The Journal of Bone & Joint Surgery

Selected Instructional Course Lecture | May 18, 2011

Massive Rotator Cuff Tears without Arthropathy: When to Consider Reverse Shoulder Arthroplasty

Kevin L. Harreld, MD¹; Brian L. Puskas, MD¹; Mark Frankle, MD¹

¹ Shoulder and Elbow Division, Florida Orthopaedic Institute, 13020 Telecom Parkway North, Tampa, FL 33637. E-mail address for M. Frankle: frankle@pol.net

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An Instructional Course Lecture, American Academy of Orthopaedic SurgeonsLook for this and other related articles in Instructional Course Lectures, Volume 61, which will be published by the American Academy of Orthopaedic Surgeons in February 2012:• “Arthroscopic Repair Techniques for Massive Rotator Cuff Tears,” by Jeffrey S. Abrams, MD, and Frederick S. Song, MDPrinted with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2012 in Instructional Course Lectures, Volume 61. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

J Bone Joint Surg Am, 2011 May 18;93(10):973-984

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Extract

Patients with large, retracted rotator cuff tears present a surgical challenge to relieve pain and restore shoulder function. However, the term massive rotator cuff tear has only recently been adopted. The first studies to employ this description were published in the late 1970s and early 1980s, focusing on techniques and outcomes associated with freeze-dried rotator cuff allografts or muscle transfers^1,2. Since then, massive rotator cuff tears have been increasingly recognized, and are now a topic of particular emphasis in clinical and biomechanical research. A PubMed search yields almost 350 articles on this topic, with nearly 200 studies published within the last five years. Despite this increased focus, an optimal treatment has yet to be established. Current studies outline a variety of techniques to address such tears, including debridement with acromioplasty^3,4, biceps tenotomy⁵, tenotomy with tuberoplasty⁶, partial repair^7,8, complete arthroscopic repair^9,10, mini-open repair^11,12, tissue augmentation^13,14, tendon transfer^15,16, deltoid flap^17,18, hemiarthroplasty^19,20, and reverse shoulder arthroplasty^21,22. The definition of massive rotator cuff tear has been inconsistent. Commonly accepted definitions include a tear size >5 cm^3,23, a complete tear of at least two tendons^24,25, or both²⁶. However, the more important distinction, rather than tear size or number of tendons involved, is the healing potential of the tendon and the ability to technically achieve a satisfactory repair. A massive rotator cuff tear is not necessarily an irreparable tear²⁷. Determining healing potential is critical to selecting the appropriate surgical strategy, as a subset of rotator cuff tears remains irreparable²⁸. Many acute tears may be quite large and may involve two or more tendons, but they may still be mobile and repairable. Conversely, smaller tears may prove to be irreparable and may represent a separate clinical entity.

Figures in this Article

Introduction

Reverse shoulder arthroplasty is a well-established and reliable treatment for patients with rotator cuff tear arthropathy^29-31. However, in the absence of cartilage disease, arthroplasty may be a less obvious decision for both the patient and the surgeon. We outline the history, indications, outcomes, and pitfalls associated with the use of reverse shoulder arthroplasty to manage irreparable tears without arthritis.

To understand appropriate application of reverse shoulder arthroplasty in this patient population, one must first appreciate the pathology and glenohumeral instability that occurs in the rotator cuff deficient shoulder.

Pathomechanics and Rationale of Reverse Shoulder Arthroplasty

The rotator cuff musculature acts as a dynamic stabilizer to the glenohumeral joint, centering the humeral head on the glenoid^32-34. An intact rotator cuff creates “concavity compression,” a mechanism that imparts stability to this otherwise unconstrained joint and establishes a stable fulcrum against which the deltoid can rotate the humeral head and elevate the arm^35-37. This concept is supported by electromyographic evidence that rotator cuff contraction precedes the larger force-generating contraction of the deltoid during active arm elevation³⁸. A stable fulcrum requires intact coronal and transverse muscular force couples. The subscapularis and infraspinatus-teres muscle complex provide the transverse-plane force couple, and the inferior portion of the rotator cuff on the humeral head provides the coronal-plane force couple^3,7. Minimal glenohumeral translations occur in the normal shoulder throughout arm elevation and abduction^39-41.

In a shoulder with a rotator cuff tear, the deltoid muscle increases force generation to compensate for the loss of the abduction torque provided by the rotator cuff muscles^42-44. The increase in deltoid force that occurs with an isolated supraspinatus tear is relatively small and is compensated by co-contraction of the large adductors (latissimus dorsi and pectoralis major muscles) and remaining rotator cuff muscles. Consequently, glenohumeral stability is generally preserved^42,45. However, as the rotator cuff tear extends posteriorly, the normal force couples are disrupted and concavity compression is lost⁴⁵. Increasingly large deltoid abduction forces are generated, and the stabilizing effect of the remaining rotator cuff musculature is lost. Co-contraction of the adductors is no longer sufficient to counter the deltoid force. The joint reaction force vector migrates outside the glenoid rim, and instability results^42,43,45. As a consequence of the loss of a stable fulcrum, the deltoid force no longer rotates the humeral head on the glenoid, but pulls it in a superior direction^3,45,46 (Fig. 1). This superior translation of the humeral head has previously been confirmed in several studies investigating the biomechanical effects of rotator cuff deficiency^46-51.

Fig. 1

Anteroposterior radiograph of the right shoulder, demonstrating superior migration of the humeral head, which is indicative of a massive rotator cuff tear.

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Restoration of appropriate force couples may be achieved with a partial or complete tendon repair, resulting in reestablishment of a stable fulcrum for elevation^12,14,52-54. However, many large tears are associated with high rates of recurrent tendon defects on follow-up examinations^11,55-57. There is evidence of an association between recurrent repair defects and postoperative strength deficits and outcome scores^55,57-59. When appropriate force couples cannot be adequately reestablished, a stable fulcrum for humeral head rotation is not achieved. Abnormal superior translations of the humeral head persist, leading to shoulder pseudoparalysis and eventual anterior-superior escape of the humeral head. In this setting, a reversed prosthetic articulation blocks superior translation of the humerus, allows the deltoid tension to be restored, and provides stability to the glenohumeral joint. The superior pull of the deltoid is converted into a rotational moment, and elevation of the arm is restored^30,60-62.

History of Reverse Shoulder Arthroplasty

Early reverse shoulder arthroplasty was designed to improve clinical outcomes for patients with rotator cuff deficiency and associated glenohumeral arthritis^63-68. Previous attempts to manage this population with highly constrained so-called “fixed fulcrum” anatomical type designs were unsatisfactory due to a high complication rate, and these devices were eventually abandoned^69-72. Conversely, early reverse shoulder arthroplasty series reported complication rates from 16% to 31%^64,68. However, when reporting on failures of shoulder arthroplasty in the 1970s, modern authors now routinely group the higher complication rates of highly constrained anatomical devices with the lower complication rates observed with early reverse designs. Furthermore, failure in both of these devices is consistently attributed to a center of rotation that is lateral to the face of the glenoid^62,73-77.

Boileau et al. cited the results of two early studies on reverse devices with a lateral center of rotation in developing their argument for a medial center of rotation at the level of the glenoid face⁶², stating that these early devices failed due to “excessive torque and shear forces at the glenoid component-bone interface.” However, careful review of these studies reveals that such a conclusion may be questioned. In the first study, there were five (16%) device “failures” (defined as removal of the prosthesis) in thirty-one patients. Three of these were due to dislocation, one to a “wrenched shoulder,” and one to persistent pain. At a mean three and one-half year follow-up, there were no reported baseplate failures⁶⁴. Subsequently, Broström et al. reported on their five-year experience in patients with rheumatoid arthritis. In this study, the authors noted increased loosening of the glenoid component, attributed to the constraint inherent in the device. Improved pain relief and ability to perform activities of daily living were noted in all seventeen shoulders⁷⁸. Describing torque at the baseplate-bone interface as a uniformly causative factor in implant failure must be regarded cautiously. Alternative contributing factors may include the type of disease that is present, the degree of constraint, the adequacy of glenoid fixation, and the notable lack of bone in-growth potential in early devices.

Modern series of devices with a lateral center of rotation reflect a continued improvement in design with fewer reported baseplate-related complications than those seen in the early studies. In one recent study, there were four reported baseplate failures in sixty-nine shoulders at a mean of fifty-two months of follow-up⁷⁹. However, all failures occurred in an early baseplate design in which 3.5-mm nonlocking screws were used, and no failures were reported for the current locking-screw design. In a further, focused study of ninety-six shoulders in which a baseplate design with locking screw technology was employed, no glenoid fixation failures were reported at a minimum follow-up period of two years⁶¹. In another study of patients with acquired glenoid bone defects, there was no evidence of baseplate loosening in 143 shoulders, despite the presence of abnormal glenoids in fifty-six patients⁸⁰. In contrast, current devices with a medial center of rotation have reported complication rates as high as 60%, with scapular notching (i.e., a defect of the inferior neck of the scapula, presumably occurring from contact with the humeral socket) frequently reported^81,82 (Fig. 2). Both implant designs relieve pain and improve active forward elevation, and designs with both a medial and lateral center of rotation are widely used in the treatment of rotator-cuff deficient conditions.

Fig. 2

Classification of scapular notching, as described by Sirveaux et al⁸¹. The defect of the bone in the inferior part of the glenoid component is classified according to the size of the defect as seen on the radiograph. A defect is classified as grade 1 when it is confined to the pillar; grade 2, when it is in contact with the lower screw; grade 3, when it is over the lower screw; and grade 4, when it extends under the baseplate. (Reproduced and adapted, with permission and copyright © of the British Editorial Society of Bone and Joint Surgery, from: Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86:388-95.)

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Indications and Contraindications

The decision to perform a reverse shoulder arthroplasty in patients with massive rotator cuff tears without evidence of glenohumeral arthritis must be individualized. Eligible candidates for reverse shoulder arthroplasty should demonstrate forward pseudoparalysis, with active forward elevation of <90°, and should have weakness of the rotator cuff musculature on physical examination²². Often, these patients will have full, passive shoulder motion. Yet, some patients may instead exhibit stiffness on physical examination of the shoulder. This is often the result of soft-tissue contractures or scarring from previous surgery rather than glenohumeral arthritis.

The following three clinical scenarios in which application of a reverse shoulder arthroplasty would be beneficial illustrate the appropriate indications for this device.

Scenario 1. An elderly patient with comorbidities (e.g., smoking or diabetes) predictive of poor healing of the rotator cuff^83-86 presents after an acute-on-chronic rotator cuff tear. The patient has pseudoparalysis (forward elevation of <90°) and pain, and, although there is no anterior-superior escape of the humeral head, magnetic resonance imaging reveals rotator cuff atrophy^87-90 (Fig. 3). In this scenario, a reverse shoulder arthroplasty offers the potential for reliable return of function and relief of pain with a decreased risk of reoperation compared with attempted rotator cuff repair.

Fig. 3

Scenario 1. Preoperative anteroposterior radiograph of the right shoulder demonstrates no evidence of escape of the humeral head (A), but magnetic resonance imaging demonstrates severe atrophy of the supraspinatus and infraspinatus muscles (arrows in B) and the patient has pseudoparalysis of the right shoulder (C) on clinical examination.

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Scenario 2. A patient has a massive rotator cuff tear with pseudoparalysis, pain, and clinically (but not radiographically) evident anterior-superior escape of the humeral head (dynamic instability) (Fig. 4).

Fig. 4

Scenario 2. Preoperative anteroposterior radiograph of the right shoulder demonstrates no evidence of escape of the humeral head (A), but examination reveals clinically apparent anterior-superior escape of the humeral head. The prominence of the humeral head (B) is apparent when the patient attempts to abduct the shoulder.

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Scenario 3. A patient has a massive rotator cuff tear with pseudoparalysis, pain, and obvious (both clinically and radiographically evident) anterior-superior escape of the humeral head^28,91-93 (Fig. 5).

Fig. 5

Scenario 3. Frank instability and escape of the humeral head in the right shoulder is apparent both radiographically (A) and clinically (B).

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Our approach to the patient with a massive rotator cuff tear without arthritis is summarized in the algorithm in Figure 6. Reverse shoulder arthroplasty is contraindicated in patients with a massive rotator cuff tear and a nonfunctional deltoid muscle. Deltoid dysfunction may be due to cervical radiculopathy, injury from previous open rotator cuff surgery, or axillary nerve injury.

Fig. 6

Algorithm for approach to a patient with a massive rotator cuff tear. RCR = rotator cuff repair, and RSA = reverse shoulder arthroplasty.

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Outcomes

Early reports of reverse shoulder arthroplasty are favorable, but generally include only patients with rotator cuff deficiency and associated arthrosis of the glenohumeral joint^{29-31,73,81,94-97}. Although some subsequent studies stratify the study population by etiology, none of these initial reports describe outcomes based on the presence or absence of concomitant glenohumeral arthritis^61,82,98. Werner et al. reported that the reoperation rate was lower and the final Constant score⁹⁹ was higher in patients who were initially treated with a primary reverse shoulder arthroplasty than in patients who were treated with a reverse shoulder arthroplasty after a prior failed rotator cuff repair or failed arthroplasty⁸². Cuff et al. noted similar findings, with improved outcomes in primary use of reverse shoulder arthroplasty compared with use in revision settings⁶¹. While both of these studies suggest a more favorable outcome after reverse shoulder arthroplasty for those patients without prior surgery for a rotator cuff tear, neither study described the degree of associated glenohumeral arthritis in these patients. Wall et al. reported the outcomes after reverse shoulder arthroplasty in a subgroup of thirty-four shoulders with massive rotator cuff tears and no associated arthritis¹⁰⁰. There was no difference in outcomes between this group and a group of patients who underwent a primary reverse shoulder arthroplasty for treatment of rotator cuff tear arthropathy. All patients undergoing a primary surgical procedure had a better result than those with previous failed rotator cuff surgery or failed arthroplasty¹⁰⁰.

More recently Boileau et al. reported their experience with forty-six shoulders in forty-four patients who underwent reverse shoulder arthroplasty after failed surgical management of a rotator cuff tear²². All patients had undergone only one prior surgical procedure, either attempted repair or palliative treatment (biceps tenotomy or acromioplasty). Sixty-one percent of shoulders had radiographic evidence of glenohumeral arthritis. There was no difference in final pain scores, Constant scores, or range of motion between those with and without arthritis and no difference in the amount of improvement between the two groups. Comparing patients with a preoperative active forward elevation of <90° or >90°, there was a significant difference in the amount of improvement achieved in Constant scores and forward elevation. The group with preserved forward elevation of >90° preoperatively experienced a decrease in mean forward elevation from 146° to 122° after implantation of the reverse shoulder arthroplasty. They also experienced a smaller improvement in Constant scores and were generally more dissatisfied with their result (27%) compared with the group that had shoulder pseudoparalysis (7%).

In another report, the outcomes after reverse shoulder arthroplasty for management of an irreparable rotator cuff tear were studied in sixty shoulders (fifty-eight patients) in which there was no evidence of osteoarthritis⁷⁹. The authors found an improvement in the total American Shoulder and Elbow Surgeons score¹⁰¹, from 33.3 preoperatively to 75.4 postoperatively, which was similar to previously reported results in a patient population with rotator cuff deficiency and osteoarthritis³⁰. These authors noted significant improvements in the Simple Shoulder Test score¹⁰², the visual analog scores for pain and function¹⁰³, and the Short Form-36 physical component. Range of motion in forward elevation improved from 53° to 134°, and external rotation improved from 27° to 51°. No significant differences were found between those patients with prior failed rotator cuff surgery and those undergoing a primary procedure. In this study population, only four patients had preserved preoperative forward flexion of >90°. Range of motion improved in three of these four patients. The one other patient experienced a decrease in forward elevation from 95° to 90°. All four of these patients described their satisfaction as good or excellent. However, three complications occurred in two patients within this specific subset: baseplate failure and hematoma in one patient and postoperative dislocation in another⁷⁹.

These studies demonstrate that, following reverse shoulder arthroplasty, equivalent improvement and final outcome may be obtained in patients with rotator cuff tears with or without associated glenohumeral osteoarthritis. Patients undergoing a primary shoulder intervention with a reverse implant tend to experience better outcomes than those with failed prior surgery. However, the results after reverse shoulder arthroplasty in patients with preserved forward elevation of >90° preoperatively are not as good as those in patients who are pseudoparalytic preoperatively. Patients who have more preoperative forward elevation may be at an increased risk of having perioperative complications or diminished functional improvement compared with patients who have shoulder pseudoparalysis. Consequently, they may also be at risk of having lower satisfaction scores following treatment with a reverse shoulder arthroplasty.

Complications

There is some heterogeneity in studies reporting complications after reverse shoulder arthroplasty. However, a review of published series reveals sufficient commonalities to allow meaningful conclusions. The most common complication in many reports has been scapular notching^{31,81,82,104-107}. However, in devices with a glenosphere employing a lateral center of rotation, a much lower prevalence of scapular notching has been reported^29,61,108. Biomechanical data also suggest that scapular notching is probably increased in devices that have a medial center of rotation^109,110. Some studies have found postoperative dislocation to be the most frequent complication^61,82,100. Although not reported in all series, an increased infection rate, up to 16% (three of nineteen) in the study by Boileau et al.³¹, has been reported in revision surgery^31,98,100. Previous surgery is a risk factor for increased complications¹⁰⁰, reoperations⁸², and lower implant survival rates⁹⁸.

Postoperative fracture of the acromion is another common complication, but it is less well understood^29,30,82. Frequently, it occurs within the acromion proper but it may occur at the base of the acromion, where it is more accurately described as a fracture of the scapular spine (Fig. 7). A common presentation of acromial fracture is pain after a fall, a sporting activity, or a vigorous therapy session. However, a traumatic event is not necessary for fracture. A fatigue-type insufficiency fracture from overtensioning the deltoid is one possible explanation for such fractures⁶². However, the results from one recent study could not demonstrate a correlation between the degree of humeral lengthening and postoperative acromial fracture¹¹¹. Current studies demonstrate that, although these patients may improve from their preoperative status, ultimate functional outcome is diminished^112,113. Preoperative acromial fracture or os acromiale do not adversely affect outcome¹¹³.

Fig. 7

Acromial fracture following reverse shoulder arthroplasty. A: Radiograph demonstrating a fracture (arrow) of the acromion at the location of the meso-acromion. B: Radiograph depicting a fracture (arrow) at the base of the acromion along the scapular spine.

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In a mixed group of patients with and without arthritis, Boileau et al. reported an 8.7% complication rate, including one glenosphere dissociation, one axillary granuloma, one postoperative periprosthetic fracture, and one instance of aseptic humeral loosening. There were no postoperative dislocations²². Mulieri et al. reported a 20% complication rate in patients without associated arthritis. However, four baseplate failures were thought to be design-related and, after baseplate design modification, no further failures were reported. Excluding the baseplate failures, the complication rate was 13%. Complications included three acromial fractures, one periprosthetic humeral fracture, one dislocation, one broken screw, one hematoma, and one deep infection⁷⁹. The complication rates in the patient population without arthritis do not appear to be significantly different from the previously reported complication rates after reverse shoulder arthroplasty in patients with osteoarthritis.

Potential Pitfalls

Reverse shoulder arthroplasty is a reliable and successful method of treating patients with rotator cuff deficiency, particularly those with shoulder pseudoparalysis. However, pseudoparalysis presents in a varied fashion, with sudden or progressive weakness, with or without associated pain, and with a variable history of an antecedent traumatic event. One must maintain a high index of suspicion for other conditions that may present with a pseudoparalytic shoulder. Cervical radiculopathies and deltoid dehiscence or detachment are two conditions that may mimic pseudoparalysis due to rotator cuff deficiency, but these conditions are unlikely to be managed successfully with a reverse shoulder arthroplasty.

A thorough physical and neurological examination of the extremity and cervical spine can differentiate a massive rotator cuff tear from cervical radiculopathy. Patients with a radiculopathy usually have pain in a dermatomal distribution into the hand. Referred trapezial and periscapular pain often accompany the radicular component. Conversely, pain from a rotator cuff tear typically does not radiate distal to the elbow. Reproduction of painful symptoms with flexion and extension of the spine or with performance of the Spurling maneuver is indicative of cervical spine pathology.

The deltoid and rotator cuff muscles are innervated predominantly from the C5 and C6 nerve roots. Typically, cervical disc herniations between C4 and C5 impinge on the C5 nerve root and may cause pain and numbness down the side of the neck, over the top of the shoulder, to the lateral aspect of the deltoid muscle. This may be associated with varying degrees of muscle weakness of the deltoid or rotator cuff muscles. A massive rotator cuff tear frequently involves the infraspinatus and teres minor muscles, resulting in more weakness in external rotation with the arm at the side or at 90° of abduction as compared with the weakness seen in patients with a C5 root impingement. In an isolated C6 radiculopathy due to a cervical disc herniation between C5 and C6, a patient may have weakness of the deltoid muscle without clinically apparent involvement of the rotator cuff muscles. Pain radiating down the lateral side of the arm and forearm to the tip of the thumb and index finger is common. Biceps weakness in elbow flexion and supination, weakness in wrist extension, and a diminished brachioradialis reflex are signs of a cervical radiculopathy. Advanced cases of C5 or C6 nerve root compression can cause deltoid atrophy and disproportionate weakness of the trapezius. Figures 8 and 9 demonstrate the clinical case of a patient referred for evaluation for a reverse shoulder arthroplasty in whom electromyographic analysis confirmed C6 radiculopathy.

Fig. 8

T2-weighted magnetic resonance imaging of the left shoulder (A and B) reveals a large, full-thickness rotator cuff tear (arrow shown in A) with severe atrophy (arrows shown in B) of the supraspinatus, infraspinatus, and teres minor. C and D: Clinical examination suggests shoulder pseudoparalysis due to a massive rotator cuff tear.

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Fig. 9

Anteroposterior radiograph of the left shoulder (A) demonstrates no evidence of static superior migration of the humeral head. Further physical examination reveals a profound weakness in biceps flexion (B) and an inability to supinate the forearm (C). This patient was subsequently found to have a C6 radiculopathy and evidence of deltoid denervation. A reverse shoulder arthroplasty would be expected to provide no functional improvement in such a patient.

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In the normal shoulder, the deltoid is responsible for more than 50% of the force necessary to elevate the arm in the plane of the scapula¹¹⁴. Consequently, deltoid dysfunction may mimic shoulder pseudoparalysis due to rotator cuff deficiency. As this muscle is primarily responsible for powering forward elevation and abduction in the shoulder that has undergone reverse shoulder arthroplasty, it is critical to recognize a nonfunctional deltoid preoperatively. Deltoid dehiscence, proximal detachment, or axillary nerve injury can all result from prior surgery and should be considered in pseudoparalytic patients who have a history of prior rotator cuff repair, particularly those with a prior open repair^115-118. Whatley et al. described successful treatment of preoperative deltoid dysfunction in two of three patients with use of a deltoidplasty coupled with a reverse shoulder arthroplasty and a Nice-L'Episcopo latissimus-teres major muscle transfer¹¹⁴.

Lastly, successful application of the reverse shoulder arthroplasty is predicated on eliminating pathologic superior translation of the humeral head and restoring a stable fulcrum for the deltoid. The preoperative ability of a patient to elevate the arm forward beyond 90° suggests the presence of intact force couples and the existence of a stable fulcrum. Special care should be taken in considering reverse shoulder arthroplasty for these patients, particularly in the absence of glenohumeral arthritis. Performing a reverse shoulder arthroplasty in this setting is associated with increased rates of patient dissatisfaction and increased risk of complications^22,79. One should consider diagnostic injections of local anesthetic into the glenohumeral joint in the preoperative evaluation, or other procedures such as partial rotator cuff repair or biceps tenotomy, rather than a reverse shoulder arthroplasty.

Overview

Reverse shoulder arthroplasty can be reliably applied to patients who are experiencing shoulder instability and pseudoparalysis from a massive rotator cuff tear. In appropriately selected patients, one can anticipate comparable functional improvement, pain relief, and patient satisfaction in patients without evidence of glenohumeral arthritis as compared with those with more advanced arthropathy. Surgeons should maintain a high index of suspicion for conditions that may mimic pseudoparalysis that is caused by a massive rotator cuff tear but that are in fact representative of underlying deltoid muscle deficiency. Particular care should be taken when considering reverse shoulder arthroplasty for treatment of a nonarthritic shoulder with a massive rotator cuff tear if the patient has preserved forward elevation of >90°.

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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the Foundation for Orthopaedic Research and Education. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DJO Surgical).

Topics

joint disorders ; rotator cuff ; shoulder region ; rotator cuff injury ; shoulder replacement arthroplasty ; humerus head

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Kevin L. Harreld, Brian L. Puskas, Mark Frankle; Massive Rotator Cuff Tears without ArthropathyWhen to Consider Reverse Shoulder Arthroplasty. The Journal of Bone & Joint Surgery. 2011 May;93(10):973-984.

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