Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Joseph P. Iannotti, MD, PhD*,
Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
Posted December 2006
Whether use of a glenoid component represents the best
prosthetic management for osteoarthritis of the shoulder has been debated for
the last three decades. In the study by Rispoli et al., the authors
retrospectively evaluated the long-term (mean, >10.0 years) clinical and
radiographic results of a cohort of sixty consecutive patients who underwent
hemiarthroplasty for treatment of primary osteoarthritis. This retrospective
review evaluated a patient self-reported level of pain, a physician-assessed
Neer classification of outcome (excellent, satisfactory, and unsatisfactory), the
revision of the prosthesis (survivorship analysis), and the radiographic
evaluation. The authors noted a high occurrence of late glenoid wear and bone
loss resulting in deterioration in function and increased pain (41% of patients)
with long-term follow-up. In 20% of the total group of patients, revision
arthroplasty was performed to implant a glenoid component. Survivorship
analysis demonstrated a less favorable outcome when compared with historical
controls, from the same institution, of patients who had undergone total
shoulder arthroplasty for treatment of primary osteoarthritis1. Other,
smaller retrospective clinical studies have demonstrated similar results after hemiarthroplasty
for treatment of noninflammatory arthritis2,3. This study would
support the recommendation, for most patients with primary osteoarthritis, of
total shoulder arthroplasty as a preferred treatment over hemiarthroplasty.
In a recent study, Wirth et al. presented mid-term to long-term
clinical results of selected patients with glenohumeral arthritis who underwent
hemiarthroplasty4 with good-to-excellent clinical outcome. That
study defined a subpopulation of patients with osteoarthritis in whom they
could successfully achieve glenoid bone contouring and soft-tissue balancing to
achieve a centered humeral head within a structurally sound glenoid vault. Wirth
et al. concluded that these surgical anatomic criteria were critical to the
success of the hemiarthroplasty. The reason for the difference in outcome after
hemiarthroplasty as described in the studies by Wirth et al. and Rispoli et al.
is difficult to determine with any degree of certainty but may be due to the
criteria used for patient selection, the surgical technique, the method of follow-up
evaluation, or differences in the duration of follow-up after the index surgery.
In the study by Rispoli et al., nine patients had moderate or severe glenoid
bone loss. Shoulders with such involvement were excluded for hemiarthroplasty by
Wirth et al. The study by Wirth et al. had a mean duration of follow-up of 7.5
years, whereas the study by Rispoli et al. had a mean duration of follow-up of 11.3
years. The survivorship analysis in the study by Rispoli et al. showed a
significant decrease in survivorship after ten years, suggesting that the
longer follow-up period in the Rispoli study may account for the apparent
differences in outcome between these two studies. In addition, the average age
of the patients in the Wirth study was sixty-three years, whereas the average
age in the Rispoli study was fifty-nine years. The study by Rispoli et al.
demonstrated a protective effect of increased age when evaluating survivorship
of the prosthesis. In that study, the surgeons selected patients for
hemiarthroplasty because of their relatively young age, higher activity level,
or severe central glenoid bone loss. Each of these preoperative patient and
disease characteristics may lead to a less favorable long-term outcome after
hemiarthroplasty.
The presence and severity of glenoid bone loss, eccentric
wear, or humeral head subluxation are factors that affect clinical outcome5.
These anatomic factors are present in varying degrees of severity in patients
with primary osteoarthritis. Hemiarthroplasty and total shoulder arthroplasty are
associated with varying degrees of clinical success depending on the severity
of these anatomic factors5. In the Wirth study, shoulders with glenoid
wear and humeral head subluxation were excluded for hemiarthroplasty or, if
these conditions were present, they were corrected at the time of surgery. In
the study by Rispoli et al., shoulders with these preoperative factors were not
excluded for hemiarthroplasty. These differences between the two studies may
also explain the apparent difference in outcome.
Neither Wirth et al. nor Rispoli et al. reported on a series
of patients with similar indications for total shoulder arthroplasty and
similar lengths of follow-up. Rather, these were retrospective nonrandomized
studies that compared the outcome after hemiarthroplasty and total shoulder
arthroplasty. In another study, total shoulder arthroplasty had better clinical
results than hemiarthroplasty when there was moderate to severe posterior
glenoid bone loss as well as when there was minimal posterior glenoid bone loss
or humeral head subluxation5.
Two prospective randomized clinical trials have evaluated
the effectiveness of hemiarthroplasty and total shoulder arthroplasty in
patients with primary osteoarthritis6,7. In one study, Gartsman et.
al. identified a trend toward a more favorable outcome after total shoulder
arthroplasty6. This study had a small sample size but, on the basis
of the data, the authors suggested that a study with approximately twice the
number of patients would have shown statistical significance in favor of total
shoulder arthroplasty. In another, very recent prospective randomized study by
Lo et al., the authors did not find a significant difference in quality-of-life
indicators when comparing hemiarthroplasty with total shoulder arthroplasty7.
The sample size in that study was also not large enough to demonstrate
statistical significance, but all parameters indicated a clear trend toward a
more favorable outcome with total shoulder arthroplasty.
The literature and the paper by Rispoli et al. demonstrate
that, when the duration of follow-up extends beyond the first five to ten
years, there is an increasing prevalence of pain due to progressive glenoid
arthrosis after hemiarthroplasty2,3. There is also an increase in the
prevalence of glenoid component loosening in this same time frame when total
shoulder arthroplasty is performed1. The fact that both problems
increase with time suggests that an important goal for future study will be to define
the difference in outcome between total shoulder arthroplasty and
hemiarthroplasty with longer-term follow-up and with use of a consecutive
series of patients with the same clinical indications, surgical techniques, and
methods of follow-up evaluation. This type of study would allow us to know the
long-term consequences associated with glenoid bone loss and pain after
hemiarthroplasty and to compare them with the consequences of bone loss and
pain associated with glenoid component loosening after total shoulder
arthroplasty. An alternative but less favorable study design to such a
prospective randomized clinical trial would be to compare hemiarthroplasty and
total shoulder arthroplasty in a carefully stratified retrospective study of a
very large patient population of patients with at least five years of follow-up.
Multivariate statistical analysis would allow the stratification of the disease
and patient variables known to affect the outcome and might therefore help
define the long-term negative consequences of glenoid-related problems after hemiarthroplasty
and total shoulder arthroplasty.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his
immediate family, is affiliated or associated.
References
1. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with the Neer prosthesis: long-term results J Shoulder Elbow Surg. 1997;6:495-505.
2. Cofield RH, Frankle MA, Zuckerman JD. Humeral head replacement for glenohumeral arthritis. Semin Arthroplasty. 1995;6;214-21.
3. Levine WN, Djurasovic M, Glasson JM, Pollock RG, Flatow EL, Bigliani LU. Hemiarthroplasty for glenohumeral osteoarthritis: results correlated to degree of glenoid wear. J Shoulder Elbow Surg. 1997;6:449-54.
4. Wirth MA, Tapscott S, Southworth C, Rockwood CA Jr. Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88:964-73.
5. Iannotti JP, Norris TR. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J. Bone Joint Surg Am. 2003;85:251-8.
6. Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am. 2000;82:26-34.
7. Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87:2178-85.
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