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Minimally Invasive Versus Conventional Joint Arthroplasty
Osteoarthritis Supplement
Minimally Invasive Versus Conventional Joint Arthroplasty Nicholas A. Kenney, MD, Kevin W. Farmer, MD Abstract: With an aging population, as well as a heightened interest in physical activity, the demand for surgical treatment of osteoarthritis of the knee, hip, and shoulder has continued to expand. This demand traditionally has been met with total joint replacements as the definitive treatment. However, with the development of newer, minimally invasive techniques, patients are being offered a greater variety of options for pain relief and improvement in function. These surgical options, varying widely from arthroscopic treatment to partial joint replacements, have been met with mixed results as they have been applied to the treatment of osteoarthritis. Although they are limited in their application and target population, minimally invasive procedures may greatly enhance the outcome of the patient, as well as prevent or delay the need for future total joint arthroplasty. The purpose of this article is to review minimally invasive surgical options for the treatment of osteoarthritis of the hip, knee, and shoulder. We also examine their appropriate application, limitations, clinical outcomes, and associated complications. A brief review of total joint arthroplasty for the aforementioned joints has been included to provide a comparison of the associated clinical outcomes and surgical complications. PM R 2012;4:S134-S140
INTRODUCTION Osteoarthritis of the major extremity joints is a common problem that affects a large portion of our population. Knee osteoarthritis affects 13% of patients older than 60 years and is predicted to affect 20% of those who survive to the next decade [1]. The lifetime risk of symptomatic hip osteoarthritis has been estimated to be 25% [2]. Shoulder osteoarthritis is much less common, affecting less than 1% of the general population; however, it affects 5% of those presenting with complaints of other shoulder pathology [3]. Total joint arthroplasties are commonly performed procedures, with more than 400,000 total knee arthroplasties (TKAs) and more than 200,000 total hip arthroplasties (THAs) performed in the United States in 2003 [4]. These numbers are expected to increase rapidly over time to an estimated 3.5 million TKAs performed annually by the year 2030 [4]. The combination of an increasing number of procedures performed, an aging population, the younger ages of patients at the time of implantation, and increased life span has led to greater component wear and failure, which in turn has resulted in an ever-growing revision arthroplasty burden. Current estimates place the risk of revision of THA and TKA at approximately 1% per year [5]. The demand for revision arthroplasty is expected to double by 2015 for TKA and by 2026 for THA [4]. Revision total shoulder arthroplasties (TSAs) are expected to triple by 2015 [6]. Given these increasing revision rates, surgeons are embracing less-invasive surgical options for osteoarthritis in younger patients. Arthroscopy, partial replacements, and bone-preserving techniques all have been proposed as possible options to treat osteoarthritis in this population, with the goal of delaying total joint arthroplasty (TJA) as long as possible. These procedures have been met with mixed success, which emphasizes the importance of proper patient selection. PM&R
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N.A.K. Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL. Disclosure: nothing to disclose K.W.F. Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL.Address correspondence to: K.W.F., 3450 Hull Road, PO Box 112727, Gainesville, FL 32611-2727; e-mail: [email protected] Disclosure: nothing to disclose
© 2012 by the American Academy of Physical Medicine and Rehabilitation Vol. 4, S134-S140, May 2012 DOI: 10.1016/j.pmrj.2012.01.006
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KNEE Knee Arthroscopy Although its role is limited, knee arthroscopy may provide a minimally invasive option; however, significant controversy exists regarding the role of arthroscopy in the osteoarthritic knee. The theories of how arthroscopy can be beneficial in osteoarthritis are multifactorial. Simple lavage and debridement may wash out and dilute the degradative enzymes and free particles in the joint. Chondroplasty can be used to remove loose or fibrillating cartilage fragments that may be a source of pain and inflammation. Partial meniscectomy is used to trim tears in the meniscus that may generate pain or cause mechanical symptoms such as catching or locking of the knee. To date there are a lack of quality studies demonstrating efficacy of arthroscopy for knee osteoarthritis. Early studies had shown initial improvement in 52%-88% of arthritic patients treated with arthroscopic lavage and debridement [7,8]. On the contrary, other studies, including a randomized controlled trial by Moseley et al [9], have indicated no benefit in arthroscopic lavage or debridement versus placebo surgery. The American Academy of Orthopedic Surgery recommended “against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic osteoarthritis of the knee” [10]. Considerable controversy persists, but several good prognostic factors for arthroscopic treatment appear to exist, including acute onset of increased pain, a specific twisting mechanism of injury, mechanical symptoms, recent effusion, loose bodies, normal mechanical alignment, an isolated chondral flap or fracture, isolated unicompartmental disease, and meniscal tears [11]. Both degenerative and acute meniscal tears have favorable prognostics; however, acute tears have even better outcomes [11]. Complications of knee arthroscopy are estimated to occur in 1.6% of cases and include risks of anesthesia, nerve injury from portal placement (0.6%) (particularly the infrapatellar branch of the saphenous nerve), deep vein thrombosis (0.24%), and infection (0.15%) [12-16]. Arthroscopy does not alter the natural history of osteoarthritis, and progression of disease is likely to occur. Arthroscopy is not the standard of care for knee osteoarthritis, and patients should be well informed about the potential for symptoms to persist after surgical intervention.
Unicompartmental Arthroplasty Unicompartmental arthroplasty of the knee refers to arthroplasty of only 1 of the 3 compartments of the knee—the medial or lateral tibiofemoral or patellofemoral. This procedure differs from a classic TKA, in which all 3 compartments are resurfaced. The goal is to provide pain relief through a less-invasive procedure while preserving many of the native
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knee structures. This approach allows for an implant that more closely resembles normal knee function [17] while having less blood loss, a quicker recovery, decreased perioperative morbidity, and minimized bone resection [18]. The limited bone resection is useful in younger patients because it allows for a future revision to a TKA if needed. The indications for a unicompartmental arthroplasty include high-grade chondromalacia limited to one compartment, knee range of motion of at least 15°-90°, less than 10° varus deformity and less than 5° valgus deformity that are passively correctable, an intact anterior cruciate ligament, no evidence of inflammatory arthritis, and no subluxation of the knee [19]. Patellofemoral arthroplasty has similar indications, with an additional contraindication of patellar malalignment defined by a lateralized tibial tubercle and a Q angle greater than 20° [20]. Results of short to medium duration in this relatively newer procedure demonstrate favorable outcomes, with 10year follow-up revealing 92% of patients in the study had excellent results [21,22] and implant survival rates from 89%-95% [21,23]. Failed unicompartmental arthroplasties typically are revised to a TKA, with early evidence suggesting implant survivorship similar to that of a primary TKA [24]. However, the authors of a recent review noted a 4-fold increase in the revision rate and a significantly worse clinical outcome for TKA conversions from a unicompartmental arthroplasty compared with primary TKAs [25]. Complications associated with unicompartmental arthroplasty include those of any arthroplasty, such as loosening of components (3% at 15 years), deep vein thrombosis (0.1%), deep infection (0.007%), and instability (0.002%) [26-28]. However, in unicompartmental arthroplasty, there is the added concern for advanced degeneration of the compartments that were not treated with the reconstruction. Studies have shown a progression of degeneration of the patellofemoral compartment in up to 38% of patients [29] and up to 46% in the contralateral tibiofemoral compartment at 11 years [30]. To minimize the risk of early failure, unicompartmental arthroplasty should be limited to patients with isolated unicompartmental disease who also have normal alignment and stability.
Total Knee Arthroplasty Total knee arthroplasty (TKA) is a commonly performed procedure with proven long-term success for patients with advanced degenerative joint disease who do not respond to nonsurgical measures and are limited in their daily activities. Many well-designed studies have been published, with researchers reporting 25-year implant survival rates at greater than 90% at 10 years and 85%-95% at 15 years [31]. Although it has been difficult to assess clinical outcomes given the high variability among studies, Kane et al [32] noted an approximate doubling of functional scores in both clinician-
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and patient-recorded outcome scales at greater than 5 years from the time of surgery. Complications associated with TKA can be attributed to patient factors, surgical factors, and material factors. Patient factors, such as poor compliance with the postoperative regimen and comorbidities, can lead to issues with stiffness, infection, deep vein thrombosis, and wound healing compromise [33]. Surgical factors, such as component malposition, can contribute to postoperative knee stiffness, instability, or patellar maltracking [33]. Material factors tend to be involved in late complications, such as wearing of the polyethylene bearing, leading to loosening of implants [34]. Instability is estimated to occur in approximately 1%-2% of cases, neurologic injury in 0.3%-2%, vascular complications in 0.2%-0.3%, and fatal pulmonary embolus in 0.1%-0.2% [31]. Overall, TKA is associated with an 8% rate of perioperative complications within 6 months of the procedure [32]. It is contraindicated in patients with long-standing infection and those with a deficient extensor mechanism. TKA is the gold standard for tricompartmental osteoarthritis with a proven track record of success, and in long-term studies it has demonstrated good outcomes. It should be the surgical procedure of choice for degenerative joint disease of the knee in an older patient who does not respond to nonsurgical management.
HIP Hip Arthroscopy Hip arthroscopy has been increasingly used and studied in the past 30 years to treat various pathologic entities of the hip, including degenerative joint disease. In particular, it has been used in younger patients with early signs and symptoms of osteoarthritis who may not be appropriate candidates for surgical reconstructive options. Improvements in instruments and techniques have led this to be one of the most rapidly evolving fields in orthopedic surgery. Indications for hip arthroscopy include intra-articular loose bodies, labral tears, femoral acetabular impingement, focal chondral lesions, and early-stage osteoarthritis and osteonecrosis [35,36]. In relation to osteoarthritis, the indications have been an area of controversy because of mixed results from follow-up studies. Some authors suggest that arthroscopic treatment of degenerative lesions, such as focal chondral defects or labral tears, can decrease pain and potentially slow the degenerative process [37]. Recent evidence has not supported these early claims [36,38]. Much like its role in treatment of knee arthritis, arthroscopy of the hip can achieve successful results with proper expectations, limited procedural intervention, and proper patient selection. Numerous investigators have shown that young patients, typically younger than 40 years, as well as those with normal or low-grade cartilage defects, have the
best outcomes. In up to 90% of this population, the need for a total hip replacement at 10-year follow-up from hip arthroscopy can be delayed [38,39]. However, the majority of follow-up studies have shown very poor results in older patients, in those with long-standing symptoms, and in those with radiographic evidence of osteoarthritis. Most of these patients progress to THA within 2 years and have little to no relief of pain or improvement in daily activities [38]. Given this evidence, no role currently exists for hip arthroscopy in the setting of osteoarthritis with radiographic changes. Complications of hip arthroscopy are rare and typically transient. Serious complications, including abdominal compartment syndrome, have been reported. The overall incidence of complications has been reported to be between 0.5%-1.4%, with the most common being scuffing of the cartilage and transient peroneal or pudendal palsies from the traction required for the procedure [40,41].
Hip Resurfacing/Hemiarthroplasty Hip resurfacing is a surgical technique in which the degenerative femoral head is “capped” with a metal implant, which then articulates with the native acetabulum, or with a metal socket, if the acetabulum is resurfaced as well. Although the modern metal-on-metal implant configuration has been popularized in the past 20 years, hip resurfacing has been performed since the 1950s with various materials and designs, many of which showed significant failure rates and were thus abandoned. However, results with current implants and technologies have been promising [42]. The proposed advantages of hip resurfacing include preserved bone in the femoral head and neck, which may allow for an easier revision surgery [43], a reduced dislocation rate compared with total hip replacement [44], and a more anatomic restoration of gait and hip biomechanics [45,46]. Current evidence suggests that hip resurfacing is most appropriate in younger, active males [47]. The contraindications for hip resurfacing are more extensive than those for a traditional THA and are particularly crucial for this procedure. Severe bone loss from the femoral head, large femoral neck cysts, and poor-quality bone, such as in osteoporosis, directly leads to short-term catastrophic failure via femoral neck fractures below the implant. Other relative contraindications include women of child-bearing age, body mass index ⬎35, inflammatory arthritis, age ⬎65 years, and a discrepancy in leg lengths ⬎2 cm [48,49]. Results with the newer generation metal-on-metal resurfacing products generally have been successful, but the results of long-term studies with these implants are still pending. Amstutz et al [43] studied 400 hip resurfacing implants in patients with a mean age of 48 years with a 2- to 6-year follow-up. They showed an overall implant survival rate of 94% at 4 years. In a meta-analysis by Smith et al [50], 3799 hip resurfacing implants were compared with 3282 total hip
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implants and showed equal or better functional outcomes with resurfacing and only a slight increase in loosening and revision rates. Overall, most studies have shown a success rate for hip resurfacing from 94%-100% at short-term follow-up of 5 years or less, with higher activity levels compared with THA [48,51]. Some new evidence does lead to concern about poor longer-term survival for metal-on-metal hip resurfacing, with increasing failure rates of 25% noted at 6 years [52]. Complications associated with hip resurfacing include femoral neck fracture, component loosening, and metal allergy and hypersensitivity to the metal ion debris resulting from wear of the metal-on-metal implant [53]. Femoral neck fracture is a catastrophic complication requiring revision to THA and has been estimated to occur in approximately 1.4% of patients, with the fracture rate for women being twice that of men [54]. Hemiarthroplasty involves replacement of the femoral head with a metal ball that is attached to a stem that fits into the femoral canal and is fixed with cement or bony growth onto the stem. The acetabulum is not resurfaced in a hemiarthroplasty prosthesis; instead, the procedures relies on the native acetabular cartilage to articulate with the implant. This concept differs from resurfacing in that significantly more bone is resected when a hemiarthroplasty is performed. Hemiarthroplasty has shown dismal results for treatment of osteoarthritis at 10-year follow-up. Pellegrini et al [55] reviewed 173 hemiarthroplasties, with 57% treating a primary diagnosis of osteoarthritis. Not only was the failure rate high for these implants at 20%, but they also were associated with a significantly more difficult revision to a THA. Hemiarthroplasty should have a limited role in the treatment of osteoarthritis of the hip. Indications for use of hip hemiarthroplasty are femoral neck fractures and femoral head osteonecrosis [56].
Total Hip Arthroplasty THA is a commonly performed procedure involving replacement of the femoral head and acetabulum of the hip. Many variations of implant materials exist, such as metalon-metal components, ceramic-ceramic, and metal-polyethylene (plastic) combinations. The most commonly used materials are a metal femoral head matched to a polyethylene acetabular liner. THA is indicated for treatment of degenerative disease of the hip in the patient who has not responded to nonsurgical measures and is preferable in older patients with decreased activity levels. With evolution of new technologies, total hip replacements have achieved very high success rates and increasing length of survival. Some national joint registries, such as the one in Sweden, track implants and patient outcomes on a large scale. In reviewing 93,000 implants during a 10-year period, a survival rate of 91%-94% was demonstrated [57]. Outside of joint registry data, research studies have been
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more implant specific but have generally shown a nearly identical result. The original cemented implant design has shown a survivorship of up to 90% at a mean of 25 years follow-up [58]. Long-term studies are lacking for cementless implants because their use has only recently flourished, but they do show a very low revision rate of 4% at an average 10-year followup. Studies have shown that 86% of patients have good to excellent clinical results with a THA and significant functional improvement, with the Harris hip score improving from an average of 51 preoperatively to 94 postoperatively [59]. Patients often can obtain functional return to lowimpact activities. Complications associated with THA include infection, fracture around the implant (periprosthetic fracture), leg length discrepancy, dislocation, and thromboembolism [6062]. The incidence of infection is less than 1%; dislocation, 1%-3%; and periprosthetic fracture, 0.1%-2.5%, with infection and dislocation having their highest risk within the first 6 months of surgery [60]. Limb length inequality is a frequent factor in malpractice claims and accounts for 4.7% of medical errors as identified by The Joint Commission [61]. Finally, the incidence of pulmonary embolism in patients with THA is approximately 1%, reaching that level at approximately 6 weeks after surgery [62], with one quarter developing during the perioperative hospital stay [60].
SHOULDER OSTEOARTHRITIS Arthroscopy Shoulder arthroscopy has become the gold standard for many intra-articular pathologies. The role of shoulder arthroscopy in glenohumeral osteoarthritis has been met with limited success in a very specific subset of patients. In a retrospective review of 81 patients who were, on average, 47 years of age, Van Thiel et al [63] found that arthroscopic debridement significantly improved the range of motion, pain, and functional scores postoperatively. A total of 19.8% of patients (16/81) progressed to TSA by 10 months. The best outcomes were associated with patients with residual joint space and the absence of large osteophytes at preoperative evaluation [63]. Guyette et al [64] followed 36 patients who had a subacromial decompression with debridement for osteoarthritis and noted that outcomes were best in patients with minimal degenerative chondral changes. Recent reports have demonstrated promising results for arthroscopic glenoid resurfacing with biologic patches [65]. At this time, arthroscopic debridement appears to have a role in young patients with early degenerative changes and minimal findings on radiographs. Subacromial decompressions and capsular releases may improve outcomes, and there may be a future role for arthroscopic resurfacing. Patients and referring physicians should be aware that results appear to be
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temporary and may only serve to delay the need for future arthroplasty.
Resurfacing Shoulder resurfacing differs from a conventional stemmed shoulder arthroplasty in that the patient’s humeral head is preserved by reaming it to a concentric sphere and fitting it with a metal cap. This procedure can be performed as a humeral resurfacing only in conjunction with a biologic resurfacing of the glenoid, or with a standard polyethylene glenoid component [66-68]. The preservation of the humeral head bone stock and lack of stemmed component may facilitate future revision surgery. In addition, by preserving the humeral head, resurfacing offers the advantage of maintaining the patient’s natural humeral neck orientation, height, and inclination [69]. Given these benefits, the use of humeral resurfacing has increased, especially in younger patients. In a review of 103 resurfacing replacements with a mean follow-up of 6.8 years, Levy and Copeland [67] noted excellent results in patients with osteoarthritis (improvement of 70% adjusted Constant score for totals, and 50% for humerus only). Poorer results were noted in rotator cuff arthropathy (improvement of 35% adjusted Constant score) and posttraumatic arthritis (improvement of 38% adjusted Constant score). At final follow-up, 94% of patients felt as though their shoulder had improved with surgery, and the authors stated that outcomes were similar to a traditional shoulder arthroplasty. In a prospective study of 36 patients with osteoarthritis who were younger than 55 years, Bailie et al [70] found excellent results at a mean follow-up of 38 months (range, 24-60 months). Thirty-five of the patients reported returning to their full activities, including a wide array of exercises. Recently, authors also have reported good short-term outcomes in combining humeral resurfacing with biologic resurfacing of the glenoid [68]. Humeral resurfacing has provided good short- to medium-term outcomes in select patient populations with low complication rates. It is an appealing option in younger patients with osteoarthritis, with at least 60% of the humeral bone stock reported to be maintained [66]. More recent partial replacement options for focal humeral head defects also have been described with promising outcomes [71]. Longer follow-up studies are needed to analyze the longevity of this procedure.
Hemiarthroplasty and TSA Shoulder arthroplasties have been rapidly increasing in use during the past 2 decades. These procedures have had very good success in the older population, with significant improvements in pain and function [72]. In comparison with the much more commonly performed procedures of TKA
and THA, patients undergoing shoulder arthroplasty have fewer complications, shorter length of hospital stays, and lower costs [73]. However, failure of fixation of the polyethylene glenoid has been termed the “weak link” in the construct, leading surgeons to look for alternatives in younger patients. Hemiarthroplasty (replacing the humeral head only) has been used in patients with concerns of longevity of the glenoid replacement. In patients younger than 50 years, Sperling et al [74] compared 62 hemiarthroplasties and 29 TSAs with a mean follow-up of 16.7 years. The estimated 20-year survival for hemiarthroplasty was 74% compared with 84% for TSA. Nineteen percent of hemiarthroplasties were revised, mostly because of glenoid arthrosis. Levine et al [75] noted that outcomes for hemiarthroplasties were worse in patients with eccentric glenoid wear compared with those with concentric wear. Hemiarthroplasties for shoulder osteoarthritis in younger patients appears to have a decreasing role. Long-term survival is limited by glenoid arthrosis, and revision outcomes of hemiarthroplasties to TSAs have been shown to have worse outcomes than do primary TSAs [76]. Several authors have described hemiarthroplasty combined with biologic glenoid resurfacing with mixed short-term success [77-79]. Currently, hemiarthroplasty has a limited role in younger patients with osteoarthritis, a role that may continue to decrease as newer resurfacing options are developed.
CONCLUSIONS Osteoarthritis of the hip, knee, and shoulder affects a large percentage of the aging population. Total joint replacements have a long, proven track record of success in properly chosen patients. The concerns for increasing numbers of revision arthroplasties have led to a trend toward less-invasive options in younger patients (defined as younger than 50 years). Physicians should be aware of the importance of proper patient selection in using these less-invasive options, because many of these procedures have a narrow scope of potential candidates. Arthroscopy has a limited role in persons with osteoarthritis, and hip hemiarthroplasty is rarely used in persons with osteoarthritis. Resurfacing options are becoming more popular and are supported by positive shortterm outcome data; however, long-term data are lacking. TJA is the procedure of choice for osteoarthritis of the shoulder, hip, and knee in older patients with moderate to lower activity levels. In younger, active patients with greater activity demands, resurfacing offers a less-invasive option that preserves bone stock for future revision to a TJA if necessary.
REFERENCES 1. Holt HL, Katz JN, Reichmann WM. Forecasting the burden of advanced knee osteoarthritis over a 10-year period in a cohort of 60-64 year-old US adults. Osteoarthritis Cartilage 2011;19:44-50.
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2. Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis Cartilage 2010;18:1372-1379. 3. Nakagawa Y, Hyakuna K, Otani S, Hashitani M, Nakamura T. Epidemiologic study of glenohumeral osteoarthritis with plain radiography. J Shoulder Elbow Surg 1999;8:580-584. 4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-785. 5. Labek G, Thaler M, Janda W, Agreiter M, Stockl B. Revision rates after total joint replacement: Cumulative results from worldwide joint register datasets. J Bone Joint Surg Br 2011;93-B:293-297 6. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-1120. 7. Baumgartner MR, Cannon WD Jr, Vittori JM, Schmidt ES, Maurer RC. Arthroscopic debridement of the arthritic knee. Clin Orthop 1990;253: 197-202. 8. Jackson RW, Silver R, Marans H. Arthroscopic treatment of degenerative joint disease. Arthroscopy 1986;2:114. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81-88. 10. AAOS Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee (Nonarthroplasty), December 6, 2008. Available at http:// www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 20, 2012. 11. Hunt SA, Jazrawi LM, Sherman OH. Arthroscopic management of osteoarthritis of the knee. J Am Acad Orthop Surg 2002;10:356-363. 12. Small N. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 13. Kim TK, Savino RM, McFarland EG, Cosgarea AJ. Neurovascular complications of knee arthroscopy. Am J Sports Med 2002;30:619629. 14. Jaureguito JW, Greenwald AE, Wilcox JF, Paulos LE, Rosenberg TD. The incidence of deep vein thrombosis after arthroscopic knee surgery. Am J Sports Med 1999;27:707-710. 15. Bert JM, Giannini D, Nace L. Antibiotic prophylaxis of the knee: Is it necessary? Arthroscopy 2007;23:4-6. 16. Reigstad O, Grimsgaard C. Complications in knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2006;14:473-477. 17. Patil S, Colwell CW Jr, Ezzet KA, D’Lima DD. Can normal knee kinematics be restored with unicompartmental knee replacement? J Bone Joint Surg Am 2005;87:332-338. 18. Laurencin CT, Zelicof SB, Scott RD, Ewald FC. Unicompartmental versus total knee arthroplasty in the same patient: A comparative study. Clin Orthop Relat Res 1991;273:151-156. 19. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am 1989;71:145-150. 20. Lonner JH. Patellofemoral arthroplasty. J Am Acad Orthop Surg 2007; 15:495-506. 21. Berger RA, Meneghini RM, Jacobs JJ, et al. Results of unicompartmental knee arthroplasty at a minimum of 10 years follow-up. J Bone Joint Surg Am 2005;87:999-1006. 22. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am 2003;85-A:1968-1973. 23. Gioe TJ, Killeen KK, Hoeffel DP, et al. Analysis of unicompartmental knee arthroplasty in a community based implant registry. Clin Orthop Relat Res 2003;416:111-119. 24. Johnson S, Jones P, Newman JH. The survivorship and results of total knee replacements converted from unicompartmental knee replacements. Knee 2007;14:154-157.
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25. Pearse AJ, Hooper GJ, Rothwell A, Frampton C. Survival and functional outcome after revision of a unicompartmental to a total knee replacement. J Bone Joint Surg Br 2010;92-B(4):508-512. 26. Price AJ, Waite JC, Svard U. Long-term clinical results of the medial Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res 2005;435:171-180. 27. Berend KR, Morris MJ, Lombardi AV. Unicompartmental knee arthroplasty: Incidence of transfusion and symptomatic thromboembolic disease. Orthopedics 2010;33:8-10. 28. Price AJ, Svard U. A second decade life table survival analysis of the Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res 2011;469:174-179. 29. Hernigou P, Deschamps G. Patellar impingement following unicompartmental arthroplasty. J Bone Joint Surg Am 2002;84:1132-1137. 30. Squire MW, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC. Unicompartmental knee replacement: A minimum 15 year follow-up study. Clin Orthop Relat Res 1999;367:61-72. 31. Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg 2010;18:406-416. 32. Kane RL, Saleh KJ, Witt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 2005;87:1719-1724. 33. Lonner JH, Lotke PA. Aseptic complications after total knee arthroplasty. J Am Acad Orthop Surg 1999;7:311-324. 34. Amstutz HC, Campbell P, Kossovsky N, Clarke IC. Mechanism and clinical significance of wear debris-induced osteolysis. Clin Orthop Relat Res 1992;276:7-18. 35. Byrd JW. Hip arthroscopy: Surgical indications. Arthroscopy 2006;22: 1260-1262. 36. Stevens MS, LeGay DA, Glazebrook MA, Amirault D. The evidence for hip arthroscopy: Grading the current indications. Arthroscopy 2010; 26:1370-1383. 37. Jerosch J, Schunck J, Khoja A. Arthroscopic treatment of the hip in early and midstage degenerative joint disease. Knee Surg Sports Traumatol Arthrosc 2006;14:641-645. 38. McCarthy JC, Jarrett BT, Ojeifo O, Lee JA, Bragdon CR. What factors influence long-term survivorship after hip arthroscopy? Clin Orthop Relat Res 2011;469:362-371. 39. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy 1999;15:132-137. 40. Sampson TG. Complications of hip arthroscopy. Clin Sports Med 2001;20:831-835. 41. Clarke MT, Arora A, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clin Orthop Relat Res 2003;406:84-88. 42. Amstutz HC, Grigoris P, Dorey FJ. Evolution and future of surface replacement of the hip. J Orthop Sci 1998;3:169-186. 43. Amstutz HC, Beaule PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen T. Metal-on-metal hybrid surface arthroplasty: Two to six-year follow-up study. J Bone Joint Surg Am 2004;86:28-39. 44. McMinn D, Treacy R, Lin K, Pynsent P. Metal-on-metal surface replacement of the hip: Experience of the McMinn prosthesis. Clin Orthop Relat Res 1996;329:89-98. 45. Mont MA, Seyler TM, Ragland PS, Bhave A, Erhart J, Starr R. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. Arthroplasty 2007;22:100-108. 46. Silva M, Lee KH, Heisel C, Dela Rosa MA, Schmalzried TP. The biomechanical results of total hip resurfacing arthroplasty. J Bone Joint Surg Am 2004;86:40-46. 47. Spencer RF. Evolution in hip resurfacing design and contemporary experience with an uncemented device. J Bone Joint Surg Am 2011;93: 84-88. 48. Mont MA, Ragland PS, Etienne G, Seyler TM, Schmalzried TP. Hip resurfacing arthroplasty. J Am Acad Orthop Surg 2006;14:454-463.
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49. Beaule PE, Antoniades J. Patient selection and surgical technique for surface arthroplasty of the hip. Orthop Clin North Am 2005;36:177185. 50. Smith TO, Nichols R, Donell ST, Hing CB. The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: A metaanalysis and systematic review. Acta Orthop 2010;81:684-695. 51. Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favorably with THA at 2 years follow up. Clin Orthop Relat Res 2006;453:123-131. 52. Langton DJ, Jameson SS, Joyce TJ, et al. Accelerating failure rate of the ASR total hip replacement. J Bone Joint Surg Br 2011;93:1011-1016. 53. Shimmin A, Beaule PE, Campbell P. Metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg Am 2008;90:637-654. 54. Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: A national review of 50 cases. J Bone Joint Surg Br 2005;87:463-464. 55. Pellegrini VD Jr, Heiges BA, Bixler B, Lehman EB, Davis CM III. Minimum ten-year results of primary bipolar hip arthroplasty for degenerative arthritis of the hip. J Bone Joint Surg Am 2006;88:18171825. 56. McConville OR, Bowman AJ Jr, Kilfoyle RM, McConville JF, Mayo RA. Bipolar hemiarthroplasty in degenerative arthritis of the hip: 100 consecutive cases. Clin Ortho Relat Res 1990;251:67-74. 57. Soderman P, Malchau H, Herberts P, Johnell O. Are the findings in the Swedish National Total Hip Arthroplasty Register valid? J Arthroplasty 2000;15:884-889. 58. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five year survivorship of two thousand consecutive primary Charnley total hip replacements: Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 2002;84-A:171-177. 59. Archibeck MJ, Berger RA, Jacobs JJ, et al. Second-generation cementless total hip arthroplasty: Eight to eleven-year results. J Bone Joint Surg Am 2001;83-A:1666-1673 60. Phillips CB, Barrett JA, Losina E, et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003;85:2026. 61. Clark CR, Huddleston HD, Schoch EP III, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 2006; 14:38-45. 62. White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998;158:1525-1531. 63. Van Thiel GS, Sheehan S, Frank RM, et al. Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthroscopy 2010;26:1451-1455.
64. Guyette TM, Bae H, Warren RF, Craig E, Wickiewicz TL. Results of arthroscopic subacromial decompression in patients with subacromial impingement and glenohumeral degenerative joint disease. J Shoulder Elbow Surg 2002;11:299-304. 65. Savoie FH III, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: Midterm results. Arthroscopy 2009;25:864-871. 66. Burgess DL, McGrath MS, Bonutti PM, Marker DR, Delanois RE, Mont MA. Shoulder resurfacing. J Bone Joint Surg Am 2009;91-A:1228-1238 67. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. J Bone Joint Surg Br 2001;83-B:213-221. 68. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg 2009;18:915-919. 69. Copeland S. The continuing development of shoulder replacement: “reaching the surface.” J Bone Joint Surg Am 2006;88-A:900-905. 70. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am 2008;90-A:110-117. 71. Uribe JW, Botto-van Bemden A. Partial humeral head resurfacing for osteonecrosis. J Shoulder Elbow Surg 2009;18:711-716. 72. Foruria AM, Sperling JW, Ankem HK, Oh LS, Cofield RH. Total shoulder replacement for osteoarthritis in patients 80 years of age and older. J Bone Joint Surg Br 2010;92-B:970-974. 73. Farmer KW, Hammond JW, Queale WS, Keyurapan E, McFarland EG. Shoulder arthroplasty versus hip and knee arthroplasties: A comparison of outcomes. Clin Orthop Relat Res 2007;455:183-189. 74. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg 2004;13: 604-613. 75. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU. Hemiarthroplasty for glenohumeral arthritis: Results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-454. 76. Sperling JW, Cofield RH. Revision total shoulder arthroplasty for the treatment of glenoid arthrosis. J Bone Joint Surg Am 1998;80-A:860867. 77. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am 2009;91A:419-424 78. Wirth MA. Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid. J Bone Joint Surg Am 2009;91-A:1109-1119 79. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Two to fifteen-year outcomes. J Bone Joint Surg Am 2007;89A:727-734
Minimally Invasive Versus Conventional Joint Arthroplasty Nicholas A. Kenney, MD, Kevin W. Farmer, MD Abstract: With an aging population, as well as a heightened interest in physical activity, the demand for surgical treatment of osteoarthritis of the knee, hip, and shoulder has continued to expand. This demand traditionally has been met with total joint replacements as the definitive treatment. However, with the development of newer, minimally invasive techniques, patients are being offered a greater variety of options for pain relief and improvement in function. These surgical options, varying widely from arthroscopic treatment to partial joint replacements, have been met with mixed results as they have been applied to the treatment of osteoarthritis. Although they are limited in their application and target population, minimally invasive procedures may greatly enhance the outcome of the patient, as well as prevent or delay the need for future total joint arthroplasty. The purpose of this article is to review minimally invasive surgical options for the treatment of osteoarthritis of the hip, knee, and shoulder. We also examine their appropriate application, limitations, clinical outcomes, and associated complications. A brief review of total joint arthroplasty for the aforementioned joints has been included to provide a comparison of the associated clinical outcomes and surgical complications. PM R 2012;4:S134-S140
INTRODUCTION Osteoarthritis of the major extremity joints is a common problem that affects a large portion of our population. Knee osteoarthritis affects 13% of patients older than 60 years and is predicted to affect 20% of those who survive to the next decade [1]. The lifetime risk of symptomatic hip osteoarthritis has been estimated to be 25% [2]. Shoulder osteoarthritis is much less common, affecting less than 1% of the general population; however, it affects 5% of those presenting with complaints of other shoulder pathology [3]. Total joint arthroplasties are commonly performed procedures, with more than 400,000 total knee arthroplasties (TKAs) and more than 200,000 total hip arthroplasties (THAs) performed in the United States in 2003 [4]. These numbers are expected to increase rapidly over time to an estimated 3.5 million TKAs performed annually by the year 2030 [4]. The combination of an increasing number of procedures performed, an aging population, the younger ages of patients at the time of implantation, and increased life span has led to greater component wear and failure, which in turn has resulted in an ever-growing revision arthroplasty burden. Current estimates place the risk of revision of THA and TKA at approximately 1% per year [5]. The demand for revision arthroplasty is expected to double by 2015 for TKA and by 2026 for THA [4]. Revision total shoulder arthroplasties (TSAs) are expected to triple by 2015 [6]. Given these increasing revision rates, surgeons are embracing less-invasive surgical options for osteoarthritis in younger patients. Arthroscopy, partial replacements, and bone-preserving techniques all have been proposed as possible options to treat osteoarthritis in this population, with the goal of delaying total joint arthroplasty (TJA) as long as possible. These procedures have been met with mixed success, which emphasizes the importance of proper patient selection. PM&R
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N.A.K. Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL. Disclosure: nothing to disclose K.W.F. Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL.Address correspondence to: K.W.F., 3450 Hull Road, PO Box 112727, Gainesville, FL 32611-2727; e-mail: [email protected] Disclosure: nothing to disclose
© 2012 by the American Academy of Physical Medicine and Rehabilitation Vol. 4, S134-S140, May 2012 DOI: 10.1016/j.pmrj.2012.01.006
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KNEE Knee Arthroscopy Although its role is limited, knee arthroscopy may provide a minimally invasive option; however, significant controversy exists regarding the role of arthroscopy in the osteoarthritic knee. The theories of how arthroscopy can be beneficial in osteoarthritis are multifactorial. Simple lavage and debridement may wash out and dilute the degradative enzymes and free particles in the joint. Chondroplasty can be used to remove loose or fibrillating cartilage fragments that may be a source of pain and inflammation. Partial meniscectomy is used to trim tears in the meniscus that may generate pain or cause mechanical symptoms such as catching or locking of the knee. To date there are a lack of quality studies demonstrating efficacy of arthroscopy for knee osteoarthritis. Early studies had shown initial improvement in 52%-88% of arthritic patients treated with arthroscopic lavage and debridement [7,8]. On the contrary, other studies, including a randomized controlled trial by Moseley et al [9], have indicated no benefit in arthroscopic lavage or debridement versus placebo surgery. The American Academy of Orthopedic Surgery recommended “against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic osteoarthritis of the knee” [10]. Considerable controversy persists, but several good prognostic factors for arthroscopic treatment appear to exist, including acute onset of increased pain, a specific twisting mechanism of injury, mechanical symptoms, recent effusion, loose bodies, normal mechanical alignment, an isolated chondral flap or fracture, isolated unicompartmental disease, and meniscal tears [11]. Both degenerative and acute meniscal tears have favorable prognostics; however, acute tears have even better outcomes [11]. Complications of knee arthroscopy are estimated to occur in 1.6% of cases and include risks of anesthesia, nerve injury from portal placement (0.6%) (particularly the infrapatellar branch of the saphenous nerve), deep vein thrombosis (0.24%), and infection (0.15%) [12-16]. Arthroscopy does not alter the natural history of osteoarthritis, and progression of disease is likely to occur. Arthroscopy is not the standard of care for knee osteoarthritis, and patients should be well informed about the potential for symptoms to persist after surgical intervention.
Unicompartmental Arthroplasty Unicompartmental arthroplasty of the knee refers to arthroplasty of only 1 of the 3 compartments of the knee—the medial or lateral tibiofemoral or patellofemoral. This procedure differs from a classic TKA, in which all 3 compartments are resurfaced. The goal is to provide pain relief through a less-invasive procedure while preserving many of the native
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knee structures. This approach allows for an implant that more closely resembles normal knee function [17] while having less blood loss, a quicker recovery, decreased perioperative morbidity, and minimized bone resection [18]. The limited bone resection is useful in younger patients because it allows for a future revision to a TKA if needed. The indications for a unicompartmental arthroplasty include high-grade chondromalacia limited to one compartment, knee range of motion of at least 15°-90°, less than 10° varus deformity and less than 5° valgus deformity that are passively correctable, an intact anterior cruciate ligament, no evidence of inflammatory arthritis, and no subluxation of the knee [19]. Patellofemoral arthroplasty has similar indications, with an additional contraindication of patellar malalignment defined by a lateralized tibial tubercle and a Q angle greater than 20° [20]. Results of short to medium duration in this relatively newer procedure demonstrate favorable outcomes, with 10year follow-up revealing 92% of patients in the study had excellent results [21,22] and implant survival rates from 89%-95% [21,23]. Failed unicompartmental arthroplasties typically are revised to a TKA, with early evidence suggesting implant survivorship similar to that of a primary TKA [24]. However, the authors of a recent review noted a 4-fold increase in the revision rate and a significantly worse clinical outcome for TKA conversions from a unicompartmental arthroplasty compared with primary TKAs [25]. Complications associated with unicompartmental arthroplasty include those of any arthroplasty, such as loosening of components (3% at 15 years), deep vein thrombosis (0.1%), deep infection (0.007%), and instability (0.002%) [26-28]. However, in unicompartmental arthroplasty, there is the added concern for advanced degeneration of the compartments that were not treated with the reconstruction. Studies have shown a progression of degeneration of the patellofemoral compartment in up to 38% of patients [29] and up to 46% in the contralateral tibiofemoral compartment at 11 years [30]. To minimize the risk of early failure, unicompartmental arthroplasty should be limited to patients with isolated unicompartmental disease who also have normal alignment and stability.
Total Knee Arthroplasty Total knee arthroplasty (TKA) is a commonly performed procedure with proven long-term success for patients with advanced degenerative joint disease who do not respond to nonsurgical measures and are limited in their daily activities. Many well-designed studies have been published, with researchers reporting 25-year implant survival rates at greater than 90% at 10 years and 85%-95% at 15 years [31]. Although it has been difficult to assess clinical outcomes given the high variability among studies, Kane et al [32] noted an approximate doubling of functional scores in both clinician-
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and patient-recorded outcome scales at greater than 5 years from the time of surgery. Complications associated with TKA can be attributed to patient factors, surgical factors, and material factors. Patient factors, such as poor compliance with the postoperative regimen and comorbidities, can lead to issues with stiffness, infection, deep vein thrombosis, and wound healing compromise [33]. Surgical factors, such as component malposition, can contribute to postoperative knee stiffness, instability, or patellar maltracking [33]. Material factors tend to be involved in late complications, such as wearing of the polyethylene bearing, leading to loosening of implants [34]. Instability is estimated to occur in approximately 1%-2% of cases, neurologic injury in 0.3%-2%, vascular complications in 0.2%-0.3%, and fatal pulmonary embolus in 0.1%-0.2% [31]. Overall, TKA is associated with an 8% rate of perioperative complications within 6 months of the procedure [32]. It is contraindicated in patients with long-standing infection and those with a deficient extensor mechanism. TKA is the gold standard for tricompartmental osteoarthritis with a proven track record of success, and in long-term studies it has demonstrated good outcomes. It should be the surgical procedure of choice for degenerative joint disease of the knee in an older patient who does not respond to nonsurgical management.
HIP Hip Arthroscopy Hip arthroscopy has been increasingly used and studied in the past 30 years to treat various pathologic entities of the hip, including degenerative joint disease. In particular, it has been used in younger patients with early signs and symptoms of osteoarthritis who may not be appropriate candidates for surgical reconstructive options. Improvements in instruments and techniques have led this to be one of the most rapidly evolving fields in orthopedic surgery. Indications for hip arthroscopy include intra-articular loose bodies, labral tears, femoral acetabular impingement, focal chondral lesions, and early-stage osteoarthritis and osteonecrosis [35,36]. In relation to osteoarthritis, the indications have been an area of controversy because of mixed results from follow-up studies. Some authors suggest that arthroscopic treatment of degenerative lesions, such as focal chondral defects or labral tears, can decrease pain and potentially slow the degenerative process [37]. Recent evidence has not supported these early claims [36,38]. Much like its role in treatment of knee arthritis, arthroscopy of the hip can achieve successful results with proper expectations, limited procedural intervention, and proper patient selection. Numerous investigators have shown that young patients, typically younger than 40 years, as well as those with normal or low-grade cartilage defects, have the
best outcomes. In up to 90% of this population, the need for a total hip replacement at 10-year follow-up from hip arthroscopy can be delayed [38,39]. However, the majority of follow-up studies have shown very poor results in older patients, in those with long-standing symptoms, and in those with radiographic evidence of osteoarthritis. Most of these patients progress to THA within 2 years and have little to no relief of pain or improvement in daily activities [38]. Given this evidence, no role currently exists for hip arthroscopy in the setting of osteoarthritis with radiographic changes. Complications of hip arthroscopy are rare and typically transient. Serious complications, including abdominal compartment syndrome, have been reported. The overall incidence of complications has been reported to be between 0.5%-1.4%, with the most common being scuffing of the cartilage and transient peroneal or pudendal palsies from the traction required for the procedure [40,41].
Hip Resurfacing/Hemiarthroplasty Hip resurfacing is a surgical technique in which the degenerative femoral head is “capped” with a metal implant, which then articulates with the native acetabulum, or with a metal socket, if the acetabulum is resurfaced as well. Although the modern metal-on-metal implant configuration has been popularized in the past 20 years, hip resurfacing has been performed since the 1950s with various materials and designs, many of which showed significant failure rates and were thus abandoned. However, results with current implants and technologies have been promising [42]. The proposed advantages of hip resurfacing include preserved bone in the femoral head and neck, which may allow for an easier revision surgery [43], a reduced dislocation rate compared with total hip replacement [44], and a more anatomic restoration of gait and hip biomechanics [45,46]. Current evidence suggests that hip resurfacing is most appropriate in younger, active males [47]. The contraindications for hip resurfacing are more extensive than those for a traditional THA and are particularly crucial for this procedure. Severe bone loss from the femoral head, large femoral neck cysts, and poor-quality bone, such as in osteoporosis, directly leads to short-term catastrophic failure via femoral neck fractures below the implant. Other relative contraindications include women of child-bearing age, body mass index ⬎35, inflammatory arthritis, age ⬎65 years, and a discrepancy in leg lengths ⬎2 cm [48,49]. Results with the newer generation metal-on-metal resurfacing products generally have been successful, but the results of long-term studies with these implants are still pending. Amstutz et al [43] studied 400 hip resurfacing implants in patients with a mean age of 48 years with a 2- to 6-year follow-up. They showed an overall implant survival rate of 94% at 4 years. In a meta-analysis by Smith et al [50], 3799 hip resurfacing implants were compared with 3282 total hip
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implants and showed equal or better functional outcomes with resurfacing and only a slight increase in loosening and revision rates. Overall, most studies have shown a success rate for hip resurfacing from 94%-100% at short-term follow-up of 5 years or less, with higher activity levels compared with THA [48,51]. Some new evidence does lead to concern about poor longer-term survival for metal-on-metal hip resurfacing, with increasing failure rates of 25% noted at 6 years [52]. Complications associated with hip resurfacing include femoral neck fracture, component loosening, and metal allergy and hypersensitivity to the metal ion debris resulting from wear of the metal-on-metal implant [53]. Femoral neck fracture is a catastrophic complication requiring revision to THA and has been estimated to occur in approximately 1.4% of patients, with the fracture rate for women being twice that of men [54]. Hemiarthroplasty involves replacement of the femoral head with a metal ball that is attached to a stem that fits into the femoral canal and is fixed with cement or bony growth onto the stem. The acetabulum is not resurfaced in a hemiarthroplasty prosthesis; instead, the procedures relies on the native acetabular cartilage to articulate with the implant. This concept differs from resurfacing in that significantly more bone is resected when a hemiarthroplasty is performed. Hemiarthroplasty has shown dismal results for treatment of osteoarthritis at 10-year follow-up. Pellegrini et al [55] reviewed 173 hemiarthroplasties, with 57% treating a primary diagnosis of osteoarthritis. Not only was the failure rate high for these implants at 20%, but they also were associated with a significantly more difficult revision to a THA. Hemiarthroplasty should have a limited role in the treatment of osteoarthritis of the hip. Indications for use of hip hemiarthroplasty are femoral neck fractures and femoral head osteonecrosis [56].
Total Hip Arthroplasty THA is a commonly performed procedure involving replacement of the femoral head and acetabulum of the hip. Many variations of implant materials exist, such as metalon-metal components, ceramic-ceramic, and metal-polyethylene (plastic) combinations. The most commonly used materials are a metal femoral head matched to a polyethylene acetabular liner. THA is indicated for treatment of degenerative disease of the hip in the patient who has not responded to nonsurgical measures and is preferable in older patients with decreased activity levels. With evolution of new technologies, total hip replacements have achieved very high success rates and increasing length of survival. Some national joint registries, such as the one in Sweden, track implants and patient outcomes on a large scale. In reviewing 93,000 implants during a 10-year period, a survival rate of 91%-94% was demonstrated [57]. Outside of joint registry data, research studies have been
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more implant specific but have generally shown a nearly identical result. The original cemented implant design has shown a survivorship of up to 90% at a mean of 25 years follow-up [58]. Long-term studies are lacking for cementless implants because their use has only recently flourished, but they do show a very low revision rate of 4% at an average 10-year followup. Studies have shown that 86% of patients have good to excellent clinical results with a THA and significant functional improvement, with the Harris hip score improving from an average of 51 preoperatively to 94 postoperatively [59]. Patients often can obtain functional return to lowimpact activities. Complications associated with THA include infection, fracture around the implant (periprosthetic fracture), leg length discrepancy, dislocation, and thromboembolism [6062]. The incidence of infection is less than 1%; dislocation, 1%-3%; and periprosthetic fracture, 0.1%-2.5%, with infection and dislocation having their highest risk within the first 6 months of surgery [60]. Limb length inequality is a frequent factor in malpractice claims and accounts for 4.7% of medical errors as identified by The Joint Commission [61]. Finally, the incidence of pulmonary embolism in patients with THA is approximately 1%, reaching that level at approximately 6 weeks after surgery [62], with one quarter developing during the perioperative hospital stay [60].
SHOULDER OSTEOARTHRITIS Arthroscopy Shoulder arthroscopy has become the gold standard for many intra-articular pathologies. The role of shoulder arthroscopy in glenohumeral osteoarthritis has been met with limited success in a very specific subset of patients. In a retrospective review of 81 patients who were, on average, 47 years of age, Van Thiel et al [63] found that arthroscopic debridement significantly improved the range of motion, pain, and functional scores postoperatively. A total of 19.8% of patients (16/81) progressed to TSA by 10 months. The best outcomes were associated with patients with residual joint space and the absence of large osteophytes at preoperative evaluation [63]. Guyette et al [64] followed 36 patients who had a subacromial decompression with debridement for osteoarthritis and noted that outcomes were best in patients with minimal degenerative chondral changes. Recent reports have demonstrated promising results for arthroscopic glenoid resurfacing with biologic patches [65]. At this time, arthroscopic debridement appears to have a role in young patients with early degenerative changes and minimal findings on radiographs. Subacromial decompressions and capsular releases may improve outcomes, and there may be a future role for arthroscopic resurfacing. Patients and referring physicians should be aware that results appear to be
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temporary and may only serve to delay the need for future arthroplasty.
Resurfacing Shoulder resurfacing differs from a conventional stemmed shoulder arthroplasty in that the patient’s humeral head is preserved by reaming it to a concentric sphere and fitting it with a metal cap. This procedure can be performed as a humeral resurfacing only in conjunction with a biologic resurfacing of the glenoid, or with a standard polyethylene glenoid component [66-68]. The preservation of the humeral head bone stock and lack of stemmed component may facilitate future revision surgery. In addition, by preserving the humeral head, resurfacing offers the advantage of maintaining the patient’s natural humeral neck orientation, height, and inclination [69]. Given these benefits, the use of humeral resurfacing has increased, especially in younger patients. In a review of 103 resurfacing replacements with a mean follow-up of 6.8 years, Levy and Copeland [67] noted excellent results in patients with osteoarthritis (improvement of 70% adjusted Constant score for totals, and 50% for humerus only). Poorer results were noted in rotator cuff arthropathy (improvement of 35% adjusted Constant score) and posttraumatic arthritis (improvement of 38% adjusted Constant score). At final follow-up, 94% of patients felt as though their shoulder had improved with surgery, and the authors stated that outcomes were similar to a traditional shoulder arthroplasty. In a prospective study of 36 patients with osteoarthritis who were younger than 55 years, Bailie et al [70] found excellent results at a mean follow-up of 38 months (range, 24-60 months). Thirty-five of the patients reported returning to their full activities, including a wide array of exercises. Recently, authors also have reported good short-term outcomes in combining humeral resurfacing with biologic resurfacing of the glenoid [68]. Humeral resurfacing has provided good short- to medium-term outcomes in select patient populations with low complication rates. It is an appealing option in younger patients with osteoarthritis, with at least 60% of the humeral bone stock reported to be maintained [66]. More recent partial replacement options for focal humeral head defects also have been described with promising outcomes [71]. Longer follow-up studies are needed to analyze the longevity of this procedure.
Hemiarthroplasty and TSA Shoulder arthroplasties have been rapidly increasing in use during the past 2 decades. These procedures have had very good success in the older population, with significant improvements in pain and function [72]. In comparison with the much more commonly performed procedures of TKA
and THA, patients undergoing shoulder arthroplasty have fewer complications, shorter length of hospital stays, and lower costs [73]. However, failure of fixation of the polyethylene glenoid has been termed the “weak link” in the construct, leading surgeons to look for alternatives in younger patients. Hemiarthroplasty (replacing the humeral head only) has been used in patients with concerns of longevity of the glenoid replacement. In patients younger than 50 years, Sperling et al [74] compared 62 hemiarthroplasties and 29 TSAs with a mean follow-up of 16.7 years. The estimated 20-year survival for hemiarthroplasty was 74% compared with 84% for TSA. Nineteen percent of hemiarthroplasties were revised, mostly because of glenoid arthrosis. Levine et al [75] noted that outcomes for hemiarthroplasties were worse in patients with eccentric glenoid wear compared with those with concentric wear. Hemiarthroplasties for shoulder osteoarthritis in younger patients appears to have a decreasing role. Long-term survival is limited by glenoid arthrosis, and revision outcomes of hemiarthroplasties to TSAs have been shown to have worse outcomes than do primary TSAs [76]. Several authors have described hemiarthroplasty combined with biologic glenoid resurfacing with mixed short-term success [77-79]. Currently, hemiarthroplasty has a limited role in younger patients with osteoarthritis, a role that may continue to decrease as newer resurfacing options are developed.
CONCLUSIONS Osteoarthritis of the hip, knee, and shoulder affects a large percentage of the aging population. Total joint replacements have a long, proven track record of success in properly chosen patients. The concerns for increasing numbers of revision arthroplasties have led to a trend toward less-invasive options in younger patients (defined as younger than 50 years). Physicians should be aware of the importance of proper patient selection in using these less-invasive options, because many of these procedures have a narrow scope of potential candidates. Arthroscopy has a limited role in persons with osteoarthritis, and hip hemiarthroplasty is rarely used in persons with osteoarthritis. Resurfacing options are becoming more popular and are supported by positive shortterm outcome data; however, long-term data are lacking. TJA is the procedure of choice for osteoarthritis of the shoulder, hip, and knee in older patients with moderate to lower activity levels. In younger, active patients with greater activity demands, resurfacing offers a less-invasive option that preserves bone stock for future revision to a TJA if necessary.
REFERENCES 1. Holt HL, Katz JN, Reichmann WM. Forecasting the burden of advanced knee osteoarthritis over a 10-year period in a cohort of 60-64 year-old US adults. Osteoarthritis Cartilage 2011;19:44-50.
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2. Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic hip osteoarthritis in his or her lifetime. Osteoarthritis Cartilage 2010;18:1372-1379. 3. Nakagawa Y, Hyakuna K, Otani S, Hashitani M, Nakamura T. Epidemiologic study of glenohumeral osteoarthritis with plain radiography. J Shoulder Elbow Surg 1999;8:580-584. 4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-785. 5. Labek G, Thaler M, Janda W, Agreiter M, Stockl B. Revision rates after total joint replacement: Cumulative results from worldwide joint register datasets. J Bone Joint Surg Br 2011;93-B:293-297 6. Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-1120. 7. Baumgartner MR, Cannon WD Jr, Vittori JM, Schmidt ES, Maurer RC. Arthroscopic debridement of the arthritic knee. Clin Orthop 1990;253: 197-202. 8. Jackson RW, Silver R, Marans H. Arthroscopic treatment of degenerative joint disease. Arthroscopy 1986;2:114. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347:81-88. 10. AAOS Clinical Practice Guideline on the Treatment of Osteoarthritis of the Knee (Nonarthroplasty), December 6, 2008. Available at http:// www.aaos.org/research/guidelines/oakguideline.pdf. Accessed January 20, 2012. 11. Hunt SA, Jazrawi LM, Sherman OH. Arthroscopic management of osteoarthritis of the knee. J Am Acad Orthop Surg 2002;10:356-363. 12. Small N. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988;4:215-221. 13. Kim TK, Savino RM, McFarland EG, Cosgarea AJ. Neurovascular complications of knee arthroscopy. Am J Sports Med 2002;30:619629. 14. Jaureguito JW, Greenwald AE, Wilcox JF, Paulos LE, Rosenberg TD. The incidence of deep vein thrombosis after arthroscopic knee surgery. Am J Sports Med 1999;27:707-710. 15. Bert JM, Giannini D, Nace L. Antibiotic prophylaxis of the knee: Is it necessary? Arthroscopy 2007;23:4-6. 16. Reigstad O, Grimsgaard C. Complications in knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2006;14:473-477. 17. Patil S, Colwell CW Jr, Ezzet KA, D’Lima DD. Can normal knee kinematics be restored with unicompartmental knee replacement? J Bone Joint Surg Am 2005;87:332-338. 18. Laurencin CT, Zelicof SB, Scott RD, Ewald FC. Unicompartmental versus total knee arthroplasty in the same patient: A comparative study. Clin Orthop Relat Res 1991;273:151-156. 19. Kozinn SC, Scott R. Unicondylar knee arthroplasty. J Bone Joint Surg Am 1989;71:145-150. 20. Lonner JH. Patellofemoral arthroplasty. J Am Acad Orthop Surg 2007; 15:495-506. 21. Berger RA, Meneghini RM, Jacobs JJ, et al. Results of unicompartmental knee arthroplasty at a minimum of 10 years follow-up. J Bone Joint Surg Am 2005;87:999-1006. 22. Pennington DW, Swienckowski JJ, Lutes WB, Drake GN. Unicompartmental knee arthroplasty in patients sixty years of age or younger. J Bone Joint Surg Am 2003;85-A:1968-1973. 23. Gioe TJ, Killeen KK, Hoeffel DP, et al. Analysis of unicompartmental knee arthroplasty in a community based implant registry. Clin Orthop Relat Res 2003;416:111-119. 24. Johnson S, Jones P, Newman JH. The survivorship and results of total knee replacements converted from unicompartmental knee replacements. Knee 2007;14:154-157.
Vol. 4, Iss. 5S, 2012
S139
25. Pearse AJ, Hooper GJ, Rothwell A, Frampton C. Survival and functional outcome after revision of a unicompartmental to a total knee replacement. J Bone Joint Surg Br 2010;92-B(4):508-512. 26. Price AJ, Waite JC, Svard U. Long-term clinical results of the medial Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res 2005;435:171-180. 27. Berend KR, Morris MJ, Lombardi AV. Unicompartmental knee arthroplasty: Incidence of transfusion and symptomatic thromboembolic disease. Orthopedics 2010;33:8-10. 28. Price AJ, Svard U. A second decade life table survival analysis of the Oxford unicompartmental knee arthroplasty. Clin Orthop Relat Res 2011;469:174-179. 29. Hernigou P, Deschamps G. Patellar impingement following unicompartmental arthroplasty. J Bone Joint Surg Am 2002;84:1132-1137. 30. Squire MW, Callaghan JJ, Goetz DD, Sullivan PM, Johnston RC. Unicompartmental knee replacement: A minimum 15 year follow-up study. Clin Orthop Relat Res 1999;367:61-72. 31. Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. J Am Acad Orthop Surg 2010;18:406-416. 32. Kane RL, Saleh KJ, Witt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 2005;87:1719-1724. 33. Lonner JH, Lotke PA. Aseptic complications after total knee arthroplasty. J Am Acad Orthop Surg 1999;7:311-324. 34. Amstutz HC, Campbell P, Kossovsky N, Clarke IC. Mechanism and clinical significance of wear debris-induced osteolysis. Clin Orthop Relat Res 1992;276:7-18. 35. Byrd JW. Hip arthroscopy: Surgical indications. Arthroscopy 2006;22: 1260-1262. 36. Stevens MS, LeGay DA, Glazebrook MA, Amirault D. The evidence for hip arthroscopy: Grading the current indications. Arthroscopy 2010; 26:1370-1383. 37. Jerosch J, Schunck J, Khoja A. Arthroscopic treatment of the hip in early and midstage degenerative joint disease. Knee Surg Sports Traumatol Arthrosc 2006;14:641-645. 38. McCarthy JC, Jarrett BT, Ojeifo O, Lee JA, Bragdon CR. What factors influence long-term survivorship after hip arthroscopy? Clin Orthop Relat Res 2011;469:362-371. 39. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy 1999;15:132-137. 40. Sampson TG. Complications of hip arthroscopy. Clin Sports Med 2001;20:831-835. 41. Clarke MT, Arora A, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clin Orthop Relat Res 2003;406:84-88. 42. Amstutz HC, Grigoris P, Dorey FJ. Evolution and future of surface replacement of the hip. J Orthop Sci 1998;3:169-186. 43. Amstutz HC, Beaule PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen T. Metal-on-metal hybrid surface arthroplasty: Two to six-year follow-up study. J Bone Joint Surg Am 2004;86:28-39. 44. McMinn D, Treacy R, Lin K, Pynsent P. Metal-on-metal surface replacement of the hip: Experience of the McMinn prosthesis. Clin Orthop Relat Res 1996;329:89-98. 45. Mont MA, Seyler TM, Ragland PS, Bhave A, Erhart J, Starr R. Gait analysis of patients with resurfacing hip arthroplasty compared with hip osteoarthritis and standard total hip arthroplasty. Arthroplasty 2007;22:100-108. 46. Silva M, Lee KH, Heisel C, Dela Rosa MA, Schmalzried TP. The biomechanical results of total hip resurfacing arthroplasty. J Bone Joint Surg Am 2004;86:40-46. 47. Spencer RF. Evolution in hip resurfacing design and contemporary experience with an uncemented device. J Bone Joint Surg Am 2011;93: 84-88. 48. Mont MA, Ragland PS, Etienne G, Seyler TM, Schmalzried TP. Hip resurfacing arthroplasty. J Am Acad Orthop Surg 2006;14:454-463.
S140
Kenney and Farmer
MINIMALLY INVASIVE VS CONVENTIONAL JOINT ARTHROPLASTY
49. Beaule PE, Antoniades J. Patient selection and surgical technique for surface arthroplasty of the hip. Orthop Clin North Am 2005;36:177185. 50. Smith TO, Nichols R, Donell ST, Hing CB. The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: A metaanalysis and systematic review. Acta Orthop 2010;81:684-695. 51. Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favorably with THA at 2 years follow up. Clin Orthop Relat Res 2006;453:123-131. 52. Langton DJ, Jameson SS, Joyce TJ, et al. Accelerating failure rate of the ASR total hip replacement. J Bone Joint Surg Br 2011;93:1011-1016. 53. Shimmin A, Beaule PE, Campbell P. Metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg Am 2008;90:637-654. 54. Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: A national review of 50 cases. J Bone Joint Surg Br 2005;87:463-464. 55. Pellegrini VD Jr, Heiges BA, Bixler B, Lehman EB, Davis CM III. Minimum ten-year results of primary bipolar hip arthroplasty for degenerative arthritis of the hip. J Bone Joint Surg Am 2006;88:18171825. 56. McConville OR, Bowman AJ Jr, Kilfoyle RM, McConville JF, Mayo RA. Bipolar hemiarthroplasty in degenerative arthritis of the hip: 100 consecutive cases. Clin Ortho Relat Res 1990;251:67-74. 57. Soderman P, Malchau H, Herberts P, Johnell O. Are the findings in the Swedish National Total Hip Arthroplasty Register valid? J Arthroplasty 2000;15:884-889. 58. Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five year survivorship of two thousand consecutive primary Charnley total hip replacements: Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 2002;84-A:171-177. 59. Archibeck MJ, Berger RA, Jacobs JJ, et al. Second-generation cementless total hip arthroplasty: Eight to eleven-year results. J Bone Joint Surg Am 2001;83-A:1666-1673 60. Phillips CB, Barrett JA, Losina E, et al. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am 2003;85:2026. 61. Clark CR, Huddleston HD, Schoch EP III, Thomas BJ. Leg-length discrepancy after total hip arthroplasty. J Am Acad Orthop Surg 2006; 14:38-45. 62. White RH, Romano PS, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998;158:1525-1531. 63. Van Thiel GS, Sheehan S, Frank RM, et al. Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthroscopy 2010;26:1451-1455.
64. Guyette TM, Bae H, Warren RF, Craig E, Wickiewicz TL. Results of arthroscopic subacromial decompression in patients with subacromial impingement and glenohumeral degenerative joint disease. J Shoulder Elbow Surg 2002;11:299-304. 65. Savoie FH III, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: Midterm results. Arthroscopy 2009;25:864-871. 66. Burgess DL, McGrath MS, Bonutti PM, Marker DR, Delanois RE, Mont MA. Shoulder resurfacing. J Bone Joint Surg Am 2009;91-A:1228-1238 67. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the shoulder. J Bone Joint Surg Br 2001;83-B:213-221. 68. Lee KT, Bell S, Salmon J. Cementless surface replacement arthroplasty of the shoulder with biologic resurfacing of the glenoid. J Shoulder Elbow Surg 2009;18:915-919. 69. Copeland S. The continuing development of shoulder replacement: “reaching the surface.” J Bone Joint Surg Am 2006;88-A:900-905. 70. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. J Bone Joint Surg Am 2008;90-A:110-117. 71. Uribe JW, Botto-van Bemden A. Partial humeral head resurfacing for osteonecrosis. J Shoulder Elbow Surg 2009;18:711-716. 72. Foruria AM, Sperling JW, Ankem HK, Oh LS, Cofield RH. Total shoulder replacement for osteoarthritis in patients 80 years of age and older. J Bone Joint Surg Br 2010;92-B:970-974. 73. Farmer KW, Hammond JW, Queale WS, Keyurapan E, McFarland EG. Shoulder arthroplasty versus hip and knee arthroplasties: A comparison of outcomes. Clin Orthop Relat Res 2007;455:183-189. 74. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg 2004;13: 604-613. 75. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU. Hemiarthroplasty for glenohumeral arthritis: Results correlated to degree of glenoid wear. J Shoulder Elbow Surg 1997;6:449-454. 76. Sperling JW, Cofield RH. Revision total shoulder arthroplasty for the treatment of glenoid arthrosis. J Bone Joint Surg Am 1998;80-A:860867. 77. Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JJ. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am 2009;91A:419-424 78. Wirth MA. Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid. J Bone Joint Surg Am 2009;91-A:1109-1119 79. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Two to fifteen-year outcomes. J Bone Joint Surg Am 2007;89A:727-734