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Cementless Humeral Resurfacing Arthroplasty in Active Patients Less
Than Fifty-five Years of Age
David S. Bailie, Paulo J. Llinas and Todd S. Ellenbecker
J Bone Joint Surg Am. 2008;90:110-117. doi:10.2106/JBJS.F.01552
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C OPYRIGHT Ó 2008
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Cementless Humeral Resurfacing
Arthroplasty in Active Patients Less
Than Fifty-five Years of Age
By David S. Bailie, MD, Paulo J. Llinas, MD, and Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS
Investigation performed at The Orthopedic Clinic Association, Scottsdale, Arizona
Background: Cementless humeral resurfacing arthroplasty is a bone-conserving arthroplasty option for patients with
glenohumeral arthritis. It has been successful in the older patient population. However, data regarding the results of
arthroplasty in younger, more active patients are lacking. We report the two-year results of this procedure in active patients who were less than fifty-five years of age.
Methods: We reviewed prospectively collected clinical data on a series of thirty-six patients under fifty-five years of age
with end-stage glenohumeral arthrosis, but without osteonecrosis, who had undergone a cementless humeral resurfacing
hemiarthroplasty performed by a single surgeon. All patients were followed for a minimum of two years. We assessed pain,
function, and patient satisfaction and documented all complications. Radiographs were evaluated for implant loosening.
Results: The thirty-six patients had a mean age of 42.3 years and were followed for a mean of 38.1 months. Scores
measured with a visual analog pain scale, the Single Assessment Numeric Evaluation (SANE) scale, and the American
Shoulder and Elbow Surgeons (ASES) scale all improved significantly from preoperatively to two years postoperatively
(p < 0.001). Complications included one traumatic subscapularis rupture at six weeks, three cases of arthrofibrosis, and
one deep hematoma. No obvious radiographic evidence of loosening was noted at the time of the latest follow-up. One
shoulder was converted to a stemmed total shoulder arthroplasty at twenty-four months because of pain, but the implant
was not loose at the revision. The remaining thirty-five patients were satisfied with the outcome at the time of the latest
follow-up and had returned to their desired activity.
Conclusions: Cementless humeral resurfacing arthroplasty is a viable treatment option for younger, active patients.
Early results indicate that the desired function and pain relief can be expected. Implant loosening and glenoid wear do
not appear to be concerns in the short term despite the high activity levels of many patients. Long-term follow-up is
needed to determine if these results persist.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
C
urrently, glenohumeral osteoarthritis in younger, active
patients is a condition without an ideal solution. These
patients desire a treatment that will provide pain relief
and restore their ability to perform activities of daily living but
also, in some cases, that will enable them to return to sports
participation. When nonoperative measures fail, arthroplasty
may be considered. However, it is not well understood which
activities can be performed without affecting the life span of the
implant. This is particularly true for cemented glenoid components, which are known to loosen in up to 39% of patients by
the time of mid-term to long-term follow-up1. In addition, active
patients participating in collision sports have a theoretical risk of
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits (consulting fees associated with course
instruction) of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Biomet Orthopedics). 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 authors, or a member of their immediate families, are affiliated or associated.
A video supplement to this article will be available from the Video Journal of Orthopaedics. A video clip will be available at the JBJS web site,
www.jbjs.org. The Video Journal of Orthopaedics can be contacted at (805) 962-3410, web site: www.vjortho.com.
J Bone Joint Surg Am. 2008;90:110-7
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doi:10.2106/JBJS.F.01552
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sustaining a periprosthetic fracture of the humeral shaft, which
may be difficult to treat in a patient with a stemmed implant.
As early as 1980, humeral head resurfacing was proposed
as a treatment for glenohumeral arthrosis in an attempt to
preserve the original anatomy and avoid humeral head resection
by using an uncemented surface replacement with a central
peg2. Preservation of the humeral head allowed the native inclination, offset, head-shaft angle, and version of the humerus
to be maintained, facilitating later revision to a conventional
total shoulder arthroplasty if needed3,4.
There is limited available information regarding the results of arthroplasty in younger patients5-7. The primary purpose of this study was to report the results of cementless
humeral resurfacing arthroplasty in a consecutive series of
patients who were younger than fifty-five years of age.
Materials and Methods
rom 2001 to 2004, the senior author (D.S.B.) performed
287 shoulder arthroplasties in patients with symptomatic
end-stage glenohumeral arthrosis. Of these, thirty-eight consecutive patients were younger than fifty-five years of age and
were treated with a cementless humeral resurfacing arthroplasty (Copeland Mark-2, MacroBond; Biomet, Warsaw,
Indiana); they were included in this study. Patients with radiographic evidence of osteonecrosis, with or without any degree of head collapse, were not considered candidates for this
procedure because of our concern that the cementless humeral resurfacing arthroplasty might not address bone pain or
structural abnormalities of the humeral head in a patient with
osteonecrosis. Two patients were lost to follow-up.
Conservative treatment, including physical therapy, intraarticular injections (corticosteroids and/or hyaluronic acid),
and/or arthroscopic débridement, had failed for all patients.
The age of fifty-five years or less was chosen because of the
typical high level of activity of this patient population in our
community as well as reports in the literature that suggest
possible problems with traditional arthroplasty in this age
group1,8. In addition, we have had experience with younger
patients requesting a treatment that may allow them to return
to athletic activity. Many patients in this series had previously
been told by other medical providers that no options other
than conservative treatment were available.
This study was approved by our institutional review
board, and all enrolled patients provided informed consent to
undergo the surgical procedure and follow-up examinations,
including completion of the rating instruments used in this
investigation. Treatment options other than cementless humeral resurfacing arthroplasty, including total shoulder replacement and humeral head replacement with or without
biologic resurfacing of the glenoid, had been discussed with
the patients. After 2003, some of these patients were also enrolled in a simultaneous multicenter, prospective study of cementless humeral resurfacing arthroplasty in which no patient
age or pathological conditions were specifically excluded.
Data collected included the suspected etiology of the
arthrosis, the visual analog pain score (marked on a 10-cm
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line, with 0 indicating ‘‘no pain’’ and 10, ‘‘worst pain ever’’),
the Single Assessment Numeric Evaluation (SANE) score9, the
American Shoulder and Elbow Surgeons Score (ASES)10, stability, and patient satisfaction. The SANE and ASES are validated scoring measures and have been described elsewhere9,10.
Routine anteroposterior and axillary lateral radiographs were
made preoperatively, at the first postoperative visit, at six
months, at one year, and then annually thereafter. They were
evaluated for loosening, determined by the presence of implant
migration or progression of radiolucent lines around the implant4,6. Because radiographs were not standardized (they were
made with different techniques and by different technicians as
the patients were not always seen at the same office), the degree
of glenoid erosion, the glenohumeral relationship, and the
acromiohumeral relationship were all evaluated with gross
observation of the radiographs only (i.e., no specific measurements were made). Glenoid wear patterns were classified
on the basis of the criteria described by Walch et al.11.
Surgical Procedure (Figs. 1-A through 1-D)
All surgical procedures were performed by the same surgeon in
an outpatient surgical center, with the patient discharged on
either the same day or the following morning, depending on
his or her desire to stay overnight. All patients were treated
with a cementless humeral resurfacing arthroplasty that was
performed by the senior author (D.S.B.) with use of the Biomet
Copeland Mark-2 MacroBond implant. A first-generation cephalosporin was administered intravenously thirty to sixty minutes prior to the incision. Clindamycin was used for patients
with a known allergy to cephalosporins. A general anesthetic in
conjunction with a preoperative interscalene block was used
for all patients. The patient was placed in a semi-reclined
position with the arm draped free.
A deltopectoral approach was used, with preservation of
the pectoralis major tendon and the circumflex humeral vessels. Aggressive soft-tissue releases of the subscapularis and the
anterior and inferior aspects of the capsule were performed
when necessary to improve tendon excursion. These included
a 360° release of the subscapularis tendon (the coracohumeral
ligament and the rotator interval, the inferior aspect of the
capsule, the anterior aspect of the capsule, and any anterior
subcoracoid adhesions). The anterior aspect of the capsule was
left attached to the subscapularis to enhance suture fixation of
the tendon back to its stump on the lesser tuberosity. Posterior
capsular plication was not performed, and excessive posterior
laxity after implant placement and subscapularis repair was
eliminated with closure of the rotator interval.
Tenodesis of the long head of the biceps was done routinely
in all patients, as prior to this study we had observed recalcitrant
biceps tenosynovitis after arthroplasty in more active patients. The
biceps was repaired with nonabsorbable suture to the surrounding
rotator cuff tissue at its entrance into the joint at the end of the
procedure. The intra-articular portion of the biceps tendon was
released from the superior aspect of the labrum and was excised.
The cementless humeral resurfacing arthroplasty was
performed with use of the previously described technique3,4.
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Fig. 1-A
Preoperative axillary radiograph of a forty-seven-year- old man, made twenty years
after anterior coracoid transfer for the treatment of shoulder instability, demonstrating intra-articular screw penetration and posttraumatic degenerative arthritis.
The most appropriately sized implant was chosen and was
placed with respect for anatomic version and inclination,
which varied among patients. Specifically, the implant that
provided the best head coverage was chosen. When the ideal
size appeared to be between available options, the smaller size
was chosen to prevent ‘‘overstuffing’’ of the joint. Cement was
not used; autogenous or allograft cancellous bone was utilized
to fill minor humeral head defects. No patient was treated with
structural grafting.
The glenoid was treated in some patients, if clinically
indicated at the time of the surgery and on the basis of radiographic findings (eccentricity of the glenoid and/or cystic
changes). No glenoid replacements were used regardless of the
glenoid type, but biologic resurfacing with a meniscal allograft
or human dermis allograft (GraftJacket; Wright Medical Technology, Arlington, Tennessee) or microfracture (for focal, contained chondral defects) was performed in some patients.
When there was eccentric absence of articular cartilage, the
remaining cartilage was débrided manually to restore the glen-
oid surface to a more symmetric concavity and to restore
version of the glenoid. In addition, contained cystic glenoid
defects were filled with allograft cancellous bone when they
were >5 mm in diameter. When this was performed, the defect
was covered with human dermal allograft to keep the graft in
place. Full-thickness rotator cuff tears were repaired with use
of suture anchors, but partial tears, subacromial impingement,
and arthritis of the acromioclavicular joint were not addressed.
Finally, degenerative labral tears were débrided to a stable rim
prior to placement of the implant. An anatomic repair of the
subscapularis, without medialization or z-lengthening, was
always performed regardless of the preoperative range of external rotation. Suture anchor repair was employed along the
lesser tuberosity when the subscapularis tendon grossly appeared thinner laterally or when we used an implant that
seemed to rest near the insertion after impaction, as the latter
may jeopardize the tendon insertion. The deltopectoral interval, subcutaneous tissues, and skin were all closed with absorbable sutures. No drains were used.
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Fig. 1-B
Extensive humeral head damage and defects were seen intraoperatively.
A standard sling or SlingShot pillow sling (BREG, Vista,
California) was used for up to six weeks. Home exercises were
started on the first postoperative day and included passive
circumduction and pendulums as well as active range-ofmotion exercises such as saws (back and forth movement of
the arm in the coronal plane with a flexed elbow) and tummy
rubs (back and forth movement across the abdomen in the
coronal plane) with the shoulder in up to 20° to 30° of elevation. External rotation was allowed to within 30° of that
obtained during the surgery, after the subscapularis repair.
Fig. 1-C
The cementless humeral resurfacing arthroplasty implant is in place.
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Fig. 1-D
Axillary radiograph, made two years postoperatively, showing the implant
matching the patient’s anatomy and the humeral head centered on the
glenoid.
Formal physical therapy was started after the first postoperative office visit, between ten and fourteen days following the
surgery, and was continued for three months. A standardized
rehabilitation program was followed with use of precautions to
protect the subscapularis for the initial six weeks12. This involved limitations of active internal rotation resistance, and
external rotation motion was limited to within 30° of the
maximal external rotation obtained during the surgery after
subscapularis repair.
Statistical Methods
Paired t tests were used to test for differences between the preoperative and two-year postoperative mean scores measured
with the outcome rating scales. Significance was set at the 0.001
level with use of a Bonferroni adjustment.
Results
hirty-eight patients who were less than fifty-five years of
age were treated by the senior one of us between 2001 and
2004. Two patients were lost to follow-up. Thus, thirty-six patients followed for a minimum of two years were available for
this study. The mean age at the time of the operation was 42.3
years (range, twenty-eight to fifty-four years), and the latest
follow-up evaluation was at a mean of 38.1 months (range,
twenty-four to sixty months). The proposed etiology of the
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arthrosis was posttraumatic in three patients, post-instability/
stabilization in seven, chondrolysis after recent prior surgery in
three, and idiopathic or microtraumatic in twenty-three. Three
patients underwent cancellous bone-grafting combined with
biologic resurfacing with GraftJacket to treat a contained glenoid defect resulting from loosening of screw fixation that had
been used for a prior coracoid transfer. One patient received a
lateral meniscal allograft to treat posterior instability and a
deficient labrum. Two patients underwent microfracture of
small (<1-cm) chondral defects of the glenoid, and eighteen
had manual débridement of articular cartilage, but not reaming, to restore uniform concavity to the glenoid fossa. In the
eight patients who appeared to have an early, type-B1, glenoid
wear pattern according to the system of Walch et al.11, the
residual articular cartilage anteriorly was débrided down to
subchondral bone, and any small central ridge, if present, was
flattened with use of a high-speed burr. This grossly restored
glenoid version as there was no apparent osseous deficit or
erosion. Two shoulders in which the anterior articular surface
was absent and the posterior surface was intact were treated in
a similar manner. In these cases, care was taken to not penetrate deep into the supporting subchondral bone and only
enough bone was removed to restore the gross uniform concave appearance of the glenoid fossa.
Four patients had simultaneous repair of isolated rotator
cuff tears, which ranged in size from 1 to 4 cm2. Eleven patients
had pathological involvement of the long head of the biceps,
including partial tears, SLAP tears involving the insertion,
hypertrophic tenosynovitis, and loose bodies in the bicipital
groove. As mentioned, all patients, even those without pathological involvement of the biceps tendon, underwent a biceps
tenodesis.
There were no major intraoperative complications such
as neurovascular injury, infection, fracture, or gross malpositioning of the implants. A deep hematoma developed in one
patient and was evacuated at three weeks after the surgery. In
one patient, who had had multiple previous operations on the
shoulder, the subscapularis repair ruptured at four weeks, when
he lifted a heavy object overhead. Three weeks later, he underwent subscapularis repair with suture anchors and allograft
augmentation. Arthrofibrosis (defined as substantial functional loss of motion not responsive to rehabilitation for three
months) developed in three patients. Arthroscopic débridement and selective capsular release in order to restore at least
90° of external rotation in the 90° abducted position was successful in all three patients. Two of these cases of arthrofibrosis
were associated with a preoperative diagnosis of chondrolysis
and capsular thickening.
Preoperatively, gross evaluation of the radiographs demonstrated a concentric glenohumeral relationship in twentyeight patients (Walch type A1 in twenty-six and type A2 in
two), minimal posterior subluxation (<33% as determined
with gross observation; Walch type B1) in eight, and no cases
of an advanced biconcave glenoid (Walch type B2). However,
two patients who had a B1 classification radiographically showed,
at the time of surgery, some very early signs of biconcavity with
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TABLE I Results of Outcome Rating Scores Following
Cementless Humeral Resurfacing Arthroplasty*
Score
Preoperative
At Two Years
7.5 ± 1.7
1.3 ± 0.6
Single Assessment Numeric
Evaluation (SANE)
24.7 ± 9.2
90.4 ± 4.7
American Shoulder and Elbow
Surgeons (ASES)
29.8 ± 11.1
87.7 ± 12.6
Visual analog pain scale
*The values are given, in points, as the mean and standard
deviation.
a small central ridge at the junction between the eburnated
posterior bone and the remaining anterior articular cartilage.
Walch type C (frank posterior subluxation or severe osseous
glenoid erosion) was not seen in any patient.
The results of the outcome scores used in this investigation are displayed in Table I. The visual analog pain score
(mean and standard deviation) improved from 7.5 ± 1.7 points
preoperatively to 1.3 ± 0.6 points at two years (p < 0.001). Pain
did not change significantly from two years postoperatively to
the time of the latest follow-up (at a mean of 38.1 months).
The mean SANE score improved significantly from 24.7 ± 9.2
points preoperatively to 90.4 ± 4.7 points at two years (p <
0.001). The mean total ASES score improved significantly from
29.8 ± 11.1 points preoperatively to 87.7 ± 12.6 points at two
years (p < 0.001).
Radiographic evaluation did not demonstrate any case of
obvious loosening of the implant at any time-period.
Thirty-five patients were satisfied with the result of the
procedure and indicated that it had allowed them to return to
their desired activities at a satisfactory level. One continued to
have pain and underwent a total shoulder arthroplasty at twentyfour months. The pain continued following this revision, although it was not as severe.
Six patients indicated that they had voluntarily decreased
their level of activity but said that this was not related to a poor
result or pain but to a fear of implant failure. Although we did
not use a specific sports functional outcomes measure, some
patients did specify their sports activity on the ASES questionnaire. Examples of sports activities listed on the ASES
questionnaire included self-directed conditioning programs
such as resistance training, yoga, or Pilates (thirty-four patients); trail mountain biking (four); golf (sixteen); hockey
(two); tennis (four); power-lifting (three); bobsled push (one,
an Olympic athlete); and competitive recreational basketball
(six).
Discussion
e report the results of cementless humeral resurfacing
arthroplasty with a Biomet Copeland Mark-2 implant
in thirty-six patients, younger than fifty-five years old, who
were treated between 2001 and 2004 and were followed pro-
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spectively for a minimum of two years (average, 38.1 months).
We found substantial patient satisfaction, a perceived return of
function, and decreased pain with neither gross loosening nor
radiolucent lines around the humeral implant.
Cementless humeral resurfacing arthroplasty with use of
this implant has previously been reported to be successful in
patients with many forms of glenohumeral disease at a mean
age of 73.4 years3,4. Initially placed in conjunction with a glenoid component, this implant has been shown to be beneficial
even when used as a humeral head replacement alone3,4. Although the rate of loosening has been reported to be lower
with use of hydroxyapatite-coated implants3,4, our experience
with the MacroBond prosthesis has been satisfactory.
Although there were some complications in our series,
all have been reported in association with the standard surgical
technique for any shoulder replacement and were not specific
to this humeral resurfacing prosthetic design1,5. In fact, our
overall complication rate with cementless humeral resurfacing
arthroplasty was lower than that reported in association with
stemmed prostheses1,3,13,14. Our one patient who underwent
revision to a total shoulder arthroplasty did not have substantial improvement even after the revision, indicating a possible
unidentified etiology of the pain. However, other authors have
suggested that conversion of even a stemmed humeral head
replacement to a total shoulder arthroplasty does not yield
high satisfaction rates15,16.
In younger patients with more advanced stages of glenohumeral arthrosis, arthroscopic treatment yields poor results,
similar to those obtained in nonathletic patients17. Overall,
there seems to be a consensus regarding the limited effectiveness of arthroscopic chondral débridement in patients with
established glenohumeral arthritis17-19. Brislin et al. reported a
surgical technique involving use of a porcine xenograft patch
on the glenoid in young patients with glenohumeral arthrosis20. Preliminary results regarding pain relief and improvement of the range of motion in ten young patients were good.
The results of that study have not yet been reproduced in larger
numbers of patients over a substantial length of time. Furthermore, limited studies of biologic glenoid resurfacing with
use of other materials have shown some promising, albeit
short-term, results21-24.
Glenohumeral arthrodesis is an option for young patients
with advanced arthritis, as it offers a definitive solution without
the complications associated with replacement. However, once
informed about the resulting functional restrictions, young patients often prefer procedures that allow joint mobility25.
The definitive option for the treatment of glenohumeral
arthrosis remains shoulder arthroplasty. Usually, it is indicated
when the patient’s quality of life has not been improved by
previously described alternatives. Humeral head replacement
and total shoulder arthroplasty are traditional options for
patients with advanced arthrosis1,7,26-32. It was not the purpose
of this study to compare these two procedures. At present, no
overall consensus has been reached favoring one over the other,
and this study does not offer any conclusions that help to determine this issue.
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We presently recommend modification of sports activity
to our young, active patients who have undergone shoulder
arthroplasty, regardless of the type of implant that was used.
Although we do not necessarily advocate specific ‘‘do’s and
don’ts,’’ we recommend that patients be educated regarding the
potential negative impact that rigorous physical activity, especially collision sports, may have on the longevity of the
implant and the need for additional surgery; however, definitive data are not presently available. On the basis of an opinion
survey of the members of the ASES, Healy et al. provided
guidelines for returning to sports activity following shoulder
arthroplasty33. However, specific indications and a data-driven
algorithm for the return to sports activity are not presently
available.
Sperling et al. reported the results of humeral head replacement and Neer total shoulder arthroplasty in patients
with glenohumeral arthrosis who were younger than fifty years
of age7. Follow-up at fifteen years confirmed pain relief and
improvement in motion after both procedures. The rates of
survival of the humeral head replacements were 82% at ten
years and 75% at twenty years, and the rates of survival of the
total shoulder replacements were 97% and 84%, respectively.
However, use of a modified Neer outcome rating system to
assess the patients’ daily performance ability showed unsatisfactory results in 60% of those who had undergone humeral
head replacement and in 48% of those who had undergone
total shoulder arthroplasty. Although we recognize our lack
of a comparable control group, a major limitation of our
study, we think that the substantial improvement in terms of
pain relief and function in this challenging patient population
demonstrates that cementless humeral resurfacing arthroplasty, without glenoid prosthetic replacement, is an acceptable option.
We attribute the achievement of a concentric position of
the humerus as seen on postoperative radiographs, even in
patients in whom a slightly eccentric glenoid-wear pattern had
been demonstrated preoperatively, primarily to three factors.
First, we performed an aggressive soft-tissue release (anteriorly
and inferiorly) without subscapularis lengthening in order to
restore motion. The release theoretically improves subscapularis excursion postoperatively and, without tendon lengthening, may improve subscapularis strength. This may in turn
help to reduce the posterior vector forces caused by an anterior
soft-tissue contracture, and we think that such forces are an
important factor contributing to progressive posterior glenoid
wear. In addition, any abnormal glenoid version in this patient
group appeared to be related to asymmetric patterns of wear of
the articular cartilage and not to true glenoid bone erosion.
This allowed us to restore ‘‘apparent version’’ by removing any
residual articular cartilage, thus returning the functional glenoid version to a nearly anatomic status in any given patient.
Finally, according to Walch et al.11, a type-B1 glenoid may
become worse with age and may transition to type B2 over
time; thus, since our patients were younger, it is possible that a
severe, type-B2 pattern had not yet had time to develop. We
postulate that restoration of version with preservation of the
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supporting subchondral bone (i.e., not reaming to cancellous
bone) in patients of a younger age may potentially restore
more symmetric forces on the glenoid and delay the development of eccentric glenoid wear. We think that, to accomplish this, an anatomic reconstruction involving both bone and
soft tissue should be performed. This can be accomplished
with either a cementless humeral resurfacing arthroplasty or
with an anatomic stemmed hemiarthroplasty. We chose cementless humeral resurfacing arthroplasty without glenoid prosthetic replacement for our patients, although this study does
not allow direct comparison of resurfacing arthroplasty with a
stemmed implant design in this patient group. Clearly, we will
not know the answer to this question until longer-term data
can be evaluated.
We did not routinely resurface the glenoid in these cases.
Meniscal allograft was used in only one patient because of our
experience with three cases, referred to the senior author, in
which a meniscal allograft had been placed on the glenoid
without evidence of instability and the outcome was a stiff,
painful shoulder with a displaced bucket-handle tear of the
allograft found at the time of arthroscopic débridement.
GraftJacket human dermal allograft was used in three
patients in this series. We utilized this material because it was
readily available at our institution. In addition, we had determined intraoperatively that cancellous bone-grafting of substantial glenoid defects was required, and this material seemed
to hold the graft in place. It held sutures well and was easily
trimmed to fit in situ.
This study had several limitations. Although the patients
were enrolled prospectively, there was no control group treated
with stemmed arthroplasty (hemiarthroplasty or total shoulder arthroplasty) for comparison. Therefore, we cannot conclude that cementless humeral resurfacing arthroplasty is better
than other arthroplasty methods for young patients. Furthermore, this is primarily a report on functional improvement
after cementless humeral resurfacing arthroplasty; data on
range of motion, specific radiographic measurements, and
strength are not presented because of a lack of standardization.
However, it is encouraging that thirty of the thirty-six patients
were able to participate in their desired level of activity after
cementless humeral resurfacing arthroplasty. We did not use a
specific outcomes measure of sports activity, as the initial goal
of this study was to simply evaluate the overall outcome and
patient satisfaction following cementless humeral resurfacing
arthroplasty in a challenging patient population. We recognize
that, although patients may have experienced substantial improvement and performed at their individual desired level of
activity after the procedure, there is no way to standardize this
aspect of the data. We are also aware that this relatively high
activity level may deteriorate and that longer-term follow-up is
needed to determine if these results persist.
Long-term follow-up is critical to determine if the
treatment of end-stage glenohumeral arthrosis with cementless
humeral resurfacing arthroplasty in younger, active patients is
viable. Despite promising early results, with good pain relief
and functional outcomes, we still have concerns over the
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T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G
V O LU M E 90 -A N U M B E R 1 J A N UA R Y 2 008
d
d
d
longevity of this implant in highly active patients. In addition,
the concern over progressive glenoid erosion and the outcomes
of revision to a more standard arthroplasty remains substantial. Furthermore, our experience has indicated that many of
these patients do not adhere to recommended activity restrictions. They often choose their level of sports participation
on the basis of the pain that they experience and their ability to
perform at a level that they individually deem to be acceptable.
In this group, whose goal is to return to a ‘‘more normal’’
lifestyle as defined by them, cementless humeral resurfacing
arthroplasty appears to be a viable alternative to other standard
treatments at least in the short term. The patients who were
enrolled in this study would not consider doing nothing as an
option and had obtained unsatisfactory results from conservative treatment. It remains to be seen whether cementless
humeral resurfacing arthroplasty is truly a better option. A
prospective, randomized, long-term study comparing ce-
CE M E N T L E S S H U M E R A L RE S U R FAC I N G A RT H RO P L A S T Y I N
A C T I V E P AT I E N T S L E S S T H A N F I F T Y - F I V E Y E A R S O F A G E
mentless humeral resurfacing arthroplasty with a stemmed
humeral head replacement and total shoulder arthroplasty in
this patient population is required in order to answer that
question. n
David S. Bailie, MD
The Orthopedic Clinic Association, 9377 East Bell Road, Suite 231,
Scottsdale, AZ 85260. E-mail address: [email protected]
Paulo J. Llinas, MD
Fundacion Clinica Valle del Lili, Carrera 98 No. 18-49, P.O. Box 331 9090,
Cali, Colombia. E-mail address: [email protected]
Todd S. Ellenbecker, DPT, MS, SCS, OCS, CSCS
Physiotherapy Associates, Scottsdale Sports Clinic, 9917 North 95th
Street, Scottsdale, AZ 85258. E-mail address: [email protected]
References
1. Bohsali KI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006;88:2279-92.
2. Jonsson E, Egund N, Kelly I, Rydholm U, Lidgren L. Cup arthroplasty of the
rheumatoid shoulder. Acta Orthop Scand. 1986;57:542-6.
3. Levy O, Copeland SA. Cementless surface replacement arthroplasty of the
shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis. J Bone Joint
Surg Br. 2001;83:213-21.
4. Levy O, Copeland SA. Cementless surface replacement arthroplasty
(Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg.
2004;13:266-71.
5. Hayes PR, Flatow EL. Total shoulder arthroplasty in the young patient. Instr
Course Lect. 2001;50:73-88.
6. Burroughs PL, Gearen PF, Petty WR, Wright TW. Shoulder arthroplasty in the
young patient. J Arthroplasty. 2003;18:792-8.
7. 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;13:604-13.
8. Hettrich CM, Weldon E 3rd, Boorman RS, Parsons IM 4th, Matsen FA 3rd.
Preoperative factors associated with improvements in shoulder function after
humeral hemiarthroplasty. J Bone Joint Surg Am. 2004;86:1446-51.
9. Williams GN, Gangel TJ, Arciero RA, Uhorchak JM, Taylor DC. Comparison of the
Single Assessment Numeric Evaluation method and two shoulder rating scales.
Outcomes measures after shoulder surgery. Am J Sports Med. 1999;27:214-21.
10. Barrett WP, Franklin JL, Jackins SE, Wyss CR, Matsen FA 3rd. Total shoulder
arthroplasty. J Bone Joint Surg Am. 1987;69:865-72.
11. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in
primary glenohumeral osteoarthritis. J Arthroplasty. 1999;14:756-60.
12. Ellenbecker TS, Bailie DS. Shoulder arthroplasty in the athletic shoulder. In:
Andrews JR, Wilk KE, Reinold M, editors. The athlete’s shoulder. Philadelphia:
Elsevier Saunders. In press.
13. Maynou C, Petroff E, Mestdagh H, Dubois HH, Lerue O. [Clinical and radiologic
outcome of humeral implants in shoulder arthroplasty]. Acta Orthop Belg.
1999;65:57-64. French.
14. Matsen FA 3rd, Ianotti JP, Rockwood CA Jr. Humeral fixation by press-fitting of
a tapered metaphyseal stem: a prospective radiographic study. J Bone Joint Surg
Am. 2003;85:304-8.
15. Sperling JW, Cofield RH: Revision total shoulder arthroplasty for the treatment
of glenoid arthrosis. J Bone Joint Surg Am. 1998;80:860-7.
16. Carroll RM, Izquierdo R, Vaquez M, Blaine TA, Levine WN, Bigliani LU. Conversion of painful hemiarthroplasty to total shoulder arthroplasty: long term results.
J Shoulder Elbow Surg. 2004;13:599-603.
17. Cameron BD, Galatz LM, Ramsey ML, Williams GR, Iannotti JP. Non-prosthetic
management of grade IV osteochondral lesions of the glenohumeral joint. J
Shoulder Elbow Surg. 2002;11:25-32.
18. Weinstein DM, Bucchieri JS, Pollock RG, Flatow EL, Bigliani LU. Arthroscopic
debridement of the shoulder for osteoarthritis. Arthroscopy. 2000;16:471-6.
19. Ellman H, Harris E, Kay SP. Early degenerative joint disease simulating impingement syndrome: arthroscopic findings. Arthroscopy. 1992;8:482-7.
20. Brislin KJ, Savoie FH, Field LD, Ramsey JR. Surgical treatment for glenohumeral arthritis in the young patient. Tech Shoulder Elbow Surg. 2004;5:165-9.
21. Burkhead WZ Jr, Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg. 1995;4:263-70.
22. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty
for the arthritic shoulder: description of a new technique. Tech Shoulder Elbow
Surg. 2001;2:247-54.
23. Nowinski DO, Burkhead WZ. Hemiarthroplasty with biologic glenoid resurfacing
5-13 year outcomes. Read at the Annual Meeting of the American Academy of
Orthopaedic Surgeons; 2003 Feb 5-9; New Orleans, LA.
24. Wirth MA. The parachute technique for interpositional meniscal allograft fixation in shoulder arthroplasty. Read at the Annual Meeting of the American Academy
of Orthopaedic Surgeons; 2004 Mar 10-14; San Francisco, CA.
25. Wilde AH, Brems JJ, Boumphrey FR. Arthrodesis of the shoulder. Current indications and operative technique. Orthop Clin North Am. 1987;18:463-72.
26. Neer CS 2nd. Replacement arthroplasty for glenohumeral osteoarthritis. J
Bone Joint Surg Am. 1974;56:1-13.
27. Edwards TB, Kadakia NR, Boulahia A, Kempf JF, Boileau P, Nemoz C, Walch G.
A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment
of primary glenohumeral osteoarthritis. Results of a multicenter study. J Shoulder
Elbow Surg. 2003;12:207-13.
28. 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.
29. Bishop JY, Flatow EL. Humeral head replacement versus total shoulder arthroplasty: clinical outcomes—a review. J Shoulder Elbow Surg. 2005;14(1 Suppl
S):141S-146S.
30. Antuna SA, Sperling JW, Cofield RH, Rowland CM. Glenoid revision surgery
after total shoulder arthroplasty. J Shoulder Elbow Surg. 2001;10:217-24.
31. Hawkins RJ, Bell RH, Jallay B. Total shoulder arthroplasty. Clin Orthop Relat
Res. 1989;242:188-94.
32. Torchia ME, Cofield RH, Settergren CR. Total shoulder arthroplasty with
the Neer prosthesis: long term results. J Shoulder Elbow Surg. 1997;6:
495-505.
33. Healy WL, Iorio R, Lemos MJ. Athletic activity after joint replacement. Am J
Sports Med. 2001;29:377-88.