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Hemiarthroplasty in rotator cuff-deficient shoulders
Hemiarthroplasty in rotator cuff-deficient shoulders Gerald R. Williams, Jr, MD, and Charles A. Rockwood, Jr, MD, Philadelphia, Pa., and San Antonio, Texas Between 1974 and 1990 a Neer humeral hemiarthroplasty was used in 20 patients (21 shoulders) with combined glenohumeral arthritis and complete degenerative lesions of the rotator cuff. Patients were monitored for an average of 4 years (range 2 to 6.6 years). The coracoacromial ligament was preserved as a restraint against anterosuperior displacement. The rotator cuff defect was irreparable, and no attempt was made to cover the superior defect. Two patients underwent transfer of the sternocostal portion of the pectoralis major to the lesser tuberosity for subscapularis insufficiency and anterior subluxation. After the operation rehabilitation of the deltoid was aggressively pursued. With limited goals criteria described by Neer, 18 (86%) shoulders achieved satisfactory results. Pain scores improved from a mean of 2.9 (scale of 0 to 3) before operation to 0.6 after operation. All patients had lower pain scores after operation. However, only 12 shoulders had no pain (pain score of 0). Average active flexion improved to 120 ~ after operation from 70 ~ before operation. However, five patients achieved less than 90 ~ of active flexion after operation. Active external rotation improved from a mean of 27 ~ (range 0 ~ to 65 ~ to a mean of 46 ~ (range 0 ~ to 70~ No instances of postoperative instability occurred. Although the results of hemiprosthetic replacement in this difficult patient population are inferior to results experienced by patients with an intact rotator cuff, the improvement of pain and preservation of function obtained make it an attractive alternative to arthrodesis, resection arthroplasty, or constrained arthroplasty. (J SHOULDERELBOWSURG 1996;5:362-7.)
Replacement of the glenohumeral joint with a nonconstrained prosthesis was introduced and popularized by Neer. 1s-r7 Subsequent authors* have confirmed the effectiveness of unconstrained prosthetic replacement for a variety of conditions affecting the glenohumeral joint including rheumatoid arthritis, ankylosing spondylitis and other seronegative arthropathies, avascular necrosis, radiation necrosis, fracture or fracture-dislocation, primary osteoarthritis, and posttraumatic arthritis. Despite the documented success and increasing use of nonconstrained prosthetic replacement, conFrom the Deparlment of Orthopaedic Surgery, Hospital of the Universily of Pennsylvania; and the Department of Orthopaedic Surgery, Universily of Texas Health Science Center. Reprint requests: Gerald R. Williams, Jr, MD, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 32/!/72171
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cerns about the durability of the glenoid component have arisen, 8' 1,~ particularly in cases involving chronic rotator cuff insufficiency and proximal humeral migration.r~ The purpose of this study was to retrospectively review the results of humeral hemiarthroplasty for degenerative arthritis combined with chronic irreparable rotator cuff disease. MATERIAL A N D METHODS
From February 1974 through February 1990, 22 humeral hemiarthroplasties using the Neer prosthesis were performed in 21 patients with degenerative arthritis of the glenohumeral joint combined with irreparable full-thickness defects of the rotator cuff. One patient died of unrelated causes during the follow-up period. The remaining 20 patients (21 shoulders) were available for review. All data were obtained by retrospective chart review. Before the operation all patients un*References 1, 2, 4-6, 8, 11, 12, 14.
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derwent history and physical examination and routine radiography. Preoperative radiographs included an anteroposterior view in the plane of the scapula with the humerus in internal and external rotation and an axillary view. Patients with suspected posterior glenoid insufficiency on the axillary view underwent computed axial tomography (CAT scan). Final follow-up examination was performed at an average of 4 years after the operation (range 2 to 6.6 years). Postoperative radiographic examination was not available for all patients at standard intervals. Therefore it was not analyzed for purposes of this study. Preoperative and postoperative strength measurements were not standardized and therefore were not used. The average age of the patients was 72 years (range 59 to 80 years), and women outnumbered men 16 to 4. The dominant arm was involved in 17 cases. The right arm was affected in 13 cases. One patient underwent bilateral hemiarthroplasties 3 years apart. The duration of symptoms before arthroplasty averaged 4.4 years (range 1 month to 8 years). A history of multiple corticosteroid injections was present in six patients. One patient reported receiving between 20 and 25 steroid injections over a 3.5-year period. Seven patients had undergone a total of 12 operative procedures on the involved shoulder before presentation. These procedures included acromioplasty and cuff repair, resection of a greater tuberosity nonunion and cuff repair, distal clavicle excision, Magnuson-Stack reconstruction, arthroscopic staple capsulorraphy, rotator cuff allograft reconstruction, acromioclavicular joint cyst excision, and repair of the long head of the biceps and axillary nerve. The axillary nerve injury occurred during a revision acromioplasty and allografl rotator cuff reconstruction before presentation at our institution. The repair failed, and the patient had chronic anterior deltoid dennervation. Recurrent cystic, massive swelling about the glenohumeral joint was present in three shoulders (Figure 1). All three shoulders had undergone multiple aspirations before presentation. One patient had ipsilateral axillary adenopathy in addition to recurrent glenohumeral effusions, which had previously undergone biopsy and showed nonspecific inflammation. One additional patient had a cystic mass located subcutaneously superior to the acromioclavicular joint, which communicated with the glenohumeral joint on arthrography. This has been termed the "geyser" sign7 This mass had per-
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Figure 1 Recurrent, massive, cystic swelling of gleno humeral joint in patient with cuff tear arthropathy.
sisted despite two attempts by previous surgeons at local resection. Pain was graded as none (0), mild (1), moderate (2), or severe (3). Severe pain was constant, interfered with all daily activities (including sleep), and required daily antiinflammatory or analgesic medication (i. e., narcotics). Moderate pain was present with some daily activities, did not routinely interfere with sleep, and required frequent antiinflammatory medication but not narcotic analgesics. Mild pain was present only with vigorous activity and required only infrequent (less than once per week) antiinflammatory medication. Range of motion was measured actively with the patient seated. A handheld goniometer was used for all measurements of flexion and external rotation. Internal rotation was measured by the highest posterior vertebral level attained actively. Results were graded according to two different grading systems: (1) a modification of the grading system established by Neer et al. ~7 for patients with intact or reparable rotator cuff muscles and (2) Neer et al.'s limited goals criteria 17 for patients with permanent rotator cuff insufficiency. Under Neer et al.'s complete criteria, results are graded as excellent, satisfactory, and unsatisfactory. An excellent result indicates full use of the arm, no significant pain, strength approaching normal, flexion to within 35 ~ of the opposite side, and rotation of 90% of the opposite side. A satisfactory
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result indicates that the patient is satisfied with the result, pain is no more than occasional, function for daily activities is good, flexion is 90 ~ to 135 ~ and rotation is 50% of the opposite side. For the purposes of this study these criteria were applied without strength data. Results were also graded according to the limited goals criteria established by Neer et al. 17 Neer et al. established this category so that patients with poorly functioning rotator cuff muscles could be rated as a successful result if they had good pain relief and "useful" shoulder function, even if they did not fit the rigid criteria of a successful result in patients with intact or reparable rotator cuffs. Pollock et al. 1~ used a similar system in grading their results after prosthetic replacement in rotator cuff deficient shoulders. For the purposes of this study a satisfactory outcome was experienced when the patient was satisfied and the pain was none or mild. Surgical technique. Patient positioning and superficial surgical exposure for hemiarthroplasty in the rotator cuff-deficient shoulder are identical to the techniques used for routine shoulder replacement. However, there are some important differences in the remainder of the surgical technique for hemiprosthetic replacement in the cuff-deficient shoulder that deserve special emphasis. The most important of these differences is the preservation of the coracoacromial ligament, which may be sacrificed during shoulder replacement with an intact or reparable cuff. During hemiarthroplasty in the rotator cuff-deficient shoulder, the coracoacromial ligament should be preserved because of its function as a restraint against anterosuperior subluxation or dislocation. In cases of significant internal rotation contracture, subscapularis lengthening is necessary to restore anterior and posterior rotator cuff balance. If passive external rotation with the arm at the side is less than 0 ~ then coronal Z-plasty of the subscapularis is required. In cases of more moderate internal rotation contracture (passive external rotation of 0 ~ or greater), medial advancement of the subscapularis insertion is indicated. In this procedure the subscapularis tendon is incised directly from its insertion site on the lesser tuberosity and is reattached through drill holes at the edge of the humeral osteotomy site. This advances the subscapularis tendon approximately 1.5 to 2 cm and will result in a relative gain in external rotation. In 15 shoulders in this series no significant internal rotation contracture occurred. The subscapularis was divided intratendinously and repaired ana-
J. Shoulder Elbow Surg. September~October 1996 tomically. In six shoulders the tendon was advanced to the edge of the osteotomy site because of moderate internal rotation contracture. No patient required coronal Z-plasty of the subscapularis. If the preoperative axillary lateral and CAT scan reveal posterior glenoid erosion, two options (in the absence of a glenoid component) for correction exist: (1) flattening the anterior glenoid and (2) decreasing the amount of humeral component retroversion. In severe cases of posterior glenoid wear, there is actually a line or ridge separating the anterior and posterior portions of the glenoid. Under these circumstances the glenoid is assymetrically reamed or burred anteriorly to provide a more even surface for articulation with the humerus. In less severe cases of posterior glenoid insufficiency, decreasing the humeral component retroversion to 10 ~ to 15 ~ from 25 ~ to 30 ~ is adequate to prevent posterior subluxation after the operation. Nine patients in this series had documented posterior glenoid erosion, which was treated by decreasing the humeral component retroversion to 10 ~ to 15 ~ No patient required assymetric glenoid reaming. The size and method of fixation of the humeral prosthesis depend on the length of the subscapularis and remaining rotator cuff muscles and on the quality of the proximal humeral metaphysis. With the trial prosthesis in place there should be adequate subscapularis length to allow 30 ~ of external rotation with the arm at the side. In addition, the arm should lie freely across the patient's abdomen, the humeral head should translate 50% of its width posteriorly on the glenoid fossa, and the glenohumeral joint should passively flex 120 ~ or more. In this series all patients received a 22 mm Neer prosthesis (Figure 2). Twenty of the 21 shoulders received a press-fit humeral component. One patient required cement fixation because of severe cystic formation and bone loss in the proximal humeral metaphysis. Two patients required transfer of the sternocostal portion (i. e., the deep portion) of the pectoralis major to the lesser tuberosity to prevent anterior instability of the prosthesis caused by subscapularis insufficiency. In all cases the superior rotator cuff defect was irreparable. No attempt was made to close the superior defect through the use of local or distant muscle transfers. Postoperative rehabilitation. Postoperative rehabilitation emphasizes immediate and progressive passive and active assisted exercises Supine passive flexion and external rotation exer-
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Figure 2 Preoperative anteroposterior (A) and axillary (B) radiographs of 80-year-old woman with chronic, severe, rotator cuff insufficiency and glenohumeral arthritis. Postoperative radiograph (C) reveals articulation of humeral component with acromion, superior glenoid, and acromioclavicular joint. cises are begun immediately. An overhead pulley is added early in the postoperative period. If the patient has a symptomatic opposite shoulder and cannot use it to passively lift the operated arm, then an overhead pulley system can be installed on the bed frame to assist with passive flexion. Within the first postoperative week the patient is encouraged to use the arm for daily activities, and the sling is discontinued except when the patient is in a public place and at risk for injury. The range of motion has usually improved enough to institute strengthening exercises at 6 to 8 weeks after operation. The remaining muscles of the rotator cuff (i. e., subscapularis and teres minor) are rehabilitated through the use of a home exercise program with colored elastic bands with gradually increasing resistance. A specific anterior deltoid-strengthening program is also prescribed and performed four to six times per day. Vigorous anterior deltoid rehabilitation is essential for overhead function, because the rotator cuff is deficient.
RESULTS Radiographs. Preoperative radiographs revealed proximal humeral migration (i. e., acromiohumeral interval of 7 mm or less) in all patients. In
addition, all patients had varying degrees of glenohumeral arthritis with erosion of the glenoid, humeral collapse, and scant osteophyte formation. Nine patients (nine shoulders) had significant posterior glenoid wear documented by CAT scan. As mentioned previously, postoperative radiographs were not analyzed for the purposes of this study. Pain. The overwhelming reason that patients sought medical attention was unremitting pain. Therefore pain relief was the primary objective of surgery. Before the operation the pain rating was severe in 19 shoulders, moderate in one shoulder, and mild in one shoulder. The patient with mild pain had an acromiodavicular joint cyst that had recurred after two previous attempts at removal. After the operation 12 shoulders had no pain, six shoulders had mild pain, and three shoulders had moderate pain. Mild or no pain was present in 86% of shoulders. Mean pain score improved to 0.6 after the operation from 2.9 before the operation. Of the three patients with moderate pain, two had undergone three previous attempts at rotator cuff repair or reconstruction with an allograft rotator cuff; one had denervation of the anterior deltoid. All three patients had severe pain before the operation and stated that the hemiarthroplasty had been helpful.
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Range of m o t i o n . Active flexion improved from an average preoperative value of 70 ~ (range 0 ~ to 155 ~ to a postoperative average of 120 ~ (range 15 ~ to 160~ Sixteen of the 21 shoulders could achieve 90 ~ or more of active elevation. Two of the five shoulders with less than 90 ~ of flexion improved from preoperative values of 45 ~ and 0 ~ to postoperative values of 85 ~ and 15 ~, respectively. The remaining three shoulders with less than 90 ~ of postoperative active flexion were unchanged from preoperative values of 45 ~, 45 ~, and 85 ~. Active external rotation increased from a preoperative mean of 27 ~ (range 0 ~ to 65 ~ to a postoperative mean of 46 ~ (range 0 ~ to 70~ Six patients underwent medial advancement of the subscapularis tendon because of significant internal rotation contracture. Before the operation two patients could actively externally rotate 0 ~ one patient 5 ~, and three patients 15 ~. Medial subscapularis advancement in these six patients resulted in an average increase of active external rotation of 30 ~ (range 0 ~ to 45~ Before the operation only two patients could actively internally rotate to the T12 level or higher. After the operation 11 patients could reach the T12 level or higher, and all but three patients could reach the sacrum. Stability. No instances of postoperative anterior or posterior instability occurred. This included nine shoulders with posterior glenoid wear in whom the prosthesis was implanted in less than physiologic retroversion (i. e., 10 ~ to 15~ Result ratings. The shoulders were rated according to modified standard and limited goals criteria established by Neer et al. 17' 18 With only the range of motion, pain, and patient satisfaction portions of Neer's standard criteria, there were 0 excellent, 14 (67%) satisfactory, and seven unsatisfactory results. With limited goals criteria that place a premium on pain relief and patient satisfaction, 18 (86%) satisfactory and three unsatisfactory results occurred. DISCUSSION Although the overall rate of glenoid loosening for all diagnostic categories appears to be relatively low, 1~ 1~ Franklin et al. ~~ reported an association between glenoid loosening and rotator cuff deficiency with proximal humeral migration. Seven of the 14 patients in their series with rotator cuff deficiency demonstrated glenoid component Ioos-
J. ShoulderElbow Surg. September/October 1996 ening, whereas none of the 16 patients with an intact cuff had glenoid loosening. There appeared to be a direct correlation between proximal humeral migration and glenoid loosening. They theorized that the superior eccentric loading of the glenoid component caused increased compressive stresses on the superior rim of the prosthesis, resulting in loosening and superior tilting of the component. They referred to this phenomenon as the "rocking horse" glenoid. They credited Gristina et al. 11 with first recognizing that a significant shift of the instant center of rotation of a prosthetic glenohumeral joint could abnormally stress the glenoid anchorage. Franklin et al. 1~ concluded that glenoid resurfacing "is indicated in shoulder arthroplasty procedures where the rotator cuff is intact or reconstructed" but that the "ideal procedure for the shoulder with damaged joint surfaces and a non-reconstructible cuff has yet to be determined." In 1993 Arntz et al. 3 reported on the use of a hemiarthroplasty in 18 shoulders (16 patients) with massive rotator cuff defects and loss of the glenohumeral joint surfaces. Their follow-up ranged from 2.1 to 10.1 years. The patients were not candidates for total shoulder replacement because of the severe nonreconstructible rotator cuff deficiency and proximal displacement of the humeral head. Pain was decreased and active forward elevation was improved from an average of 66 ~ before the operation to 109 ~ after the operation. While recognizing that combined glenohumeral arthritis and severe rotator cuff insufficiency is a difficult problem, other authors 7' 13, 19 have experienced less consistent pain relief with hemiarthroplasty. Brownlee and Cofield 7 reported on 20 patients who were treated with replacement arthroplasty and rotator cuff reconstruction for "rotator cuff arthropathy." Six patients were lost to follow-up or died, and the remaining 14 patients (16 shoulders) were monitored for an average of 4 years (range 2 to 6.8 years). Eight shoulders received a standard Neer total shoulder arthroplasty, four shoulders received a Neer total shoulder replacement with a hooded glenoid component, and four shoulders received a humeral hemiarthroplasty. All patients had extensive mobilization and repair or reconstruction of massive rotator cuff defects; two required fascial grafts. After the operation pain was reduced in all patients but was most improved in the standard total shoulder group. Glenoid loosening occurred in three shoulders. The authors concluded that total
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shoulder arthroplasty combined with rotator cuff repair was the procedure of choice in this difficult patient population. Lohr et al. 13 reported on 22 shoulders with cuff tear arthropathy that were replaced with hemiarthroplasty, unconstrained total shoulder arthroplasty, or semiconstrained (i. e., hooded glenoid) total shoulder arthroplasty. Hemiprosthetic replacement yielded the poorest results for pain relief, whereas the unconstrained and semiconstrained devices resulted in a high incidence of radiologic and clinical loosening. The authors concluded that cuff tear arthropathy remains "one of the most difficult entities to treat." Pollock et al. 18 recently compared the results of total shoulder replacement with humeral hemiarthroplasty in 30 shoulders with rotator cuff deficiency at an average of 41 months after the operation. Satisfactory pain relief was obtained in 95% of the hemiarthroplasty group and 91% of the total shoulder arthroplasty group. Active elevation improved from an average preoperative value of 60 ~ to a postoperative value of 112 ~ in the hemiarthroplasty group compared with an improvement of 2 ~ (average 82 ~ after the operation) in the total shoulder arthroplasty group. Hemiprosthetic replacement also required a shorter operative time and a shorter hospital stay. Therefore the authors preferred hemiarthroplasty to total shoulder replacement in rotator cuff-deficient shoulders. Our study indicates that when scored with Neer's standard postoperative shoulder score, the results of hemiarthroplasty in cuff-deficient shoulders are clearly inferior to those of shoulder arthroplasty in patients with glenohumeral arthritis and an intact rotator cuff. 8' 12, ~s, rz If discriminating strength and functional data were included, the percentage of satisfactory results could conceivably be even lower than the reported 67%. Neer et al. lz recognized that pain relief and patient satisfaction were the most important variables in this group of patients with deficient muscles. With these less stringent criteria 86% of patients in our series had satisfactory results. The reduction of pain and preservation of function provided by hemiarthroplasty in patients with glenohumeral arthritis and irreparable rotator cuff deficiency make it an attractive alternative to arthrodesis, resection arthroplasty, and constrained arthroplasty. In addition, the potential complication of glenoid component loosening is avoided. Longer follow-up is
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necessary to determine whether the initial pain relief achieved with hemiarthroplasty is maintained over time. REFERENCES
1. Adams MA, Weiland AJ, Moore JR. Nonconstrained total shoulder arthroplasly. Orthop Trans 1986;10:232. 2. AmstutzHC, Thomas BJ, KaboJM, Jinnah RH, Dorey FJ. The DANA total shoulder arthroplasly. J Bone Joint Surg Am 1988;70A: 1174 82. 3. Arntz CT, Jackins S, Motsen FA. Prostheticreplacement of the shoulder for the treatmentof defects in the rotator cuff and the surface of the glenohumeral joint. J Bone Joint Surg Am 1993 ;75A:485-91. 4. Bade HA, Warren RF, Ranawat CS, Inglis AE. Long term results of Neer total shoulder arthroplasty. In Bateman JE, Welsh RP, editors. Surgery of the shoulder. St Louis: CV Mosby, 1984:294 302. 5. BarretlWP, ThornhillTS, ThomasWH, Gebhardt EM, Sledge CB. Nonconstrained tolal shoulder arthroplasty for patients with polyarticular rheumatoid arthritis. Orthop Tlans 1987; 11:238. 6. BremsJJ, Wilde AH, Borden LS, Boumphrey FRS. Glenoid lucent lines. Orthop Trans 1986;10:231. 7. Brownlee RC, Cofield RH. Shoulder replacement in cuff tear arthropathy. Orthop Trans 1986;10:230. 8. Cofield RH. Total shoulder arthroplasly with the Neer proslhesis. J BoneJoint Surg Am 1984;66A:899-906. 9. Craig EV. The geyser sign and torn rotator cuff: clinical significance and pathomechanics. Clin Orthop 1984;191 : 213-5. 10. Franklin JL, Barrett WP, Jackins SE, Matsen FA. Glenoid loosening in total shoulder arthroplasty: association with rotator cuff deficiency. J Arthroplasty 1988;31:3946. 11. Gristina AG, Roman RL, Kammire GC, Webb LX. Total shoulder replacement. Orthop Clin North Am 1987;18: 445-53. 12. Hawkins RJ, Bel] RH,Jallay B. Experiencewith the Neer total shoulder arthroplasty: a review of 70 cases. Orthop Trans 1986;10:232. 13. LohrJF,Cofield RH, Uhtoff HK. Glenoid component loosening in cuff tear arthropathy. J BoneJoinl Surg 1991;73B(suppl II):106. 14. McEIwain JP, English E. The early results of porous-coated total shoulderarthroplasty. Clin Orthop 1987;218:217-24. 15. Neer CS II. Glenohumeral arthroplasty.In Neer CS II, editor. Shoulder reconstruction. Philadelphia: WB Saunders Com pany, 1990:143 272. 16. Neer CS Ih Replacement arthroplasly for glenohumeral osleoarlhritis. J BoneJoint Surg Am 1974;56A:1-13. 17. Neer CS II, Watson KC, Stanton FJ. Recentexperience in total shoulderreplacement.J BoneJoint Surg Am 1982;64A: 31937. 18. Pollock RG, Deliz ED, Mcllveen SJ, Flatow EL, Bigliani LU. Prosthetic replacemenl in rotator cuff deficient shoulders. J SHOUtDERELBOWSURG1992;1:173 86. 19. Zuckerman JD, Cofield RH. Proximal humeral prosthetic replacement in glenohumeral arthritis. Orthop Trans 1986;1 O: 231.
Replacement of the glenohumeral joint with a nonconstrained prosthesis was introduced and popularized by Neer. 1s-r7 Subsequent authors* have confirmed the effectiveness of unconstrained prosthetic replacement for a variety of conditions affecting the glenohumeral joint including rheumatoid arthritis, ankylosing spondylitis and other seronegative arthropathies, avascular necrosis, radiation necrosis, fracture or fracture-dislocation, primary osteoarthritis, and posttraumatic arthritis. Despite the documented success and increasing use of nonconstrained prosthetic replacement, conFrom the Deparlment of Orthopaedic Surgery, Hospital of the Universily of Pennsylvania; and the Department of Orthopaedic Surgery, Universily of Texas Health Science Center. Reprint requests: Gerald R. Williams, Jr, MD, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Copyright 9 1996 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/96/$5.00 + 0 32/!/72171
362
cerns about the durability of the glenoid component have arisen, 8' 1,~ particularly in cases involving chronic rotator cuff insufficiency and proximal humeral migration.r~ The purpose of this study was to retrospectively review the results of humeral hemiarthroplasty for degenerative arthritis combined with chronic irreparable rotator cuff disease. MATERIAL A N D METHODS
From February 1974 through February 1990, 22 humeral hemiarthroplasties using the Neer prosthesis were performed in 21 patients with degenerative arthritis of the glenohumeral joint combined with irreparable full-thickness defects of the rotator cuff. One patient died of unrelated causes during the follow-up period. The remaining 20 patients (21 shoulders) were available for review. All data were obtained by retrospective chart review. Before the operation all patients un*References 1, 2, 4-6, 8, 11, 12, 14.
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derwent history and physical examination and routine radiography. Preoperative radiographs included an anteroposterior view in the plane of the scapula with the humerus in internal and external rotation and an axillary view. Patients with suspected posterior glenoid insufficiency on the axillary view underwent computed axial tomography (CAT scan). Final follow-up examination was performed at an average of 4 years after the operation (range 2 to 6.6 years). Postoperative radiographic examination was not available for all patients at standard intervals. Therefore it was not analyzed for purposes of this study. Preoperative and postoperative strength measurements were not standardized and therefore were not used. The average age of the patients was 72 years (range 59 to 80 years), and women outnumbered men 16 to 4. The dominant arm was involved in 17 cases. The right arm was affected in 13 cases. One patient underwent bilateral hemiarthroplasties 3 years apart. The duration of symptoms before arthroplasty averaged 4.4 years (range 1 month to 8 years). A history of multiple corticosteroid injections was present in six patients. One patient reported receiving between 20 and 25 steroid injections over a 3.5-year period. Seven patients had undergone a total of 12 operative procedures on the involved shoulder before presentation. These procedures included acromioplasty and cuff repair, resection of a greater tuberosity nonunion and cuff repair, distal clavicle excision, Magnuson-Stack reconstruction, arthroscopic staple capsulorraphy, rotator cuff allograft reconstruction, acromioclavicular joint cyst excision, and repair of the long head of the biceps and axillary nerve. The axillary nerve injury occurred during a revision acromioplasty and allografl rotator cuff reconstruction before presentation at our institution. The repair failed, and the patient had chronic anterior deltoid dennervation. Recurrent cystic, massive swelling about the glenohumeral joint was present in three shoulders (Figure 1). All three shoulders had undergone multiple aspirations before presentation. One patient had ipsilateral axillary adenopathy in addition to recurrent glenohumeral effusions, which had previously undergone biopsy and showed nonspecific inflammation. One additional patient had a cystic mass located subcutaneously superior to the acromioclavicular joint, which communicated with the glenohumeral joint on arthrography. This has been termed the "geyser" sign7 This mass had per-
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Figure 1 Recurrent, massive, cystic swelling of gleno humeral joint in patient with cuff tear arthropathy.
sisted despite two attempts by previous surgeons at local resection. Pain was graded as none (0), mild (1), moderate (2), or severe (3). Severe pain was constant, interfered with all daily activities (including sleep), and required daily antiinflammatory or analgesic medication (i. e., narcotics). Moderate pain was present with some daily activities, did not routinely interfere with sleep, and required frequent antiinflammatory medication but not narcotic analgesics. Mild pain was present only with vigorous activity and required only infrequent (less than once per week) antiinflammatory medication. Range of motion was measured actively with the patient seated. A handheld goniometer was used for all measurements of flexion and external rotation. Internal rotation was measured by the highest posterior vertebral level attained actively. Results were graded according to two different grading systems: (1) a modification of the grading system established by Neer et al. ~7 for patients with intact or reparable rotator cuff muscles and (2) Neer et al.'s limited goals criteria 17 for patients with permanent rotator cuff insufficiency. Under Neer et al.'s complete criteria, results are graded as excellent, satisfactory, and unsatisfactory. An excellent result indicates full use of the arm, no significant pain, strength approaching normal, flexion to within 35 ~ of the opposite side, and rotation of 90% of the opposite side. A satisfactory
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result indicates that the patient is satisfied with the result, pain is no more than occasional, function for daily activities is good, flexion is 90 ~ to 135 ~ and rotation is 50% of the opposite side. For the purposes of this study these criteria were applied without strength data. Results were also graded according to the limited goals criteria established by Neer et al. 17 Neer et al. established this category so that patients with poorly functioning rotator cuff muscles could be rated as a successful result if they had good pain relief and "useful" shoulder function, even if they did not fit the rigid criteria of a successful result in patients with intact or reparable rotator cuffs. Pollock et al. 1~ used a similar system in grading their results after prosthetic replacement in rotator cuff deficient shoulders. For the purposes of this study a satisfactory outcome was experienced when the patient was satisfied and the pain was none or mild. Surgical technique. Patient positioning and superficial surgical exposure for hemiarthroplasty in the rotator cuff-deficient shoulder are identical to the techniques used for routine shoulder replacement. However, there are some important differences in the remainder of the surgical technique for hemiprosthetic replacement in the cuff-deficient shoulder that deserve special emphasis. The most important of these differences is the preservation of the coracoacromial ligament, which may be sacrificed during shoulder replacement with an intact or reparable cuff. During hemiarthroplasty in the rotator cuff-deficient shoulder, the coracoacromial ligament should be preserved because of its function as a restraint against anterosuperior subluxation or dislocation. In cases of significant internal rotation contracture, subscapularis lengthening is necessary to restore anterior and posterior rotator cuff balance. If passive external rotation with the arm at the side is less than 0 ~ then coronal Z-plasty of the subscapularis is required. In cases of more moderate internal rotation contracture (passive external rotation of 0 ~ or greater), medial advancement of the subscapularis insertion is indicated. In this procedure the subscapularis tendon is incised directly from its insertion site on the lesser tuberosity and is reattached through drill holes at the edge of the humeral osteotomy site. This advances the subscapularis tendon approximately 1.5 to 2 cm and will result in a relative gain in external rotation. In 15 shoulders in this series no significant internal rotation contracture occurred. The subscapularis was divided intratendinously and repaired ana-
J. Shoulder Elbow Surg. September~October 1996 tomically. In six shoulders the tendon was advanced to the edge of the osteotomy site because of moderate internal rotation contracture. No patient required coronal Z-plasty of the subscapularis. If the preoperative axillary lateral and CAT scan reveal posterior glenoid erosion, two options (in the absence of a glenoid component) for correction exist: (1) flattening the anterior glenoid and (2) decreasing the amount of humeral component retroversion. In severe cases of posterior glenoid wear, there is actually a line or ridge separating the anterior and posterior portions of the glenoid. Under these circumstances the glenoid is assymetrically reamed or burred anteriorly to provide a more even surface for articulation with the humerus. In less severe cases of posterior glenoid insufficiency, decreasing the humeral component retroversion to 10 ~ to 15 ~ from 25 ~ to 30 ~ is adequate to prevent posterior subluxation after the operation. Nine patients in this series had documented posterior glenoid erosion, which was treated by decreasing the humeral component retroversion to 10 ~ to 15 ~ No patient required assymetric glenoid reaming. The size and method of fixation of the humeral prosthesis depend on the length of the subscapularis and remaining rotator cuff muscles and on the quality of the proximal humeral metaphysis. With the trial prosthesis in place there should be adequate subscapularis length to allow 30 ~ of external rotation with the arm at the side. In addition, the arm should lie freely across the patient's abdomen, the humeral head should translate 50% of its width posteriorly on the glenoid fossa, and the glenohumeral joint should passively flex 120 ~ or more. In this series all patients received a 22 mm Neer prosthesis (Figure 2). Twenty of the 21 shoulders received a press-fit humeral component. One patient required cement fixation because of severe cystic formation and bone loss in the proximal humeral metaphysis. Two patients required transfer of the sternocostal portion (i. e., the deep portion) of the pectoralis major to the lesser tuberosity to prevent anterior instability of the prosthesis caused by subscapularis insufficiency. In all cases the superior rotator cuff defect was irreparable. No attempt was made to close the superior defect through the use of local or distant muscle transfers. Postoperative rehabilitation. Postoperative rehabilitation emphasizes immediate and progressive passive and active assisted exercises Supine passive flexion and external rotation exer-
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Figure 2 Preoperative anteroposterior (A) and axillary (B) radiographs of 80-year-old woman with chronic, severe, rotator cuff insufficiency and glenohumeral arthritis. Postoperative radiograph (C) reveals articulation of humeral component with acromion, superior glenoid, and acromioclavicular joint. cises are begun immediately. An overhead pulley is added early in the postoperative period. If the patient has a symptomatic opposite shoulder and cannot use it to passively lift the operated arm, then an overhead pulley system can be installed on the bed frame to assist with passive flexion. Within the first postoperative week the patient is encouraged to use the arm for daily activities, and the sling is discontinued except when the patient is in a public place and at risk for injury. The range of motion has usually improved enough to institute strengthening exercises at 6 to 8 weeks after operation. The remaining muscles of the rotator cuff (i. e., subscapularis and teres minor) are rehabilitated through the use of a home exercise program with colored elastic bands with gradually increasing resistance. A specific anterior deltoid-strengthening program is also prescribed and performed four to six times per day. Vigorous anterior deltoid rehabilitation is essential for overhead function, because the rotator cuff is deficient.
RESULTS Radiographs. Preoperative radiographs revealed proximal humeral migration (i. e., acromiohumeral interval of 7 mm or less) in all patients. In
addition, all patients had varying degrees of glenohumeral arthritis with erosion of the glenoid, humeral collapse, and scant osteophyte formation. Nine patients (nine shoulders) had significant posterior glenoid wear documented by CAT scan. As mentioned previously, postoperative radiographs were not analyzed for the purposes of this study. Pain. The overwhelming reason that patients sought medical attention was unremitting pain. Therefore pain relief was the primary objective of surgery. Before the operation the pain rating was severe in 19 shoulders, moderate in one shoulder, and mild in one shoulder. The patient with mild pain had an acromiodavicular joint cyst that had recurred after two previous attempts at removal. After the operation 12 shoulders had no pain, six shoulders had mild pain, and three shoulders had moderate pain. Mild or no pain was present in 86% of shoulders. Mean pain score improved to 0.6 after the operation from 2.9 before the operation. Of the three patients with moderate pain, two had undergone three previous attempts at rotator cuff repair or reconstruction with an allograft rotator cuff; one had denervation of the anterior deltoid. All three patients had severe pain before the operation and stated that the hemiarthroplasty had been helpful.
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Range of m o t i o n . Active flexion improved from an average preoperative value of 70 ~ (range 0 ~ to 155 ~ to a postoperative average of 120 ~ (range 15 ~ to 160~ Sixteen of the 21 shoulders could achieve 90 ~ or more of active elevation. Two of the five shoulders with less than 90 ~ of flexion improved from preoperative values of 45 ~ and 0 ~ to postoperative values of 85 ~ and 15 ~, respectively. The remaining three shoulders with less than 90 ~ of postoperative active flexion were unchanged from preoperative values of 45 ~, 45 ~, and 85 ~. Active external rotation increased from a preoperative mean of 27 ~ (range 0 ~ to 65 ~ to a postoperative mean of 46 ~ (range 0 ~ to 70~ Six patients underwent medial advancement of the subscapularis tendon because of significant internal rotation contracture. Before the operation two patients could actively externally rotate 0 ~ one patient 5 ~, and three patients 15 ~. Medial subscapularis advancement in these six patients resulted in an average increase of active external rotation of 30 ~ (range 0 ~ to 45~ Before the operation only two patients could actively internally rotate to the T12 level or higher. After the operation 11 patients could reach the T12 level or higher, and all but three patients could reach the sacrum. Stability. No instances of postoperative anterior or posterior instability occurred. This included nine shoulders with posterior glenoid wear in whom the prosthesis was implanted in less than physiologic retroversion (i. e., 10 ~ to 15~ Result ratings. The shoulders were rated according to modified standard and limited goals criteria established by Neer et al. 17' 18 With only the range of motion, pain, and patient satisfaction portions of Neer's standard criteria, there were 0 excellent, 14 (67%) satisfactory, and seven unsatisfactory results. With limited goals criteria that place a premium on pain relief and patient satisfaction, 18 (86%) satisfactory and three unsatisfactory results occurred. DISCUSSION Although the overall rate of glenoid loosening for all diagnostic categories appears to be relatively low, 1~ 1~ Franklin et al. ~~ reported an association between glenoid loosening and rotator cuff deficiency with proximal humeral migration. Seven of the 14 patients in their series with rotator cuff deficiency demonstrated glenoid component Ioos-
J. ShoulderElbow Surg. September/October 1996 ening, whereas none of the 16 patients with an intact cuff had glenoid loosening. There appeared to be a direct correlation between proximal humeral migration and glenoid loosening. They theorized that the superior eccentric loading of the glenoid component caused increased compressive stresses on the superior rim of the prosthesis, resulting in loosening and superior tilting of the component. They referred to this phenomenon as the "rocking horse" glenoid. They credited Gristina et al. 11 with first recognizing that a significant shift of the instant center of rotation of a prosthetic glenohumeral joint could abnormally stress the glenoid anchorage. Franklin et al. 1~ concluded that glenoid resurfacing "is indicated in shoulder arthroplasty procedures where the rotator cuff is intact or reconstructed" but that the "ideal procedure for the shoulder with damaged joint surfaces and a non-reconstructible cuff has yet to be determined." In 1993 Arntz et al. 3 reported on the use of a hemiarthroplasty in 18 shoulders (16 patients) with massive rotator cuff defects and loss of the glenohumeral joint surfaces. Their follow-up ranged from 2.1 to 10.1 years. The patients were not candidates for total shoulder replacement because of the severe nonreconstructible rotator cuff deficiency and proximal displacement of the humeral head. Pain was decreased and active forward elevation was improved from an average of 66 ~ before the operation to 109 ~ after the operation. While recognizing that combined glenohumeral arthritis and severe rotator cuff insufficiency is a difficult problem, other authors 7' 13, 19 have experienced less consistent pain relief with hemiarthroplasty. Brownlee and Cofield 7 reported on 20 patients who were treated with replacement arthroplasty and rotator cuff reconstruction for "rotator cuff arthropathy." Six patients were lost to follow-up or died, and the remaining 14 patients (16 shoulders) were monitored for an average of 4 years (range 2 to 6.8 years). Eight shoulders received a standard Neer total shoulder arthroplasty, four shoulders received a Neer total shoulder replacement with a hooded glenoid component, and four shoulders received a humeral hemiarthroplasty. All patients had extensive mobilization and repair or reconstruction of massive rotator cuff defects; two required fascial grafts. After the operation pain was reduced in all patients but was most improved in the standard total shoulder group. Glenoid loosening occurred in three shoulders. The authors concluded that total
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shoulder arthroplasty combined with rotator cuff repair was the procedure of choice in this difficult patient population. Lohr et al. 13 reported on 22 shoulders with cuff tear arthropathy that were replaced with hemiarthroplasty, unconstrained total shoulder arthroplasty, or semiconstrained (i. e., hooded glenoid) total shoulder arthroplasty. Hemiprosthetic replacement yielded the poorest results for pain relief, whereas the unconstrained and semiconstrained devices resulted in a high incidence of radiologic and clinical loosening. The authors concluded that cuff tear arthropathy remains "one of the most difficult entities to treat." Pollock et al. 18 recently compared the results of total shoulder replacement with humeral hemiarthroplasty in 30 shoulders with rotator cuff deficiency at an average of 41 months after the operation. Satisfactory pain relief was obtained in 95% of the hemiarthroplasty group and 91% of the total shoulder arthroplasty group. Active elevation improved from an average preoperative value of 60 ~ to a postoperative value of 112 ~ in the hemiarthroplasty group compared with an improvement of 2 ~ (average 82 ~ after the operation) in the total shoulder arthroplasty group. Hemiprosthetic replacement also required a shorter operative time and a shorter hospital stay. Therefore the authors preferred hemiarthroplasty to total shoulder replacement in rotator cuff-deficient shoulders. Our study indicates that when scored with Neer's standard postoperative shoulder score, the results of hemiarthroplasty in cuff-deficient shoulders are clearly inferior to those of shoulder arthroplasty in patients with glenohumeral arthritis and an intact rotator cuff. 8' 12, ~s, rz If discriminating strength and functional data were included, the percentage of satisfactory results could conceivably be even lower than the reported 67%. Neer et al. lz recognized that pain relief and patient satisfaction were the most important variables in this group of patients with deficient muscles. With these less stringent criteria 86% of patients in our series had satisfactory results. The reduction of pain and preservation of function provided by hemiarthroplasty in patients with glenohumeral arthritis and irreparable rotator cuff deficiency make it an attractive alternative to arthrodesis, resection arthroplasty, and constrained arthroplasty. In addition, the potential complication of glenoid component loosening is avoided. Longer follow-up is
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necessary to determine whether the initial pain relief achieved with hemiarthroplasty is maintained over time. REFERENCES
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