Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty

ARTICLE IN PRESS J Shoulder Elbow Surg (2018) ■■, ■■–■■

www.elsevier.com/locate/ymse

ORIGINAL ARTICLE

Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty Mihir M. Sheth, BSa, Daniel Sholder, BSb, Joseph Abboud, MDb, Mark D. Lazarus, MDb, Matthew L. Ramsey, MDb, Gerald R. Williams, MDb, Surena Namdari, MDb,* a

Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA Rothman Institute of Orthopaedics, Thomas Jefferson University Hospitals, Philadelphia, PA, USA

b

Background: The impending burden of revision shoulder arthroplasty has increased interest in outcomes of revision procedures. Painful glenoid arthrosis following hemiarthroplasty is a common cause of reoperation, and conversion to anatomic total shoulder arthroplasty is one option. Methods: We identified patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period in a single tertiary-care health system. Presurgical and operative data were analyzed for 28 patients who met the inclusion and exclusion criteria. Patients were contacted at a minimum of 2 years’ follow-up after revision surgery for functional outcome scores, reoperations, and implant survival. Results: The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants. The mean American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Single Assessment Numerical Evaluation score were 78 ± 20, 2.3 ± 2.6, and 71 ± 24, respectively. The mean Short Form 12 mental and physical scores were 49 ± 10 and 43 ± 9, respectively. Of the patients, 17 (81%) were either satisfied or very satisfied with their outcome. Complications were seen in 10 patients (36%), and 6 patients (21%) required reoperation. Conclusions: Anatomic total shoulder arthroplasty following hemiarthroplasty can achieve successful outcomes and implant survival rates. Given our poor understanding of reverse shoulder arthroplasty longevity, this procedure should remain an option for patients with glenoid arthrosis and an intact rotator cuff. Level of evidence: Level IV; Case Series; Treatment Study © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Revision shoulder arthroplasty; hemiarthroplasty; anatomic total shoulder arthroplasty; complications; reoperations; painful glenoid arthrosis; failed hemiarthroplasty

The institutional review board of Thomas Jefferson University Hospitals has approved this study (15D.417). *Reprint requests: Surena Namdari, MD, Rothman Institute, Department of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut St, Fifth Floor, Philadelphia, PA 19107, USA. E-mail address: [email protected] (S. Namdari).

The increasing use of shoulder arthroplasty20 will increase the burden of revision surgery, placing an emphasis on understanding outcomes of these procedures. While the popularity of hemiarthroplasty (HA) has waned in recent years owing to accumulating evidence that anatomic total shoulder arthroplasty (aTSA) provides superior pain relief and

1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2018.03.018

ARTICLE IN PRESS 2 functional outcomes,3,6,11 aTSA is limited by the risk of glenoid component loosening and alterations in glenoid bone stock that can complicate revision surgery. Primary HA is often performed in young patients to avoid these complications. HA has also been shown to be a reasonable option in certain etiologies of glenohumeral arthrosis, such as osteonecrosis12,18,27 and rheumatoid arthritis,4,12 and remains an option in the treatment of complex proximal humeral fractures.17 Despite these roles, HA can result in glenoid erosion, which is the main cause of clinical deterioration and short- and medium-term revisions.13,21,26,29 Placement of a glenoid component with conversion to an aTSA is an option for treatment of failed HA; however, the results of this operation are not commonly reported. Given that both HA and aTSA are likely to fail within the life span of young patients, it is important to determine the outcomes of revision procedures to properly counsel patients during their initial surgical decision making. The purpose of this study was to report and analyze the indications, results, implant survival rates, and complications in a series of patients who underwent revision of a failed HA to an aTSA.

Methods We identified patients who underwent revision shoulder arthroplasty in a single tertiary-care health system from 2000 to 2015. Cases were identified by Current Procedural Terminology codes 23470 (HA), 23472 (total shoulder arthroplasty), 23473 (revision of total shoulder arthroplasty, humeral or glenoid component), and 23474 (revision of total shoulder arthroplasty, humeral and glenoid component). The inclusion criteria included revision of an HA to an aTSA for the indication of painful glenoid arthrosis, an intact rotator cuff, and a minimum of 2 years’ clinical follow-up. If patients underwent revision of the aTSA prior to 2-year follow-up, they were included in the survival analysis but functional outcome scores were not obtained. We excluded patients undergoing conversion of an antibiotic spacer to an aTSA and cases with preoperative clinical or radiographic signs of infection. Preoperative variables were collected by retrospective chart review. Variables included age, sex, dominant-sided surgery, Charlson Comorbidity Index score,9 and diagnosis for the original HA. Operative notes were reviewed to evaluate rotator cuff status, concomitant procedures (including biological resurfacing, glenoid reaming, bone grafting, component type, and stem revisions), and intraoperative complications. Direct patient contact and retrospective chart review were used to determine implant survival, reoperations, and postoperative complications. For surviving implants, patient-reported outcome measures including the American Shoulder and Elbow Surgeons (ASES) score,16 Single Assessment Numerical Evaluation,32 visual analog scale for pain (10-point scale),5 Short Form 12 Health Survey,7 and patient satisfaction (on a scale of 1-5, with 1 being very dissatisfied and 5 being very satisfied) were obtained. Implant survival was calculated using Kaplan-Meier analysis, with survival being defined as retention of components that were placed at the time of conversion from HA to aTSA.

M.M. Sheth et al.

Statistical analysis Outcome scores following revision aTSA were analyzed for measures of central tendency and variation. Implant survival following aTSA was summarized using the Kaplan-Meier method as a function of time elapsed from revision surgery.

Results During the study period, 618 patients underwent revision shoulder arthroplasty at our institution and 47 patients underwent glenoid component placement following HA. After applying the inclusion criteria, we retrospectively reviewed the medical records of 28 patients (60%) who underwent conversion of an HA to an aTSA. The mean age at the time of the index HA was 52 ± 12 years (range, 30-75 years); 12 patients were younger than 50 years (Table I). There were 7 women and 21 men. The dominant extremity was involved in 17 patients. The mean Charlson Comorbidity Index score was 2.1 (range, 0-6). Three patients underwent multiple non-arthroplasty surgical procedures prior to index HA. The indications for the primary HA included osteoarthritis (19), osteonecrosis of the humeral head (6), post-traumatic arthritis (2), and fracture (1). The primary HA was stemmed in 19 patients, and a resurfacing implant was used in 9 patients; concomitant procedures included concentric glenoid reaming (2), glenoid biological resurfacing (2), and glenoid bone grafting (1). All patients were indicated for revision to aTSA because of painful glenoid arthrosis. In addition, 3 patients were found to have small, repairable rotator cuff tears (2 supraspinatus and 1 subscapularis, all of which were full thickness) at the time of surgery, and 1 patient had a nonunion from a prior lesser tuberosity osteotomy at the time of surgery. The mean time from HA to aTSA was 4.8 ± 3.7 years (range, 0.7-12.3 years). The mean age at the time of revision to aTSA was 57 ± 12 years (range, 33-77 years).

Operative findings and techniques All patients underwent glenoid component implantation (25 cemented all-polyethylene glenoid components and 3 allpolyethylene posteriorly augmented glenoid components). All 9 patients with resurfacing HA underwent stem implantation, and 8 standard-length stems (42%) were revised because of component malpositioning. Two patients underwent glenoid allograft impaction for contained defects, and one patient required a bulk allograft for a large, uncontained posterior defect. All 3 rotator cuff tears were repaired at the time of surgery, and the lesser tuberosity nonunion was also repaired. Cultures were obtained in a standard fashion in all cases and demonstrated bacterial growth in 3 patients, all with Cutibacterium (formerly Propionibacterium) acnes. These cases underwent infectious disease consultation and appropriate antibiotic treatment.

ARTICLE IN PRESS Hemiarthroplasty to anatomic total shoulder arthroplasty Table I

Baseline characteristics

Patient No.

Surgical procedures prior to HA

1 2 3

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

RCR (SSc) Acromioplasty Biceps tenodesis

.

Chondroplasty

(5 unspecified surgical procedures, including acromioplasty)

3

Age at HA, yr

Indication

Stemmed

41 59 41

AVN AVN AVN

Yes Yes No

53 66 45 64

AVN AVN AVN Fracture OA OA OA OA OA OA OA OA OA OA OA OA OA OA OA OA PTA PTA

Yes Yes Yes Yes Yes No Yes No Yes No No No Yes No Yes Yes Yes Yes No Yes Yes Yes

RA

Yes Yes No

66 72 54 64 45 43 56 53 69 44 46 51 42 75 62 31 30 30 48 56

Concomitant procedures

Complications and reoperations

RCR (SSc) Pectoralis transfer

Time to aTSA, yr 11.4 7.5 6.0

1.2 1.1 6.8 10.7 3.2

Biological resurfacing

Ream and run

Glenoid bone grafting Ream and run

I&D Chondroplasty

Ream and run RCR (SSc) Biological resurfacing

0.8 3.8 0.9 8.3 8.4 8.7 10.0 0.7 1.1 6.9 1.3 2.0 1.8 0.7 5.5 2.5 12.3 1.5 4.3

HA, hemiarthroplasty; aTSA, anatomic total shoulder arthroplasty; AVN, avascular necrosis; RCR, rotator cuff repair; SSc, subscapularis; OA, osteoarthritis; PTA, post-traumatic arthritis; I&D, irrigation and débridement.

Complications, implant survival, and reoperations There were 3 intraoperative complications (11%) at the time of conversion from failed HA to aTSA, including fracture (humeral shaft in 1 and greater tuberosity in 1) and iatrogenic rotator cuff tear (1). There were 10 postoperative complications (36%), including subscapularis failure (3), infection (1), humeral component loosening (1), hemarthrosis (1), lesser tuberosity nonunion (1), brachial plexus injury (1), glenoid loosening (1), and posterior-superior rotator cuff tear (1). Thus, in total, 13 intraoperative and postoperative complications occurred, giving an overall complication rate of 46%. The 2- and 5-year implant survival rates by KaplanMeier analysis were 93% (26 of 28 patients) and 86% (12 of 14 patients), respectively. Following revision to aTSA, reoperation was required in 6 patients (21.4%). Of these patients, 2 did not require revision of any components (irrigation

and débridement in 1 and open subscapularis repair in 1). Reoperations involving component revision included humeral stem revision (2), arthroscopic glenoid excision (1), reverse shoulder arthroplasty (RSA) (1), and cement spacer placement (1). No patients who required glenoid grafting or a stepped component underwent reoperation. Of the 3 patients with rotator cuff tears at the time of aTSA, 2 had surviving implants at 84 and 40 months following surgery. The third patient underwent revision to RSA.

Outcomes in cases of implant survival Functional outcome scores were obtained from 21 of the 24 patients with surviving implants at a mean follow-up of 5.1 years (range, 2.0-9.4 years) after revision aTSA and 9.8 years after index HA (range, 3.3-23.3 years) (Table II). The mean ASES score was 78 ± 20 (range, 20-100). The mean pain

ARTICLE IN PRESS 4

M.M. Sheth et al. Table II

Outcomes of patients with surviving implants Follow-up, yr

Patient No. 3 4 5 7 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Mean

* 3.3 3.3 * 7.6 8.5 7.0 7.0 6.9 6.8 4.1 3.5 3.3 2.8 2.3 2.0 8.0 8.7 2.8 4.8 3.0 9.4 * 2.3

Complications

Hemarthrosis

Subscapularis failure

LT nonunion Subscapularis failure

Brachial plexus stretch

ASES score

SANE score

VAS score

SF-12 M score

SF-12 P score

PS rating

68 93

70 85

3 0

54 58

42 51

3 5

20 78 100 87 72 92 87 83 88 98 77 98 100 97 52 55 48 82

20 80 95 90 66 90 90 70 75 95 50 85 99 100 98 55 40 70

8 2 0 0 2 1 1 1 0 0 2 0 0 0 6 5 5 2

49 33 54 58 42 41 58 62 50 61 33 55 49 58 36 52 25 60

31 42 50 57 40 54 38 53 36 51 42 59 53 54 33 46 37 42

1 5 5 5 4 5 5 4 5 5 5 5 5 5 4 3 2 5

67 78 ± 20

30 71 ± 24

4 2.3 ± 2.6

59 49 ± 10

32 43 ± 9

4 4.3 ± 1.1

Subscapularis failure

ASES, American Shoulder and Elbow Surgeons; SANE, Single Assessment Numerical Evaluation; VAS, visual analog scale for pain; SF-12 M, Short Form 12 mental component; SF-12 P, Short Form 12 physical component; PS, patient satisfaction; LT, lesser tuberosity. * Patient not available for follow-up.

score was 2.3 ± 2.6 (range, 0-8). The mean Single Assessment Numerical Evaluation score was 71 ± 24 (range, 20100). The mean Short Form 12 mental and physical scores were 49 ± 10 (range, 25-62) and 43 ± 9 (range, 26-59), respectively. Of these patients, 17 (81%) were either satisfied or very satisfied with the current status of their shoulder whereas 2 (10%) were neutral and 2 (10%) were either dissatisfied or very dissatisfied.

Discussion Progressive glenoid wear following HA is a common cause of pain and clinical deterioration and has been reported as the most common cause of reoperation.1,24 Revision of an HA to an aTSA can yield successful results and reasonable implant survival rates at midterm follow-up. As is typical of revision operations, intraoperative and postoperative complications are common and can compromise results. There are few reports on revision of failed HA to aTSA in the literature (Table III).8,10,14,23,25,28,30 Carroll et al8 concluded that conversion of a humeral head replacement to an aTSA is a salvage procedure based on inferior results compared with primary aTSA and unsatisfactory results in 7 of

16 patients by the Neer criteria. It should be noted that in terms of self-reported satisfaction, 12 of 16 patients in their study would have undergone the procedure again. Dines et al10 reported a better experience, with satisfactory or excellent results in 11 of 16 patients undergoing revision of a failed HA to an aTSA. Sperling and Cofield28 also reported a better experience, with satisfactory or excellent results in 11 of 18 patients. Our study adds support to the notion that revision of HA to aTSA for the indication of glenoid-sided arthrosis can produce good outcomes at short- and medium-term followup; however, complication and reoperation rates are substantial and have diverse etiologies. A theoretical advantage to performing primary HA as opposed to aTSA in young patients is the preservation of glenoid bone stock for future revisions. Our cohort was relatively young at the time of the index HA procedure (average age, 52 years) and underwent revision surgery within an average of 5 years. Similarly, Sperling and Cofield28 demonstrated a high rate of conversion of HA to aTSA within 5 years of the index HA. There is concern regarding asymmetrical glenoid wear when an HA fails. Carroll et al8 found a significant number (64%) of patients with posterior and superior wear who required eccentric reaming of existing bone stock anteriorly to allow for glenoid placement. In our

ARTICLE IN PRESS Hemiarthroplasty to anatomic total shoulder arthroplasty Table III

5

Previously reported outcomes of revision of painful HA to TSA

Study

n

Mean follow-up, yr

Sperling and Cofield,28 1998

22

5.5

Ramappa et al,23 2000

17

4.1

Carroll et al,8 2004

16

5.5

Dines et al,10 2006

16

6.3

—

Sajadi et al,25 2010

6

2.3

Hartel et al,14 2015

7

3.4

UCLA Motion from 5.0 to 6.3; improved in 4, no change in 2 —

Streubel et al,30 2016 Current study

6

28

5.1

ROM

• Active abduction: 94° to 124° • AER: 34° to 58°

“Significant improvements in range of motion” • AFE: 93° to 144° • AER: 27° to 58°

• AFE: 112° to 148° • AER: 31° to 38°*

Functional scores

• Pain: from 4.3 to 2.2 • NC: 8 E, 3 S, 7 US

Significant improvements in pain

• • • • • • • • • •

ASES: 74 (47-95) VAS: 2.4 (0-6) 11 of 15 were satisfied NC: 7 US (5 because of inadequate pain relief) UCLA: 26.0 L’Insalata: 80.3 Satisfaction: 3.38 NC: 6 E, 5 G, 5 F UCLA Pain: 2.7 to 6 UCLA Function: 3.8 to 5.5

• Constant: 51.7 • Relative Constant: 72.7 • DASH: 48.3 • SF-36 P: 43.3 4 US, 2 S

• • • •

ASES: 75 (13-100) Pain: 2.3 (0-8) SANE: 71 (20-100) 18 of 25 satisfied or very satisfied

Complications

Component revision and survivorship

3 (14%) (brachial plexus stretch [1], infection [1], synovitis associated with instability [1]) 6 (36%)

2 of 22 revised, both in patients with inflammatory arthritis (RA, SLE)

4 of 17 revised, survivorship of 81% at 5 yr and 68% at 10 yr 3 of 22 revised

5 (31%) (glenoid loosening [2], subacromial impingement [2], infection [1]) None

None

—

—

1 (14%)

None

2 of 6 (instability [1], anterosuperior escape [1]) 10 (36%)

No reoperations

4 (14%), 86% at 5 yr (12 of 14)

HA, hemiarthroplasty; TSA, total shoulder arthroplasty; ROM, range of motion; NC, Neer criteria; E, excellent; S, satisfactory; AER, active external rotation; RA, rheumatoid arthritis; SLE, systemic lupus erythematosus; AFE, active forward elevation; SF-36, Short Form-12; US, unsatisfactory; ASES, American Shoulder and Elbow Surgeons score; VAS, visual analog scale for pain; UCLA, University of California, Los Angeles shoulder rating score; G, good; F, fair; DASH, Disabilities of the Arm, Shoulder and Hand score; SANE, Single Assessment Numerical Evaluation. * Not statistically significant.

experience, 6 patients (21%) required a stepped glenoid component (3), glenoid reaming (2), or glenoid bone grafting (1). Despite improvements in component design, revision surgery following HA is complex and abnormal glenoid wear patterns that require modifications in surgical technique are not uncommon and pose technical challenges. An interesting finding was that the most common causes of failure of revision to aTSA were rotator cuff related and were not related to component failure. Certainly, RSA is often a more reliable option for glenoid deformity, bone loss, and rotator cuff insufficiency. The results of revision of a failed HA to an aTSA should be placed within

the context of the results of alternative procedures. Previously published studies have suggested that RSA may be a viable treatment option for failed HA, albeit for different indications than in the patients in our study. Levy et al15 reported on 29 patients who underwent RSA after HA for glenoid arthrosis following fracture and rotator cuff insufficiency at a mean of 2.9 years’ follow-up. Twenty-three patients rated their outcome as satisfactory, good, or excellent; the mean ASES score improved from 22 to 52.1; and the complication rate was 28%. Patel et al22 examined 15 cases of RSA after HA for various indications—all including soft-tissue failure— and reported a mean improvement in the ASES score from

ARTICLE IN PRESS 6

M.M. Sheth et al.

24.0 to 66.2 at a mean follow-up of 41 months. Other studies on RSA after HA have similarly found reasonable or salvagelevel functional outcomes but complication rates ranging from 14% to 36%.2,19,31 Hartel et al14 retrospectively compared functional outcomes and complications in 7 shoulders revised to aTSA versus 12 shoulders revised to RSA following HA at a mean of 3.4 years’ follow-up. In patients with revision to RSA, they found a lower postoperative Constant score (31.1 vs 51.7), smaller improvement in the Constant score (19.1 vs 38.4), and higher complication rate (25% vs 14%). With the lack of long-term implant survival data for RSA, poor salvage options for failure, and lack of published outcomes for patients who underwent RSA for a similar indication to patients in this study, revision to an aTSA continues to have a role for isolated glenoid-sided arthrosis with an intact rotator cuff. In young patients, we believe that revision to an aTSA should be the first-line treatment. There are multiple limitations to this study stemming from its retrospective design. As mentioned earlier, the small number of patients is not sufficient to statistically determine clinically important differences in outcomes based on preoperative factors. The patient group itself is heterogeneous with regard to concomitant procedures at the time of index HA and revision aTSA; however, we believe that this is representative of the complexity of this patient population. We did not have functional outcome scores prior to revision surgery; thus, we are unable to quantify the amount of improvement from the preoperative state. We did not have complete radiographic follow-up and cannot comment on glenohumeral alignment or radiolucent lines. Finally, there is no comparative cohort, and it is unclear whether patients would have been better served by revision to RSA.

Conclusions Conversion of a failed HA to an aTSA in patients with glenoid-sided arthrosis can produce satisfactory functional results at early term and midterm follow-up. Despite this, patients should be counseled regarding the complication and reoperation risks. Given the similar results of conversion of HA to RSA in the literature, conversion to aTSA should remain a viable option for treatment of glenoid arthrosis following primary HA with an intact rotator cuff. Larger studies are needed to determine factors that influence the likelihood of implant failure.

Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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