DEFINITION

Eddie Y. Lo Wayne Z. Burkhead

 

Glenohumeral osteoarthritis (OA) occurs with the progressive degeneration of articular cartilage.

 

Hemiarthroplasty (HA) is the prosthetic replacement of the humeral side without placing a polyethylene spacer on the glenoid surface.

 

Biologic resurfacing involves concentric reaming of the glenoid, with or without biologic tissue interposition over the articular surface.

ANATOMY

 

Glenohumeral joint includes the bony articulation and the static/dynamic soft tissue components.

 

The bony articulation includes the glenoid and humeral head. This is supported by static ligamentous structures, including the glenohumeral ligaments, joint capsule, and capsulolabral complex.

 

The dynamic structures include the four rotator cuff tendons. They maintain the glenohumeral joint alignment via balanced muscular forces. If this balance is lost, the humeral head is at risk of anterior, posterior, or superior translation.

 

The short head of the biceps tendon inserts on the coracoid process and is extra-articular. The long head of the biceps tendon, however, inserts on the supraglenoid tubercle, which is intra-articular but extrasynovial. Its biomechanical function in the shoulder remains controversial.

PATHOGENESIS

 

The development of OA is the chronic degeneration of articular cartilage through the intricate involvement of genetic, metabolic, biochemical, biomechanical, and social factors. Most of this is discussed in prior chapters, but the key points will again be elucidated.

 

Cartilage is an aneural structure, so the pain from OA arises from the noncartilaginous structures of the shoulder.

 

 

The inflammatory component of the pain is often associated with the capsular synovitis.

 

The mechanical component of the pain can be associated with the abnormal biomechanical forces on the bone.

 

During the development of arthritis, the osteochondral junction as well as the osteophytes become infiltrated with

neurovascular structures, becoming a source of pain generator.26 Abnormal biomechanical forces on this subchondral bone is symptomatically felt as pain.

 

Substance P, cyclooxygenase 2 (COX-2), and tumor necrosis factor α (TNF-α) molecules can be identified in the subchondral bone as biochemical mediators of pain.21

 

Arnoldi et al1,2 compared patients with pain versus those without pain and found that pain symptoms correlated with development of high intraosseous pressure. If this pressure is relieved via osteotomy, the pain can be decompressed.

 

Intraosseous hypertension can then lead to decreased interstitial fluid flow, decreasing the nutrient supply to the chondrocytes, and inducing chondrocyte apoptosis.

 

NATURAL HISTORY

 

Primary OA usually occurs with no antecedent event, whereas secondary OA results from another coexisting problems such as previous micro- and macrotrauma, chronic instability, massive rotator cuff tear, or avascular necrosis. If the primary

causes are not treated, OA will progressively worsen over time.

 

The most common wear pattern in OA is the posterior wear. As OA progresses, the posterior wear can exacerbate, eventually leading to humeral head subluxation. Clinically, these patients have higher revision rates and worse function,

even after undergoing total shoulder arthroplasty (TSA).14

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Patients typically present with chronic, insidious pain with or without an acute exacerbation event.

 

Another common complaint is stiffness or decreased passive range of motion. The stiffness symptom can be temporal with worst symptoms in the morning, with improvement by midday.

 

On examination, patients usually have decreased active and passive range of motion. During examination, loud clunks or crepitus can be felt or heard.

 

Patients generally present with good rotator cuff strength, but one needs to distinguish between true weakness versus weakness secondary to pain. An effective diagnostic tool is local anesthetic injection intra-articularly, which would relieve patient's pain symptoms and allow the practitioner to truly evaluate cuff strength.

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Standard anteroposterior, axillary, and scapular Y radiographs of the shoulder are routinely obtained. These are reviewed to confirm the diagnosis of OA with intact rotator cuff.

 

The four signs of OA include subchondral sclerosis, subchondral cyst, joint space narrowing, and osteophyte formation.

 

 

P.3819

 

If the integrity of the rotator is in question, advanced imaging including computed tomography (CT) arthrogram or magnetic resonance imaging (MRI) can be obtained.

 

CT scans may be helpful in assessing concentric versus eccentric glenoid wear. Severity of wear can be noted for intraoperative adjustment of glenoid version.

 

Full-length humeral x-rays of both sides can be helpful if there is significant humeral bone loss. The length of bone loss can be calculated based on side-to-side comparison.

DIFFERENTIAL DIAGNOSIS

 

 

 

 

 

 

Inflammatory arthritis Chondrolysis Adhesive capsulitis Rotator cuff tear Cuff tear arthropathy Infection

NONOPERATIVE MANAGEMENT

 

The first-line treatment for OA is nonoperative, which includes life modification, physical therapy, and pain management.

 

 

Physical therapy can help maintain joint mobility and strength but adds little benefit to long-term symptom relief.25

 

Pain medications can include a combination of nonsteroidal anti-inflammatory drugs, acetaminophen, or opioid medications.

 

Cortisone injection can be a useful adjunct in treatment of the inflammatory component of shoulder pain. The exact number of injections, frequency, and end point in treatment is dependent on the patient's age, degree of progression, and overall health.

 

Hyaluronate injection has shown recent promise in treating osteoarthritic knee pain.4 However, in recent studies comparing

hyaluronate to steroid, there has been no significant difference in clinical benefit noted.7

 

There have been no published comparative studies evaluating the efficacy of surgery versus placebo or other nonsurgical options.

SURGICAL MANAGEMENT

 

The gold standard surgical treatment for glenohumeral arthritis with an intact rotator cuff is TSA. TSA has been shown to be superior to HA in reliably reducing pain, improving mobility, and overall function in patients with primary arthritis.

 

 

Edwards et al10 found that TSA was superior to HA in treatment of OA with adjusted Constant score of 96% for TSA and 86% for HA.

 

The only level 1 randomized clinical trial by Gartsman et al12 demonstrated that TSA provided greater pain relief and internal rotation than HA; however, given the limited patient number, no significant difference in patient outcomes were identified.

 

Radnay et al22 performed a meta-analysis including 1952 patients and mean follow-up of 43.4 months. The superiority in clinical outcomes (pain, range of motion, and satisfaction) were confirmed. They also found that 1.7% of glenoid components required revision, whereas 8.1% of HA required revision for pain.

 

Sandow et al24 evaluated their prospective cohort of 13 HA and 20 TSA at minimum of 10 years follow-up. They found that 42% of the TSA were pain-free, whereas 0% of the HA were pain-free. In addition, there were 31% of the HA patients who required revision, compared to 10% of the TSA patients.

 

There are, however, situations where placement of a TSA is suboptimal, including rotator cuff deficiency and glenoid deficiency. Another relative contraindication is the use of HA in treatment of OA of young patients, where the expectation is that the glenoid component will inevitably loosen over their lifetime.

 

 

In treating patients 55 years old or younger, Bartelt et al3 found that severe glenoid lucency or component loosening occurred in 29.4% at 6.6 years.

 

Denard et al9 treated a cohort of young patient with cemented keeled glenoid and found a survival rate of only 62.5% at 10 years.

 

Alternative treatments available in this patient population include the use of humeral head resurfacing arthroplasty, which has the advantage of preserving humeral bone stock.

 

 

However, recent study in the Australian Registry shows increased risk of revision at 2 years.15

 

The inconsistent results associated with surface replacements may be due to the difficulty of exposure and soft tissue balance. Other authors have reported on the tendency to overstuff the joint and inability to restore joint line.18,19

 

On the glenoid side, use of glenoid resurfacing with or without biologic tissue augmentation may have a potential in offering patients long-term pain relief while preserving the option of TSA later in life.

 

In this chapter, the authors describe the surgical techniques in performing shoulder HA as well as glenoid resurfacing with or without the use of biologic tissue augmentation.

 

Preoperative Planning

 

The key consideration for planning a shoulder arthroplasty is the evaluation of the bony structures and the associated soft tissue component.

 

If there are clinical or radiographic evidence such as chronic instability or cuff failure, consideration must be given for a constrained prosthesis such as reverse shoulder arthroplasty.

 

If patient had a prior Putti-Platt procedure, one can expect a shortened subscapularis tendon. At this time, the approach for subscapularis take down should be either osteotomy or Z-lengthening.

 

If patient had a prior Magnuson-Stack procedure, one should consider starting the osteotomy more laterally to reposition

the subscapularis tendon more anatomically.

 

If there is significant glenoid bone wear, corrective strategies with high side reaming or bone grafting procedures may be

used. In cases of severe wear and humeral head subluxation, Walch et al27 suggested that patients would do better with a reverse shoulder arthroplasty.

 

If the glenoid bone loss is central, then one can also plan for autograft versus allograft use.

 

If there is concern for infection, preoperative workup including complete blood count, chemistry panel, erythrocyte sedimentation rate, and C-reactive protein markers should be obtained. Preoperative joint aspiration and intraoperative

 

P.3820

biopsies for culture can be routinely done to rule a subtle infection. If there is a concern for infection, glenoid resurfacing with biologic tissue interposition should not be performed.

 

Positioning

 

Patient is placed in the beach-chair position with arm hanging at the side.

 

The body is supported by a beanbag. The shoulder blade is supported in the back via folding over the posterosuperior corner of the beanbag or using additional towels for support.

 

 

 

 

FIG 1 • A,B. Two figures are shown to demonstrate the beach-chair positioning of the patient. The operative arm is prepped and draped, with arm secured in an arm holder. The patient is sitting up approximately 60 to 70 degrees.

 

 

The operated shoulder is widely draped to include the coracoid. Iodine-impregnated drapes are used to cover over the operative field to minimize risk of bacterial contamination (FIG 1A,B).

 

The arm is prepped and placed in an arm holder with elbow gently bent at 90 degrees and arm abducted approximately 20 degrees.

 

The bony landmarks, including clavicle, coracoid, and anterior acromion are identified and marked.

 

The incision is marked out with approximately 15 cm in length and centered over the coracoid, extending over the humeral

insertion of the pectoralis major tendon.

TECHNIQUES

Humeral Exposure

A long deltopectoral approach is performed. The cephalic vein is mobilized medially.

 

 

The biceps tendon is identified in the intertubercular groove and released from the supraglenoid tubercle for later tenodesis.

 

The top 1 cm of the pectoralis tendon is released from the humeral shaft.

 

The three borders of the subscapularis (superior, lateral, and inferior) are identified, and the subscapularis is detached in one of three ways: fleck osteotomy, tenotomy, or peeled off from the bone.

 

The subscapularis is tagged and released in continuity with the underlying capsule from the humeral neck and then mobilized on its superior, posterior, and inferior surfaces.

 

Resection of the anteroinferior capsule is not routinely performed but would be considered in case of limited external rotation.

 

The capsulectomy would help with both increased excursion of the subscapularis and improved glenohumeral range of motion.

 

The anterior circumflex vessels are identified and ligated with metallic clips.

 

At this time, the arm is externally rotated, and a periosteal elevator is placed over the medial neck to retract the soft tissue and expose the inferior humeral neck.

 

The arm is progressively externally rotated as the inferior humeral capsule is released from the inferior and posterior neck.

 

The latissimus dorsi tendon is now visible over the medial shaft and is also released for enhancing the exposure.

 

Now, the arm can be fully externally rotated and extended to expose the entire humeral head.

 

Four retractors are now placed to fully expose the head: Bennett retractor placed over the medial neck, Chandler retractor is placed intra-articularly to distract the head, a deltoid retractor is placed laterally to protract the humerus, and a small Hohmann retractor over the head to expose the posterior rotator cuff (TECH FIG 1).

 

 

 

TECH FIG 1 • Humeral exposure is shown with four retractors placed around the humeral shaft. Small Hohmann retractor superiorly, deltoid retractor laterally, Chandler retractor medially (intra-articular), and Bennett retractor medially (shaft).

 

 

P.3821

Humeral Hemiarthroplasty

 

The “ring” of osteophytes is now removed from the humeral head with rongeurs for ease of identifying the true humeral neck.

 

Then, the humeral osteotomy is performed along the true anatomic neck (TECH FIG 2A).

(In general, the senior author's preference is to turn attention to the glenoid side at this point, but for ease of this discussion, the remainder of the humeral preparation is discussed.)

 

A starter awl is placed 9 mm posterior to the bicipital groove, which aligns with the center of the humeral head (TECH FIG 2B).

 

 

Distal shaft is hand reamed sequentially until there is light cortical resistance. Humeral inclination is measured. Sequential broaching is performed until there is good metaphyseal fit to the prosthesis (TECH FIG 2C).

 

Trial prosthesis is seated. Humeral head trial is fitted and rotated to obtain maximal coverage of the cut surface (TECH FIG 2D).

 

 

 

TECH FIG 2 • A. Humeral osteotomy is made anatomically, paralleling the anatomic neck. B. Starting awl is positioned 9 mm posterior to the bicipital groove, which is anatomically aligned with the center of the shaft. C. Broaching is sequentially performed until good metaphyseal fit is met. On the neck of the broach, one can measure the inclination of the humeral cut. D. Trial prosthesis is placed with humeral head trial positioned to obtain maximal coverage of the cut surface. The joint can then be reduced to test soft tissue tension. E. Intraoperative fluoroscopy is obtained to evaluate the position of the humeral prosthesis as well as the size of the humeral head. F. If increased posterior translation is noted, nonabsorbable sutures can be placed in the posterior joint capsule to decrease the posterior capsular space. (continued)

 

An intraoperative fluoroscopic scan can be obtained to confirm the height and position of the humeral implant (TECH FIG 2E).

 

With the humeral component reduced, the stability of the implant can also be examined to have 50% anteroposterior translation and 1/2 to 2/3 inferior translation. If there is increased posterior translation identified, humeral version and head version can be adjusted if necessary.

 

Posterior capsulorrhaphy sutures can also be passed to restrict further posterior translation (TECH FIG 2F).

 

At this time, heavy nonabsorbable sutures are placed in the humeral neck for subscapularis repair later (TECH FIG 2G).

 

Humeral implant is then impacted in place, with the choice of cementation determined by the operating surgeon. The senior author's preference is to pressurize antibiotic cement distally in the humeral shaft and to place bone graft around the proximal body of the prosthesis to allow proximal osteointegration (TECH FIG 2H).

 

 

TECH FIG 2 • (continued) G. Subscapularis repair is performed according to the way it was taken down. In this case, tenotomy was performed, so two nonabsorbable transosseous sutures are placed medially in preparation of later repair. Multiple additional figure-of-eight sutures will be placed in the tendon and tendon stump to reattach the subscapularis.

H. A hybrid cementation technique is used during the insertion of the humeral prosthesis. The proximal portion of the stem is covered with bone autograft from humeral head, allowing bony integration to occur. The distal portion will be fixed with antibiotic cement.

 

 

 

Glenoid Resurfacing

P.3822

 

 

Once the humeral neck cut is made, the authors' preference is to prepare the glenoid side before the humeral side. Four retractors are placed to fully expose the glenoid:

 

Fukuda retractor is placed along the posteroinferior glenoid margin to retract the humeral head. This can be replaced by a Darragh retractor if it is too bulky.

 

Classical Rowe or Bankart retractor is used along the anterior glenoid neck to retract the subscapularis and anterior capsule.

 

Two small Hohmann or Darragh retractors can be also placed over the coracoid and posterosuperior glenoid, respectively, to fully expose the glenoid (TECH FIG 3A).

 

Once the glenoid is exposed, the Tornier Aequalis reamers (Tornier Inc., Minneapolis, MN) are used to concentrically ream the glenoid (TECH FIG 3B).

 

This reamer size and curvature correspond to the curvature of the back of a glenoid implant.

 

 

 

TECH FIG 3 • A. glenoid exposure is shown. Four retractors are placed: Bankart retractor anteroinferior, Hohmann retractor anterosuperior, small Darragh retractor (or Hohmann) posterosuperior, and medium Darragh retractor posteroinferior. B. Concentric glenoid reaming is performed to provide a smooth articulation for humeral prosthesis. Reaming should be performed only down to subchondral bone.

 

Glenoid version can be partially corrected with motorized reamers by selectively removing the high side.

 

Because most of the male patients are large and robust in stature, double extra large and triple extra large reamers are often employed to ream down to subchondral bone.

 

Most arthroplasty systems use a cannulated system to access glenoid and perform reaming; however, given the soft tissue exposure, one may not have a straight perpendicular path to the glenoid, which limits the efficacy of this system.

 

If that is the case, drill a central pilot hole and insert a reamer with blunt tip into the pilot hole for concentric reaming.

 

2.4-mm drill holes are then placed along the glenoid surface. Each hole is 2 mm apart and about 5 mm deep.

 

This technique is consistently used by the senior author, with the goal of decompressing intraosseous hypertension1,2 and potentially denervate the subchondral bone.26

 

P.3823

Biologic Tissue Interposition

 

After glenoid preparation with a reamer, careful evaluation of the glenoid labrum is performed.

 

If there are healthy adequate labrum, then no. 2 nonabsorbable sutures can be passed circumferentially around the labrum to help fixate the graft.

 

If the labrum is focally deficient or of poor quality to retain sutures, double-loaded absorbable suture anchors (Panalok Lupine Double-Strand Anchor with Orthocord, DePuy Mitek Inc., Raynham, MA) are placed at the area of deficiency to aid in fixation of the graft (TECH FIG 4A).

 

With regard to the choice of glenoid graft, there are a number of reports supporting the use of various tissue options, including fascia lata autograft, Achilles tendon allograft as well as meniscal allograft.

 

 

 

TECH FIG 4 • A. Multiple drill holes are placed on the surface of the glenoid. Additional nonabsorbable sutures are placed in the labrum circumferentially. Suture anchors are used if there are no labrum available for suture placement.

B. Dermal allograft is doubled over the long side and sutured along the edge. Glenoid sutures are now passed through the graft. C. Dermal allograft is now inset onto the surface of the glenoid.

 

Currently, the senior author prefers using acellular dermal allograft, which has shown promising results with chondrocyte infiltration of the biologic scaffold.8

The acellular dermal allograft is thawed in room temperature and soaked in either commercially available plasma preparations or humeral bone marrow aspirate.

A 5- × 7-cm allograft is folded over its long axis to fit the glenoid shape and the free edge of the graft sewn together with a running heavy nonabsorbable suture (TECH FIG 4B).

The graft is now inset by passing all sutures from the labrum or suture anchors through the graft in horizontal mattress fashion.

The sutures are passed from posterosuperior to anteroinferior and tied sequentially (TECH FIG 4C).

P.3824

Soft Tissue Closure

The subscapularis repair is then individualized, dependent on the technique of detachment.

Subscapularis peel was repaired back via transosseous technique using 1-mm cottony Dacron (Dektanel). These heavy nonabsorbable sutures repaired the tendon usually at least 1 to 2 cm medial to its anatomic location to gain external rotation.

Osteotomies were repaired with a dual row repair, whereas tenotomies were repaired with figure-of-eight no. 2 Ethibond sutures as well as two medial cottony Dacron sutures via transosseous fashion.

The rotator interval is closed with the arm in 30 degrees of external rotation.

Biceps soft tissue tenodesis is performed with a locking suture in the rotator interval region and into the pectoralis major.

 

Routine wound closure was then completed with closure of the deltopectoral interval.

 

PEARLS AND PITFALLS
	Poor ▪ Remove all retractors and reevaluate the deltopectoral approach. humeral ▪ Assess the biceps tendon. If the biceps is not detached, it can limit humeral external rotation. exposure ▪ Then, evaluate pectoralis and latissimus dorsi tendons to confirm it is adequately released. Completely release the inferior humeral attachment of the glenohumeral capsule.     Poor glenoid ▪ Reexpose the humeral head. Can remove as much of the humeral head as the rotator cuff exposure insertion point would allow. Sometimes, a biplanar cut to the back of the humeral head may be necessary. Release the glenohumeral ligament circumferentially, if necessary. Release the triceps insertion at the inferior edge of the glenoid. Reposition all the retractors. In revision cases where there is extensive scar tissue, the short head of the biceps can be released off of the coracoid via tenotomy or osteotomy for improved anterior exposure.     Excessive ▪ Intraoperatively, if increased posterior subluxation is noted, it can place capsulorrhaphy posterior sutures in the posterior glenohumeral capsule. subluxation ▪ If the glenoid is retroverted, more of the anterior glenoid can be reamed to correct version up to 15 degrees. If retroversion is excessive of 15 degrees, humeral head can be used as bone block over the posterior glenoid to correct version.     Humeral ▪ Preoperative planning to assess out the length of humeral bone loss bone loss ▪ Determine whether allograft, allograft prosthesis composite, or alternative implant is necessary.

 

	Glenoid ▪ Compaction grafting of contained glenoid defect can be done with humeral head autograft. bone loss ▪ If glenoid defect is uncontained, structural graft from distal clavicle, humerus, or iliac crest may be necessary.

 

POSTOPERATIVE CARE

 

 

Postoperatively, all patients are treated as standard TSA patients, with a Velpeau arm sling for 3 weeks. If only an HA was performed, patients were kept in a sling for 3 weeks with no motion.

 

 

After 3 weeks, pendulum exercises were initiated as well as passive range of motion in external rotation and elevation. At 6 weeks, the sling was removed and active-assisted range of motion was then started in all directions.

 

If glenoid resurfacing was performed, then immediate passive range-of-motion exercises were started for external rotation and elevation to avoid postoperative stiffness. The external rotation motion is limited to neutral.

 

 

At 3 weeks, the sling was removed and active-assisted range of motion was started. At 6 weeks, resistance exercises started.

 

Full activity (including sports and/or manual labor) is allowed between 3 and 6 months after surgery depending on functional recovery.

 

OUTCOMES

 

Because of the concern of early failure with TSA, various attempts at biologic resurfacing of the glenoid have been attempted (Table 1).

 

 

Burkhead and Hutton5 treated 14 patients with shoulder HA and biologic resurfacing using either anterior humeral capsule or fascia lata autograft. With Neer rating scale, the authors found pain relief to be excellent in 5 patients and good in 1 patient.

 

Krishnan et al16 reported a follow-up study including Burkhead's cohort. This study included using anterior capsule, autogenous fascia lata, and Achilles allograft as interpositional graft. They found improved American Shoulder and Elbow Surgeons (ASES) scores from 39 to 91 and only 14% unsatisfactory results. This cohort had a revision rate of 8.3% (3/36) to TSA. The authors concluded that anterior capsule was not a durable bearing and was associated with higher rate of poor results.

 

Table 1 A Comprehensive List of Clinical Literature on Hemiarthroplasty with Biologic Glenoid Resurfacing

Burkhead

and Hutton5

Hemi

Ream + N/A

drill

Capsule/fascia

lata

Neer rating: 5

(excellent) 1 (satisfied)

0%

Krishnan et

al16

Hemi

Ream + N/A

drill

Capsule/fascia

lata/Achilles allograft

ASES 91 Neer

unsatisfactory 14%

8.33%

 

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Humeral Side

Glenoid Side

Preoperative Glenoid Wear

Graft

Postoperative Clinical Outcome

Revision Rate

 

Elhassan et al11	Hemi + resurfacing	Ream (occ drill)	Substantial eccentric wear, 77%	Achilles allograft (few fascia lata + capsule)	Constant 43% SANE 33%	85%
Lee et al18	Resurfacing	Ream	N/A	Capsule	ASES 74 Constant 84%	9%
Nicholson et	Hemi +	Ream	Moderate to	Lateral	ASES 69 SST	13%
al20	resurfacing		severe wear, 30%;	meniscus	7.8
			moderate to
			severe
			subluxation,
			20%
Wirth28 Hemi		Ream	Moderate to	Lateral	ASES 67 SST	14%
		(occ	severe wear,	meniscus	7.3
		drill)	27%;
			moderate to
			severe
			subluxation,
			44%
Lee et al17 Hemi		Ream +	Eccentric,	Lateral	DASH 28 SST	21%
		drill	58%	meniscus	8
Saltzman et	Hemi	Ream	Moderate to	None	SST 9.5	14%
al23			severe wear, 77%;
			subluxation,
			27%
Burkhead,	Hemi	Ream +	Moderate to	Acellular	ASES 82	9%
unpublished,		drill	severe wear,	dermal	WOOS 82
2013			7%	allograft

 

 

ASES, American Shoulder and Elbow Surgeons; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoulder Test; DASH, Disabilities of the Arm, Shoulder, and Hand; WOOS, Western Ontario Osteoarthritis of the Shoulder.

The average revision rate is about 19%. There is great variability in type of humeral prosthesis used, glenoid preparation, and type of biologic tissue used. There is also wide variation of concentric versus eccentric glenoid treated. These factors may potentially contribute to overall differences in outcome.

 

 

Clinton et al6 used the ream-and-run technique and found that it offered similar functional results as TSA by 18 months after surgery.

 

Gilmer et al13 also published on the midterm outcome of a similar cohort and found a 4% revision rate to TSA. Patient cohort with the best prognosis included male patients, age older than 60 years old, primary OA etiology, no prior surgery, and higher preoperative simple shoulder test score greater than 5 points.

 

Meniscal allograft was also used as a potential graft by several authors.

 

Wirth28 found improved ASES scores (30 to 67) in 27 patients. There were no revisions at 35 months follow-up.

 

Nicholson et al20 also used meniscal allograft in 30 patients and found average ASES score of 69 postoperatively. They had a revision rate of 6.7% at 18 months follow-up and correlated failure to early mobilization after surgery.

 

 

On the contrary, Elhassan et al11 reported on 13 patients undergoing biologic resurfacing with Achilles allograft, fascia lata, and anterior capsule. They found overall poor results with 76.9% (10/13) revision rate to TSA.

 

However, this cohort included a mixture of patients with concentric and eccentric glenoid wear as well as HA and humeral head resurfacing. As shown in recent studies, eccentric glenoid wear14 and the use of stemless surface replacements19 can be associated with inferior postoperative outcomes.

 

In a study by Lee et al,18 the combination of biologic resurfacing and humeral head resurfacing was used.16 They found their glenoid erosion rate to be as high as 56%, which they attributed to overstuffing the joint or progressive cuff failure, which can also be caused secondarily by the prior.

 

Clinically, this can be associated with an elevated risk of early revision with surface replacements, as shown in the Australian Shoulder Registry.15

COMPLICATIONS

 

The highest risk of complications is persistent pain from OA, requiring revision to TSA. This has been shown to occur at 8% to 85%.3,6,11,16,18,20,28

 

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Glenoid erosion is another major complication that can arise from not placing a glenoid component. This can occur at a rate as high as 56%. The frequency may unacceptably high due to overstuffing the joint, use of resurfacing arthroplasty, and being osteoporotic.

 

Postoperative stiffness can occur after this procedure. In Matsen's study, biologic glenoid resurfacing can take up to 18 months, before achieving maximal functional recovery.6

 

Postoperative impingement symptoms or cuff failure can occur. The true incidence of this etiology is unclear, but in our personal series, as many as 19% of the patients can have clinical impingement symptoms that can be treated with cortisone injection and/or arthroscopic treatment.

 

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2. Arnoldi CC, Linderholm H, Müssbichler H. Venous engorgement and intraosseous hypertension in osteoarthritis of the hip. J Bone Joint Surg Br 1972;54(3):409-421.

    

    

3. Bartelt R, Sperling JW, Schleck CD, et al. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg 2011;20(1):123-130.

    

    

4. Blaine T, Moskowitz R, Udell J, et al. Treatment of persistent shoulder pain with sodium hyaluronate: a randomized, controlled trial. A multicenter study. J Bone Joint Surg Am 2008;90(5):970-979.

    

    

5. Burkhead WZ Jr, Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg 1995;4(4):263-270.

    

    

6. Clinton J, Franta AK, Lenters TR, et al. Nonprosthetic glenoid arthroplasty with humeral hemiarthroplasty and total shoulder arthroplasty yield similar self-assessed outcomes in the management of comparable patients with glenohumeral

   arthritis. J Shoulder Elbow Surg 2007;16(5):534-538.

    

    

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