Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger

Seventy-eight Neer hemiarthroplasties and thirty-six Neer total shoulder arthroplasties were performed in patients aged 50 years or younger between January 1, 1976, and December 31, 1985. Sixty-two hemiarthroplasties and twenty-nine total shoulder arthroplasties with complete preoperative evaluation, operative records, and a minimum 15-year follow-up (mean, 16.8 years) or follow-up until revision were included in the clinical analysis. Sixteen patients died, and seven were lost to follow-up. All 114 shoulders were included in the survival analysis. There was significant long-term pain relief (P < .01) and improvement in active abduction (P < .01) and external rotation (P < .01) with both procedures. There was not a significant difference between total shoulder arthroplasty and hemiarthroplasty with regard to pain relief, abduction, or external rotation. Radiographs were available for 53 hemiarthroplasties and 25 total shoulder arthroplasties with a minimum 10-year follow-up. Humeral periprosthetic lucency was present more frequently after total shoulder arthroplasty (60%) compared with hemiarthroplasty (34%) (P = .0079). Glenoid erosion was present in 38 of 53 hemiarthroplasties (72%). Glenoid periprosthetic lucency was present in 19 of 25 total shoulder arthroplasties (76%). The results were graded by use of a modified Neer result rating system. Among the hemiarthroplasties, there were 6 excellent (10%), 19 satisfactory (30%), and 37 unsatisfactory results (60%). Among total shoulder arthroplasties, there were 6 excellent (21%), 9 satisfactory (31%), and 14 unsatisfactory results (48%). The estimated survival rate for hemiarthroplasty was 82% (95% CI, 74%-92%) at 10 years and 75% (95% CI, 64%-86%) at 20 years. The estimated survival rate for total shoulder arthroplasty was 97% (95% CI, 91%-100%) at 10 years and 84% (95% CI, 68%-98%) at 20 years. The data from this study indicate that there is marked long-term pain relief and improvement in motion with shoulder arthroplasty. However, there is a moderate rate of hemiarthroplasty revision for painful glenoid arthritis. Unsatisfactory result ratings were most commonly a result of motion restriction from soft-tissue abnormalities. Great care must be exercised, and alternative methods of treatment considered, before either hemiarthroplasty or total shoulder arthroplasty is offered to patients aged 50 years or younger.     

Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis

BACKGROUND: The indications for resurfacing of the glenoid in patients who have osteoarthritis of the shoulder are not clearly defined; some investigators routinely perform hemiarthroplasty whereas others perform total shoulder arthroplasty. METHODS: Forty-seven patients (fifty-one shoulders) who were scheduled to have a shoulder arthroplasty for the treatment of degenerative osteoarthritis were randomly assigned, according to a random-numbers table, to one of two groups: replacement of the humeral head with resurfacing of the glenoid with a polyethylene component with cement (total shoulder arthroplasty [twenty-seven shoulders]) or replacement of the humeral head without resurfacing of the glenoid (hemiarthroplasty [twenty-four shoulders]). All patients received the same type of humeral component, and all operations were performed by or under the direct supervision of the same surgeon. The patients were followed for a mean of thirty-five months (range, twenty-four to seventy-two months) postoperatively. Evaluation was performed with use of the scoring systems of the University of California at Los Angeles and the American Shoulder and Elbow Surgeons. RESULTS: No difference was observed between the preoperative scores for the two groups of patients. Postoperatively, the mean scores with use of the University of California at Los Angeles system and the American Shoulder and Elbow Surgeons system were 23.2 points (range, 10 to 31 points) and 65.2 points (range, 15 to 94 points), respectively, after hemiarthroplasty and 27.4 points (range, 9 to 34 points) and 77.3 points (range, 3 to 100 points), respectively, after total shoulder arthroplasty. With the numbers available for study, no significant difference was found between the two operative groups with respect to the postoperative score. (Thirty-five subjects per group would be needed, assuming an effect size of 0.60 and a power of 0.80.) Total shoulder arthroplasty provided significantly greater pain relief (p = 0.002) and internal rotation (p = 0.003) than hemiarthroplasty did. Total shoulder arthroplasty also provided superior results in the specific areas of patient satisfaction, function, and strength, although none of these differences were found to be significant, with the numbers available. Total shoulder arthroplasty was associated with increased cost ($1177), operative time (thirty-five minutes), and blood loss (150 milliliters) per patient compared with hemiarthroplasty. To date, none of the total shoulder arthroplasties in the study group have been revised. Hemiarthroplasty yielded equivalent results for elevation and external rotation. Three of the twenty-five patients who had had a hemiarthroplasty needed a subsequent operation for resurfacing of the glenoid. The mean cost for the revision operations was $15,998. CONCLUSIONS: Total shoulder arthroplasty provided superior pain relief compared with hemiarthroplasty in patients who had glenohumeral osteoarthritis, but it was associated with an increased cost of $1177 per patient.     

Shoulder arthroplasty for osteoarthritis secondary to glenoid dysplasia

BACKGROUND: Between 1980 and 1997, six patients (seven shoulders) with glenoid dysplasia and osteoarthritis underwent shoulder arthroplasty at our institution because of moderate or severe shoulder pain. There were four hemiarthroplasties and three total shoulder arthroplasties. METHODS: All six patients (seven shoulders) were followed for a minimum of two years or until the time of revision surgery. The average duration of follow-up was 7.3 years (range, 1.3 to sixteen years). RESULTS: One shoulder treated with total shoulder arthroplasty underwent revision surgery because of infection and loosening of the glenoid component 5.8 years following the arthroplasty. Three shoulders treated with hemiarthroplasty underwent revision to total shoulder arthroplasty as a result of glenoid arthrosis at sixteen months, twenty months, and thirty-four months. In each of these shoulders, glenoid deficiency and cartilage loss were not addressed at the time of the original hemiarthroplasty. The one shoulder that did not undergo revision after hemiarthroplasty had a glenoid osteotomy performed at the time of the hemiarthroplasty. CONCLUSIONS: The data from this study suggest that glenoid deficiency and cartilage wear should be addressed in some way at the time of shoulder arthroplasty in patients with glenoid dysplasia.     

Total shoulder arthroplasty

Seventy Neer Series II total shoulder arthroplasties were performed in 65 patients. The average age was 69 years. The average follow-up period was 40 months. Rheumatoid arthritis or osteoarthritis was the diagnosis in 34 and 29 shoulders, respectively. Rotator cuff tears were identified in 18 patients. There were no infections, neurological injuries, or vascular injuries, or vascular injuries. Two glenoid fractures and two humeral shaft fractures were sustained intraoperatively. Uniformly, excellent pain relief was obtained regardless of the disease process. The resultant average increase in range of motion (ROM) was 60 degrees of active forward elevation and 18 degree of external rotation. Radiolucent lines were present in 17 humeral components; however, none was symptomatic or had progressed in thickness. Five glenoid components demonstrated progression of radiolucency, and two required revision. Both of these were in patients with rheumatoid arthritis. Although pain relief was uniformly good among all patient groups, a statistically significant degree of improvement in ROM was found in individuals with osteoarthritis. The etiology of the disease process and the status of the rotator cuff may determine the eventual outcome in individuals treated with total shoulder arthroplasty.     

Clinical results of revision shoulder arthroplasty for glenoid component loosening

We retrospectively reviewed 32 patients who underwent glenoid revision surgery after total shoulder arthroplasty to compare the results of revision total shoulder arthroplasty with those of revision hemiarthroplasty and to identify factors associated with poor results after revision shoulder arthroplasty for glenoid component loosening. Results were reviewed at a mean follow-up of 4 years (range, 2-8 years). Glenoid reimplantation resulted in significant pain relief (P < .0001), improvement in American Shoulder and Elbow Surgeons (ASES) score (P < .02), and external rotation (24 degrees to 44 degrees , P < .004). Revision to a hemiarthroplasty also resulted in significant pain relief (P < .01) and improvement in ASES score (P < .05). For the treatment of glenoid loosening without glenohumeral instability, both reimplantation of a glenoid component and revision to a hemiarthroplasty improved function, satisfaction, and level of pain. Reimplantation of a new glenoid component offered greater improvements in pain (P < .008) and external rotation (increase of 20 degrees versus 3 degrees , P < .03) compared with hemiarthroplasty. For patients with preoperative glenohumeral instability, revision surgery did not improve motion, function, or pain significantly. Risk factors associated with a poor outcome after revision arthroplasty included persistent glenohumeral instability, rotator cuff tears, and malunion of the greater tuberosity.     

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.     

Shoulder arthroplasty in sickle cell patients with humeral head avascular necrosis

The purpose of this study was to evaluate the results of shoulder arthroplasty for the treatment of avascular necrosis in patients with sickle cell disease. Medical records, radiographs, operative reports, and outcome scores of 8 adult patients with sickle cell disease were evaluated. The mean follow-up was 51 months (range, 2-10 years). Seven patients had a hemiarthroplasty, and one had a total shoulder arthroplasty. One patient had an intraoperative rotator cuff tear. Two had sickle cell crises in the immediate postoperative period. In one patient, stiffness developed that required arthroscopic capsular release 22 months after her arthroplasty. Another patient with a hemiarthroplasty underwent revision to a total shoulder arthroplasty 5 years after the index procedure. The mean American Shoulder and Elbow Surgeons score improved by 31.9 points. However, only 2 patients reported improvement in pain as assessed with a visual analog scale. Although shoulder arthroplasty provides improvements in range of motion and function in the majority of patients, pain relief is less predictable.     

Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND: The results of shoulder arthroplasty for osteoarthritis have been reported to be excellent or good for the majority of patients, but the value of using a glenoid component and the anatomic factors that affect outcome are still debated. The purpose of this study was to evaluate the influence of an operatively confirmed full-thickness tear of the rotator cuff, the severity of preoperative erosion of glenoid bone, preoperative radiographic evidence of subluxation of the humeral head, and the severity of preoperative loss of the passive range of motion on the outcome of total shoulder arthroplasty and hemiarthroplasty. METHODS: In a multicenter clinical outcome study, we evaluated 128 shoulders in 118 patients with primary osteoarthritis who had been followed for a mean of forty-six months (range, twenty-four to eighty-seven months). RESULTS: Patients with <10 degrees of passive external rotation preoperatively had significantly less improvement in external rotation after hemiarthroplasty (p = 0.006). Thirteen (10%) of the 128 shoulders had a repairable full-thickness tear of the supraspinatus tendon, but these tears did not affect the overall American Shoulder and Elbow Surgeons score, the decrease in pain, or patient satisfaction. Severe or moderate eccentric glenoid erosion was seen in twenty-nine (23%) of the 128 shoulders, and total shoulder arthroplasty resulted in significantly better passive total elevation and active external rotation as well as a trend toward significantly better active forward flexion than did hemiarthroplasty in these shoulders. The humeral head was subluxated posteriorly in twenty-three shoulders (18%), and when they were compared with the other shoulders in the study, these shoulders were found to have lower final American Shoulder and Elbow Surgeons scores, more pain, and decreased active external rotation following either total shoulder arthroplasty or hemiarthroplasty. CONCLUSIONS: On the basis of our data, we recommend the use of a glenoid component in shoulders with glenoid erosion. Humeral head subluxation was associated with a less favorable result regardless of the type of shoulder arthroplasty and must be considered in preoperative planning and counseling. Severe loss of the passive range of motion preoperatively was associated with a decreased passive range of motion postoperatively. A repairable tear of the supraspinatus tendon is not a contraindication to the use of a glenoid component. .     

Neer total shoulder replacement in rheumatoid arthritis

Forty-two shoulders in 37 patients with polyarthritis were treated with Neer total shoulder replacements and reviewed 12 to 66 months afterwards. There was good pain relief and improvement in function, but the range of movement was less than that seen after replacements for osteoarthritis; this may have been related to the fact that 34 shoulders had abnormal rotator cuff tendons. Although there was a high incidence of radiolucent lines around the glenoid component, there was no clinical evidence of loosening. There were a few complications, but on the whole we feel that the Neer total shoulder arthroplasty is a valuable procedure for a patient with polyarthritis.     

A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis

BACKGROUND: A systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder. METHODS: We conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion. RESULTS: A total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 +/- 0.3) compared with hemiarthroplasty (mean, 6.6 +/- 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I(2) = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13 degrees (95% confidence interval, 0.5 degrees to 26 degrees ) in favor of the total shoulder arthroplasty group (p = 0.008). CONCLUSIONS: At a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time.     

Glenoid Reconstruction in Revision Shoulder Arthroplasty

Failed shoulder arthroplasty associated with glenoid bony deficiency is a difficult problem. Revision surgery is complex with unpredictable outcome. We asked whether revision shoulder arthroplasty with glenoid bone grafting could lead to good outcome. We retrospectively reviewed 21 patients who underwent glenoid bone grafting using corticocancellous bone grafting or impaction grafting using cancellous bone graft. Three patients underwent revision TSA, five patients hemiarthroplasty, 10 patients hemiarthroplasty with biologic resurfacing of the glenoid, and three patients revision to reverse TSA. The patients had minimum 25 months followup (average, 45 months; range, 25-92 months). All patients had improvement in their range of motion and the Constant-Murley score. Most improvement occurred in patients with glenoid reimplantation. Patients who underwent revision reverse TSA had improvement in shoulder flexion but decrease in external rotation motion. We conclude revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible.     

Characteristics of unsatisfactory shoulder arthroplasties

Failure of shoulder arthroplasty is often defined as a complication or the need for revision, but it may also be viewed as a result that does not meet the expectations of the patient. To enhance our understanding of failed shoulder arthroplasties, we identified the characteristics common to a series of 139 consecutive patients who came to our shoulder consultation service because of dissatisfaction with the result of their shoulder arthroplasty. Primary osteoarthritis (28%) and proximal humeral fractures (26%) were the most common indications for the initial arthroplasty. Seventy-three shoulders (fifty-two percent) had at least one surgery before arthroplasty was performed. Seventy-four percent of the shoulders were stiff, 35% were unstable, and in the total shoulders, 59% of the glenoids were loose. Components were substantially malpositioned in 23%. Forty-two percent of shoulders with a failed hemiarthroplasty had substantial glenoid erosion, and 43% of shoulders that had undergone a hemiarthroplasty for fracture had nonunion of the tuberosities. Patients demonstrated impaired shoulder function; on average, they could perform only 2 of 12 shoulder functions. The rate of revision underestimated the rate of failure, as 23% of arthroplasties did not undergo revision. The challenge of achieving patient satisfaction after arthroplasty may be greater than previously recognized. Many of these unsatisfactory shoulder arthroplasties did not meet the criteria for failure used in previously published series. These observations suggest that greater attention to achieving proper component position, postoperative motion, and in fracture cases, fixation of the tuberosities may lead to increased patient satisfaction after shoulder arthroplasty.     

Shoulder arthroplasty for the treatment of inflammatory arthritis

BACKGROUND: Prosthetic replacement of the glenohumeral joint can relieve pain and improve shoulder function for patients with end-stage inflammatory arthritis. The purpose of this study was to prospectively analyze the clinical, functional, and radiographic outcomes of shoulder reconstruction with hemiarthroplasty or total shoulder arthroplasty. METHODS: In this multicenter prospective study, clinical history, physical examination, and self-assessment tools including a visual analogue scale, the Simple Shoulder Test, and an activities questionnaire were used to measure comfort, quality of life, and function. Radiographic outcome was determined by assessing the severity of the disease, the adaptation of the prosthesis to the anatomy, the implant position and relationships, and the restoration of glenohumeral alignment. RESULTS: At the time of follow-up, at a minimum of twenty-four months (mean, thirty-nine months), the thirty-six shoulders treated with a hemiarthroplasty and the twenty-five treated with a total shoulder arthroplasty showed significant improvement (p < 0.0001) as demonstrated by the visual analogue scale and the Simple Shoulder Test as well as improvements in the components of the activities questionnaire. Active forward elevation was significantly better (p < 0.004) after the total shoulder arthroplasties than after the hemiarthroplasties. The presence of extremely severe disease did not affect the clinical outcome. Prosthetic adaptation to the anatomy and restoration of glenohumeral alignment resulted in significant improvement in certain motion parameters and were associated with one another (p < 0.001). Restoration of glenohumeral alignment resulted in significant improvements in overall quality of life (p = 0.038), use of the arm for work and play (p = 0.014), and range of motion (p = 0.0004) compared with those parameters when alignment had not been restored. Glenoid erosion occurred in four of the shoulders treated with hemiarthroplasty. Two of the glenoid components used in the total shoulder arthroplasties loosened. CONCLUSIONS: Patients with inflammatory arthritis treated with hemiarthroplasty or total shoulder arthroplasty can be expected to have improved comfort, range of motion, and function. Restoration of glenohumeral alignment appears to lead to even greater improvement in these clinical parameters.     

Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial

BACKGROUND: Both total shoulder arthroplasty and hemiarthroplasty have been used commonly to treat severe osteoarthritis of the shoulder; however, their effect on disease-specific quality-of-life outcome is unknown. The purpose of this study was to compare the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty in patients with osteoarthritis of the shoulder. METHODS: Forty-two patients with a diagnosis of osteoarthritis of the shoulder were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she "crossed over" was used for the analysis. RESULTS: Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty (90.6 +/- 13.2 and 81.5 +/- 24.1 points, respectively; p = 0.18). The other outcome measures demonstrated similar findings. Two patients in the hemiarthroplasty group crossed over to the other group by undergoing a revision to a total shoulder arthroplasty because of glenoid arthrosis. CONCLUSIONS: Both total shoulder arthroplasty and hemiarthroplasty improve disease-specific and general quality-of-life measurements. With the small number of patients in our study, we found no significant differences in these measurements between the two treatment groups. LEVEL OF EVIDENCE: Therapeutic Level I.     

Shoulder arthroplasty for arthritis after instability surgery

BACKGROUND: We are not aware of any large published studies regarding the intermediate to long-term results of shoulder arthroplasty performed for the treatment of osteoarthritis after instability surgery. Therefore, we reviewed the results of this procedure, the risk factors for an unsatisfactory outcome, and the rates of failure in our patients. METHODS: Between January 1, 1978, and December 31, 1997, thirty-three patients (thirty-three shoulders) with glenohumeral arthritis after instability surgery were treated with a shoulder arthroplasty at our institution. Two patients were excluded from the study: one died less than two years postoperatively, and one had not been managed by the senior surgeon. The remaining thirty-one patients, including twenty-one patients who had had a total shoulder arthroplasty and ten who had had a hemiarthroplasty, were followed for a minimum of two years (mean, seven years) or until the time of revision surgery. The mean age at the time of the shoulder arthroplasty was forty-six years. RESULTS: Shoulder arthroplasty was associated with significant pain relief (p < 0.001) as well as significant improvement in external rotation (from 4 degrees to 43 degrees; p < 0.001) and active abduction (from 94 degrees to 141 degrees; p < 0.001). There was not a significant difference between the hemiarthroplasty group and the total shoulder arthroplasty group with regard to postoperative external rotation, active abduction, or pain. According to a modification of the rating system of Neer et al., there were four excellent, two satisfactory, and four unsatisfactory results in the hemiarthroplasty group and three excellent, five satisfactory, and thirteen unsatisfactory results in the total shoulder arthroplasty group. Three patients in the hemiarthroplasty group and eight patients in the total shoulder arthroplasty group underwent revision surgery. The estimated survival of the components (and 95% confidence interval) was 97% (91% to 100%) at two years, 86% (74% to 99%) at five years, and 61% (42% to 86%) at ten years. CONCLUSIONS: The data from the present study suggest that shoulder arthroplasty for the treatment of osteoarthritis of the glenohumeral joint following instability surgery in this relatively young group of patients provides pain relief and improved motion but is associated with high rates of revision surgery and unsatisfactory results due to component failure, instability, and pain due to glenoid arthritis.     

Surgical options for the young patient with glenohumeral arthritis

Young patients with glenohumeral arthritis are an ongoing treatment challenge. They typically have high demands of their shoulders, require long-term durability due to their young age, and often have altered local anatomy, through their disease process (instability arthropathy, juvenile rheumatoid arthritis, etc.) or from previous surgery (capsulorraphy arthropathy, chondrolysis, etc.). Workup to evaluate underlying causes of early arthritis, and to exclude infectious causes are necessary. When nonoperative management fails, arthroscopic debridement, hemiarthroplasty (isolated, with glenoid reaming, or with biological interposition), and total shoulder arthroplasty are treatment options available to the treating surgeon. Debridement or hemiarthroplasty can provide pain relief for a subset of patients, but results have not been reproducible across the literature and have not been durable over time. Total shoulder arthroplasty provides the most reliable pain relief, but long-term glenoid loosening and wear continue to lead to high revision rates in this patient population.     

Bone preserving technique for reverse arthroplasty: The preferred management option for osteoarthritis with glenoid bone loss in patients 70 and older

Elderly patients with shoulder arthritis and glenoid bone loss represent a challenging patient population. Surgical treatment options include hemiarthroplasty, anatomic total shoulder arthroplasty (TSA) with bone grafting or augmentation, and reverse total shoulder arthroplasty (RSA). The RSA has multiple advantages compared to anatomic TSA, particularly in an older patient population with glenoid bone loss.RSA with an augmented glenoid baseplate is ideal for the treatment of patients who have glenoid bone loss. The augmented base plate has many advantages including bone preservation, longer central and peripheral screws, ability to dial the augment to match the region of bone deficiency, and lateralization to improve tensioning on the deltoid and rotator cuff. Additionally, a bone preserving RSA is possible with an augmented glenoid baseplate in patients with no glenoid bone loss.     

Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases

Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed in 247 patients in patients with rheumatoid arthritis. One hundred and eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean, 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients had died and 1 was lost to follow-up. All 303 shoulders were included in the survival analysis. There was significant long term pain relief (P < .0001), improvement in active abduction (P < .0001), and external rotation (P < .0001) with both hemiarthroplasty and total shoulder arthroplasty (TSA). There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and TSA for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with TSA. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for TSA (P = .04). Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2-year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%). The data from this study indicate that there is marked long-term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, TSA appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery.     

Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years

Nineteen shoulder arthroplasties for the treatment of nontraumatic avascular necrosis of the humeral head were evaluated. The osteonecrosis was idiopathic in 6 shoulders, was a result of corticotherapy in 10, occurred after radiation in 2, and occurred after Gaucher's disease in 1. A total shoulder arthroplasty was performed in 5 cases and a hemiarthroplasty in 14. At 7 years' follow-up (range, 2 to 12 years), there were 7 excellent, 9 satisfactory, and 3 unsatisfactory results. The Constant score averaged 58 points, for an adjusted score of 78%. Radiolucent lines were present around 2 glenoid components, and 1 was radiographically loose. In 2 cases with humeral head replacement, there was painful glenoid wear. Shoulder arthroplasty for nontraumatic avascular necrosis yields satisfactory results with a pain-free shoulder in more than 80% of cases. However, limitation of motion often persists. Better results can be expected with shorter preoperative delay, when preoperative pain is moderate and range of motion preserved and when the etiology is not postradiation avascular necrosis, which in our series yielded the worst results.     

Ipsilateral total shoulder and elbow arthroplasties in patients who have rheumatoid arthritis.

BACKGROUND: The data on seventeen patients with rheumatoid arthritis who had been managed with ipsilateral total shoulder and elbow arthroplasties were analyzed to determine whether the operative technique, the presence of total shoulder and total elbow prostheses in the same upper extremity, or complications of the arthroplasties affected the result in each joint or the overall functional outcome of the upper extremity. METHODS: Seventeen patients with rheumatoid arthritis who were managed with a total of eighteen ipsilateral total shoulder and elbow arthroplasties were evaluated. The most recent physical examination was at an average of six years and six months (range, two years and one month to fourteen years) postoperatively. Radiographs, including 40-degree oblique and axillary radiographs of the shoulder as well as anteroposterior and lateral radiographs of the elbow, were made at an average of six years and eleven months (range, two years and two months to twenty-two years and eleven months) postoperatively. The radiographs of the shoulder were examined for loosening of the glenoid component, glenohumeral subluxation, and radiolucency at the bone-cement or bone-implant interface. The functional results of the total shoulder arthroplasties were evaluated with use of the rating systems of Neer et al. and Cofield. The Mayo elbow-performance score was used to evaluate elbow function. A rating system was also developed to assess the overall function of the upper extremity, including pain and motion of both the elbow and the shoulder. With this system, the overall function of the upper extremity was rated as excellent, good, fair, or poor. RESULTS: Evaluation of the shoulders revealed substantial relief of pain and an increase in active elevation. On radiographic evaluation, eight glenoid and five humeral components were considered to be loose. There were no reoperations. According to the rating system of Neer et al., eight shoulders had a satisfactory result and eight had an unsatisfactory result with limited active abduction. Limited-goals rehabilitation was successful after one shoulder arthroplasty and unsuccessful after another. There were two type-B periprosthetic humeral fractures. There was also substantial relief of pain in the elbows as well as an increase in the extension-flexion arc; the pronation-supination arc was sufficient for tasks of daily living. There was no radiographic loosening. Two elbows had an avulsion of the triceps, and two had aseptic loosening (one of which also had a worn bushing); all four needed a reoperation. One other elbow had persistent ulnar neuritis. The average interval between the arthroplasties was two years and eight months when the shoulder was replaced first and three years and five months when the elbow was replaced first. The interval between the joint replacements and the sequence of the joint replacements were not found to influence the outcome. Function of the extremity was improved by replacement of either the shoulder or the elbow alone; however, it improved significantly only when both joints were replaced (p = 0.03). According to combined clinical outcomes scores, there were nine excellent outcomes, four good outcomes, four fair outcomes, and one poor outcome after ipsilateral total shoulder and elbow arthroplasties. CONCLUSIONS: When there is severe arthritis of both the shoulder and the elbow, consideration should be given to replacing both joints in order to obtain optimum functional and clinical outcomes. The possibility of fracture of the humeral shaft necessitates an alteration of the technique for ipsilateral total shoulder and elbow arthroplasties.