The role of CTA design implants for cuff tear arthropathy

[mtomaino]

I recently received the following question via the "Contact Dr. Tomaino" section of my website--drtomaino.com.
I have full thickness tears of my Supra and Infraspinatus muscles. Avascular Necrosis, Moderate to Severe Arthritis. The humeral head is elevated. I am a 57 year old male who is still quite active and the options of a Fusion or Delta replacementeverse shoulder replacement) put restrictions that will severly limit my abilities to participate in most activities. Possibly I could be a candidate for a C.T.A. procedure? I have MRI and XRays available. Range of motion is still good, pain is the most limiting factor at this point. Hope you can help. Thank you for your time.

Although reverse shoulder designs were historically indicated for arthritis secondary to failed cuff repair or even psedoparalysis secondary to irreparable cuff tears without arthritis, design improvements have expanded the indications. Indeed, the Reverse is a valid option for revision of failed total shoulder arthroplasty, and to treat the inability to raise the arm---even in younger patients. Recent clinical reviews have shown that objective outcomes, including internal rotation, compare favorably with the results after total shoulder replacement. What is recognized is that improvements are relative to the preop status; so too are postoperative narcotic needs after surgery.
That having been said, if a patient is very active, and younger than 65-70, there still is a valid role for hemiarthroplasty----meaning a partial replacement. The CTA design (which stands for cuff tear arthropathy) has an extended articular surface to allow articulation with the glenoid as well as the under surface of the acromion. Outcomes can be very good BUT, there can be no "escape" --meaning the head of the humerus is unstable out the front-- AND preoperative elevation must be above the horizontal---which typically means that an adequate force couple exists to empower the deltoid without requiring the Reverse shoulder design.

Nowadays a non-stemmed implant is available which allows a CTA design as a resurfacing device; this can easily be revised to a stemmed Reverse design down the road, if an when pain relief becomes unsatisfactory and/or when function begins to decline. For functional external rotation to exist some teres minor is needed.