Service in 1935 under Darrach and
established himself as a pioneer in the study of the rota-
tor cuff (RC) and its pathology.1 With seminal studies on
lesions of the RC and their surgical repair published in the
otator
he
rience
Figure 12–1 Harrison Lloyd McLaughlin, M.D., F.A.C.S.
10.1055/978-1-58890-635-9c012_f001
14530_C12.indd 138
1940s and 1950s, McLaughlin staked his position as an
innovative thinker in the pathology and treatment of RC
disease.2–5 Although best known for his contributions to
the field of shoulder instability, and, in particular, posterior
dislocation, with an operative procedure bearing his name,
his theories on RC pathology have served as the foundation
for successive leaders of the Columbia Shoulder Service.2
In his report on 100 consecutive patients and their long-
term follow-up, McLaughlin wrote, “Operative experiences
soon demonstrated that no two tendon ruptures were sim-
ilar or amenable to identical repair techniques, that each
required a plastic tenorrhaphy suited to its own original
characteristics . . .” He realized that the three prerequisites
to a successful repair included “1) The snug apposition of
healthy to healthy tissue without tension at the site of re-
pair. 2) The restoration of continuity between the short ro-
tator muscle bellies and the humerus. 3) The restoration of
a smooth surface for articulation with the acromion. . .” He
also suggested the impingement phenomenon in which
the RC and bursa are compressed between the humeral
head and acromion, which has been expanded upon by
following leaders of the Columbia Shoulder Service, Drs.
Charles S. Neer and Louis U. Bigliani.2
The Legacy of Charles S. Neer, II
Charles S. Neer, M.D. (Fig. 12–2) is considered by many
to be the father of modern shoulder surgery. Dr. Neer de-
veloped the first widely used prosthetic shoulder replace-
ment, established the most commonly used classification
of proximal humerus fractures, and advanced the man-
agement of shoulder instability.3–8 Neer created the first
shoulder fellowship in the world and initiated the great
legacy of the Columbia Shoulder Service. Many leaders in
shoulder surgery around the world have either trained un-
der Neer and with those whom he trained. With respect
to the RC-deficient shoulder, Neer first described the ra-
diographic and clinical features of arthritis associated with
massive RC tear in 1977 and, in 1983, Neer coined the term
cuff tear arthropathy in his classic paper on the subject.4,5
Neer reported on 26 patients with cuff tear arthropa-
thy (CTA) who underwent surgical reconstruction with to-
tal shoulder replacement at Columbia between 1975 and
1983.4 He described their symptoms as “remarkably simi-
lar,” consisting of “long-standing and progressively increas-
1/31/08 11:06:37 AM
 12 Treating the Rotator Cuff–Deficient Shoulder: The Columbia University Experience
Figure 12–2 Charles S. Neer, M.D.
10.1055/978-1-58890-635-9c012_f002
ing pain that was worse at night, was exacerbated by use
and activity, and was made more intense by movement of
the humerus against the scapula . . . and the patients com-
plained of inability to elevate or externally rotate the shoul-
der.” Physical examination revealed swelling of the shoulder
resulting from synovial fluid communicating between the
glenohumeral joint and the subacromial space (the “fluid
sign”), atrophy of the supraspinatus and infraspinatus mus-
cles with corresponding weakness of external rotation (ER)
and abduction, decreased active elevation (only 2 patients
of 26 could actively elevate above 90 degrees), and crepitus
at the glenohumeral joint line. Radiographic findings were
described as “characteristic,” consisting of collapse of the
proximal humerus, instability of the glenohumeral joint,
loss of the acromiohumeral distance, and erosion of the su-
perior glenoid, inferior acromion, coracoid, distal clavicle,
and greater tuberosity (Fig. 12–3).
At the time of surgery, Neer found a large, complete RC
tear in all patients, involving the supraspinatus in all, the
infraspinatus in all but one, and often involving the sub-
scapularis and teres minor muscles as well. Instability was
also common, with 14 shoulders exhibiting passive dislo-
cation and 12 shoulders demonstrating fixed dislocation.
Dramatic cartilage loss was noted, and radiographic find-
14530_C12.indd 139
139
Figure 12–3 Anteroposterior radiograph of one of Dr. Neer’s cuff
tear arthropathy patients. Note superior head migration and cor-
responding loss of the acromiohumeral interval, superior glenoid
erosion creating a biconcave glenoid, erosion of the acromion, and
rounding off of the greater tuberosity.
10.1055/978-1-58890-635-9c012_f003
ings of coracoacromial arch erosions were confirmed at
surgery. Neer also performed histologic studies, and found
that the humeral head became covered with a disordered
fibrous membrane, with the underlying bone osteoporotic
and hypervascular. He also found areas at points of fixed
contact with the scapula that resembled changes seen in
osteoarthritis with complete loss of articular cartilage and
subchondral sclerosis. Finally, he found fragments of artic-
ular cartilage in subsynovial layers which resembled those
found in neuropathic joints and hypothesized that these
were the products of instability and subsequent abnormal
trauma to the articular surfaces.
Neer’s theory regarding the etiology of CTA was also
put forth in this seminal paper.4 He proposed the hypoth-
esis that the reason this condition only affects the gleno-
humeral joint and not other joints is because of the shoul-
der’s unique dependence on the soft tissue for stability and
relative lack of bony constraint. He hypothesized that both
nutritional and mechanical factors are important in the de-
velopment of CTA:
Nutritional factors imposed by the massive tear include loss
of a closed joint space and impaired movement of the gleno-
humeral joint. The loss of a closed joint space with leaking
synovial fluid under reduced pressure would be expected to
deter the perfusion of nutrients into the articular cartilage.
Joint inactivity has been shown to lead to structural altera-
tions in articular cartilage as well as to biochemical changes
in the water and glycosaminoglycan content of the cartilage
1/31/08 11:06:37 AM
 140 Rotator Cuff Deficiency of the Shoulder
and capsule. Both then, loss of a closed joint space and inac-
tivity, are thought to contribute to the atrophy of the articular
cartilage of the humeral head. Inactivity is also thought to
cause disuse osteoporosis of the subchondral bone, in accord-
ance with Wolff’s law, which may eventually lead to collapse
of the subchondral bone . . . The mechanical factors include
gross instability of the humeral head on the glenoid as well
as upward migration of the head against the acromion and
acromioclavicular joint. Loss of the stabilizing functions of
the long head of the biceps following rupture or displace-
ment of its tendon as well as of the RC contribute to at least
two types of instability. Anterior and posterior subluxations
and dislocations produce abnormal trauma and injury to the
articular surfaces of the humeral head and glenoid. Eventu-
ally the incongruous head may erode through the glenoid
into the coracoid process. The upward instability and upward
migration of the head escalate the previously described proc-
ess of subacromial impingement.6 Impingement wear erodes
the anterior part of the acromion, the acromioclavicular joint,
and the outer part of the clavicle. Instability of the head seems
to be essential for the development of its collapse.4
Neer treated his 26 patients with total shoulder arthro-
plasty (Fig. 12–4), which is now considered to be less pref-
erable than hemiarthroplasty due to early glenoid loosen-
ing from eccentric loading and increased lateral offset.7–14
He remarked, “surgical reconstruction of these shoulders is
especially difficult.” Nevertheless, he found that only one
of the 26 patients did not consider the procedure helpful.
His paper first describing the entity of CTA laid the ground-
Figure 12–4 A total shoulder arthroplasty performed by Dr. Neer
for the patient from Fig. 12–3. Note the superior migration of the
humeral head and the subsequent eccentric loading of the superior
aspect of the glenoid prosthesis.
10.1055/978-1-58890-635-9c012_f004
14530_C12.indd 140
work for many subsequent investigations and treatments
for this previously unrecognized condition.
One such subsequent investigation performed at Co-
lumbia is that of Pollock et al.7 In this study, 30 shoulders
with glenohumeral arthritis and RC deficiency, which had
undergone prosthetic replacement, were retrospectively
reviewed at an average of 41 months follow-up. Of these,
19 had undergone hemiarthroplasty and 11 had undergone
total shoulder arthroplasty. All had an attempt at RC repair.
Both total shoulder arthroplasty and hemiarthroplasty had
similar levels of pain relief and patient satisfaction. The
most interesting finding was that, despite similar levels
of pain relief, the group undergoing hemiarthroplasty dis-
played a significant improvement in active forward elevation
(+52 versus +2 degrees) postoperatively compared with
those undergoing total shoulder arthroplasty. The sur-
geons felt that hemiarthroplasty afforded greater ease of
RC repair because the lateral offset of the humerus was
decreased relative to that of total shoulder arthroplasty,
and that this technical factor might be responsible for im-
proved postoperative active elevation. Because of these
findings, hemiarthroplasty has been the procedure of
choice at Columbia for CTA over the past decade.
Treatment of Cuff Tear Arthropathy
Overview
At Columbia, a significant number of patients with CTA
are treated every year. These patients are approached in
a systematic way, utilizing multiple treatment modalities.
The most important variables that factor into our treat-
ment decision include patient age, functional status, pain
level, active and passive range of motion, and findings on
preoperative imaging studies. The first decision to make
is whether the patient is better suited for nonoperative
treatment or is a candidate for surgical reconstruction.
Typically, all patients with CTA have a trial of nonoperative
treatment, consisting of antiinflammatory medications
and physical therapy to strengthen the remaining fibers of
the teres minor and subscapularis in an attempt to recre-
ate a force-couple to restore some active elevation to the
shoulder. For patients in reasonable health who fail nonop-
erative treatment, we recommend surgical reconstruction
of the shoulder. For patients with multiple comorbidities
for whom surgery is perilous, we continue with definitive
nonoperative treatment.
Once it has been decided that surgery is indicated, we
must decide which prosthesis or procedure is indicated.
Potential solutions to this problem include débridement,
open RC repair with or without tendon transfers, arthro-
desis, resection arthroplasty, and prosthetic arthroplasty.
Prosthetic choices include hemiarthroplasty designs such
as resurfacing implants, traditional stemmed components,
1/31/08 11:06:38 AM
 12 Treating the Rotator Cuff–Deficient Shoulder: The Columbia University Experience
and newer expanded heads that cover the greater tuber-
osity. At Columbia, Neer had extensive experience with
traditional total shoulder arthroplasty for CTA as well as
enlarged glenoid components that increase superior con-
straint (Fig. 12–5).5 Traditional glenoid replacement has
been subsequently shown to result in unacceptably high
rates of failure secondary to superior humeral head migra-
tion, glenoid loosening, and poor functional results.7,8
In recent years, there has been renewed enthusiasm for
the reverse total shoulder prosthesis based on Grammont’s
design improvements detailed elsewhere in this textbook.
At Columbia, several dozen reverse total shoulder arthro-
plasties have been performed with promising early results.
The most important factor in the success of this implant is
choosing the correct indications.
Hemiarthroplasty remains an excellent option for pa-
tients with CTA if the right indications exist.7,9–20 While
the reverse prosthesis is promising and seems attractive,
it may not be indicated in all cases. We approach this pro-
cedure with both excitement and caution due to reports
of high rates of short-term complications by experienced
surgeons in Europe and in the United States.10,11 At Colum-
bia, this new technology is utilized for very specific and
narrow indications with good short-term results. The ideal
indication for the reverse prosthesis is for patients over the
age of 70 with both pseudoparalysis and advanced CTA.
It is also indicated for more complex reconstructive situ-
ations, including revision of failed hemiarthroplasty for
fracture with tuberosity nonunion, and other revision situ-
ations without a functional RC; however, results for such
revision cases have been less consistent. We do not utilize
this prosthesis in patients who have greater than 90 de-
grees of active forward elevation, those under age 70 or
who anticipate heavy activity levels postoperatively, those
with poor glenoid bone stock, or in those who have an in-
competent deltoid. Hemiarthroplasty is indicated in those
patients with active forward elevation above 90 degrees.
A B
14530_C12.indd 141
141
Our contraindications to hemiarthroplasty include deltoid
deficiency and a disrupted coracoacromial arch with an-
terosuperior escape.12,13
Hemiarthroplasty
The patient is positioned ~30 degrees upright in a beach-
chair position with a short arm board under the affected
extremity. The shoulder is exposed through a standard
deltopectoral approach. The proximal one third of the
pectoralis major tendon is released with cautery. The sub-
scapularis is carefully released as far lateral as possible, so
that as much length as possible can be achieved in the sub-
scapularis tendon. The goal of subscapularis reconstruction
is to advance it as far superiorly as possible, often to the
anterior part of the greater tuberosity. The subscapularis is
reattached more medially at the surgical neck cut. This will
also add length. It is critical to preserve the coracoacromial
ligament to maintain the coracoacromial arch in the RC-
deficient shoulder. The biceps tendon is usually ruptured,
but if present it should be preserved. The head is then dis-
located by positioning the extremity in adduction, extension,
and ER. We use the Zimmer Bigliani–Flatow shoulder ar-
throplasty system (Zimmer, Inc., Warsaw, IN). The canal is
reamed until there is a palpable tight fit, then the reamer
is used to align the proximal humerus cutting jig. The head
is resected at the level of the articular margin in ~30 de-
grees of retroversion. In CTA, retroversion between 30 to
40 degrees is preferred to minimize anterosuperior sub-
luxation. It is sometimes difficult to determine where the
articular margin stops and the greater tuberosity begins
because the cartilage is absent and the greater tuberosity
has been eroded significantly. In these situations, preop-
erative templating is critical, using the contralateral shoul-
der as a guide if possible. The rule of thumb is to resect less
rather than more of the humeral head. We frequently use
10.1055/978-1-58890-635-9c012_f005
Figure 12–5 Examples of semiconstrained total shoul-
der replacements performed by Dr. Neer for cuff-tear
arthropathy. (A) A 200% glenoid component; (B) a 600%
glenoid component.
1/31/08 11:06:39 AM
 142 Rotator Cuff Deficiency of the Shoulder
a stem proximally coated with trabecular metal, allowing
bone ingrowth. The majority of patients are osteoporotic,
or have otherwise poor bone quality, with excessively ca-
pacious canal diameters, and require proximal cementing
technique for increased axial and rotational stability.
We prefer an attempt at RC repair if possible. Frequently,
the cuff will be irreparable, but if some posterior cuff can
be repaired, it can function in concert with the subscapula-
ris to obtain a “force-couple” which may allow the patient
increased forward elevation even in the absence of a su-
praspinatus tendon.14 When repair is possible, we prefer to
secure it using transosseous tunnels. If there is significant
“acetabularization” of the coracoacromial arch, we try to
match the humeral head replacement to the preoperative
humeral head size and maintain its superiorly migrated
position within the coracoacromial arch. If the greater tu-
berosity remains, it is smoothed to improve the congruity
of the humeral head articulation with the acromion. Care
should be taken to avoid overstuffing the joint with a head
component that is too large, as this will result in postop-
erative stiffness and can lead to subscapularis failure.
The subscapularis repair is a critical part of the proce-
dure. The subscapularis was cut as far lateral as possible
to preserve its length for superior transposition to the an-
terior part of the greater tuberosity. The anterior repair is
medialized to the cut surgical neck area of the humerus to
help maximize tendon length. It is critical to have a wide
bone surface on the neck of the humerus for optimum ten-
don-bone contact. If possible, the superior and posterior
cuff should also be repaired. The posterior attachment, in-
cluding the teres minor, should never be detached as this
will lead to weakness of ER.
Postoperatively, rehabilitation focuses on protecting
the repair of the RC repair, which in most cases is prima-
rily the subscapularis. All patients are placed into a super-
vised postoperative physical therapy program for at least 6
weeks following surgery. Patients are protected in a sling
for 4 to 6 weeks and they are started on pendulum exer-
cises, ER exercises with a stick to 30 degrees, and passive
supine elevation to a limit of 130 degrees. At 6 weeks, they
are gradually advanced to isometrics and strengthening.
Case Study
Figure 12–6 represents an illustrative case of an 81-year-
old woman with longstanding, progressive right shoulder
pain and decreased active motion. Physical exam revealed
active forward elevation of 90 degrees, ER of 20 degrees, and
internal rotation (IR) to the side. An anteroposterior (AP)
radiograph and coronal oblique magnetic resonance imag-
ing (MRI) scan are shown in Fig. 12–6A,B. The patient failed
nonoperative treatment including corticosteroid injection
and antiinflammatory medications. She then underwent
hemiarthroplasty using a Zimmer Bigliani–Flatow humeral
head replacement (Zimmer, Inc., Warsaw, IN). Fig. 12–6C–H
14530_C12.indd 142
depict the surgical technique and findings. She underwent
rehabilitation as outlined above and achieved postoperative
range of motion of 100 degrees elevation. The postoperative
AP radiograph is shown in Fig. 12–6I.
Results
Recently, we looked up our results of hemiarthroplasty for
arthritis with massive RC tears. Goldberg et al15 reviewed
34 shoulders in 31 patients having undergone hemiarthro-
plasty for either CTA or osteoarthritis with a massive RC
tear from 1985 to 2000. Patients with rheumatoid arthritis,
osteonecrosis, or fracture sequelae were excluded. The av-
erage patient age was 72 years at surgery and the average
follow-up was 8.5 (2 to 16) years. All patients underwent
hemiarthroplasty with an attempted partial repair of the
residual RC tissue. In all patients, both the supraspinatus
and infraspinatus tendons were torn, in 35% three tendons
were torn, and in 12%, four tendons were torn.
At the time of follow-up, 76% of patients had satisfied
Neer’s “limited goals” criteria.5 To meet these “limited
goals,” the patient must have no or mild pain, must be
pleased with the procedure, and must be independent with
activities of daily living. There were two reoperations; an
arthroscopic distal clavicle excision and a greater tuberos-
ity exostectomy, but no revisions of the hemiarthroplasty.
All patients had significant improvement in terms of for-
ward elevation and ER. The most significant finding was
that patients with preoperative active forward elevation
of >90 degrees, 88% satisfied limited goals and had better
pain relief (p = 0.001) and better ASES scores (p = 0.002)
than those who could not actively elevate over 90 degrees
preoperatively. It can be concluded that hemiarthroplasty
for arthritis with a massive RC tear has good long-term
results overall, low complication rates, and has excellent
results in patients with preoperative active forward eleva-
tion >90 degrees.
Reverse Shoulder Arthroplasty
The shoulder is approached through a deltopectoral ap-
proach. This is chosen over the anterosuperior approach be-
cause it both preserves the deltoid and allows better visu-
alization of the inferior glenoid, resulting in the ability to
give the baseplate 10 to 15 degrees of inferior tilt. If present,
the biceps tendon is released and tenodesed to soft tissues
at the end of the case. The subscapularis is taken down as
in the above technique for hemiarthroplasty and tagged for
later repair. The humeral head is dislocated in adduction,
extension, and ER. We utilize the Zimmer TM Reverse Shoul-
der system (Zimmer, Inc., Warsaw, IN). The humeral canal is
identified and reamed to a tight fit. The reamer is then left
in as an alignment guide for the humeral head cutting jig.
The head is cut conservatively to maintain length and del-
toid tension, with more removed later if the reduction is too
1/31/08 11:06:39 AM
 12 Treating the Rotator Cuff–Deficient Shoulder: The Columbia University Experience 143

Figure 12–6 Illustrative case of hemiarthroplasty for cuff tear ar-
thropathy, performed by Dr. Bigliani. (A) Anteroposterior (AP) radio-
graph, showing superior migration, biconcave glenoid, acetabular
erosion, coracoid erosion. (B) Magnetic resonance imaging scan
showing massive rotator cuff tear and communication of joint fluid
with bursal space. (C) Deltopectoral approach revealing large fluid
10.1055/978-1-58890-635-9c012_f006
collections within the bursal space. (D) Incision of the bursal spaces
reveals large calcium deposits. (E) The humeral head is dislocated,
revealing complete loss of rotator cuff attachment. (F) Zimmer
Bigliani–Flatow humeral head cutting jig in 30 degrees retroversion.
(G) The humeral head replacement in situ. (H) After subscapularis
repair. (I) Postoperative AP radiograph.

14530_C12.indd 143 1/31/08 11:06:39 AM

 Figure 12–7 Illustrative case of reverse shoulder arthroplasty for
cuff tear arthropathy (CTA). (A) Pseudoparalysis – active forward
elevation to only 25 degrees. (B) Anteroposterior (AP) radiograph
showing CTA. (C) Standard deltopectoral approach. (D) Dislocation
of the humeral head showing complete absence of rotator cuff.
(E) Placement of the Zimmer proximal humerus cutting jig in 10
10.1055/978-1-58890-635-9c012_f007
14530_C12.indd 144
degrees retroversion. (F) Reaming of the proximal humeral meta-
physis. (G) Drill hole for center peg over guide wire. (H) Reaming the
glenoid. (I) The baseplate is implanted. (J) The stem is cemented.
(K) Sutures for the subscapularis repair are passed through the stem.
(L) The polyethylene is impacted into position. (M) The reverse ar-
throplasty is reduced. (N) Postoperative AP radiograph.
1/31/08 11:06:42 AM
 12 Treating the Rotator Cuff–Deficient Shoulder: The Columbia University Experience
tight. The cut is made at ~10 degrees of retroversion. The
range is from 0 to 20 degrees of retroversion depending on
the pathology of the patient. The metaphysisis then reamed
and the trial component inserted. A humeral head cap is
then placed to protect the thin shell of cortical bone during
retraction for exposure of the glenoid.
An extensive anteroinferior capsulectomy is performed,
taking care to protect the axillary nerve. It is critical to re-
lease the capsule all the way to the inferior lip of the glenoid
so that the baseplate can be placed in its optimal position,
flush with the inferior lip. Once the inferior glenoid is visu-
alized, the guidewire is placed in the inferior aspect of the
glenoid, such that the baseplate lies flush with the inferior
lip and there is no superior angulation.16 This is then over-
drilled and the glenoid is reamed. The central peg of the
baseplate is coated with trabecular metal to promote bone
ingrowth and is impacted into position. The baseplate is
then fixed with superior and inferior locking screws. The
superior screw is directed at the hard cortical bone at the
base of the coracoid process and the inferior screw is di-
rected straight down the scapular neck. The glenosphere is
then impacted into position and the humeral polyethylene
component is trialed. The reduction should be tight and
not gap with manual traction. It should be stable through a
complete range of motion, and especially in adduction, IR,
and extension, the typical position of instability.
The humeral component is then cemented, to prevent
subsidence and possible late instability. The polyethylene
component is impacted into position and the shoulder re-
duced. Stability is reaffirmed again before closing. The sub-
scapularis is repaired again as described above. A hemovac
drain is placed because the incidence of symptomatic he-
matoma has been documented to be high following this
procedure by Werner et al.11 The arm is placed in neutral
rotation with an emphasis on avoiding extension by placing
a pillow under the affected arm.
Postoperative rehabilitation is deferred for 4 to 6 weeks.
The arm is taken out of the sling during this time only for
References
1. Marmor L. Harrison Lloyd McLaughlin, M.D., F.A.C.S.: The Sixth Alan
Deforest Smith memorial lecture. J Trauma 1991;31(3):310–315
2. McLaughlin H. Lesions of the musculotendinous cuff of the shoul-
der: i. the exposure and treatment of tears with retraction. J Bone
Joint Surg. 1944;26(1):31–51
3. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior
and multidirectional instability of the shoulder. A preliminary re-
port. J Bone Joint Surg Am 1980;62(6):897–908
4. Neer C, Craig E, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg
Am 1983;65-A(9):1232–1244
5. Neer C, Watson K, Stanton F. Recent experience in total shoulder
replacement. J Bone Joint Surg Am 1982;64-A:319–337
6. Neer C. Reconstructive surgery and rehabilitation of the shoulder.
In: Kelley W, Harris E, Ruddy S, CB S, eds. Textbook of Rheumatol-
ogy. Vol. 2. Philadelphia, PA: WB Saunders; 1981:1949
14530_C12.indd 145
145
elbow and wrist exercises. At 4 to 6 weeks, patients begin
both passive and active motion. Despite our relatively long
period of immobilization, we have not had problems with
stiffness and have had only one case of instability.
Case Study
Figure 12–7 represents an illustrative case of an 85-year-
old woman with longstanding, progressive right shoulder
pain and decreased active motion. Her forward elevation
on the right is only 30 degrees (Fig. 12–7A). Her AP ra-
diograph is shown in Fig. 12–7B. She failed nonoperative
treatment including corticosteroid injection and antiin-
flammatory medications. She then underwent reverse to-
tal shoulder arthroplasty using a Zimmer reverse implant
Fig. 12–7C–M depict the surgical technique and findings.
She underwent rehabilitation as outlined above. The post-
operative AP is shown in Fig. 12–7N.
Conclusions
Treatment of the RC-deficient shoulder by the Shoulder
Service at Columbia has evolved over the past 60 years
since McLaughlin wrote about his experiences with RC re-
pairs. Neer’s discovery of the pathological entity of CTA has
paved the way for a multitude of technological advance-
ments affording better alternatives for today’s patients.
Perhaps Neer summarizes CTA best, by saying, “surgical
reconstruction of these shoulders is especially difficult.”4
Although it is clear from recent studies discussed here that
the problem is still not solved, reasonable alternatives ex-
ist in the form of hemiarthroplasty and reverse shoulder
arthroplasty, as long as the indications for each are strictly
adhered to. Clearly, more research is necessary to decrease
complications and improve patient outcomes in this dif-
ficult condition.
7. Pollock RG, Deliz ED, McIlveen SJ, Flatow EL, Bigliani LU. Prosthetic
replacement in rotator-cuff deficient shoulders. J Shoulder Elbow
Surg 1992;1:173–186
8. Franklin J, Barrett W, Jackins S, Matsen F. Glenoid loosening in total
shoulder arthroplasty. association with rotator cuff deficiency. J
Arthroplasty 1988;3(1):39–46
9. Zeman CA, Arcand MA, Cantrell JS, Skedros JG, Burkhead WZ Jr.
The rotator cuff-deficient arthritic shoulder: diagnosis and surgical
management. J Am Acad Orthop Surg 1998;6(6):337–348
10. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The
reverse shoulder prosthesis for glenohumeral arthritis associated
with severe rotator cuff deficiency. A minimum two-year follow-up
study of sixty patients. J Bone Joint Surg Am 2005;87(8):1697–1705
11. Werner CML, Steinmann PA, Gilbart M, Gerber C. Treatment of
painful pseudoparesis due to irreparable rotator cuff dysfunction
1/31/08 11:06:45 AM
 146 Rotator Cuff Deficiency of the Shoulder
with the Delta III reverse-ball-and-socket total shoulder prosthe-
sis. J Bone Joint Surg Am 2005;87(7):1476–1486
12. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthro-
plasty for glenohumeral arthritis associated with severe rotator
cuff deficiency. J Bone Joint Surg Am 2001;83-A(12):1814–1822
13. Field LD, Dines DM, Zabinski SJ, Warren RF. Hemiarthroplasty of
the shoulder for rotator cuff arthropathy. J Shoulder Elbow Surg
1997;6(1):18–23
14. Burkhart SS. Fluoroscopic comparison of kinematic patterns in
massive rotator cuff tears. A suspension bridge model. Clin Orthop
Relat Res 1992; (284):144–152
15. Goldberg S, Rieger K, Kim H, Stanwood W, Levine W, Bigliani L.
Hemiarthroplasty for shoulder arthritis with massive tears of the
rotator cuff. Paper presented at: American Academy of Orthopae-
dic Surgeons Annual Meeting; March 22–26, 2006; Chicago, IL
16. Nyffeler RW, Werner CML, Gerber C. Biomechanical relevance of
glenoid component positioning in the reverse Delta III total shoul-
der prosthesis. J Shoulder Elbow Surg 2005;14(5):524–528
17. McLaughlin H. Lesions of the musculotendinous cuff of the
shoulder: II. differential diagnosis of rupture. JAMA 1945;128:
563–568
18. McLaughlin H. Lesions of the musculotendinous cuff of the shoul-
der: III. observations on pathology, course, and treatment of cal-
cium deposits. Ann Surg 1946;124:354–362
14530_C12.indd 146
19. McLaughlin H. Lesions of the musculotendinous cuff of the shoul-
der: IV. some observations based upon the results of surgical re-
pair. J Bone Joint Surg. 1951;33-A:76–86
20. Neer CS II. Articular replacement for the humeral head. J Bone Joint
Surg Am 1955;37A:215–228
21. Neer CS II. Displaced proximal humeral fractures. I. Classification
and evaluation. J Bone Joint Surg Am 1970;52(6):1077–1089
22. Hawkins RJ, Bell RH, Jallay B. Total shoulder arthroplasty. Clin Or-
thop Relat Res 1989;242:188–194
23. Jensen KL, Williams GR Jr, Russell IJ, Rockwood CA Jr. Rotator cuff
tear arthropathy. J Bone Joint Surg Am 1999;81(9):1312–1324
24. DiGiovanni J, Marra G, Park JY, Bigliani LU. Hemiarthroplasty for
glenohumeral arthritis with massive rotator cuff tears. Orthop Clin
North Am 1998;29(3):477–489
25. Collins DN, Harryman DT II. Arthroplasty for arthritis and rotator
cuff deficiency. Orthop Clin North Am 1997;28(2):225–239
26. Arntz CT, Jackins S, Matsen FA III. Prosthetic replacement of the
shoulder for the treatment of defects in the rotator cuff and
the surface of the glenohumeral joint. J Bone Joint Surg Am
1993;75(4):485–491
27. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg 1996;5(5):362–367
1/31/08 11:06:45 AM
 13 Treating the Rotator Cuff–Deficient
Shoulder: The Florida Orthopaedic
Institute Experience
Mark A. Frankle, Derek Pupello, and Derek Cuff
Based in Tampa, Florida, the Florida Orthopaedic Institute
is a multispecialty orthopedic group that was formed in
1990. This practice has evolved over the past 16 years and
is currently composed of 30 orthopedic surgeons who are
all subspecialty trained and practicing in the various disci-
plines of orthopedic surgery. Each year the group routinely
sees over 150,000 patient visits and performs over 12,000
surgical procedures.
In 1992, the Shoulder and Elbow Service of the Florida
Orthopaedic Institute was formed. Since its inception, the
service has rapidly grown and now treats a large number
of patients with a wide range of shoulder pathology. Last
year, the service had 13,000 patient visits, and a substantial
number of these patients, ~2,200 suffered from a combina-
tion of arthritis and rotator cuff (RC) dysfunction. This ex-
tensive clinical experience with the RC-deficient shoulder
since the early 1990s has led to an evolution in the way we
evaluate and care for these patients. The manner in which
we surgically treat these patients has markedly changed
over the years in an effort to improve patient function and
outcome. I will attempt to present our experiences and the
knowledge we have gained in our effort to treat the RC-
deficient shoulder.
da
Early Experience
In the early 1990s, the treatment of the RC-deficit shoulder
remained a dilemma. Multiple treatments had been tried
over the course of several decades in an effort provide pain
relief and improved function in this group of patients with
irreparable cuff tears. In the RC-deficient shoulder, the
force couple of the joint is disrupted, allowing the deltoid
to produce a change in the overall direction of the joint
forces and destabilize the glenohumeral joint with its su-
periorly directed pull.1 In the 1970s, surgeons attempted
to offset this through glenohumeral arthrodesis; however,
they found this procedure ineffective. Cofield and Briggs2
reported on their arthrodesis experience of 12 patients
with RC-tear arthropathy in 1979. Six of the 12 required
another operation due to proximal migration, nonunion, or
acromioclavicular pain.
Surgeons also attempted to use constrained total shoul-
der arthroplasty in the early 1970s and 1980s in an effort
to treat the RC-deficient shoulder. Due to the constraints of
this prosthesis, these implants were found to have a signif-
icant failure rate with early glenoid loosening. In 1982, Let-
tin et al3 reported on 10 of 49 shoulders who were treated
in this manner and developed early glenoid component
loosening; eventually, most surgeons deserted this total
shoulder construct. The use of unconstrained total shoul-
der arthroplasty was also tried in an attempt to treat this
difficult problem. This method was found to be problem-
atic secondary to the “rocking horse” effect on the glenoid
as described by Franklin and colleagues.4 They found that
superior migration of the humeral head correlated with
increased glenoid loosening due to the eccentric forces the
glenoid was experiencing. Subsequently, unconstrained
arthroplasty fell out of favor.
At the start of my practice in the early 1990s, hemi-
arthroplasty had become the gold standard of treatment
in the RC-deficient shoulder. Multiple studies5–7 reported
that this approach produced significant pain relief with
variable gains in forward elevation. Successful results
were reported at 60 to 80% using Neer’s limited goals cri-
teria. However, some surgeons, including myself, were not
fully satisfied with the results of this procedure. Sanchez-
Sotelo6 and colleagues reported on 33 shoulders in 30 pa-
tients who had undergone a hemiarthroplasty for cuff tear
arthropathy (CTA) and found that progressive superior mi-
gration and progressive glenoid bone loss occurred in 8 of
33 shoulders and 16 of 33 showed acromial bone loss with
two fractures. I too noted that many of my patients had
initial pain relief with this operation, but with longer fol-
low-up demonstrated progressive anterosuperior instabil-
ity, progressive bone loss, and unsatisfactory results.
We decided to review retrospectively 21 consecutive
hemiarthroplasties we performed for CTA, which had at
least 2 years of follow-up. The average age of these pa-
tients was 71.5 years old and the mean follow-up was 73
months. Five of the 21 patients had previous RC surgery. All
of these patients underwent an anatomical humeral head
replacement. In this group of patients, we saw a decrease
in their level of pain, but no significant improvement in
function. The postoperative ASES and VAS function, for-
ward flexion, and abduction did not improve significantly
from the preoperative values. With respect to patient sat-
isfaction, only 24% of the responses were excellent or good
after hemiarthroplasty. In fact, 47% of the patients were
dissatisfied after hemiarthroplasty. The radiographic find-
ings in this study were equally discouraging. Sixteen of
these 21 patients demonstrated progression of proximal
148 Rotator Cuff Deficiency of the Shoulder

A B
Figure 13–1 (A,B) A postoperative x-ray of a hemiarthroplasty preformed for rotator cuff deficiency. Note the proximal migration of the humeral
component and the erosion of the superior aspect of the glenoid. 10.1055/978-1-58890-635-9c013_f001

subluxation or progression of erosion of the glenoid (Fig.
13–1). The location of progressive instability and erosion
was most commonly superior and anterior. Many of these
hemiarthroplasties were deemed failures and the reopera-
tion rate in this series was 35%. Given these results I began
to search for a better way to treat these patients.
effort to treat the cuff-deficient shoulder. I sought to keep
the basic concept of Grammont’s reversal of the anatomy,
but I wanted the COR to remain outside of the glenoid as it
is in the normal shoulder anatomy. This led to my design
of the Reverse Shoulder Prosthesis (RSP; Encore Medical
Corp., Austin, Texas) (Fig. 13–2).

Reversing the Trend

From experience, I determined that hemiarthroplasty was
not solving the problem of the RC-deficient shoulder. I be-
came interested in a surgical procedure that was being per-
formed in Europe: surgeons were using a “reversed” shoul-
der design that had been tried almost three decades ago.7
The initial attempts had used a small glenoid ball within
a large humeral socket; this had resulted in a highly con-
strained arthroplasty. This ultimately had led to high rates
of glenoid loosening and hence the procedure was aban-
doned. In the early 1990s, Grammont and Baulot8 reported
on the Delta (Depuy Orthopaedics, Inc., Warsaw, Indiana)
reversed shoulder arthroplasty for CTA. In their design,
they used a smaller humeral socket in relation to a larger
glenoid hemisphere with the center of rotation (COR) at
the glenoid. This design resulted in pain reduction and im-
provement in functional ROM in multiple studies.9,10
To learn more about the reverse design and procedure,
I traveled to Europe and spent time with Gilles Walch
(Clinique Sainte Anne Lumière, Lyon, France) and Pascal
Boileau (Hôpital de l'Archet, Nice, France), from whom I
learned a great deal about the Delta (Depuy, Warsaw, Indi-
ana) prosthesis. I was interested in using this prosthesis for
one of my patients; however, I could not get Food & Drug 10.1055/978-1-58890-635-9c013_f002
Administration (FDA) approval to use the device in the
United States. So, I began designing a reverse prosthesis in Figure 13–2 The Reverse Shoulder Prosthesis.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience 149

Using the Reverse Shoulder Prosthesis

From 1998 to December 2007, I had performed 773 reverse
shoulder arthroplasties. We have kept a database on these
patients since 1999 to promote our understanding of how
this device treats the RC-deficient shoulder. We evaluate
several outcome measures on each of our patients preop-
eratively and postoperatively and videotape each patient
to assist in documenting the ROM. This has allowed us to
obtain a wealth of information on this patient population.
Currently, my indications for the use of a RSP are

-Irreparable RC tear with glenohumeral arthritis

-Irreparable RC tear with glenohumeral instability
-Failed hemiarthroplasty
-Painful and loose total shoulder arthroplasty with RC
deficiency
Figure 13–3 Ideal position of the central baseplate screw. This screw
My contraindications for this surgical procedure are
follows the centering line as described by Matsen.12 The screw should
-Nonfunctional deltoid muscle exit anteriorly on the scapular neck and is typically around 25 mm in
-Active sepsis length to achieve adequate purchase.
10.1055/978-1-58890-635-9c013_f003
-Excessive glenoid bone loss
-Debilitating neurologic disorder
addition to a scalene block. An extended deltopectoral ap-
-Metal allergy
proach is employed and up to two thirds of the pectoralis
Patients who meet the above indications and have failed major tendon is released. The subdeltoid, subacromial, and
conservative management are candidates to undergo the subcoracoid spaces are released. If the subscapularis ten-
following surgical techniques. don is intact, it is released off the lesser tuberosity just
medial to the long head of the biceps, allowing atraumatic
dislocation of the humeral head with gentle external rota-
Preoperative Considerations and tion (ER) and extension of the arm. The capsule is then
released completely around the humeral neck. Aggressive
Operative Technique
Primary Reverse Shoulder Prosthesis
All patients who undergo a primary RSP receive the same
preoperative workup.11 All patients must have recent x-rays
and a preoperative computed tomography (CT) scan. The x-
rays show the position of the humerus relative to the glenoid
and reveal the degenerative changes of the humerus, glenoid,
and acromion. The axial cuts of the CT scan are evaluated to
look at the wear pattern on the glenoid and plan for proper
central screw placement of the baseplate. In patients who
demonstrate minimal glenoid bone loss, the ideal position
of the central screw will follow the path of the centering line
as described by Matsen and Lippitt12 (Fig. 13–3), in which
the central screw exits anteriorly on the scapular neck. This
typically will provide at least 25 mm of bone for the screw to
achieve purchase. In the majority of our primary RSP cases,
we are able to position the central screw in this position.
For surgery, the patient is placed in the upright beach-
chair position with the head firmly secured and the arm
draped free. The operative arm is positioned sufficiently off
the side of the table to allow for unobstructed movement
in adduction and hyperextension of the shoulder (Fig.
13–4). The patient is administered a general anesthetic in Figure 13–4 Patient prepped and draped in the beach-chair position.
10.1055/978-1-58890-635-9c013_f004
150 Rotator Cuff Deficiency of the Shoulder
B C
resection of any osteophytes is then performed. A neck cut
is made in 30 degrees of retroversion. This cut is made at a
slightly higher level than for a traditional arthroplasty (Fig.
13–5). Sequential broaches are used to prepare the canal.
A B
10.1055/978-1-58890-635-9c013_f005
Figure 13–5 (A) The humerus is cut in 30 de-
grees of retroversion using a version guide and
the forearm as a reference. (B) Cutting guide is
placed; an oscillating saw is used for the humeral
head cut. (C) A thin head cut is used for Reverse
Shoulder Prosthesis cases.
The proximal humerus is then reamed using the smallest
metaphyseal reamer (Fig. 13–6A). Any remaining osteo-
phytes and a portion of the calcar are then resected back
to a recessed position (Fig. 13–6B). The humeral broach is
10.1055/978-1-58890-635-9c013_f006
Figure 13–6 (A,B) Proximal humeral reamers are used to prepare
the humerus.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
Figure 13–7 A 360-degree periglenoid exposure is performed to
prepare for baseplate insertion. 10.1055/978-1-58890-635-9c013_f007
left in place until implantation of the glenoid component
is completed. This sequence allows for sufficient resection
of the proximal humerus to aid in glenoid exposure. The
delay of the last two humeral reamers until the glenoid
preparation is complete maintains adequate humeral bone
stock to support retraction during glenoid preparation.
Glenoid exposure is accomplished by retracting the
proximal humerus posteriorly utilizing a posterior glenoid
retractor, and performing an aggressive 360-degree subpe-
A B
Figure 13–8 (A) A 2.5-mm drill is oriented with 10 to 15 degrees of inferior tilt. (B) The glenoid is tapped along the drill path.
10.1055/978-1-58890-635-9c013_f008
151
riosteal periglenoid capsular release. A Hohman retractor
is then placed anteriorly on the glenoid neck, and a second
Hohman retractor is placed at the superior aspect of the
glenoid (Fig. 13–7). With protection of the axillary nerve,
the inferior capsule is then resected. Once satisfactory vis-
ualization of the glenoid is accomplished, a centering hole
is drilled using a 2.0-mm drill with a slight inferior tilt, fol-
lowed by the 6.5-mm tap (Fig. 13–8). The tap is left in the
glenoid to serve as a guide for placement of the cannulated
glenoid reamers. Sequential cannulated convex ream-
ers are then used to prepare the glenoid for the baseplate
insertion (Fig. 13–9). Next, a fixed angle hydroxyapatite-
coated glenoid baseplate is screwed into place with secure
purchase (Fig. 13–10). Four 5.0-mm locking peripheral
fixation screws are inserted into the glenoid baseplate. In
cases where the locked screw pathway does not have suf-
ficient bone, 3.5-mm nonlocking cortical screw is used and
angled to achieve secure fixation in bone. An appropriately
sized glenosphere (32-mm neutral, 32 - 4 mm, 36-mm
neutral, 36 - 4 mm, 40-mm neutral, 40 - 4 mm) (Fig. 13–11)
is then selected, depending on the degree of soft tissue
contracture, the size of the patient, the quality of glenoid
bone, and the expected degree of instability. It is placed
onto the baseplate via a Morse taper. A retaining screw
is then placed into the central hole on the glenosphere
to augment the Morse taper attachment to the baseplate
(Fig. 13–12). The humeral reaming is then completed and
a trial humeral socket is chosen from a selection of sizes
(neutral, neutral-semi-constrained, +4 mm, +4-mm semi-
constrained, +8 mm, +8-mm semi-constrained) depending
on the soft tissue balancing and degree of instability. Af-
ter reduction with the humeral broach and a trial humeral
socket (Fig. 13–13), transosseous sutures are placed into
the lesser tuberosity for future subscapularis repair. Next,
the appropriate-size humeral implant that would allow a
2-mm circumferential cement interface around the com-
ponent is selected and routinely cemented in place with
antibiotic-laden cement. Our standard practice has been to
152 Rotator Cuff Deficiency of the Shoulder

use antibiotic-laden cement in all cemented arthroplasties

as it has been found to reduce the risk of deep wound in-
fection. The joint is then reduced and checked for stability
especially in abduction, extension, and internal rotation
(the position of greatest instability) and achievement of full
passive elevation is confirmed. Finally the subscapularis
is repaired through drill holes followed by routine closure
using #2 braided polyester sutures. Standard radiographs
are obtained immediately postoperatively (Fig. 13–14).

Figure 13–9 The glenoid is reamed over the tap.
10.1055/978-1-58890-635-9c013_f009
Postoperative Rehabilitation
A shoulder immobilizer is worn for 6 weeks while pendu-
lum-type exercises are performed. After the first 6 weeks,
the patient is transitioned to a sling and supine active as-
sisted ROM exercises are initiated. Active assisted elevation
can begin at 6 weeks, but resistive exercises are delayed un-

A B
Figure 13–10 (A) The glenoid baseplate is then inserted. (B) Implanted Reverse Shoulder Prosthesis baseplate with four 5.0-mm locking screws.
10.1055/978-1-58890-635-9c013_f010

10.1055/978-1-58890-635-9c013_f011

Figure 13–11 There are several options for glenosphere

selection with varying diameters and offsets.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience 153

Figure 13–13 A sawbones model demonstrating a reduction with

trial components in place. 10.1055/978-1-58890-635-9c013_f013

symptomatic with a RC that is nonfunctional. These pa-

Figure 13–12 An implanted glenosphere.
10.1055/978-1-58890-635-9c013_f012
til 12 weeks after surgery. Strengthening and stretching ex-
ercises should continue with maximal functional improve-
ment expected to occur about one year after surgery.
Previous Arthroplasty and Conversion
to Reverse Shoulder Prosthesis
In my practice, I encounter a high volume of referred pa-
tients who have had previous arthroplasty and remain
tients present with pain and poor function of the affected
extremity. Their previous arthroplasties have included
hemiarthroplasty or a bipolar, unconstrained total shoul-
der arthroplasty, and reverse shoulder arthroplasty. The
etiologies for the initial arthroplasty have included proxi-
mal humeral fracture, CTA, and glenohumeral arthritis.
In these groups of revision cases, special technical
measures are required. Each of these groups of patients has
a specific pathology that can be due to the previous proce-
dure they have undergone. We classify these patients into
different groups based on their prior procedure because
this tends to dictate the type of pathology the patient will
have during revision surgery. This allows us to have a pr-
eoperative plan as to what obstacles may be encountered

10.1055/978-1-58890-635-9c013_f014

A Figure 13–14 (A,B) Postoperative x-ray of the Reverse Shoulder Prosthesis.

154 Rotator Cuff Deficiency of the Shoulder

during the revision and enables us to have all the neces-

sary equipment present and ready for the case. Therefore,
one must have an effective way to remove the previous
implant, and then deal with the additional pathology that
can be present in each of these groups of patients.

The Problems of Instability and Bone Loss

For instance, when revising a hemiarthroplasty for frac-
ture, the surgeon should be prepared to deal with scarred
down tuberosities, the proximal humeral bone loss and
instability that can be present after implant removal. To
optimize results, we attempt to recognize this in the pre-
operative setting and plan for it. Additionally, a bipolar or a
hemiarthroplasty with a larger humeral head can produce
a patulous deltoid, making stability an issue in attempting
to convert to the RSP. In this situation, one must anticipate
the need for more conforming sockets and replacing bone
loss to avoid postoperative dislocation. In cases of revision
after hemiarthroplasty for CTA, one must be prepared for
the glenoid bone erosion that often has occurred and may Figure 13–15 Failed hemiarthroplasty with proximal humeral bone loss,
require bone grafting. If it is an unconstrained total shoul- superior migration of the humeral component, and glenoid erosion.
der that is being converted, the surgeon should have an 10.1055/978-1-58890-635-9c013_f015

effective way of removing the glenoid component and ce-

ment to prepare a good bony bed for baseplate implanta-
tion. Lastly, in revising a reverse shoulder arthroplasty the
surgeon must be prepared to encounter broken screws and
other failed hardware. The following sections illustrate our
current surgical approach of converting to the RSP in these
complex cases, and have provided us with reasonable out-
comes, which are described below.
Conversion Hemiarthroplasty for
Fracture
The primary concern in the revision surgery of a hemiar-
throplasty for fracture is removal of the implant and the
potential for proximal humeral bone loss as well as insta-
bility (Fig. 13–15). We obtain recent plain x-rays and a CT
scan of these patients prior to surgery. The plain films give
us information regarding what type of humeral compo-
nent is in place so we can plan for its removal, and also
allows us to look at the tuberosities. The CT scan is impera-
tive to evaluate proximal humeral bone stock as well as the
position of the tuberosities because they are commonly in
a malunited or nonunited position. If the CT scan reveals
a greater tuberosity that has retracted to a posterior posi-
tion, it is valuable information in that we will have to look
for this fragment at the time of surgery. Failure to remove
this fragment at the time surgery can influence the patient
outcome and cause pain, a decrease in postoperative ROM,
or possible instability. The CT scan also provides detail of
the glenoid anatomy to plan for the central screw place-
ment of our baseplate. Before these cases, we are sure to
request a proximal humeral allograft as this may be re-
quired during surgery.
For surgery the patient is positioned in the upright beach-
chair position and is administered a general anesthetic in
addition to a scalene block. The skin incision may utilize
previous skin incisions if they are close to the deltopectoral
interval. If the previous incision is not in close proximity to
the deltopectoral groove a separate skin incision must be
made. This incision is centered directly over the deltopec-
toral groove and is often longer than the incision used for
primary surgery. By making the incision slightly longer, it
allows for identification of undisturbed tissue planes and
can assist in defining normal anatomical planes.
Meticulous dissection must be done using a layered ap-
proach; it often takes additional time due to thick scar for-
mation. Large subcutaneous flaps are created to correctly
identify the deltoid and the pectoralis major. Once the cor-
rect location of the deltopectoral interval is found, it can
then be divided. First, the deltoid needs to be identified and
adequately mobilized. We try to begin proximally, as de-
scribed above, and find the triangular fat interval between
the proximal deltoid and pectoralis major. If this plane has
become obscured due to scar tissue, we start distally sepa-
rating the distal deltoid from the humeral shaft and then
working proximally. The use of Homan retractors placed un-
der the proximal deltoid and under the acromion may help
to develop the subdeltoid and subacromial spaces, which
must be freed. Often the pectoralis major may be scarred
down to the conjoined tendon. Additional time is taken to
identify the pectoralis major and separate it from the un-
derlying conjoined tendon. Separating these two structures
is necessary to find the lateral edge of the conjoined tendon.
 13 Treating the Rotator Cuff-Deficient Shoulder: The Florida Orthopaedic Institute Experience
Figure 13–16 Intraoperative photo showing removal of the head
component. 10.1055/978-1-58890-635-9c013_f016
Once this is found, the subcoracoid space can be identified
and freed from the underlying subscapularis, which can be
scarred to the conjoined tendon. The axillary nerve can then
be palpated, and a tug test is performed.
Next, the RC is assessed to identify remaining portions.
If the subscapularis tendon is intact, it is released subpe-
riosteally from the proximal humerus, allowing atraumatic
dislocation of the humeral hemiarthroplasty with gentle ER
and extension of the arm. The humeral capsule is released
circumferentially from the humeral neck. If the humeral
prosthesis is modular, the humeral head is dislodged from
the Morse taper of the humeral stem using a forked wedge
impactor (Fig. 13–16). The tuberosity position and integ-
A component prior to exposure of fins.
155
rity are then assessed. If either tuberosity is malunited,
it is removed to freely release the RC. Additionally, if the
greater tuberosity is healed in an inferoposterior position
the RC is released off this fragment.
Removal of the hemiarthroplasty is performed in a
stepwise fashion. Circumferential exposure of the proxi-
mal portion of the humeral component is established with
the removal of all soft tissue, bone ingrowth, and cement
from around the humeral head, collar, and fins of the pros-
thesis. This is accomplished using careful dissection with
the aid of an osteotome and a high speed burr. In cases of
proximally coated stems, a thin flexible osteotome is used
to create space between the prosthesis and the bone or ce-
ment interface (Fig. 13–17). Once the medial neck and fins
are properly exposed (Fig. 13–18), the arm is elevated to
90 degrees of abduction and placed on a Mayo stand. The
Carbide punch bone tamp (Moreland Revision Set; DePuy
Orthopaedics, Inc., Warsaw, Indiana) is placed onto an edge
on the medial neck of the prosthesis, and a mallet is used
to deliver a series of controlled horizontal forehand blows
parallel to the humeral shaft to initially dislodge the hemi-
arthroplasty from the cortical bone or cement mantle (Fig.
13–19). Once the prosthesis is loose, the arm is placed into
full adduction and the tamp is used in an upward fashion
parallel to the humeral shaft to deliver the hemiarthro-
plasty stem out of the intramedullary canal (Fig. 13–20). In
cases in which the stem is difficult to remove, more aggres-
sive measures may have to be taken to loosen the implant.
In these cases the humerus can be split along the medial
cortex to facilitate stem removal (Fig. 13–21). If that is un-
successful, a larger medial window can be created to dis-
lodge the stem and remove the implant (Fig. 13–22).
Once the humeral hemiarthroplasty is removed, the
subscapularis is tagged for future repair. Any additional
heterotopic ossification and osteophytes are resected.
When present, the previous cement mantle is left intact.
Sequential handheld diaphyseal reamers are placed within
B
10.1055/978-1-58890-635-9c013_f017
Figure 13–17 (A) Intraoperative photo
demonstrating use of a flexible osteotome
to expose all fins of the humeral implant.
(B) Sawbones model demonstrating humeral
156 Rotator Cuff Deficiency of the Shoulder

10.1055/978-1-58890-635-9c013_f018

Figure 13–18 (A) Intraoperative photo

showing exposure fins on the humeral com-
ponent. (B) Sawbones model showing fins
A B now exposed.

the intramedullary canal to gently prepare the humerus,
and a trial broach is introduced until it is seated just dis-
tal to the neck cut. The remainder of the surgical proce-
dure consists of inserting the RSP in a similar manner to
that described earlier in this chapter. The main difference
in these cases of conversion of the hemiarthroplasty for
fracture is that a proximal humeral allograft may need to
be added due to humeral bone loss. In our early revision
arthroplasty cases, we have experienced some polyethyl-
ene failures in patients who had moderate to severe bone
loss preoperatively on the humeral side and did not have a
proximal humeral allograft placed.
In cases where the proximal humerus has severe bone
loss (Fig. 13–23), we now employ the use of a proximal hu-
meral allograft to support the cemented humeral compo-
nent. A fresh frozen humeral allograft is prepared to match
the proximal humerus. To do this, we cut the humeral head
of the proximal humeral allograft at the level of the ana-
tomical neck and remove all the cancellous allograft bone
from the intramedullary canal. We then determine the ap-
propriate height of the allograft by inspecting how much
diaphyseal bone remains and estimating how much proxi-
mal humerus will need to be replaced to restore the bone
stock and allow for a stable reduction (Fig. 13–24). An os-

10.1055/978-1-58890-635-9c013_f019

Figure 13–19 (A) The arm is initially placed in 90 degrees of abduc-

tion on a Mayo stand to allow the surgeon to use parallel forehand
blows in line with the humerus in an effort to loosen the prosthesis.
(B,C) A tamp is placed on the medial aspect of the prosthesis as the
C forehand blows are applied.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience 157

10.1055/978-1-58890-635-9c013_f020

Figure 13–20 (A–C) Once the component is loose the arm is placed
in full adduction and upward blows parallel to the humerus are used to
C deliver the humeral component from the intramedullary canal.

Figure 13–21 A split of the medial calcar of the proximal humerus Figure 13–22 If the component remains fixed, a medial window can
may be necessary in cases where implant extraction is difficult. be used to help with extraction. 10.1055/978-1-58890-635-9c013_f022
10.1055/978-1-58890-635-9c013_f021
158 Rotator Cuff Deficiency of the Shoulder

cillating saw is then used to create a step-cut of the meta-

Figure 13–23 Intraoperative photo after removal of humeral com-
ponent showing severe proximal humeral bone loss.
10.1055/978-1-58890-635-9c013_f023
physeal bone where 5 cm of bone remain laterally creating
a lateral plate and 1 to 2 cm of bone remain medially (Fig.
13–25). All soft tissue is removed with the exception of the
subscapularis tendon, which can later be used for repair of
the patient’s subscapularis. The proximal humeral allograft
is then cabled to the native humerus and a humeral guide
is used to ensure that the humeral stem and allograft are
oriented correctly (Fig. 13–26). The humeral component is
then cemented into this construct and the cables are tight-
ened (Fig. 13–27). It is especially in these revision cases
that we try and consider the various humeral implants
(neutral, neutral semi-constrained, +4 mm, +4-mm semi-
constrained, +8 mm, +8-mm semi-constrained) depending
on the soft tissue balancing and degree of instability.

B
10.1055/978-1-58890-635-9c013_f024

Figure 13–24 (A) A trial reduction is performed to measure the

height of the allograft that will be needed in fashioning the proximal
humeral allograft. (B) Intraoperative photo showing a trial reduction
A to assess the amount of proximal humeral bone loss.

10.1055/978-1-58890-635-9c013_f025

Figure 13–25 (A) A step-cut osteotomy is performed. The amount

A B
of medial calcar that is left is determined by the measurement
made during trial reduction establishing the appropriate height
of the allograft. (B) A proximal humeral allograft is shown here.
The humerus is cut at the anatomical neck. All cancellous bone is
removed from the intramedullary canal. An oscillating saw is used
to create a step-cut of the metaphyseal bone leaving 5 cm of bone
laterally creating a lateral plate and 1 to 2 cm of bone remaining
medially. The subscapularis is left intact and used in the subscapu-
laris repair.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience 159

Augmentation of the proximal humerus with allo-

graft provides three distinct advantages. First, the corti-
cal support of the allograft provides additional rotational
and structural stability thereby decreasing stress on the
humeral component. Also of importance, the allograft
provides a subscapularis tendon that can be utilized for
subscapularis repair. Lastly, reestablishing the proximal
humerus may improve deltoid function. Adding the allo-
graft increases the distance from the COR to the action of
the deltoid muscle increasing the lateral offset and mo-
ment arm of the deltoid.

Conversion of a Hemiarthroplasty for

Figure 13–26 Sawbones model demonstrating how the proximal
humeral allograft is then cabled to the native humerus and a version
guide is used to ensure the correct orientation as the humeral stem is
placed into the allograft construct. 10.1055/978-1-58890-635-9c013_f026
Cuff Tear Arthropathy to the Reverse
Shoulder Prosthesis
Patients with a previous hemiarthroplasty for CTA may
develop pain and decreased function as a result from

A B

10.1055/978-1-58890-635-9c013_f027

Figure 13–27 (A) Sawbones, (B) intraoperative, and (C) post-

C operative photos showing the final construct.
160 Rotator Cuff Deficiency of the Shoulder

progressive glenoid erosion. Thus, as the glenoid erodes,

continual loss of glenoid bone stock arises and may pro-
duce difficulty in obtaining adequate fixation of the gle-
noid component. Preoperative planning to evaluate the
morphology and amount of glenoid bone loss utilizing
recent x-rays and a CT scan is especially valuable in these
cases. We do this to gain an understanding as to where
the optimal bone stock will be to safely place our central
screw for our baseplate fixation. In patients who demon-
strate minimal glenoid bone loss, the ideal position of the
central screw will follow the path of the centering line as
described by Matsen, in which the central screw exits an-
teriorly on the scapular body. This typically will provide
at least 25 mm of bone for the screw to achieve purchase.
However, in cases of severe glenoid bone loss, this position
of the center screw will provide for an inadequate amount
of bone to secure the screw (<25 mm). Therefore, a differ-
ent orientation of the screw should be achieved to increase
the amount of bone captured by this screw. In our work Figure 13–29 Preoperative computed tomography (CT) scan dem-
examining cadaveric shoulders as well as our operative onstrating the location of the intersection between the scapular
experience, we have found that a dense column of bone spine and the scapular body. CT is used to identify the anticipated
is present in the area where the scapular spine meets the trajectory of the center screw. 10.1055/978-1-58890-635-9c013_f029
scapular body (Fig. 13–28). When evaluating the CT in the
preoperative setting, we try to identify the anticipated tra-
jectory of the center screw (Fig. 13–29). Additionally, in and the glenoid is exposed in the same manner as mentioned
these circumstances of significant glenoid bone loss, resto- above. As noted, the main difference in these revisions is the
ration of glenoid bone stock with bone grafting techniques potential for glenoid bone loss to be present; thus the insertion
has been helpful. of the glenoid components can differ in this scenario.
The patient positioning and a layered surgical approach in It can be a significant challenge reconstructing the gle-
these revisions is the same as mentioned above in the section noid side and achieving stable fixation when there is minimal
on revising hemiarthroplasties that were placed for fracture. bone stock present. In our experience with revision surgery
The hemiarthroplasty is removed in a similar stepwise fashion the rate of failure has been higher in those with glenoid-

A B

Figure 13–28 This area where the scapular spine meets the scapular
body typically contains a dense region of bone. This area of bone may
allow screw purchase in the revision setting.
10.1055/978-1-58890-635-9c013_f028
C D
Figure 13–30 Sawbones model depiction of glenoid bone loss.
(A) No bone loss, (B) superior bone loss, (C) posterior bone loss, and
(D) anterior bone loss.10.1055/978-1-58890-635-9c013_f030
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
sided bone loss. In reviewing the pattern of glenoid bone loss,
the most common is eccentric posterosuperior bone loss. The
next most common pattern of bone loss is superior, followed
by posterior, and finally anterior (Fig. 13–30). In addition to
loss of the peripheral bone, a varying degree of the central
cavity of the glenoid may be eroded, and can progress to
involve the entire glenoid neck.
The following methodology has been utilized to deal
with glenoid bone loss. In cases of severe posterior gle-
noid bone loss (Fig. 13–31), it is critical to obtain adequate
purchase with our central screw of the baseplate. As noted
above, a dense column of bone is present in the area where
the scapular spine meets the scapular body. To access this
column of dense bone, we orient the drill slightly more
posteriorly than we would for a primary RSP with no gle-
noid bone loss (Fig. 13–32). This posterior trajectory al-
lows penetration of this thick bony area at the base of the
scapular spine. In tapping this area after drilling, we have
been able to achieve an impressive amount of purchase
despite the level of bone loss (Fig. 13–33). The superior
and inferior screws are in line with the central screw of the
baseplate; therefore, if the central screw is properly posi-
tioned, the superior and inferior screws typically will have
excellent purchase as well. Once this central position is felt
to be adequate, we place a structural bone graft around
the 6.5-mm tap (Fig. 13–34). The structural allograft is se-
cured with Kirschner wires. The glenoid is then reamed to
allow the grafted region to match the rest of the glenoid
(Fig. 13–35). A similar change of orientation of the central
screw has been successful in the other defects, but the po-
sition of the graft will be dependent on the original defect.
In global defects where the entire glenoid has been eroded
Figure 13–31 X-ray demonstrating superior migration of the hemi-
arthroplasty with superior glenoid erosion.
10.1055/978-1-58890-635-9c013_f031
161
and the only remaining bone is the junction of the coracoid
base with the scapular body spine junction, central screw
fixation down the column of bone between the scapular
spine has been successful.
The baseplate is then placed via the central screw and
the superior, inferior, anterior, and posterior screws are
placed to secure the baseplate (Fig. 13–36). A glenosphere
with a more medial COR (-4 mm) and extended hooded
coverage may also now be used to dial into any remain-
ing defect, providing additional support of the graft and
a decreased amount of force across the baseplate-glenoid
interface (Fig. 13–37). We have found this strategy suc-
cessful regardless of the location of bone loss—whether it
is posterior, superior, or anterior. The surgery is then com-
pleted by inserting the humeral component in the same
manner that has been discussed in the previous sections.
Conversion of an Unconstrained Total
Shoulder Arthroplasty to Reverse
Shoulder Prosthesis
Patients who have had an unconstrained total shoulder
arthroplasty as their index procedure differ from the pa-
tients discussed in the above section in that they have a
cemented glenoid component in place. If the RC is non-
functional, the glenoid component may have loosened due
to the “rocking horse” phenomenon that was discussed
earlier. The nonfunctional RC also leads to instability as the
humeral component migrates proximally. These complica-
tions often lead to pain and poor function necessitating
revision. Once again, preoperative x-rays and a CT scan are
obtained (Fig. 13–38). These studies are used to gain infor-
mation about the implant that is in place, and to evaluate
the glenoid in preparation for baseplate placement.
The patient positioning, surgical approach, and removal
of the humeral component is the same as mentioned in the
above sections describing revision. The key difference in
these cases is the removal of the glenoid component. This
is done carefully to effectively remove the previous cement
to prepare a good bony bed for baseplate implantation.
Overaggressive removal of the cement can lead to glenoid
bone loss. Often there is cavernous area in the glenoid due
to a previous pegged or keeled component and this can
give the appearance that there is not adequate bone for
fixation. Once again, in these settings we drill in a more
posterior direction to engage the bone at the intersection
of the scapular spine with the scapular body (Fig. 13–39).
If significant bone loss is present after removal of the com-
ponent, we use the above-mentioned glenoid bone graft-
ing techniques. Once again, a -4 mm glenosphere may be
needed to decrease forces across the baseplate interface if
bone loss is extensive. The surgery is completed with the
same technique mentioned above when implanting the
humeral component (Fig. 13–40).
162 Rotator Cuff Deficiency of the Shoulder

C D

10.1055/978-1-58890-635-9c013_f032

Figure 13–32 (A) Preoperative radiograph, and (B) computed tom-

ography scan showing the proper trajectory of the central screw that
will be necessary in this revision setting where bone loss is present.
(C) Sawbones model, and (D) intraoperative photo showing poste-
rior glenoid bone loss. (E) Sawbones model demonstrating the pos-
terior trajectory of the 2.5 mm drill used in bone loss cases to engage
E the dense bone at the junction of the scapular spine and body.
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
Figure 13–33 Depth gauge in place showing the posterior trajectory
of the central screw for cases with severe glenoid bone loss.
10.1055/978-1-58890-635-9c013_f033
Removal of Bipolar Arthroplasty and
Conversion to the Reverse Shoulder
Prosthesis
The concern in revising a bipolar arthroplasty is that the
larger humeral head can stretch out the deltoid making
stability an issue in attempting to convert to the RSP. In this
situation, one must anticipate the need for more conform-
ing sockets and replacing bone loss to avoid postoperative
dislocation. Preoperative x-rays and CT scan are evaluated
in the standard fashion to prepare for surgery.
The patient positioning, surgical approach, and removal
of the humeral component is the same as mentioned above
in the other sections describing revision. The same tech-
niques are utilized for insertion of the glenosphere. The
10.1055/978-1-58890-635-9c013_f035
Figure 13–35 (A,B) The glenoid has been reamed over the
allograft to allow the grafted region to match the rest of the
glenoid.
163
Figure 13–34 A case with superior glenoid bone loss. The structural
allograft is placed around the 6.5-mm tap and secured with Kirschner
wires. 10.1055/978-1-58890-635-9c013_f034
most critical portion in these cases is implantation of the
humeral component. If severe bone loss is present on the
humeral side, a proximal humeral allograft may be placed
using the techniques described earlier. In trialing these hu-
meral components, it is imperative to asses the tension in
the deltoid. If the previous implant has produced a patu-
lous deltoid then instability may be problem. In trialing,
one must chose from a selection of sizes (neutral, neutral
semi-constrained, +4 mm, +4-mm semi- constrained, +8
mm, +8-mm semiconstrained) depending on the soft tissue
balancing and degree of instability in effort to pick the best
component.
B
164 Rotator Cuff Deficiency of the Shoulder

10.1055/978-1-58890-635-9c013_f036

Figure 13–36 (A) Sawbones and (B) intraoperative photo

A showing a posterior glenoid defect that has been grafted.

Revision of a Reverse Prosthesis to Refinement of Our Techniques

the Reverse Shoulder Prosthesis
In revising a reverse prosthesis, the main concern is the
associated bone loss and retained failed hardware. Preop-
erative planning should try and estimate the amount and
location of bone loss both on the humerus and glenoid. The
previous location of retained hardware often can be left in
place, but broken screw location should be noted as it can
block placement of additional screws.
It is important to point out the changes in our surgi-
cal technique and the modifications in the design of the
RSP that have occurred with time and experience. These
changes stem from the results we have seen in our patients
and from the biomechanical studies we have undertaken.
Since 1998, several modifications have been made to re-
duce the likelihood of mechanical failure. As noted in our
technique we now use four 5.0 mm locked cortical screws

A B
Figure 13–37 (A) Model demonstrating posterior glenoid bone of a case in which the glenoid was grafted and the central screw of
loss. The hooded portion of the glenosphere is positioned over the the baseplate was directed in a more posterior trajectory.
grafted region to provide additional support. (B) Postoperative x-ray 10.1055/978-1-58890-635-9c013_f037
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
B
C
Figure 13–38 (A) Preoperative x-ray of a failed total shoulder with
proximal migration of the humeral component. (B) Preoperative
computed tomography scan with arrow depicting the target of the
central screw. (C) After removal of the glenoid component, there can
be cavernous defects where the glenoid fixation once was.
10.1055/978-1-58890-635-9c013_f038
165
Figure 13–39 Intraoperative photo showing 2.5-mm drill bit with
slight posterior trajectory due to glenoid bone loss after removal of
the glenoid component. 10.1055/978-1-58890-635-9c013_f039
instead of 3.5 mm nonlocked screws, as was initially done,
to secure the glenoid baseplate. This locked design inhibits
toggling at the bone–baseplate interface, and the larger
diameter shank allows for an increased force to failure as
we reported in 2005.13 Another adaptation is the angle at
which the baseplate is inserted. A slight 10- to 15-degree
inferior tilt is used for the orientation of the baseplate with
respect to the glenoid. We found that this minimizes shear
forces across the bone–baseplate interface, and makes the
compressive forces more uniform across this interface.13
Lastly, in patients with poor glenoid bone quality we were
concerned about the fixation of the baseplate. This led us
to develop glenospheres that differed from our standard
implant, which has the lateral COR to optimize motion and
decrease the chance of impingement. The glenospheres
with the -4 mm option allow us to choose to medialize the
COR of our implant in the subset of patients with subop-
timal glenoid bone stock. This more medial COR increases
the moment arm and decreases the stress at the bone–
baseplate interface at the glenoid.
Two modifications have been used to improve the
stability of the glenohumeral articulation. Larger gleno-
spheres (36 mm and 40 mm) are now available. This al-
lows for greater coverage than the smaller diameter 32-
mm head. Deeper, semi-constrained sockets are available
for the humeral side to provide greater stability at the ar-
ticulation. In this case, we must sacrifice some theoretical
ROM for stability. Our algorithm for component selection
is seen in Fig. 13–41.
Finally, to reduce the chance of component dissocia-
tion, two modifications have been made. To reduce the risk
of glenosphere dissociation from the baseplate, a 3.5 mm
retaining screw is now used to lock the glenosphere to the
baseplate and augment the Morse taper between the two
components. Additionally a metal shell has been added
to the polyethylene liner on the humeral socket. This de-
creases the likelihood of the polyethylene dissociating
from the humeral stem.
166 Rotator Cuff Deficiency of the Shoulder
A B
Results
Primary Reverse Shoulder Prosthesis as
the Treatment for Cuff Tear Arthropathy
Since 1999, we have had 215 shoulders that were treated
with a primary RSP arthroplasty with >2-year follow-up.
Figure 13–41 Our algorithm for glenosphere selection. RSP, Reverse Shoulder Prosthesis; GH, glenohumeral; COR, center of rotation; ROM,
range of motion. 10.1055/978-1-58890-635-9c013_f041
10.1055/978-1-58890-635-9c013_f040
Figure 13–40 (A,B) Postoperative x-rays after
conversion of a total shoulder to a Reverse Shoul-
der Prosthesis. Note the posterior trajectory of
the central screw to engage the dense bone at the
junction of the scapular spine and body.
Fifteen of these patients have subsequently died and 12
were lost to follow-up, leaving 188 shoulders available for
analysis at 2 years. One hundred three of these procedures
were performed on shoulders with no previous history of
any surgery, and 85 had previous history of RC surgery.
Both groups of patients have shown statistically signifi-
cant improvements when preoperative and postoperative
American Shoulder and Elbow Surgeon’s (ASES) pain scores
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
were compared.14 The group without surgery showed an
average improvement from 15.0 to 39.8 (p < 0.0001), and
the group with previous surgery improved from 16.1 to
37.6 (p < 0.0001). Both groups have shown statistically sig-
nificant improvements with respect to preoperative and
postoperative ASES functional scores. The group without
surgery showed average improvements of 15.9 to 30.6 (p
< 0.0001), and the previous surgery group improved from
16.2 to 28.8 (p < 0.0001). The visual analog scores for func-
tion and pain also showed statistically significant improve-
ments postoperatively.
With respect to ROM, each group of patients has had
statistically significant improvements in their forward
elevation and abduction. The patients without surgery
improved their forward elevation from 61 to 122 degrees
(p < 0.0001) and their abduction from 50 to 111 degrees
(p < 0.0001). When considering ER, the group of patients
without surgery demonstrated an average postoperative
increase of 12 degrees (p < 0.005). The group with prior
surgery showed a slight increase in postoperative ER, but
did not reach statistical significance. Overall, treatment of
the RC-deficient shoulder with the RSP has been a very
reliable way to decrease our patients’ pain and improve
their function.
Conversion of Failed Hemiarthroplasty
for Fracture to the Reverse Shoulder
Prosthesis
Some of the techniques mentioned here grew out of our
experience with patients who have had a failed hemiar-
throplasty for fracture. These patients may present with
stiffness, tuberosity malunion, or nonunion resulting in a
nonfunctional RC, instability, and glenoid arthritis. These
failures related to glenoid arthritis and RC deficiency due
to tuberosity malunion, nonunion, or resorption can be
devastating to the patient’s function. Since 2007, we have
had 61 patients who were treated for failed hemiarthro-
plasty for fracture with conversion to the RSP and are at
least 2 years into their follow-up. Of this group, 5 have
passed away and 2 have been lost to follow-up, leaving 54
shoulders available for our analysis. All of these patients
had some degree of glenoid arthritis and an irreparable
RC due to malunion, nonunion, or tuberosity resorption.
All of these patients were managed with a single-stage
conversion. Of this group of patients, some were treated
with a proximal humeral allograft in conjunction with the
implantation of the RSP.
These patients had a substantial improvement in their
pain and functional scores. The ASES scores for pain im-
proved from 13.2 to 31.8 (p < 0.0001) and the ASES func-
tion scores improved for 13.0 to 19.4 (p = 0.015). The visual
analog scores for pain and function also showed statisti-
cally significant improvements. The forward flexion in this
167
group of patients went from 45.7 to 74.2 degrees after sur-
gery (p = 0.0002). Abduction improved from 36.6 to 66.4
degrees after surgery (p < 0.0001).
This group of patients presents a difficult predicament
for the shoulder surgeon. The addition of the proximal hu-
meral allograft has become an important component of our
reconstruction on the humeral side in these cases. Given our
experiences we feel that this procedure is a viable salvage for
patients who have a failed hemiarthroplasty for fracture and
have no other reconstruction options. The surgery is techni-
cally demanding and can have significant complications.
Failed Hemiarthroplasty for Glenoid
Arthritis and a Rotator Cuff-Deficient
Shoulder
We have followed a group of patients who had severe pain
and loss of function after undergoing an index procedure
of hemiarthroplasty for glenohumeral arthritis associ-
ated with severe RC deficiency. It is in this patient popu-
lation that we most consistently encounter some degree
of glenoid bone. Over time, the hemiarthroplasty tends to
migrate proximally and erode the articular surface of the
glenoid, producing pain. It is not uncommon for us to be
required to perform our glenoid bone-grafting techniques
in these cases due to significant glenoid bone loss. To date,
we have 20 shoulders in 19 patients whom we have fol-
lowed for >2 years after we performed their revision sur-
gery. Each of these patients was treated with a single-stage
conversion to a RSP. The average age at the time of revision
surgery was 72 years old.
We have performed preoperative and postoperative
clinical and radiographic assessments on these patients. We
felt it was important to document the position of the ar-
throplasty with respect to subluxation, and to radiographi-
cally evaluate the amount of bone loss on the glenoid and
humeral sides before and after conversion to the RSP. We
noted that 90% of the shoulders (18/20) had moderate to se-
vere static shift in joint position preoperatively. Moderate to
severe peripheral glenoid erosion was seen in 65% (13/20),
and 40% (8/20) had moderate to severe acromial erosion.
Clinically, the results from this group of patients have
been promising. All patients had statistically significant im-
provements in their visual analog scale pain score and func-
tional score. Statistically significant improvements were
also seen in the average total ASES scores, forward flexion
(49.7 to 76.1 degrees), and abduction (42.2 to 77.2 degrees).
The goal of the conversion to the RSP in this group of
patients was pain relief, and was achieved in all the pa-
tients. It was an added bonus that we found statistically
significant improvements in functional scores and ROM. In
our experience, conversion to the RSP is a good option to
treat the patient with a failed hemiarthroplasty who has
significant pain and poor function.
168 Rotator Cuff Deficiency of the Shoulder
Failed Total Shoulder Arthroplasty
Converted to the Reverse Shoulder
Prosthesis
Conventional unconstrained total shoulder arthroplasty
requires a functional RC for the shoulder to perform prop-
erly. We have performed revision surgery in a group of pa-
tients who had a primary total shoulder arthroplasty in
which the RC has subsequently failed. These patients pre-
sented with pain and decreased function due to the proxi-
mal migration of the humeral component. To date, we have
17 shoulders which underwent this conversion and are at
least 2 years out from their revision surgery. Two patients
have passed away leaving 15 for analysis with at least 2
years of follow-up.
Our results in this group show that conversion to the
RSP can decrease pain and increase function. These pa-
tients' ASES pain scores went from 18.3 to 33.1 (p = 0.0062)
and the ASES functional scores improved from 11.6 to 25.4
(p = 0.0022) after surgery. The visual analog pain scores de-
creased (p = 0.0062) and the visual analog function scores
increased (p = .0003). The average preoperative forward
flexion for these patients was 36 degrees and increased to
93 degrees after surgery (p = 0.0005). The abduction went
from 29 to 83 degrees (p = 0.0004) and ER improved from
8 to 51 degrees (p = 0.0073).
Conversion of Bipolar Arthroplasty
To date we have converted 11 bipolar arthroplasties to the
RSP. Nine of these have follow-up greater than 2 years and
are available for analysis. Due to the small sample size, we
have not been able to achieve statistical significance with
respect to patient outcomes, despite the fact the trends
demonstrate improvement postoperatively. The data we
have shows postoperative improvement in ASES pain and
function scores, visual analog pain and function scores,
and ROM.
Revision of Reverse Prosthesis and
Conversion to the Reverse Shoulder
Prosthesis
To date, we have revised 16 reverse shoulder arthroplasties
and converted them to the RSP, nine of whom have greater
than 2-year follow-up and are available for analysis. This
group of patients have demonstrated improvement in
their ASES scores from 33.1 to 71.9 (p = 0.0089). They have
also had statistically significant improvement in forward
flexion from 63 to 134 degrees (p = 0.001) and abduction
from 45 to 107 degrees (p = 0.0004).
Complications
The Reverse Shoulder Replacement has been associated
with certain complications. Some of these complications
have been related to the prosthesis itself, whereas others
were related to the pathology that was treated. We have ex-
perienced complications on the glenoid and humeral side
of the arthroplasty, and have also dealt with issues of ac-
romial fracture, component disassociation, instability, and
infection. Complications are much more common in the
revision setting because these are technically more difficult
operations. Revision surgery with the RSP in our studies
showed a high complication rate (30%). This is similar to
other large series in the literature. Boileau et al14 reported
42% of his patients required reoperation after conversion
of failed hemiarthroplasty to a reverse prosthesis. Based
on our experience the high complication rate in revision
surgery appears to be related to the amount of preopera-
tive bone loss. As noted earlier in the chapter, over the years
we have made modifications to the device and to our tech-
niques in an effort to minimize these complications.
The main glenoid complication we have encountered
has been due to failure of fixation of the baseplate. In de-
signing an implant with a more lateral COR, the forces at
the glenoid are increased in comparison to the more me-
dial COR in Grammont’s design. In our early series, almost
all the failures requiring revision were due to mechanical
failure of the baseplate. In each of the revision surgeries,
evaluation of the porous surface of the glenoid baseplate
revealed no evidence of osseous ingrowth. The number of
glenoid baseplate failures in this initial study prompted us
to explore ways to improve the baseplate fixation. Since
our initial study, we have made the previously mentioned
changes to our technique, most notably using 5.0-mm
locked cortical screws to secure the baseplate. Prior to
making this change we had a total of 23 baseplate fail-
ures. Since making this change, we have seen a marked
improvement in our fixation and have had zero baseplate
failures. We will continue to follow this cohort of patients
closely and plan to report these findings at their 2-year
postoperative point. In the revision setting our glenoid
complications have been much higher in the patients with
significant bone loss. Our positioning of our central screw
in dense bone, and the glenosphere option of a more me-
dial COR have helped to limit glenoid complications in the
patients with poor bone stock.
On the humeral side, we have treated four postoperative
periprosthetic fractures. These have been related to patient
falls or trauma. A few of these patients have required revi-
sion surgery with either open reduction and fixation or
conversion to a long-stem prosthesis. We have also seen
polyethelene failure on the humeral side in a third of our
patients. These were patients in our revision of hemiar-
throplasty group who had experienced proximal humeral
 13 Treating the Rotator Cuff–Deficient Shoulder: The Florida Orthopaedic Institute Experience
bone loss and were not treated with a proximal humeral
allograft at the time of their revision. In our series on failed
hemiarthroplasty the patients who did undergo proximal
humeral allograft did not encounter this problem. We be-
lieve the cortical support of the allograft provides addi-
tional rotational and structural stability, thereby decreas-
ing stress on the humeral component. We now employ the
use of proximal humeral allografting in our patients with
severe bone loss. In our series of primary reverse shoulder
arthroplasty, we have seen only one case of humeral loos-
ening and this has not been a significant issue.
Instability is another complication seen in our patients
after undergoing reversed arthroplasty. We have had an
overall dislocation rate of 3.1% (24/773). Two modifica-
tions have been used to improve the stability of the gleno-
humeral articulation. Larger glenospheres (36 mm and 40
mm) are now available and used. This allows for greater
coverage than the smaller diameter 32 mm head. Deeper,
semi-constrained sockets are available for the humeral
side to provide greater stability at the articulation if insta-
bility is a concern.
Component disassociation has been a reported compli-
cation of reversed arthroplasty. Humeral disassociation has
occurred in 1.2% (9/773) of our patients and glenosphere
disassociation has occurred in 0.5% (4/773). To combat
this, we have added a 3.5-mm retaining screw to lock the
glenosphere to the baseplate and augment the Morse taper
between the two components. Additionally, a metal shell
has been added to the polyethylene liner on the humeral
socket to limit this complication.
Acromial fracture has been reported in the literature
and has been seen in our patient population. Overall we
have had four patients sustain a postoperative acromial
fracture. One of these acromial fractures was felt to be a re-
sult of overaggressive physical therapy. Consequently, we
References
1. Parsons IM, Apreleva M, Fu FJ et al. The effect of rotator cuff tears
on reaction forces at the glenohumeral joint. J Orthop Res 2002;
20(3):439–446
2. Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-
term functional results. J Bone Joint Surg Am 1979;61(5):668–677
3. Lettin AW, Copelan SA, Scales JT. The Stanmore total shoulder re-
placement. J Bone Joint Surg Br 1982;64(1):47–51
4. Franklin JL, Barrett WP, Jackine SE, et al. Glenoid loosening in total
shoulder arthroplasty. Association with rotator cuff deficiency. J
Arthroplasty 1988;3(1):39–46
5. Arntz CT, Matsen RA III, Jackins S. Surgical management of complex
irreparable rotator cuff deficiency. J Arthroplasty 1991;6(4):363–
370
6. Sanchez-Sotelo J, Cofield RH, Rowland CM. Shoulder hemiarthro-
plasty for glenohumeral arthritis associated with severe rotator
cuff deficiency. J Bone Joint Surg Am 2001;83-A(12):1814–1822
7. Fenlin JM Jr. Total glenohumeral joint replacement. Orthop Clin
North Am 1975;6(2):565–583
169
no longer use a formal physical therapist in the early post-
operative setting. Patients are instructed how to do active
assisted ROM at the 6-week point and do these exercises
themselves. At present, patients who sustain an acromial
fracture are treated symptomatically and open reduction
and internal fixation is not performed.
Deep postoperative infections have occurred in 2.1%
(16/773) of our patients. These have been treated with
aggressive débridements, intravenous antibiotics, and re-
tention of the prosthesis. We have not had to remove any
implants for recurrent infections that were not able to be
eradicated. In our series, there have been three cases of
postoperative hematoma that required return to the oper-
ating room for evacuation of the hematoma.
It is important to note that scapular notching is a com-
mon reported complication of those patients treated with
a reversed device that has the COR at the glenoid. In a re-
cent multicenter study using this type of device, the inci-
dence of notching was reported at 64%.17 In our series of
patients treated with the RSP with the more lateral offset
of the COR, scapular notching has not been an issue. We
feel this is one of the significant benefits to this design.
Conclusion
The development of the RSP has been an interesting jour-
ney. In our attempts to find a better way to treat patients,
we have gained significant insight into the RC-deficient
shoulder. We have utilized clinical data, biomechanical
studies, and implant design to arrive at a treatment that
we feel is the best option to help these patients now. In
the coming years, we will continue to follow our patients
closely in an effort to continue to gain more information
about the RC-deficient shoulder and the RSP.
8. Grammont PM, Baulot E. Delta shoulder prosthesis for rotator cuff
rupture. Orthopedics 1993;16(1):65–68
9. Jacobs R, Debeer P, De Smet L. Treatment of rotator cuff arthrop-
athy with reversed Delta shoulder prosthesis. Acta Orthop Belg
2001;67(4):344–347
10. Boulahia A, Edwards TB, Walch G, et al. Early results of a reverse design
prosthesis in the treatment of arthritis of the shoulder in elderly pa-
tients with a large rotator cuff tear. Orthopedics 2002;25(2):129–133
11. Frankle M, Levy J, Pupello D, Siegal S, Saleem A, Mighell M, Vasey
M. The reverse shoulder prosthesis for glenohumeral arthritis as-
sociated with severe rotator cuff deficiency. A minimum two-year
follow-up study of sixty patients: Surgical technique. JBJS Am Sep
2006;88:178–190
12. Matsen MA, Lippitt SB. Shoulder Surgery Principles and Proce-
dures. 1st ed. Philadelphia, PA: WB Saunders; 2004:495–496
13. Harman M, Frankle M, Vasey M, Banks S. Initial glenoid component
fixation in reverse total shoulder arthroplasty: a biomechanical
evaluation. J Shoulder Elbow Surg 2005; 14(1): S162–S167
170 Rotator Cuff Deficiency of the Shoulder
14. Richards RR, An KN, Bigliani LU, Friedman RJ, Gartsman GM, Gris-
tina AG, et al. A standardized method for the assessment of shoul-
der function. J Shoulder Elbow Surg 1994;3:347–352
15. Gutierrez S, Griewe M, Frankle M, Siegal S. Biomechanical com-
parison of component position and hardware failure in the reverse
shoulder prosthesis. J Shoulder Elbow Surg 2007;35:9–12
16. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse
prosthesis: design, rational, and biomechanics. J Shoulder Elbow
Surg 2005;14:147s–161s
17. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Gram-
mont inverted total shoulder arthroplasty in the treatment of
glenohumeral osteoarthritis with massive rupture of the cuff. Re-
sults of a multicentre study of 80 shoulders. J Bone Joint Surg Br
2004;86:388–395
18. Williams GR Jr, Rockwood CA Jr. Hemiarthroplasty in rotator cuff-
deficient shoulders. J Shoulder Elbow Surg 1996;5(5):362–367
19. Pollock RG, Deliz ED, McIlveen SJ, et al. Prosthetic replacement
in rotator cuff deficient shoulders. Orthopaedic Transactions
1993;16:774–775
 14 Tissue Engineering for the Rotator
Cuff–Deficient Shoulder
Joshua S. Dines, Daniel P. Grande, and David M. Dines

Surgical repair of rotator cuff (RC) tears often results in
good to excellent results. However, when evaluated by ul-
trasound or magnetic resonance imaging (MRI), up to 50%
of these tears has been shown to fail to heal.1–6 Many pa-
tients improve clinically; nevertheless, results are clearly
better in cases where the repaired tendon heals.1,2 Initially,
efforts to enhance healing focused on improving mechani-
cal factors, such as the type of suture used, type of knots
used, and anchor configuration. Recently, studies have
focused on improving the biologic process of healing.7–10
Extracellular matrix scaffolds, growth factors, and gene
therapy all may play a role in improving RC tendon healing
in the future. In addition, the ideal healing of massive RC
tears will involve reversal of the fatty muscle degeneration
that accompanies these tears.
Extracellular Matrix Scaffolds
At this time, extracellular matrices (ECMs) are the most
commonly used biologic augments to tendon healing.
ECMs are commercially available patches that are Food &
Drug Administration (FDA) approved for clinical use for re-
e inforcement of soft tissues that are repaired with suture or
suture anchors during RC surgery.3 The scaffolds provide a
three-dimensional matrix, which can attract host cells and
can provide a site-specific matrix for cell migration. They
are resorbable materials around which the body rebuilds
more structurally and functionally appropriate treatment.
Dejardin’s study,4 in which porcine small intestine submu-
cosa (SIS; DePuy Biologics, Raynham, Massachusetts) was
used to treat RC tears in dogs, showed that eventually the
patch is reabsorbed from the implantation site; and it is re-
placed with site-appropriate, host-derived tissue. Because
these ECMs are not approved as interposition material to
replace absent tendon or to provide the full mechanical
strength for the tendon repair, they tend to offer more of
a biologic than mechanical advantage with regards to ten-
don healing. The two main groups of ECMs are those from
dermis and those from small intestine submucosa (Table
14–1).
Collagen-rich ECMs from small intestine submucosa
(SIS) include the Restore Patch and the CuffPatch.5 The Re-
store Patch (Depuy Orthopaedics, Warsaw Indiana) was the
first ECM to receive FDA approval for use in RC repair. It is
comprised of 10 layers of porcine small intestine submu-
cosa that has been devitalized so that it theoretically does
not contain any viable cells. That being said, a recent study
actually confirmed the presence of porcine DNA in Restore.6
It is likely that this is a remnant of tissue processing. The
extracellular matrix of the SIS is comprised mainly of type
I collagen, fibronectin, chondroitin sulfate, heparin sulfate,
and a variety of growth factors, including transforming
growth factor-beta (TGF-␤), vascular endothelial growth
factor (VEGF), and fibroblast growth factor 2 (FGF-2).9–15
Restore is not artificially cross-linked, and it is packaged in
a dehydrated form. This contrasts with the CuffPatch (Ar-
throtek, Warsaw Indiana), which is an eight-layer, acellular,
porcine SIS scaffold. Unlike the Restore, following lamina-
tion of the layers, the ECM is cross-linked, and it is packaged
in its hydrated form.
GraftJacket, TissueMend, Zimmer Collagen Repair Patch,
and Permacol are ECMs derived from dermis.7 GraftJacket
Regenerative Tissue Matrix (Wright Medical, Arlington,
Texas) comes from processed human allograft skin from
which the epidermis, cells, and cell remnants have been re-

Table 14–1 Commercially Available Extracellular Matrices Patches for Rotator Cuff Repair 10.1055/978-1-58890-635-9c014_t001

Chemically
Product Manufacturer Source Tissue type cross-linked?

GraftJacket tissue matrix Wright medical (Arlington, Tennessee) Human Dermis No

TissueMend soft tissue Stryker Orthopaedics (Mahwah, New Jersey) Bovine Fetal dermis No
repair matrix
Zimmer collagen repair patch Zimmer (Warsaw, Indiana) Porcine Dermis Yes
Restore orthobiologic implant DePuy Orthopaedics (Warsaw, Indiana) Porcine Small intestine submucosa (SIS) No

CuffPatch bioengineered Arthrotek (Warsaw, Indiana) Porcine Small intestine submucosa (SIS) Yes
tissue reinforcement

From Derwin K, Baker A, Spragg K, Leigh D, Iannotti JP. Commercial extracellular matrix scaffolds for rotator cuff tendon repair: biomechanical, biochem-
ical, and cellular properties. J Bone Joint Surg Am 2006; 88:2265–2272. Adapted by permission
172 Rotator Cuff Deficiency of the Shoulder
moved. The remaining dermal layer is freeze dried to retain
the extracellular architecture and vascular channels.7 Bio-
chemical components in the matrix include collagen, elastin,
and proteoglycans. Like the Restore patch, it is packaged dry
and is not cross-linked. The patch comes in a variety of thick-
nesses, which can be used for different surgical situations.
TissueMend Soft Tissue Repair matrix (Stryker Ortho-
paedics, Mahwah, New Jersey) is derived from fetal bovine
dermis.7 It is an acellular, non-artificially cross-linked col-
lagen membrane that is one layer thick. Type I and type III
collagens are the primary component of the ECM. Tissue-
Mend is packaged dry.
The Zimmer Collagen Repair Patch (Zimmer, Warsaw,
Indiana) is very similar to the Permacol surgical implant.7
Both are acellular sheets of cross-linked porcine dermis.
Cellular material, fats, and soluble proteins are removed
prior to the material being cross-linked with diisocyanate,
which makes it resistant to enzymatic degradation.
Derwin and colleagues performed an in vitro study
comparing the biochemical, biomechanical, and cellular
properties of these patches to each other and to normal
tendon.7 Samples of GraftJacket, TissueMend, Restore, and
CuffPatch were tested for stiffness and modulus. In addi-
tion, hydroxyproline, glycosaminoglycan, and DNA content
were quantified. The group found that commercial ECMs
required 10 to 30% stretch before the patches started to
bear significant load. Once stretched enough, though, each
ECM exhibited a stiffer, linear region and an appreciable
breaking strength.7 Overall, SIS ECMs (Restore, Cuffpatch)
were stiffer than those of dermal origin (GraftJacket, Tis-
sueMend) and reached their maximum mechanical prop-
erties at lower levels of stretch. At physiological levels of
strain for tendon, the biomechanically tested, material
properties of the ECMs tested were an order of magni-
tude less than human RC tendon (Fig. 14–1). In terms of
biochemical composition, the ECMs tested had similar
amounts of hydroxyproline and chondroitin/dermatan
sulfate glycosaminoglycan as fresh tendon.7 Despite being
60
FDS Tendon
50
Graft Jacket
Tissue Mend
40 Restore
Stress (MPa)
Cuff Patch
30
20
10
0
0.0 0.2 0.4 0.6 0.8
Grip-to-Grip Strain
marketed as “acellularized” biomaterials, TissueMend, Re-
store, and Graftjacket all contained measurable amounts
of DNA; only in CuffPatch was DNA content negligible.
The results of this study support the argument that
these patches tend to be more of a biological enhancement
to healing as opposed to devices intended to restore me-
chanical function. Because there are limited clinical stud-
ies evaluating the use of ECMs in RC repair, it is difficult
to comment on the implications of animal DNA in these
patches. Acellularization is performed for three reasons:
to reduce antigenicity,8 enhance host cell infiltration with
appropriate cells,9 and prevent transmission of infection.12
Case reports of noninfectious edema, following the use
of Restore, contend that the reactions are, in part, due to
the presence of porcine DNA. However, further studies are
needed to determine the clinical implications of incom-
plete acellularization.13,14 To date, only a few clinical stud-
ies evaluate ECMs for RC repair.
Clinical Studies of Extracellular Matrices
Small intestine submucosa ECMs have been used success-
fully in the repair of abdominal walls,13 vascular grafts,14
and bladder reconstruction.15 The orthopedic literature
has several studies documenting the enhancement of
tendon healing secondary to the use of SIS scaffolds.16–24
Unfortunately, clinical studies have not been as promis-
ing. Sclamberg et al19 retrospectively reviewed 11 con-
secutive patients who underwent open treatment with
SIS reinforcement for massive or large RC tears. Patients
were evaluated with postoperative MRI at a minimum of
6 months after the index repair and with clinical exam.
Re-tears were documented in 10 of 11 patients. Only one
repair remained intact per MRI at 10 months postopera-
tively. There were no statistically significant differences
between preoperative and postoperative shoulder scores,
and 5 patients scored worse postoperatively. The authors
10.1055/978-1-58890-635-9c014_f001
Figure 14–1 Stress-strain curves of FDS Tendon compared
with extracellular matrices. (From Derwin K, Baker A, Spragg
K, Leigh D, Iannotti JP. Commercial extracellular matrix scaf-
folds for rotator cuff tendon repair: biomechanical, bio-
1.0
chemical, and cellular properties. J Bone Joint Surg Am 2006;
88:2265–2272. Reprinted by permission.)

concluded that the use of SIS ECMs for large and massive
RC tears is ineffective.
A more recent study by Iannotti et al13 echoed these poor
results. A randomized, controlled study was performed
on 30 patients with large or massive, chronic two-tendon
tears. The RCs were treated with open repair using bone
tunnels and a combination of modified Mason–Allen and
horizontal sutures; and all patients underwent concomitant
acromioplasty. Fifteen patients were randomized to a group
that underwent repair augmented with the Restore patch.
The patch was sewn under tension over the top of the re-
pair from tendon to bone. All patients were evaluated at one
year postoperatively with magnetic resonance arthrogram
(MRA), PENN shoulder score, and SF-36 questionnaire. Nine
of 15 repairs healed in the control group versus four in the
augmented group (p = 0.11). When the rate of healing was
adjusted for the effect of tear size, repairs done without the
Restore patch were 7% more likely to heal. In addition, the
median postoperative PENN shoulder score was 83 points
in the augmented repair group and 91 in the control group.
In this study, 15 more patients would have been needed
to show a statistically significant less favorable result with
the use of the Restore patch; however, according to the au-
thors, “. . . there was no reason to continue the protocol . . .
when [they] already had a clear indication that augmenta-
tion would not improve the clinical result.”13 The authors
concluded that surgical repair with SIS did not improve the
rate of tendon healing and did not improve clinical outcome
scores. In fact, there was a trend toward less favorable re-
sults in patients treated with the ECM.13
The use of these scaffolds is not without complications.
In the above referenced study by Iannotti et al, 3 of the 15
patients developed a sterile inflammatory reaction. These
manifestations developed between 3 and 4 weeks postop-
eratively. One patient was treated with irrigation and dé-
bridement; one was treated with oral antibiotics until re-
sults from a shoulder aspiration came back as negative for
infection; and the final patient’s symptoms (erythema and
increased skin temperature) resolved without treatment.
The final PENN shoulder scores in these patients tended to
be among the highest for the augmentation group, indicat-
ing that these reactions did effect final outcome.13 Mal-
carney and colleagues reported on 25 patients undergoing
RC repair with a Restore patch augment.14 Four of these
patients developed an overt inflammatory reaction at an
average of 13 days after surgery. All patients were treated
with open irrigation and débridement. As mentioned
above, it is possible that these reactions stem from porcine
DNA still present in the patch, but further immunologic
studies and increased clinical follow up is necessary to bet-
ter understand the potential complications of these ECMs.
The use of ECMs in animal models has produced good
results in terms of improved healing. Unfortunately, these
results have not extrapolated well to human beings, espe-
cially when used for large or massive tears. In the future, as
our understanding of these scaffolds and tissue engineer-
14 Tissue Engineering for the Rotator Cuff–Deficient Shoulder 173
ing improves, we may be able to modify these ECMs with
growth factors to enhance their biological effects and with
other materials to enhance their mechanical contribution.
Preclinical studies are already underway using different
growth factors to enhance RC tendon healing.
Biologic Process of Tendon Healing
Over the past 5 years, our knowledge of the healing process
of RC tears and the growth factors involved has increased
tremendously. Tendon architecture consists of collagen fi-
brils embedded in a matrix of proteoglycan.20 Type I col-
lagen predominates, and between the collagen bundles
are fibroblasts (the most prevalent cell type in tendons).21
During the first week of tendon healing, proliferating tis-
sue from the paratendon penetrates the gap between the
tendon stumps and fills the gap with undifferentiated, dis-
organized fibroblasts. Capillary buds invade the area and
with the fibroblasts, compose the granulation tissue be-
tween the tendon ends. By day 3, collagen synthesis can
be detected; after about 2 weeks, the tendon ends appear
to be fused by a fibrous bridge. Fibroblast proliferation and
collagen production in the granulation tissue continues,
and between the third and fourth weeks, the fibroblasts
begin to orient themselves along the axis of the tendon.
Collagen fibers at the site of the tear initially remain dis-
organized, while collagen distant to the lesion becomes
more organized.22
Many recent studies have focused on the intrinsic
healing properties of RC tendons.3.4,7–13 Kobayashi et al3
showed that in the healing of full-thickness tears of avian
supracoracoid tendon, the expression of ␣1 (III) lasted
longer than ␣1 (I) procollagen messenger ribonucleic acid
(mRNA). Studies overwhelmingly support the belief that
the healing process progresses from the bursal side to the
joint side.23,24 This was shown in an experimentally created,
full-thickness tear of the RC tendon.9 In a rat model study,
it was noted that type XII collagen, aggrecan, and biglycan
were also increased in the healing tissue.3 Type XII colla-
gen is a fibril-associated collagen that binds to type-I colla-
gen and projects into the ground matrix. Based on a study
of acute supraspinatus tendon tears in a rabbit model that
showed an inhibition of the healing process by matrix
metalloproteinase (MMP-2), tissue inhibitor matrix metal-
loproteinase 1 (TIMP-1; an inhibitor of the MMP family)
was used to enhance healing.25 Another interesting finding
was that a large percentage of fibroblasts in the torn, hu-
man RC contain smooth muscle actin (SMA).8
Several different growth factors have been studied for
their effects on tendon cells, such as TGF-␤, growth dif-
ferentiation factor 5 (GDF-5) platelet-derived growth fac-
tor-␤ (PDGF-␤), and insulin-like growth factor-1 (IGF-1).
TGF-␤ increases the level of SMA, and hence fibroblasts in
these tissues. Myofibroblasts have been thought to play a
role in wound contracture and the retractile phenomenon
174 Rotator Cuff Deficiency of the Shoulder
observed during the fibrotic process.26 GDF-5, a member
of the TGF-␤ superfamily, has been shown to enhance
tendon healing in animal models. A study by Nakase et
al showed that cartilage-derived morphogenic protein 1
(CDMP1; an analogue of GDF-5) is activated at the site of
RC tendon tears.27,28 Yoshikawa and Abrahamsson29 stud-
ied the effects of PDGF-␤ on proteoglycan, collagen, non-
collagen protein, and DNA synthesis in tendons during
short-term cultures. PDGF-␤ stimulated DNA and matrix
synthesis in a dose-dependent manner in multiple tendon
types IGF-1 is another growth factor with possible clini-
cal utility in tendon repair.30 Intratendinous injection of
IGF-1 was delivered to an equine flexor tendonitis model.
At the conclusion of the study, harvested tendons that re-
ceived IGF-1 exhibited decreased local soft tissue swelling.
In addition, cell proliferation and collagen content was in-
creased compared with the controls. Biomechanically, the
IGF-1-treated tendons were stiffer. This data supports the
potential use of locally administered IGF-1 to affect tendon
healing. Clearly, many different cells and growth factors
play a role in the healing process. As our understanding of
the process at cellular level improves, the hope is that we
can use tissue engineering to enhance the process.
Tissue Engineering and Gene Therapy
Tissue engineering involves the application of scientific
principles toward creating living tissue to replace, repair,
or augment diseased tissue.31 Gene therapy is the trans-
fer of a certain gene into a cell so that the cell translates
the gene into a specific protein. Scaffolds to support tissue
growth are a necessary component of tissue engineering.
By using a gene-therapy, tissue-engineered approach, one
can select growth factors with documented roles in tendon
healing to improve the healing process of RC repairs and
deliver them locally at physiological concentrations.
In addition to the naturally derived scaffolds discussed
above, synthetic polymers, such as poly-L-lactic acid (PLLA)
and polyglycolic acid (PGA), can also be used as scaffolds.
SIS and dermal ECMs are attractive due to their remod-
eling potential, which allows for replacement with host
tissue. Downsides include the incomplete removal of ani-
mal DNA elements from their matrices and concerns about
the biomechanical properties of the new tendon formed in
their place. Synthetic polymers can be designed for use in
specific tissues and can be mass produced.32 Studies have
shown that both PGA and PLLA can serve as carriers of cells
and extracellular matrix and can be used to deliver specific
growth factors to sites of tendon repair.33,34 Augmentation
of these scaffolds with the use of cell therapy, growth fac-
tors, or gene therapy may result in faster tendon healing
and more biomechanically normal tendon formation.
Cell therapy aims to improve and accelerate tendon
healing by enhancing cellular activity at the repair site. The
process begins with procuring, purifying, and culturing
particular cells. These are then seeded onto a carrier (scaf-
fold) and implanted into the repair site. Many different cell
types can be incorporated into the scaffold. Studies to date
have focused on the use of mesenchymal stem cells (MSCs),
tenocytes, and fibroblasts due to the roles they play in ten-
don healing. Uncommitted MSCs can replicate as undif-
ferentiated cells, with the potential to differentiate toward
tendon tissue.35 Several studies have been done, assessing
the effects of MSC implantation into tendon defects.35,36 In
one study, the material properties of MSC-based repairs
were up to 33% better than control repairs.37 Butler et al36
showed that by 4 weeks, tendon repairs treated with MSCs
exhibited twice the structural properties of contralateral
controls and 50 to 60% of the stiffness and strength of nor-
mal tendons that were not surgically treated.
Growth factors are proteins that stimulate cell migra-
tion and proliferation as well as the synthesis of new tis-
sue.38 As outlined above, several growth factors are critical
to the tendon repair process. Gene therapy can be used
to induce local production of these growth factors. Gene
therapy involves the transfer of a gene construct into a cell.
The cell is then instructed to translate this into mRNA, thus
overexpressing specific cytokines that play key roles in the
healing process. Although the use of tissue engineering
and gene therapy to enhance tendon healing holds prom-
ise; thus far, research has been limited to in vitro work
and studies in small animal models. Further testing and
long-term preclinical studies are needed until these ap-
plications can be deemed safe and beneficial for use in RC
repairs in human beings.
The Future
Recently, our group presented data on the use of a novel,
tissue engineering, gene therapy approach to RC tendon
healing.22 In part 1 of the study, we successfully transduced
rat tendon fibroblasts with two different growth factors
(IGF-1, PDGF-␤) via retroviral vector. These transduced cells
were then seeded onto a PGA scaffold, and their effect on
nontransduced local responder cells was calculated. IGF-1-
transduced cells stimulated collagen synthesis by 30% over
controls and DNA synthesis by over 100% compared with
controls. PDGF-␤-transduced cells increased collagen syn-
thesis more than 300% versus controls (Fig. 14–2). Based on
these results, we evaluated the use of the gene-enhanced,
tissue-engineered patch in a rat model of RC tendon tears.
RC tears were surgically created in adult Sprague Daw-
ley rats. Two weeks later, the tears were repaired with
suture alone (control) or with suture + PGA scaffold with
IGF-1 or PDGF-␤ incorporated. Histologically, both experi-
mental groups demonstrated qualitative improvements in
repair, with better organization of tendon fiber bundles
and evidence of neovascularization (Fig. 14–3). Biome-
chanically, our results demonstrated that IGF-1-enhanced
repairs were significantly better (p < 0.05) in terms of max-
 14 Tissue Engineering for the Rotator Cuff–Deficient Shoulder 175

Collagen (PDGF)
Collagen (IGF)

200000
180000 100000
160000
80000
CPM/H3-Proline

140000

CPM/H3-Proline
120000
60000
100000
80000 40000
60000
20000
40000
20000
0
0
Tendon Cont. PDGF Exp. Tendon Cont. IGF Exp.
A B
Figure 14–2 Increased collagen synthesis in experimental subjects versus controls. (A) Platelet-derived growth factor-␤ (PDGF-␤). (B) Insulin-
like growth factor-1 (IGF-1). 10.1055/978-1-58890-635-9c014_f002

imum deformation and load to failure than controls and
the PDGF-␤-enhanced group. Results of this study indicate
that IGF-1 enhanced RC tendon repairs in a small animal
model. Clearly, further studies are necessary before this
becomes a viable treatment option for human being RC
tendon tears, but it does provide promise that we may be
able to use biology to enhance surgery in the future.
Other Considerations: Muscle
Degeneration
To date, most work regarding surgical improvement of RC
repairs has focused on ensuring tendon healing to their in-
sertions on the anatomic footprint of the greater tuberosity.
Another consideration that must be addressed, if one is to
maximize function after RC repairs, involves the possibil-
ity to reversing the well-documented, fatty muscle degen-
eration that occurs in the muscle bellies of the RC muscles
after tendon tears.39 Uthoff et al40 used a rabbit model to
see if early reattachment (6-weeks status postdetachment
of the supraspinatus tendon) would reverse fat accumula-
tion and muscle atrophy in the supraspinatus. They found
that although fat accumulation and atrophy could not be
reversed, earlier repair (compared with later reattachment)
prevented an increase in fat accumulation. Gerber’s group
found similar results in a sheep model.41 They showed that
muscle atrophy and infiltration by fat cells led to impair-
ment of the physiological properties of the muscle, which
were irreversible in their experimental model.
Engineering skeletal muscle tissue that can generate con-
trolled and efficient mechanical power would be extremely
valuable toward achieving excellent results after RC re-
pairs. However, there are few reports in the literature that
address this issue.42,43 In contrast to tendons, which con-
tain ~70% extracellular matrix, skeletal muscle has a much

A B
Figure 14–3 (A) Experimental group tendon; note organized collagen orientation (H&E, low power). (B) Control group tendon; disorganized
collagen, increased vascularity. 10.1055/978-1-58890-635-9c014_f003
176 Rotator Cuff Deficiency of the Shoulder
smaller percentage of ECM (~5%).44 Therefore, the ideal
scaffold used to regenerate skeletal muscle would have at
least 95% void space that could be occupied with cells. In
addition, skeletal muscle is highly organized as a result
of myocyte migration, alignment, and fusion; a process
that most scaffolds do not allow.41 Another obstacle to the
use of scaffolds to regenerate skeletal muscle tissue stems
from the fact that scaffolds function as a force shunt that
“results in a derangement of the transmission of mechani-
cal signals to individual muscle fibers . . . which inhibits the
generation of active contractile force . . . [and] interferes
with the primary function of muscle as a tissue.”44 Other
technological challenges exist including the establishment
of adequate vascular supply to the muscle, the develop-
ment of a functioning neuromuscular junction interface,
and a functioning musculotendinous junction that facili-
tates force transmission. The successful engineering of
skeletal muscle involves all of the above issues and is years
away from being a viable clinical option. Nevertheless, the
ability to regenerate such tissue would be extremely ben-
eficial in terms of improving patients’ outcomes after the
repair of massive RC tears.
Summary
Despite improvements in our understanding and treatment
of RC tears, our ability to get surgically repaired tendons to
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 Index
Page numbers followed by f or t indicate material in figures or tables respectively.
A Columbia University experience
Abduction, 2
in cuff tear arthropathy, 68
in reverse shoulder arthroplasty,
98–102, 99f-101f
Academy of Orthopedics (AO), 58
Acetabularization, 12–13, 13f, 53–54,
67, 120, 142
Acromial complications, in reverse
shoulder arthroplasty,
127–128, 128f, 131f, 169
Acromiohumeral distance, 12, 21, 21f,
117, 120–121, 126
Acromion fractures, 58, 127–128, 169
Acromioplasty, 61, 126
Actin, smooth muscle, 173
Aequalis reverse prosthesis, 108
Age, and treatment options, 18, 122,
137
American experience, in reverse
shoulder arthroplasty, 76–104
American Shoulder and Elbow
Surgeons (ASES) score, 74,
166–168
Anterior superior escape, 63t
Anteroposterior radiograph, 68, 68f,
121
Antiinflammatory drugs, 9–10,
120–121, 137, 140
Arthritis
in cuff tear arthropathy, 51, 52f. See
also Cuff tear arthropathy
primary, 13–14
in surgical algorithm, 63t
and treatment options, 122
Arthrodesis, 61, 121–122, 147
Arthroplasty, 61. See also Reverse
shoulder arthroplasty; Total
shoulder arthroplasty
age and, 18
clinical presentation and, 18, 19f
14530inx.indd 179
with, 138–146
contraindications to, 68
current options in, 15–16
Florida Orthopaedic Institute
experience with, 147–170
indications for, 68
Mayo Clinic experience with,
135–137
outcomes of, 16–18, 17f, 18t
Arthroscopic debridement, 21, 23–24,
24f, 60, 63t, 120, 122–123,
137
patient positioning for, 122
postoperative care in, 123
surgical technique of, 122
Arthroscopic grasper, 25, 26f, 28, 30f
Arthroscopy
for massive rotator cuff tears, 21–36,
60–61
approach in, 23–24
cleaning up in, 23, 24f, 60
complications of, 33, 34f
contraindication to, 21, 22f
goal of, 21
indications for, 21
infraspinatus tendon
advancement in, 24, 24f-25f
initial arthroscopic evaluation in,
24–26, 26f-27f
interval slides in, 26–27, 27f-28f
partial repair in, 24, 24f-25f
patient information on, 22–23
portals for, 24–25, 26f
postoperative immobilization in,
31–33
repair in, 28–30, 30f-31f, 60–61
suprascapular nerve
decompression in, 23, 27–28,
29f
technique of, 24–30
tissue augmentation/
enhancement in, 21, 30–31,
33, 33f, 34, 34f
treatment options in, 21
primary goal of, 21
for rotator cuff-deficient shoulder,
60–61, 120
Articular cartilage loss, 57–58, 63t
Aspiration, of fluid, 68
Association for the Study of Internal
Fixation (ASIF), 82
Augmentation, tissue, 21, 30–31,
33–34, 33f-34f, 61, 171–177
Axial humeral rotation, 2
Axillary lateral radiographs, 68
B
Ball-and-socket prosthesis, 105, 105f,
136
Baseplates, in reverse shoulder
arthroplasty, 107–108, 108f
compressive strength at, 82–83,
83f-84f
failed, scanning electron microscopy
of, 85–86, 86f
fixation, glenosphere options and,
93–96, 93f, 93t, 94f
maximum load to fixation failure at,
83–84, 84f
micromotion of, 84–85, 85f, 87, 87f,
93–96
position of, 88–92, 149, 149f, 151,
152f
biomechanical analysis of, 88–90,
89f-90f
radiographic study of, 91–92, 92f
three-dimensional finite element
analysis of, 90–91, 91f-92f
Belly press test, 63t
Biceps tendon rupture, 125–126
Biceps tenodesis, arthroscopic, 21
1/31/08 11:08:21 AM
 180 Index
Biceps tenotomy
arthroscopic, 21, 23–24, 24f, 60, 63t,
117, 120
patient positioning for, 122
postoperative care in, 123
surgical technique of, 122
indications for, 121–122
outcomes of, 125–126
Biceps transfer interposition grafting
(BTIG), 44–45
contraindications to, 44
indications for, 44
outcomes of, 44–45
surgical technique for, 44–45, 45f
Bickel, William, 136
Biomechanics
of reverse shoulder arthroplasty
American experience, 76–104
French experience, 105–119
of rotator cuff, 1–7
of rotator cuff tear classification, 15,
15f, 15t
of rotator cuff tear pathophysiology,
12–13, 13f
Bipolar prostheses, 16, 18t, 105
revision to reverse shoulder,
153–154, 163, 168
Boileau, Pascal, 108, 148
Bone loss
and revision arthroplasty, 154, 156,
159–161, 160f-164f
in rotator cuff-deficient shoulder,
53, 53t, 57–59, 58f, 63t
BTIG. See Biceps transfer interposition
grafting
Burkhart classification, 14–15, 14f
Bursal augmentation, 30–31, 32f
C preoperative planning, 56–57, 116
Calcium phosphate crystals, 51
Capsule changes, 59–60, 63t
Captured center tear, 14, 14f
Carbide punch bone tamp, 155
Cartilage-derived morphogenic
protein 1 (CDMP1), 175
Cartilage loss, 57–58, 63t
Cell therapy, 174
Center of rotation (COR)
and deltoid force, 99–102, 101f
Grammont reverse design, 76, 76f,
106, 106f, 148
Reverse Shoulder Prosthesis, 80–82
Central cartilage loss, 57
Central screw, in reverse shoulder
arthroplasty
baseplate micromotion with, 84–85,
85f
compressive strength of, 82–83,
83f-84f
failure of, scanning electron
microscopy of, 85–86, 86f
14530inx.indd 180
maximum load to fixation failure,
83–84, 84f
positioning of, 149, 149f
Chondroitin-4 sulfate, 8
Chondroitin-6 sulfate, 8
Classic cuff tear arthropathy, 51–53,
52f, 67f
Classification, 12–20, 53–55
Burkhart, 14–15, 14f
Farvard, 12, 14
Hamada-Fukuda, 12, 14, 54, 54f, 116,
120
outcomes depending on, 16–18, 17f-
18f, 18t
pathomechanic and
pathomorphologic, 15, 15f,
15t, 16f
Seebauer, 15–18, 15f-18f, 15t, 18t,
54, 55f, 67–68
Collagen, 8, 8f, 173–174
Collagenase, 51
Columbia Shoulder Service, 138
Columbia University experience,
138–146
with hemiarthroplasty, 140–142,
143f
with reverse shoulder arthroplasty,
141–145, 144f
with total shoulder arthroplasty,
140–141
Compression, in reverse shoulder
arthroplasty, 82–83, 83f-84f
Compressive component, of muscle
force vector, 5–6, 5f
Compressive loading, 4
Computed tomography (CT)
of bone loss, 58, 58f
of fatty infiltration, 56–57, 57t, 121
for revision planning, 154, 160, 160f,
161, 162f, 163, 165f
Concavity-compression model, 58–59
Constrained implant, 16, 69, 105–106,
135–137, 136t, 147
Contractile force, 1–2, 1f
Controlled fracture, in reverse
shoulder arthroplasty, 124,
125f
Conversion to reverse prosthesis,
153–169
from bipolar arthroplasty, 153–154,
163, 168
bone loss and, 154, 156, 159–161,
160f-164f
fixation in, 160, 160f
from hemiarthroplasty, 153–161
for cuff tear arthropathy, 159–161,
160f-164f
for fracture, 154–159, 154f-159f,
167
for glenoid arthritis, 167
for rotator cuff-deficient shoulder,
167
instability and, 154
preoperative imaging for, 154,
160–161, 162f, 163, 165f
from previous reverse prosthesis,
164, 168
results of, 167–168
from total shoulder arthroplasty,
153–154, 161, 165f-166f, 168
COR. See Center of rotation
Coracoacromial arch, 53
Coracohumeral ligament, 8, 8f, 26–27,
27f-28f
Corticosteroids, 9, 120
Crystalline-induced arthritis
arthropathy, 13–14, 51
CT. See Computed tomography
CTA. See Cuff tear arthropathy
CuffPatch, 171–172, 171t
Cuff tear arthropathy (CTA), 51
classic, 51–53, 52f, 67f
classification of, 12–20, 52f, 53–55,
67–68
clinical manifestations of, 51, 67
Columbia University experience
with, 138–146
as contraindication to arthroscopy,
21, 22f
etiologies of, characteristics of,
13–14
Florida Orthopaedic Institute
experience with, 147–170
hemiarthroplasty for, 67–75,
135–136, 135f-136f
hemiarthroplasty revision for,
159–161, 160f-164f
hemorrhagic theory of, 51
historical background on, 51, 67,
138–140, 145
imaging of, 68
inflammatory theory of, 51
Mayo Clinic experience with,
135–137
mechanical theory of, 52–53, 67,
68f, 139–140
nonoperative treatment of, 137
nutritional theory of, 52, 67,
139–140
patient history in, 68
physical exam in, 68
post-repair, 13, 37
primary, 13
radiographic findings of, 68, 68f,
139, 139f
reverse shoulder arthroplasty for,
116–118, 159–161, 166–167
surgical algorithm for, 61–62, 63t
surgical treatment of, 60–62. See
also specific procedures
contraindications to, 68
1/31/08 11:08:22 AM

indications for, 68
limited-goal, 69, 142, 147
options in, 68–70
treatment algorithm for, 137
treatment goals in, 69
type Ia, 15, 15f, 15t, 54, 55f, 67–68
type Ib, 15, 15f, 15t, 54, 55f, 67–68
type IIa, 15, 15f, 15t, 54, 55f, 67–68
type IIb, 15, 15f, 15t, 54, 55f, 67–68
Cyclooxygenases, 9
Cytokines, 9
D 33–34, 33f-34f, 61, 171–177
Darrach, William, 138
Darrach retractors, 70
Debridement
arthroscopic, 21, 23–24, 24f, 60, 63t,
120, 122–123, 137
patient positioning for, 122
postoperative care in, 123
surgical technique of, 122
open, 61
for postoperative infection, 169
Delta I prosthesis, 108
Delta II prosthesis, 108
Delta III prosthesis. See Grammont
reverse shoulder design
Deltoid contour loss, with Grammont
reverse shoulder design, 80,
81f
Deltoid force, in reverse shoulder
arthroplasty, 99–102, 101f,
101t, 106, 106f, 108–110, 109f,
116, 116f
Deltoid muscle
changes in, 60, 63t
as “engine” of Grammont design,
106, 106f
reconstruction of, 60
rehabilitation of, 10
seven portions of, 109, 109f
Deltoid transfer, 45–46
advantages of, 45
contraindication to, 46
outcomes of, 46
postoperative management of,
45–46
surgical technique for, 45–46, 46f
Deltopectoral approach
for hemiarthroplasty, 69–70, 71f,
141
for reverse shoulder arthroplasty,
123–124, 142, 149
Dermis, tissue scaffolds from, 33, 33f,
171–172, 171t
Descente test, 116
Double-interval slide, 26–27, 27f-28f
Drop sign, 117, 120
Drug treatment, for massive
irreparable tears, 9–10
Dynamic instability, 59
14530inx.indd 181
Dynamic radiography, 55, 56f
Dynamic stability index, 6
E Fractures
ECMs. See Extracellular matrix
scaffolds
Elderly patients, challenges of, 122
Elevation, 2
combined loss with external
rotation loss, 118
painful loss of, 117, 117f
Enhancement, tissue, 21, 30–31,
Extended humeral head prosthesis,
69–70, 70f
External rotation, 2
combined loss with elevation loss,
118
in cuff tear arthropathy, 68
isolated loss of, 117–118, 117f
postoperative, 73–74
with reverse shoulder arthroplasty,
111–113
External rotation lag, 63t, 117, 120
Extracellular matrix scaffolds, 33,
171–173, 176
biochemical composition of, 172
clinical studies of, 172–173
commercially available, 171t
complications of, 173
mechanical properties of, 172, 172f
for muscle regeneration, 175–176
Extrinsic mechanism of injury, 4
F Glenoid component. See also
Farvard classification, 12, 14
Fatty infiltration, of muscle, 23, 57t,
116–118, 121–122
imaging of, 56–57, 57t, 121
reversal of, 175–176
Femoralization, 12–13, 67
Fibroblasts, 173–174
Finite element analysis, of reverse
shoulder arthroplasty, 90–91,
91f-92f, 94, 95t
Florida Orthopaedic Institute
experience, 148–170
early, 147–148
with hemiarthroplasty, 147–148
with reverse shoulder arthroplasty,
148–169
component selection, 165, 166f
conversion, 153–164
primary, 149–153
refinement of techniques, 164–
165
reversing trend in, 148
with total shoulder arthroplasty, 147
Fluid
accumulation of, 68, 139
aspiration of, 68
Index 181
Force couple, 10, 10f, 14–15, 33, 44,
52–53, 67, 68f, 142, 147
Force vectors, muscle, 5–6, 5f
acromion, 58, 127–128, 169
controlled, in reverse shoulder
arthroplasty, 124, 125f
hemiarthroplasty revision for,
154–159, 154f-159f, 167
scapular spine, 128
Fracture Service (New York
Orthopaedic Hospital), 138
Freeze-dried dermal tissue, 33, 33f,
171–172, 171t
French experience
in reverse shoulder arthroplasty,
105–119, 113t, 123–131
in rotator cuff-deficient shoulder,
120–134
Functional assessment, 121
Functional rotator cuff tear, 10
G
Gene therapy, 171, 174–176
Glenohumeral arthritis
in cuff tear arthropathy, 51, 52f. See
also Cuff tear arthropathy
and treatment options, 122
Glenoid articular surfaces, loss of, 57,
63t
Glenoid-baseplate interface, in reverse
shoulder arthroplasty, 82–83,
83f-84f
Glenoid bone loss, 58–59, 58f, 63t
Glenospheres
in reverse shoulder arthroplasty,
93–96, 93f, 93t, 106–108,
152f, 165, 166f, 169
in total shoulder arthroplasty,
136–137, 136f
Glenoid fixation
bone loss and, 58–59
in reverse shoulder arthroplasty,
82–88, 106–107, 125, 145,
149, 149f, 151, 152f
Glenoid preparation, in reverse
shoulder arthroplasty,
124–125, 145, 151, 151f
Glenoid-sided complications, in
reverse shoulder arthroplasty,
76–96, 77t-79t, 114–115,
130–131, 131t, 168–169
Glenoid torque, in reverse shoulder
arthroplasty, 106f, 111
Glenospheres
center of rotation, distance from
glenoid to, 82t, 93–96, 93f,
93t, 94f
deltoid force comparison of, 99–102,
101f
1/31/08 11:08:22 AM
 182 Index
Glenospheres (continued)
fixation with 5.0–mm screws,
86–88, 88f, 89t
Grammont reverse design, 76,
106–108, 107f-108f
implantation of, 125, 145, 151, 153f
micromotion of, 82t
options in, 93–96, 93f, 93t, 94f, 152f,
165, 166f, 169
position of, 88–92, 127, 127f
biomechanical analysis of, 88–90,
89f-90f
radiographic study of, 91–92, 92f
three-dimensional finite element
analysis of, 90–91, 91f-92f
Reverse Shoulder Prosthesis, 80–81,
81f
sizes of, 82t, 93t, 169
Global fatty regeneration index (GFDI),
23
Global Shoulder System, 17
Goutallier scale, 23, 56, 121
Graft Jacket, 33, 33f, 171–172, 171t
Grammont, Paul, 105
Grammont reverse shoulder design,
76–80, 76f, 148
American experience with, 76–104
baseplate/glenosphere position in,
88–92
baseplate micromotion in, 84–85,
85f, 87, 87f, 93–96
baseplate of, 83, 83f-84f, 107, 108f
biomechanical analysis of, 88–90,
89f-90f, 93, 95t, 108–110, 110f
complications of, 130–131, 131t
glenoid-sided, 76–96, 77t-79t,
114–115, 130
humeral-sided, 96–102, 113–114,
130
compressive strength of, 82–83,
83f-84f
deltoid as “engine” of, 106, 106f
deltoid force with, 99–102, 101f, 106,
106f, 108–110, 109f, 116, 116f
development of, 76, 105–108, 107f
finite element analysis of, 90–91,
91f-92f, 94, 95t
5.0–mm screws in, 86–88
French experience with, 105–119
glenoid component (glenosphere
of), 106, 107f
glenoid fixation of, 82–88, 106–107
glenoid torque in, 106f, 111
glenosphere options in, 93–96, 93f,
93t, 94f
humeral component of, 106, 107f
indications for, primary and
extended, 116
infection with, 115–116, 130–131
instability/stability with, 97–98, 98f,
110–111, 110f, 113, 130–131
14530inx.indd 182
limitations of, 76–80, 111–118
load to failure for, 82, 82t
loss of deltoid contour with, 80, 81f
loss of rotational strength with, 80,
81f
maximum load to fixation failure,
83–84, 84f
medialized center of rotation, 76,
76f, 106, 106f
moment arms with, 99–102, 101t
muscle function with, 99–102
patient candidates for, 116–118
preoperative evaluation for, 116
range of motion with, 76–80, 98–99,
99f-100f, 111–113, 112f, 116,
126–127, 167
range-specific strength with, 102
scapular notching with, 76, 114–115,
115f, 128–130, 129f-130f
tendon transfers with, 111, 112f
Granulation tissue, 173
Grasper, arthroscopic, 25, 26f, 28, 30f
Growth differentiation factor 5 (GDF-
5), 173–174
Growth factors, 30–31, 32f, 33, 171,
173–176
H patient positioning for, 70, 71f, 141
Hamada-Fukuda classification, 12, 14,
54, 54f, 116, 120
Healing
biologic process of, 173–174
cell therapy for, 174
future directions in, 175–176
gene therapy for, 171, 174–176
growth factors for, 30–31, 32f, 33,
171, 174–176
muscle regeneration in, 175–176
tissue augmentation/enhancement
for, 21, 30–31, 33–34, 33f-34f,
61, 171–177
Hematoma, in reverse shoulder
arthroplasty, 113
Hemiarthroplasty, 63t, 67–75, 121
age and, 18, 137
bony landmarks in, 70, 71f
case study of, 142, 143f
clinical presentation and, 18, 19f
closure in, 73
Columbia University experience
with, 140–142, 143f
contraindications to, 141
conversion to reverse shoulder
prosthesis, 153–161, 167–169
complications in, 168–169
computed tomography for, 154,
160, 160f
for cuff tear arthropathy, 159–161
for fracture, 154–159, 154f
incision and exposure in,
154–155
patient positioning for, 154
prosthesis removal in, 155,
155f-158f
proximal humeral allograft in,
156–159, 158f-159f
results of, 167
for glenoid arthritis, 167
outcomes of, 167
for rotator cuff-deficient shoulder,
167
deltopectoral approach for, 69–70,
71f, 141
extended humeral head prosthesis
in, 69–70, 70f
Florida Orthopaedic Institute
experience with, 147–148,
148f
humeral head resection in, 70–72,
71f-73f, 141–142
implant placement in, 72, 73f
indications for, 137, 141
intraoperative imaging in, 73, 74f
Mayo Clinic experience with,
135–136, 135f-136f
outcomes of, 16–18, 16f-17f, 69–70,
73–74, 121, 135–136, 140, 143,
147–148, 148f
postoperative care and
rehabilitation in, 73, 142
repair in, 142
vs. reverse shoulder arthroplasty,
137
surgical technique of, 70–73,
141–142
vs. total shoulder arthroplasty, 69
trial prostheses in, 71–72, 73f
Hemorrhagic shoulder of the elderly,
51
Hemorrhagic theory, of cuff tear
arthropathy, 51
Histology, 8, 8f
History, patient, 68, 121
Hornblower’s sign, 116–117, 120
Horse pericardium, 33
Humeral allograft, for conversion of
hemiarthroplasty, 156–159,
158f-159f
Humeral articular surface, loss of,
57–58, 63t
Humeral bone loss, 53, 57–59, 63t
Humeral component, in reverse
shoulder arthroplasty, 96, 96f,
106–108, 107f-108f
Humeral cup, in Grammont prosthesis,
107–108, 108f
Humeral head migration, in
arthroscopic management,
33, 34f
Humeral head prosthesis, extended,
69–70, 70f
1/31/08 11:08:22 AM

Humeral head replacement. See
Hemiarthroplasty
Humeral neck, in Grammont
prosthesis, 107–108, 108f
Humeral preparation, in reverse
shoulder arthroplasty, 124,
142–145, 150–151, 150f
Humeral rotation, axial, 2
Humeral-sided complications, in
reverse shoulder arthroplasty,
96–102, 113–114, 130–131,
168–169
Humeral stem, in Grammont
prosthesis, 107–108, 108f
Hyaluronan, 10
Hydroxyapatite crystals, 51
I 44–45, 45f
Iliac crest graft, in reverse shoulder
arthroplasty, 127, 128f
Imaging, 68. See also specific
modalities
Indications for treatment, 121–122
Infection, in reverse shoulder
arthroplasty, 115–116,
130–131, 169
Inflammation, 9
Inflammatory arthritis, 13
Inflammatory theory, of cuff tear
arthropathy, 51
Infraspinatus muscle
in abduction, 2
atrophy of, 68
contractile force of, 1–2, 1f
in elevation, 2
force vectors of, 5–6
moment arm of, 2
in reverse shoulder arthroplasty,
99–102
physiological cross-section area of, 1
repair of, 2–3
retraction of, 2–3
in rotation, 2
Infraspinatus tendon
anterior advancement of, 24, 24f-25f
histology of, 8
mechanical properties of, 3–4
repair of, 2–3
stabilization by, 12
structural properties of, 3–4
tears of, 2
triceps transfer for, 42
Instability, in reverse shoulder
arthroplasty, 97–98, 110–111,
110f, 113, 130–131, 154, 169
Instability, joint, 52f, 59, 63t
dynamic, 59
static, 59
Insulin-like growth factor-1 (IGF-1),
173–175, 175f
Internal rotation, 2
14530inx.indd 183
with reverse shoulder arthroplasty,
111
Interval slides, 26–27, 27f-28f
Intraoperative imaging, in
hemiarthroplasty, 73, 74f
Intrinsic mechanism of injury, 4
Irreparable rotator cuff tears, 8–11
chronic, 9
clinical presentation of, 9
drug treatment of, 9–10
natural history of, 9
nonoperative treatment of, 9–10
overview of, 62f
physical therapy for, 10
prevalence of, 8–9
tendon transfers for, 37–49
biceps interposition grafting,
combined pectoralis major and
latissimus dorsi, 41–42
deltoid, 45–46, 46f
latissimus dorsi, 39–40, 39f-40f
pectoralis major, 40–41, 41f
subscapularis, 37–39, 38f
teres minor, 43–44, 44f
trapezius, 46–47, 47f
triceps, 42–43, 42f-43f
J suprascapular nerve
Joint instability, 52f, 59, 63t
dynamic, 59
static, 59
Joint mover, rotator cuff as, 1–2, 1f
Joint stabilizer, rotator cuff as, 5–6
Joint torque, 2–3
K chronic, 9
Kessel reverse shoulder design, 82
L in cuff tear arthropathy, 51. See also
Latissimus dorsi transfer, 39–40, 61,
63t, 120
combined with pectoralis major
transfer, 41–42
indications for, 42
outcomes of, 42
postoperative management of, 42
surgical technique for, 42
contraindication to, 39
indication for, 39
outcomes of, 39–40
with reverse shoulder arthroplasty,
111, 112f
surgical technique for, 39–40, 39f-40f
Length-tension relationship, 1–2, 1f
with Grammont reverse shoulder
design, 80, 81f
L’épaule sénile hémorragique, 51
Limited-goal rehabilitation, 16, 121
Limited-goal surgery, 69, 142, 147
Lyon, France, experience, 120–134
Index 183
M
Magnetic resonance imaging (MRI)
of cuff tear arthropathy, 68
of fatty infiltration, 121
of massive rotator cuff tear, 22f, 23,
23f, 37
preoperative planning, 56–57
texture correlation technique, 4–5
Massive rotator cuff tears
arthroscopic management of, 21–36,
60–61, 120
approach in, 23–24
cleaning up in, 23, 24f, 60
complications of, 33, 34f
contraindication to, 21, 22f
goal of, 21
indications for, 21
infraspinatus tendon
advancement in, 24, 24f-25f
initial arthroscopic evaluation in,
24–26, 26f-27f
interval slides in, 26–27, 27f-28f
partial repair in, 24, 24f-25f
patient information on, 22–23
portals for, 24–25, 26f
postoperative immobilization in,
31–33
repair in, 28–30, 30f-31f, 60–61
decompression in, 23, 27–28,
29f
technique of, 24–30
tissue augmentation/
enhancement in, 21, 30–31,
33, 33f, 34, 34f
treatment options in, 21
clinical findings of, 22
clinical presentation of, 9, 21–23
Rotator cuff-tear arthropathy
definition of, 21, 22f, 37
diagnostic evaluation of, 23
drug treatment of, 9–10
irreparable, 8–11, 37–49, 62f
magnetic resonance imaging of, 22f,
23, 23f, 37
natural history of, 9
nonoperative treatment of, 9–10
open soft tissue procedures for, 61
overview of, 62f
physical therapy for, 10
prevalence of, 8–9
tendon transfers for, 37–49
biceps interposition grafting,
44–45, 45f
combined pectoralis major and
latissimus dorsi, 41–42
deltoid, 45–46, 46f
latissimus dorsi, 39–40, 39f-40f
pectoralis major, 40–41, 41f
1/31/08 11:08:23 AM
 184 Index
Massive rotator cuff tears (continued)
subscapularis, 37–39, 38f
teres minor, 43–44, 44f
trapezius, 46–47, 47f
triceps, 42–43, 42f-43f
Material properties, of rotator cuff,
3–5
Matrix metalloproteinase, 173
Mattress locking stitch, T-type, 28, 31f
Mayo Clinic experience, 135–137
with hemiarthroplasty, 135–136,
135f-136f
with reverse shoulder arthroplasty,
137
with total shoulder arthroplasty,
136–137, 136f, 136t
McConnell head holder, 70, 71f
McLaughlin, Harrison L., 138, 138f, 145
Mechanical stress and strain, 4
Mechanical theory, of cuff tear
arthropathy, 52–53, 67, 68f,
139–140
Mechanisms of injury, 4–5
Medialized center of rotation, 76, 76f,
99–101, 106, 106f
Mesenchymal stem cells (MSCs), 174
Methylprednisolone, 9
Michael Reese prosthesis, 136, 136t
Micromotion
baseplate, 84–85, 85f, 87, 87f, 93–96
glenospheres and, 82t
Milwaukee shoulder, 12–14, 51
Minimally invasive techniques, 21. See
also Arthroscopy
Moment arm (MA), 2
in reverse shoulder arthroplasty,
99–102
MRI. See Magnetic resonance imaging
Muscle(s)
contractile force of, 1–2, 2f
degeneration of, reversal of, 175–176
fatty infiltration of, 23, 56–57, 57t,
116–118, 121–122, 175–176
force vectors of, 5–6, 5f
physiological cross-section area of, 1
retraction of, 2–3
Muscle function, with reverse
shoulder arthroplasty, 99–102
Muscle loss, 53, 53t, 56–57
Muscle regeneration, 175–176
Muscle transfers, 37–49. See also
Tendon transfers
Myofibroblasts, 173–174
N (PDGF-_), 173–175, 175f
Neer, Charles S., 138–140, 139f, 145
Neer hooded glenoid component, 136f,
137
Neer II prosthesis, 69
Nerve loss, 53t
New York Orthopaedic Hospital, 138
14530inx.indd 184
New York Presbyterian Hospital, 138
Nonoperative treatment, 9–10, 120,
122, 137–138
Nonsteroidal antiinflammatory drugs,
9–10, 137
Nutritional theory, of cuff tear
arthropathy, 52, 67, 139–140
O in reverse shoulder arthroplasty,
Open soft tissue procedures, 61
Osteoarthritis
in cuff tear arthropathy, 51, 52f. See
also Cuff tear arthropathy
glenohumeral, 51, 52f
primary, 13–14
and treatment options, 122
Osteopenia, 9
Osteoporosis, 9, 124
P Proximal humeral bone loss, 59
Painful shoulder, 117, 117f
Painful stiff shoulder, 117, 117f
Patch graft, 2–3, 3f. See also Tissue
scaffolds
Pathology of rotator cuff-deficient
shoulder, 55–60, 57t. See also
specific pathologies
Pathomechanic classification, 15, 15f,
15t
Pathomorphologic classification, 15,
15f, 15t
Patient history, 68, 121
Pectoralis major transfer, 40–41, 61,
63t, 120–121
combined with latissimus dorsi
transfer, 41–42
indications for, 42
outcomes of, 42
postoperative management of, 42
surgical technique for, 42
indications for, 40–41
outcomes of, 41
surgical technique for, 41, 41f
Pegasus Biologics OrthADAPT
Bioimplant, 33
Permacol, 171–172
Physical exam, 68, 116, 120, 139
Physical therapy, 10, 120–121, 137, 140
Physiological cross-section area, 1
Pierce and grab suture technique, 30,
31f
Piston mechanism, 113
Platelet-derived growth factor, 31, 32f
Platelet-derived growth factor-_
Polyethylene components, humeral,
96f, 106–108, 107f, 145
Polyethylene disassociation, in reverse
shoulder arthroplasty, 96–97,
168—169
Polyglycolic acid (PGA), 174–175
Poly-L-lactic acid (PLLA), 174
Porcine intestine, for tissue scaffold,
33, 33f, 172
Post-rotator cuff-repair arthropathy,
13, 37
Prostheses. See specific designs and
procedures
Prosthetic loosening, 16
114–115, 127–128, 128f, 148
in total shoulder arthroplasty, 61,
68–69, 136–137, 147
Proteases, 9
Proteinase, 51
Proteoglycan, 173–174
Proximal humeral allograft,
for conversion of
hemiarthroplasty, 156–159,
158f-159f
Pseudoparalytic shoulder, 117, 117f,
120, 122, 137, 141
Pulsed ultrasound, 30–31
R
Radiographs, 68, 68f, 121. See also
specific applications
classification by, 53–55, 56f
intraoperative, 73, 74f
Range of motion, 2
in cuff tear arthropathy, 68
in reverse shoulder arthroplasty,
76–80, 98–99, 99f-100f,
111–113, 112f, 116, 126–127,
167
in rotator cuff-deficient shoulder,
120
Range-specific strength, after reverse
shoulder arthroplasty, 102
Reese, Michael, 136
Rehabilitation
in hemiarthroplasty, 73, 142
limited goal, 16, 121
patient’s ability for, 121
in reverse shoulder arthroplasty,
125, 145, 152–153, 169
as treatment, 10, 120–121, 137
Replacement, shoulder. See Reverse
shoulder arthroplasty;
Shoulder arthroplasty; Total
shoulder arthroplasty
Restore Patch (Graft), 33, 33f, 171–173,
171t
Retraction, muscle, 2
Reverse shoulder arthroplasty, 61, 63t,
123–125
acromial problems with, 127–128,
128f, 131f, 169
Aequalis design, 108
age and, 18, 122
American experience with, 76–104
1/31/08 11:08:23 AM

approach for, 123–124, 127, 142, 149
baseplate failure in, scanning
electron microscopy of,
85–86, 86f
baseplate/glenosphere position in,
88–92, 127, 127f, 149, 149f,
151, 152f
biomechanical analysis of, 88–90,
89f-90f
radiographic study of, 91–92, 92f
three-dimensional finite element
analysis of, 90–91, 91f-92f
baseplate micromotion in, 84–85,
85f, 87, 87f, 93–96
case study of, 144f, 145
clinical presentation and, 18, 19f
Columbia University experience
with, 141–145, 144f
complications in, 130–131, 131t,
168–169
glenoid-sided, 76–96, 77t-79t,
114–115, 130, 168–169
humeral-sided, 96–102, 113–114,
130, 168–169
compression in, 82–83, 83f-84f
contraindications to, 149
controlled fracture in, 124, 125f
deltoid force in, 99–102, 101f, 106,
106f, 108–110, 109f, 116, 116f
finite element analysis of, 90–91,
91f-92f, 94, 95t
5.0–mm screws for, 86–88, 88f, 89t
Florida Orthopaedic Institute
experience with, 148–169
French experience with, 105–119,
113t, 123–131
functional results of, 126–127
glenoid fixation in, 82–88, 106–107,
125, 145, 149, 149f, 151, 152f
glenoid implantation in, 125, 145,
151, 153f
glenoid preparation in, 124–125,
145, 151, 151f
glenoid torque in, 106f, 111
glenosphere options in, 93–96, 93f,
93t, 94f, 152f, 165, 166f, 169
Grammont design, 76–80, 76f, 148
humeral cut in, 150, 150f
humeral implantation in, 125, 145,
151–152, 153f
humeral preparation in, 124,
142–145, 150–151, 150f
indications for, 116–118, 122, 137,
141, 149
infection with, 115–116, 130–131,
169
instability/stability in, 97–98, 98f,
110–111, 110f, 113, 130–131,
154, 169
Kessel design, 82
load to failure in, 82, 82t
14530inx.indd 185
maximum load to fixation failure,
83–84, 84f
Mayo Clinic experience with, 137
moment arms with, 99–102,
101t
muscle function with, 99–102
outcomes of, 16–18, 17f-18f, 18t,
126–131, 166–168
patient candidates for, 116–118
patient positioning for, 123, 149,
149f
polyethylene components in, 96f,
106, 107f
polyethylene disassociation in,
96–97, 168–169
postoperative radiography in, 152,
153f
postoperative rehabilitation in, 125,
145, 152–153, 169
preoperative evaluation for, 116
primary, 149–153, 166–167
principles of, 6, 6f, 61–62, 108–110,
110f
prosthesis design, 61, 62f
prosthetic loosening in, 114–115,
127–128, 128f
radiological results of, 127–130
range of motion with, 76–80, 98–99,
99f-100f, 111–113, 112f, 116,
126–127, 167
range-specific strength after, 102
rationale and biomechanics of,
76–119
Reverse Shoulder Prosthesis, 76,
80–82, 148, 148f
revision or conversion to, 153–169
from bipolar arthroplasty,
153–154, 163, 168
bone loss and, 154, 156, 159–161,
160f-164f
fixation in, 160, 160f
from hemiarthroplasty, 153–161
for cuff tear arthropathy,
159–161, 160f-164f
for fracture, 154–159, 154f-159f,
167
for glenoid arthritis, 167
for rotator cuff-deficient
shoulder, 167
instability and, 154
preoperative imaging for, 154,
160–161, 162f, 163, 165f
from previous reverse prosthesis,
164, 168
results of, 167–168
from total shoulder arthroplasty,
153–154, 161, 165f-166f, 168
scapular notching with, 76, 80f,
114–115, 115f, 128–130, 129f-
130f, 169
as standard treatment, 61–62
Index 185
surgical technique for, 123–125,
142–145, 149–153
tendon transfers with, 111, 112f
Zimmer TM system, 142–145, 144f
Reverse Shoulder Prosthesis (RSP), 76,
80–82, 148, 148f
baseplate/glenosphere position in,
88–92
baseplate micromotion in, 84–85,
85f, 87, 87f, 93–96
baseplate of, 83, 83f-84f
biomechanical analysis of, 88–90,
89f-90f, 93, 95t
center of rotation, 80–82
compressive strength of, 82–83,
83f-84f
deltoid force with, 99–102, 101f
finite element analysis of, 90–91,
91f-92f, 94, 95t
5.0–mm screws in, 86–88, 88f, 89t
glenoid fixation of, 82–88, 106–107
glenoid-sided complications of,
80–96
glenosphere options in, 93–96, 93f,
93t, 94f
humeral-sided complications of,
96–102
initial design of, 80–82, 81f
instability/stability with, 97–98, 98f
maximum load to fixation failure,
83–84, 84f
moment arms with, 99–102, 101t
muscle function with, 99–102
range of motion with, 98–99, 99f-
100f
range-specific strength with, 102
Revision to reverse prosthesis,
153–169
from bipolar arthroplasty, 153–154,
163, 168
bone loss and, 154, 156, 159–161,
160f-164f
fixation in, 160, 160f
from hemiarthroplasty, 153–161
for cuff tear arthropathy, 159–161,
160f-164f
for fracture, 154–159, 154f-159f,
167
for glenoid arthritis, 167
for rotator cuff-deficient shoulder,
167
instability and, 154
preoperative imaging for, 154,
160–161, 162f, 163, 165f
from previous reverse prosthesis,
164, 168
results of, 167–168
from total shoulder arthroplasty,
153–154, 161, 165f-166f, 168
Rheumatoid arthritis, 12–13
Rocking-horse effect, 105, 121, 147, 161
1/31/08 11:08:23 AM
 186 Index
Rotation, 2
combined loss with elevation loss,
118
in cuff tear arthropathy, 68
isolated loss of, 117–118, 117f
postoperative, 73–74
prosthetic center of
and deltoid force, 99–102, 101f
Grammont reverse design, 76, 76f,
106, 106f, 148
Reverse Shoulder Prosthesis,
80–82
with reverse shoulder arthroplasty,
111–113
Rotator cuff
anatomy of, 8
biomechanics of, 1–7
functions of, 1
histology of, 8, 8f
as joint mover, 1–2
as joint stabilizer, 5–6
material properties of, 3–5
muscles of
contractile force of, 1–2, 2f
force vectors of, 5–6, 5f
physiological cross-sectional area
of, 1
Rotator cuff–deficient shoulder
arthroscopic procedures for, 60–61,
120
classification of, 12–20, 53–55
Columbia University experience
with, 138–146
Florida Orthopaedic Institute
experience with, 148–170
Lyon, France, experience with,
120–134
Mayo Clinic experience with,
135–137
McLaughlin’s legacy and, 138, 145
Neer’s legacy and, 138–140, 145
pathology of, 55–60, 57t. See also
specific pathologies
spectrum of disease in, 51–66, 52f,
53t
surgical algorithm for, 61–62, 63t
surgical treatment of, 60–62. See
also specific procedures
treatment indications in, 121–122
treatment options for, 120–121
Rotator cuff repair. See also specific
procedures
and joint torque, 2–3
main goals of, 37
Rotator cuff tear(s)
classification of, 14–15, 53–55
in cuff tear arthropathy, 51. See also
Rotator cuff-tear arthropathy
functional, 10
healing of
biologic process of, 173–174
14530inx.indd 186
muscle regeneration in, 175–176
promotion of, 21, 30–31, 33–34,
61, 171–177
and joint torque, 2–3
massive
arthroscopic management of,
21–36, 60–61, 120
definition of, 21, 22f, 37
irreparable, 8–11, 37–49, 62f
open soft tissue procedures for, 61
overview of, 62f
surgical algorithm for, 61–62, 63t
tendon transfers for, 37–49
mechanisms of, 4–5
extrinsic, 4
intrinsic, 4
pathophysiology of, biomechanics
of, 12–13, 13f
prevalence of, 8–9
primary, 13
repair of. See Rotator cuff repair;
specific procedures
Rotator cuff-tear arthropathy
classic, 51–53, 52f, 67f
classification of, 12–20, 52f, 53–55,
67–68
clinical manifestations of, 51, 67
Columbia University experience
with, 138–146
as contraindication to arthroscopy,
21, 22f
etiologies of, characteristics of,
13–14
Florida Orthopaedic Institute
experience with, 147–170
hemiarthroplasty for, 67–75,
135–136, 135f-136f
hemiarthroplasty revision for,
159–161, 160f-164f
hemorrhagic theory of, 51
historical background on, 51, 67,
138–140, 145
imaging of, 68
inflammatory theory of, 51
Mayo Clinic experience with,
135–137
mechanical theory of, 52–53, 67,
68f, 139–140
nonoperative treatment of, 137
nutritional theory of, 52, 67, 139–140
patient history in, 68
physical exam in, 68
post-repair, 13, 37
primary, 13
radiographic findings of, 68, 68f,
139, 139f
reverse shoulder arthroplasty for,
116–118, 159–161, 166–167
surgical algorithm for, 61–62, 63t
surgical treatment of, 60–62. See
also specific procedures
contraindications to, 68
indications for, 68
limited-goal, 69, 142, 147
options in, 68–70
treatment algorithm for, 137
treatment goals in, 69
type Ia, 15, 15f, 15t, 54, 55f, 67–68
type Ib, 15, 15f, 15t, 54, 55f, 67–68
type IIa, 15, 15f, 15t, 54, 55f, 67–68
type IIb, 15, 15f, 15t, 54, 55f, 67–68
RSP. See Reverse Shoulder Prosthesis
S
Sarcomere, shortening and
lengthening of, 1–2, 1f
Scaffolds
synthetic, 175
tissue, 33, 33f, 61, 171–173, 175–176
Scapular notching
avoidance of, techniques for, 130
classification of, 128–130, 129f-130f
in reverse shoulder arthroplasty, 76,
80f, 114–115, 115f, 128–130,
129f, 169
Scapular spine fracture, in reverse
shoulder arthroplasty, 128
Screw fixation, in reverse shoulder
arthroplasty, 82–88, 106–107,
125
baseplate micromotion with, 84–85,
85f, 87, 87f
Columbia University experience
with, 145
compressive strength of, 82–83,
83f-84f
failure of, scanning electron
microscopy of, 85–86, 86f
5.0–mm screws for, 86–88
Florida Orthopaedic Institute
experience with, 149, 149f,
151, 152f, 160, 160f, 164–165
locking and nonlocking screws for,
86, 86f
maximum load to fixation failure,
83–84, 84f
in revision setting, 160, 160f
Seebauer classification, 15–18, 15f-18f,
15t, 18t, 54, 55f, 67–68
Semiconstrained implant, 69, 105,
135–137
Servo-hydraulic machine, 85, 85f
Sever-L’Episcopo procedure, 42
Shear component, of muscle force
vector, 5–6, 5f
Shoulder and Elbow Service, of Florida
Orthopaedic Institute, 147
Shoulder arthroplasty, 61. See
also Reverse shoulder
arthroplasty; Total shoulder
arthroplasty
age and, 18
1/31/08 11:08:23 AM

clinical presentation and, 18, 19f
Columbia University experience
with, 138–146
contraindications to, 68
current options in, 15–16
Florida Orthopaedic Institute
experience with, 147–170
indications for, 68
Mayo Clinic experience with,
135–137
outcomes of, 16–18, 17f, 18t
Shoulder replacement. See Reverse
shoulder arthroplasty;
Shoulder arthroplasty; Total
shoulder arthroplasty
Shoulder Service
Columbia University, 138, 145
New York Orthopaedic Hospital, 138
Shoulder surgery, Neer as father of
modern, 138
Simple Shoulder Test (SST), 74
Sirveaux classification, of scapular
notching, 128–130, 129f
Small intestine submucosa (SIS)
scaffolds, 171–173, 171t, 174
Smooth muscle actin (SMA), 173
Sodium hyaluronan, 10
Soft tissue augmentation/
enhancement, 21, 30–31,
33–34, 33f-34f, 61, 171–177
Soft tissue procedures, open, 61
Soft tissue tenodesis, 21
Spectrum of disease, 51–66, 52f, 53t
Stability, in reverse shoulder
arthroplasty, 97–98, 98f,
110–111, 110f, 113, 130–131,
169
Stable center tear, 14, 14f
Stanmore prosthesis, 136, 136t
Static instability, 59
Stem cells, mesenchymal, 174
Stress and strain, 4–5
Subacromial space, changes in, 60, 63t
Subcoracoid space, changes in, 60, 63t
Subdeltoid space, changes in, 60, 63t
Subscapularis muscle
in abduction, 2
in elevation, 2
force vectors of, 5–6
moment arm of, 2
in reverse shoulder arthroplasty,
99–102
physiological cross-section area of, 1
in rotation, 2
stabilization by, 12
Subscapularis tendon
mechanical properties of, 4
structural properties of, 4
tear of, pectoralis major transfer for,
40–41, 120–121
Subscapularis transfer, 37–39
14530inx.indd 187
complications of, 38–39
indications for, 37
outcomes of, 38–39
postoperative management of, 38
surgical technique for, 37–39, 38f
Superior approach, for reverse
shoulder arthroplasty, 127
Superolateral approach, for reverse
shoulder arthroplasty, 123
Suprascapular nerve, arthroscopic
decompression of, 23, 27–28,
29f
Supraspinatus muscle
atrophy of, 68
contractile force of, 1–2, 1f
degeneration of, reversal of, 175
force vectors of, 5–6
physiological cross-section area of, 1
repair of, 2–3
retraction of, 2–3
Supraspinatus tendon
aging and, 4
compressive properties of, 4
histology of, 8, 8f
mechanical properties of, 3
medial advancement on, 2–3
repair of, 2–3
stabilization by, 12
stress and strain on, 4–5
superior transposition of, 3
tears of, 2
aging and, 9
triceps transfer for, 42
tensile properties of, 3
Surgical treatment, 60–62. See also
specific procedures
algorithm for, 61–62, 63t
contraindications to, 68
indications for, 68
limited-goal, 69, 142, 147
modern, Neer as father of, 138
options in, 68–70
Synthetic scaffolds, 175
T 136–137, 136f, 136t
Tendon healing, 21, 30–31, 33–34, 61,
171–177
Tendon loss, 53, 53t, 56–57
Tendon transfers, 37–49, 61, 120–121
age and, 122
biceps interposition grafting, 44–45,
45f
combined pectoralis major and
latissimus dorsi, 41–42
deltoid, 45–46, 46f
latissimus dorsi, 39–40, 39f, 61, 63t,
111, 112f, 120
pectoralis major, 40–41, 41f, 61, 63t,
120–121
with reverse shoulder arthroplasty,
111, 112f
Index 187
subscapularis, 37–39, 38f
teres major, 111, 112f
teres minor, 43–44, 44f
trapezius, 46–47, 47f
triceps, 42–43, 42f-43f
Teres major transfer, with reverse
shoulder arthroplasty, 111,
112f
Teres minor muscle
force vectors of, 5–6
physiological cross-section area of, 1
in rotation, 2
Teres minor transfer, 43–44
indications for, 43
outcomes of, 44
postoperative management of, 43
surgical technique for, 43–44, 44f
Texture correlation technique, 4–5
Therabands, 73
Tissue augmentation/enhancement,
21, 30–31, 33–34, 33f-34f, 61,
171–177
Tissue engineering, 171–177
Tissue inhibitor matrix
metalloproteinase, 173
TissueMend, 171–172, 171t
Tissue scaffolds, 33, 33f, 61, 171–173,
176
biochemical composition of, 172
clinical studies of, 172–173
commercially available, 171t
complications of, 173
mechanical properties of, 172, 172f
for muscle regeneration, 175–176
Torque, joint, 2–3
Total shoulder arthroplasty
Columbia University experience
with, 140–141
failure of, 61, 68–69, 121, 136–137,
147
Florida Orthopaedic Institute
experience with, 147
vs. hemiarthroplasty, 69
Mayo Clinic experience with,
Neer’s experience with, 140, 140f,
141, 141f
outcomes of, 137, 140
reverse. See Reverse shoulder
arthroplasty
revision to reverse shoulder
prosthesis, 153–154, 161,
165f-166f, 168
Transforming growth factor-β (TGF-β),
173–174
Trapezius transfer, 46–47
indication for, 47
surgical technique for, 46–47, 47f
Triceps transfer, 42–43
indications for, 42–43
outcomes of, 43
1/31/08 11:08:24 AM
 188 Index
Triceps transfer (continued)
postoperative management of, 42
surgical technique for, 42–43, 42f-
43f
T-type mattress locking stitch, 28, 31f
Tuberoplasty, arthroscopic, 60, 120
Type Ia cuff tear arthropathy, 15, 15f,
15t, 54, 55f, 67–68
Type Ib cuff tear arthropathy, 15, 15f,
15t, 54, 55f, 67–68
Type IIa cuff tear arthropathy, 15, 15f,
15t, 54, 55f, 67–68
Type IIb cuff tear arthropathy, 15, 15f,
15t, 54, 55f, 67–68
U X-rays, 68, 68f, 121. See also specific
Ultrasound, pulsed, 30–31
14530inx.indd 188
Unconstrained implant, 69, 105, 147 classification by, 53–55, 56f
revision to reverse prosthesis, 161, intraoperative, 73, 74f
165f-166f, 168
Unstable center tear, 14 Y
Young patients, 122
V
Visual Analog Scale, 74 Z
Zimmer Bigliani-Flatow arthroplasty
W system, 141–142, 143f
Walch, Gilles, 108, 148 Zimmer Collagen Repair Patch,
171–172, 171t
X Zimmer TM Reverse Shoulder system,
Xenografts, for tissue repair 142–145, 144f
augmentation, 33, 33f,
172–173
applications
1/31/08 11:08:24 AM