These authors conducted a retrospective multicenter study all aged 60 years or less undergoing either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis with aminimum of 24-month follow-up.
202 patients with a mean age of 55.3 years (range, 36-60 years) underwent TSA with a mean follow-up of 9 years (range, 2-24.7 years). Revision arthroplasty was performed in 33 (16.3%) shoulders, with glenoid failure associated with the revision in 29 shoulders (88%). Survivorship analysis demonstrated 95% free of revision at 5 years, 83% at 10 years, and 60% at 20-year follow-up.
31 patients with a mean age of 52.5 years (range, 38-60 years) underwent HA with a mean followup of 8.7 years (range, 2-21.4 years). Revision arthroplasty was performed in 5 (16.1%) shoulders, with glenoid erosion as the cause for revision in 4 shoulders (80%). HA survivorship analysis demonstrated 84% free from revision at 5 years and 79% at the final follow-up.
The survival curves for the two groups are shown below.
Comment: One of the big questions regarding retrospective studies such as this is "why did surgeons elect HA in 31 of the 233 patients with primary arthritis?" While the article did not discuss the risk of selection bias in the limitations section, this confounder needs to be considered. Could it be that this selection was made because the surgeons performing these 31 cases were uncomfortable with at TSA in these cases or because the pathoanatomy precluded use of a glenoid? A hint may be gained by comparing the glenoid types in the two groups. From the chart below, it is evident that the hemiarthroplasty group contained a disproportionate percentage of the difficult type C glenoids and proportionately fewer of the relatively easy type B1 glenoids.
The reader would also be interested comparing the preoperative Constant Scores for both groups. While these data are available for the TSA group:
comparable data are not provided for the HA group, in spite of the title of Table III:
While this article provides additional data that the glenoid is the "weak link" in shoulder arthroplasty, it does not appear to provide data useful for comparing and contrasting TSA and HA in similar patients.
Ream and run and total shoulder: patient and shoulder characteristics in five hundred forty-four concurrent cases
These authors use two different types of joint replacement to treat cases of shoulder arthritis with intact rotator cuffs.
One is a conventional total shoulder that covers the glenoid with a plastic socket that matches the metal humeral head component (TSA).
The other is a ream and run in which the glenoid is reamed to the shape that matches the metal humeral head component (RnR).
The decision between the two options is made by the patient and the surgeon after a thorough discussion of the pros and cons of each method for the individual patient.
These authors analyzed the patient characteristics, shoulder characteristics, and two year clinical outcomes of 544 patients having RnR or TSA at the same institution during the same six year period.
Patients having the RnR were more likely to be male (92.0% vs. 47.0%), younger (58 ± 9 vs. 67 ± 10 years), married (83.2% vs. 66.8%), from outside of the authors' state (51.7% vs. 21.7%), commercially insured (59.1% vs. 25.2%), and to have type B2 glenoids (46.0% vs. 27.8%) as well as greater glenoid retroversion (19 ± 11 vs. 15 ± 11 degrees) (p < .001).
The average two year SST score for the RnRs was 10.0 ± 2.6 vs. 9.5 ± 2.7 for the TSAs. The percent of maximum possible improvement (%MPI) for the RnRs averaged 72 ± 39% vs. 73 ± 29% for the TSAs.
Patients with work-related shoulder problems had lower two year SSTs and lower %MPIs. Younger patients having TSAs did less well than older patients.
Female patients having RnRs did less well than those having TSAs (p < 0.001).
Female patients having RnRs did less well than those having TSAs (p < 0.001).
Forty-seven patients (9%) had a second procedure within the study period.
Among the 281 patients having a TSA, 13 (5%) had repeat procedures during the period of this study. The average age at the index total shoulder arthroplasty for the patients having a second procedure after a total shoulder was 57 ± 13 years, ten years younger that the average age of 67 ± ten years at the index TSA for those not having a second procedure (p = 0.002). Seven of the 13 (54%) patients having a second procedure after a TSA were female while 142 of the 268 (53%) not having a second procedure were female (p = 0.954). Six TSAs (2%) had a closed manipulation under anesthesia at an average of 15 weeks after their index arthroplasty. Two patients (1%) had arthroscopic procedures at other institutions— details of these arthroscopies were not available. Five patients (2%) had an open procedure at an average of six months after their index arthroplasty; these included two subscapularis repairs and three prosthetic revisions. Intra-operative cultures were obtained in three (60%) of these open revisions; none were positive.
Among the 263 patients having a ream and run procedure, 34 (13%) had a second procedure during the study period. The average age of the patients having a second procedure after a ream and run was 55 ± ten years in comparison to 58 ± nine years for the group not having a second procedure (p = 0.018). Seven (21%) of the 34 patients having a second procedure were female in comparison to 14 (6%) of the 229 ream and run patients not having a second procedure (p = 0.004). Twenty (8%) had a closed manipulation under anaesthesia at an average of 22 weeks after their index arthroplasty. Fourteen patients (5%) had an open procedure at an average of 15 months after their index arthroplasty; these included six exchanges of the humeral head component with soft tissue release, five complete single stage humeral component exchanges without additional glenoid surgery, and three conversions to a total shoulder. Intra-operative tissue and explant cultures were obtained in 12 (86%) of these open revisions; seven (58%) of these cultures were positive for Propionibacterium (Cutibacterium). All patients with positive cultures were males with the initial diagnosis of osteoarthritis; the average age (±SD) of these patients was 54 ± ten years.
The authors concluded that excellent outcomes can be achieved for appropriately selected patients having either procedure. They noted that the RnR was used more commonly for more severe pathology (i.e. type B2 and retroverted glenoids).
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