Wednesday, April 10, 2013

Humeral resurfacing for arthritis - the shoulder cap

A ‘resurfacing’ humeral arthroplasty is one in which the humeral head is shaped to receive a metal surface placed on the bone without a stem down the medullary canal. The thought is that this represents a ‘conservative’ approach to shoulder arthroplasty in that it requires resection of less humeral bone than a conventional humeral arthroplasty. 

This is an observational case series study reporting the functional and radiological outcome of a resurfacing arthroplasty in shoulders with a  during a mean follow-up of 4 years for 102 consecutive patients with osteoarthritis (OA-47.1%), rheumatoid arthritis (RA–40.2%), rotator cuff arthropathy (RCA–8.8%), and avascular necrosis (AVN–3.9%).

They found that the highest patient satisfaction and lowest pain levels were achieved with shoulders with the diagnosis of avascular necrosis. Osteoarthritis and rheumatoid arthritis were less good and rotator cuff tear arthropathy did least well.

The complication rate in this series was high. One patient had a postoperative infection, another had radiological signs of osteolysis. Thirteen patients (12.9%) were revised in the group having the standard prosthesis: 6 with RA (1 to hemiarthroplasty, 3 to total arthroplasty, and 2 to reverse), three with OA (1 to hemiarthroplasty and 2 to total arthroplasty), and 4 with cuff tear arthropathy (all revised to reverse arthroplasty). There were 6 out of 11 revisions in the extended head prosthesis group;  2 were to reverse arthroplasty, 1 to hemiarthroplasty due to excessive glenoid wear and impossible glenosphere implantation, and 3 patients are awaiting reverse arthroplasty. There are 8 additional shoulders with extended heads that are planned for revision.

We are unsure of the role that this prosthesis should play in the management of glenohumeral arthritis. Almost all shoulders with arthritis (with the exception of early AVN) have changes to the glenoid as well as the humeral articular surfaces. This prosthesis alone does not address the glenoid side and, furthermore, retaining the extra bone blocks good access to the glenoid for either a ream and run or a total shoulder. 

The unresolved glenoid changes are demonstrated in the x-rays shown below on a patient who presented to us for revision who had pain and stiffness after a humeral resurfacing.

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