Monday, January 15, 2018

When did they do a humeral hemiarthroplasty for osteoarthritis?

Long-term outcomes of humeral head replacement for the treatment of osteoarthritis; a report of 44 arthroplasties with minimum 10-year follow-up

These authors identified 60 patients who underwent humeral head hemiarthroplasty for osteoarthritis from November 8, 1978, through January 15, 1997. 44 of these (average age 58 (37-77) years) had a mean follow-up of 17 years (range, 10-30 years).

During the study period, 541 shoulders underwent anatomic total shoulder arthroplasty for osteoarthritis. Hemiarthroplasty was performed for patients who were younger (although 20% were older than 65 years), with higher activity levels, and who had full-thickness cartilage loss over a portion of or the entire glenoid surface with either minimal glenoid erosion or severe central erosion that would compromise glenoid fixation (n = 10). Intraoperatively, 9 shoulders had small to medium rotator cuff tears (all <3 cm in diameter) which were repaired.

Patients experienced significant pain relief postoperatively that was maintained during the longterm follow-up (P < .01), but a subgroup of 11 patients reporting persistent moderate or severe pain. 

In the 25 of the original 60 shoulders with 5 years of radiographic follow-up, Kaplan-Meier survival analysis demonstrated moderate to severe glenoid erosion in 50% at 5 years, which increased to 59% at 15 years and 88% at 20 years.  The only factor that predicted postoperative glenoid erosion was early age at the time of initial operation

Ten of 44 (22.7%) shoulders underwent revision surgery, predominantly for glenoid arthrosis (n = 9). 

Comment: The patients included in this retrospective followup study had a wide range of characteristics. Three different types of implants were used. Nine had rotator cuff tears and the rest apparently did not. While the authors state that hemiarthroplasty was performed for patients who were younger, the age range extended up to 77 years of age at the time of surgery, 9 (20%) were older than 65 years. Six patients had biconcave glenoids. The glenoid surface pathology ranged from a full-thickness cartilage loss over a portion of the glenoid surface to severe central erosion that would compromise glenoid fixation, preluding a total shoulder arthroplasty (n = 10). Since these 10 patients with severe glenoid erosion would be expected to continue to have glenoid erosion after hemiarthroplasty, it would be of interest to know the results if these patients were excluded.

The authors provide the following statement about their indications, "At our institution, hemiarthroplasty is offered as an option for active patients with reservations about their desire to maintain a lifelong weight-bearing restriction in the operative extremity as well as for those with deficient glenoid bone stock." It is apparent that these are two quite different groups of patients. For each, it would be of interest to know the authors' current surgical alternatives for managing these challenging situations.