Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. The results of shoulder arthroplasty in patients with rheumatoid arthritis. Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis. Shoulder arthroplasty in the young patient. Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions.
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.
                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.
                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.
                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.
                Therapeutic Level I. Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed in 247 patients in patients with rheumatoid arthritis. One hundred and eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean, 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients had died and 1 was lost to follow-up. All 303 shoulders were included in the survival analysis. There was significant long term pain relief (P < .0001), improvement in active abduction (P < .0001), and external rotation (P < .0001) with both hemiarthroplasty and total shoulder arthroplasty (TSA). There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and TSA for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with TSA. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for TSA (P = .04). Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2-year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%). The data from this study indicate that there is marked long-term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, TSA appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery. The indications for resurfacing of the glenoid in patients who have osteoarthritis of the shoulder are not clearly defined; some investigators routinely perform hemiarthroplasty whereas others perform total shoulder arthroplasty.
                Forty-seven patients (fifty-one shoulders) who were scheduled to have a shoulder arthroplasty for the treatment of degenerative osteoarthritis were randomly assigned, according to a random-numbers table, to one of two groups: replacement of the humeral head with resurfacing of the glenoid with a polyethylene component with cement (total shoulder arthroplasty [twenty-seven shoulders]) or replacement of the humeral head without resurfacing of the glenoid (hemiarthroplasty [twenty-four shoulders]). All patients received the same type of humeral component, and all operations were performed by or under the direct supervision of the same surgeon. The patients were followed for a mean of thirty-five months (range, twenty-four to seventy-two months) postoperatively. Evaluation was performed with use of the scoring systems of the University of California at Los Angeles and the American Shoulder and Elbow Surgeons.
                No difference was observed between the preoperative scores for the two groups of patients. Postoperatively, the mean scores with use of the University of California at Los Angeles system and the American Shoulder and Elbow Surgeons system were 23.2 points (range, 10 to 31 points) and 65.2 points (range, 15 to 94 points), respectively, after hemiarthroplasty and 27.4 points (range, 9 to 34 points) and 77.3 points (range, 3 to 100 points), respectively, after total shoulder arthroplasty. With the numbers available for study, no significant difference was found between the two operative groups with respect to the postoperative score. (Thirty-five subjects per group would be needed, assuming an effect size of 0.60 and a power of 0.80.) Total shoulder arthroplasty provided significantly greater pain relief (p = 0.002) and internal rotation (p = 0.003) than hemiarthroplasty did. Total shoulder arthroplasty also provided superior results in the specific areas of patient satisfaction, function, and strength, although none of these differences were found to be significant, with the numbers available. Total shoulder arthroplasty was associated with increased cost ($1177), operative time (thirty-five minutes), and blood loss (150 milliliters) per patient compared with hemiarthroplasty. To date, none of the total shoulder arthroplasties in the study group have been revised. Hemiarthroplasty yielded equivalent results for elevation and external rotation. Three of the twenty-five patients who had had a hemiarthroplasty needed a subsequent operation for resurfacing of the glenoid. The mean cost for the revision operations was $15,998.
                Total shoulder arthroplasty provided superior pain relief compared with hemiarthroplasty in patients who had glenohumeral osteoarthritis, but it was associated with an increased cost of $1177 per patient. We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups. In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ. Shoulder arthroplasty with a stemmed prosthesis is a recognized treatment for rheumatoid arthritis of the shoulder. The humeral component of the Copeland cementless surface replacement arthroplasty consists of a cup for surface replacement with a short central peg for primary fixation to the bone. We hypothesized that surface replacement may offer some advantages over stemmed prostheses.
                Between 1986 and 1998, seventy-five shoulders underwent surface replacement arthroplasty (thirty-three hemiarthroplasties and forty-two total shoulder arthroplasties) for the treatment of rheumatoid arthritis. The results of these procedures were reviewed after an average duration of follow-up of 6.5 years. Patients were assessed with use of the Constant score, a patient satisfaction score, and radiographs.
                The average Constant score was 47.9 points (age and sex-adjusted score, 71%) in the hemiarthroplasty group and 53.4 points (age and sex-adjusted score, 76%) in the total shoulder replacement group. The mean range of active flexion improved from 50 degrees in the hemiarthroplasty group and 47 degrees in the total shoulder replacement group to 101 degrees and 104 degrees, respectively. Seventy-two of the seventy-five shoulders were considered by the patients to be much better or better at the time of the review. Of the sixty-eight humeral implants that were evaluated radiographically, fifty-six (82%) showed no lucencies, eleven (16%) showed localized lucencies of <1 mm in width, and one was definitely loose. Of the thirty-nine glenoid implants that were evaluated radiographically, nineteen (49%) showed no lucencies, nineteen showed localized lucencies of <1 mm, and one was definitely loose. No lucencies were observed adjacent to the hydroxyapatite-coated implants. Thirty-nine (57%) of the sixty-eight shoulders showed some degree of superior subluxation. Three patients required a major reoperation: two required a revision because of loosening of both components, and one patient with pain at the site of a hemiarthroplasty had a revision to a total shoulder arthroplasty to provide relief.
                The indications for this surface replacement are the same as those for the conventional stemmed prostheses, but the surface replacement has the advantage of bone preservation as well as avoidance of the potential complications associated with a long humeral stem in rheumatoid bone. This procedure is not suitable for severely damaged joints in which the humeral head is insufficient or too soft. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence. We reviewed the performance of 22 shoulder implant arthroplasties in 19 patients age 50 or younger at surgery. Patients were evaluated by telephone interview, written questionnaire, and radiographic examination. The average age at surgery was 38.6 years, and the average follow-up was 5.6 years. Patients were grouped by disease process (rheumatoid arthritis [RA], avascular necrosis [AVN], trauma, and hemophilic arthropathy [HA]) and type of prosthesis (total vs. hemiarthroplasty). The highest scores (best shoulder function) were seen in patients with hemiarthroplasty for HA. Patients with hemiarthroplasty for trauma and AVN scored similarly, whereas those with a hemiarthroplasty for RA scored lowest. Patients with RA who had a total shoulder arthroplasty scored higher than patients with hemiarthroplasty. When patients in our population with longer follow-up were compared with those with a shorter follow-up, no downward trends in shoulder function were seen. Accelerated deterioration of function of shoulder arthroplasties was not observed in our young patient population. This study was undertaken to determine whether patients with severe rheumatoid arthritis and irreparable rotator cuff rupture can be treated successfully with the Grammont shoulder arthroplasty. Seven patients with rheumatoid arthritis (8 shoulders) with nonreconstructible rotator cuff lesions and Larsen stage-V radiographic changes of the glenoid and the humeral head underwent a Grammont reverse shoulder arthroplasty. The Constant score improved from a mean of 17 points (range 4 to 25) preoperatively to a mean of 63 points (range 41 to 79) at a mean of 54 months (range 48 to 73) after shoulder arthroplasty. The mean strength at 90 degrees of abduction measured 3.6 kg (range 1 to 6). Shoulder instability was not observed. Complications included septic implant loosening (1 shoulder), aseptic glenoid loosening (2), and failed acromion osteosynthesis following the transacromial approach (3). These data of Grammont arthroplasty are encouraging with respect to restoration of stability and satisfactory function in rheumatoid, cuff-deficient shoulders. However, glenoid loosening remained a serious problem, and transacromial approaches were complicated by failure of acromial fixation.
Total shoulder arthroplasty seems to offer an advantage in terms of shoulder function, with no other clinical benefits over hemiarthroplasty. More studies are needed to compare clinical outcomes of surgery using different components and techniques in patients with osteoarthritis of the shoulder. There is a need for studies comparing shoulder surgery to sham, placebo and other non-surgical treatment options.