Hemiarthroplasty with dermal allograft revised to a ream and run

An active man in his 50s had a right shoulder hemiarthroplasty with dermal matrix allograft to treat glenohumeral osteoarthritis.

Postoperatively his shoulder became painful, weak and stiff. At the time of presentation to us his shoulder x-rays were as shown below.

A clinic skin culture grew out 1+ Cutibacterium. 

He elected to have a single stage revision to a ream and run with impaction allografting of a standard humeral stem. At surgery, there was no evidence of residual allograft. He was placed on the red antibiotic protocol.

Two of his intrapoperative specimens grew out Cutibacterium.

His postoperative x-rays are shown below.

At 10.5 weeks after surgery he was preparing to go back to his heavy duty job as a block mason. He sent this video (which he graciously allowed us to show here) (click on this link). 

Obviously, this is a very well motivated patient. 

We'll follow him closely to assess his long term recovery.

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Revision cuff surgery - is dermal matrix allograft of greater value than a smooth and move?

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation

These authors studied patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears. 28 patients had minimum 2 year clinical followup but only 13 had postoperative imaging by MRI or ultrasound - four of these had retears. Three patients had another revision surgery.  Only 6 patients had both preoperative and postoperative outcome scores. In these the ASES score improved from 56 to 85 (P = .03) and the SANE score improved from 42 to 76 (P = .03).

The cost of the dermal matrix allograft is not mentioned in this paper.

Comment: The data presented in this paper do not enable the reader to see the value of dermal matrix allograft - the change in scores is available for less that 25% of the cases and less than 50% had post operative imaging of the cuff. 

This paper needs to be viewed in light of the results of a much larger series of patients having irreparable cuff tears treated without attempting to re-establish tendon continuity:

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery.

In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

These authors concluded that smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.

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Which patients with shoulder arthritis are likely to benefit from Interpositional human dermal allograft?

Arthroscopic Joint Preservation in Severe Glenohumeral Arthritis Using Interpositional Human Dermal Allograft

These authors reported results of arthroscopic glenoid resurfacing for glenohumeral arthritis at an average of 60 month clinical followup or until revision. Patients lost to follow-up and those included in a prior study were excluded.

The visual analog scale pain score improved from a median of 7 to 2. Median ASES score improved from 47 to 76; active forward elevation improved from 110 to 140.

The rate of revision to prosthetic arthroplasty was 23% after a mean of 45 months. The mean age of revised shoulders (60 years) was higher than that of surviving shoulders (53 years). The preoperative ASES score of revised shoulders (34) was lower than that of surviving shoulders (47). 

Revisions included hemiarthroplasty in 3 shoulders, anatomic total shoulder arthroplasty in 4, and reverse total shoulder arthroplasty in 3.

With multivariate analysis, exact odds ratios for age and preoperative ASES score as risk factors for revision were 1.3 (95% CI, 1.0-1.6; P . .02) and 0.9 (95% CI, 0.8-1.0; P . .003), respectively.

Comment: In considering the appropriate use for this procedure, it would be of interest to know the effect of glenoid type (e.g. A2 vs B2), sex, and prior surgery on the outcomes. It would also be of interest to know the relationship of radiographic joint space at followup to the clinical outcome. Finally, it would be of interest to know the outcomes of revisions: were they comparable to the results that would have been expected if the arthroplasty was performed primarily, or were the results inferior when performed as a revision?

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'See from which cities our patients come.

Failure of meniscal allograft and acellular dermal matrix interposition in treating glenohumeral arthritis

The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis

The authors express worry about the use of total shoulder arthroplasty in young patients because of the risk of early failure of the glenoid component. Similarly, they worry that humeral head replacement without attention to the glenoid may lead to progressive joint space narrowing, glenoid erosion, and diminishing outcomes over time. For these reasons, they and others have explored alternative treatment approaches, such as biologic resurfacing of the glenoid using a lateral meniscus allograft or human acellular dermal tissue matrix for young patients with symptomatic glenohumeral arthritis.

They performed reaming of the glenoid to create a concentric surface with punctate bleeding in hopes of adhesion and healing of the interposed tissue to the native glenoid. The interposition was then fixed to the periphery of glenoid using sutures.

They report the results of 41 of 45 patients with average age 42.2 years (range, 18.1-60.2 years (31 with lateral meniscus and 10 with dermal matrix) available for follow-up at an average of 2.8 years. They defined failure as (1) conversion to a total shoulder arthroplasty or reverse total shoulder arthroplasty, (2) recommendation of conversion to a total shoulder arthroplasty or reverse total shoulder arthroplasty by the treating surgeon, (3) revision surgery for graft removal, or (4) patient-reported disabling pain (VAS ≥ 8) or loss of function, or (5) postoperative ASES score of less than 50 points, or both.

The overall clinical failure rate was 51.2%. The lateral meniscal allograft cohort had a failure rate of 45.2%, with a mean time to failure of 3.4 years. Human acellular dermal tissue matrix interposition had a failure rate of 70.0%, with a mean time to failure of 2.2 years.

We observe that young and active individuals with arthritis present a substantially greater challenge than their older less active counterparts, as previously emphasized in this Blog. Some, but surely not all, of these individuals may merit consideration for a ream and run procedure.

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