Cuff Tear Arthropathy



Chronic massive rotator cuff defect

- uncovered humeral articular cartilage

- high riding humeral head

- abrasion by undersurface of coracoacromial arch





- introduced term "cuff tear arthropathy"

- included significant rotator cuff diagnosis & arthritis in older patients

- especially women

- synovial fluid contained calcium phosphate crystals + proteases




Crystal induced arthropathy

- hydroxyapatite-mineral phase in altered capsule, synovium or degenerate articular cartilage

- induce synthesis of proteolytic enzymes

- destruction of cartilage via collagenase, stromeolysin

- origin of crystals unclear

- 1° or 2° to arthritis

- erosion of head begins superiorly rather than centrally


Cuff tear theory

- loss of cuff leads to mechanical and nutritional alterations in shoulder

- due to loss of closed joint space and altered range of motion




4% of massive cuff tears go on to arthroplasty



- tears with unbalanced force couplet go on to arthropathy 

- massive tear that are balanced & / or above equator don't go onto to arthropathy




Women > men

60% bilateral




Recurrent swelling

Loss of Motion

Night pain




1.  Superior migration of head 

- defined as AHI / acromiohumeral interval of 7mm or less


Humeral Head Superior Migration


2.  Collapse of proximal head articular surface 


3.  Proximal humerus becomes "Femoralized" 

- erosion of greater tuberosity


4.  Coracoacromial arch becomes "acetabularized"

- often articulates with acromion

- periarticular soft tissue calcification


Acromial Acetabularisation




RC Arthropathy CT





- no superior migration

- beard osteophytes






Often appropriate 

- many patients only mild symptoms

- patients elderly

- accept limited ROM

- analgesia


Operative Management


1.  Acromioplasty & tendon debridement 


Not indicated with superior migration

- can consider biceps tenotomy if still intact


2.  Arthrodesis


Poorly tolerated in elderly 

- significant pseudoarthrosis & re-operation rate in osteoporotic bone

- reserve for those with non functioning deltoid


3.  TSR 


Increased loosening of glenoid component if TSR

- superior migration of head due to unopposed deltoid

-"rocking horse" phenomenon 


4.  Hemiarthroplasty



- < 70

- intact CA arch

- anterior deltoid muscle



- do not oversize head

- can cut in some valgus to allow articulation with acromion

- correct size allows arm to lie freely across abdomen

- head to translate 50% posterior / anterior / inferior

- subscapularis to be re-attached without bow stringing

- margin convergence of cuff as possible for force couplet

- reattach CA ligament to prevent superior escape





- 18 of 21 satisfactory

- good pain relief

- ROM often not improved



- concept of limited goals category

- 20° of ER and 90° of forward elevation


Poor prognosis

- previous acromioplasty

- previous division CA ligament

- deltoid insufficiency


5.  CTA Humeral Head


Depuy Cuff Tear Arthropathy

- arc of surface > 180o

- allows articulation of lateral head with acromion

- increased articulation in abduction and ER


CTA HemiarthroplastyCTA Head APCTA Head 2


6.  Reverse TSR



- > 70

- functioning deltoid



- medialises the centre of rotation

- increases lever arm for deltoid

- semiconstrained - prevents superior migration

- deltoid acts to stabilise shoulder