Monday, June 17, 2013

Total shoulder vs Hemiarthroplasty - a randomized control trial - 10 year followup

Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade?

The authors of this very well done study compared a group of 31 patients that were randomized to hemiarthroplasty (HA) or total shoulder replacement (TSR) in surgery after glenoid exposure. There were 13 hemis and 20 totals. Patients were assessed to a minimum of 10 years postoperatively. They had a complete followup on all patients apart from those who died.

Inclusion criteria were (1)  a reasonable expectation that the rotator cuff was intact and (2) advanced osteoarthitis without evidence of infection, inflammatory disease, or previous fracture. Patients were advised that they would not necessarily be in the trial if, at operation, they were deemed more suitable for one of the surgical options on the basis of the existing recommendations favoring HA or TSR. Specifically, patients who had excessive glenoid erosion, a very flat glenoid shape, or major glenoid cysts, all of which are regarded as a contraindication to HA, did not constitute an appropriate comparative group because the performance of a HA in this particular patient would prejudice the results of HA.

There were no statistically significant differences between the groups at 10 years with respect to pain, function, and daily activities, however at 6 months and 1 year, the total shoulder patients had less pain than the hemiarthroplasty patients (P < .05), and this became more apparent at 2 years postoperatively (P < .02). Four HA patients were revised to TSR due to severe pain secondary to glenoid erosion. Two shoulders in the TSR group have been revised. Nine of the 13 HA patients (69%) and 18 of the 20 TSR patients (90%) remained in situ at death or at the 10-year review.

It is of interest that the Human Subjects Committee suspended the study because of the differences found in the results at 2 years.

This study reminds us that osteoarthritis is a condition that affects both the humeral and the glenoid sides of the joint. Attending to only one side of the joint may not provide the desired result. In such cases a total shoulder or a ream and run procedure seem preferable to a hemiathroplasty, either with a stem or with a surface replacement.

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