Monday, July 1, 2013

Biological interposition for shoulder arthritis in patients under 50

Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years

Because of the risk of glenoid component failure in younger and more active individuals, there has been an interest in exploring alternatives to total shoulder arthroplasty. These authors report on 44 patients younger than 50 years of age, 23 having hemiarthroplasty alone (HA) and 21 having hemiarthroplasty with biological resurfacing (BR) of the glenoid using an interposed graft, such as a meniscus allograft (although it is not clear whether other types of graft, such as joint capsule, graft jacket, autogenous fascia lata, and Achilles allograft were used as well).

At a mean follow-up of 3.7 years, six of 23 patients in the hemiarthroplasty and 12 of 21 patients in the biological resurfacing group had either revision surgery or an American Shoulder and Elbow Surgeons score <50.

The young age of these patients is of great interest. The 20 shoulders available for follow-up in the HA group were a mean age of 33.9 ± 9.4 years (range, 16.8-49.6 years). The 20 shoulders available for follow-up in the BR group were a mean age of 37.7 ± 8.9 years (range, 19.0-53.7 years).

It is also of interest that many of these patients had prior surgery. Ten HA patients had no prior surgery, and 10 were noted to have had at least 1 prior surgery. These operations included arthroscopic debridement (n = 7), stabilization (n = 10), superior labrum anterior posterior repair (n = 2), resection for chondroblastoma (n = 1), and bony glenoid reconstruction (n = 1). Eight BR patients had undergone no prior surgery, with 12 patients noted to have had at least 1 prior surgery, which included stabilization for recurrent instability (n = 15), arthroscopic debridement (n = 5), loose body removal (n = 2) and thermal capsulorrhaphy (n = 1).

Many of these patients had diagnoses other than primary osteoarthritis. Primary indications for surgery in the HA group were avascular necrosis (AVN; n = 7), post-traumatic degenerative joint disease (DJD; n = 5), postsurgical DJD (n = 2), primary osteoarthritis (OA; n = 1), chondroblastoma (n = 1), glenoid dysplasia (n = 1), and rheumatoid arthritis (RA; n = 2).  Primary indications for surgery in the BR were postcapsulorrhaphy DJD (n = 10), OA (n = 6), and AVN (n = 1). 

These demographics drive home the point that young individuals with arthritis are quite different than the usual patients having shoulder arthroplasty. There is no 'ideal' treatment for these patients. While some may have avascular necrosis without glenoid pathology in which case hemiarthroplasty alone may be selected, this is unusual. When the glenoid is altered, especially if there is posterior glenoid erosion, some type of glenoid arthroplasty - either a ream and run or a total shoulder - may need to be considered. This report and others point out that 'biological resurfacing' may not be the procedure of choice.

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