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Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder
J Shoulder Elbow Surg (2012) 21, 1484-1491
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Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder Adam A. Sassoon, MDa, Peter C. Rhee, DOa, Cathy D. Schleck, BSb, William S. Harmsen, MSb, John W. Sperling, MD, MBAa, Robert H. Cofield, MDa,* a b
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Department of Biostatistics, Mayo Clinic, Rochester, MN, USA Background: Patients treated with humeral head replacement (HHR) may require revision to total shoulder arthroplasty (TSA) due to glenoid arthrosis. This study characterizes the outcomes of revision TSA in patients who initially underwent HHR for nontraumatic glenohumeral arthritis. Methods: From 1982 to 2005, 68 shoulders underwent revision TSA for glenoid arthrosis. The initial HHR was performed for non–fracture-related arthritis. Revisions were grouped according to complexity for analysis. Stem revision and soft tissue reconstruction were assessed in relation to outcome. Results: Pain scores decreased from 4.4 to 2.8, abduction increased from 85 to 116 , external rotation increased from 36 to 48 , and internal rotation remained unchanged. Survivorship free of repeat revision was 95.6%, 84.1%, and 72.9% at 1, 5, and 10 years. The Neer rating yielded 20 excellent, 10 satisfactory, and 38 unsatisfactory outcomes. No differences in motion, survivorship, or the Neer rating occurred between groups by procedure complexity. There was, however, less reduction in pain for the group requiring a humeral stem revision. Of the 9 shoulders with postoperative instability, 7 had compromised soft tissues preoperatively. Conclusions: Revision TSA after HHR results in decreased pain and increased motion. Result ratings, however, are quite variable and, in many cases, unsatisfactory. Stratification of the procedures according to complexity does not demonstrate differences in motion, satisfaction, or survivorship. Stem revision, however, results in reduced pain score improvement. Coexisting instability associated with subscapularis and anterior shoulder capsule damage may not be correctable using an unconstrained shoulder arthroplasty. Level of evidence: Level III, Retrospective Case Control Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Revision total shoulder arthroplasty; painful glenoid arthritis; humeral head replacement; nontraumatic shoulder
This study received approval from the Mayo Clinic Investigational Review Board (08-00481-4; last approval date: 7-28-2008.) *Reprint requests: Robert H. Cofield, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA. E-mail address: [email protected] (R.H. Cofield).
Humeral head replacement (HHR) is one option in the treatment of glenohumeral arthritis. The proponents of HHR cite decreased costs, operative time, blood loss, and technical demands compared with total shoulder arthroplasty (TSA).3 Painful glenoid arthrosis occurs in a subset
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.11.028
Revision TSA for glenoid arthrosis of patients, leading to consideration of placing a glenoid component and making it the most common indication for revision surgery after HHR.11 A previous study of 16 consecutive patients concluded that revision TSA after HHR should be considered as a salvage procedure with inferior outcomes compared with primary TSA.1 An earlier study at our institution demonstrated that 7 of 18 patients who underwent revision TSA after the development of glenoid arthrosis had an unsatisfactory result as assessed by modified Neer scores.11 The present study represents an expansion on our previous work with a larger group of patients and longer clinical follow-up. The aims of this study are to (1) to characterize the outcomes of revision TSA for painful glenoid arthrosis after an elective HHR in a large series and (2) assess the affect of stem exchange and soft tissue reconstruction on TSA outcome in this patient population. Our hypothesis is that revision procedures that are more technically demanding will lead to a disproportionate amount of any unsatisfactory results encountered.
Materials and methods Our institution’s orthopedic total joint registry was used to identify patients who underwent a revision TSA for the treatment of moderate or severe pain after a HHR. All cases were performed between 1981 and 2005 by the senior author (R.H.C.). We included all patients who underwent the index HHR as a definitive treatment for non–fracture-related arthropathy, with clinical follow-up for a minimum of 2 years. Patients were stratified by the complexity of bony and soft tissue reconstruction efforts required during revision TSA. Revisions were categorized as simple bony (SB) revisions (glenoid component placement with or without humeral head exchange) or complex bony (CB) revisions (glenoid component placement and humeral stem revision) and analyzed. Revisions were then regrouped and reanalyzed according to their need for soft tissue reconstruction; procedures qualified as either simple soft (SS) tissue revisions (revision total shoulder arthroplasty without additional repairs or reconstructions) or complex soft (CS) tissue revisions (revision TSA with rotator cuff tear repair or capsular alteration for instability).
1485 a useful guide. Low-grade infection is always a concern, and a white blood cell count with differential, erythrocyte sedimentation rate, and C-reactive protein concentration are obtained. If symptoms suggestive of an infection are present, joint aspiration and cell count and culture for anaerobic and aerobic organisms are performed. The clinical and functional status of all TSAs performed at our institution are recorded using a standard shoulder analysis sheet and archived in a total joint registry. Pain in the shoulder is defined as patient report of ‘‘no pain’’ (1 point), ‘‘slight pain’’ (2 points), ‘‘pain after unusual activity’’ (3 points), ‘‘moderate pain’’ (4 points), or ‘‘severe pain’’ (5 points).7 Patient satisfaction was defined by patient response as ‘‘much better’’ (1 point), ‘‘better’’ (2 points), ‘‘the same’’ (3 points), or ‘‘worse’’ (4 points) from immediately before surgery to the latest follow-up. Active abduction and external rotation were recorded in degrees. Active internal rotation was measured as the most cephalad posterior vertebral segment that could be reached by the thumb. The overall status of the shoulder was assessed with a modification of the Neer rating system.2,7 An excellent score was given if the patient had ‘‘no’’ or ‘‘slight pain,’’ external rotation to at least 45 , active abduction to at least 140 , and was ‘‘satisfied’’ with the result. A satisfactory rating consisted of ‘‘no’’ or ‘‘slight pain,’’ or ‘‘moderate pain only with vigorous activity,’’ external rotation to at least 20 , active abduction to at least 90 , and the patient being ‘‘satisfied’’ with the outcome. If any of the criteria for a satisfactory result were not met, or if any additional operative procedures were required, the result was considered unsatisfactory.
Operative technique All revisions were performed through an anterior approach, using the deltopectoral or anteromedial approach, as previously described.4 The subscapularis was divided 1 cm medial to its insertion (32 shoulders) or incised from the humerus if external rotation was less than 30 (32 shoulders). The tendon was managed with a Z-plasty in 2 shoulders, and no mention was made of the method of addressing the subscapularis in 2 operative reports. The humeral component was removed in cases of malposition or aseptic loosening. It was also removed in some instances to facilitate exposure of the glenoid and for revision of monoblock components requiring humeral head exchange. Rotator cuff tears were repaired with heavy sutures. In cases of bone loss about the proximal humerus or the glenoid, allograft or autograft bone was used (Fig. 1 and Fig. 2).
Clinical evaluation
Statistical methods
Preoperatively, the history and physical examination are most important. To further evaluate this condition, current X-ray images, including an axillary view, are necessary to visualize the loss of glenoid cartilage and the security and position of the humeral component. If additional glenoid bone loss has occurred, computed tomography (CT) evaluation is useful to determine whether enough bone remains to place the glenoid component. A number of associated problems can also contribute to the patient’s pain, including humeral implant issues, rotator cuff tearing, instability, or low-grade infection. Fluoroscopy of the proximal humerus with rotation of the arm can determine humeral version. If rotator cuff deficiency is questioned, an ultrasound evaluation is
Descriptive statistics are reported as mean (range) for continuous measures and number (percentage) for discrete variables. The clinical outcomes assessment included 68 shoulders (rerevised shoulders and those not revised but that had at least 2 years of clinical follow-up). In shoulders that had a rerevision, the last clinical information before rerevision was used. Associations of pain, abduction, and external and internal rotation with SB vs CB revision as well as with SS vs CS tissue revision were assessed using a two-sample t test (assuming unequal variances). The associations of sex with SB vs CB revision and with SS vs CS tissue revision were assessed with the Fisher exact test. The associations of the Neer rating with SB vs
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Figure 1 Preoperative (A) and postoperative (B) images of a painful humeral head replacement with glenoid arthrosis that was revised to total shoulder arthroplasty using a metal-backed glenoid component. The humeral stem was revised because of malposition and to facilitate glenoid exposure. CB revision and SS vs CS tissue revision were assessed using an extension of the Fisher exact test for ordered contingency tables. A paired t test was used to compare preoperative vs postoperative changes in pain, active abduction, and external and internal rotation. Postoperative assessments were made at the last clinical contact, and among those rerevised, at the last clinical contact before the rerevision. All 68 shoulders were monitored from the date of revision TSA to rerevision or the last follow-up. Implant survival free of rerevision was estimated with the Kaplan-Meier method, reporting the estimate and 95% confidence interval (CI). The a level was set at 0.05 for statistical significance.
A.A. Sassoon et al.
Figure 2 Preoperative (A) and postoperative (B) images of a painful humeral head replacement with glenoid arthrosis that was revised to total shoulder arthroplasty using a polyethylene glenoid component. The humeral stem was revised due to component malposition.
Results Overall patient demographics Between 1981 and 2005, the senior author (R.H.C.) performed 116 revisions of HHRs to TSAs in 115 patients for the treatment of glenoid arthrosis. Seventy-one of these revised HHRs in 70 patients were initially placed for a non–fracture-related reason. Two patients were lost to follow-up at 3 and 4 months postoperatively, and 1 patient died 12 months after her procedure, leaving 68 shoulders
Revision TSA for glenoid arthrosis available for clinical analysis. Thirty-eight (56%) of the index HHRs were placed in the treatment of osteoarthritis, 10 (15%) for rheumatoid arthritis, 6 (9%) for osteonecrosis, and 14 (21%) for instability-related arthropathy. Of the index HHRs, 28 (39%) were performed at our institution and the remaining 43 (61%) were performed elsewhere. Thirty-six revisions (53%) were performed in men and 32 (47%) in women. The patients were a mean age of 55 14 years (range, 23-81 years). Revisions were performed on 42 dominant extremities. The mean duration of clinical follow-up for all patients was 75 months (range, 6-188 months). The mean clinical follow-up in 53 shoulders that did not require a rerevision procedure was 65 months (range, 25-188 months), whereas the median clinical follow-up for the 15 shoulders requiring a rerevision was 49 months (range, 6-125 months). The mean time from HHR to revision TSA for all patients in this series was 3.75 years (range, 5 months-17 years). This interval was 4.5 and 2.8 years, respectively, in the CB and SB groups and 3.2 and 4.5 years, respectively, in the CS and SS tissue groups. There were no significant differences in the duration of HHR retention between the CS and SS tissue groups; however, the CB group had a significantly longer time to revision than the SB group (P ¼ .03). A deltopectoral approach was used in 55 procedures and an anteromedial approach in 13. Bone graft augmentation was used for contained defects in 15 shoulders. Humeral grafting was required in 7 shoulders (4 allografts and 3 autografts), glenoid grafting (all were autografts) in 7, and grafting in 1 shoulder was required on both sides of the joint (both were allografts). Cemented, all-polyethylene glenoid components were used in 42 cases and metalbacked glenoid components were used in 26. Metal-backed components were rarely used after 1994 due to accelerated polyethylene wear, osteolysis, and component loosening; currently, they are no longer used. Stem fixation for revised humeral components was press-fit in 28 cases and cementbased in 10. Cement fixation was used when there was not a tight press-fit proximally in the metaphysis and distally in the diaphysis.
Overall clinical results Mean pain scores after revision TSA were reduced from 4.4 0.9 preoperatively to 2.8 1.4 postoperatively (P < .001). Range of motion also improved from 85 43 to 116 51 (P < .001) after revision TSA for mean abduction, and mean external rotation improved from 36 26 to 48 29 (P ¼ .003). There were no functional gains in internal rotation, which remained at L4 3 vertebral levels preoperatively and postoperatively ( P ¼ .98). The modified Neer rating indicated an excellent result in 20 revisions (29%), a satisfactory result in 10 (15%), and an unsatisfactory result in 38 (56%). The reasons for an unsatisfactory result were pain scores in 14, motion
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Figure 3 Survivorship of total shoulder arthroplasty free from revision in all patients.
deficiencies in 14, instability in 6, patient dissatisfaction in 2, and a combination of factors in 2. Thirty-four complications developed and included broken hardware in 1, subluxation/instability in 9, limited motion in 2, soft tissue rupture in 3, extensive wear in 3, symptomatic component loosening in 1, infection in 5, periprosthetic fractures in 4, greater tuberosity fracture in 1, dislocations in 2, soft tissue contracture in 1, and osteolysis in 2. Of those with postoperative subluxation, 7 were in the CS tissue revision group. The direction of instability was anterior or anterior-superior in 8 shoulders, 4 of which had preoperative anterior shoulder laxity and 2 had preoperative rotator cuff tearing. Fifteen shoulders required a rerevision procedure at a mean of 46.3 months. Seven TSAs underwent rerevision for instability, 1 for infection, 1 for pain of unknown etiology, 4 for osteolysis/loosening, 1 for broken wires and screws after a fall, and 1 for limited active motion after a subscapularis rupture. Kaplan-Meier survival analysis for revision TSA free of rerevision was 95.6% at 1 year (95% CI, 90.8-100), 84.1% at 5 years (95% CI, 75.4-93.8), and 72.9% at 10 years (95% CI, 61.1-87.1; Fig. 3).
Subgroup analysis: SB vs CB revision There were 38 cases (56%) of humeral stem revision at the time of glenoid placement, comprising our CB revision group. Eleven stems were removed secondary to malposition. Three stems were loose at the time of revision TSA. Twenty-three stems were removed to facilitate exposure. One stem was revised to promote greater stability with the glenoid component. Thirty shoulders retained their index HHR stems. Stem fixation for revised humeral components was press-fit in 28 cases and cement-based in 10. Humeral bone grafting was used in 8 shoulders in the CB group and none in the SB group. Patient sex distribution was similar between the SB (18 men, 12 women) and CB (18 men, 20 women; P ¼ .23) groups. There was a difference in mean age at surgery (59 15 vs 51 13 years, P ¼ .04) and a difference in
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A.A. Sassoon et al.
Table I (A) Comparative statistics for simple and complex bony revisions P)
Variable
Simple bony
Complex bony
Pre-op Pain Abduction External rotation Internal rotation Post-op Pain Abduction External rotation Internal rotation Difference (post-op to pre-op) Pain Abduction External rotation Internal rotation
Mean (SD) 4.6 (0.6) 79.2 (39.0) 37.0 (26.6) 6.4 (3.8)
Mean (SD) 4.2 (1.1) 89.7 (46.0) 33.9 (26.3) 6.9 (3.2)
2.6 119.3 51.2 7.1
(1.4) (45.6) (23.9) (3.3)
3.0 113.4 46.2 6.6
(1.4) (55.5) (31.9) (3.4)
0.24 0.63 .46 .55
2.0 40.2 12.9 0.7
(1.4) (49.2) (32.7) (3.9)
1.2 23.7 12.2 0.5
(1.6) (52.7) (34.2) (4.0)
.03 .19 .93 .25
.05 .31 .64 .55
(B) Neer rating for simple and complex bony revisions Neer rating
Simple bony
Complex bony
Py
Excellent Satisfactory Unsatisfactory
11 4 15
9 6 23
.53
SD, standard deviation. ) Comparison using a two-sample t test assuming unequal variances. y Comparisons using Fisher exact test.
time from HHR to revision TSA (2.8 2.1 vs 4.4 4.0 years, P ¼ .03) between the SB and CB groups, respectively. The mean preoperative pain scores were 4.6 in the SB group and 4.2 in the CB group, which was significant (P ¼ .05). There were no differences with regard to preoperative range of motion or in the absolute postoperative pain or range of motion scores; however, a difference in the change of pain scores was observed in the SB compared with the CB group (2.0 vs 1.2; P ¼ .03). No differences in the modified Neer rating between the 2 groups existed (P ¼ .53; Table I). Kaplan-Meier survival analysis for revision TSA free from rerevision was 90.0% (95% CI, 79.9-100) at 1 year, 79.0% (95% CI, 65.3-95.6) at 5 years, and 67.7% (95% CI, 47.4-96.8) at 10 years for the SB revision group. The CB group rerevision-free percentages were 100% at 1 year, 88.4% at 5 years (95% CI, 78.3-99.8), and 77.0% (95% CI, 63.2-93.9) at 10 years for the CB revision group. There were no differences in implant survivorship between the two groups (CB hazard ratio [HR], 0.52; 95% CI, 0.191.41; P ¼ .20; Fig. 4).
Subgroup analysis: SS vs CS tissue revision There were 38 revisions that required soft tissue reconstruction and were included in the CS tissue revision group (56%). Within the CS group, 24 patients required a capsular
Figure 4 Survivorship of total shoulder arthroplasty free from revision for complex and simple bony revisions.
alteration for instability, 3 required a rotator cuff repair, and 11 required both additional procedures. In all of those with capsular alterations for instability, the glenoid component was placed in neutral position and the humeral component was placed between 20 and 40 of retroversion. A loose anterior or posterior segment of the capsule was tightened surgically in 7 cases. Release of tight capsular tissue was done in the others, placing a somewhat larger humeral head to balance the joint anteriorly and posteriorly. The 14 rotator cuff tears involved the supraspinatus, with some having extension into the infraspinatus. The tear
Revision TSA for glenoid arthrosis
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Table II (A) Comparative statistics for simple and complex soft tissue revisions Variable
Simple soft tissue
Complex soft tissue
P)
Pre-op Pain Abduction External rotation Internal rotation Post-op Pain Abduction External rotation Internal rotation Differences (post-op to pre-op) Pain Abduction External rotation Internal rotation
Mean (SD) 4.2 (0.8) 96.7 (42.1) 41.7 (26.0) 6.8 (3.4)
Mean (SD) 4.4 (1.0) 75.9 (42.1) 30.3 (25.7) 6.5 (3.5)
.27 .05 .08 .76
2.8 124.5 53.3 7.3
(1.4) (47.0) (24.9) (3.1)
2.8 109.3 44.6 6.4
(1.5) (53.8) (30.9) (3.5)
.98 .22 .21 .23
1.4 27.8 10.2 0.3
(1.6) (50.7) (28.3) (3.7)
1.7 33.4 14.3 0.3
(1.6) (52.7) (37.0) (4.2)
.51 .66 .60 .55
(B) Neer rating for simple and complex soft tissue revisions Neer Rating
Simple soft tissue
Complex soft tissue
Py
Excellent Satisfactory Unsatisfactory
9 6 15
11 4 23
.53
SD, standard deviation. ) Comparison using a two-sample t test assuming unequal variances. y Comparisons using Fisher exact test.
sizes were medium (less than 1 to 3 cm in longest diameter) or were large (greater than 3 to 5 cm). There were no massive tears and no full-thickness tearing of the subscapularis tendon. Thirty revisions were included in the SS tissue revision group. Patient sex distribution was similar in the SS (19 men, 11 women) and CS (17 men, 21 women; P ¼ .15) groups. There were no differences in mean age at surgery between the SS and CS groups (54 12 vs 55 16 years, P ¼ .73) or in the time from HHR to revision TSA (4.5 3.1 vs 3.2 3.6 years, P ¼ .12). The SS group had significantly higher preoperative abduction compared with the CS group (96.7 42.1 vs 75.9 42.1 ; P ¼ .05). There were no other differences in preoperative and postoperative pain and function, nor was there a difference in the change of these values between the 2 groups. There were no differences in the modified Neer rating between the 2 groups (P ¼ .53; Table II). Kaplan-Meier survival analysis for revision TSA free from rerevision was 100% at 1 year, 87.7% (95% CI, 75.5%-100%) at 5 years, and 70.5% (95% CI, 52.7%94.2%) at 10 years for the SS tissue revision group and was 92.1% (95% CI, 83.9%-100%) at 1 year, 80.8% (95% CI, 68.9%-94.8%) at 5 years, and 75.5% (95% CI, 61.2%93.0%) at 10 years for the CS tissue revision group. There were no differences in implant survivorship between the 2 groups (CS group HR, 1.03; 95% CI, 0.37-2.84; P ¼ .96; Fig. 5).
Figure 5 Survivorship of total shoulder arthroplasty free from revision for complex and simple soft tissue revisions.
Discussion Previous studies at our institution investigating the longterm results of HHR in non–fracture-related glenohumeral arthrosis patient subgroups collectively demonstrate that the development of painful glenoid arthrosis is a significant cause for concern. Rispoli et al8 demonstrated that 9 of 51 HHRs (18%) used primarily in the treatment of osteoarthritis were revised for painful glenoid arthritis. In a similar
1490 Table III
A.A. Sassoon et al. Summary of results from revision total shoulder arthroplasty studies
Study (first author)
N
Avg F-U (years)
D Pain
D Abduction (deg)
D ER (deg)
Sperling11 Carroll1 Hattrup5 This study
18 15 17 68
5.5 5.5 4.7 7.0
4.3 to 2.1) ? to 2.4y 8.8 to 2.4y 4.4 to 2.8)
94 93 63 85
32 27 12 36
to to to to
124 144 116 116
to to to to
58 58 47 48
Excellent/ Sat No. (%)
Unsatisfactory No. (%)
11 8 12 30
7 7 5 38
(61) (53) (71) (44)
(39) (47) (29) (56)
Avg, average; ER, external rotation; F-U, follow-up; Sat, satisfactory. ) Score based within a pain scale of 0 to 5. y Score based within a pain scale of 0 to 10.
study, Smith et al9 showed that 2 of 31 primary HHRs (6%) in the setting of osteonecrosis suffered the same fate. Sperling et al10 investigated 10 HHRs used in the treatment of instability-related arthritis, and 3 (30%) of the implants required revision secondary to symptomatic glenoid arthrosis. In another study by Sperling et al,12 8 of 95 primary HHRs (8%) used to treat rheumatoid arthritis required a revision for the same reason. The results of revision TSA for glenoid arthrosis in the setting of a failed HHR have been examined in previous studies. Sperling et al11 demonstrated that in 18 revision TSAs performed for glenoid arthrosis, patients had significant improvement in mean pain scores (4.3 to 2.2 of 5), mean active abduction (94 to 124 ), and mean external rotation (32 to 58 ). Despite these gains, 7 of the 18 revisions (39%) were unsatisfactory due to limited motion or the need for a subsequent procedure.11 Carroll et al1 had similar results in their study of 15 revision TSAs, with 7 (47%) of these procedures yielding unsatisfactory results. The Carroll study differed from the Sperling study, however, in that Carroll et al noted a predominance of unsatisfactory results due to unacceptable pain relief. The Carroll study also showed a postoperative increase in mean forward elevation (93 to 144 ) and external rotation (27 to 58 ). More recently, Hattrup5 reviewed 17 revision TSAs after glenoid arthrosis, and 5 patients (29%) also had unsatisfactory results. Again, patients showed improvements in pain scores (8.8 to 2.4 of 10), forward flexion (73 to 124 ), abduction (63 to 116 ), and external rotation (12 to 47 ). The results from these previous investigations are summarized alongside our overall results in Table III. The results from this larger study solidify these previous findings. Mean pain scores for patients decreased (P < .001), mean abduction was increased (P < .001), and mean external rotation was increased (P ¼ .001). The Neer rating for all patients yielded 20 excellent, 10 satisfactory, and 38 unsatisfactory outcomes. This indicates that although pain decreases and active range of motion increases after revision TSA, unsatisfactory outcomes remain common. Owing to the small number of patients included in previous studies, it had been difficult to isolate patient characteristics that might have led to the unsatisfactory results. Potential candidates include patients who required a revision of their
humeral stem and patients who required additional soft tissue reconstruction at the time of their revision TSA. Stem exchange occurred in 17, 11, and 12 of the revisions reviewed in the 3 aforementioned studies by Sperling et al,11 Carroll et al,1 and Hattrup.5 Our study included 38 revisions that required a stem exchange and were stratified into the CB group. The CB group had less improvement between preoperative and postoperative pain scores compared with revisions performed without a stem exchange. The CB group did not differ from the SB group with regards to overall postoperative pain scores, range of motion, survivorship, or Neer rating. However, although not statistically significant as seen in Table I, 50% of those without a stem revision had an excellent or satisfactory result, whereas only 39% with a stem revision were in these categories. Capsular alteration and rotator cuff repair occurred in 38 of the revision TSAs reviewed in this study, defining a CS tissue revision subgroup. Capsular repair and or rotator cuff repair was only performed in 4 patients in the Hattrup5 series (24%). This was thought to be a potential source of increased satisfaction in his series compared with other studies. However, when the CS group was compared with the SS group in our investigation, there were no significant differences in postoperative pain, range of motion, survivorship, or Neer rating. However, there are subtle differences in Table II. The SS group had somewhat better range of motion and a larger proportion of excellent or satisfactory result ratings. In addition, of the 9 patients with a complication of postoperative instability, 7 were in the CS revision group. Levy et al6 reviewed the results of 19 reverse TSA procedures in the treatment of failed HHR with rotator cuff deficiency. Patients in their series had improvement in mean pain scores (7.3 to 2.5 of 9), mean forward flexion (49 to 76 ), and mean abduction (42 to 77 ). Fifteen patients (79%) in the Levy et al series were satisfied with their result. Although these results are not directly comparable with those of our CS group, secondary to the added stringent range of motion criteria that a Neer rating demands for a satisfactory grade, the reverse TSA also presents itself as a valuable salvage tool for a select group of patients. The limitations of the study included its retrospective nature and the absence of a control group. The study was developed over many years. Follow-up was by patient visit
Revision TSA for glenoid arthrosis and questionnaire. There was considerable variability resulting in the need to also address a malpositioned, loosened, or obstructive humeral component, and the need to address soft tissue deficiencies be they related to rotator cuff tearing, capsular stretching, or capsule contracture. There are strengths of the study. The material was developed at 1 institution, there was 1 surgeon, there was a standard method of data collection, and it is a large series that better displays the effects of the procedure as a whole and the effect of variations of humeral component issues and soft tissue problems. Patients can benefit from this procedure with a reduction in pain and an improvement in motion on average. The need for stem revision does have an effect on lessening the amount of pain reduction and reducing somewhat the number of excellent or satisfactory ratings. Soft tissue alterations can have a profound effect on this procedure, although the soft tissue alterations had little effect on pain relief. They had some effect on increasing the postoperative range of motion and contributed substantially to the development of the major complication of instability. As such, reverse shoulder arthroplasty should be considered as a treatment option for patients in whom HHR has failed who have glenoid arthritis but who also have preoperative instability due to a large or massive rotator cuff tear or thinning with stretching of the anterior shoulder capsule and subscapularis muscle-tendon unit.6
Conclusion Revision TSA after HHR results in decreased pain and increases in range of motion. Result ratings, however, are quite variable and in many cases unsatisfactory. Stratification of the procedures according to complexity does not demonstrate statistical differences in range of motion, patient satisfaction, or survivorship. The need for stem revision, however, results in lesser pain score improvement, and coexisting rotator cuff tearing or instability associated with subscapularis and anterior shoulder capsule damage may not be fully correctable using an unconstrained shoulder arthroplasty design.
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Disclaimer Dr Cofield receives royalties from Smith/Nephew. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Carroll RM, Izquierdo R, Vazquez M, Blaine TA, Levine WN, Bigliani LU. Conversion of painful hemiarthroplasty to total shoulder arthroplasty: Long-term results. J Shoulder Elbow Surg 2004;16:599603. doi:10.1016/j.jse.2004.03.016 2. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am 1984;66:899-906. 3. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 2000;82:26-34. 4. Gill DRJ, Cofield RH, Rowland C. The anteromedial approach for shoulder arthroplasty: The importance of the anterior deltoid. J Shoulder Elbow Surg 2004;13:532-7. doi:10.1016/j.jse.2004.02.009 5. Hattrup SJ. Revision total shoulder arthroplasty for painful humeral head replacement with glenoid arthrosis. J Shoulder Elbow Surg 2009; 18:220-4. doi:10.1016/j.jse.2008.09.006 6. Levy JC, Virani N, Pupello Frankle M. Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency. J Bone Joint Surg Br 2007;89:189-95. doi:10.1302/0301-620X.89B2.18161 7. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-37. 8. Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Humeral head replacement for the treatment of osteoarthritis. J Bone Joint Surg Am 2006;88:2637-44. doi:10.2106/JBJS.E.01383 9. Smith RG, Sperling JW, Cofield RH, Hattrup SJ, Schleck CD. Shoulder hemiarthroplasty for steroid-associated osteonecrosis. J Shoulder Elbow Surg 2008;17:685-8. doi:10.1016/j.jse.2008.01.149 10. Sperling JW, Antuna SA, Sanchez-Sotelo J, Schleck CD, Cofield RH. Shoulder arthroplasty for arthritis after instability surgery. J Bone Joint Surg Am 2002;84:1775-81. 11. Sperling JW, Cofield RH. Revision total shoulder arthroplasty for the treatment of glenoid arthrosis. J Bone Joint Surg Am 1998;80: 860-7. 12. Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder vs. hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg 2007;16:683-90. doi: 10.1016/j.jse.2007.02.135
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Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder Adam A. Sassoon, MDa, Peter C. Rhee, DOa, Cathy D. Schleck, BSb, William S. Harmsen, MSb, John W. Sperling, MD, MBAa, Robert H. Cofield, MDa,* a b
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA Department of Biostatistics, Mayo Clinic, Rochester, MN, USA Background: Patients treated with humeral head replacement (HHR) may require revision to total shoulder arthroplasty (TSA) due to glenoid arthrosis. This study characterizes the outcomes of revision TSA in patients who initially underwent HHR for nontraumatic glenohumeral arthritis. Methods: From 1982 to 2005, 68 shoulders underwent revision TSA for glenoid arthrosis. The initial HHR was performed for non–fracture-related arthritis. Revisions were grouped according to complexity for analysis. Stem revision and soft tissue reconstruction were assessed in relation to outcome. Results: Pain scores decreased from 4.4 to 2.8, abduction increased from 85 to 116 , external rotation increased from 36 to 48 , and internal rotation remained unchanged. Survivorship free of repeat revision was 95.6%, 84.1%, and 72.9% at 1, 5, and 10 years. The Neer rating yielded 20 excellent, 10 satisfactory, and 38 unsatisfactory outcomes. No differences in motion, survivorship, or the Neer rating occurred between groups by procedure complexity. There was, however, less reduction in pain for the group requiring a humeral stem revision. Of the 9 shoulders with postoperative instability, 7 had compromised soft tissues preoperatively. Conclusions: Revision TSA after HHR results in decreased pain and increased motion. Result ratings, however, are quite variable and, in many cases, unsatisfactory. Stratification of the procedures according to complexity does not demonstrate differences in motion, satisfaction, or survivorship. Stem revision, however, results in reduced pain score improvement. Coexisting instability associated with subscapularis and anterior shoulder capsule damage may not be correctable using an unconstrained shoulder arthroplasty. Level of evidence: Level III, Retrospective Case Control Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Revision total shoulder arthroplasty; painful glenoid arthritis; humeral head replacement; nontraumatic shoulder
This study received approval from the Mayo Clinic Investigational Review Board (08-00481-4; last approval date: 7-28-2008.) *Reprint requests: Robert H. Cofield, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA. E-mail address: [email protected] (R.H. Cofield).
Humeral head replacement (HHR) is one option in the treatment of glenohumeral arthritis. The proponents of HHR cite decreased costs, operative time, blood loss, and technical demands compared with total shoulder arthroplasty (TSA).3 Painful glenoid arthrosis occurs in a subset
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.11.028
Revision TSA for glenoid arthrosis of patients, leading to consideration of placing a glenoid component and making it the most common indication for revision surgery after HHR.11 A previous study of 16 consecutive patients concluded that revision TSA after HHR should be considered as a salvage procedure with inferior outcomes compared with primary TSA.1 An earlier study at our institution demonstrated that 7 of 18 patients who underwent revision TSA after the development of glenoid arthrosis had an unsatisfactory result as assessed by modified Neer scores.11 The present study represents an expansion on our previous work with a larger group of patients and longer clinical follow-up. The aims of this study are to (1) to characterize the outcomes of revision TSA for painful glenoid arthrosis after an elective HHR in a large series and (2) assess the affect of stem exchange and soft tissue reconstruction on TSA outcome in this patient population. Our hypothesis is that revision procedures that are more technically demanding will lead to a disproportionate amount of any unsatisfactory results encountered.
Materials and methods Our institution’s orthopedic total joint registry was used to identify patients who underwent a revision TSA for the treatment of moderate or severe pain after a HHR. All cases were performed between 1981 and 2005 by the senior author (R.H.C.). We included all patients who underwent the index HHR as a definitive treatment for non–fracture-related arthropathy, with clinical follow-up for a minimum of 2 years. Patients were stratified by the complexity of bony and soft tissue reconstruction efforts required during revision TSA. Revisions were categorized as simple bony (SB) revisions (glenoid component placement with or without humeral head exchange) or complex bony (CB) revisions (glenoid component placement and humeral stem revision) and analyzed. Revisions were then regrouped and reanalyzed according to their need for soft tissue reconstruction; procedures qualified as either simple soft (SS) tissue revisions (revision total shoulder arthroplasty without additional repairs or reconstructions) or complex soft (CS) tissue revisions (revision TSA with rotator cuff tear repair or capsular alteration for instability).
1485 a useful guide. Low-grade infection is always a concern, and a white blood cell count with differential, erythrocyte sedimentation rate, and C-reactive protein concentration are obtained. If symptoms suggestive of an infection are present, joint aspiration and cell count and culture for anaerobic and aerobic organisms are performed. The clinical and functional status of all TSAs performed at our institution are recorded using a standard shoulder analysis sheet and archived in a total joint registry. Pain in the shoulder is defined as patient report of ‘‘no pain’’ (1 point), ‘‘slight pain’’ (2 points), ‘‘pain after unusual activity’’ (3 points), ‘‘moderate pain’’ (4 points), or ‘‘severe pain’’ (5 points).7 Patient satisfaction was defined by patient response as ‘‘much better’’ (1 point), ‘‘better’’ (2 points), ‘‘the same’’ (3 points), or ‘‘worse’’ (4 points) from immediately before surgery to the latest follow-up. Active abduction and external rotation were recorded in degrees. Active internal rotation was measured as the most cephalad posterior vertebral segment that could be reached by the thumb. The overall status of the shoulder was assessed with a modification of the Neer rating system.2,7 An excellent score was given if the patient had ‘‘no’’ or ‘‘slight pain,’’ external rotation to at least 45 , active abduction to at least 140 , and was ‘‘satisfied’’ with the result. A satisfactory rating consisted of ‘‘no’’ or ‘‘slight pain,’’ or ‘‘moderate pain only with vigorous activity,’’ external rotation to at least 20 , active abduction to at least 90 , and the patient being ‘‘satisfied’’ with the outcome. If any of the criteria for a satisfactory result were not met, or if any additional operative procedures were required, the result was considered unsatisfactory.
Operative technique All revisions were performed through an anterior approach, using the deltopectoral or anteromedial approach, as previously described.4 The subscapularis was divided 1 cm medial to its insertion (32 shoulders) or incised from the humerus if external rotation was less than 30 (32 shoulders). The tendon was managed with a Z-plasty in 2 shoulders, and no mention was made of the method of addressing the subscapularis in 2 operative reports. The humeral component was removed in cases of malposition or aseptic loosening. It was also removed in some instances to facilitate exposure of the glenoid and for revision of monoblock components requiring humeral head exchange. Rotator cuff tears were repaired with heavy sutures. In cases of bone loss about the proximal humerus or the glenoid, allograft or autograft bone was used (Fig. 1 and Fig. 2).
Clinical evaluation
Statistical methods
Preoperatively, the history and physical examination are most important. To further evaluate this condition, current X-ray images, including an axillary view, are necessary to visualize the loss of glenoid cartilage and the security and position of the humeral component. If additional glenoid bone loss has occurred, computed tomography (CT) evaluation is useful to determine whether enough bone remains to place the glenoid component. A number of associated problems can also contribute to the patient’s pain, including humeral implant issues, rotator cuff tearing, instability, or low-grade infection. Fluoroscopy of the proximal humerus with rotation of the arm can determine humeral version. If rotator cuff deficiency is questioned, an ultrasound evaluation is
Descriptive statistics are reported as mean (range) for continuous measures and number (percentage) for discrete variables. The clinical outcomes assessment included 68 shoulders (rerevised shoulders and those not revised but that had at least 2 years of clinical follow-up). In shoulders that had a rerevision, the last clinical information before rerevision was used. Associations of pain, abduction, and external and internal rotation with SB vs CB revision as well as with SS vs CS tissue revision were assessed using a two-sample t test (assuming unequal variances). The associations of sex with SB vs CB revision and with SS vs CS tissue revision were assessed with the Fisher exact test. The associations of the Neer rating with SB vs
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Figure 1 Preoperative (A) and postoperative (B) images of a painful humeral head replacement with glenoid arthrosis that was revised to total shoulder arthroplasty using a metal-backed glenoid component. The humeral stem was revised because of malposition and to facilitate glenoid exposure. CB revision and SS vs CS tissue revision were assessed using an extension of the Fisher exact test for ordered contingency tables. A paired t test was used to compare preoperative vs postoperative changes in pain, active abduction, and external and internal rotation. Postoperative assessments were made at the last clinical contact, and among those rerevised, at the last clinical contact before the rerevision. All 68 shoulders were monitored from the date of revision TSA to rerevision or the last follow-up. Implant survival free of rerevision was estimated with the Kaplan-Meier method, reporting the estimate and 95% confidence interval (CI). The a level was set at 0.05 for statistical significance.
A.A. Sassoon et al.
Figure 2 Preoperative (A) and postoperative (B) images of a painful humeral head replacement with glenoid arthrosis that was revised to total shoulder arthroplasty using a polyethylene glenoid component. The humeral stem was revised due to component malposition.
Results Overall patient demographics Between 1981 and 2005, the senior author (R.H.C.) performed 116 revisions of HHRs to TSAs in 115 patients for the treatment of glenoid arthrosis. Seventy-one of these revised HHRs in 70 patients were initially placed for a non–fracture-related reason. Two patients were lost to follow-up at 3 and 4 months postoperatively, and 1 patient died 12 months after her procedure, leaving 68 shoulders
Revision TSA for glenoid arthrosis available for clinical analysis. Thirty-eight (56%) of the index HHRs were placed in the treatment of osteoarthritis, 10 (15%) for rheumatoid arthritis, 6 (9%) for osteonecrosis, and 14 (21%) for instability-related arthropathy. Of the index HHRs, 28 (39%) were performed at our institution and the remaining 43 (61%) were performed elsewhere. Thirty-six revisions (53%) were performed in men and 32 (47%) in women. The patients were a mean age of 55 14 years (range, 23-81 years). Revisions were performed on 42 dominant extremities. The mean duration of clinical follow-up for all patients was 75 months (range, 6-188 months). The mean clinical follow-up in 53 shoulders that did not require a rerevision procedure was 65 months (range, 25-188 months), whereas the median clinical follow-up for the 15 shoulders requiring a rerevision was 49 months (range, 6-125 months). The mean time from HHR to revision TSA for all patients in this series was 3.75 years (range, 5 months-17 years). This interval was 4.5 and 2.8 years, respectively, in the CB and SB groups and 3.2 and 4.5 years, respectively, in the CS and SS tissue groups. There were no significant differences in the duration of HHR retention between the CS and SS tissue groups; however, the CB group had a significantly longer time to revision than the SB group (P ¼ .03). A deltopectoral approach was used in 55 procedures and an anteromedial approach in 13. Bone graft augmentation was used for contained defects in 15 shoulders. Humeral grafting was required in 7 shoulders (4 allografts and 3 autografts), glenoid grafting (all were autografts) in 7, and grafting in 1 shoulder was required on both sides of the joint (both were allografts). Cemented, all-polyethylene glenoid components were used in 42 cases and metalbacked glenoid components were used in 26. Metal-backed components were rarely used after 1994 due to accelerated polyethylene wear, osteolysis, and component loosening; currently, they are no longer used. Stem fixation for revised humeral components was press-fit in 28 cases and cementbased in 10. Cement fixation was used when there was not a tight press-fit proximally in the metaphysis and distally in the diaphysis.
Overall clinical results Mean pain scores after revision TSA were reduced from 4.4 0.9 preoperatively to 2.8 1.4 postoperatively (P < .001). Range of motion also improved from 85 43 to 116 51 (P < .001) after revision TSA for mean abduction, and mean external rotation improved from 36 26 to 48 29 (P ¼ .003). There were no functional gains in internal rotation, which remained at L4 3 vertebral levels preoperatively and postoperatively ( P ¼ .98). The modified Neer rating indicated an excellent result in 20 revisions (29%), a satisfactory result in 10 (15%), and an unsatisfactory result in 38 (56%). The reasons for an unsatisfactory result were pain scores in 14, motion
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Figure 3 Survivorship of total shoulder arthroplasty free from revision in all patients.
deficiencies in 14, instability in 6, patient dissatisfaction in 2, and a combination of factors in 2. Thirty-four complications developed and included broken hardware in 1, subluxation/instability in 9, limited motion in 2, soft tissue rupture in 3, extensive wear in 3, symptomatic component loosening in 1, infection in 5, periprosthetic fractures in 4, greater tuberosity fracture in 1, dislocations in 2, soft tissue contracture in 1, and osteolysis in 2. Of those with postoperative subluxation, 7 were in the CS tissue revision group. The direction of instability was anterior or anterior-superior in 8 shoulders, 4 of which had preoperative anterior shoulder laxity and 2 had preoperative rotator cuff tearing. Fifteen shoulders required a rerevision procedure at a mean of 46.3 months. Seven TSAs underwent rerevision for instability, 1 for infection, 1 for pain of unknown etiology, 4 for osteolysis/loosening, 1 for broken wires and screws after a fall, and 1 for limited active motion after a subscapularis rupture. Kaplan-Meier survival analysis for revision TSA free of rerevision was 95.6% at 1 year (95% CI, 90.8-100), 84.1% at 5 years (95% CI, 75.4-93.8), and 72.9% at 10 years (95% CI, 61.1-87.1; Fig. 3).
Subgroup analysis: SB vs CB revision There were 38 cases (56%) of humeral stem revision at the time of glenoid placement, comprising our CB revision group. Eleven stems were removed secondary to malposition. Three stems were loose at the time of revision TSA. Twenty-three stems were removed to facilitate exposure. One stem was revised to promote greater stability with the glenoid component. Thirty shoulders retained their index HHR stems. Stem fixation for revised humeral components was press-fit in 28 cases and cement-based in 10. Humeral bone grafting was used in 8 shoulders in the CB group and none in the SB group. Patient sex distribution was similar between the SB (18 men, 12 women) and CB (18 men, 20 women; P ¼ .23) groups. There was a difference in mean age at surgery (59 15 vs 51 13 years, P ¼ .04) and a difference in
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A.A. Sassoon et al.
Table I (A) Comparative statistics for simple and complex bony revisions P)
Variable
Simple bony
Complex bony
Pre-op Pain Abduction External rotation Internal rotation Post-op Pain Abduction External rotation Internal rotation Difference (post-op to pre-op) Pain Abduction External rotation Internal rotation
Mean (SD) 4.6 (0.6) 79.2 (39.0) 37.0 (26.6) 6.4 (3.8)
Mean (SD) 4.2 (1.1) 89.7 (46.0) 33.9 (26.3) 6.9 (3.2)
2.6 119.3 51.2 7.1
(1.4) (45.6) (23.9) (3.3)
3.0 113.4 46.2 6.6
(1.4) (55.5) (31.9) (3.4)
0.24 0.63 .46 .55
2.0 40.2 12.9 0.7
(1.4) (49.2) (32.7) (3.9)
1.2 23.7 12.2 0.5
(1.6) (52.7) (34.2) (4.0)
.03 .19 .93 .25
.05 .31 .64 .55
(B) Neer rating for simple and complex bony revisions Neer rating
Simple bony
Complex bony
Py
Excellent Satisfactory Unsatisfactory
11 4 15
9 6 23
.53
SD, standard deviation. ) Comparison using a two-sample t test assuming unequal variances. y Comparisons using Fisher exact test.
time from HHR to revision TSA (2.8 2.1 vs 4.4 4.0 years, P ¼ .03) between the SB and CB groups, respectively. The mean preoperative pain scores were 4.6 in the SB group and 4.2 in the CB group, which was significant (P ¼ .05). There were no differences with regard to preoperative range of motion or in the absolute postoperative pain or range of motion scores; however, a difference in the change of pain scores was observed in the SB compared with the CB group (2.0 vs 1.2; P ¼ .03). No differences in the modified Neer rating between the 2 groups existed (P ¼ .53; Table I). Kaplan-Meier survival analysis for revision TSA free from rerevision was 90.0% (95% CI, 79.9-100) at 1 year, 79.0% (95% CI, 65.3-95.6) at 5 years, and 67.7% (95% CI, 47.4-96.8) at 10 years for the SB revision group. The CB group rerevision-free percentages were 100% at 1 year, 88.4% at 5 years (95% CI, 78.3-99.8), and 77.0% (95% CI, 63.2-93.9) at 10 years for the CB revision group. There were no differences in implant survivorship between the two groups (CB hazard ratio [HR], 0.52; 95% CI, 0.191.41; P ¼ .20; Fig. 4).
Subgroup analysis: SS vs CS tissue revision There were 38 revisions that required soft tissue reconstruction and were included in the CS tissue revision group (56%). Within the CS group, 24 patients required a capsular
Figure 4 Survivorship of total shoulder arthroplasty free from revision for complex and simple bony revisions.
alteration for instability, 3 required a rotator cuff repair, and 11 required both additional procedures. In all of those with capsular alterations for instability, the glenoid component was placed in neutral position and the humeral component was placed between 20 and 40 of retroversion. A loose anterior or posterior segment of the capsule was tightened surgically in 7 cases. Release of tight capsular tissue was done in the others, placing a somewhat larger humeral head to balance the joint anteriorly and posteriorly. The 14 rotator cuff tears involved the supraspinatus, with some having extension into the infraspinatus. The tear
Revision TSA for glenoid arthrosis
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Table II (A) Comparative statistics for simple and complex soft tissue revisions Variable
Simple soft tissue
Complex soft tissue
P)
Pre-op Pain Abduction External rotation Internal rotation Post-op Pain Abduction External rotation Internal rotation Differences (post-op to pre-op) Pain Abduction External rotation Internal rotation
Mean (SD) 4.2 (0.8) 96.7 (42.1) 41.7 (26.0) 6.8 (3.4)
Mean (SD) 4.4 (1.0) 75.9 (42.1) 30.3 (25.7) 6.5 (3.5)
.27 .05 .08 .76
2.8 124.5 53.3 7.3
(1.4) (47.0) (24.9) (3.1)
2.8 109.3 44.6 6.4
(1.5) (53.8) (30.9) (3.5)
.98 .22 .21 .23
1.4 27.8 10.2 0.3
(1.6) (50.7) (28.3) (3.7)
1.7 33.4 14.3 0.3
(1.6) (52.7) (37.0) (4.2)
.51 .66 .60 .55
(B) Neer rating for simple and complex soft tissue revisions Neer Rating
Simple soft tissue
Complex soft tissue
Py
Excellent Satisfactory Unsatisfactory
9 6 15
11 4 23
.53
SD, standard deviation. ) Comparison using a two-sample t test assuming unequal variances. y Comparisons using Fisher exact test.
sizes were medium (less than 1 to 3 cm in longest diameter) or were large (greater than 3 to 5 cm). There were no massive tears and no full-thickness tearing of the subscapularis tendon. Thirty revisions were included in the SS tissue revision group. Patient sex distribution was similar in the SS (19 men, 11 women) and CS (17 men, 21 women; P ¼ .15) groups. There were no differences in mean age at surgery between the SS and CS groups (54 12 vs 55 16 years, P ¼ .73) or in the time from HHR to revision TSA (4.5 3.1 vs 3.2 3.6 years, P ¼ .12). The SS group had significantly higher preoperative abduction compared with the CS group (96.7 42.1 vs 75.9 42.1 ; P ¼ .05). There were no other differences in preoperative and postoperative pain and function, nor was there a difference in the change of these values between the 2 groups. There were no differences in the modified Neer rating between the 2 groups (P ¼ .53; Table II). Kaplan-Meier survival analysis for revision TSA free from rerevision was 100% at 1 year, 87.7% (95% CI, 75.5%-100%) at 5 years, and 70.5% (95% CI, 52.7%94.2%) at 10 years for the SS tissue revision group and was 92.1% (95% CI, 83.9%-100%) at 1 year, 80.8% (95% CI, 68.9%-94.8%) at 5 years, and 75.5% (95% CI, 61.2%93.0%) at 10 years for the CS tissue revision group. There were no differences in implant survivorship between the 2 groups (CS group HR, 1.03; 95% CI, 0.37-2.84; P ¼ .96; Fig. 5).
Figure 5 Survivorship of total shoulder arthroplasty free from revision for complex and simple soft tissue revisions.
Discussion Previous studies at our institution investigating the longterm results of HHR in non–fracture-related glenohumeral arthrosis patient subgroups collectively demonstrate that the development of painful glenoid arthrosis is a significant cause for concern. Rispoli et al8 demonstrated that 9 of 51 HHRs (18%) used primarily in the treatment of osteoarthritis were revised for painful glenoid arthritis. In a similar
1490 Table III
A.A. Sassoon et al. Summary of results from revision total shoulder arthroplasty studies
Study (first author)
N
Avg F-U (years)
D Pain
D Abduction (deg)
D ER (deg)
Sperling11 Carroll1 Hattrup5 This study
18 15 17 68
5.5 5.5 4.7 7.0
4.3 to 2.1) ? to 2.4y 8.8 to 2.4y 4.4 to 2.8)
94 93 63 85
32 27 12 36
to to to to
124 144 116 116
to to to to
58 58 47 48
Excellent/ Sat No. (%)
Unsatisfactory No. (%)
11 8 12 30
7 7 5 38
(61) (53) (71) (44)
(39) (47) (29) (56)
Avg, average; ER, external rotation; F-U, follow-up; Sat, satisfactory. ) Score based within a pain scale of 0 to 5. y Score based within a pain scale of 0 to 10.
study, Smith et al9 showed that 2 of 31 primary HHRs (6%) in the setting of osteonecrosis suffered the same fate. Sperling et al10 investigated 10 HHRs used in the treatment of instability-related arthritis, and 3 (30%) of the implants required revision secondary to symptomatic glenoid arthrosis. In another study by Sperling et al,12 8 of 95 primary HHRs (8%) used to treat rheumatoid arthritis required a revision for the same reason. The results of revision TSA for glenoid arthrosis in the setting of a failed HHR have been examined in previous studies. Sperling et al11 demonstrated that in 18 revision TSAs performed for glenoid arthrosis, patients had significant improvement in mean pain scores (4.3 to 2.2 of 5), mean active abduction (94 to 124 ), and mean external rotation (32 to 58 ). Despite these gains, 7 of the 18 revisions (39%) were unsatisfactory due to limited motion or the need for a subsequent procedure.11 Carroll et al1 had similar results in their study of 15 revision TSAs, with 7 (47%) of these procedures yielding unsatisfactory results. The Carroll study differed from the Sperling study, however, in that Carroll et al noted a predominance of unsatisfactory results due to unacceptable pain relief. The Carroll study also showed a postoperative increase in mean forward elevation (93 to 144 ) and external rotation (27 to 58 ). More recently, Hattrup5 reviewed 17 revision TSAs after glenoid arthrosis, and 5 patients (29%) also had unsatisfactory results. Again, patients showed improvements in pain scores (8.8 to 2.4 of 10), forward flexion (73 to 124 ), abduction (63 to 116 ), and external rotation (12 to 47 ). The results from these previous investigations are summarized alongside our overall results in Table III. The results from this larger study solidify these previous findings. Mean pain scores for patients decreased (P < .001), mean abduction was increased (P < .001), and mean external rotation was increased (P ¼ .001). The Neer rating for all patients yielded 20 excellent, 10 satisfactory, and 38 unsatisfactory outcomes. This indicates that although pain decreases and active range of motion increases after revision TSA, unsatisfactory outcomes remain common. Owing to the small number of patients included in previous studies, it had been difficult to isolate patient characteristics that might have led to the unsatisfactory results. Potential candidates include patients who required a revision of their
humeral stem and patients who required additional soft tissue reconstruction at the time of their revision TSA. Stem exchange occurred in 17, 11, and 12 of the revisions reviewed in the 3 aforementioned studies by Sperling et al,11 Carroll et al,1 and Hattrup.5 Our study included 38 revisions that required a stem exchange and were stratified into the CB group. The CB group had less improvement between preoperative and postoperative pain scores compared with revisions performed without a stem exchange. The CB group did not differ from the SB group with regards to overall postoperative pain scores, range of motion, survivorship, or Neer rating. However, although not statistically significant as seen in Table I, 50% of those without a stem revision had an excellent or satisfactory result, whereas only 39% with a stem revision were in these categories. Capsular alteration and rotator cuff repair occurred in 38 of the revision TSAs reviewed in this study, defining a CS tissue revision subgroup. Capsular repair and or rotator cuff repair was only performed in 4 patients in the Hattrup5 series (24%). This was thought to be a potential source of increased satisfaction in his series compared with other studies. However, when the CS group was compared with the SS group in our investigation, there were no significant differences in postoperative pain, range of motion, survivorship, or Neer rating. However, there are subtle differences in Table II. The SS group had somewhat better range of motion and a larger proportion of excellent or satisfactory result ratings. In addition, of the 9 patients with a complication of postoperative instability, 7 were in the CS revision group. Levy et al6 reviewed the results of 19 reverse TSA procedures in the treatment of failed HHR with rotator cuff deficiency. Patients in their series had improvement in mean pain scores (7.3 to 2.5 of 9), mean forward flexion (49 to 76 ), and mean abduction (42 to 77 ). Fifteen patients (79%) in the Levy et al series were satisfied with their result. Although these results are not directly comparable with those of our CS group, secondary to the added stringent range of motion criteria that a Neer rating demands for a satisfactory grade, the reverse TSA also presents itself as a valuable salvage tool for a select group of patients. The limitations of the study included its retrospective nature and the absence of a control group. The study was developed over many years. Follow-up was by patient visit
Revision TSA for glenoid arthrosis and questionnaire. There was considerable variability resulting in the need to also address a malpositioned, loosened, or obstructive humeral component, and the need to address soft tissue deficiencies be they related to rotator cuff tearing, capsular stretching, or capsule contracture. There are strengths of the study. The material was developed at 1 institution, there was 1 surgeon, there was a standard method of data collection, and it is a large series that better displays the effects of the procedure as a whole and the effect of variations of humeral component issues and soft tissue problems. Patients can benefit from this procedure with a reduction in pain and an improvement in motion on average. The need for stem revision does have an effect on lessening the amount of pain reduction and reducing somewhat the number of excellent or satisfactory ratings. Soft tissue alterations can have a profound effect on this procedure, although the soft tissue alterations had little effect on pain relief. They had some effect on increasing the postoperative range of motion and contributed substantially to the development of the major complication of instability. As such, reverse shoulder arthroplasty should be considered as a treatment option for patients in whom HHR has failed who have glenoid arthritis but who also have preoperative instability due to a large or massive rotator cuff tear or thinning with stretching of the anterior shoulder capsule and subscapularis muscle-tendon unit.6
Conclusion Revision TSA after HHR results in decreased pain and increases in range of motion. Result ratings, however, are quite variable and in many cases unsatisfactory. Stratification of the procedures according to complexity does not demonstrate statistical differences in range of motion, patient satisfaction, or survivorship. The need for stem revision, however, results in lesser pain score improvement, and coexisting rotator cuff tearing or instability associated with subscapularis and anterior shoulder capsule damage may not be fully correctable using an unconstrained shoulder arthroplasty design.
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Disclaimer Dr Cofield receives royalties from Smith/Nephew. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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