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Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty Aydın BUDEYRI, Raffaele Garofalo, Sumant G. Krishnan www.elsevier.com/locate/bios
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To appear in: Seminars in Arthroplasty Cite this article as: Aydın BUDEYRI, Raffaele Garofalo and Sumant G. Krishnan, Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty, Seminars in Arthroplasty,doi:10.1053/j.sart.2017.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty
Authors Aydın BUDEYRI, MD, FEBOT 1, 2 Raffaele Garofalo, MD3 Sumant G Krishnan, MD2
Affliations 1
Baylor University Medical Center The Shoulder Center, Dallas/TX USA
2
SANKO University, Faculty of Medicine Department of Orthopaedics and Traumatology, Gaziantep/TURKEY
3
Upper limb unit, F Miulli Hospital, Acquaviva delle fonti-Ba, ITALY
Corresponding Author: Aydın BUDEYRI, MD, FEBOT [email protected] +1-469-2260078
ABSTRACT In the past 2 decades, advancements have been made in procedures for preserving and restoring the function of the proximal humerus when treating glenohumeral (GH) osteoarthritis. This review addresses two surgical options for GH osteoarthritis in the young patient, stemless total shoulder arthroplasty and resurfacing arthroplasty. These procedures preserve bone stock, have low complication rates, ease future revision if indicated, and report equal if not superior results compared with stemmed implant options. Comparative studies
especially of long-term clinical outcomes of humeral resurfacing and stemless implants are still needed to make an informed treatment decision, especially in the young patient.
Introduction Osteoarthritis (OA) of the glenohumeral (GH) joint can cause severe pain and disability. Shoulder OA is frequently associated with a tear or atrophy of the rotator cuff which deteriorates over time (1, 2). Degenerative OA of the GH joint is less common than that of the hip and knee especially in young patients, but becomes more common at individual ages (3, 4). Patients younger than fifty five years of age with glenohumeral osteoarthritis are usually diagnosed to have atypical glenohumeral joint anatomy (5-8). This is quite a similar pathology to elderly patients with glenohumeral osteoarthritis with posterior subluxation and posterior glenoid erosion (9). Young patients are challenging to treat as they typically have high expectations of their shoulders and require a long-term fix due to their age. Advances in surgical shoulder OA treatments are proving advantageous to young patients. Therefore, the aim of this article is to review and reveal the philosophy, techniques, advantages, and evidence based outcomes of the resurfacing shoulder arthroplasty and the stemless total shoulder arthroplasty for the young glenohumeral osteoarthritis patients under 50 years old. Surgical Management of Glenohumeral Osteoarthritis Shoulder implant systems and glenoid resurfacing are successfully used for the surgical treatment of severe GH disorders after non-operative treatment failure. There is an increasing use of shoulder prosthesis implantations, with an annual growth of between 6% and 13% (10). These implant systems have shown significant improvements in function, pain, range of
motion, and quality of life over mid-term follow-up (11-15). Appropriate decisions about surgical options in young patients with OA are more limited. Manufacturers have introduced various stemmed humeral systems over the last 45 years with a slow transition towards shortening the humeral stem and adoption of cementless, or “press-fit” application techniques. The evolution in device stem length has attempted to address the complications of stemmed prostheses, such as loosening, fractures, and wear which often result in high rates of revision surgery in the young patient population (13, 16). Removal of a humeral stem after conventional implants often results in further proximal bone destruction (17) and leads to suboptimal revision results (16, 18). Humeral component designs with stems have the potential to cause proximal bone loss due to osteolysis and stress shielding (19, 20). These complications are important as bone loss limits the future treatment options available to young patients (17, 21). Resurfacing and stemless prostheses have provided an alternative to conventional arthroplasty. Open Resurfacing Arthroplasty An option for the young patient with shoulder OA is open resurfacing arthroplasty. Resurfacing arthroplasty may be summarized as the reaming of the humeral head’s surface that is affected by osteoarthritis and implanting of a metal-alloy cap to the area (Figure 1) to presserve the glenohumeral articulation congruency meanwhile preserving the proximal humeral bone stock (15, 22-27). If needed, the cap can be mated against a conventional glenoid prosthesis (28). In the late 1970s, Steffee and Moore published the first article on humeral resurfacing procedures using a cemented prosthesis (29). Copeland developed a cementless surface replacement (30) providing a segue into most current designs with a press-fit installation. To encourage bone in-growth, modern designs feature a hydroxyapatite or ceramic porous
coating. The newer technique using partial resurfacing with modern articular prostheses are proving useful for the treatment of asymmetric chondral defects (Figure 1).
Advantages Humeral resurfacing provides potential advantages for younger patients and has been associated with low complication rates in studies with follow-up times ranging from eight months to seven years (22-24, 29, 31-40). Resurfacing arthroplasty systems preserve proximal humeral metaphyseal bone stock as no osteotomy is performed, leading to minimal bone resection. This is potentially beneficial for the younger patient, who may require a revision with a stemmed prosthesis in the future. The head-shaft angle is not affected, benefiting the biomechanical restoration of the joint. In addition, resurfacing arthroplasty has been reported to reveal low implant loosening rates and to reflect the functional outcomes of hemiarthroplasty (27, 32). They are useful in cases of distorted proximal humeral anatomy. Resurfacing arthroplasty boasts a short operative time and reports a low prevalence of periprosthetic fractures, a concern for the young, more active patient. The revision rates of humeral resurfacing arthroplasty designs are usually comparable to or better than arthroplasty designs with stems (23, 24). Disadvantages The most frequent complication of resurfacing arthroplasty is loosening. This results because many resurfacing arthroplasty components are too large which leads to “overstuffing” (41). Accurate recreation of the three dimensional proximal humeral anatomy, including sizing, angling and depth is imperative to proper functioning. Increasing the thickness of the humeral head by only 5mm, decreases the range of glenohumeral motion by 20°-30° (42) and
decreasing the thickness of the humeral head by 5mm reduces glenohumeral joint excursion by 24° (43). A decreased range of motion, weaker flexion, and/or instability in the joint can lead to poor patient satisfaction. Finally, when a revision procedure is required, attempts to establish a reliable glenoid exposure intraoperatively may result in future iatrogenic complications since the humeral head and the resurfacing arthroplasty will make the surgical exposure difficult, inhibiting the visualization of the glenoid. Indications and contraindications for resurfacing arthroplasty Indications for shoulder resurfacing include pain and/or impaired function that do not respond to non-operative treatments. Shoulder resurfacing may be useful for treating patients requiring arthroplasty but who suffer deformities which make the use of a stemmed prosthesis difficult (30). Contraindications for shoulder resurfacing include four-part fractures of the humerus and inadequate bone stock (22). Outcomes of resurfacing arthroplasty Recent studies have demonstrated successful results following the use of shoulder resurfacing prostheses (31). In 2005, in a prospective study of fifty-two patients who had undergone shoulder resurfacing, after an average of 34 months follow-up, Thomas et al. reported an improvement in Constant score from a mean of 16 points to 54 points (37) after resurfacing procedure. The authors stated these results were comparable with outcomes of modern stemmed prostheses. Buchner et al. in 2008 (33), in a matched-pair analysis, compared 22 resurfacing arthroplasties with 22 total shoulder arthroplasties in a mean of 12 months follow-up period. The mean length of hospital stay, operative time, and the estimated blood loss were significantly higher in the total anatomic shoulder arthroplasty group. The total anatomic shoulder arthroplasty group they had investigated revealed a significant increase in the mean range of motion and Constant score outcome measures. They concluded
that the stemmed total shoulder arthroplasty revealed better results while the resurfacing arthroplasty was revealed to be a useful option in younger patients by means of bone stock preservation. A prospective study by Bailie et al. in 2008 (32) on the use of an uncemented resurfacing prosthesis in thirty-six patients younger than 55 years of age with GH osteoarthritis revealed that humeral resurfacing can be used in the young, active population. After a mean final follow-up time of thirty-eight months, the outcomes on the VAS pain scale, the SANE scale, and the ASES scale had improved significantly. Thirty-five of the patients reported that they had satisfactorily returned to athletic activities and this activity was not associated with early prosthesis failure. In 2014, Lebon et al. (44), in a comparative, retrospective, single center study of resurfacing arthroplasty versus total anatomic shoulder arthroplasty, reported no significant difference in functional outcome measures in a minimum follow-up period of 44 months. Better outcome scores were reported in the total anatomic shoulder arthroplasty with stem designs. Higher rates of revision were reported in the resurfacing arthroplasty designs. While resurfacing reports improved pre- to post-surgical outcomes and various benefits to the young patient, data are limited by small studies, short follow-ups, and a lack of a comparison groups. When compared to TSA, resurfacing appears to perform inferiorly in the current literature. Long term, methodologically improved studies are required to assess resurfacing arthroplasty.
Stemless total shoulder arthroplasty The design of a total anatomic shoulder prosthesis can be adapted and evolved towards the needs of a young glenohumeral osteoarthritis patient with efforts to eliminate the complications such as iatrogenic bone loss in a revision setting, periprosthetic fracture,
malpositionings, and component loosenings. The stemless total shoulder arthroplasy with a metaphyseal impaction fixation have been a popular treatment of choice for primary or secondary OA specially among young populations (45). The stemless design has the potential to relieve pain, to reveal satisfactory patient satisfaction and range of motion outcome measures (46, 47). Stemless prostheses designs aim to restore the local anatomy, through a simple automatically centering technique. In stemless arthroplasty options, the defected humeral head is resected in a two dimensional resection and implantation technique. Controversely, resurfacing arthroplasty is a three dimensional reaming and implantation technique making the accuracy of the procedure potentially more prone to mistakes. The aim is to simplify the technique of implantation, to preserve bone stock and to allow reliable glenoid exposure (Figure 2). Advantages Stemless designs are canal sparing, through press-fit, metaphyseal fixation, and they remove less humeral bone then TSA, thereby preserving the local anatomy for ease of revision if necessary (48). They can be placed even in the presence of shaft deformity or humeral malalignment and provide near-perfect anatomic restoration. Glenoid exposure is simpler during stemless implant procedures as compared with humeral head resurfacing (49, 50). Few stem-related complications are reported (49) including fractures. Future revision is simpler as the complications of stem removal are avoided (47, 51). A theoretical decreased surgical time and less blood loss are also reported (52). Disadvantages Stemless designs also have disadvantages. The humeral head resection should be extremely deliberate and accurate. As a flat and stable bone-implant interface the resection surface of the humeral head should allow for the mechanical stability and the osseointegration of the implant. Poor bone quality is a current obstacle to effective use of the
stemless design, though there is currently no objective measure of bone quality for determining the appropriateness of the canal-sparing implant in a surgical candidate. The only current intraoperative examination of suitable bone quality, the “thumb test,” is subjective (15). Little long-term data is available on stemless implant longevity (46) although available studies report a low rate of loosening over mid-term follow-up (47). Indications and contraindications Stemless prosthesis are indicated for the same symptoms as resurfacing arthroplasty, including pain and/or decreased function, unresponsive to non-surgical treatment (49). Similar to resurfacing arthroplasty, stemless total shoulder arthroplasty is a reliable option for the patient with shoulder deformity, eliminating the consequences of implanting a stemmed humeral component (49, 53) and can even be implanted on metallic implants at the humeral head region such as suture anchors, staples and screws (54). The contraindication for the stemless total shoulder arthroplasty, since it is a canal-sparing technique, is the proximal humerus bone density compromise (45, 48, 49, 51, 53, 55). Although, a new technique described by Plachel 2017 uses the Eclipse (the only stemless system utilizing screw fixation) combined with a humeral autograft, even in the face of large humeral bone defect (56). Availability Stemless metaphyseal anchored implants, were introduced in Europe in 2004 (47). Various stemless implants (Figure 3) are currently available. The Biomet Total Evolutive Shoulder System (TESS) (Zimmer Biomet, Warsaw, Indiana) is the original stemless total shoulder arthroplasty systems on the market. Following TESS, Mathys Affinis Short (Mathys, Bettlach, Switzerland) in 2008 and the Sidus (Zimmer Biomet, Warsaw, Indiana) were introduced in 2012. Then the Easytech (FX Solutions) was introduced in 2015. Later on, the Lima Shoulder Modular Replacement (SMR) Stemless shoulder system (Lima Corporate,
Italy), an innovative type of a convertible platform system also with a reverse arthroplasty conversion option was released in 2015. All these systems are impaction implanted. The Eclipse shoulder prosthesis (Arthrex, Inc., Naples, FL, USA) was introduced in 2005. What set the Eclipse apart was its insertion method over a compression screw. None of the previously mentioned implants have FDA approval for implantation in the USA. A new innovation, the Simpliciti (Wright Medical, Memphis, TN) stemless total shoulder arthroplasty system was approved by the FDA in 2015. Stemless shoulder arthroplasty outcomes Studies have shown good clinical and radiographic results at short- and mid-term follow-up (45-48, 51, 53, 55, 57) comparable with outcomes reported with stemmed prosthesis (46, 58). Only three implants have at least mid-term follow-up; the Eclipse, Simpliciti, and TESS. The rest have only short-term results and most have no reported trials. The most recent systematic literature review, by Hawi et al., reported 11 studies (929 cases), between 2010 and 2016 (58). His studies revealed statistically significant functional and clinical improvement in a follow-up period from 6 to 72 months. Stemless humeral implant complications ranged only from 0 to 7.9 %. The authors reported that while some arthroplasty systems are associated with changes on radiological exam, there appears to be no perceivable clinical relevance. The first stemless shoulder arthroplasty trial on the TESS, including 63 patients, was published in 2010 by Huguet et al. (53). At 3-year minimum follow-up, the mean Constant score rose 45 points from preoperative scores. Mean forward elevation and external rotation to the side improved significantly. Radiologically, there were no complications such as osteolysis, stress shielding, or radiolucency around the stemless humeral implant. The five intraoperative fractures reported healed without complication. Seven implants were removed with the 3-year revision rate reaching 11.1 %.
In 2011, Kadum et al. (51) reported on 56 patients who received TESS implants with a mean of 14 months follow-up. There were no complications in their report. In 2013, Razmjou et al. (55), in a comparative, prospective, longitudinal study, reported the clinical and radiological outcomes of two designs with humeral stems versus the TESS. All the prosthetic designs revealed significant relief in pain, patient satisfaction and function. The TESS group did not reveal radiolucency or stress shielding evidence. In 2013, Berth et al. (48), in a randomized, comparative, prospective, longitudinal study, reported the results of the TESS versus the Mathys Affinis stemmed implant in OA patients. After a minimum of 2-years follow-up with 82 patients, no differences in function or range of motion were detected with significant improvements in the Constant score, DASH score, and active range of motion. The mean operative time was significantly longer and the estimated blood loss significantly greater with the stemmed arthroplasty group compared to the stemless group. No difference in hospital length of stay was identified. No complications were reported including any evidence of radiolucent lines, osteolysis or revisions. In 2015, Meier et al. (57), in a comparative case series of 24 patients, reported the TESS versus the stemmed Aequalis prosthesis (Tournier, Lyon, France) outcomes over a 6month follow-up. No significant difference was reported. Moroder (59) reported a case-control study with 24 matched patient pairs of stemmed and TESS implants over a mean of 35 months follow-up. No significant difference in pain score, Constant score, strength, ASES, subjective shoulder value, patient satisfaction, or range of motion was reported. No loosening was observed but complications included a case of dislocation and two cases of scapular notching in the stemless group and 9 cases of scapular notching in the stemmed group. In the stemless group, surgical time was significantly shorter and the average hospital stay significantly longer.
One trial reported the outcomes of the Mathys Affinis Short Stemless Prosthesis (45), including 12 OA patients over a 24-month follow-up 38 patients over a 12-month follow-up. No complications were reported. Habermeyer et al. (46) reported on a prospective study involving 78 patients over a 5-year minimum follow-up after implantation with the Eclipse system. Significantly improved range of motion and Constant score outcome measures were reported in this study. The complication rate and the revision rate were 12.8 % and 9% respectively. One case of an incomplete lucent line and three cases of partial osteolysis with two of these cases demonstrating notable loosening were reported. Over a third of cases also showed signs of stress shielding but without notable clinical significance. In 2017, Hawi et al. (47), in a prospective cohort of the Eclipse system, in a study population of 43 patients, with a mean of follow-up 9 years, reported good clinical and radiological long-term outcomes. The rate revision rate was around 7%. There were no complications. The Constant score and range of motion functional outcome measures were significantly improved. One patient was diagnosed to reveal incomplete radiolucency with no clinical significance. In 2016, Churchill et al. (15) published results of a prospective, single-arm, multicenter study with 2-year minimum follow-up of 298 patients using the Simpliciti. They reported a significant improvement in pain, range of motion, strength, and functional outcome measures. Radiographic analysis determined no evidence of osteolysis or loosening and the revision rate was 2%. In 2017, Collin et al. (60), in a prospective, multicenter trial, investigated the Simpliciti system with 47 patients, in a minimum two years of follow-up period. The mean improvement of the Constant score was 36 points and the mean satisfaction rate was 87%. Complications included two revisions, none due to loosening, and 17 cases of radiolucent areas. Most recently in 2017, Uschok et al. (61), in a randomized comparative prospective study, investigated the stemless humeral component versus a conventional stem, among
twenty-nine patients, with a minimum of 5 years of follow-up. No significant differences were reported for the range of motion and Constant score outcome measures. A significant difference occurred in the radiographic analysis with a lower bone mineral density in 41% of stemmed group and in 0% of the stemless group. Also, radiolucent lines were statistically more frequent in the stemmed group.
Future Research Shoulder resurfacing and stemless prostheses may become more popular as the advantages become clearer and materials improve. Newer surgical approaches may become less invasive and more efficacious. Most of the recent reports only include a limited patient population, revealing the evident need for large, randomized, prospective studies. Significant differences exist between the various stemless implants and the results from one design do not apply to all stemless designs, which necessitates trials of each device. Critical evaluations of an implant’s design features and a review of each surgical case are needed to choose the most appropriate implant. New implant materials hold promise for improving arthroplasty durability and survival but continue to require large clinical investigations. As both resurfacing and stemless designs rely on stable bone for implantation, additional studies are needed to establish an objective test for acceptable bone quality even as surgical technique improves.
Conclusion Young patients with GH arthritis present unique surgical treatment challenges. When non-operative management fails, several surgical options may be considered. Resurfacing arthroplasty and stemless replacement arthroplasty are viable options for the young patient with advanced shoulder OA of the GH joint.
Caution with resurfacing arthroplasty is needed as it may lead to overstuffing or low stuffing of the GH joint, disturbing the rotator cuff muscle’s force couplings and biomechanical function. By the technical point of view, since resurfacing arthroplasty is a three dimensional reconstruction technique in a single step, the problem is the inaccuracy to reconstruct an accurately medialized/centered center of rotation with the resurfacing arthroplasty technique in that single step. But instead, with a stemless total shoulder arthroplasty technique, we are technically capable of to implant what we have resected and to adjust the center of rotation medialization, humeral lateralization and distalization parameters. Both by the glenoid and humeral components, one by one, by the relevants of this three dimension, accurate reconstruction may be performed one at a time at each relevant step of this three dimension. While shoulder resurfacing has not demonstrated superior results in most trials as compared to TSA, it has the benefit of preserving bone stock for young patients, especially if partial resurfacing techniques are employed, for those who may require future revisions. Current review reveals evidence-based good clinical outcomes and radiological results on stemless shoulder arthroplasty versus stemmed arthroplasty designs in the short and midterm follow-up periods. Potential advantages to the young patient include decreased bone resection, shorter operative times, a low prevalence of fractures, and the potential to ease revision if needed. Further research is needed to establish the long-term outcomes for both procedures. Stemless shoulder arthroplasty designs more accurately reconstruct the GH joint center of motion and rotation, revealing superior, satisfactory near anatomic and native shoulder functional outcomes that are especially advantageous to the young population.
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55.
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clinical and radiologic outcomes of total shoulder arthroplasty: A prospective study. J Shoulder Elbow Surg 22:206-14, 2013 56.
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arthroplasty. Obere Extrem 12:183-185, 2017 57.
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Figure 1. a) Demonstration of the resurfacing prosthesis – GLOBAL CAP Shoulder System (Figure provided by manufacturer DePuy Synthes Company) b) Cannulated instrumentation for resurfacing procedure. (Figure provided by manufacturer DePuy Synthes Company)
a.
b.
Figure 2. Demonstration of anatomic stemless TSA (Wright Medical, Memphis, TN).
Figure 3. Examples of available anatomic stemless prosthesis. a) The Biomet Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA) b) The Arthrex Eclipse Prosthesis (Arthrex, Naples, USA) c) The Mathys Affinis Short Stemless Prosthesis (Mathys, Betlach, Switzerland) d) The Simpliciti Stemless Prosthesis (Wright Medical, Memphis, TN) (Figures provided by the manufacturers). a.
b.
c.
d.
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Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty Aydın BUDEYRI, Raffaele Garofalo, Sumant G. Krishnan www.elsevier.com/locate/bios
PII: DOI: Reference:
S1045-4527(17)30086-X https://doi.org/10.1053/j.sart.2017.12.002 YSART50774
To appear in: Seminars in Arthroplasty Cite this article as: Aydın BUDEYRI, Raffaele Garofalo and Sumant G. Krishnan, Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty, Seminars in Arthroplasty,doi:10.1053/j.sart.2017.12.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Shoulder replacement for glenohumeral osteoarthritis in young patients: Stemless total shoulder arthroplasty trumps resurfacing arthroplasty
Authors Aydın BUDEYRI, MD, FEBOT 1, 2 Raffaele Garofalo, MD3 Sumant G Krishnan, MD2
Affliations 1
Baylor University Medical Center The Shoulder Center, Dallas/TX USA
2
SANKO University, Faculty of Medicine Department of Orthopaedics and Traumatology, Gaziantep/TURKEY
3
Upper limb unit, F Miulli Hospital, Acquaviva delle fonti-Ba, ITALY
Corresponding Author: Aydın BUDEYRI, MD, FEBOT [email protected] +1-469-2260078
ABSTRACT In the past 2 decades, advancements have been made in procedures for preserving and restoring the function of the proximal humerus when treating glenohumeral (GH) osteoarthritis. This review addresses two surgical options for GH osteoarthritis in the young patient, stemless total shoulder arthroplasty and resurfacing arthroplasty. These procedures preserve bone stock, have low complication rates, ease future revision if indicated, and report equal if not superior results compared with stemmed implant options. Comparative studies
especially of long-term clinical outcomes of humeral resurfacing and stemless implants are still needed to make an informed treatment decision, especially in the young patient.
Introduction Osteoarthritis (OA) of the glenohumeral (GH) joint can cause severe pain and disability. Shoulder OA is frequently associated with a tear or atrophy of the rotator cuff which deteriorates over time (1, 2). Degenerative OA of the GH joint is less common than that of the hip and knee especially in young patients, but becomes more common at individual ages (3, 4). Patients younger than fifty five years of age with glenohumeral osteoarthritis are usually diagnosed to have atypical glenohumeral joint anatomy (5-8). This is quite a similar pathology to elderly patients with glenohumeral osteoarthritis with posterior subluxation and posterior glenoid erosion (9). Young patients are challenging to treat as they typically have high expectations of their shoulders and require a long-term fix due to their age. Advances in surgical shoulder OA treatments are proving advantageous to young patients. Therefore, the aim of this article is to review and reveal the philosophy, techniques, advantages, and evidence based outcomes of the resurfacing shoulder arthroplasty and the stemless total shoulder arthroplasty for the young glenohumeral osteoarthritis patients under 50 years old. Surgical Management of Glenohumeral Osteoarthritis Shoulder implant systems and glenoid resurfacing are successfully used for the surgical treatment of severe GH disorders after non-operative treatment failure. There is an increasing use of shoulder prosthesis implantations, with an annual growth of between 6% and 13% (10). These implant systems have shown significant improvements in function, pain, range of
motion, and quality of life over mid-term follow-up (11-15). Appropriate decisions about surgical options in young patients with OA are more limited. Manufacturers have introduced various stemmed humeral systems over the last 45 years with a slow transition towards shortening the humeral stem and adoption of cementless, or “press-fit” application techniques. The evolution in device stem length has attempted to address the complications of stemmed prostheses, such as loosening, fractures, and wear which often result in high rates of revision surgery in the young patient population (13, 16). Removal of a humeral stem after conventional implants often results in further proximal bone destruction (17) and leads to suboptimal revision results (16, 18). Humeral component designs with stems have the potential to cause proximal bone loss due to osteolysis and stress shielding (19, 20). These complications are important as bone loss limits the future treatment options available to young patients (17, 21). Resurfacing and stemless prostheses have provided an alternative to conventional arthroplasty. Open Resurfacing Arthroplasty An option for the young patient with shoulder OA is open resurfacing arthroplasty. Resurfacing arthroplasty may be summarized as the reaming of the humeral head’s surface that is affected by osteoarthritis and implanting of a metal-alloy cap to the area (Figure 1) to presserve the glenohumeral articulation congruency meanwhile preserving the proximal humeral bone stock (15, 22-27). If needed, the cap can be mated against a conventional glenoid prosthesis (28). In the late 1970s, Steffee and Moore published the first article on humeral resurfacing procedures using a cemented prosthesis (29). Copeland developed a cementless surface replacement (30) providing a segue into most current designs with a press-fit installation. To encourage bone in-growth, modern designs feature a hydroxyapatite or ceramic porous
coating. The newer technique using partial resurfacing with modern articular prostheses are proving useful for the treatment of asymmetric chondral defects (Figure 1).
Advantages Humeral resurfacing provides potential advantages for younger patients and has been associated with low complication rates in studies with follow-up times ranging from eight months to seven years (22-24, 29, 31-40). Resurfacing arthroplasty systems preserve proximal humeral metaphyseal bone stock as no osteotomy is performed, leading to minimal bone resection. This is potentially beneficial for the younger patient, who may require a revision with a stemmed prosthesis in the future. The head-shaft angle is not affected, benefiting the biomechanical restoration of the joint. In addition, resurfacing arthroplasty has been reported to reveal low implant loosening rates and to reflect the functional outcomes of hemiarthroplasty (27, 32). They are useful in cases of distorted proximal humeral anatomy. Resurfacing arthroplasty boasts a short operative time and reports a low prevalence of periprosthetic fractures, a concern for the young, more active patient. The revision rates of humeral resurfacing arthroplasty designs are usually comparable to or better than arthroplasty designs with stems (23, 24). Disadvantages The most frequent complication of resurfacing arthroplasty is loosening. This results because many resurfacing arthroplasty components are too large which leads to “overstuffing” (41). Accurate recreation of the three dimensional proximal humeral anatomy, including sizing, angling and depth is imperative to proper functioning. Increasing the thickness of the humeral head by only 5mm, decreases the range of glenohumeral motion by 20°-30° (42) and
decreasing the thickness of the humeral head by 5mm reduces glenohumeral joint excursion by 24° (43). A decreased range of motion, weaker flexion, and/or instability in the joint can lead to poor patient satisfaction. Finally, when a revision procedure is required, attempts to establish a reliable glenoid exposure intraoperatively may result in future iatrogenic complications since the humeral head and the resurfacing arthroplasty will make the surgical exposure difficult, inhibiting the visualization of the glenoid. Indications and contraindications for resurfacing arthroplasty Indications for shoulder resurfacing include pain and/or impaired function that do not respond to non-operative treatments. Shoulder resurfacing may be useful for treating patients requiring arthroplasty but who suffer deformities which make the use of a stemmed prosthesis difficult (30). Contraindications for shoulder resurfacing include four-part fractures of the humerus and inadequate bone stock (22). Outcomes of resurfacing arthroplasty Recent studies have demonstrated successful results following the use of shoulder resurfacing prostheses (31). In 2005, in a prospective study of fifty-two patients who had undergone shoulder resurfacing, after an average of 34 months follow-up, Thomas et al. reported an improvement in Constant score from a mean of 16 points to 54 points (37) after resurfacing procedure. The authors stated these results were comparable with outcomes of modern stemmed prostheses. Buchner et al. in 2008 (33), in a matched-pair analysis, compared 22 resurfacing arthroplasties with 22 total shoulder arthroplasties in a mean of 12 months follow-up period. The mean length of hospital stay, operative time, and the estimated blood loss were significantly higher in the total anatomic shoulder arthroplasty group. The total anatomic shoulder arthroplasty group they had investigated revealed a significant increase in the mean range of motion and Constant score outcome measures. They concluded
that the stemmed total shoulder arthroplasty revealed better results while the resurfacing arthroplasty was revealed to be a useful option in younger patients by means of bone stock preservation. A prospective study by Bailie et al. in 2008 (32) on the use of an uncemented resurfacing prosthesis in thirty-six patients younger than 55 years of age with GH osteoarthritis revealed that humeral resurfacing can be used in the young, active population. After a mean final follow-up time of thirty-eight months, the outcomes on the VAS pain scale, the SANE scale, and the ASES scale had improved significantly. Thirty-five of the patients reported that they had satisfactorily returned to athletic activities and this activity was not associated with early prosthesis failure. In 2014, Lebon et al. (44), in a comparative, retrospective, single center study of resurfacing arthroplasty versus total anatomic shoulder arthroplasty, reported no significant difference in functional outcome measures in a minimum follow-up period of 44 months. Better outcome scores were reported in the total anatomic shoulder arthroplasty with stem designs. Higher rates of revision were reported in the resurfacing arthroplasty designs. While resurfacing reports improved pre- to post-surgical outcomes and various benefits to the young patient, data are limited by small studies, short follow-ups, and a lack of a comparison groups. When compared to TSA, resurfacing appears to perform inferiorly in the current literature. Long term, methodologically improved studies are required to assess resurfacing arthroplasty.
Stemless total shoulder arthroplasty The design of a total anatomic shoulder prosthesis can be adapted and evolved towards the needs of a young glenohumeral osteoarthritis patient with efforts to eliminate the complications such as iatrogenic bone loss in a revision setting, periprosthetic fracture,
malpositionings, and component loosenings. The stemless total shoulder arthroplasy with a metaphyseal impaction fixation have been a popular treatment of choice for primary or secondary OA specially among young populations (45). The stemless design has the potential to relieve pain, to reveal satisfactory patient satisfaction and range of motion outcome measures (46, 47). Stemless prostheses designs aim to restore the local anatomy, through a simple automatically centering technique. In stemless arthroplasty options, the defected humeral head is resected in a two dimensional resection and implantation technique. Controversely, resurfacing arthroplasty is a three dimensional reaming and implantation technique making the accuracy of the procedure potentially more prone to mistakes. The aim is to simplify the technique of implantation, to preserve bone stock and to allow reliable glenoid exposure (Figure 2). Advantages Stemless designs are canal sparing, through press-fit, metaphyseal fixation, and they remove less humeral bone then TSA, thereby preserving the local anatomy for ease of revision if necessary (48). They can be placed even in the presence of shaft deformity or humeral malalignment and provide near-perfect anatomic restoration. Glenoid exposure is simpler during stemless implant procedures as compared with humeral head resurfacing (49, 50). Few stem-related complications are reported (49) including fractures. Future revision is simpler as the complications of stem removal are avoided (47, 51). A theoretical decreased surgical time and less blood loss are also reported (52). Disadvantages Stemless designs also have disadvantages. The humeral head resection should be extremely deliberate and accurate. As a flat and stable bone-implant interface the resection surface of the humeral head should allow for the mechanical stability and the osseointegration of the implant. Poor bone quality is a current obstacle to effective use of the
stemless design, though there is currently no objective measure of bone quality for determining the appropriateness of the canal-sparing implant in a surgical candidate. The only current intraoperative examination of suitable bone quality, the “thumb test,” is subjective (15). Little long-term data is available on stemless implant longevity (46) although available studies report a low rate of loosening over mid-term follow-up (47). Indications and contraindications Stemless prosthesis are indicated for the same symptoms as resurfacing arthroplasty, including pain and/or decreased function, unresponsive to non-surgical treatment (49). Similar to resurfacing arthroplasty, stemless total shoulder arthroplasty is a reliable option for the patient with shoulder deformity, eliminating the consequences of implanting a stemmed humeral component (49, 53) and can even be implanted on metallic implants at the humeral head region such as suture anchors, staples and screws (54). The contraindication for the stemless total shoulder arthroplasty, since it is a canal-sparing technique, is the proximal humerus bone density compromise (45, 48, 49, 51, 53, 55). Although, a new technique described by Plachel 2017 uses the Eclipse (the only stemless system utilizing screw fixation) combined with a humeral autograft, even in the face of large humeral bone defect (56). Availability Stemless metaphyseal anchored implants, were introduced in Europe in 2004 (47). Various stemless implants (Figure 3) are currently available. The Biomet Total Evolutive Shoulder System (TESS) (Zimmer Biomet, Warsaw, Indiana) is the original stemless total shoulder arthroplasty systems on the market. Following TESS, Mathys Affinis Short (Mathys, Bettlach, Switzerland) in 2008 and the Sidus (Zimmer Biomet, Warsaw, Indiana) were introduced in 2012. Then the Easytech (FX Solutions) was introduced in 2015. Later on, the Lima Shoulder Modular Replacement (SMR) Stemless shoulder system (Lima Corporate,
Italy), an innovative type of a convertible platform system also with a reverse arthroplasty conversion option was released in 2015. All these systems are impaction implanted. The Eclipse shoulder prosthesis (Arthrex, Inc., Naples, FL, USA) was introduced in 2005. What set the Eclipse apart was its insertion method over a compression screw. None of the previously mentioned implants have FDA approval for implantation in the USA. A new innovation, the Simpliciti (Wright Medical, Memphis, TN) stemless total shoulder arthroplasty system was approved by the FDA in 2015. Stemless shoulder arthroplasty outcomes Studies have shown good clinical and radiographic results at short- and mid-term follow-up (45-48, 51, 53, 55, 57) comparable with outcomes reported with stemmed prosthesis (46, 58). Only three implants have at least mid-term follow-up; the Eclipse, Simpliciti, and TESS. The rest have only short-term results and most have no reported trials. The most recent systematic literature review, by Hawi et al., reported 11 studies (929 cases), between 2010 and 2016 (58). His studies revealed statistically significant functional and clinical improvement in a follow-up period from 6 to 72 months. Stemless humeral implant complications ranged only from 0 to 7.9 %. The authors reported that while some arthroplasty systems are associated with changes on radiological exam, there appears to be no perceivable clinical relevance. The first stemless shoulder arthroplasty trial on the TESS, including 63 patients, was published in 2010 by Huguet et al. (53). At 3-year minimum follow-up, the mean Constant score rose 45 points from preoperative scores. Mean forward elevation and external rotation to the side improved significantly. Radiologically, there were no complications such as osteolysis, stress shielding, or radiolucency around the stemless humeral implant. The five intraoperative fractures reported healed without complication. Seven implants were removed with the 3-year revision rate reaching 11.1 %.
In 2011, Kadum et al. (51) reported on 56 patients who received TESS implants with a mean of 14 months follow-up. There were no complications in their report. In 2013, Razmjou et al. (55), in a comparative, prospective, longitudinal study, reported the clinical and radiological outcomes of two designs with humeral stems versus the TESS. All the prosthetic designs revealed significant relief in pain, patient satisfaction and function. The TESS group did not reveal radiolucency or stress shielding evidence. In 2013, Berth et al. (48), in a randomized, comparative, prospective, longitudinal study, reported the results of the TESS versus the Mathys Affinis stemmed implant in OA patients. After a minimum of 2-years follow-up with 82 patients, no differences in function or range of motion were detected with significant improvements in the Constant score, DASH score, and active range of motion. The mean operative time was significantly longer and the estimated blood loss significantly greater with the stemmed arthroplasty group compared to the stemless group. No difference in hospital length of stay was identified. No complications were reported including any evidence of radiolucent lines, osteolysis or revisions. In 2015, Meier et al. (57), in a comparative case series of 24 patients, reported the TESS versus the stemmed Aequalis prosthesis (Tournier, Lyon, France) outcomes over a 6month follow-up. No significant difference was reported. Moroder (59) reported a case-control study with 24 matched patient pairs of stemmed and TESS implants over a mean of 35 months follow-up. No significant difference in pain score, Constant score, strength, ASES, subjective shoulder value, patient satisfaction, or range of motion was reported. No loosening was observed but complications included a case of dislocation and two cases of scapular notching in the stemless group and 9 cases of scapular notching in the stemmed group. In the stemless group, surgical time was significantly shorter and the average hospital stay significantly longer.
One trial reported the outcomes of the Mathys Affinis Short Stemless Prosthesis (45), including 12 OA patients over a 24-month follow-up 38 patients over a 12-month follow-up. No complications were reported. Habermeyer et al. (46) reported on a prospective study involving 78 patients over a 5-year minimum follow-up after implantation with the Eclipse system. Significantly improved range of motion and Constant score outcome measures were reported in this study. The complication rate and the revision rate were 12.8 % and 9% respectively. One case of an incomplete lucent line and three cases of partial osteolysis with two of these cases demonstrating notable loosening were reported. Over a third of cases also showed signs of stress shielding but without notable clinical significance. In 2017, Hawi et al. (47), in a prospective cohort of the Eclipse system, in a study population of 43 patients, with a mean of follow-up 9 years, reported good clinical and radiological long-term outcomes. The rate revision rate was around 7%. There were no complications. The Constant score and range of motion functional outcome measures were significantly improved. One patient was diagnosed to reveal incomplete radiolucency with no clinical significance. In 2016, Churchill et al. (15) published results of a prospective, single-arm, multicenter study with 2-year minimum follow-up of 298 patients using the Simpliciti. They reported a significant improvement in pain, range of motion, strength, and functional outcome measures. Radiographic analysis determined no evidence of osteolysis or loosening and the revision rate was 2%. In 2017, Collin et al. (60), in a prospective, multicenter trial, investigated the Simpliciti system with 47 patients, in a minimum two years of follow-up period. The mean improvement of the Constant score was 36 points and the mean satisfaction rate was 87%. Complications included two revisions, none due to loosening, and 17 cases of radiolucent areas. Most recently in 2017, Uschok et al. (61), in a randomized comparative prospective study, investigated the stemless humeral component versus a conventional stem, among
twenty-nine patients, with a minimum of 5 years of follow-up. No significant differences were reported for the range of motion and Constant score outcome measures. A significant difference occurred in the radiographic analysis with a lower bone mineral density in 41% of stemmed group and in 0% of the stemless group. Also, radiolucent lines were statistically more frequent in the stemmed group.
Future Research Shoulder resurfacing and stemless prostheses may become more popular as the advantages become clearer and materials improve. Newer surgical approaches may become less invasive and more efficacious. Most of the recent reports only include a limited patient population, revealing the evident need for large, randomized, prospective studies. Significant differences exist between the various stemless implants and the results from one design do not apply to all stemless designs, which necessitates trials of each device. Critical evaluations of an implant’s design features and a review of each surgical case are needed to choose the most appropriate implant. New implant materials hold promise for improving arthroplasty durability and survival but continue to require large clinical investigations. As both resurfacing and stemless designs rely on stable bone for implantation, additional studies are needed to establish an objective test for acceptable bone quality even as surgical technique improves.
Conclusion Young patients with GH arthritis present unique surgical treatment challenges. When non-operative management fails, several surgical options may be considered. Resurfacing arthroplasty and stemless replacement arthroplasty are viable options for the young patient with advanced shoulder OA of the GH joint.
Caution with resurfacing arthroplasty is needed as it may lead to overstuffing or low stuffing of the GH joint, disturbing the rotator cuff muscle’s force couplings and biomechanical function. By the technical point of view, since resurfacing arthroplasty is a three dimensional reconstruction technique in a single step, the problem is the inaccuracy to reconstruct an accurately medialized/centered center of rotation with the resurfacing arthroplasty technique in that single step. But instead, with a stemless total shoulder arthroplasty technique, we are technically capable of to implant what we have resected and to adjust the center of rotation medialization, humeral lateralization and distalization parameters. Both by the glenoid and humeral components, one by one, by the relevants of this three dimension, accurate reconstruction may be performed one at a time at each relevant step of this three dimension. While shoulder resurfacing has not demonstrated superior results in most trials as compared to TSA, it has the benefit of preserving bone stock for young patients, especially if partial resurfacing techniques are employed, for those who may require future revisions. Current review reveals evidence-based good clinical outcomes and radiological results on stemless shoulder arthroplasty versus stemmed arthroplasty designs in the short and midterm follow-up periods. Potential advantages to the young patient include decreased bone resection, shorter operative times, a low prevalence of fractures, and the potential to ease revision if needed. Further research is needed to establish the long-term outcomes for both procedures. Stemless shoulder arthroplasty designs more accurately reconstruct the GH joint center of motion and rotation, revealing superior, satisfactory near anatomic and native shoulder functional outcomes that are especially advantageous to the young population.
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Figure 1. a) Demonstration of the resurfacing prosthesis – GLOBAL CAP Shoulder System (Figure provided by manufacturer DePuy Synthes Company) b) Cannulated instrumentation for resurfacing procedure. (Figure provided by manufacturer DePuy Synthes Company)
a.
b.
Figure 2. Demonstration of anatomic stemless TSA (Wright Medical, Memphis, TN).
Figure 3. Examples of available anatomic stemless prosthesis. a) The Biomet Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA) b) The Arthrex Eclipse Prosthesis (Arthrex, Naples, USA) c) The Mathys Affinis Short Stemless Prosthesis (Mathys, Betlach, Switzerland) d) The Simpliciti Stemless Prosthesis (Wright Medical, Memphis, TN) (Figures provided by the manufacturers). a.
b.
c.
d.