Friday, October 20, 2017

Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid

Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid
These authors presented their experience with 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years.

These surgeons performed the first 13 surgeries with standard reamers. They then performed the subsequent 11 surgeries with reamers that were 2 mm larger in diameter than the prosthetic humeral head diameter. Fourteen shoulders received an Affiniti prosthesis (Tornier), and 10 received a Global AP hemiarthroplasty prosthesis (DePuy Synthes).

In 22 cases they performed lesser tuberosity osteotomies They routinely sutured the biceps to soft tissue at the upper border of the pectoralis major tendon. They excised the labrum in all cases. They reamed the glenoid to correct deformity and version. If correction of deformity or version necessitated reaming into subchondral bone, then the surgeons did so. After surgery, patients  began passive supine elevation (140) and external rotation (40) on the first postoperative day.

Here are the radiographs they present

Twenty of their patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, Penn Shoulder Score (PSS), and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012).

Their early results of humeral hemiarthroplasty with concentric glenoid reaming were good to excellent in only 52.3% of patients.  47.7% of their patients exhibited either poor results or required revision surgery.

These surgeons are to be commended in presenting their results with their technique, which in some important ways contrasts with that which we have described (see this link):
(1) we routinely use a 56 mm diameter humeral head and a 58 mm diameter reamer
(2) we do not use the Affinity prosthesis
(3) we do not perform lesser tuberosity osteotomies
(4) we preserve the labrum in all cases
(5) we routinely preserve the biceps tendon
(6) we do not attempt to correct glenoid version
(7) we use an anteriorly eccentric humeral head and/or rotator interval plication to manage posterior instability
(8) we do not stretch the subscapularis to 40 degrees
(9) we obtain standardized pre and postoperative axillary 'truth' radiographs (see below), so that the centering of the humeral head and the reshaping of the reamed glenoid can be evaluated.

The results of this report of 24 shoulders can be compared with a recent publication regarding the outcomes of 101 patients having the ream and run procedure for primary arthritis (see this link) or a previous report of 176 cases (see this link). Neither of these publications from the Journal of Bone and Joint Surgery was referenced in the report.

As emphasized in the prior post (see link), The ream and run: not for every patient, every surgeon or every problem. Patients and surgeons should not consider this procedure unless they are comfortable with its demands.

The reader may also be interested in these posts:

Information about shoulder exercises can be found at this link.

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