Commentary & Perspective

Commentary & Perspective on
"Humeral Hemiarthroplasty with Biologic Resurfacing of the Glenoid for Glenohumeral Arthritis. Two to Fifteen-Year Outcomes"
by Sumant G. Krishnan, MD, et al.

Commentary & Perspective by
Frederick A. Matsen III, MD*,
University of Washington, Seattle, Washington

Posted April 2007

At a time when implant costs are soaring, when glenoid component failure remains an unsolved problem in total shoulder arthroplasty^1,2, when arthritis secondary to arthroscopic and other surgical misadventures is creating yet younger individuals with loss of glenohumeral articular cartilage, when individuals of all ages are putting shoulder arthroplasties to greater and greater functional demands, and when newer implant designs are increasingly expensive, it is indeed timely to consider whether there is a better way to manage the concave side of the arthritic glenohumeral joint.

A new approach to glenoid arthroplasty needs to be tested against rigorous criteria: (1) the clinical outcomes need to compare favorably with existing techniques, (2) the surface must be durable, (3) the surface must be firmly fixed to the subjacent bone, (4) the surface must effectively distribute the humeral load to the bone of the glenoid, (5) the surface must provide sufficient intrinsic stability to enable the concavity compression mechanism to center the humeral head in the glenoid, and (6) the new solution cannot be associated with more complications than current solutions.

We are indebted to Krishnan et al. for bringing forward a creative option for our consideration. The concept of resurfacing the glenoid with a biological rather than a prosthetic surface is exciting in that it offers the possibility of meeting each of the above criteria as well as allowing repair and remodeling with use—attributes that can never be incorporated into nonbiological components.

These authors present a series of patients with primary or secondary glenohumeral degenerative joint disease treated with a variety of biological materials (local capsular flap, autogenous fascia lata, and Achilles tendon allograft) interposed between a prosthetic humeral head and glenoid bone. At the time of surgery, the glenoid bone was decorticated to a bleeding surface and the graft was secured to four points on the glenoid periphery. A standard humeral hemiarthroplasty was then performed.

In terms of clinical outcomes, the American Shoulder and Elbow Surgeons (ASES) scores and Neer scores obtained by Krishnan et al. matched or exceeded those recently reported in this journal for total shoulder arthroplasty (Tables I and II). This is remarkable, considering that five of the thirty-six shoulders had unsatisfactory Neer scores, three had postoperative instability, two had infection, and one had brachial plexitis.

The results can also be characterized in terms of the five other suggested criteria for evaluating the options for glenoid arthroplasty.

1. Durability: The average radiographic joint space diminished from 2.9 mm immediately after surgery to 1.3 mm at the time of the most recent follow-up. It is not clear whether the residual radiographic joint space was occupied by the original interpositional material or by new tissue ingrowth.

2. Fixation to bone: No data were provided on the degree to which the grafts healed and remained fixed to the subjacent bone.

3. Load distribution: Glenoid erosion averaged 7.2 mm, apparently becoming stable after several years. It may be that this erosion takes place until the load is evenly distributed across the surface of the glenoid bone.

4. Intrinsic stability: Three of the thirty-six shoulders demonstrated postoperative instability. It is not clear whether this procedure re-establishes the glenoid concavity or whether these cases of instability were due to lack of effective concavity or to other causes.

5. New problems: Of the seven shoulders in which autogenous anterior capsule was used, three became unstable and one became infected. One of eleven shoulders in which autogenous fascia lata was used became infected. Finally, although no donor site complications were reported, harvesting of autograft from a distant site does require a second incision. By contrast there were no unsatisfactory results in the shoulders that received Achilles tendon allograft.

In conclusion, this paper encourages shoulder surgeons to continue to pursue cost-effective solutions for the management of the wide range of individuals with debilitating glenohumeral arthritis and to seek robust and consistent methods for evaluating outcomes in a way that enables comparison among procedures, patients, and surgeons. This is particularly true of efforts, such as that described in this paper, to address the unsolved concave side of the arthroplasty. As additional procedures, including nonprosthetic glenoid resurfacing and humeral hemiarthroplasty (the so-called "ream-and-run" procedure) and meniscus allograft, come to the fore, the rigor of analysis will become even more important.

*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. A commercial entity (DePuy) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

References

1. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88:2279-92.
2. Hasan SS, Leith JM, Campbell B, Kapil R, Smith KL, Matsen FA 3rd. Characteristics of unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg. 2002;11:431-41.
3. 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.
4. Martin SD, Zurakowski D, Thornhill TS. Uncemented glenoid component in total shoulder arthroplasty: survivorship and outcomes. J Bone Joint Surg Am. 2005;87:1284-92.
5. 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.
6. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. J Bone Joint Surg Am. 1998;80:464-73.

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