Thursday, July 23, 2015

Shoulder arthritis in the young - biological resurfacing has a high failure rate

Unacceptable failure of hemiarthroplasty combined with biological glenoid resurfacing in the treatment of glenohumeral arthritis in the young

These authors used GraftJacket for glenoid resurfacing combined with humeral resurfacing or a stemmed hemiarthroplasty in 6 patients with a mean age of 47 years (34-57 years). Before GraftJacket was available, they treated 5 patients with a meniscal allograft and 6 with capsular interposition arthroplasty.

At a mean of 16 months (9-22 months) after the GraftJacket was implanted, 5 of the 6 patients were revised to a total shoulder arthroplasty or a reverse total shoulder arthroplasty. The sixth patient was dissatisfied but declined further surgery. The mean relative, preoperative Constant score decreased from 35% (range, 13%-61%) to 31% (range, 15%-43%) at revision or latest follow-up.

Of the 5 patients with meniscal allograft, 3 underwent revision at a mean of 22 months (range, 12-40 months), and 4 of the 6 patients with capsular interposition were revised at a mean of 34 months (range, 23-45 months). The mean relative Constant scores preoperatively and at revision or latest follow-up were 44% (range, 19%-68%) and 58% (range, 9%-96%) for the meniscal allograft patients and 47% (range, 38%-62%) and 63% (range, 32%-92%) for the capsular interposition cases.

Interestingly, only 3 of these patients had B2 glenoids.

Comment: We have previously documented that shoulder arthritis in young individuals is challenging for three reasons: (1) more complex pathology (AVN, chondrolysis, post-surgical arthritis, post-traumatic arthritis, etc), (2) greater patient expectations, and (3) greater longevity of the patient.  Almost all of these patients were under 50 years of age. 13 had dislocation arthropathy, one had static posterior subluxation, one had post traumatic AVN, 13 had a history of instability. Many had had prior surgery for instability. Their Table II shows that many of these surgeries were big: bone block procedures, Latarjet procedures, glenoid osteotomies, and humeral rotational osteotomies!

Understandably surgeons are searching for approaches to shoulder arthroplasty that are more durable than a total shoulder with its recognized rate of glenoid component failure and its obligatory sacrifice of glenoid bone stock. To whit, a quote from these authors "glenoid component loosening has remained a major concern and accounts for 32% of the complications after TSA, occurring in up to
44% of patients and leading to revision in at least 0.8% of TSAs per year."
The concept of interposing a human dermal collagen allograft, allograft meniscus or capsule in between the humeral head and the glenoid reminds us of a mortar and pestle

The interposed tissue cannot be expected to hold up against a pestle applying a force of approximately one times body weight.

In recognizing the high failure rate of interposition on one hand and the high failure rate of polyethylene glenoid components in young patients on the other , the authors (somewhat strangely) state "New alternative techniques with the potential to preserve the original glenoid bone stock, such as osteochondral glenoid allograft".  It is not clear that a glenoid allograft preserves original glenoid bone stock.

In our practice we continue to manage patients with the conditions described in this article using the ream and run procedure, in that the ream and run is free of the risks of biological interposition or a plastic glenoid and in that it preserves glenoid and humeral bone stock. The results of this procedure in a large series are well documented - see this link.


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