Use total shoulder arthroplasty

Proven track record makes this a viable procedure for the young osteoarthritic patient.

Issue: May 2008

ByWilliam N. Levine, MD

Resurfacing procedures can be thought of as a bone-preserving operation. A theoretical advantage to performing a bone-preserving operation is it will make for an easier revision.

William N. Levine, MD
William N. Levine

However, for those of us who do any amount of shoulder arthroplasty, that theoretical advantage is not necessarily realized in clinical practice. I would rather do one good operation that will last longer than do an inferior operation that you have to revise in 5 years because of theoretical advantages.

There is little evidence that humeral head resurfacing improves outcomes over standard shoulder hemiarthroplasty.

Remember that we operate on these patients for one reason and one reason alone: pain. It is also critically important to remember that patients’ Visual Analog Pain scores following biologic resurfacing and hemiarthroplasty are always higher (ie, more pain) compared to a total shoulder arthroplasty. So even though the biologic resurfacing patients are doing well with respect to pain control, it is not as good as a standard total shoulder replacement (TSR).

There are pros and cons for shoulder arthroplasty in the young patient, but the biggest concern is glenoid loosening in a 50-year-old active person.

Waning enthusiasm

There are also concerns with resurfacing, including erosion and subluxation of the graft tissue. Any amount of posterior glenoid erosion is a relative contraindication of this technique, unless the glenoid is reamed to correct the increased retroversion (ie, take down the high anterior side). That is critically important because patients presenting with early osteoarthritis (OA) of the shoulder are usually those who have the worst posterior erosion, such as those with post-capsulorrhaphy arthropathy or, more rarely, just an early aggressive onset of OA.

Therefore, the initial enthusiasm for biologic glenoid resurfacing among many shoulder surgeons has waned over the past few years. I think it has a role, but the indications have narrowed even further, and long-term follow-up is critically important.

We recently published a systematic review of the peer-reviewed literature published from 1966 to 2004 comparing TSR to hemiarthroplasty. We looked at pain relief, range of motion, patient satisfaction and revision surgery. We identified 25 studies involving almost 2,000 patients at an average follow-up of 43.4 months. Unfortunately, there was a variety of outcomes measures that were used, and the average level of evidence was a very poor 3.73.

However, in the absence of prospective, randomized double-blind studies, these systematic reviews and meta-analyses serve as valuable tools to investigate the literature.

In terms of pain relief, we found 14 studies with 1,200 shoulders that demonstrated that postoperative pain relief improved with TSR more than hemiarthroplasty.

With respect to range of motion, postoperative forward elevation and gains in forward elevation, they all favored TSR over humeral head replacement. Most importantly, however, we found that TSR patients are more significantly satisfied (97%) compared to 80% with humeral head replacement. That means 20% of your patients with a hemiarthroplasty are not particularly happy with their shoulder.

Loosening

Glenoid loosening is always discussed as a major concern for not putting in an implant. Our systematic review revealed that 7.7% of patients required revision surgery in 1,500 patients from 14 studies. Analyzing this more closely, if metal-backed glenoids are removed, which have historically been problematic, revision for a standard all-polyethylene glenoid is only 1.7%. This needs to be compared to the 8.1% rate of failed hemiarthoplasties that required conversion to TSR secondary to pain during the study period.

Therefore, the need for glenoid revision after TSR is less common than the need for a glenoid resurfacing after an unsuccessful hemiarthroplasty. Furthermore, converting a painful hemiarthroplasty to a TSR is not a “slam dunk.” You don’t necessarily get pain relief and functional outcomes that are seen following a well-performed primary TSR.

Therefore, the real question we must ask is, “Am I burning a bridge with my index operation?”

In summary, a hemiarthroplasty with biological resurfacing does have theoretical advantages. But there’s very little evidence to compel us at this point to think about that for a 50-year-old patient compared to performing a well-done total shoulder replacement, which has a proven track record and very high patient satisfaction.

For more information:

William N. Levine, MD, can be reached at 622 W 168th St., PH-11, New York, NY 10032; 212-305-0762; e-mail: wnl1@columbia.edu.

Reference:

Levine WN. Controversies in shoulder and elbow arthroplasty. 50-year-old male with OA: TSA is the way to go. Presented at Orthopedics Today Hawaii 2008. Jan. 13-16, 2008. Lahaina, Maui, Hawaii.

Radnay CS, Setter KJ, Chambers L, et al. Total shoulder replacement compared with humeral replacement for the treatment of primary glenohumeral osteoarthritis: A systematic review. J Shoulder Elbow Surg. 2007;16(4):396-402.