J Shoulder Elbow Surg (2014) -, 1-12
www.elsevier.com/locate/ymse
Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up Ofer Levy, MD, MCh(Orth), FRCS*, Oren Tsvieli, MD, Julia Merchant, MRCS, Lora Young, FRCS (Tr&Orth), Alberto Trimarchi, MD, Rupen Dattani, MD, FRCS (Tr&Orth), Ruben Abraham, FRCA, Stephen A. Copeland, FRCS, Ali Narvani, FRCS (Tr&Orth), Ehud Atoun, MD Reading Shoulder Unit, Royal Berkshire and Berkshire Independent Hospitals, Reading, Berkshire, UK Background: The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. Methods: Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. Results: The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. Conclusions: CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the The Royal Berkshire Hospital Audit and Review Board (IRB) approved the study (Study No. 8-13/3845).
*Reprint requests: Ofer Levy, MD, MCh(Orth), FRCS, Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, Berkshire RG1 6UZ, UK. E-mail address: [email protected] (O. Levy).
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.11.035
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patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Arthroplasty; cementless; hydroxyapatite; resurfacing; shoulder; surface replacement; young
Shoulder arthroplasty is performed increasingly frequently with good results in patients who are usually elderly. The treatment of shoulder arthritis and arthropathy in the young patient remains a challenging issue. Young patients have higher functional demand and would like to resume all of their activities, including all sporting activities. This raises concerns regarding the risks of failure and need for early revision shoulder arthroplasty or even the need for a number of revision surgeries during their lifetime. The experience of shoulder arthroplasty with stemmed implants in young patients showed worse and less predictable results than in the older patient population, with a high percentage of unsatisfactory results and a high percentage of revision surgery.9,22,23 Recent reports have presented more favorable short-term to midterm outcomes,3,11,19 yet, with a high rate of revision surgery and reoperation.3,11,19 Cementless surface replacement arthroplasty (CSRA) of the shoulder was introduced in the mid-1980s as a treatment for glenohumeral arthrosis in an attempt to restore anatomy, preserve bone, and avoid humeral head resection.13-15,25 The patient-specific anatomy, including the native inclination, offset, head-shaft angle, and version of the humerus, is restored by following the anterior and inferior line of the anatomic neck of the humerus and finding the center of the humeral head with the initial guidewire using a jig in parallel to the line of the anatomic neck.13-15,25 Preservation of the bone stock of the humeral head facilitates easier later revision to a stemmed total shoulder arthroplasty (TSA),13-15 stemless or stemmed reverse TSA (rTSA),1,12 or arthrodesis,14 should the need arise. Available data regarding the short-term and midterm results of shoulder resurfacing arthroplasty in younger patients are limited.2,7,10 Our study evaluated the long-term results of CSRA for the treatment of glenohumeral arthritis in patients aged younger than 50 years with more than 10 years of follow-up (range, 10-25 years).
Materials and methods The patients eligible for this study were identified from our institution’s computerized database. The inclusion criteria were patients who were aged 50 years or younger at the time of surgery and had a minimum of 10 years of follow-up since the procedure at the time of the review. The data for all these patients were collected prospectively on the institutional database. All procedures were performed by the 2 senior authors (O.L. and S.A.C.).
Between 1988 and 2003, 54 consecutive CSRAs (Copeland Shoulder; Biomet, Swindon, UK) were performed in 49 patients (25 men, 24 women), with 5 patients undergoing bilateral procedures. Patients were aged younger than 50 years, with a mean age of 38.9 years (range, 22-50 years) at the time of surgery. The indications for shoulder resurfacing were pain and dysfunction and the etiology for the arthroplasty included: 16 shoulders with avascular necrosis (AVN; mainly corticosteroid induced), 20 with rheumatoid arthritis, 7 with instability arthropathy, 5 with early onset of primary osteoarthritis, 3 with malunion and fracture sequelae, 2 with postinfection arthropathy, and 1 with psoriatic arthritis. All patients with adequate humeral bone stock (usually less than 40% bone loss), excluding those with acute fracture, will have resurfacing prosthesis in our institution. There were 17 TSAs with a metal-backed glenoid implant (Fig. 1) and 37 humeral head resurfacing with microfracture of the glenoid (humeral surface arthroplasty [HSA]) (Fig. 2). At the latest follow-up, 3 patients (4 shoulders) had died of unrelated causes, and 8 patients were lost to follow-up (came from abroad for surgery or moved and were lost to follow-up), leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years).
Surgical procedure The operative technique and postoperative management have been described previously.14 The principles of bone preservation and minimal bone removal remained unchanged. All components were cementless press-fit impacted, and all implants used after 1993 were hydroxyapatite (HA) coated. In this series, 15 non-HAcoated implants and 39 HA-coated implants were used. At the operation, the state of the deltoid muscle, the rotator cuff, and the glenoid bone was assessed and recorded. The deltopectoral approach was used in 20 shoulders and the anterosuperior (Neviaser-Mackenzie) approach14,17 in 34. The deltopectoral approach was used until 1993, and since 1993, the anterosuperior approach (Neviaser-Mackenzie approach) was the preferred approach and was usually used, unless the deltopectoral approach was used for a previous procedure. When humeral head resurfacing is performed, all steps as for TSA are performed, but without insertion of a glenoid implant. A thorough release around the glenoid is performed to enable the humeral head to be pushed away (posteroinferiorly) and to get a good soft tissue balance. Release of the subscapularis contracture and release of the anterior soft tissues tightness allows the resurfaced humeral head to recenter on the glenoid by achieving soft tissue balance in the horizontal plane. The thorough release around the glenoid enables insertion of a glenoid component (if desired) or to perform microfracture to promote fibrocartilage cover on the glenoid.27
Long-term shoulder resurfacing in young patients
3 Table I
Rotator cuff status at surgery for different diagnoses
Diagnosis
Rotator cuff status
No.
Rheumatoid arthritis
Intact Bursal side tear Poor qualitydin continuation Poor qualitydrotator cuff tear Full-thickness tear Full-thickness rear Intact Intact Poor qualitydin continuation Full-thickness tear Intact Intact
9 1 4 1 5 1 16 4 2 1 5 3
Full-thickness tear Poor qualitydin continuation
1 1
Psoriatic arthritis Avascular necrosis Instability arthropathy
Primary osteoarthritis Post-trauma fracture sequela Postinfection arthropathy
Table II Rotator cuff status at surgery for total shoulder arthroplasty and humeral head resurfacing Operation
Rotator cuff status
No.
Humeral head resurfacing
Intact Bursal side tear Poor-quality rotator cuffdin continuation Full-thickness tear Poor qualitydrotator cuff tear Intact Poor-quality rotator cuffdin continuation Full-thickness tear
24 1 5
Total shoulder arthroplasty Figure 1 Copeland surface replacement arthroplastydtotal shoulder arthroplasty.
3 1 13 2 5
Rotator cuff state at surgery The rotator cuff at surgery was intact in 37 shoulders. Deficient rotator cuff of various degrees, from partial-thickness tear to attenuated tendon in continuation to full-thickness tear was found in 17 shoulders. Twenty-four shoulders in the humeral resurfacing group (hemiarthroplasty-HSA) and 13 shoulders in the TSA group had intact rotator cuff. The repairable cuff tears were 1 to 3 cm in size, and were repaired with transosseous sutures. The rotator cuff status is detailed in Tables I and II. Extensive rotator cuff tears in 5 shoulders could not be repaired at the time of the resurfacing, including 2 with rheumatoid arthritis, 1 with postinstability arthropathy, 1 with AVN, and 1 with osteoarthritis.
Rehabilitation The patients followed our routine rehabilitation protocol after shoulder arthroplasty with supervised physiotherapy for 3 to 6 months that included a deltoid rehabilitation regimen, hydrotherapy, and self-exercises after that up to 1 year.
Clinical evaluation Figure 2 Copeland surface replacement arthroplastydhumeral surface arthroplasty.
Functional results were assessed using the Constant score4-6,16 and a patient-satisfaction score (Subjective Shoulder Value [SSV] or
4 Single Assessment Numeric Evaluation score [SANE]).8,14,16,28 SANE (or SSv) is a visual analog score marked on a 10-cm line, with 0 indicating ‘‘not satisfied’’ and 10 indicating ‘‘very satisfied.’’ The Constant score is a maximum of 100 points and can be adjusted for age and sex. The age- and sex-adjusted (ASadj) Constant score is expressed as percentage of the expected score for the patient’s age and sex.4,5 All patients were asked specific questions about return to full activities, work, and sports.16 Sport activities were assessed using specific questions regarding return to sports in the functional questionnaire used in our institution.16 For all of the patients available for follow-up, the shoulder function and range of movements at the last follow-up were recorded on video.
Radiographic evaluation Preoperative anteroposterior and axillary views radiographs were used for all patients. Unfortunately, computed tomography scans were not routinely performed in those early years. Anteroposterior and axillary views radiographs were evaluated postoperatively, at 6 months, annually, and biannually initially and at the last follow-up. Radiographs were assessed for glenohumeral subluxation, periprosthetic lucency, component shift in position, and glenoid erosion according to Torchia et al.26 The presence or absence of lucent lines and their width were assessed relative to time from surgery. Periprosthetic lucency was graded as 0, none; 1, 1 mm incomplete; 2, 1 mm complete; 3, 1.5 mm incomplete; 4, 1.5 mm complete; or 5, 2 mm complete. Definite loosening was defined as a change in the position of the component, and probable loosening was defined as an unchanged position but progressive radiolucent lines (>2 mm wide) involving all or part of the component. Glenohumeral subluxation was evaluated with regard to direction and degree and was graded as none, mild (center of prosthetic head translated 50% relative to center of glenoid). Glenoid erosion was graded as none, mild (erosion into subchondral bone), moderate (medialization of glenoid subchondral bone with hemispheric conforming deformation of glenoid), or severe (complete hemispheric deformation of glenoid with bone loss to base of coracoid process).
Statistical analysis A paired t test was used to compare preoperative vs postoperative changes in Constant scores, patient satisfaction score, pain, active abduction, and external and internal rotation. Postoperative assessments were made at the last clinical contact. In patients with a revision, the last clinical information and the last radiograph before revision were used. The radiographic outcomes of subluxation and humeral lucency were assessed in the same way as for clinical outcomes. We estimated implant survival free of revision with the Kaplan-Meier method, reporting the estimate and 95% confidence interval (CI).
O. Levy et al.
Results Functional outcome The mean raw Constant score increased from 10.5 points to 62.0 points (P < .0001; Fig. 3, A), the mean ASadj Constant score increased from 11.5% to 71.8% (P < .0001; Fig. 3, B). The mean ASadj Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with the mean ASadj Constant score for total resurfacing arthroplasty of 58.1% (Fig. 4). The best results were observed for the AVN patients, with a mean ASadj Constant score improving from 13% (raw 12 points) preoperatively to 85% (raw 75 points) in the last follow-up. These were followed by the primary osteoarthritis group results and the rheumatoid arthritis group with more modest results (Table III, Figs. 3-5). However, all of the rheumatoid arthritis patients were extremely satisfied with their shoulder resurfacing. These results are a reflection of the state of the rotator cuff.
Pain and motion Patients had significant pain relief and increases in shoulder range of movement with shoulder resurfacing. The pain score improved from a mean of 0.8 preoperatively to a mean of 13.8 of 15 at the most recent follow-up. The mean pain score improved from 0 of 15 preoperatively to a mean of 14.0 of 15 at the most recent followup for TSA and improved from a mean of 1.25 of 15 preoperatively to a mean of 12.4 of 15 at the most recent follow-up for HSA. The improvements in pain scores were statistically significant (P < .001). The improvements in motion were as follows: mean improvement in active elevation of 38 , from 78 preoperatively to 116 (range 30 -180 ) at the most recent follow-up for humeral head resurfacing (hemiarthroplasty with microfracture). The mean improvement in active elevation was 51 , from 42 preoperatively to 93 at the most recent follow-up for TSA (Fig. 5, A). The mean improvement in active abduction was 53 , from 55 preoperatively to 108 (range 30 -180 ) at the most recent follow-up for humeral head resurfacing (hemiarthroplasty with microfracture) and from 38 preoperatively to 81 for TSA (Fig. 5, B). The mean external rotation improvement was 38 , from 13 preoperatively to 51 at the most recent follow-up (Fig. 5, C). Mean internal rotation improved from 13 (palm to buttock) preoperatively to 47 (range 30 -90 ; palm to lumbar spine) at the most recent follow-up (Fig. 5, D). The elevation range of motion for HSA vs TSA for the different diagnoses is presented in Fig. 6.
Patient satisfaction At the time of their last follow-up, or the last follow-up before revision, the average SSV was 8.7 of 10. Forty of 49
Long-term shoulder resurfacing in young patients
5
A
B
Figure 3 (A) Mean raw Constant score per diagnosis. (B) Mean age and sex adjusted Constant score by diagnosis. AVN, avascular necrosis; FU, follow-up; Ingo, preoperative; OA, osteoarthritis; RA, rheumatoid arthritis.
patients (81.6%) felt much better and better from preoperatively. Even the patients who were revised were satisfied with their resurfacing until deterioration occurred that led to the revision surgery.
Return to work and sports All patients, beside the early revisions, indicated that the resurfacing had allowed them to return to their desired activities at a satisfactory level. Most patients returned to sports activities such as resistance training, yoga, Pilates, tennis, squash, golf, horse riding, polo, gym, weight lifting, sailing, flying, judo and martial arts, cycling, trail mountain biking, bike riding, hockey, cricket, and others.
Complications, reoperations, and revisions Two male patients with instability-associated arthropathy required revision of the total shoulder replacement to shoulder arthrodesis, 1 for deep infection and instability and the other for persistent instability. They were treated with arthrodesis in the first few weeks after surgery. Both patients had severe instability arthropathy, and both had undergone multiple previous operations for stabilization but were still unstable. Both remained unstable with the resurfacing prosthesis. One developed deep infection as well with Staphylococcus aureus. In hindsight, it was clearly poor patient selection and the wrong indication for surgery.
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Figure 4 Mean age- and sex-adjusted Constant score for humeral surface arthroplasty vs total shoulder arthroplasty (TSA) by diagnosis. AVN, avascular necrosis; FU, follow-up; Ingo, preoperative; OA, osteoarthritis; RA, rheumatoid arthritis.
Table III Diagnosis
Clinical Outcome Patients, Raw No. Constant score
Avascular necrosis 16 Rheumatoid arthritis 20 Instability arthropathy 7 Fracture sequela 3 Osteoarthritis 5 Postinfection arthropathy 2 Psoriatic arthropathy 1 Total 54 Mean scores
ASadj Constant score
Humeral head resurfacing
Resurfacing TSA
Ingo Last Ingo Last Patients, Last FU FU FU No. raw Constant score
Last FU ASadj Constant score
Patients, Last FU No. raw Constant score
Last FU ASadj Constant score
12 9 10 11 13 5 15
75 62 63 58 67 56 43
86 78 69 72 76 66 46
1 11 1 1
65 54 25 21
71 63 27 23
67.1
77.7
50.4
58.1
75 56 57 46 67 56 43
13 10 11 12 14 6 16
85 68 62 55 76 66 46
15 6 6 2 4 2 1 36
10.5 62.0 11.5 71.8
14
ASadj, age- and sex-adjusted; FU, follow-up; Ingo, preoperative; TSA, total shoulder arthroplasty.
One patient underwent arthroscopic capsular release for stiffness, Two patients required arthroscopic subacromial decompression and acromioclavicular joint excision arthroplasty due to impingement and acromioclavicular joint symptoms, and 1 patient with a humeral head resurfacing for arthritis secondary to infection required arthroscopic rotator cuff repair. In 1 shoulder, the interlocking screw through the peg of the mark 1 humeral component had to be removed. Seven shoulders were revised to stemmed prosthesis. One 48-year-old woman with osteonecrosis fell 1 year after the index operation and sustained a fracture at the distal
edge of the humeral resurfacing component at the humeral surgical neck. This required revision to a stemmed TSA prosthesis. In 3 patients (1 male and 2 female) with rheumatoid arthritis, 4 shoulders (1 bilateral) with non-HA-coated implants, were revised from TSA resurfacing to stemmed TSAs due to loosening of the glenoid and the humeral components 8 years, 10 years, 10 years, and 10 years after the index procedure, respectively. One female patient with HSA for AVN was revised to a stemmed TSA 16 years after the index procedure due to glenoid erosion. One female patient with HSA for
Long-term shoulder resurfacing in young patients
7
A
B
C
D
Figure 5 (A) Mean forward elevation (degrees), (B) mean abduction (degrees), (C) mean external rotation (degrees), and (D) mean external rotation (points) for humeral surface arthroplasty (HSA) and total shoulder arthroplasty.
rheumatoid arthritis was revised elsewhere to a stemmed TSA 14 years after the index procedure due to rotator cuff failure. Two patients were revised to a Verso stemless rTSA (Innovative Design Orthopaedics, London, UK [formerly by Biomet, Swindon, UK]) due to rotator cuff failure 23 years and 16 years post-surgery (rheumatoid arthritis and postinfection arthropathy; Fig. 7). One additional patient (postinfection arthropathy) is awaiting revision to rTSA due to rotator cuff failure 13 years after resurfacing (Table IV). Of the 7 shoulders that underwent revision arthroplasty to a stemmed implant, 6 had satisfactory outcome of the secondary procedure. The 2 patients revised to the Verso stemless rTSA, showed excellent results, with no pain, full function, and nearly full range of motion at 2 years and 7 years, respectively, after the revision. They rated their satisfaction as 10 of 10, with Constant scores of 82 and 87 points (Fig. 7).1,12 We estimated implant survival free of revision with the Kaplan-Meier survival curve for all patients aged 50 years or younger receiving shoulder resurfacing arthroplasty. The estimated revision-free survival rate for humeral head resurfacing (hemi) was 97% (95% CI, 0.92-1.02) at 5 years, 97% (95% CI, 0.92-1.02) at 11 years, 91% (95% CI, 0.87-
0.96) at 14 years, and 85% (95% CI, 0.81-0.89) at 22 years. The estimated revision-free survival rate for TSA was 100% (95% CI, 0.95-1.05) at 5 years, 71% (95% CI, 0.68-0.75) at 11 years, 71% (95% CI, 0.68-0.75) at 14 years, and 61% (95% CI, 0.58-0.64) at 22 years (Fig. 8).
Radiologic review In 35 of 38 shoulders (92%) available for recent radiographic follow-up (or last follow-up before revision), the humeral implants showed no lucencies, 2 showed localized lucent lines of less than 1 mm, and 1 implant was loose. All of the lucencies were observed in TSAs. There were 9 glenoid implants (TSAs), of which 4 were loose (44%) and 1 (11%) showed a localized lucent line less than 1 mm thick. Some degree of superior migration, as an indication for rotator cuff failure or incompetence, was noted in 22 of the 38 shoulders (58%): 15 (39%) had severe superior migration, 5 (13%) had moderate superior migration, and 2 (5%) had mild superior migration. Sixteen shoulders (42%) showed no superior migration. Moderate to severe glenoid erosion was present in 32% (4 severe and 8 moderate) of the shoulders at an average
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O. Levy et al.
A
B
Figure 6 (A) Mean forward elevation in degrees for (A) the humeral surface arthroplasty (HSA) and (B) the total shoulder arthroplasty (TSA) by diagnosis. AVN, avascular necrosis; OA, osteoarthritis; RA, rheumatoid arthritis.
Figure 7 arthritis.
Revision to the Verso stemless reverse total shoulder arthroplasty (rTSA) 23 years after TSA resurfacing for rheumatoid
follow-up of more than 14.5 years; however, most of these patients still had a continued good result in measured outcomes. The glenoid erosion was correlated
to the rotator cuff failure with superior migration of the humeral head and was more prevalent in the rheumatoid arthritis patients.
Long-term shoulder resurfacing in young patients Table IV
9
Revisions
Gender Age at Diagnosis index Op (y)
Side Hemi/Total
Male
Revision to
Age at Time from Indication for revision revision (y) index Op (y)
50
RA
R
TSA Copeland mark 2 Stemmed TSA
58
8
Female 25 Female 32
RA RA
L R
TSA Copeland mark 2 Verso TSA Copeland mark 2 Stemmed TSA
45 42
23 10
Female 32
RA
L
TSA Copeland mark 2 Stemmed TSA
43
10
Female 39
RA
R
TSA Copeland mark 2 Stemmed TSA
49
10
Female 34
RA
L
HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark
Stemmed TSA
48
14
Glenoid and humeral loosening Rotator cuff failure Glenoid and humeral loosening Glenoid and humeral loosening Glenoid and humeral loosening Rotator cuff failure
Verso
59
16
Rotator cuff failure
Planned Revision 51 to Verso Stemmed TSA 61
13
Rotator cuff failure
17
Glenoid erosion
Male
43
Female 38 Female 44 Female 48
Postinfection R Postinfection R AVN AVN
L R
3 2 3 3 Stemmed TSA
50
2
Fracture
2
AVN, avascular necrosis; HSA, humeral shoulder arthroplasty; L, left; RA, rheumatoid arthritis; R, right; TSA, total shoulder arthroplasty.
Figure 8 Kaplan-Meier survival curve for all patients aged 50 years or younger receiving shoulder resurfacing arthroplasty. The estimated revision-free survival rate for humeral surface arthroplasty (HSA; hemi) was 97% at 5 years, 97% at 11 years, 91% at 14 years, and 85% at 22 years. The estimated revision-free survival rate for total shoulder arthroplasty (TSA) was 100% at 5 years, 71% at 11 years, 71% at 14 years, and 61% at 22 years.
Discussion Available data on the long-term results of shoulder arthroplasty in young patients have been limited. We report the long-term results of CSRA with the Copeland implant in 54 shoulders in 49 patients, aged younger than 50 years, who were treated between 1988 and 2003 and were monitored prospectively for a minimum of 10 years (range, 10-25 years;, average, 14.5 years). We found substantially decreased pain, high patient satisfaction, and a perceived return of function, including sporting activities.
Young patients have higher functional demand and would like to resume all of their activities, including all sporting activities. Any artificial joint, resurfacing or stemmed, may have a limited life span. The higher functional demand of the young patient may accelerate the joint wear. There is therefore increased probability of the need for revision surgery during their lifetime. Furthermore, the participation of the younger patient in different sporting activities, including collision sports, increases the theoretical risk of sustaining a periprosthetic fracture that with a stemmed implant may occur at the humeral shaft and may be difficult to treat. The use of a resurfacing implant will reduce the risk of midshaft fractures. With resurfacing, the traumatic fractures will tend to be metaphyseal and most can be treated conservatively or by easy conversion to stemmed implant, as in the case in this series. Because there are reduced risks of shaft fractures, the patients have less limitation on return to full sporting activities. CSRA has previously been reported to be successful in elderly patients with different etiologies of glenohumeral arthritis, with a mean age of 73.4 years.7,13-15,18 Copeland,7 Levy,14 Bailie et al,2 and Lee et al10 reported good shortterm and midterm results with resurfacing arthroplasty in young patients. Bailie et al2 reported significant improvement of the American Shoulder and Elbow Surgeons score and the Single Assessment Numeric Evaluation score from preoperatively to 2 years postoperatively, and 30 of the 36 patients were able to participate in their desired level of activity (including sports) after cementless humeral resurfacing arthroplasty.
10 Lee et al10 reported the results of surface replacement hemiarthroplasty of the shoulder with biologic resurfacing of the glenoid with interposed anterior capsule in 18 shoulders of patients aged younger than 55 years, with average followup of 4.8 years. The postoperative Constant score was 71.4 points (ASadj, 83.9%), with average active forward elevation of 130 , and 83% were satisfied with their shoulder resurfacing. None of the implants were loose, but 56% of shoulders showed moderate to severe glenoid erosion. Sperling et al22 reported the results of shoulder arthroplasty with stemmed prostheses in patients aged younger than 50 years. Follow-up at 15 years showed pain relief and improvement in motion after both humeral head replacement (HHR) and TSA. The rates of survival of the HHRs were 82% at 10 years and 75% at 20 years, and the rates of survival of the TSAs were 97% and 84%, respectively. Revision rate was 22% in the HHRs and 14% in the TSAs. Patient satisfaction was poor: 60% of those with HHR and 48% of those with TSA were unsatisfied with the results. In our series, 40 of 49 young patients (81.6%) with shoulder resurfacing were pleased with their shoulders and felt much better and better from preoperatively, with overall mean satisfaction score of 8.7 of 10. A more recent study from Bartelt et al3 showed similar results to their previous study,22 with a high rate of revision surgery or radiographic failure particularly in hemiarthroplasty. Thirty percent of the patients with HHR were revised at mean of 4.5 years from the index arthroplasty, and 7% of the patients with TSA were revised at mean of 10.9 years from the index arthroplasty. Glenoid loosening was present in 10 of 34 (29.4%) of the patients with TSA at a mean follow-up of 7 years. The Kaplan-Meier survival curve for patients aged 50 years or younger receiving shoulder resurfacing arthroplasty showed estimated revision-free survival rate at 11 years of 97% for humeral head resurfacing (HSA-hemiarthroplasty) compared with 71% for TSA, survival of 91% for HSA compared with 71% for TSA at 14 years, and 85% for HSA compared with 61% for TSA at 22 years after resurfacing. Our survival rates for HSA (85% at 22 years) are similar to Sperling et al,22 who reported 84% survival for TSA at 20 years. Our survival rates for TSA (61% at 22 years) are slightly inferior to survival reported by Sperling et al of 75% at 20 years for stemmed hemiarthroplasty. We believe that the increased polyethylene wear and loosening in our series was due to use of metal-backed glenoids. The improved functional outcome in this series is because the glenoid is not ignored by performing hemiarthroplasty. A thorough capsular release of 360 around the glenoid is performed in all cases, whether a total shoulder replacement with insertion of a glenoid component is preformed or just humeral head resurfacing (hemiarthroplasty) is done. Therefore, good soft tissues balance is achieved. The comparison between hemiarthroplasties and TSAs in the literature is often flawed because some surgeons will not access or deal with the glenoid at all when performing
O. Levy et al. hemiarthroplasty. This stage is crucial to achieve the optimal results from surface replacement arthroplasty (as well as any other hemiarthroplasty). In this series, CSRA provides good symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years. This improvement is maintained over more than 10 years and up to 25 years after surgery. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the average SSV at final follow-up was 8.7 of 10. The best results were observed for the AVN patients, with mean ASadj Constant score of improving from 13% (raw, 12 points) preoperatively to 85% (raw, 75 points) in the last follow-up. In our series, 10 of 54 shoulders (18.5%) required revision arthroplasty (excluding the 2 early arthrodesis cases). The mean time from the index arthroplasty to the revision surgery was 12 years. Beside 1 shoulder with traumatic periprosthetic fracture at 1 year after the resurfacing, the rest were after a long period that spans 8 to 23 years after the index resurfacing. The indications for revision were rotator cuff failure in 4 shoulders (3 HSA and 1 TSA), glenoid loosening and reciprocal humeral loosening in 4 TSA shoulders, glenoid erosion in 1 HSA shoulder, and 1 traumatic periprosthetic fracture. Some degree of superior migration as an indication for rotator cuff failure or incompetence was seen in 58% of the 38 shoulders: 15 (39%) with severe superior migration, 5 (13%) with moderate superior migration, and 2 (5%) with mild superior migration. Sixteen shoulders (42%) showed no superior migration. Deterioration of rotator cuff function or tear seems to occur with time and occurs similarly with all types of shoulder arthroplasties, stemmed and resurfacing, especially in shoulders with rheumatoid arthritis.15,20,21,24,26 There is no relation to the geometry of the prosthesis. With resurfacing we try to reproduce the normal anatomy of the humeral head, including humeral head version, inclination, and offset, and compensate for the wear on both sides of the joint (humerus and glenoid) with an overall offset of 6 mm. This was shown in a previous study of our group.25 Overall, there are no differences in the geometry of a properly done resurfacing and a properly done stemmed prosthesis. In our series, moderate to severe glenoid erosion was present in 32% (4 severe and 8 moderate) of the shoulders at an average follow-up of more than 14.5 years. Lee et al10 found 56% of moderate to severe glenoid erosion in shoulder resurfacing with anterior capsule interposition on the glenoid at an average follow-up of more than 5 years. It is possible that the capsule interposition created tightness in the joints and led to increased glenoid erosion. However, most of their patients had a continued good result in measured outcomes. Sperling et al22 reported 72% of glenoid erosion for a stemmed prosthesis hemiarthroplasty. In our series, the glenoid erosion correlated to the rotator cuff failure with superior migration of the humeral head and was more prevalent in the rheumatoid arthritis patients.
Long-term shoulder resurfacing in young patients No loosening was seen in the HSA group. Lucent lines and implant loosening were seen only in the TSA group. These may result from the glenoid polyethylene wear and reaction to the debris particles from polyethylene wear. The revision rate seems to be higher than in the elderly age group, yet slightly lower than in the stemmed series. Unlike in the Sperling et al3,22,23 series, most of the revisions in our study were needed in the TSA group, mainly due to polyethylene wear and consequent loosening. Four shoulders required revision due to rotator cuff tear and dysfunction. Should a surface replacement fail, revision to a stemless or stemmed TSA (anatomic or reverse) can be easily achieved with simple removal of the humeral surface component. Especially because there is no cement or prosthetic stem in the humerus, bone stock is consequently maintained and the original anatomy largely preserved. All revision arthroplasties were easier to perform, and of the 7 shoulders that underwent revision arthroplasty to a stemmed implant, the outcome of the secondary procedure was satisfactory in 6. The 2 patients who required revision to rTSA could be revised to a Verso stemless rTSA, which is a bone-preserving prosthesis. These patients showed excellent results, with no pain, full function, and nearly full range of motion. They rated their satisfaction as 10 of 10 with Constant scores of 82 and 87 points.1,12 These patients underwent their revision arthroplasty to a rTSA at the ages of 45 and 59 years. At this young age, the use of a stemless rTSA preserves the options for any further revision that might be needed.1,12 A limitation of our study is that we had no control group treated with stemmed arthroplasty (hemiarthroplasty or TSA) for comparison. However, we can compare our results with resurfacing arthroplasty to the published series with stemmed arthroplasty. A few variables in our series must be accounted for: There were a variety of diagnoses (AVN, rheumatoid arthritis, instability arthropathy, primary osteoarthritis, fracture sequelae, postinfectious arthropathy, and psoriatic arthritis) with different rotator cuff and soft tissues conditions that may have affected the prognosis. However, these are the usual etiologies for which young patients need to have arthroplasty and can be compared with other series. Approximately one-third of the patients were treated with TSA and the other two-thirds were treated with HSA and microfracture. We have separated the results to describe each group separately. Approximately one-third of the HSAs were non-HA coded, whereas the other two-thirds were. This does not appear to be an important variable in the study. The integrity of the rotator cuff affects the outcome. This has been discussed.
Conclusions Shoulder resurfacing provides good symptomatic and functional results in the treatment of glenohumeral
11 arthropathy in 81.6% of patients aged younger than 50 years of age. This improvement is maintained over more than 10 years after surgery, with a high patient satisfaction score of 8.7 of 10. Forty of 49 young patients (81.6%) with shoulder resurfacing were pleased with their shoulders; however, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All of the revision arthroplasty options are preserved, including less invasive procedures.
Disclaimer Stephen Copeland receives royalties from Biomet as designing surgeon. None of the other authors, their immediate families, and any research foundations with which they are affiliated have received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Atoun E, Van Tongel A, Hous N, Narvani A, Relwani J, Abraham R, et al. Reverse shoulder arthroplasty with a short metaphyseal humeral stem. Int Orthop 2014;38:1213-8. http://dx.doi.org/10.1007/s00264014-2328-8 2. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am 2008;90:110-7. http://dx.doi.org/10.2106/JBJS.F.01552 3. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg 2011;20:123-30. http://dx.doi.org/10.1016/j.jse. 2010.05.006 4. Constant C. Age related recovery of shoulder function after injury [thesis]. Cork, Ireland: University College; 1986. 5. Constant CR, Gerber C, Emery RJ, Sojbjerg JO, Gohlke F, Boileau P. A review of the Constant score: modifications and guidelines for its use. J Shoulder Elbow Surg 2008;17:355-61. http://dx.doi.org/10. 1016/j.jse.2007.06.022 6. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4. 7. Copeland SA, Levy O, Brownlow HC. Resurfacing arthroplasty of the shoulder. Tech Shoulder Elbow Surg 2003;4:199-210. 8. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 2007;16:717-21. http:// dx.doi.org/10.1016/j.jse.2007.02.123 9. Hayes PR, Flatow EL. Total shoulder arthroplasty in the young patient. Instr Course Lect 2001;50:73-88. 10. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg 2009;18:915-9. http://dx.doi.org/10.1016/j.jse. 2009.01.014 11. Levy JC, Virani NA, Frankle MA, Cuff D, Pupello DR, Hamelin JA. Young patients with shoulder chondrolysis following arthroscopic
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O. Levy et al. shoulder surgery treated with total shoulder arthroplasty. J Shoulder Elbow Surg 2008;17:380-8. http://dx.doi.org/10.1016/j.jse.2007.11.004 Levy O, Atoun E, Narvani A, Abraham R, Hous N, Even T, et al. Does reverse shoulder need a stem? 2–7 years Follow-up with stemless reverse total shoulder Prosthesis. J Shoulder Elbow Surg 2013;22:e323. http://dx.doi.org/10.1016/j.jse.2012.12.021 Levy O, Copeland SA. Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg 2004;13:266-71. http://dx.doi.org/10.1016/j.jse.2004.01.005 Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 2001;83:213-21. Levy O, Funk L, Sforza G, Copeland SA. Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis. J Bone Joint Surg Am 2004;86-A:512-8. Levy O, Copeland SA, Sforza G, Narvani A. Shoulder assessment questionnaire. Available from: http://www.readingshoulderunit.com/ uploads/files/documents/RSUShoulder_assessment_questionnaire_March 2014.pdf. Accessed October 20, 2014. Mackenzie D. The antero superior exposure of a total shoulder replacement. Arthop Traumatol 1993;2:71-7. Mullett H, Levy O, Raj D, Even T, Abraham R, Copeland SA. Copeland surface replacement of the shoulder. Results of an hydroxyapatite-coated cementless implant in patients over 80 years of age. J Bone Joint Surg Br 2007;89:1466-9. http://dx.doi.org/10.1302/ 0301-620X.89B11.18850 Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. J Bone Joint Surg Br 2008;90:764-9. http://dx.doi.org/ 10.1302/0301-620X.90B6.20387
20. Sneppen O, Fruensgaard S, Johannsen HV, Olsen BS, Sojbjerg JO, Andersen NH. Total shoulder replacement in rheumatoid arthritis: proximal migration and loosening. J Shoulder Elbow Surg 1996;5:47-52. 21. Sojbjerg JO, Frich LH, Johannsen HV, Sneppen O. Late results of total shoulder replacement in patients with rheumatoid arthritis. Clin Orthop Relat Res 1999;366:39-45. 22. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year followup of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg 2004;13:604-13. http://dx.doi.org/10.1016/j.jse.2004.03.013 23. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am 1998;80:464-73. 24. Stewart MP, Kelly IG. Total shoulder replacement in rheumatoid disease: 7- to 13-year follow-up of 37 joints. J Bone Joint Surg Br 1997;79:68-72. 25. Thomas SR, Sforza G, Levy O, Copeland SA. Geometrical analysis of Copeland surface replacement shoulder arthroplasty in relation to normal anatomy. J Shoulder Elbow Surg 2005;14:186-92. http://dx. doi.org/10.1016/j.jse.2004.06.013 26. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results. J Shoulder Elbow Surg 1997;6:495-505. 27. Tytherleigh-Strong GM, Levy O, Sforza G, Copeland SA. The role of arthroscopy for the problem shoulder arthroplasty. J Shoulder Elbow Surg 2002;11:230-4. http://dx.doi.org/10.1067/mse.2002.122257 28. Williams GN, Gangel TJ, Arciero RA, Uhorchak JM, Taylor DC. Comparison of the Single Assessment Numeric Evaluation method and two shoulder rating scales. Outcomes measures after shoulder surgery. Am J Sports Med 1999;27:214-21.
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Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up Ofer Levy, MD, MCh(Orth), FRCS*, Oren Tsvieli, MD, Julia Merchant, MRCS, Lora Young, FRCS (Tr&Orth), Alberto Trimarchi, MD, Rupen Dattani, MD, FRCS (Tr&Orth), Ruben Abraham, FRCA, Stephen A. Copeland, FRCS, Ali Narvani, FRCS (Tr&Orth), Ehud Atoun, MD Reading Shoulder Unit, Royal Berkshire and Berkshire Independent Hospitals, Reading, Berkshire, UK Background: The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. Methods: Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. Results: The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. Conclusions: CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the The Royal Berkshire Hospital Audit and Review Board (IRB) approved the study (Study No. 8-13/3845).
*Reprint requests: Ofer Levy, MD, MCh(Orth), FRCS, Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, Berkshire RG1 6UZ, UK. E-mail address: [email protected] (O. Levy).
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.11.035
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patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Arthroplasty; cementless; hydroxyapatite; resurfacing; shoulder; surface replacement; young
Shoulder arthroplasty is performed increasingly frequently with good results in patients who are usually elderly. The treatment of shoulder arthritis and arthropathy in the young patient remains a challenging issue. Young patients have higher functional demand and would like to resume all of their activities, including all sporting activities. This raises concerns regarding the risks of failure and need for early revision shoulder arthroplasty or even the need for a number of revision surgeries during their lifetime. The experience of shoulder arthroplasty with stemmed implants in young patients showed worse and less predictable results than in the older patient population, with a high percentage of unsatisfactory results and a high percentage of revision surgery.9,22,23 Recent reports have presented more favorable short-term to midterm outcomes,3,11,19 yet, with a high rate of revision surgery and reoperation.3,11,19 Cementless surface replacement arthroplasty (CSRA) of the shoulder was introduced in the mid-1980s as a treatment for glenohumeral arthrosis in an attempt to restore anatomy, preserve bone, and avoid humeral head resection.13-15,25 The patient-specific anatomy, including the native inclination, offset, head-shaft angle, and version of the humerus, is restored by following the anterior and inferior line of the anatomic neck of the humerus and finding the center of the humeral head with the initial guidewire using a jig in parallel to the line of the anatomic neck.13-15,25 Preservation of the bone stock of the humeral head facilitates easier later revision to a stemmed total shoulder arthroplasty (TSA),13-15 stemless or stemmed reverse TSA (rTSA),1,12 or arthrodesis,14 should the need arise. Available data regarding the short-term and midterm results of shoulder resurfacing arthroplasty in younger patients are limited.2,7,10 Our study evaluated the long-term results of CSRA for the treatment of glenohumeral arthritis in patients aged younger than 50 years with more than 10 years of follow-up (range, 10-25 years).
Materials and methods The patients eligible for this study were identified from our institution’s computerized database. The inclusion criteria were patients who were aged 50 years or younger at the time of surgery and had a minimum of 10 years of follow-up since the procedure at the time of the review. The data for all these patients were collected prospectively on the institutional database. All procedures were performed by the 2 senior authors (O.L. and S.A.C.).
Between 1988 and 2003, 54 consecutive CSRAs (Copeland Shoulder; Biomet, Swindon, UK) were performed in 49 patients (25 men, 24 women), with 5 patients undergoing bilateral procedures. Patients were aged younger than 50 years, with a mean age of 38.9 years (range, 22-50 years) at the time of surgery. The indications for shoulder resurfacing were pain and dysfunction and the etiology for the arthroplasty included: 16 shoulders with avascular necrosis (AVN; mainly corticosteroid induced), 20 with rheumatoid arthritis, 7 with instability arthropathy, 5 with early onset of primary osteoarthritis, 3 with malunion and fracture sequelae, 2 with postinfection arthropathy, and 1 with psoriatic arthritis. All patients with adequate humeral bone stock (usually less than 40% bone loss), excluding those with acute fracture, will have resurfacing prosthesis in our institution. There were 17 TSAs with a metal-backed glenoid implant (Fig. 1) and 37 humeral head resurfacing with microfracture of the glenoid (humeral surface arthroplasty [HSA]) (Fig. 2). At the latest follow-up, 3 patients (4 shoulders) had died of unrelated causes, and 8 patients were lost to follow-up (came from abroad for surgery or moved and were lost to follow-up), leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years).
Surgical procedure The operative technique and postoperative management have been described previously.14 The principles of bone preservation and minimal bone removal remained unchanged. All components were cementless press-fit impacted, and all implants used after 1993 were hydroxyapatite (HA) coated. In this series, 15 non-HAcoated implants and 39 HA-coated implants were used. At the operation, the state of the deltoid muscle, the rotator cuff, and the glenoid bone was assessed and recorded. The deltopectoral approach was used in 20 shoulders and the anterosuperior (Neviaser-Mackenzie) approach14,17 in 34. The deltopectoral approach was used until 1993, and since 1993, the anterosuperior approach (Neviaser-Mackenzie approach) was the preferred approach and was usually used, unless the deltopectoral approach was used for a previous procedure. When humeral head resurfacing is performed, all steps as for TSA are performed, but without insertion of a glenoid implant. A thorough release around the glenoid is performed to enable the humeral head to be pushed away (posteroinferiorly) and to get a good soft tissue balance. Release of the subscapularis contracture and release of the anterior soft tissues tightness allows the resurfaced humeral head to recenter on the glenoid by achieving soft tissue balance in the horizontal plane. The thorough release around the glenoid enables insertion of a glenoid component (if desired) or to perform microfracture to promote fibrocartilage cover on the glenoid.27
Long-term shoulder resurfacing in young patients
3 Table I
Rotator cuff status at surgery for different diagnoses
Diagnosis
Rotator cuff status
No.
Rheumatoid arthritis
Intact Bursal side tear Poor qualitydin continuation Poor qualitydrotator cuff tear Full-thickness tear Full-thickness rear Intact Intact Poor qualitydin continuation Full-thickness tear Intact Intact
9 1 4 1 5 1 16 4 2 1 5 3
Full-thickness tear Poor qualitydin continuation
1 1
Psoriatic arthritis Avascular necrosis Instability arthropathy
Primary osteoarthritis Post-trauma fracture sequela Postinfection arthropathy
Table II Rotator cuff status at surgery for total shoulder arthroplasty and humeral head resurfacing Operation
Rotator cuff status
No.
Humeral head resurfacing
Intact Bursal side tear Poor-quality rotator cuffdin continuation Full-thickness tear Poor qualitydrotator cuff tear Intact Poor-quality rotator cuffdin continuation Full-thickness tear
24 1 5
Total shoulder arthroplasty Figure 1 Copeland surface replacement arthroplastydtotal shoulder arthroplasty.
3 1 13 2 5
Rotator cuff state at surgery The rotator cuff at surgery was intact in 37 shoulders. Deficient rotator cuff of various degrees, from partial-thickness tear to attenuated tendon in continuation to full-thickness tear was found in 17 shoulders. Twenty-four shoulders in the humeral resurfacing group (hemiarthroplasty-HSA) and 13 shoulders in the TSA group had intact rotator cuff. The repairable cuff tears were 1 to 3 cm in size, and were repaired with transosseous sutures. The rotator cuff status is detailed in Tables I and II. Extensive rotator cuff tears in 5 shoulders could not be repaired at the time of the resurfacing, including 2 with rheumatoid arthritis, 1 with postinstability arthropathy, 1 with AVN, and 1 with osteoarthritis.
Rehabilitation The patients followed our routine rehabilitation protocol after shoulder arthroplasty with supervised physiotherapy for 3 to 6 months that included a deltoid rehabilitation regimen, hydrotherapy, and self-exercises after that up to 1 year.
Clinical evaluation Figure 2 Copeland surface replacement arthroplastydhumeral surface arthroplasty.
Functional results were assessed using the Constant score4-6,16 and a patient-satisfaction score (Subjective Shoulder Value [SSV] or
4 Single Assessment Numeric Evaluation score [SANE]).8,14,16,28 SANE (or SSv) is a visual analog score marked on a 10-cm line, with 0 indicating ‘‘not satisfied’’ and 10 indicating ‘‘very satisfied.’’ The Constant score is a maximum of 100 points and can be adjusted for age and sex. The age- and sex-adjusted (ASadj) Constant score is expressed as percentage of the expected score for the patient’s age and sex.4,5 All patients were asked specific questions about return to full activities, work, and sports.16 Sport activities were assessed using specific questions regarding return to sports in the functional questionnaire used in our institution.16 For all of the patients available for follow-up, the shoulder function and range of movements at the last follow-up were recorded on video.
Radiographic evaluation Preoperative anteroposterior and axillary views radiographs were used for all patients. Unfortunately, computed tomography scans were not routinely performed in those early years. Anteroposterior and axillary views radiographs were evaluated postoperatively, at 6 months, annually, and biannually initially and at the last follow-up. Radiographs were assessed for glenohumeral subluxation, periprosthetic lucency, component shift in position, and glenoid erosion according to Torchia et al.26 The presence or absence of lucent lines and their width were assessed relative to time from surgery. Periprosthetic lucency was graded as 0, none; 1, 1 mm incomplete; 2, 1 mm complete; 3, 1.5 mm incomplete; 4, 1.5 mm complete; or 5, 2 mm complete. Definite loosening was defined as a change in the position of the component, and probable loosening was defined as an unchanged position but progressive radiolucent lines (>2 mm wide) involving all or part of the component. Glenohumeral subluxation was evaluated with regard to direction and degree and was graded as none, mild (center of prosthetic head translated 50% relative to center of glenoid). Glenoid erosion was graded as none, mild (erosion into subchondral bone), moderate (medialization of glenoid subchondral bone with hemispheric conforming deformation of glenoid), or severe (complete hemispheric deformation of glenoid with bone loss to base of coracoid process).
Statistical analysis A paired t test was used to compare preoperative vs postoperative changes in Constant scores, patient satisfaction score, pain, active abduction, and external and internal rotation. Postoperative assessments were made at the last clinical contact. In patients with a revision, the last clinical information and the last radiograph before revision were used. The radiographic outcomes of subluxation and humeral lucency were assessed in the same way as for clinical outcomes. We estimated implant survival free of revision with the Kaplan-Meier method, reporting the estimate and 95% confidence interval (CI).
O. Levy et al.
Results Functional outcome The mean raw Constant score increased from 10.5 points to 62.0 points (P < .0001; Fig. 3, A), the mean ASadj Constant score increased from 11.5% to 71.8% (P < .0001; Fig. 3, B). The mean ASadj Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with the mean ASadj Constant score for total resurfacing arthroplasty of 58.1% (Fig. 4). The best results were observed for the AVN patients, with a mean ASadj Constant score improving from 13% (raw 12 points) preoperatively to 85% (raw 75 points) in the last follow-up. These were followed by the primary osteoarthritis group results and the rheumatoid arthritis group with more modest results (Table III, Figs. 3-5). However, all of the rheumatoid arthritis patients were extremely satisfied with their shoulder resurfacing. These results are a reflection of the state of the rotator cuff.
Pain and motion Patients had significant pain relief and increases in shoulder range of movement with shoulder resurfacing. The pain score improved from a mean of 0.8 preoperatively to a mean of 13.8 of 15 at the most recent follow-up. The mean pain score improved from 0 of 15 preoperatively to a mean of 14.0 of 15 at the most recent followup for TSA and improved from a mean of 1.25 of 15 preoperatively to a mean of 12.4 of 15 at the most recent follow-up for HSA. The improvements in pain scores were statistically significant (P < .001). The improvements in motion were as follows: mean improvement in active elevation of 38 , from 78 preoperatively to 116 (range 30 -180 ) at the most recent follow-up for humeral head resurfacing (hemiarthroplasty with microfracture). The mean improvement in active elevation was 51 , from 42 preoperatively to 93 at the most recent follow-up for TSA (Fig. 5, A). The mean improvement in active abduction was 53 , from 55 preoperatively to 108 (range 30 -180 ) at the most recent follow-up for humeral head resurfacing (hemiarthroplasty with microfracture) and from 38 preoperatively to 81 for TSA (Fig. 5, B). The mean external rotation improvement was 38 , from 13 preoperatively to 51 at the most recent follow-up (Fig. 5, C). Mean internal rotation improved from 13 (palm to buttock) preoperatively to 47 (range 30 -90 ; palm to lumbar spine) at the most recent follow-up (Fig. 5, D). The elevation range of motion for HSA vs TSA for the different diagnoses is presented in Fig. 6.
Patient satisfaction At the time of their last follow-up, or the last follow-up before revision, the average SSV was 8.7 of 10. Forty of 49
Long-term shoulder resurfacing in young patients
5
A
B
Figure 3 (A) Mean raw Constant score per diagnosis. (B) Mean age and sex adjusted Constant score by diagnosis. AVN, avascular necrosis; FU, follow-up; Ingo, preoperative; OA, osteoarthritis; RA, rheumatoid arthritis.
patients (81.6%) felt much better and better from preoperatively. Even the patients who were revised were satisfied with their resurfacing until deterioration occurred that led to the revision surgery.
Return to work and sports All patients, beside the early revisions, indicated that the resurfacing had allowed them to return to their desired activities at a satisfactory level. Most patients returned to sports activities such as resistance training, yoga, Pilates, tennis, squash, golf, horse riding, polo, gym, weight lifting, sailing, flying, judo and martial arts, cycling, trail mountain biking, bike riding, hockey, cricket, and others.
Complications, reoperations, and revisions Two male patients with instability-associated arthropathy required revision of the total shoulder replacement to shoulder arthrodesis, 1 for deep infection and instability and the other for persistent instability. They were treated with arthrodesis in the first few weeks after surgery. Both patients had severe instability arthropathy, and both had undergone multiple previous operations for stabilization but were still unstable. Both remained unstable with the resurfacing prosthesis. One developed deep infection as well with Staphylococcus aureus. In hindsight, it was clearly poor patient selection and the wrong indication for surgery.
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Figure 4 Mean age- and sex-adjusted Constant score for humeral surface arthroplasty vs total shoulder arthroplasty (TSA) by diagnosis. AVN, avascular necrosis; FU, follow-up; Ingo, preoperative; OA, osteoarthritis; RA, rheumatoid arthritis.
Table III Diagnosis
Clinical Outcome Patients, Raw No. Constant score
Avascular necrosis 16 Rheumatoid arthritis 20 Instability arthropathy 7 Fracture sequela 3 Osteoarthritis 5 Postinfection arthropathy 2 Psoriatic arthropathy 1 Total 54 Mean scores
ASadj Constant score
Humeral head resurfacing
Resurfacing TSA
Ingo Last Ingo Last Patients, Last FU FU FU No. raw Constant score
Last FU ASadj Constant score
Patients, Last FU No. raw Constant score
Last FU ASadj Constant score
12 9 10 11 13 5 15
75 62 63 58 67 56 43
86 78 69 72 76 66 46
1 11 1 1
65 54 25 21
71 63 27 23
67.1
77.7
50.4
58.1
75 56 57 46 67 56 43
13 10 11 12 14 6 16
85 68 62 55 76 66 46
15 6 6 2 4 2 1 36
10.5 62.0 11.5 71.8
14
ASadj, age- and sex-adjusted; FU, follow-up; Ingo, preoperative; TSA, total shoulder arthroplasty.
One patient underwent arthroscopic capsular release for stiffness, Two patients required arthroscopic subacromial decompression and acromioclavicular joint excision arthroplasty due to impingement and acromioclavicular joint symptoms, and 1 patient with a humeral head resurfacing for arthritis secondary to infection required arthroscopic rotator cuff repair. In 1 shoulder, the interlocking screw through the peg of the mark 1 humeral component had to be removed. Seven shoulders were revised to stemmed prosthesis. One 48-year-old woman with osteonecrosis fell 1 year after the index operation and sustained a fracture at the distal
edge of the humeral resurfacing component at the humeral surgical neck. This required revision to a stemmed TSA prosthesis. In 3 patients (1 male and 2 female) with rheumatoid arthritis, 4 shoulders (1 bilateral) with non-HA-coated implants, were revised from TSA resurfacing to stemmed TSAs due to loosening of the glenoid and the humeral components 8 years, 10 years, 10 years, and 10 years after the index procedure, respectively. One female patient with HSA for AVN was revised to a stemmed TSA 16 years after the index procedure due to glenoid erosion. One female patient with HSA for
Long-term shoulder resurfacing in young patients
7
A
B
C
D
Figure 5 (A) Mean forward elevation (degrees), (B) mean abduction (degrees), (C) mean external rotation (degrees), and (D) mean external rotation (points) for humeral surface arthroplasty (HSA) and total shoulder arthroplasty.
rheumatoid arthritis was revised elsewhere to a stemmed TSA 14 years after the index procedure due to rotator cuff failure. Two patients were revised to a Verso stemless rTSA (Innovative Design Orthopaedics, London, UK [formerly by Biomet, Swindon, UK]) due to rotator cuff failure 23 years and 16 years post-surgery (rheumatoid arthritis and postinfection arthropathy; Fig. 7). One additional patient (postinfection arthropathy) is awaiting revision to rTSA due to rotator cuff failure 13 years after resurfacing (Table IV). Of the 7 shoulders that underwent revision arthroplasty to a stemmed implant, 6 had satisfactory outcome of the secondary procedure. The 2 patients revised to the Verso stemless rTSA, showed excellent results, with no pain, full function, and nearly full range of motion at 2 years and 7 years, respectively, after the revision. They rated their satisfaction as 10 of 10, with Constant scores of 82 and 87 points (Fig. 7).1,12 We estimated implant survival free of revision with the Kaplan-Meier survival curve for all patients aged 50 years or younger receiving shoulder resurfacing arthroplasty. The estimated revision-free survival rate for humeral head resurfacing (hemi) was 97% (95% CI, 0.92-1.02) at 5 years, 97% (95% CI, 0.92-1.02) at 11 years, 91% (95% CI, 0.87-
0.96) at 14 years, and 85% (95% CI, 0.81-0.89) at 22 years. The estimated revision-free survival rate for TSA was 100% (95% CI, 0.95-1.05) at 5 years, 71% (95% CI, 0.68-0.75) at 11 years, 71% (95% CI, 0.68-0.75) at 14 years, and 61% (95% CI, 0.58-0.64) at 22 years (Fig. 8).
Radiologic review In 35 of 38 shoulders (92%) available for recent radiographic follow-up (or last follow-up before revision), the humeral implants showed no lucencies, 2 showed localized lucent lines of less than 1 mm, and 1 implant was loose. All of the lucencies were observed in TSAs. There were 9 glenoid implants (TSAs), of which 4 were loose (44%) and 1 (11%) showed a localized lucent line less than 1 mm thick. Some degree of superior migration, as an indication for rotator cuff failure or incompetence, was noted in 22 of the 38 shoulders (58%): 15 (39%) had severe superior migration, 5 (13%) had moderate superior migration, and 2 (5%) had mild superior migration. Sixteen shoulders (42%) showed no superior migration. Moderate to severe glenoid erosion was present in 32% (4 severe and 8 moderate) of the shoulders at an average
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A
B
Figure 6 (A) Mean forward elevation in degrees for (A) the humeral surface arthroplasty (HSA) and (B) the total shoulder arthroplasty (TSA) by diagnosis. AVN, avascular necrosis; OA, osteoarthritis; RA, rheumatoid arthritis.
Figure 7 arthritis.
Revision to the Verso stemless reverse total shoulder arthroplasty (rTSA) 23 years after TSA resurfacing for rheumatoid
follow-up of more than 14.5 years; however, most of these patients still had a continued good result in measured outcomes. The glenoid erosion was correlated
to the rotator cuff failure with superior migration of the humeral head and was more prevalent in the rheumatoid arthritis patients.
Long-term shoulder resurfacing in young patients Table IV
9
Revisions
Gender Age at Diagnosis index Op (y)
Side Hemi/Total
Male
Revision to
Age at Time from Indication for revision revision (y) index Op (y)
50
RA
R
TSA Copeland mark 2 Stemmed TSA
58
8
Female 25 Female 32
RA RA
L R
TSA Copeland mark 2 Verso TSA Copeland mark 2 Stemmed TSA
45 42
23 10
Female 32
RA
L
TSA Copeland mark 2 Stemmed TSA
43
10
Female 39
RA
R
TSA Copeland mark 2 Stemmed TSA
49
10
Female 34
RA
L
HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark HSA (Hemi) Copeland mark
Stemmed TSA
48
14
Glenoid and humeral loosening Rotator cuff failure Glenoid and humeral loosening Glenoid and humeral loosening Glenoid and humeral loosening Rotator cuff failure
Verso
59
16
Rotator cuff failure
Planned Revision 51 to Verso Stemmed TSA 61
13
Rotator cuff failure
17
Glenoid erosion
Male
43
Female 38 Female 44 Female 48
Postinfection R Postinfection R AVN AVN
L R
3 2 3 3 Stemmed TSA
50
2
Fracture
2
AVN, avascular necrosis; HSA, humeral shoulder arthroplasty; L, left; RA, rheumatoid arthritis; R, right; TSA, total shoulder arthroplasty.
Figure 8 Kaplan-Meier survival curve for all patients aged 50 years or younger receiving shoulder resurfacing arthroplasty. The estimated revision-free survival rate for humeral surface arthroplasty (HSA; hemi) was 97% at 5 years, 97% at 11 years, 91% at 14 years, and 85% at 22 years. The estimated revision-free survival rate for total shoulder arthroplasty (TSA) was 100% at 5 years, 71% at 11 years, 71% at 14 years, and 61% at 22 years.
Discussion Available data on the long-term results of shoulder arthroplasty in young patients have been limited. We report the long-term results of CSRA with the Copeland implant in 54 shoulders in 49 patients, aged younger than 50 years, who were treated between 1988 and 2003 and were monitored prospectively for a minimum of 10 years (range, 10-25 years;, average, 14.5 years). We found substantially decreased pain, high patient satisfaction, and a perceived return of function, including sporting activities.
Young patients have higher functional demand and would like to resume all of their activities, including all sporting activities. Any artificial joint, resurfacing or stemmed, may have a limited life span. The higher functional demand of the young patient may accelerate the joint wear. There is therefore increased probability of the need for revision surgery during their lifetime. Furthermore, the participation of the younger patient in different sporting activities, including collision sports, increases the theoretical risk of sustaining a periprosthetic fracture that with a stemmed implant may occur at the humeral shaft and may be difficult to treat. The use of a resurfacing implant will reduce the risk of midshaft fractures. With resurfacing, the traumatic fractures will tend to be metaphyseal and most can be treated conservatively or by easy conversion to stemmed implant, as in the case in this series. Because there are reduced risks of shaft fractures, the patients have less limitation on return to full sporting activities. CSRA has previously been reported to be successful in elderly patients with different etiologies of glenohumeral arthritis, with a mean age of 73.4 years.7,13-15,18 Copeland,7 Levy,14 Bailie et al,2 and Lee et al10 reported good shortterm and midterm results with resurfacing arthroplasty in young patients. Bailie et al2 reported significant improvement of the American Shoulder and Elbow Surgeons score and the Single Assessment Numeric Evaluation score from preoperatively to 2 years postoperatively, and 30 of the 36 patients were able to participate in their desired level of activity (including sports) after cementless humeral resurfacing arthroplasty.
10 Lee et al10 reported the results of surface replacement hemiarthroplasty of the shoulder with biologic resurfacing of the glenoid with interposed anterior capsule in 18 shoulders of patients aged younger than 55 years, with average followup of 4.8 years. The postoperative Constant score was 71.4 points (ASadj, 83.9%), with average active forward elevation of 130 , and 83% were satisfied with their shoulder resurfacing. None of the implants were loose, but 56% of shoulders showed moderate to severe glenoid erosion. Sperling et al22 reported the results of shoulder arthroplasty with stemmed prostheses in patients aged younger than 50 years. Follow-up at 15 years showed pain relief and improvement in motion after both humeral head replacement (HHR) and TSA. The rates of survival of the HHRs were 82% at 10 years and 75% at 20 years, and the rates of survival of the TSAs were 97% and 84%, respectively. Revision rate was 22% in the HHRs and 14% in the TSAs. Patient satisfaction was poor: 60% of those with HHR and 48% of those with TSA were unsatisfied with the results. In our series, 40 of 49 young patients (81.6%) with shoulder resurfacing were pleased with their shoulders and felt much better and better from preoperatively, with overall mean satisfaction score of 8.7 of 10. A more recent study from Bartelt et al3 showed similar results to their previous study,22 with a high rate of revision surgery or radiographic failure particularly in hemiarthroplasty. Thirty percent of the patients with HHR were revised at mean of 4.5 years from the index arthroplasty, and 7% of the patients with TSA were revised at mean of 10.9 years from the index arthroplasty. Glenoid loosening was present in 10 of 34 (29.4%) of the patients with TSA at a mean follow-up of 7 years. The Kaplan-Meier survival curve for patients aged 50 years or younger receiving shoulder resurfacing arthroplasty showed estimated revision-free survival rate at 11 years of 97% for humeral head resurfacing (HSA-hemiarthroplasty) compared with 71% for TSA, survival of 91% for HSA compared with 71% for TSA at 14 years, and 85% for HSA compared with 61% for TSA at 22 years after resurfacing. Our survival rates for HSA (85% at 22 years) are similar to Sperling et al,22 who reported 84% survival for TSA at 20 years. Our survival rates for TSA (61% at 22 years) are slightly inferior to survival reported by Sperling et al of 75% at 20 years for stemmed hemiarthroplasty. We believe that the increased polyethylene wear and loosening in our series was due to use of metal-backed glenoids. The improved functional outcome in this series is because the glenoid is not ignored by performing hemiarthroplasty. A thorough capsular release of 360 around the glenoid is performed in all cases, whether a total shoulder replacement with insertion of a glenoid component is preformed or just humeral head resurfacing (hemiarthroplasty) is done. Therefore, good soft tissues balance is achieved. The comparison between hemiarthroplasties and TSAs in the literature is often flawed because some surgeons will not access or deal with the glenoid at all when performing
O. Levy et al. hemiarthroplasty. This stage is crucial to achieve the optimal results from surface replacement arthroplasty (as well as any other hemiarthroplasty). In this series, CSRA provides good symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years. This improvement is maintained over more than 10 years and up to 25 years after surgery. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the average SSV at final follow-up was 8.7 of 10. The best results were observed for the AVN patients, with mean ASadj Constant score of improving from 13% (raw, 12 points) preoperatively to 85% (raw, 75 points) in the last follow-up. In our series, 10 of 54 shoulders (18.5%) required revision arthroplasty (excluding the 2 early arthrodesis cases). The mean time from the index arthroplasty to the revision surgery was 12 years. Beside 1 shoulder with traumatic periprosthetic fracture at 1 year after the resurfacing, the rest were after a long period that spans 8 to 23 years after the index resurfacing. The indications for revision were rotator cuff failure in 4 shoulders (3 HSA and 1 TSA), glenoid loosening and reciprocal humeral loosening in 4 TSA shoulders, glenoid erosion in 1 HSA shoulder, and 1 traumatic periprosthetic fracture. Some degree of superior migration as an indication for rotator cuff failure or incompetence was seen in 58% of the 38 shoulders: 15 (39%) with severe superior migration, 5 (13%) with moderate superior migration, and 2 (5%) with mild superior migration. Sixteen shoulders (42%) showed no superior migration. Deterioration of rotator cuff function or tear seems to occur with time and occurs similarly with all types of shoulder arthroplasties, stemmed and resurfacing, especially in shoulders with rheumatoid arthritis.15,20,21,24,26 There is no relation to the geometry of the prosthesis. With resurfacing we try to reproduce the normal anatomy of the humeral head, including humeral head version, inclination, and offset, and compensate for the wear on both sides of the joint (humerus and glenoid) with an overall offset of 6 mm. This was shown in a previous study of our group.25 Overall, there are no differences in the geometry of a properly done resurfacing and a properly done stemmed prosthesis. In our series, moderate to severe glenoid erosion was present in 32% (4 severe and 8 moderate) of the shoulders at an average follow-up of more than 14.5 years. Lee et al10 found 56% of moderate to severe glenoid erosion in shoulder resurfacing with anterior capsule interposition on the glenoid at an average follow-up of more than 5 years. It is possible that the capsule interposition created tightness in the joints and led to increased glenoid erosion. However, most of their patients had a continued good result in measured outcomes. Sperling et al22 reported 72% of glenoid erosion for a stemmed prosthesis hemiarthroplasty. In our series, the glenoid erosion correlated to the rotator cuff failure with superior migration of the humeral head and was more prevalent in the rheumatoid arthritis patients.
Long-term shoulder resurfacing in young patients No loosening was seen in the HSA group. Lucent lines and implant loosening were seen only in the TSA group. These may result from the glenoid polyethylene wear and reaction to the debris particles from polyethylene wear. The revision rate seems to be higher than in the elderly age group, yet slightly lower than in the stemmed series. Unlike in the Sperling et al3,22,23 series, most of the revisions in our study were needed in the TSA group, mainly due to polyethylene wear and consequent loosening. Four shoulders required revision due to rotator cuff tear and dysfunction. Should a surface replacement fail, revision to a stemless or stemmed TSA (anatomic or reverse) can be easily achieved with simple removal of the humeral surface component. Especially because there is no cement or prosthetic stem in the humerus, bone stock is consequently maintained and the original anatomy largely preserved. All revision arthroplasties were easier to perform, and of the 7 shoulders that underwent revision arthroplasty to a stemmed implant, the outcome of the secondary procedure was satisfactory in 6. The 2 patients who required revision to rTSA could be revised to a Verso stemless rTSA, which is a bone-preserving prosthesis. These patients showed excellent results, with no pain, full function, and nearly full range of motion. They rated their satisfaction as 10 of 10 with Constant scores of 82 and 87 points.1,12 These patients underwent their revision arthroplasty to a rTSA at the ages of 45 and 59 years. At this young age, the use of a stemless rTSA preserves the options for any further revision that might be needed.1,12 A limitation of our study is that we had no control group treated with stemmed arthroplasty (hemiarthroplasty or TSA) for comparison. However, we can compare our results with resurfacing arthroplasty to the published series with stemmed arthroplasty. A few variables in our series must be accounted for: There were a variety of diagnoses (AVN, rheumatoid arthritis, instability arthropathy, primary osteoarthritis, fracture sequelae, postinfectious arthropathy, and psoriatic arthritis) with different rotator cuff and soft tissues conditions that may have affected the prognosis. However, these are the usual etiologies for which young patients need to have arthroplasty and can be compared with other series. Approximately one-third of the patients were treated with TSA and the other two-thirds were treated with HSA and microfracture. We have separated the results to describe each group separately. Approximately one-third of the HSAs were non-HA coded, whereas the other two-thirds were. This does not appear to be an important variable in the study. The integrity of the rotator cuff affects the outcome. This has been discussed.
Conclusions Shoulder resurfacing provides good symptomatic and functional results in the treatment of glenohumeral
11 arthropathy in 81.6% of patients aged younger than 50 years of age. This improvement is maintained over more than 10 years after surgery, with a high patient satisfaction score of 8.7 of 10. Forty of 49 young patients (81.6%) with shoulder resurfacing were pleased with their shoulders; however, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All of the revision arthroplasty options are preserved, including less invasive procedures.
Disclaimer Stephen Copeland receives royalties from Biomet as designing surgeon. None of the other authors, their immediate families, and any research foundations with which they are affiliated have received any financial payments or other benefits from any commercial entity related to the subject of this article.
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