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Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up
J Shoulder Elbow Surg (2014) 23, 791-799
www.elsevier.com/locate/ymse
Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up Jonathan D. Barlow, MD, Brandon J. Yuan, MD, Cathy D. Schleck, BS, W. Scott Harmsen, MS, Robert H. Cofield, MD*, John W. Sperling, MD, MBA Mayo Clinic, Rochester, MN, USA Background: This is an update on a previously documented cohort of patients who underwent shoulder arthroplasty for rheumatoid arthritis, with a minimum 5-year clinical follow-up. Methods: The survivorship of 303 consecutive shoulder arthroplasties (108 hemiarthroplasties, 195 total shoulder arthroplasties) for rheumatoid arthritis at one institution was assessed. There were 255 arthroplasties in the clinical analysis and 188 in the radiographic analysis. Results: Kaplan-Meier survivorship free of revision at 5 years and 10 years was 96.1% and 92.9% for total shoulder arthroplasty (TSA) and 89.2% and 87.9% for hemiarthroplasty (HA). The most common indications were glenoid loosening (5%) and infection (2%) for TSA revision and glenoid arthrosis (7%) for HA revision. Pain relief was greater with TSA than with HA. In patients with an intact rotator cuff, in comparing TSA with HA, those with a TSA had greater improvements in pain scores (2.7 vs 1.8 on a 5-point scale) and degrees of elevation (45 versus 24) (P ¼ .08). Approximately 30% of humeral components and 73% of glenoid components had periprosthetic lucencies. There was a shift in position of the glenoid in 33% of TSAs, and 36% were ‘‘at risk.’’ Eighty-one percent of HAs had moderate or severe glenoid erosion. Discussion/Conclusion: Both HA and TSA provide pain relief and improved motion in patients with rheumatoid arthritis. In patients with an intact rotator cuff, pain relief and range of motion are more improved with TSA compared with HA. There is a high rate of component lucency, but component revision is uncommon. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Total shoulder arthroplasty; hemiarthroplasty; rheumatoid arthritis
Whereas shoulder arthritis is common in patients with rheumatoid arthritis (RA), shoulder arthroplasty in patients with RA has unique challenges. Decreased bone stock and a high incidence of rotator cuff tears are common in this group of patients.3,25,28 The osteopenia commonly seen in IRB: 11-003160. *Reprint requests: Robert H. Cofield, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. E-mail address: [email protected] (R.H. Cofield).
these patients can lead to increased periprosthetic fractures as well as concerns about component loosening, especially press-fit components. In addition, many patients are receiving immunosuppressive medications, increasing the risk of prosthetic infection. Concentric joint involvement and decreased bone stock increase the frequency of significant central glenoid erosion. Therefore, whereas total shoulder arthroplasty (TSA) has demonstrated improved pain and range of motion and decreased risk of revision in the general population compared with hemiarthroplasty
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.09.016
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Table I Clinical data and disease characteristics of 255 patients included in the clinical analysis Total (n ¼ 255) Median age, years (range) Gender, n (%) Female Male Rotator cuff, n (%) Intact Thin Torn
55 (17-83)
TSA (n ¼ 165) 56 (17-83)
HA (n ¼ 90) 53 (21-76)
190 (54%) 65 (26%)
120 (73%) 45 (27%)
70 (78%) 20 (22%)
83 (32%) 122 (48%) 50 (20%)
58 (35%) 71 (43%) 36 (22%)
25 (28%) 51 (57%) 14 (16%)
(HA), it is unclear if patient considerations specific to RA would make HA more favorable.3-5,7,9,10,19-21,23,26,27,29-31 Sperling et al27 documented a series of 303 consecutive shoulder arthroplasties in patients with RA. Survivorship and clinical results were published, with a minimum of 2 years of clinical follow-up. They documented improvement in range of motion and pain, with a low risk of revision in TSA and HA. In patients with an intact rotator cuff, there was improved pain relief and elevation with TSA. There was a high incidence, however, of glenoid component lucency in TSA (72%) and glenoid wear in HA (98%), making long-term durability a significant concern. This study is an update of the previously documented patient cohort, with a minimum 5-year clinical follow-up.
Materials and methods Patients All TSAs and HAs performed in patients with RA between January 1, 1976, and December 31, 1991, at 1 institution were included in the analysis. This included 108 HAs and 195 TSAs (303 total arthroplasties in 247 patients). All patients were included in the Kaplan-Meier survivorship analysis. Patients were included in the clinical analysis if they had at least 5 years of clinical follow-up or follow-up until revision. There were 30 TSAs (20 died, 10 were lost to follow-up) and 18 HAs (13 died, 5 were lost to follow-up) excluded from the clinical analysis. Therefore, there was a total of 165 TSAs available for clinical analysis (average follow-up, 13.8 years). A total of 90 HAs were available for clinical analysis (average follow-up, 13.8 years). Characteristics of the 255 patients included in the clinical analysis are summarized in Table I. Patients included in the clinical analysis were significantly younger than those who were excluded (age at surgery 57 years vs 63 years; P < .001), but there was no significant difference between the groups in terms of gender or HA versus TSA.
and the patient’s willingness to accept postoperative restrictions. The age, previous procedures, rotator cuff status, components used, additional procedures, and intraoperative complications were cataloged previously. Approximately 85% of humeral components were press-fit. These data are summarized in Table II.
Clinical assessment Patients were followed up with use of our institution’s joint registry, asking patients to return for examination, interview, and radiographs at regular intervals. Patients are sent questionnaires if they are unable to return for evaluation. Clinical analysis is recorded on the basis of a standardized shoulder analysis sheet. Range of motion is recorded in degrees. Pain scores are documented in accordance with Cofield et al6 and Neer et al.22 Pain scores were graded as follows: 1, no pain; 2, slight pain; 3, pain after unusual activity; 4, moderate pain; and 5, severe pain.
Radiographic assessment Patients were included in the radiographic analysis if they had radiographs obtained >5 years postoperatively or until revision. There were 129 TSAs and 59 HAs included in this analysis, with a median follow-up of 10.4 years. All radiographs available for each patient were reviewed. The standard series included internal and external rotation anteroposterior views and axillary view. Radiographs were specifically reviewed for periprosthetic lucency, component shift in position, glenohumeral subluxation, and glenoid erosion. Components were defined as having failed radiographically and classified ‘‘at risk’’ for clinical failure if either a complete lucent line of 1.5 mm was present or the component had shifted in position.
Statistical analysis Descriptive statistics are reported as mean (standard deviation) for continuous measures and number (percentage) for discrete assessments. A paired t test was used to compare preoperative versus postoperative changes in pain, elevation, external rotation, and internal rotation. A Fisher exact test was used to compare baseline factors, including rotator cuff tear, gender, and type of surgery, with outcomes measured at last follow-up, such as humeral lucency, humeral shift, glenoid lucency, glenoid shift, and subluxation. A two-sample t test was used to compare age at time of surgery with humeral lucency, humeral shift, glenoid lucency, glenoid shift, and subluxation. Survival free of component revision or removal was estimated with the KaplanMeier method, reporting the estimate and 95% confidence intervals. The a level for all tests was set at .05 for statistical significance.
Results
Operative technique
Survivorship analysis
Patients were indicated for TSA or HA on the basis of the surgeon’s discretion, with careful consideration given to preoperative assessment of rotator cuff status and function, glenoid bone stock,
Total shoulder arthroplasty Seventeen TSA patients had revision surgery. Nine patients (5%) had glenoid component loosening. Four of these
Surgical details and complications of 303 consecutive patients with rheumatoid arthritis undergoing shoulder arthroplasty
Total shoulder arthroplasty
Previous procedures
Component used
Additional procedures
Complications
1 Synovectomy
Humeral
165 Press-fit
11 Acromioplasty
10 Nerve injuries
6 Complete recovery 4 Partial recovery
30 Cemented
1 Acromioplasty þ distal clavicle excision 3 Distal clavicle excision
3 Wound problems
17 Humeral bone grafting
4 Intraoperative fractures
1 Superficial dehiscence with delayed closure 1 Superficial stitch abscess 1 Hematoma requiring I/D 1 Metaphyseal humerus
1 Manipulation 1 Rotator cuff repair
Glenoid
154 Neer (all cemented)
41 Cofield (17 cemented, 24 ingrowth)
9 Glenoid bone grafting
Hemiarthroplasty
1 Bursectomy 1 ORIF humeral nonunion
Humeral
91 Press-fit
Shoulder arthroplasty for rheumatoid arthritis
Table II
1 Greater tuberosity 1 Glenoid 1 Humeral shaft
11 Acromioplasty
1 Postoperative humeral shaft fracture 1 Deltoid tear, with intraoperative repair 19 complications in 18 shoulders 3 Nerve problems
1 Distal clavicle excision
5 Intraoperative fractures
13 Humeral bone grafting 1 Glenoid bone grafting
1 Wound problem
2 Complete recovery 1 Partial recovery with RSD
17 Cemented 3 1 1 1
Greater tuberosity Humeral shaft Coracoid Superficial dehiscence resolved with dressing changes
9 Complications in 9 shoulders I/D, incision and drainage; ORIF, open reduction and internal fixation; RSD, reflex sympathetic dystrophy.
793
794
J.D. Barlow et al.
Figure 1 Patient with a left total shoulder arthroplasty with an uncemented humeral component and a cemented glenoid demonstrating glenoid component loosening, which was progressive at 20 years postoperatively. The patient underwent revision with glenoid component removal and hemiarthroplasty placement.
Figure 2 Overall survivorship of total shoulder arthroplasty (TSA) and hemiarthroplasty (humeral head replacement [HHR]) in patients with rheumatoid arthritis.
patients were revised to HA (example shown in Fig. 1). Two patients underwent revision TSA and 1 underwent shoulder resection. Two patients had combined glenoid and humeral component loosening; 1 of these underwent revision TSA with cemented components and 1 underwent conversion to HA. Four patients (2%) had resection arthroplasty for infection. Two patients had rotator cuff tears with superior humeral translation. Both underwent rotator cuff repairs, with 1 being converted to HA and the other treated with revision TSA. One patient had humeral component loosening secondary to periprosthetic fracture. A final patient had instability and was treated with a revision TSA. In all TSAs, the 10-year survivorship free of revision was 92.9% (Fig. 2). In TSA with and without an intact rotator cuff, the 10-year survivorship free of revision was 96.7% (95% CI: 91.4-100) and 90.7% (95% CI: 84.1-96.8), respectively (Fig. 3; Table III). Hemiarthroplasty Eleven patients had revision surgery. Eight patients had revision for symptomatic glenoid wear. They were all revised to TSA. One patient underwent revision with open
Figure 3 Survivorship of total shoulder arthroplasty (TSA) and hemiarthroplasty (humeral head replacement [HHR]) in rheumatoid arthritis stratified by rotator cuff status.
reduction and internal fixation of a periprosthetic fracture 2 months postoperatively. One revision was completed at another institution for unknown indications. One patient had posterior instability and underwent revision to TSA with posterior capsular plication. The overall survivorship free of revision in patients with HA at 10 years was 87.9% (95% CI: 81.3-94.9) (Fig. 2). In HA with and without an intact rotator cuff, the 10-year survivorship free of revision was 75.8% (95% CI: 60.394.7) and 92.6% (95% CI: 85.8-99.1), respectively (Fig. 3; Table III). Total shoulder vs hemiarthroplasty Considering all 303 arthroplasties in a multiple variable mode that includes age at time of surgery, gender, and HA versus TSA, none of the variables was significantly associated with the risk of revision (P > .5). Limited to shoulders with an intact rotator cuff, there was a weak trend toward improved survivorship of TSA relative to HA (hazard ratio ¼ 0.4; 95% CI: 0.1-1.4; P ¼ .15). In shoulders that did not have an intact rotator cuff, age at surgery, gender, and HA versus TSA were each not significantly associated with risk of revision (P > .05).
Shoulder arthroplasty for rheumatoid arthritis Table III
795
Arthroplasty survivorship free of component revision or removal 5-year
All TSA TSA with intact rotator cuff TSA without intact rotator cuff All HA HA with intact rotator cuff HA without intact rotator cuff
10-year
20-year
Percent
Confidence interval
Percent
Confidence interval
Percent
Confidence interval
96.1 96.7 95.8 89.2 80.0 92.6
93.2-99.0 92.2-100 92.1-99.5 83.1-95.8 65.8-97.3 86.5-99.1
92.9 96.7 90.7 87.9 75.8 92.6
88.8-97.1 91.4-100 84.1-96.8 81.3-94.9 60.3-94.7 85.8-99.1
87.2 89.0 86.0 87.9 75.8 92.6
80.2-94.3 76.5-100 77.2-95.0 76.6-94.9 52.5-94.7 80.7-99.1
TSA, total shoulder arthroplasty; HA, hemiarthroplasty.
Clinical analysis Pain In patients with TSA, pain scores improved significantly with a mean decrease of 2.8 from preoperative (4.8 0.4) to final postoperative values (1.9 1.4; P < .001). In patients with HA, pain score also improved significantly with a mean decrease of 2.4 from preoperative to postoperative scores (4.8 0.4 and 2.4 1.4; P < .001; Table IV). The decrease in pain score was greater in shoulders treated with TSA (P ¼ .04). In patients with an intact rotator cuff, the decrease in pain score was also greater in patients with a TSA compared with HA (2.7 vs 1.8; P ¼ .02). In patients without an intact rotator cuff, there was no significant difference in pain relief between TSA and HA (2.7 vs 2.9; P ¼ .28; Table V). Range of motion The mean range of motion improved significantly in patients with both HA and TSA. In patients with TSA, the mean elevation improved 35 from 71 35 to 105 46 (P < .001); external rotation improved 17 from 31 26 to 48 26 (P < .001). Internal rotation did not change significantly (P ¼ .26). In patients with HA, elevation improved 32 from 70 26 to 102 37 (P < .001); external rotation improved 16 from 24 25 to 40 25 (P <.001). Internal rotation did not change significantly (P ¼ .24; Table IV). In patients with an intact rotator cuff, there was a trend toward greater improvement in elevation with TSA versus HA (45 53 and 24 46 , respectively; P ¼ .08). There was no significant difference in the amount of improvement of external rotation or internal rotation between HA and TSA with an intact rotator cuff (P ¼ .24 and P ¼ .09). In the patients without an intact rotator cuff, there was no significant difference in improvement in elevation, external rotation, or internal rotation between patients who had HA versus TSA (P > .05; Table V).
Radiographs Total shoulder arthroplasty Humeral periprosthetic lucency was detectable in 38 of the 129 (29%) TSAs available for radiographic analysis.
Position of the humeral component had shifted in 39 shoulders (30%). Of 129 humeral components, 40 (31%) were classified as being at risk for clinical failure (Table VI). Periprosthetic lucency about the glenoid component was present in 93 of 129 shoulders (73%). Female patients were more likely than male patients to have some degree of glenoid lucency (78% vs 59%; P ¼ .03). The presence of glenoid lucency was similar between patients with an intact and a torn rotator cuff (70% vs 74%; P ¼ .69). Shift in position of the glenoid component was present in 42 shoulders (33%), and no significant difference in the rate of glenoid shift was present in patients with an intact rotator cuff (32%) compared with patients with a rotator cuff tear (35%; P ¼ .71). Of 129 glenoid components, 46 (36%) were classified as at risk for clinical failure. At least some degree of superior glenohumeral subluxation was present in 104 of 129 shoulders (81%). Shoulders with a torn rotator cuff were more likely to have moderate or severe subluxation (68% vs 40%; P < .001; Table VI). Hemiarthroplasty Humeral periprosthetic lucency was present in 17 of 59 (29%) HAs. There was no difference in the presence of humeral lucency in patients undergoing TSA compared with HA. Shift in position of the humeral component was present in 18 shoulders (31%). Eighteen humeral components (31%) were classified as at risk for clinical failure. Glenoid erosion was present in 58 of 59 shoulders (98%) at last follow-up. The presence of glenoid erosion could not be statistically correlated to patient gender or status of the rotator cuff. Glenohumeral subluxation was present in 49 hemiarthroplasties (83%) (Table VI). Total shoulder vs hemiarthroplasty There was no significant association in the rate of humeral component lucency or shift between those patients who underwent TSA and those who underwent HA (P ¼ 1.0 and .60, respectively). Similarly, the presence of glenohumeral subluxation was not significantly associated with TSA or HA (P ¼ .26).
796 Table IV
J.D. Barlow et al. Clinical outcomes of shoulders with >5 years of follow-up or revised
Pain Number of shoulders Preoperative Postoperative Change, preoperative postoperative Elevation Number of shoulders Preoperative Postoperative Change, preoperative postoperative External rotation Number of shoulders Preoperative Postoperative Change, preoperative postoperative Internal rotation Number of shoulders Preoperative Postoperative Change, preoperative postoperative
Total
TSA
Mean SD
Mean SD
to
255 4.8 0.4 2.1 1.4 2.7 1.4
165 4.8 0.4 1.9 1.4 2.8 1.4
to
250 71 32 105 42 34 47
161 71 35 106 46 35 50
to
249 29 26 45 26 16 34
159 31 26 48 26 17 35
to
245 L5 3 levels L4 4 levels 0.5 5 levels
160 L4 3 levels L4 4 levels 0.4 4.6 levels
P valuey
HA P value)
Mean SD
P value)
<.001
90 4.8 0.4 2.4 1.4 2.4 1.5
<.001
.04
<.001
.59
<.001
.88
.24
.75
89 70 26 102 36 32 41
<.001
90 24 25 40 25 16 32
<.001
85 L5 4 levels L4 3 levels 0.6 4.8 levels
.26
TSA, total shoulder arthroplasty; HA, hemiarthroplasty. Values appearing in bold indicate signicance (P <.05). ) Paired t test for non-zero change within TSA and within HA. y Two-sample t test for a difference in the change between TSA and HA.
Table V
Change in clinical outcomes of shoulders by rotator cuff status, intact versus nonintact
Change, preoperative to postoperative, for:
Intact rotator cuff
Pain, mean SD Elevation, mean SD External rotation, mean SD Internal rotation, mean SD
1.8 24.4 12.6 1
HA
Nonintact rotator cuff P value) HA
TSA
1.5 2.7 1.4 45.9 44.8 52.9 24.8 21.0 37.7 4 levels 1 3.8 levels
.02 .08 .24 .09
2.7 35.2 17.4 1.1
TSA
1.4 2.9 1.4 39.2 30.2 48.0 34.6 14.3 32.8 4.9 levels 0.1 5.0 levels
P value) .28 .46 .57 .21
HA, hemiarthroplasty; TSA, total shoulder arthroplasty. Values appearing in bold indicate signicance (P <.05). ) Two-sample t test for a difference in the change between TSA and HA.
Discussion Patients with RA present unique challenges in performing shoulder arthroplasty. Osteopenia, rotator cuff tears, severe glenoid erosion, and immunosuppressing medications are common. Profound osteopenia in these patients increases concerns about press-fit implants and the long-term survivorship of glenoid components. Many patients have rotator cuff thinning or tearing, leading to superior subluxation. Taken together, these factors have decreased enthusiasm about TSA, with some advocating for HA.2,8,13,17,18
However, data support improved range of motion, pain relief, and risk of revision with TSA versus HA in the general population.1,16 The specific indications for and the intermediate and long-term outcomes of shoulder arthroplasty in patients with RA have been poorly characterized.3-5,7,9,10,19-21,23,27,29-31 The objective of this study was to assess the intermediate-term outcome (>5 years of clinical follow-up) of shoulder arthroplasty in patients with TSA. Shoulder arthroplasty had excellent long-term survivorship in this patient population. The overall 10-year
Radiographic analysis of patients Number
Glenoid Fixation
TSA Cuff intact Cuff not intact (thin or torn) HA Cuff intact Cuff not intact (thin or torn)
1 mm
2 mm
Shift
At risk
26 9 17
42 16 26
46 19 27
d d d
d d d
d d d
Uncemented
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
129 50 79
113 46 67
16 4 12
11 4 7
25 9 16
6 3 3
25 10 15
25 10 15
59 18 41
d d d
d d d
d d d
d d d
d d d
d d d
d d d
Number
Humerus Fixation
TSA Cuff intact Cuff not intact (thin or torn) HA Cuff intact Cuff not intact (thin or torn)
1.5 mm
Cemented
Shoulder arthroplasty for rheumatoid arthritis
Table VI
1 mm
1.5 mm
2 mm
Shift
Cemented
Uncemented
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
129 50 79
16 4 12
113 46 67
1 1 0
10 3 7
5 1 4
16 5 11
16 5 11
6 5 1
39 15 24
59 18 41
5 0 5
54 18 36
2 1 1
8 3 5
1 0 1
6 2 4
6 2 4
0 0 0
18 8 10
At risk
Superior Subluxation Mild
Moderate
Severe
40 16 24
29 10 19
39 14 25
36 8 28
18 8 10
19 9 10
20 3 17
10 1 9
TSA, total shoulder arthroplasty; HA, hemiarthroplasty.
797
798 survivorship was 92.9% for TSAs and 87.9% for HAs. There was a trend toward improved survivorship for TSA over HA in patients with an intact rotator cuff (96.7% vs 75.8% at 10 years; P ¼ .15). These rates of revision are in accordance with our previous report of these patients as well as with previous studies of TSA and HA in patients with RA.3,4,7,20,27 Overall, there was reasonable longevity of both TSA and HA in this patient population. Whereas pain relief was achieved with both TSA and HA, there was significantly better pain relief in patients with TSA in the setting of an intact rotator cuff. This finding has been supported in recent epidemiologic studies of shoulder arthroplasties in the general population as well as in previous series of rheumatoid patients.1,7 When there was a thin or torn rotator cuff, however, there was no significant difference in pain relief between TSA and HA, indicating the importance of rotator cuff integrity in this clinical situation. Furthermore, rotator cuff tearing could be an indication for increased use of reverse TSA, although early reports of this design demonstrate clinically important complications in this patient population.12,24,32 Similarly, patients with both HA and TSA had significant improvements in active external rotation and elevation. Patients with an intact rotator cuff had a trend toward greater improvement in elevation with TSA compared with HA. Previous studies have documented improved motion in patients with osteoarthritis and RA with TSA over HA.1,7 Despite survival durability, there was a relatively high rate of humeral component periprosthetic lucency and component shift (30%) as well as glenoid component lucency (73%). Component lucency was more common in female patients. This rate of lucency corresponds with our previous study (humeral, 32%; glenoid, 72%). Further, these correspond to historical accounts, which have documented high rates of radiographic humeral (12%-31%) and glenoid loosening (40%-86%).3,11,14,15,20,26,27,30 This may be reflective of the poor bone quality in this subgroup of patients. In spite of these radiologic changes, there was a low rate of revision for glenoid loosening (5% of TSA), and there were no revisions for isolated humeral component loosening. There was a very high rate of glenoid wear in this patient population (98%). This account mirrors our previous study as well as other studies of HA in RA.8,27 There was a 7% revision rate of HA to TSA for symptomatic glenoid arthrosis. There are several important limitations to this study. This is a retrospective registry-based study of patients with RA. There is a significant selection bias, with the surgeon choosing the implant type on the basis of several clinical factors, including bone stock and rotator cuff status. This could lead to less healthy patients and more complex cases being treated with HA rather than with TSA, influencing the results. In addition, follow-up by examination is inconsistent, and survey forms may be misinterpreted by the patient, leading to inaccuracies. A randomized trial
J.D. Barlow et al. would better assess the risks and benefits of TSA versus HA in this population. Furthermore, there were several different implants used throughout the study period, with different fixation (cemented, press-fit, all-polyethylene glenoid, metal-backed glenoid components). It is unclear how modern implants would fare in comparison.
Conclusion Overall, both HA and TSA provide reliable options for pain relief and improved elevation and external rotation in patients with RA. In patients with an intact rotator cuff, there was significantly better pain relief and a trend toward improved motion and survivorship with TSA versus HA. Whereas humeral and glenoid component lucencies were common, there were few revisions (5%) for glenoid component loosening and no revisions for isolated humeral component loosening. Seven percent of HAs were revised for symptomatic glenoid erosion.
Disclaimer Robert Cofield, MD, receives royalties from SmithNephew. John Sperling, MD, receives royalties from Biomet. All the other authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Adams JE, Sperling JW, Schleck CD, Harmsen WS, Cofield RH. Outcomes of shoulder arthroplasty in Olmsted County, Minnesota: a population-based study. Clin Orthop Relat Res 2007;455:176-82. http://dx.doi.org/10.1097/01.blo.0000238870.99980.64 2. Alund M, Hoe-Hansen C, Tillander B, Heden BA, Norlin R. Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a retrospective evaluation of 39 patients followed for 2-6 years. Acta Orthop Scand 2000;71:180-4. 3. Barrett WP, Thornhill TS, Thomas WH, Gebhart EM, Sledge CB. Nonconstrained total shoulder arthroplasty in patients with polyarticular rheumatoid arthritis. J Arthroplasty 1989;4:91-6. 4. Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br 2009;91:1197-2005. http://dx.doi.org/10.1302/0301620X.91B9.22035 5. Christie A, Dagfinrud H, Ringen HO, Hagen KB. Beneficial and harmful effects of shoulder arthroplasty in patients with rheumatoid arthritis: results from a Cochrane review. Rheumatology (Oxford) 2011;50:598-602. http://dx.doi.org/10.1093/rheumatology/keq345
Shoulder arthroplasty for rheumatoid arthritis 6. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am 1984;66:899-906. 7. Collins DN, Harryman DT 2nd, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86: 2489-96. 8. Fuerst M, Fink B, Ruther W. The DUROM cup humeral surface replacement in patients with rheumatoid arthritis. J Bone Joint Surg Am 2007;89:1756-62. http://dx.doi.org/10.2106/JBJS.F.01290 9. Gadea F, Alami G, Pape G, Boileau P, Favard L. Shoulder hemiarthroplasty: outcomes and long-term survival analysis according to etiology. Orthop Traumatol Surg Res 2012;98:659-65. http://dx.doi. org/10.1016/j.otsr.2012.03.020 10. Hambright D, Henderson RA, Cook C, Worrell T, Moorman CT, Bolognesi MP. A comparison of perioperative outcomes in patients with and without rheumatoid arthritis after receiving a total shoulder replacement arthroplasty. J Shoulder Elbow Surg 2011;20:77-85. http://dx.doi.org/10.1016/j.jse.2010.03.005 11. Hawkins RJ, Bell RH, Jallay B. Total shoulder arthroplasty. Clin Orthop Relat Res 1989:188-94. 12. Holcomb JO, Hebert DJ, Mighell MA, Dunning PE, Pupello DR, Pliner MD, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2010;19:1076-84. http:// dx.doi.org/10.1016/j.jse.2009.11.049 13. Jonsson E, Egund N, Kelly I, Rydholm U, Lidgren L. Cup arthroplasty of the rheumatoid shoulder. Acta Orthop Scand 1986;57:542-6. 14. Kelly IG. Unconstrained shoulder arthroplasty in rheumatoid arthritis. Clin Orthop Relat Res 1994:94-102. 15. Kelly IG, Foster RS, Fisher WD. Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg Br 1987;69:723-6. 16. Levine WN, Fischer CR, Nguyen D, Flatow EL, Ahmad CS, Bigliani LU. Long-term follow-up of shoulder hemiarthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2012;94:e164. http://dx.doi.org/10.2106/JBJS.K.00603 17. Levy O, Funk L, Sforza G, Copeland SA. Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis. J Bone Joint Surg Am 2004;86:512-8. 18. Marmor L. Hemiarthroplasty for the rheumatoid shoulder joint. Clin Orthop Relat Res 1977:201-3. 19. Marsh DW. Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis. J Orthop Sports Phys Ther 2006;36:600-10. http://dx.doi.org/10.2519/jospt.2006.2226
799 20. McCoy SR, Warren RF, Bade HA 3rd, Ranawat CS, Inglis AE. Total shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1989;4: 105-11. 21. Mengshoel AM, Slungaard B. Effects of shoulder arthroplasty and exercise in patients with rheumatoid arthritis. Clin Rheumatol 2005; 24:258-65. http://dx.doi.org/10.1007/s10067-004-1026-0 22. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-37. 23. Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res 2006;448:28-32. http://dx.doi.org/10. 1097/01.blo.0000224007.25636.85 24. Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10: 17-22. 25. Rozing PM, Brand R. Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1998;13:311-9. 26. Sojbjerg JO, Frich LH, Johannsen HV, Sneppen O. Late results of total shoulder replacement in patients with rheumatoid arthritis. Clin Orthop Relat Res 1999:39-45. 27. Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg 2007;16:683-90. http://dx.doi.org/10.1016/j.jse.2007.02.135 28. Tanaka N, Sakahashi H, Hirose K, Ishima T, Ishii S. Augmented subscapularis muscle transposition for rotator cuff repair during shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2006;15:2-6. http://dx.doi.org/10.1016/j.jse.2005.04.004 29. Thomas BJ, Amstutz HC, Cracchiolo A. Shoulder arthroplasty for rheumatoid arthritis. Clin Orthop Relat Res 1991:125-8. 30. Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br 2002;84:1121-5. http:// dx.doi.org/10.1302/0301-620X.84B8.12695 31. Waldman BJ, Figgie MP. Indications, technique, and results of total shoulder arthroplasty in rheumatoid arthritis. Orthop Clin North Am 1998;29:435-44. 32. Young AA, Smith MM, Bacle G, Moraga C, Walch G. Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am 2011;93:1915-23. http://dx.doi.org/10.2106/JBJS. J.00300
www.elsevier.com/locate/ymse
Shoulder arthroplasty for rheumatoid arthritis: 303 consecutive cases with minimum 5-year follow-up Jonathan D. Barlow, MD, Brandon J. Yuan, MD, Cathy D. Schleck, BS, W. Scott Harmsen, MS, Robert H. Cofield, MD*, John W. Sperling, MD, MBA Mayo Clinic, Rochester, MN, USA Background: This is an update on a previously documented cohort of patients who underwent shoulder arthroplasty for rheumatoid arthritis, with a minimum 5-year clinical follow-up. Methods: The survivorship of 303 consecutive shoulder arthroplasties (108 hemiarthroplasties, 195 total shoulder arthroplasties) for rheumatoid arthritis at one institution was assessed. There were 255 arthroplasties in the clinical analysis and 188 in the radiographic analysis. Results: Kaplan-Meier survivorship free of revision at 5 years and 10 years was 96.1% and 92.9% for total shoulder arthroplasty (TSA) and 89.2% and 87.9% for hemiarthroplasty (HA). The most common indications were glenoid loosening (5%) and infection (2%) for TSA revision and glenoid arthrosis (7%) for HA revision. Pain relief was greater with TSA than with HA. In patients with an intact rotator cuff, in comparing TSA with HA, those with a TSA had greater improvements in pain scores (2.7 vs 1.8 on a 5-point scale) and degrees of elevation (45 versus 24) (P ¼ .08). Approximately 30% of humeral components and 73% of glenoid components had periprosthetic lucencies. There was a shift in position of the glenoid in 33% of TSAs, and 36% were ‘‘at risk.’’ Eighty-one percent of HAs had moderate or severe glenoid erosion. Discussion/Conclusion: Both HA and TSA provide pain relief and improved motion in patients with rheumatoid arthritis. In patients with an intact rotator cuff, pain relief and range of motion are more improved with TSA compared with HA. There is a high rate of component lucency, but component revision is uncommon. Level of evidence: Level IV, Case Series, Treatment Study. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Total shoulder arthroplasty; hemiarthroplasty; rheumatoid arthritis
Whereas shoulder arthritis is common in patients with rheumatoid arthritis (RA), shoulder arthroplasty in patients with RA has unique challenges. Decreased bone stock and a high incidence of rotator cuff tears are common in this group of patients.3,25,28 The osteopenia commonly seen in IRB: 11-003160. *Reprint requests: Robert H. Cofield, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. E-mail address: [email protected] (R.H. Cofield).
these patients can lead to increased periprosthetic fractures as well as concerns about component loosening, especially press-fit components. In addition, many patients are receiving immunosuppressive medications, increasing the risk of prosthetic infection. Concentric joint involvement and decreased bone stock increase the frequency of significant central glenoid erosion. Therefore, whereas total shoulder arthroplasty (TSA) has demonstrated improved pain and range of motion and decreased risk of revision in the general population compared with hemiarthroplasty
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2013.09.016
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Table I Clinical data and disease characteristics of 255 patients included in the clinical analysis Total (n ¼ 255) Median age, years (range) Gender, n (%) Female Male Rotator cuff, n (%) Intact Thin Torn
55 (17-83)
TSA (n ¼ 165) 56 (17-83)
HA (n ¼ 90) 53 (21-76)
190 (54%) 65 (26%)
120 (73%) 45 (27%)
70 (78%) 20 (22%)
83 (32%) 122 (48%) 50 (20%)
58 (35%) 71 (43%) 36 (22%)
25 (28%) 51 (57%) 14 (16%)
(HA), it is unclear if patient considerations specific to RA would make HA more favorable.3-5,7,9,10,19-21,23,26,27,29-31 Sperling et al27 documented a series of 303 consecutive shoulder arthroplasties in patients with RA. Survivorship and clinical results were published, with a minimum of 2 years of clinical follow-up. They documented improvement in range of motion and pain, with a low risk of revision in TSA and HA. In patients with an intact rotator cuff, there was improved pain relief and elevation with TSA. There was a high incidence, however, of glenoid component lucency in TSA (72%) and glenoid wear in HA (98%), making long-term durability a significant concern. This study is an update of the previously documented patient cohort, with a minimum 5-year clinical follow-up.
Materials and methods Patients All TSAs and HAs performed in patients with RA between January 1, 1976, and December 31, 1991, at 1 institution were included in the analysis. This included 108 HAs and 195 TSAs (303 total arthroplasties in 247 patients). All patients were included in the Kaplan-Meier survivorship analysis. Patients were included in the clinical analysis if they had at least 5 years of clinical follow-up or follow-up until revision. There were 30 TSAs (20 died, 10 were lost to follow-up) and 18 HAs (13 died, 5 were lost to follow-up) excluded from the clinical analysis. Therefore, there was a total of 165 TSAs available for clinical analysis (average follow-up, 13.8 years). A total of 90 HAs were available for clinical analysis (average follow-up, 13.8 years). Characteristics of the 255 patients included in the clinical analysis are summarized in Table I. Patients included in the clinical analysis were significantly younger than those who were excluded (age at surgery 57 years vs 63 years; P < .001), but there was no significant difference between the groups in terms of gender or HA versus TSA.
and the patient’s willingness to accept postoperative restrictions. The age, previous procedures, rotator cuff status, components used, additional procedures, and intraoperative complications were cataloged previously. Approximately 85% of humeral components were press-fit. These data are summarized in Table II.
Clinical assessment Patients were followed up with use of our institution’s joint registry, asking patients to return for examination, interview, and radiographs at regular intervals. Patients are sent questionnaires if they are unable to return for evaluation. Clinical analysis is recorded on the basis of a standardized shoulder analysis sheet. Range of motion is recorded in degrees. Pain scores are documented in accordance with Cofield et al6 and Neer et al.22 Pain scores were graded as follows: 1, no pain; 2, slight pain; 3, pain after unusual activity; 4, moderate pain; and 5, severe pain.
Radiographic assessment Patients were included in the radiographic analysis if they had radiographs obtained >5 years postoperatively or until revision. There were 129 TSAs and 59 HAs included in this analysis, with a median follow-up of 10.4 years. All radiographs available for each patient were reviewed. The standard series included internal and external rotation anteroposterior views and axillary view. Radiographs were specifically reviewed for periprosthetic lucency, component shift in position, glenohumeral subluxation, and glenoid erosion. Components were defined as having failed radiographically and classified ‘‘at risk’’ for clinical failure if either a complete lucent line of 1.5 mm was present or the component had shifted in position.
Statistical analysis Descriptive statistics are reported as mean (standard deviation) for continuous measures and number (percentage) for discrete assessments. A paired t test was used to compare preoperative versus postoperative changes in pain, elevation, external rotation, and internal rotation. A Fisher exact test was used to compare baseline factors, including rotator cuff tear, gender, and type of surgery, with outcomes measured at last follow-up, such as humeral lucency, humeral shift, glenoid lucency, glenoid shift, and subluxation. A two-sample t test was used to compare age at time of surgery with humeral lucency, humeral shift, glenoid lucency, glenoid shift, and subluxation. Survival free of component revision or removal was estimated with the KaplanMeier method, reporting the estimate and 95% confidence intervals. The a level for all tests was set at .05 for statistical significance.
Results
Operative technique
Survivorship analysis
Patients were indicated for TSA or HA on the basis of the surgeon’s discretion, with careful consideration given to preoperative assessment of rotator cuff status and function, glenoid bone stock,
Total shoulder arthroplasty Seventeen TSA patients had revision surgery. Nine patients (5%) had glenoid component loosening. Four of these
Surgical details and complications of 303 consecutive patients with rheumatoid arthritis undergoing shoulder arthroplasty
Total shoulder arthroplasty
Previous procedures
Component used
Additional procedures
Complications
1 Synovectomy
Humeral
165 Press-fit
11 Acromioplasty
10 Nerve injuries
6 Complete recovery 4 Partial recovery
30 Cemented
1 Acromioplasty þ distal clavicle excision 3 Distal clavicle excision
3 Wound problems
17 Humeral bone grafting
4 Intraoperative fractures
1 Superficial dehiscence with delayed closure 1 Superficial stitch abscess 1 Hematoma requiring I/D 1 Metaphyseal humerus
1 Manipulation 1 Rotator cuff repair
Glenoid
154 Neer (all cemented)
41 Cofield (17 cemented, 24 ingrowth)
9 Glenoid bone grafting
Hemiarthroplasty
1 Bursectomy 1 ORIF humeral nonunion
Humeral
91 Press-fit
Shoulder arthroplasty for rheumatoid arthritis
Table II
1 Greater tuberosity 1 Glenoid 1 Humeral shaft
11 Acromioplasty
1 Postoperative humeral shaft fracture 1 Deltoid tear, with intraoperative repair 19 complications in 18 shoulders 3 Nerve problems
1 Distal clavicle excision
5 Intraoperative fractures
13 Humeral bone grafting 1 Glenoid bone grafting
1 Wound problem
2 Complete recovery 1 Partial recovery with RSD
17 Cemented 3 1 1 1
Greater tuberosity Humeral shaft Coracoid Superficial dehiscence resolved with dressing changes
9 Complications in 9 shoulders I/D, incision and drainage; ORIF, open reduction and internal fixation; RSD, reflex sympathetic dystrophy.
793
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J.D. Barlow et al.
Figure 1 Patient with a left total shoulder arthroplasty with an uncemented humeral component and a cemented glenoid demonstrating glenoid component loosening, which was progressive at 20 years postoperatively. The patient underwent revision with glenoid component removal and hemiarthroplasty placement.
Figure 2 Overall survivorship of total shoulder arthroplasty (TSA) and hemiarthroplasty (humeral head replacement [HHR]) in patients with rheumatoid arthritis.
patients were revised to HA (example shown in Fig. 1). Two patients underwent revision TSA and 1 underwent shoulder resection. Two patients had combined glenoid and humeral component loosening; 1 of these underwent revision TSA with cemented components and 1 underwent conversion to HA. Four patients (2%) had resection arthroplasty for infection. Two patients had rotator cuff tears with superior humeral translation. Both underwent rotator cuff repairs, with 1 being converted to HA and the other treated with revision TSA. One patient had humeral component loosening secondary to periprosthetic fracture. A final patient had instability and was treated with a revision TSA. In all TSAs, the 10-year survivorship free of revision was 92.9% (Fig. 2). In TSA with and without an intact rotator cuff, the 10-year survivorship free of revision was 96.7% (95% CI: 91.4-100) and 90.7% (95% CI: 84.1-96.8), respectively (Fig. 3; Table III). Hemiarthroplasty Eleven patients had revision surgery. Eight patients had revision for symptomatic glenoid wear. They were all revised to TSA. One patient underwent revision with open
Figure 3 Survivorship of total shoulder arthroplasty (TSA) and hemiarthroplasty (humeral head replacement [HHR]) in rheumatoid arthritis stratified by rotator cuff status.
reduction and internal fixation of a periprosthetic fracture 2 months postoperatively. One revision was completed at another institution for unknown indications. One patient had posterior instability and underwent revision to TSA with posterior capsular plication. The overall survivorship free of revision in patients with HA at 10 years was 87.9% (95% CI: 81.3-94.9) (Fig. 2). In HA with and without an intact rotator cuff, the 10-year survivorship free of revision was 75.8% (95% CI: 60.394.7) and 92.6% (95% CI: 85.8-99.1), respectively (Fig. 3; Table III). Total shoulder vs hemiarthroplasty Considering all 303 arthroplasties in a multiple variable mode that includes age at time of surgery, gender, and HA versus TSA, none of the variables was significantly associated with the risk of revision (P > .5). Limited to shoulders with an intact rotator cuff, there was a weak trend toward improved survivorship of TSA relative to HA (hazard ratio ¼ 0.4; 95% CI: 0.1-1.4; P ¼ .15). In shoulders that did not have an intact rotator cuff, age at surgery, gender, and HA versus TSA were each not significantly associated with risk of revision (P > .05).
Shoulder arthroplasty for rheumatoid arthritis Table III
795
Arthroplasty survivorship free of component revision or removal 5-year
All TSA TSA with intact rotator cuff TSA without intact rotator cuff All HA HA with intact rotator cuff HA without intact rotator cuff
10-year
20-year
Percent
Confidence interval
Percent
Confidence interval
Percent
Confidence interval
96.1 96.7 95.8 89.2 80.0 92.6
93.2-99.0 92.2-100 92.1-99.5 83.1-95.8 65.8-97.3 86.5-99.1
92.9 96.7 90.7 87.9 75.8 92.6
88.8-97.1 91.4-100 84.1-96.8 81.3-94.9 60.3-94.7 85.8-99.1
87.2 89.0 86.0 87.9 75.8 92.6
80.2-94.3 76.5-100 77.2-95.0 76.6-94.9 52.5-94.7 80.7-99.1
TSA, total shoulder arthroplasty; HA, hemiarthroplasty.
Clinical analysis Pain In patients with TSA, pain scores improved significantly with a mean decrease of 2.8 from preoperative (4.8 0.4) to final postoperative values (1.9 1.4; P < .001). In patients with HA, pain score also improved significantly with a mean decrease of 2.4 from preoperative to postoperative scores (4.8 0.4 and 2.4 1.4; P < .001; Table IV). The decrease in pain score was greater in shoulders treated with TSA (P ¼ .04). In patients with an intact rotator cuff, the decrease in pain score was also greater in patients with a TSA compared with HA (2.7 vs 1.8; P ¼ .02). In patients without an intact rotator cuff, there was no significant difference in pain relief between TSA and HA (2.7 vs 2.9; P ¼ .28; Table V). Range of motion The mean range of motion improved significantly in patients with both HA and TSA. In patients with TSA, the mean elevation improved 35 from 71 35 to 105 46 (P < .001); external rotation improved 17 from 31 26 to 48 26 (P < .001). Internal rotation did not change significantly (P ¼ .26). In patients with HA, elevation improved 32 from 70 26 to 102 37 (P < .001); external rotation improved 16 from 24 25 to 40 25 (P <.001). Internal rotation did not change significantly (P ¼ .24; Table IV). In patients with an intact rotator cuff, there was a trend toward greater improvement in elevation with TSA versus HA (45 53 and 24 46 , respectively; P ¼ .08). There was no significant difference in the amount of improvement of external rotation or internal rotation between HA and TSA with an intact rotator cuff (P ¼ .24 and P ¼ .09). In the patients without an intact rotator cuff, there was no significant difference in improvement in elevation, external rotation, or internal rotation between patients who had HA versus TSA (P > .05; Table V).
Radiographs Total shoulder arthroplasty Humeral periprosthetic lucency was detectable in 38 of the 129 (29%) TSAs available for radiographic analysis.
Position of the humeral component had shifted in 39 shoulders (30%). Of 129 humeral components, 40 (31%) were classified as being at risk for clinical failure (Table VI). Periprosthetic lucency about the glenoid component was present in 93 of 129 shoulders (73%). Female patients were more likely than male patients to have some degree of glenoid lucency (78% vs 59%; P ¼ .03). The presence of glenoid lucency was similar between patients with an intact and a torn rotator cuff (70% vs 74%; P ¼ .69). Shift in position of the glenoid component was present in 42 shoulders (33%), and no significant difference in the rate of glenoid shift was present in patients with an intact rotator cuff (32%) compared with patients with a rotator cuff tear (35%; P ¼ .71). Of 129 glenoid components, 46 (36%) were classified as at risk for clinical failure. At least some degree of superior glenohumeral subluxation was present in 104 of 129 shoulders (81%). Shoulders with a torn rotator cuff were more likely to have moderate or severe subluxation (68% vs 40%; P < .001; Table VI). Hemiarthroplasty Humeral periprosthetic lucency was present in 17 of 59 (29%) HAs. There was no difference in the presence of humeral lucency in patients undergoing TSA compared with HA. Shift in position of the humeral component was present in 18 shoulders (31%). Eighteen humeral components (31%) were classified as at risk for clinical failure. Glenoid erosion was present in 58 of 59 shoulders (98%) at last follow-up. The presence of glenoid erosion could not be statistically correlated to patient gender or status of the rotator cuff. Glenohumeral subluxation was present in 49 hemiarthroplasties (83%) (Table VI). Total shoulder vs hemiarthroplasty There was no significant association in the rate of humeral component lucency or shift between those patients who underwent TSA and those who underwent HA (P ¼ 1.0 and .60, respectively). Similarly, the presence of glenohumeral subluxation was not significantly associated with TSA or HA (P ¼ .26).
796 Table IV
J.D. Barlow et al. Clinical outcomes of shoulders with >5 years of follow-up or revised
Pain Number of shoulders Preoperative Postoperative Change, preoperative postoperative Elevation Number of shoulders Preoperative Postoperative Change, preoperative postoperative External rotation Number of shoulders Preoperative Postoperative Change, preoperative postoperative Internal rotation Number of shoulders Preoperative Postoperative Change, preoperative postoperative
Total
TSA
Mean SD
Mean SD
to
255 4.8 0.4 2.1 1.4 2.7 1.4
165 4.8 0.4 1.9 1.4 2.8 1.4
to
250 71 32 105 42 34 47
161 71 35 106 46 35 50
to
249 29 26 45 26 16 34
159 31 26 48 26 17 35
to
245 L5 3 levels L4 4 levels 0.5 5 levels
160 L4 3 levels L4 4 levels 0.4 4.6 levels
P valuey
HA P value)
Mean SD
P value)
<.001
90 4.8 0.4 2.4 1.4 2.4 1.5
<.001
.04
<.001
.59
<.001
.88
.24
.75
89 70 26 102 36 32 41
<.001
90 24 25 40 25 16 32
<.001
85 L5 4 levels L4 3 levels 0.6 4.8 levels
.26
TSA, total shoulder arthroplasty; HA, hemiarthroplasty. Values appearing in bold indicate signicance (P <.05). ) Paired t test for non-zero change within TSA and within HA. y Two-sample t test for a difference in the change between TSA and HA.
Table V
Change in clinical outcomes of shoulders by rotator cuff status, intact versus nonintact
Change, preoperative to postoperative, for:
Intact rotator cuff
Pain, mean SD Elevation, mean SD External rotation, mean SD Internal rotation, mean SD
1.8 24.4 12.6 1
HA
Nonintact rotator cuff P value) HA
TSA
1.5 2.7 1.4 45.9 44.8 52.9 24.8 21.0 37.7 4 levels 1 3.8 levels
.02 .08 .24 .09
2.7 35.2 17.4 1.1
TSA
1.4 2.9 1.4 39.2 30.2 48.0 34.6 14.3 32.8 4.9 levels 0.1 5.0 levels
P value) .28 .46 .57 .21
HA, hemiarthroplasty; TSA, total shoulder arthroplasty. Values appearing in bold indicate signicance (P <.05). ) Two-sample t test for a difference in the change between TSA and HA.
Discussion Patients with RA present unique challenges in performing shoulder arthroplasty. Osteopenia, rotator cuff tears, severe glenoid erosion, and immunosuppressing medications are common. Profound osteopenia in these patients increases concerns about press-fit implants and the long-term survivorship of glenoid components. Many patients have rotator cuff thinning or tearing, leading to superior subluxation. Taken together, these factors have decreased enthusiasm about TSA, with some advocating for HA.2,8,13,17,18
However, data support improved range of motion, pain relief, and risk of revision with TSA versus HA in the general population.1,16 The specific indications for and the intermediate and long-term outcomes of shoulder arthroplasty in patients with RA have been poorly characterized.3-5,7,9,10,19-21,23,27,29-31 The objective of this study was to assess the intermediate-term outcome (>5 years of clinical follow-up) of shoulder arthroplasty in patients with TSA. Shoulder arthroplasty had excellent long-term survivorship in this patient population. The overall 10-year
Radiographic analysis of patients Number
Glenoid Fixation
TSA Cuff intact Cuff not intact (thin or torn) HA Cuff intact Cuff not intact (thin or torn)
1 mm
2 mm
Shift
At risk
26 9 17
42 16 26
46 19 27
d d d
d d d
d d d
Uncemented
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
129 50 79
113 46 67
16 4 12
11 4 7
25 9 16
6 3 3
25 10 15
25 10 15
59 18 41
d d d
d d d
d d d
d d d
d d d
d d d
d d d
Number
Humerus Fixation
TSA Cuff intact Cuff not intact (thin or torn) HA Cuff intact Cuff not intact (thin or torn)
1.5 mm
Cemented
Shoulder arthroplasty for rheumatoid arthritis
Table VI
1 mm
1.5 mm
2 mm
Shift
Cemented
Uncemented
Complete
Incomplete
Complete
Incomplete
Complete
Incomplete
129 50 79
16 4 12
113 46 67
1 1 0
10 3 7
5 1 4
16 5 11
16 5 11
6 5 1
39 15 24
59 18 41
5 0 5
54 18 36
2 1 1
8 3 5
1 0 1
6 2 4
6 2 4
0 0 0
18 8 10
At risk
Superior Subluxation Mild
Moderate
Severe
40 16 24
29 10 19
39 14 25
36 8 28
18 8 10
19 9 10
20 3 17
10 1 9
TSA, total shoulder arthroplasty; HA, hemiarthroplasty.
797
798 survivorship was 92.9% for TSAs and 87.9% for HAs. There was a trend toward improved survivorship for TSA over HA in patients with an intact rotator cuff (96.7% vs 75.8% at 10 years; P ¼ .15). These rates of revision are in accordance with our previous report of these patients as well as with previous studies of TSA and HA in patients with RA.3,4,7,20,27 Overall, there was reasonable longevity of both TSA and HA in this patient population. Whereas pain relief was achieved with both TSA and HA, there was significantly better pain relief in patients with TSA in the setting of an intact rotator cuff. This finding has been supported in recent epidemiologic studies of shoulder arthroplasties in the general population as well as in previous series of rheumatoid patients.1,7 When there was a thin or torn rotator cuff, however, there was no significant difference in pain relief between TSA and HA, indicating the importance of rotator cuff integrity in this clinical situation. Furthermore, rotator cuff tearing could be an indication for increased use of reverse TSA, although early reports of this design demonstrate clinically important complications in this patient population.12,24,32 Similarly, patients with both HA and TSA had significant improvements in active external rotation and elevation. Patients with an intact rotator cuff had a trend toward greater improvement in elevation with TSA compared with HA. Previous studies have documented improved motion in patients with osteoarthritis and RA with TSA over HA.1,7 Despite survival durability, there was a relatively high rate of humeral component periprosthetic lucency and component shift (30%) as well as glenoid component lucency (73%). Component lucency was more common in female patients. This rate of lucency corresponds with our previous study (humeral, 32%; glenoid, 72%). Further, these correspond to historical accounts, which have documented high rates of radiographic humeral (12%-31%) and glenoid loosening (40%-86%).3,11,14,15,20,26,27,30 This may be reflective of the poor bone quality in this subgroup of patients. In spite of these radiologic changes, there was a low rate of revision for glenoid loosening (5% of TSA), and there were no revisions for isolated humeral component loosening. There was a very high rate of glenoid wear in this patient population (98%). This account mirrors our previous study as well as other studies of HA in RA.8,27 There was a 7% revision rate of HA to TSA for symptomatic glenoid arthrosis. There are several important limitations to this study. This is a retrospective registry-based study of patients with RA. There is a significant selection bias, with the surgeon choosing the implant type on the basis of several clinical factors, including bone stock and rotator cuff status. This could lead to less healthy patients and more complex cases being treated with HA rather than with TSA, influencing the results. In addition, follow-up by examination is inconsistent, and survey forms may be misinterpreted by the patient, leading to inaccuracies. A randomized trial
J.D. Barlow et al. would better assess the risks and benefits of TSA versus HA in this population. Furthermore, there were several different implants used throughout the study period, with different fixation (cemented, press-fit, all-polyethylene glenoid, metal-backed glenoid components). It is unclear how modern implants would fare in comparison.
Conclusion Overall, both HA and TSA provide reliable options for pain relief and improved elevation and external rotation in patients with RA. In patients with an intact rotator cuff, there was significantly better pain relief and a trend toward improved motion and survivorship with TSA versus HA. Whereas humeral and glenoid component lucencies were common, there were few revisions (5%) for glenoid component loosening and no revisions for isolated humeral component loosening. Seven percent of HAs were revised for symptomatic glenoid erosion.
Disclaimer Robert Cofield, MD, receives royalties from SmithNephew. John Sperling, MD, receives royalties from Biomet. All the other authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
References 1. Adams JE, Sperling JW, Schleck CD, Harmsen WS, Cofield RH. Outcomes of shoulder arthroplasty in Olmsted County, Minnesota: a population-based study. Clin Orthop Relat Res 2007;455:176-82. http://dx.doi.org/10.1097/01.blo.0000238870.99980.64 2. Alund M, Hoe-Hansen C, Tillander B, Heden BA, Norlin R. Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a retrospective evaluation of 39 patients followed for 2-6 years. Acta Orthop Scand 2000;71:180-4. 3. Barrett WP, Thornhill TS, Thomas WH, Gebhart EM, Sledge CB. Nonconstrained total shoulder arthroplasty in patients with polyarticular rheumatoid arthritis. J Arthroplasty 1989;4:91-6. 4. Betts HM, Abu-Rajab R, Nunn T, Brooksbank AJ. Total shoulder replacement in rheumatoid disease: a 16- to 23-year follow-up. J Bone Joint Surg Br 2009;91:1197-2005. http://dx.doi.org/10.1302/0301620X.91B9.22035 5. Christie A, Dagfinrud H, Ringen HO, Hagen KB. Beneficial and harmful effects of shoulder arthroplasty in patients with rheumatoid arthritis: results from a Cochrane review. Rheumatology (Oxford) 2011;50:598-602. http://dx.doi.org/10.1093/rheumatology/keq345
Shoulder arthroplasty for rheumatoid arthritis 6. Cofield RH. Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg Am 1984;66:899-906. 7. Collins DN, Harryman DT 2nd, Wirth MA. Shoulder arthroplasty for the treatment of inflammatory arthritis. J Bone Joint Surg Am 2004;86: 2489-96. 8. Fuerst M, Fink B, Ruther W. The DUROM cup humeral surface replacement in patients with rheumatoid arthritis. J Bone Joint Surg Am 2007;89:1756-62. http://dx.doi.org/10.2106/JBJS.F.01290 9. Gadea F, Alami G, Pape G, Boileau P, Favard L. Shoulder hemiarthroplasty: outcomes and long-term survival analysis according to etiology. Orthop Traumatol Surg Res 2012;98:659-65. http://dx.doi. org/10.1016/j.otsr.2012.03.020 10. Hambright D, Henderson RA, Cook C, Worrell T, Moorman CT, Bolognesi MP. A comparison of perioperative outcomes in patients with and without rheumatoid arthritis after receiving a total shoulder replacement arthroplasty. J Shoulder Elbow Surg 2011;20:77-85. http://dx.doi.org/10.1016/j.jse.2010.03.005 11. Hawkins RJ, Bell RH, Jallay B. Total shoulder arthroplasty. Clin Orthop Relat Res 1989:188-94. 12. Holcomb JO, Hebert DJ, Mighell MA, Dunning PE, Pupello DR, Pliner MD, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2010;19:1076-84. http:// dx.doi.org/10.1016/j.jse.2009.11.049 13. Jonsson E, Egund N, Kelly I, Rydholm U, Lidgren L. Cup arthroplasty of the rheumatoid shoulder. Acta Orthop Scand 1986;57:542-6. 14. Kelly IG. Unconstrained shoulder arthroplasty in rheumatoid arthritis. Clin Orthop Relat Res 1994:94-102. 15. Kelly IG, Foster RS, Fisher WD. Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg Br 1987;69:723-6. 16. Levine WN, Fischer CR, Nguyen D, Flatow EL, Ahmad CS, Bigliani LU. Long-term follow-up of shoulder hemiarthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am 2012;94:e164. http://dx.doi.org/10.2106/JBJS.K.00603 17. Levy O, Funk L, Sforza G, Copeland SA. Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis. J Bone Joint Surg Am 2004;86:512-8. 18. Marmor L. Hemiarthroplasty for the rheumatoid shoulder joint. Clin Orthop Relat Res 1977:201-3. 19. Marsh DW. Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis. J Orthop Sports Phys Ther 2006;36:600-10. http://dx.doi.org/10.2519/jospt.2006.2226
799 20. McCoy SR, Warren RF, Bade HA 3rd, Ranawat CS, Inglis AE. Total shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1989;4: 105-11. 21. Mengshoel AM, Slungaard B. Effects of shoulder arthroplasty and exercise in patients with rheumatoid arthritis. Clin Rheumatol 2005; 24:258-65. http://dx.doi.org/10.1007/s10067-004-1026-0 22. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replacement. J Bone Joint Surg Am 1982;64:319-37. 23. Rahme H, Mattsson P, Wikblad L, Larsson S. Cement and press-fit humeral stem fixation provides similar results in rheumatoid patients. Clin Orthop Relat Res 2006;448:28-32. http://dx.doi.org/10. 1097/01.blo.0000224007.25636.85 24. Rittmeister M, Kerschbaumer F. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions. J Shoulder Elbow Surg 2001;10: 17-22. 25. Rozing PM, Brand R. Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis. J Arthroplasty 1998;13:311-9. 26. Sojbjerg JO, Frich LH, Johannsen HV, Sneppen O. Late results of total shoulder replacement in patients with rheumatoid arthritis. Clin Orthop Relat Res 1999:39-45. 27. Sperling JW, Cofield RH, Schleck CD, Harmsen WS. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. J Shoulder Elbow Surg 2007;16:683-90. http://dx.doi.org/10.1016/j.jse.2007.02.135 28. Tanaka N, Sakahashi H, Hirose K, Ishima T, Ishii S. Augmented subscapularis muscle transposition for rotator cuff repair during shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2006;15:2-6. http://dx.doi.org/10.1016/j.jse.2005.04.004 29. Thomas BJ, Amstutz HC, Cracchiolo A. Shoulder arthroplasty for rheumatoid arthritis. Clin Orthop Relat Res 1991:125-8. 30. Trail IA, Nuttall D. The results of shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Br 2002;84:1121-5. http:// dx.doi.org/10.1302/0301-620X.84B8.12695 31. Waldman BJ, Figgie MP. Indications, technique, and results of total shoulder arthroplasty in rheumatoid arthritis. Orthop Clin North Am 1998;29:435-44. 32. Young AA, Smith MM, Bacle G, Moraga C, Walch G. Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am 2011;93:1915-23. http://dx.doi.org/10.2106/JBJS. J.00300