Clinical results of revision shoulder arthroplasty for glenoid component loosening

We retrospectively reviewed 32 patients who underwent glenoid revision surgery after total shoulder arthroplasty to compare the results of revision total shoulder arthroplasty with those of revision hemiarthroplasty and to identify factors associated with poor results after revision shoulder arthroplasty for glenoid component loosening. Results were reviewed at a mean follow-up of 4 years (range, 2-8 years). Glenoid reimplantation resulted in significant pain relief (P < .0001), improvement in American Shoulder and Elbow Surgeons (ASES) score (P < .02), and external rotation (24 degrees to 44 degrees , P < .004). Revision to a hemiarthroplasty also resulted in significant pain relief (P < .01) and improvement in ASES score (P < .05). For the treatment of glenoid loosening without glenohumeral instability, both reimplantation of a glenoid component and revision to a hemiarthroplasty improved function, satisfaction, and level of pain. Reimplantation of a new glenoid component offered greater improvements in pain (P < .008) and external rotation (increase of 20 degrees versus 3 degrees , P < .03) compared with hemiarthroplasty. For patients with preoperative glenohumeral instability, revision surgery did not improve motion, function, or pain significantly. Risk factors associated with a poor outcome after revision arthroplasty included persistent glenohumeral instability, rotator cuff tears, and malunion of the greater tuberosity.     

The results of arthroplasty in osteoarthritis of the shoulder

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff. When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present.     

Patient functional self-assessment in late glenoid component failure at three to eleven years after total shoulder arthroplasty

Failure of the glenoid component is the most common indication for late revision of a total shoulder arthroplasty (TSA). This is the first study to characterize the deterioration in patient self-assessment of shoulder function occurring with glenoid component failure at times remote from the index surgery. Of 115 total shoulders, 11 had revision by the original surgeon for isolated glenoid loosening. Simple Shoulder Test scores averaged 4.4 before TSA, rose to a mean of 11.3 after surgery, and fell to a mean of 4.6 before revision for glenoid loosening performed at a mean of 7 years after TSA. All shoulders showed a drop of at least 3 points between the peak Simple Shoulder Test score and the prerevision Simple Shoulder Test score. Periodic self-assessment of shoulder function may offer a method of screening patients for the possibility of late glenoid component failure.     

Glenoid revision is best treated with glenoid implants: Affirms

Radiographic lucency adjacent to the glenoid component is a common finding after a total shoulder arthroplasty. In fact, the majority of patients with this entity are asymptomatic and require no management. However, when there is documented progression of lucent lines, leading to clinically symptomatic loosening, revision total shoulder arthroplasty is warranted. Treatment options for revision surgery are guided by the amount of glenoid bone loss and include either reimplanation or removal. When feasible, reimplantation of the glenoid yields superior clinical results. Reimplantation strategies include reimplantation without bone grafting, one-stage reimplantation with bone grafting, two-stage reimplantation with bone grafting, and reimplantation with the use of glenoid augments. If bone loss precludes, the clinician may consider implant removal with either biologic resurfacing or hemiarthroplasty.     

Bone Grafting Severe Glenoid Defects in Revision Shoulder Arthroplasty

During revision total shoulder arthroplasty, bone grafting severe glenoid defects without concomitant reinsertion of a glenoid prosthesis may be the only viable reconstructive option. However, the fate of these grafts is unknown. We questioned the durability and subsidence of the graft and the associated clinical outcomes in patients who have this procedure. We retrospectively reviewed 11 patients with severe glenoid deficiencies from aseptic loosening of a glenoid component who underwent conversion of a total shoulder arthroplasty to a humeral head replacement and glenoid bone grafting. Large cavitary defects were grafted with either allograft cancellous chips or bulk structural allograft, depending on the presence or absence of glenoid vault wall defects, without prosthetic glenoid resurfacing. Clinical outcomes (Penn Shoulder Score, maximum 100 points) improved from 23 to 57 at a minimum 2-year followup (mean, 38 months; range, 24-73 months). However, we observed substantial graft subsidence in all patients, with eight of 11 patients having subsidence greater than 5 mm; the magnitude of graft resorption did not correlate with clinical outcome scores. Greater subsidence was seen with structural than cancellous chip allografts. Bone grafting large glenoid defects during revision shoulder arthroplasty can improve clinical outcome scores, but the substantial resorption of the graft material remains a concern. LEVEL OF EVIDENCE: Level III Prognostic study.     

Glenoid revision is best treated with glenoid implants: Opposes

Glenoid component loosening is a common cause of failure for anatomic total shoulder arthroplasty. Revision options include reimplantation of an anatomic total shoulder, conversion to a reverse shoulder arthroplasty, or bone graft of the glenoid defect alone. In the presence of an intact rotator cuff with significant glenoid bone loss, the most predictable revision option is bone graft of the glenoid defect alone. Recent studies have demonstrated good clinical outcomes and a lower complication and re-revision rate with bone graft alone compared to attempted glenoid component reimplantation.     

Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation

BACKGROUND: Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation. METHODS: Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination. RESULTS: The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6 degrees to 90.0 degrees . The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs. CONCLUSIONS: Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.     

A multicentre study of the long-term results of using a flat-back polyethylene glenoid component in shoulder replacement for primary osteoarthritis

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (SD) as endpoints. The Constant score was found to improve from a mean of 26.8 (SD 10.3) pre-operatively to 57.6 (SD 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (SD 27.4) pre-operatively to 125° (SD 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (SD 6.5) pre-operatively to 30.3° (SD 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years. Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.     

Mid-term results of a metal-backed glenoid component in total shoulder replacement

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154). Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaluated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications. We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.     

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.     

Baseplate placement in failed total shoulder replacement: Builder’s choice

Glenoid component loosening has been recognized as one of the common indications for revision surgery after total shoulder arthroplasty. Replacement with a standard glenoid component is sometimes possible when bone loss is minimal and contained within the glenoid vault. If glenoid bone stock is poor, more complex revision strategies include bone graft reconstruction, custom implants, and the use of augmented components. Reverse total shoulder arthroplasty has also developed into a platform for revision surgery. However, surgeons must be aware that when used for revision, complication rates are higher and survival times are shorter. Glenoid revision is technically demanding even for an experienced shoulder surgeon and may lead to early revision failures if done improperly. Shoulder surgeons must have a detailed understanding of expected outcomes, proper indications and current bone grafting techniques when attempting glenoid reconstruction.     

Radiographic and computed tomography analysis of cemented pegged polyethylene glenoid components in total shoulder replacement

BACKGROUND: Glenoid loosening continues to be the primary reason for failure of total shoulder arthroplasty. The purpose of this study was to evaluate, with use of a sensitive and reproducible imaging method, the radiographic and clinical results of total shoulder replacement with a pegged, cemented polyethylene glenoid implant. METHODS: Forty-three patients (forty-seven shoulders) underwent a total shoulder replacement with a cemented polyethylene glenoid component with four threaded pegs. The patients were examined clinically, with fluoroscopically guided radiographs, and with computed tomography at an average of forty months. In addition to conventional scoring of radiographic lucency, an 18-point scoring system was used to quantify cement-peg lucencies in six zones of the back surface of the glenoid component as seen on computed tomography scans. RESULTS: On the average, the absolute Constant score improved from 39 points preoperatively to 70 points at the time of follow-up (p = 0.0001) and the pain score improved from 5 to 13 points (p = 0.001). The mean active anterior elevation improved by 34 degrees (p = 0.001) and the mean abduction, by 46 degrees (p = 0.006). Two patients had symptomatic glenoid loosening requiring revision. Twenty-one of the forty-seven shoulders had radiographic lucency around the glenoid pegs, and nine had progression of the lucency by at least two grades. Computed tomography detected lucencies, primarily at the bone-cement interface, in thirty-six shoulders. The scores for the lucencies seen on the computed tomography scans were associated with the radiographic lucency scores (p < 0.001), pain scores (p = 0.04), and abduction strength (p = 0.02). Computed tomography was more sensitive than radiography with regard to identifying the number of pegs associated with lucency and the size of the lucencies. The overall reproducibility of the scoring based on the computed tomography was higher than that of the radiographic scoring. CONCLUSIONS: Computed tomography provided a more sensitive and reproducible tool for the assessment of loosening of pegged glenoid components than did fluoroscopically guided conventional radiography. Further improvement in implant design and fixation technique appears to be necessary for long-term success of cemented glenoid components.     

Computed tomography revealed the correlation between radiolucency and alignment of all-polyethylene pegged glenoid component more than 10 years after total shoulder arthroplasty in the Japanese population

BackgroundAnatomical total shoulder arthroplasty (TSA) provides successful long-term outcomes but complications can occur after 10 years that require revision. Computed tomography (CT) is a useful tool for assessing radiolucent lines around the glenoid component of TSA; however, the merits of long-term post-TSA follow up with CT are unclear. The purpose of this study was to evaluate the long-term outcomes after TSA of Japanese population and to identify factors related to radiolucency around the glenoid component using CT.MethodsA retrospective review was conducted of TSA patients who had completed at least 10 years of clinical follow up. Radiographs and CT images of the affected shoulder obtained at the last follow up were evaluated for radiolucent lines around the stem and each peg, superior inclination and retroversion of the glenoid component, subluxation index, and critical shoulder angle (CSA). Shoulder ROM, Constant–Murley score and UCLA score were compared between the preoperative and last follow up period.ResultsEighteen shoulders in 16 patients met the inclusion criteria. Mean patient age was 61 years, mean follow up period was 137 months, and mean Yian CT score was 19%. CT score was significantly highest in pegs located inferiorly (p < 0.05). Mean glenoid superior inclination was 12.6°, retroversion was ?0.3°, subluxation index was 46%, and CSA was 33.7°. Glenoid superior inclination was significantly lower (p = 0.007) in shoulders with possible loosening than in cases with no loosening (5.0° vs 15.6°). Mean Constant score and UCLA score improved significantly after TSA, from 25.8 to 10.7 points preoperatively to 70.1 and 28.9 points postoperatively, respectively. Mean shoulder flexion, internal rotation, and external rotation also showed improvement postoperatively.ConclusionTSA provides good long-term outcomes. Radiolucency was present most frequently around the inferior pegs of the glenoid component. Glenoid superior inclination may affect the formation of radiolucent lines around glenoid pegs.Level of evidenceLevel IV; Case Series; Treatment study.     

Revision shoulder arthroplasty for glenoid component loosening

Although glenoid component loosening has been recognized as a common reason for failure after total shoulder arthroplasty, there are few studies on the outcome of revision surgery for this problem. The purpose of this study is to determine the outcome of patients who underwent revision for glenoid component loosening. Between 1976 and 2002, 68 shoulders in 66 patients underwent revision for glenoid loosening at our institution. Group I consisted of 33 shoulders that underwent placement of a new glenoid component, and group II consisted of 35 shoulders that had removal and bone grafting without glenoid reimplantation. Follow-up averaged 3.8 years for group I and 6.2 years for group II. There was significant overall improvement in pain from preoperatively to postoperatively in both groups (P = .0001). Pain relief occurred in 23 of 33 shoulders in group I and in 24 of 35 in group II (P = .9203). Regarding range of motion, there was no significant change from preoperatively to postoperatively (P > .05), except for active elevation in group I (P = .0387). Patient satisfaction occurred in 24 in group I and in 19 in group II (P = .1150). The rate of survival free of reoperation at 5 years was 91% (95% confidence interval, 81% to 100%) in group I and 78% (95% confidence interval, 63% to 96%) in group II (P = .3019). When the Neer result rating was applied, 9 shoulders in group I and 3 in group II had an excellent or satisfactory result (P = .0432). Twenty shoulders had late positive cultures, most commonly, Propionibacterium acnes. Glenoid revision surgery will often lead to pain relief and patient satisfaction. There is a slight clinical benefit to reimplanting a glenoid component whenever structurally possible. Positive cultures in revision surgery are common, with uncertain clinical significance.     

Reimplantation of a glenoid component following component removal and allogenic bone-grafting

BACKGROUND: Glenoid component loosening has been a leading cause of failure of total shoulder arthroplasty. In the present study, we evaluated the outcome of reimplantation of a new glenoid component following removal of the previous glenoid component and placement of an allograft in order to determine the results, risk factors for an unsatisfactory outcome, and rate of failure associated with this procedure. METHODS: We reviewed the data on seven shoulders in seven patients. At the time of glenoid component reimplantation, two shoulders received a cemented all-polyethylene glenoid component, three received a bone-ingrowth metal-backed component with columns and screws, and two received a bone-ingrowth metal-backed component with columns and screws augmented with bone cement. The average duration of follow-up was seventy-nine months. At the time of the latest follow-up, all patients were evaluated clinically and radiographically, patient satisfaction was assessed, and the result was graded according to a modified Neer rating system. RESULTS: Two patients had positive growth of Propionibacterium acnes on culture of intraoperative specimens obtained at the time of revision surgery and had continuing pain, and both underwent repeat revision. The remaining five patients expressed satisfaction with the procedure and stated that they felt better following surgery. The mean preoperative pain score for these five patients (on a scale from 1 to 5) was 4.6, and the mean postoperative pain score was 2.4 (p = 0.0042). Range of motion, however, did not improve. The Neer rating of the result (determined for the five patients who did not undergo repeat revision) was excellent for one patient, satisfactory for one, and unsatisfactory (because of limitation of motion) for three. CONCLUSIONS: Reimplantation of a glenoid component into a previously grafted bed can provide pain relief for most patients, but motion cannot be reliably improved.     

Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial

BACKGROUND: Both total shoulder arthroplasty and hemiarthroplasty have been used commonly to treat severe osteoarthritis of the shoulder; however, their effect on disease-specific quality-of-life outcome is unknown. The purpose of this study was to compare the quality-of-life outcome following hemiarthroplasty with that following total shoulder arthroplasty in patients with osteoarthritis of the shoulder. METHODS: Forty-two patients with a diagnosis of osteoarthritis of the shoulder were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. One patient died, and all others were evaluated preoperatively and at six weeks and three, six, twelve, eighteen, and twenty-four months postoperatively with use of a standardized format including a disease-specific quality-of-life measurement tool (Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder rating scales (University of California at Los Angeles [UCLA] shoulder scale, Constant score, and American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (McGill pain score and visual analogue scale), and a global health measure (Short Form-36 [SF-36]). When a patient required revision of a hemiarthroplasty to a total shoulder arthroplasty, the last score before he or she "crossed over" was used for the analysis. RESULTS: Significant improvements in disease-specific quality of life were seen two years after both the total shoulder arthroplasties and the hemiarthroplasties. There were no significant differences in quality of life (WOOS score) between the group treated with total shoulder arthroplasty and that treated with hemiarthroplasty (90.6 +/- 13.2 and 81.5 +/- 24.1 points, respectively; p = 0.18). The other outcome measures demonstrated similar findings. Two patients in the hemiarthroplasty group crossed over to the other group by undergoing a revision to a total shoulder arthroplasty because of glenoid arthrosis. CONCLUSIONS: Both total shoulder arthroplasty and hemiarthroplasty improve disease-specific and general quality-of-life measurements. With the small number of patients in our study, we found no significant differences in these measurements between the two treatment groups. LEVEL OF EVIDENCE: Therapeutic Level I.     

Glenoid Reconstruction in Revision Shoulder Arthroplasty

Failed shoulder arthroplasty associated with glenoid bony deficiency is a difficult problem. Revision surgery is complex with unpredictable outcome. We asked whether revision shoulder arthroplasty with glenoid bone grafting could lead to good outcome. We retrospectively reviewed 21 patients who underwent glenoid bone grafting using corticocancellous bone grafting or impaction grafting using cancellous bone graft. Three patients underwent revision TSA, five patients hemiarthroplasty, 10 patients hemiarthroplasty with biologic resurfacing of the glenoid, and three patients revision to reverse TSA. The patients had minimum 25 months followup (average, 45 months; range, 25-92 months). All patients had improvement in their range of motion and the Constant-Murley score. Most improvement occurred in patients with glenoid reimplantation. Patients who underwent revision reverse TSA had improvement in shoulder flexion but decrease in external rotation motion. We conclude revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible.