Management of Glenohumeral Arthritis.

Last updated Wednesday, January 09, 2008

Results

Hemiarthroplasty results

Total shoulder arthroplasty results

The most commonly used total shoulder arthroplasty has been the Neer design. Most patient series contain a mixed diagnostic grouping, including patients with rheumatoid arthritis, osteoarthritis, old trauma, and a variety of less common diagnostic categories. As can be seen from the table, the percentage of patients achieving satisfactory pain relief is quite high, and, quite typically, slightly greater than 90% of patients report no or only slight pain following surgery. Motion data following surgery have not been as consistently reported as one might desire, but the amount of motion regained seems variable and dependent on diagnostic category. For example, in the series reported by Cofield, the mean active abduction following surgery for the entire group of patients reported was 120 degrees. (Cofield, 1984) The average return of active abduction varied greatly according to diagnosis: 141 degrees for osteoarthritis, 109 degrees for those with post-traumatic arthritis, and 103 degrees for patients with rheumatoid arthritis. The return of movement in Cofield's series was not only dependent on diagnosis but was also highly dependent on the condition of the rotator cuff and shoulder capsule and on the avoidance of complications. (Cofield, 1984)

The largest series of total shoulder arthroplasties of this category has been reported by Neer. (Neer, Watson and Stanton, 1982) He has suggested two systems for grading results. Patients who received a full rehabilitation program were graded as excellent, satisfactory, or unsatisfactory. To achieve an excellent result, the patient was enthusiastic about the operation, had no significant pain, could use the arm without limitations, strength approached normal, active elevation of the arm was within 35 degrees of the opposite normal side and external rotation was 90 per cent of the normal side. In patients with a satisfactory result, there was no more than occasional pain or aching with weather changes, good use of the shoulder for daily activities, elevation of at least 90 degrees, and rotation to 50% of the normal side. Muscle strength was at least 30% of the normal side, and the patients expressed satisfaction with the operation. In an unsatisfactory result, the above criteria were not achieved. Neer has suggested a separate evaluation category for patients who have total shoulder replacement but whose muscles could be classified as detached and not capable of recovering function after repair because of fixed contracture or denervation. Patients with substantial bone loss, particularly bone loss in the proximal humerus, might also be included within this evaluative category. In this setting, rehabilitation is aimed at achieving limited goals, the purpose being to gain a lesser range of motion but maintain stability. Neer has suggested that this limited-goals rehabilitation is successful when patients with these muscle or bone deficiencies achieve 90 degrees of elevation and 20 degrees of external rotation, maintain reasonable stability, and achieve satisfactory pain relief. Other series of results with this type of prosthesis have been reported. (Weiss, Adams, Moore, et al., 1990)

All series report lucent lines or lucent zones at the glenoid-bone cement junction. These vary considerably in frequency among the different series, ranging from 30% to 93% of shoulders reported. The keel portion of this implant serves as the significant means of attachment to the scapula, and the lucent zones seen at the cement-bone junction surrounding the keel are of great concern. The median percentage of the number of shoulders analyzed in which a lucent line was identified at the bone-cement junction of the keel part of the component is 36. The argument has been presented that when these lucent lines or zones are seen in patients they are almost always present immediately postoperatively and clearly represent an error in surgical technique. (Neer, Watson and Stanton, 1982) This may be the most common sequence of events associated with roentgenographic lucent zones at the glenoid bone-cement junction and speaks for the need for meticulous preparation of the bony bed and cementing at the time of surgery. However, it has also been reported that these lucent zones have not been present immediately after surgery but rather have developed over time. (Cofield, 1984) Green and Norris(Green and Norris, 1994b) and Slawson et al (Slawson, Everson and Craig, 1995) have recently provided a review of imaging techniques for evaluating glenohumeral arthroplasty.

Franklin and co-authors have suggested a classification system for describing the radiographic appearance of the glenoid component. (Franklin, Barrett, Jackins, et al., 1988) In Class 0, there is no lucency. In Class 1, there is lucency at the superior or inferior flange only. In Class 2, there is incomplete lucency at the keel. In Class 3, there is complete lucency up to 2 mm around the component. In Class 4, there is complete lucency greater than 2 mm around the component. In Class 5A, the component has translated, tipped, or shifted in position. And in Class 5B, the component has become dislocated from the bone.

In the series by Barrett (Barrett, Franklin, Jackins, et al., 1987) and Cofield, (Cofield, 1984) analyses have also included a shift in glenoid component position relative to the position achieved immediately following surgery. Analysis of component movement relative to the bone requires the viewing of sequential x-rays over time because often a lucent zone is not seen. This finding implies component loosening, but it can easily be overlooked if serial x-rays are not studied.

How useful was this page or article? This article is rated out of 5 stars (68 ratings). Not useful at all Not very useful Useful Very useful Extremely useful