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
(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 (<25% translation of the humeral head relative to the center of the glenoid component), moderate (25%-50% translation), or severe (>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 <20 years of clinical follow-up, and 31 shoulders undergoing reoperation were included in the survivorship analysis (total of 111 shoulders). Shoulders requiring reoperation were observed until immediately before reoperation. Implant survival, defined as free of reoperation for any cause, was estimated by the Kaplan-Meier method, reporting the estimate and 95% confidence interval (CI). Fifty-six HAs and 19 TSAs that had a minimum of 20 years of clinical follow-up or follow-up until reoperation were included in the clinical analysis. Preoperative vs postoperative changes in pain and range of motion were assessed by a paired t test. Fifty-one HAs and 17 TSAs that had a minimum of 15 years of radiographic follow-up or followup until reoperation were included in the radiographic analysis. The a level for all tests was set at .05 for statistical significance.
Results Fifty-six HAs (29 men, 27 women) and 19 TSAs (6 men, 13 women) in patients with a mean age of 40 years were
Shoulder arthroplasty in patients younger than 50 years Table II
Comparison of clinical outcomes and improvement between HA and TSA
Preoperative Pain Active abduction Active external rotation Active internal rotation Follow-up Pain Active abduction Active external rotation Active internal rotation Satisfaction Excellent or satisfactory Neer rating Differences (follow-up – preoperative) Pain Active abduction Active external rotation
analyzed at an average follow-up of 22 years (range, 0.431.3 years). Of the shoulders studied, 30 patients were able to return for formal face-to-face clinical examinations. Forty-six patients responded to a standardized joint registry questionnaire if they were unable to return for face-to-face evaluation.
Clinical results For HAs, the mean pain scores decreased significantly (P < .001). In addition, mean abduction and external rotation improved significantly (P < .001). Internal rotation remained unchanged (Table II). Of the 47 patients reporting satisfaction, 37 rated their shoulder much better or better than preoperatively (44.7% and 34%, respectively). Five rated their shoulder the same (10.6%), and 5 rated their shoulder worse (10.6%). There were a total of 7 excellent (12.5%), 8 satisfactory (14.3%), and 41 unsatisfactory results (73.2%) based on modified Neer ratings. Unsatisfactory ratings were due to reoperation in 25 shoulders. Eleven shoulders had unsatisfactory Neer ratings due to limited range of motion, 2 due to pain, 2 due to both pain and limited range of motion, and 1 due to subjective dissatisfaction. TSAs showed similar improvements in both pain (P < .001) and active abduction (P ¼ .01) and external rotation (P ¼ .02). As with HAs, internal rotation remained unchanged (Table II). Of the 16 patients reporting satisfaction, 12 rated their shoulder much better or better than preoperatively (37.5% and 37.5%, respectively). Four patients rated their outcome the same (25%), and none rated their shoulder worse. There were a total of 5 excellent (26.3%), 3 satisfactory (15.8%), and 11 unsatisfactory results (57.9%)
based on modified Neer ratings. Unsatisfactory ratings were due to reoperation in 6 shoulders. Five shoulders had unsatisfactory Neer ratings due to limited range of motion. There was no difference between HAs and TSAs in terms of Neer ratings or satisfaction at the time of most recent follow-up (P ¼ .41 and P ¼ .52, respectively). Overall, 81% of patients rated their shoulder much better or better than preoperatively. Twenty-five HAs and 6 TSAs required reoperation. Estimated 20-year survival was 75.6% (CI, 65.9-86.5) for HAs and 83.2% (CI, 70.5-97.8) for TSAs (Fig. 1). The association of HA relative to use of TSA for revision risk was not statistically significant (P ¼ .21), although use of HA was at a somewhat increased risk with hazard ratio of 1.75 (95% CI, 0.72, 4.24).
Radiographic results HA Postoperative radiographs, with a minimum follow-up of 15 years or until reoperation, were available for 51 shoulders. Recurrent subluxation was present in 14 shoulders. This was graded moderate superior in 8, severe superior in 4, moderate posterior in 1, and severe posterior in 1. Three shoulders developed new glenoid erosion. Preexisting erosion progressed in 18 shoulders. Fifteen of these had severe glenoid erosion at latest follow-up. Radiolucencies were found around 8 humeral components. Humeral lucent lines were graded 1 mm incomplete in 4, 1 mm complete in 1, 1.5 mm incomplete in 1, and 2 mm complete in 2. Three humeral components had shifted position compared with postoperative radiographs, with 1 also having a grade 5
B. Schoch et al. humeral revision because of deficient glenoid bone stock. Three shoulders required reoperation for aseptic humeral loosening, with 2 being converted to TSA and 1 undergoing a revision HA. One patient was revised to a total shoulder secondary to pain of unknown etiology. One patient required open reduction and internal fixation after a periprosthetic humeral fracture. One patient developed a deep infection 2 years after surgery requiring removal of arthroplasty components. Three shoulders underwent reoperation at outside institutions, and the details regarding the cause for reoperation are unavailable. At 20 years, reoperation-free survival was calculated to be 75.6% (CI, 65.9-86.5).
Figure 1 Kaplan-Meier curve demonstrating the reoperationfree survivorship for HAs vs TSAs.
lucent line. This resulted in 4 humeral stems (8%) being classified as at risk at the time of latest follow-up. TSA Postoperative radiographs, with a minimum follow-up of 15 years or until reoperation, were available for 17 shoulders. Recurrent superior subluxation was present in 6 shoulders. This was graded moderate superior subluxation in 3, severe superior subluxation in 2, and moderate posterior subluxation in 1. Radiolucencies were found around 11 humeral and 14 glenoid components. Humeral lucent lines were graded 1 mm incomplete in, 1 mm complete in 2, 1.5 mm incomplete in 3, 1.5 mm complete in 2, and 2 mm complete in 2. Glenoid lucent lines were graded 1 mm incomplete in 2, 1 mm complete in 3, 1.5 mm complete in 3, and 2 mm complete in 6. A shift in component position was identified in 7 humeral components and 5 glenoid components. Two humeral components with a shift in component position had a concurrent 2-mm complete lucent line, and 1 additional shoulder had a shift in position with a 1.5-mm complete lucent line, leaving 9 shoulders (53%) with an at-risk humeral component. Five of the 6 glenoid components with a grade 5 radiolucent line also had a shift in component position, leaving 6 shoulders (35%) with at-risk glenoids. All 6 shoulders with at-risk glenoid components also had humeral components at risk, leaving 12 shoulders (71%) with at-risk components at the time of most recent follow-up.
TSA Six of the 35 TSAs performed ultimately underwent reoperation. Five shoulders underwent reoperation before 20 years, with 1 additional patient being revised at 26.2 years after index arthroplasty. Three shoulders developed aseptic loosening of both the humerus and glenoid. All underwent revision to HA. One patient developed aseptic loosening of the glenoid component and underwent isolated removal of the glenoid component. The remaining 2 shoulders developed deep infections requiring removal of arthroplasty components. The 20-year reoperation-free survival was calculated to be 83.2% (CI, 70.5-97.8%).
HA vs TSA Both HA and TSA provide similar improvements in pain and range of motion at minimum 20-year follow-up (Table II). Reoperation, excluding infection, showed 20-year estimated survivorship of 76.6% (CI, 67-67.4) for HA and 89.4 (CI, 75.9-100) for TSA. This difference again associated HA with a higher risk of revision (hazard ratio, 2.40) but did not reach statistical significance (P ¼ .10). Neer ratings and patient satisfaction were similar between both groups (P ¼ .41 and P ¼ .52, respectively). Postoperative subluxation was shown to be associated with poorer Neer ratings but not with patient dissatisfaction (P ¼ .004 and P ¼ .09, respectively). Radiographic analysis showed the total shoulder humeral component to be at risk significantly more often than with HA (P < .001).
Complications and reoperation
Post-traumatic vs rheumatoid
HA Of the 75 HAs performed during the study period, 25 ultimately underwent reoperation. Twenty shoulders underwent reoperation before 20 years, with 5 additional patients being reoperated on more than 20 years after index arthroplasty. The most common indication for reoperation was painful glenoid arthrosis (16; 64%). Of the 16 shoulders with painful glenoid arthrosis, 15 were converted to TSAs. The remaining patient underwent an isolated
A subgroup analysis was performed on shoulders treated for post-traumatic arthritis (30) and rheumatoid arthritis (29) as these represented the largest populations within this cohort. Both groups showed similar improvements in pain with no significant differences between the populations. Rheumatoid shoulders had significantly less preoperative abduction than the post-traumatic shoulders (65.9 vs 86.7; P ¼ .031); however, both groups had similar postoperative measures (114.0 vs 114.8; P ¼ .95). Post-traumatic
Shoulder arthroplasty in patients younger than 50 years shoulders had significantly less preoperative external rotation than the rheumatoid shoulders (6.1 vs 20; P ¼ .021); however, both groups had similar postoperative external rotation (34.8 vs 33.6; P ¼ .89). At the time of latest followup, rheumatoid patients were more satisfied with their shoulder compared with preoperatively (88% vs 63%; P ¼ .04). Objectively, there was no significant difference in the percentage of patients with excellent or satisfactory Neer ratings. The 20-year estimated survivorship was found to be 89.9% (CI, 81.9-98.7) for the rheumatoid population and 64.9% (CI, 50.1-84.1) for the post-traumatic population (Fig. 2). A preoperative diagnosis of post-traumatic arthritis was associated with an increased risk of revision during the length of the study (P ¼ .03). Radiographic analysis showed the rheumatoid arthritis group to be affected by progressive glenoid arthrosis more often than the post-traumatic subpopulation (P ¼ .03). However, there was no difference between the groups in regard to postoperative subluxation, humeral/glenoid loosening, or components at risk.
Discussion Long-term follow-up of patients undergoing shoulder arthroplasty remains limited in comparison to the hip in knee literature. To our knowledge, this is the longest follow-up of any series on shoulder arthroplasty in the English literature. Previous studies by Levine et al evaluated 31 HAs for glenohumeral arthritis at a mean follow-up of 17.2 years.9 Their revision rate of 29% at 17.2 years is similar to our KaplanMeier analysis for HAs at 15 years [77.5% (CI, 68-87.8)] and 20 years [75.6% (CI, 65.9-86.5)], despite their having no rheumatoid patients and only 23% post-traumatic patients.16 Deshmukh et al reported the results of 72 TSAs with a minimum 10-year follow-up (average, 14 years). KaplanMeier analysis showed an estimated survival of 85% at 20 years with revision as an end point in a population that was 69% rheumatoid and <1% post-traumatic.4 This is similar to our 20-year reoperation-free survivorship of 83.2% for TSA, despite our having a higher percentage of patients with post-traumatic arthritis and similar percentage of rheumatoid patients. Clinically, both HAs and TSAs have provided lasting pain relief that remained relatively stable during the second decade of implant life (Table III). Abduction remained relatively stable, with HAs maintaining better active abduction. Active external rotation has slightly decreased in the HA group and remained relatively stable in the TSA population. Neer ratings steadily declined as follow-up extends, likely indicating increasing patient dissatisfaction as reported pain and range of motion remain relatively stable. This study showed a clinically significant rate of component loosening or shift in component position, especially in the TSA subgroup. At the time of follow-up,
Figure 2 Kaplan-Meier curve demonstrating the reoperationfree survivorship for the rheumatoid arthritis (RA) and posttraumatic populations.
23% of humeral components and 52% of glenoid components in the TSA group had grade 4 or grade 5 lucent lines. Compared with our earlier studies, humeral component lucencies have remained stable, whereas large complete glenoid lucencies have doubled.17 The strength of this study is in the long-term followup, with a mean of more than 20 years. All operations were performed by a single surgeon using a single implant. The study remains limited secondary to its design as a retrospective case series. In addition, not all patients were able to return for face-to-face follow-up visits; however, that is somewhat expected, given the large referral base of tertiary medical centers. Some patients elected to forgo imaging despite our requests for radiographs. To be inclusive for the patient group being studied clinically, radiographs were reviewed at a minimum of 15 years of follow-up. This leaves the possibility that more components may have been at risk at the time of 20-year clinical follow-up. Only 66% of shoulders included in our original study were included in this longer term follow-up study. When those shoulders of patients who died before 20-year followup or reoperation were eliminated, 89% of eligible shoulders completed the study. In addition, the modified Neer rating system may not adequately reflect the spectrum of patient outcomes. Patients may report being satisfied with their shoulder’s pain relief, motion, and function but receive an unsatisfactory Neer rating because of failure to meet minimum range of motion requirements. Total joint arthroplasty in a younger patient population places the prosthesis in an environment that is more likely to be subjected to prolonged and demanding activities. Total knee arthroplasty in the younger patient population has been shown to fail earlier than in an elderly population.6 Previous studies regarding shoulder arthroplasty have also shown patients undergoing revision surgery to be younger at the time of index arthroplasty compared with nonrevised shoulders.9 Therefore, it is important to observe these younger
B. Schoch et al. Table III
Clinical outcomes trends with increasing follow-up
Mean follow-up, years Pain Active abduction Active external rotation Active internal rotation Excellent or satisfactory Neer score
Minimum 5 years
Minimum 15 years
Minimum 20 years
Minimum 5 years
Minimum 15 years
Minimum 20 years
11.7 2.4 124 46 L2 39/74
15.3 2.3 117 41 L3 25/62
20.6 2.4 123 38 L4 15/56
13.6 2.1 104 43 L3 17/34
18.6 2.1 112 43 L3 15/29
21.6 2.1 110 42 L4 8/19
(3.5) (1.1) (49) (26) (3) (53%)
(5.7) (1.1) (48) (29) (4) (40%)
patients as they age to better guide expectations for patients considering arthroplasty.
Conclusion At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. Gains in range of motion have been maintained compared with earlier follow-up. However, in this young population, more than 60% of shoulders had unsatisfactory Neer ratings, most commonly due to reoperation or restricted motion of <90 of abduction or <20 external rotation. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient.
Disclaimer Robert H. Cofield receives royalties from Smith & Nephew. John W. Sperling receives royalties from Biomet. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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