J Shoulder Elbow Surg (2014) -, 1-6
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Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up Bradley Schoch, MDa, Cathy Schleck, BSb, Robert H. Cofield, MDa, John W. Sperling, MD, MBAa,* a b
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA Background: Little information is available on the long-term outcome of shoulder arthroplasty in young patients. The purpose of this study was to report the results, complications, and revision rate of total shoulder arthroplasties (TSAs) in patients younger than 50 years at a minimum 20-year follow-up. Materials and methods: Between 1976 and 1985, a single surgeon performed 78 Neer hemiarthroplasties (HAs) and 36 Neer TSAs in patients < 50 years. Fifty-six HAs and 19 TSAs with a minimum 20-year followup, or follow-up until reoperation, were analyzed for clinical, radiographic and survivorship outcomes. Results: Both HA and TSA showed significant improvements in pain scores (P < .001), abduction (P < .01), and external rotation (P ¼ .02). Eighty-one percent of shoulders were rated much better or better than preoperatively. Modified Neer ratings were similar between groups (P ¼ .41). Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9-86.5) for HAs and 83.2% (confidence interval, 70.5-97.8) for TSAs. Discussion: At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. However, there are a large number of unsatisfactory Neer ratings. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Total shoulder arthroplasty; hemiarthroplasty; long-term follow-up
During the past few decades, there has been a trend for arthroplasty to be performed in younger patients, but the long-term outcomes of these patients undergoing shoulder arthroplasty remain limited.8,10,12 Younger patients are typically more active and can be expected to use their operative extremity more vigorously and for a more prolonged time. Specifically, patients undergoing shoulder Approval for this study was provided by the Mayo Clinic Institutional Review Board: 12-004895. *Reprint requests: John W. Sperling, MD, MBA, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (J.W. Sperling).
arthroplasty have been shown to remain quite active.19 McCarty et al previously showed that 64% of patients undergoing shoulder arthroplasty returned to sporting activities. Of these, half increased their frequency of participation postoperatively.11 Increased activity level places this population of young patients at increased risk of arthroplasty failure or revision in the long term. Both the hip and knee literature has shown successful long-term outcomes after primary arthroplasty in the younger patient population.1,5,7,14 Previously, a report from our institution of patients younger than 50 years showed higher rates of reoperation for hemiarthroplasties (HAs) at 10 years.17 It is
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.07.016
2 important to continue to observe this population that is at increased risk, given their activity level and expectations after arthroplasty at a young age. Presently, we aim to review our experience with patients younger than 50 years undergoing shoulder arthroplasty with a minimum 20-year follow-up to assess results, complications, and revision rate.
Methods Between January 1, 1976, and December 31, 1985, 78 Neer HAs and 36 Neer total shoulder arthroplasties (TSAs) were performed in patients aged 50 years or younger by a single surgeon. Fifty-six HAs and 19 TSAs had a minimum 20-year follow-up or follow-up until reoperation (mean, 21 years; range, 0.4-31.3 years). Thirty patients died before minimum follow-up, 6 were lost to follow-up, and 3 withdrew from joints registry research. Therefore, 89% of living patients eligible for follow-up were included in this study. Patient demographics and data analysis with shorter follow-up have previously been reported.17,18 Demographic data for the cohort of patients included in this study are provided in Table I. Of the 75 arthroplasties reviewed, 12 were performed in patients undergoing bilateral shoulder arthroplasty. Ten patients underwent bilateral HA, 3 underwent bilateral TSA, and 3 underwent TSA in one shoulder and HA in the other.
Clinical evaluation All patients identified for this study were extracted from our institution’s total joint database. All total joints at our institution have been prospectively enrolled since 1969. Pain, function, and physical findings are obtained by clinical visits, letter questionnaire, or telephone interview per our joint registry protocol. Total joints are observed at 1, 2, and 5 years and every 5 years thereafter.2 Shoulder pain was scored on a 5-point scale as previously outlined by Neer et al.13 Patient satisfaction was defined as much better, better, the same, or worse compared with before surgery on the basis of the patient’s response. Motion was measured by the surgeon with a goniometer or reported by the patient with a validated questionnaire.15 Active abduction and external rotation were assessed in degrees. Active internal rotation was recorded as the most cephalad posterior vertebral segment reached by the thumb. Modified Neer ratings were determined on the basis of clinical outcome values recorded.3,13 An excellent rating required no or slight pain, external rotation of 45 , active abduction of 140 , and patient satisfaction with the postoperative outcome. A satisfactory rating required no or slight pain or moderate pain only with vigorous activity, external rotation of 20 , active abduction of 90 , and patient satisfaction with the postoperative outcome. Failure to meet any of these criteria or additional operative procedures resulted in an unsatisfactory Neer rating.
Radiographic evaluation Standardized radiographs were obtained at routine follow-up. These included AP internal and external rotation views in addition to an axillary view radiograph. Preoperative radiographs were available for 57 of the shoulders that met minimum follow-up criteria. Postoperative radiographs, with a minimum follow-up of 15 years or until reoperation, were available for 68 shoulders
B. Schoch et al. Table I Patient demographics for shoulders with minimum 20-year follow-up or until reoperation HA (n ¼ 56) Age, years (range) Sex (M/F) Mean follow-up, years (range) Diagnosis Post-traumatic Rheumatoid Osteoarthritis Avascular necrosis Other
TSA (n ¼ 19)
P value
39 (19-50) 41 (22-50) .44 29/27 6/13 .11 20.8 (0.4-31.3) 21.6 (0.8-30.4) .77
24 17 7 5
6 12 1 0
4
0
(51 HAs, 17 TSAs). Mean follow-up was 16.4 years (range, 0-31 years) for HAs and 15.5 years (range, 0-26 years) for TSAs. Radiographs were evaluated for preoperative glenoid erosion, postoperative glenoid erosion for HAs, preoperative and postoperative glenohumeral subluxation, and periprosthetic radiolucency or shift in component position between early postoperative and final follow-up radiographs. All were reviewed by 2 orthopedic surgeons; any disagreement was deferred to a third orthopedic surgeon, 1 of the 2 senior authors, for a final determination. Glenoid erosion was classified as none, mild, moderate, or severe. Glenohumeral subluxation was graded as none, mild (50% translation). Periprosthetic radiolucency was graded on a 5-point scale: none, grade 0; 1 mm incomplete, grade 1; 1 mm complete, grade 2; 1.5 mm incomplete, grade 3; 1.5 mm complete, grade 4; or 2 mm complete, grade 5. ‘‘At-risk’’ components were defined as having a change in position or having grade 4 or 5 radiolucency.16
Statistical methods Descriptive statistics are described as mean (range) for continuous measures and number (percentage) for discrete variables. Forty-five shoulders with a minimum 20 years of clinical follow-up, 35 shoulders with
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Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up Bradley Schoch, MDa, Cathy Schleck, BSb, Robert H. Cofield, MDa, John W. Sperling, MD, MBAa,* a b
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA Background: Little information is available on the long-term outcome of shoulder arthroplasty in young patients. The purpose of this study was to report the results, complications, and revision rate of total shoulder arthroplasties (TSAs) in patients younger than 50 years at a minimum 20-year follow-up. Materials and methods: Between 1976 and 1985, a single surgeon performed 78 Neer hemiarthroplasties (HAs) and 36 Neer TSAs in patients < 50 years. Fifty-six HAs and 19 TSAs with a minimum 20-year followup, or follow-up until reoperation, were analyzed for clinical, radiographic and survivorship outcomes. Results: Both HA and TSA showed significant improvements in pain scores (P < .001), abduction (P < .01), and external rotation (P ¼ .02). Eighty-one percent of shoulders were rated much better or better than preoperatively. Modified Neer ratings were similar between groups (P ¼ .41). Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9-86.5) for HAs and 83.2% (confidence interval, 70.5-97.8) for TSAs. Discussion: At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. However, there are a large number of unsatisfactory Neer ratings. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Total shoulder arthroplasty; hemiarthroplasty; long-term follow-up
During the past few decades, there has been a trend for arthroplasty to be performed in younger patients, but the long-term outcomes of these patients undergoing shoulder arthroplasty remain limited.8,10,12 Younger patients are typically more active and can be expected to use their operative extremity more vigorously and for a more prolonged time. Specifically, patients undergoing shoulder Approval for this study was provided by the Mayo Clinic Institutional Review Board: 12-004895. *Reprint requests: John W. Sperling, MD, MBA, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail address: [email protected] (J.W. Sperling).
arthroplasty have been shown to remain quite active.19 McCarty et al previously showed that 64% of patients undergoing shoulder arthroplasty returned to sporting activities. Of these, half increased their frequency of participation postoperatively.11 Increased activity level places this population of young patients at increased risk of arthroplasty failure or revision in the long term. Both the hip and knee literature has shown successful long-term outcomes after primary arthroplasty in the younger patient population.1,5,7,14 Previously, a report from our institution of patients younger than 50 years showed higher rates of reoperation for hemiarthroplasties (HAs) at 10 years.17 It is
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.07.016
2 important to continue to observe this population that is at increased risk, given their activity level and expectations after arthroplasty at a young age. Presently, we aim to review our experience with patients younger than 50 years undergoing shoulder arthroplasty with a minimum 20-year follow-up to assess results, complications, and revision rate.
Methods Between January 1, 1976, and December 31, 1985, 78 Neer HAs and 36 Neer total shoulder arthroplasties (TSAs) were performed in patients aged 50 years or younger by a single surgeon. Fifty-six HAs and 19 TSAs had a minimum 20-year follow-up or follow-up until reoperation (mean, 21 years; range, 0.4-31.3 years). Thirty patients died before minimum follow-up, 6 were lost to follow-up, and 3 withdrew from joints registry research. Therefore, 89% of living patients eligible for follow-up were included in this study. Patient demographics and data analysis with shorter follow-up have previously been reported.17,18 Demographic data for the cohort of patients included in this study are provided in Table I. Of the 75 arthroplasties reviewed, 12 were performed in patients undergoing bilateral shoulder arthroplasty. Ten patients underwent bilateral HA, 3 underwent bilateral TSA, and 3 underwent TSA in one shoulder and HA in the other.
Clinical evaluation All patients identified for this study were extracted from our institution’s total joint database. All total joints at our institution have been prospectively enrolled since 1969. Pain, function, and physical findings are obtained by clinical visits, letter questionnaire, or telephone interview per our joint registry protocol. Total joints are observed at 1, 2, and 5 years and every 5 years thereafter.2 Shoulder pain was scored on a 5-point scale as previously outlined by Neer et al.13 Patient satisfaction was defined as much better, better, the same, or worse compared with before surgery on the basis of the patient’s response. Motion was measured by the surgeon with a goniometer or reported by the patient with a validated questionnaire.15 Active abduction and external rotation were assessed in degrees. Active internal rotation was recorded as the most cephalad posterior vertebral segment reached by the thumb. Modified Neer ratings were determined on the basis of clinical outcome values recorded.3,13 An excellent rating required no or slight pain, external rotation of 45 , active abduction of 140 , and patient satisfaction with the postoperative outcome. A satisfactory rating required no or slight pain or moderate pain only with vigorous activity, external rotation of 20 , active abduction of 90 , and patient satisfaction with the postoperative outcome. Failure to meet any of these criteria or additional operative procedures resulted in an unsatisfactory Neer rating.
Radiographic evaluation Standardized radiographs were obtained at routine follow-up. These included AP internal and external rotation views in addition to an axillary view radiograph. Preoperative radiographs were available for 57 of the shoulders that met minimum follow-up criteria. Postoperative radiographs, with a minimum follow-up of 15 years or until reoperation, were available for 68 shoulders
B. Schoch et al. Table I Patient demographics for shoulders with minimum 20-year follow-up or until reoperation HA (n ¼ 56) Age, years (range) Sex (M/F) Mean follow-up, years (range) Diagnosis Post-traumatic Rheumatoid Osteoarthritis Avascular necrosis Other
TSA (n ¼ 19)
P value
39 (19-50) 41 (22-50) .44 29/27 6/13 .11 20.8 (0.4-31.3) 21.6 (0.8-30.4) .77
24 17 7 5
6 12 1 0
4
0
(51 HAs, 17 TSAs). Mean follow-up was 16.4 years (range, 0-31 years) for HAs and 15.5 years (range, 0-26 years) for TSAs. Radiographs were evaluated for preoperative glenoid erosion, postoperative glenoid erosion for HAs, preoperative and postoperative glenohumeral subluxation, and periprosthetic radiolucency or shift in component position between early postoperative and final follow-up radiographs. All were reviewed by 2 orthopedic surgeons; any disagreement was deferred to a third orthopedic surgeon, 1 of the 2 senior authors, for a final determination. Glenoid erosion was classified as none, mild, moderate, or severe. Glenohumeral subluxation was graded as none, mild (50% translation). Periprosthetic radiolucency was graded on a 5-point scale: none, grade 0; 1 mm incomplete, grade 1; 1 mm complete, grade 2; 1.5 mm incomplete, grade 3; 1.5 mm complete, grade 4; or 2 mm complete, grade 5. ‘‘At-risk’’ components were defined as having a change in position or having grade 4 or 5 radiolucency.16
Statistical methods Descriptive statistics are described as mean (range) for continuous measures and number (percentage) for discrete variables. Forty-five shoulders with a minimum 20 years of clinical follow-up, 35 shoulders with
