Techniques in Shoulder and Elbow Surgery 7(3):160Ð167...

| R E V I E W |

Superior Instrumentation Through the RotatorCuff Defect From a Deltopectoral Approach forHemiarthroplasty for Cuff Tear ArthropathyJason J. Scalise, MD and Joseph P. Iannotti, MD, PhDDepartment of Orthopaedic SurgeryThe Cleveland Clinic FoundationCleveland, OH

| ABSTRACT

Rotator cuff tear arthropathy remains a challengingproblem for the orthopaedic surgeon. In these cases,humeral prosthetic arthroplasty has yielded improve-ments in pain, whereas functional improvements havebeen less predictable. In North America and Europe, thedeltopectoral or superior surgical approach is typicallyused to gain access to the glenohumeral joint for purposesof performing a hemiarthroplasty. Each approach vio-lates different portions of the remaining soft tissuestructures, which have been shown to be important forgood postoperative function in patients with rotatorcuffYdeficient arthropathy. A modified surgical tech-nique for humeral prosthetic arthroplasty in patients withrotator cuffYdeficient arthropathy is described. In appro-priately selected patients, this surgical technique allowsfor sufficient exposure of the glenohumeral joint whilepreserving the essential functional tissues, which havebeen shown to be important in promoting an optimaloutcome in these patients.Keywords: rotator cuff tear arthropathy, hemiarthroplasty

| HISTORICAL PERSPECTIVE

Glenohumeral arthrosis associated with an irreparablerotator cuff tear represents a therapeutic challenge forthe orthopedic surgeon. Although rotator cuff teararthropathy (CTA) represents a small subset of gleno-humeral arthrosis, there are many other causes ofarthritis associated with large and massive irreparablerotator cuff tears. These other diagnoses includerheumatoid arthritis, psoriatic arthritis, crystal-inducedinflammatory arthritis, and posttraumatic arthritis. Eachof these problems can result in rotator cuff deficiencyand arthritis (RCDA) and is associated with adversejoint mechanics and profound functional limitations.

As the glenohumeral joint lacks inherent osseousconstraints, it relies significantly upon its soft tissueelements to provide stability throughout its range ofmotion. The rotator cuff functions as both motor andstabilizer of the proximal humerus during motion. Itassists with external and internal rotation as well asstrength in elevation. Importantly, it applies a compres-sive centralizing force to the humeral head in asynergistic manner during shoulder motion that ispowered by the larger deltoid, latissimus dorsi, andpectoralis major muscles. Large tears of the rotator cuffcan weaken this centralizing function, resulting inimpaired joint mechanics, diminished function, and insome instances, painful arthrosis.1Y4

Several reports have discussed the concept of atransverse force couple in the rotator cuff.5Y9 Thisconcept, supported both biomechanically and clinically,demonstrates that the anterior portion of the rotator cuff(subscapularis) may be balanced by the posterior portionof the rotator cuff (infraspinatus and teres minor)despite a large deficiency of the superior portion of therotator cuff (supraspinatus). The remaining balancedcuff affords some patients sufficient joint compressiveforces through a transverse force couple and thereforepreservation of arm elevation. In many cases, portionsof the anterior and posterior rotator cuff remain attacheddespite the presence of a massive rotator cuff tear andarthrosis. Although not sufficient to provide normalmechanics to the glenohumeral joint, when combinedwith a functioning deltoid and a stable and intactcoracoacromial (CA) arch, it affords some degree offunctionality by way of a force couple.

When this balance is compromised, the unopposedpull of the deltoid leads to increased superior humeralhead migration and articulation with the CA arch.Several studies have pointed out the importance ofmaintaining the CA arch integrity in patients withirreparable rotator cuff tears.1,3,10Y12 It has been sug-gested that the CA ligament may provide a fulcrum incuff-deficient shoulders on which the humerus may

Techniques in Shoulder and Elbow Surgery 7(3):160–167, 2006 ! 2006 Lippincott Williams & Wilkins, Philadelphia

Reprints: Joseph P. Iannotti, MD, PhD, Department of OrthopaedicSurgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, A-41Cleveland, OH 44195 (e-mail: [email protected]).

Techniques in Shoulder and Elbow Surgery160

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articulate during a functional range of motion.2,13 Inaddition, anterosuperior instability has been demon-strated clinically and experimentally when the CAligament is incompetent or absent or the normal anterior-posterior dimension of the acromion is decreased as aresult of prior surgical acromioplasty.10,14Y16 A largeretracted rotator cuff tear with an incompetent CA archmay therefore lead to disabling anterosuperior humeralescape. When this occurs, the mechanical advantage ofthe deltoid muscle is severely diminished, with resultantpoor shoulder function.17

Surgical intervention is indicated in patients withlarge irreparable rotator cuff tears and painful gleno-humeral arthropathy and in patients in whom non-operative measures have failed. When surgicalintervention is indicated, hemiarthroplasty has beenshown to provide predictable improvements in pain.However, functional improvement has been moredifficult to predict.1,3,4,18Y21 The reasons for thesevariations are likely multifactorial and arise from differ-ences in rotator cuff involvement, CA arch integrity,deltoid muscle function, and the ability of the patient toengage in appropriate postoperative rehabilitation pro-gram.1,3,10,22,23

In North America, the deltopectoral approach iscommonly used when performing shoulder hemiarthro-plasty. The deltoid origin is left attached to the acro-mion, and the CA ligament can be protected throughthis approach. However, to dislocate the joint and in-strument the proximal humerus, any remnants of theanterior rotator cuff are typically elevated from the hu-merus and subsequently repaired.

The anterosuperior approach to the shoulder, morecommonly used in Europe, is a deltoid-splittingapproach. As its name implies, it provides exposure ofthe glenohumeral joint from a superior direction justanterior to the acromion. The anterior deltoid is elevatedat its origin off the anterolateral acromion. The acromial

insertion of the CA ligament is also violated during thedeltoid elevation. With extension and adduction of thehumerus, the proximal humerus can be delivered fromthe joint under the CA arch. In cases of RCDA, thisapproach typically provides sufficient exposure to ini-tiate instrumentation of the humerus through the defectleft by the absence of a superior cuff. Furthermore, theintact portions of the subscapularis insertion can typicallybe preserved without compromising humeral head expo-sure. As noted previously, however, this exposure comesat the expense of the CA ligament and deltoid origin.

Therefore, a surgical approach to hemiarthroplastythat spares the remnants of the anterior rotator cuff, CAarch, and deltoid origin could provide an optimumcombination of soft tissue protection and adequateexposure while lending itself to a better functionalresult.

In the senior author’s experience over the last 12years, the ideal surgical technique for hemiarthroplastyfor RCDA avoids detachment and repair of the CA arch,deltoid origin, and remaining rotator cuff. Conse-quently, the objectives of the procedure are to removethe pathological bursal tissue; remove the intraarticularportion of an abnormal biceps tendon, which can be apain generator; replace the humeral head with ananatomically sized prosthesis; correct eccentric glenoidwear by creating a smooth concave surface for humeralarticulation; preserve the CA arch; protect the deltoidorigin; and preserve any intact portions of the rotatorcuff.

| INDICATIONS/CONTRAINDICATIONSAND RATIONALE FOR THESURGICAL TECHNIQUE

The indications for this technique are identical to theindications for hemiarthroplasty for RCDA; namely, theideal candidate is a patient with a massive irreparable

FIGURE 1. Preoperative radiographsdemonstrating findings characteristicof rotator cuffYdeficient arthropathyincluding narrowing of the acromial-humeral interval, femoralization of thehumeral head, acetabularization of theCA arch, and subchondral sclerosis ofthe superior humeral head.

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Hemiarthroplasty Through the Rotator Cuff Defect in Cuff Tear Arthropathy


cuff tear, painful glenohumeral arthropathy, an intactCA arch, competent deltoid, and preoperative activeelevation to shoulder level (90 degrees). Pain reliefshould be the patient’s primary goal, as functionalimprovements are less predictable for above-shoulder-level activities. Although the functional level aboveshoulder height is difficult to predict preoperatively,when the patient has active elevation to 90 degreespreoperatively, then many of these patients will havegood functional use of the hand above shoulder level forsimple activities of daily living after hemiarthroplasty.When these preoperative conditions occur, it is assumedthat the patient has a high center of humeral rotation buta stable fulcrum for rotation under the CA arch. Inaddition, it is inferred from this level of preoperativefunction that there is sufficient rotator cuff and deltoidfunction to allow for active elevation to shoulder level.

With these assumptions, the goal of the surgery is topreserve the CA arch and this stable fulcrum forshoulder elevation and humeral rotation, and preservethe remaining intact portion of the rotator cuff anddeltoid through the surgical approach. If these surgicalgoals are achieved and if the patient achieves good painrelief with improved shoulder mechanics by providing asmooth painless humeral surface with restoration of thelateral humeral offset, then the postoperative rehabil-itation will improve rotator cuff and deltoid strength aswell as scapulahumeral and scapulathoracic kinematics.When this occurs, there will be an improvement in theactive elevation after humeral hemiarthroplasty. It is thegoal of the superior approach to the humerus throughthe deltopectoral interval to maximize the potential toachieve these goals through preservation of the CA archand the remaining intact rotator cuff.

Unlike standard glenohumeral osteoarthritis, mostpatients with RCDA will demonstrate near-full passive

FIGURE 2. The proximal humerus shown in the delto-pectoral interval and beneath the CA arch. The CAligament is preserved.

FIGURE 3. Abnormal bursal tissue is removed whilepreserving intact portions of the rotator cuff.

FIGURE 4. Humeral extension, adduction, and externalrotation allow delivery of the humeral head into thedeltopectoral interval. The intact portion of the subscapu-laris remains attached anteriorly.

FIGURE 5. With the proximal humerus delivered underthe CA arch, instrumentation is possible through theosteotomized surface of the proximal humerus.


Scalise and Iannotti


range of motion preoperatively because capsular con-tracture is rarely an element of the pathology. Access tothe inferior capsule is limited through this approach,making complete capsular releases and capsulectomydifficult. As such, a prerequisite for this approach isgood passive range of motion.

If the patient has anterosuperior humeral escape orany deltoid deficiency, hemiarthroplasty performedwith any surgical technique is unlikely to improveabove-waist function. However, in patients with afunctioning deltoid and anterosuperior escape, thereverse total shoulder prosthesis has shown in earlyseries to provide an effective means of treating thisdifficult problem.24Y27

| PREOPERATIVE PLANNING

A thorough clinical examination should delineate theextent of the rotator cuff tear. An external rotation lagsign and the belly press test should be assessed as a meansto ascertain the extent of rotator cuff deficiency. Bothactive and passive range of motion should be docu-mented, but most patients with RCDA without superiorescape have full passive motion. Some patients areinhibited by pain and are unable to actively elevate theirarm much above chest level. A glenohumeral injection oflocal anesthetic can temporarily relieve the pain such thatthe patient can obtain active elevation above chest level.This finding represents a favorable prognostic indicatorfor improved postoperative active range of motion withhemiarthroplasty. Hemiarthroplasty should not beexpected to provide a predictable improvement in activeforward elevation in those patients whose range ofmotion does not improve despite adequate analgesia.Although the precise indications are yet to be delineated,in this setting, the reverse shoulder arthroplasty may

provide a better functional result when adequate deltoidfunction is present.

Imaging studies should include routine anteropos-terior, Grashey, and axillary radiographs of theshoulder (Fig. 1). These preoperative radiographs allowplanning for implant sizing and assessment of glenoidmorphology. Although many patients will present withmagnetic resonance imaging studies obtained previ-ously, after a careful examination of the shoulder, themagnetic resonance imaging usually serves to confirmthe diagnosis and rarely presents new information.

| SURGICAL TECHNIQUE

The senior author has incorporated the above goals into amodified approach to the shoulder for hemiarthroplastyin cases of RCDA for the last 12 years. The patient ispositioned in a standard beach chair configuration. Theoperative shoulder is brought beyond the edge of the

FIGURE 6. The trial humeral stem is placed in the canalso that the collar of the stem abuts the remaining portionof the humeral head.

FIGURE 7. A, Version is measured using the flat backof the broach collar as a reference. A flat instrument (anosteotome) is used to better visualize the version of theprosthesis with relation to the forearm. B, Version of theprosthesis is compared with the long axis of the forearmwith 90 degrees of elbow flexion. The stem is rotated toa position approximately 10 degrees more retrovertedthan anatomic.




table so that full adduction and extension of the shouldercan be achieved. Superficially, a standard deltopectoralskin incision is used and the deltopectoral interval isdeveloped, mobilizing the cephalic vein laterally. Theupper 2 cm of the pectoralis tendon is detached at themusculotendinous junction for 1 to 2 cm in the midtendon to facilitate exposure and avoid excessive softtissue retraction. The biceps tendon is tenodesed to theremaining pectoralis tendon. Care is taken so as not todisrupt the CA ligament as the clavipectoral fascia isincised along the lateral border of the conjoined tendon(Fig. 2). Abnormal bursal tissue is removed around thehumeral head and from the CA arch (Fig. 3). Portions ofthe rotator cuff that remain intact are preserved, and theextent of the cuff deficiency is assessed. Even inadvanced cases of RCDA, inferior insertions of thesubscapularis and infraspinatus may still be present. Alarge Darrach retractor is placed between the humeralhead and glenoid through the rotator cuff defect, and thehumeral head is gently levered from the joint and fromunder the CA arch. Humeral extension, adduction, andexternal rotation will allow delivery of the humeral headinto the deltopectoral interval (Fig. 4). Narrow Homanretractors placed beneath the remaining portions of theanterior and posterior rotator cuff exposes the proximalhumerus from a superior aspect. A reciprocating saw isused to make a freehand cut approximately 5 mm distalto the top of the humeral head and perpendicular to thehumeral shaft. In this manner, the top of the humeralhead is removed, exposing the cancellous bone andproviding access to the intramedullary canal. Startingwith the smallest humeral medullary reamers, the canalis sequentially enlarged (Fig. 5). A trial humeral stem isplaced in the canal so that the collar of the stem abuts

the remaining portion of the humeral head (Fig. 6).Alternatively, an extramedullary cutting guide can beused to estimate the humeral neck shaft angle andthereby the plane of the humeral osteotomy. The stem isrotated to a position approximately 10 degrees moreretroverted than anatomic. To measure retroversion,the flat back of the broach collar is compared with thelong axis of the forearm with 90 degrees of elbowflexion. Two straight osteotomes can be placed alongthe axis of the forearm and the flat back of the broachcollar to help visualize the correct retroversion (Fig. 7).Close attention should be given to the proximal humerusosteotomy so that excessive retroversion is avoided. Thecombination of an absent posterior rotator cuff androunded posterior articular margin osteophytes maymislead the surgeon into creating an inappropriatelyretroverted osteotomy. Using the osteotomes in theabove manner has alleviated this potential pitfall(Fig. 7). The blade of the reciprocating saw is now

FIGURE 8. The blade of the reciprocating saw is nowmade parallel to the back of the broach collar, usingit as a cutting guide; and the remaining humeralhead is removed.

FIGURE 10. The final prosthesis should sit directly andprecisely upon the cut surface of the humerus. Thedeltoid origin, CA arch (white arrow), and the anteriorrotator cuff (black arrow) remain intact.

FIGURE 9. If a DePuy CTA prosthetic (DePuy, Johnsonand Johnson) is used, then the tuberosity osteotomy ismade using the supplied cutting guide.




made parallel to the back of the broach collar, using itas a cutting guide (Fig. 8). The remaining humeral headis removed at the level of the anatomic neck, beingcareful to keep the cut within the joint to preserve theremaining rotator cuff and protecting the axillary nerve.With the head removed, the inferior portion of theosteotomy is palpated. Any inferior osteophytes areremoved with a curved osteotome. In most cases ofRCDA, these inferior osteophytes are minimal orabsent. If a capsular release is needed, it can be releasedfrom the glenoid side. A Fukuda retractor is used todisplace the proximal humerus inferiorly and posteriorly

such that the glenoid surface can be inspected. Glenoidirregularities or biconcavity is corrected by using aconcave glenoid reamer or by hand with a burr, leavinga smooth concave surface. The goal of glenoid prepara-tions in these cases is to preserve the cortical surface andremove only those irregularities that would otherwiseprevent a smooth articulation with the humeral head.Degenerative soft tissue and synovial tissue is alsoremoved, and the joint is irrigated thoroughly. Theproximal humerus is again delivered from the joint aspreviously described. The medullary canal is prepared forstem placement according to the manufacturer’s guide-lines. When the appropriate trial stem is implanted, the trialhead is applied and the joint reduced to assess stability andrange of motion. If a DePuy CTA prosthetic (DePuy,Johnson and Johnson; Warsaw, IN) is used, then theadditional cut in the tuberosity is made from the trial heador using the supplied cutting guide (Fig. 9). With the finalcomponents selected, they are assembled and implantedwith or without bone cement, depending upon theprosthetic stem design, stem stability, and bone quality.The final prosthesis should sit directly and precisely uponthe cut surface of the humerus (Fig. 10). A standardlayered closure is performed with a subcuticular runningstitch for skin closure.

In appropriately selected patients and with propersurgical technique, the remaining anatomical structuresthat have been shown to be important in patients withRCDA can be preserved (Figs. 11 and 12).

| POSTOPERATIVE CARE

Gentle passive elevation and external rotation stretchingexercises are encouraged for the first 2 postoperativeweeks, at which time cross-body adduction stretching isadded. The goal of the exercises during the first 6postoperative weeks is to maintain the range of motiondemonstrated intraoperatively. At 6 weeks, a supervisedstrengthening program is initiated. When this procedureis performed as described, there is a very stableprosthetic within an intact CA arch and the rotator cuff

FIGURE 11. Postoperative radiographs after hemiarthro-plasty for rotator cuffYdeficient arthropathy through themodified superior approach.

FIGURE 12. Postoperative clin-ical photographs demonstratingrange of motion after hemiarthro-plasty of the right shoulder forrotator cuffYdeficient arthropathyusing the modified superiorapproach.




that was intact remains intact. Under these circum-stances, there is little to prevent active range of motionor resistive exercises as soon as the patient’s pain levelwill allow. In addition, there is little need to protect theshoulder in a sling other than for the management ofearly postoperative pain. Full or near-full passive rangeof motion is a common preoperative clinical finding inRCDA. Using this approach, passive range of motionhas remained good. A near-complete absence of rotatorcuff tissue and a lack of capsular contracture preoper-atively have yielded maintenance of good passive arcsof motion postoperatively.

| SUMMARY

In appropriately selected patients, we believe thismodified surgical technique for hemiarthroplasty pro-vides an optimal approach to the proximal humerus incases of RCDA. The purpose of this technique is toprovide sufficient exposure to the proximal humeruswithout violating the remaining subscapularis, deltoidorigin, and CA ligament. Leaving the subscapularisundisturbed helps sustain the transverse force couplewith the posterior rotator cuff, which may help preservepostoperative function. Preserving the deltoid originhelps minimize the chance of postoperative deltoiddysfunction, which is the primary source of motion ofthe shoulder in patients with massive cuff tears. Notviolating the CA ligament helps preserve the CA archand thus minimizes the chance for anterosuperiorhumeral escape. Therefore, this modified technique tothe deltopectoral approach for hemiarthroplasty inpatients with RCDA aims to leave undisturbed theremaining soft tissue structures of the shoulder, whichhave been shown to be important in facilitating afavorable outcome in these patients.

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Techniques in Shoulder and Elbow Surgery 7(3):160Ð167...

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