Total shoulder arthroplasty with the Neer prosthesis

Transcription

1 This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. Total shoulder arthroplasty with the Neer prosthesis RH Cofield J Bone Joint Surg Am. 1984;66: This information is current as of November 30, 2010 Reprints and Permissions Publisher Information Click here to order reprints or request permission to use material from this article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA

2 Copyright 984 by The Journal of Bone and Joint Surgery, Incorporated Total Shoulder Arthroplasty with the Neer Prosthesis BY ROBERT H. COFIELD, M.D.*, ROCHESTER, MINNESOTA From the Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester ABSTRACT: Ofseventy-seven total shoulder-replacement arthroplasties with a Neer prosthesis, I evaluated seventy-three replacements in sixty-five patients at two to six and one-half years after the operation. The operations were performed for the treatment of osteo, rheumatoid, and old fractures or fracture-dislocations with traumatic. Postoperatively there was little or no pain even with vigorous activities in most shoulders, and active abduction improved by an average of 44 degrees, to an average of 120 degrees. The amount of abduction that was regained was related to the original diagnosis and to the amount of rotator cuff disease. Complications developed in thirteen shoulders, and five reoperations were necessary. Eight glenoid components showed radiographic evidence of loosening. Fifty-two of the remaining sixty-five shoulders had some radiolucency at the glenoid bone-cement junction. When conservative treatment for glenohumeral fails, four surgical options can be considered: resection arthroplasty, arthrodesis, prosthetic replacement of the proximal part of the humerus, and total joint-replacement arthroplasty. Before the prostheses were developed, arthrodesis was the preferred operation at the Mayo Clinic5; relief of pain was usual, and the strength of the shoulder was regained. However, postoperative care was prolonged and intensive, and functional limitations had to be accepted. Resection arthroplasty was done much less frequently, because relief of pain was less certain and the shoulder often became stiff and remained weak. When prosthetic replacement of the head of the humerus was developed, it was used nearly exclusively in patients who had complex post-traumatic lesions, and rarely for the treatment of patients with. In 1972, Bickel designed a total shoulder prosthesis of the ball-and-socket type2, and at the Mayo Clinic twelve of these prostheses were implanted as treatment for patients with osteo and post-traumatic between 1972 and In 1972 the Stanmore total shoulder replacement, also a ball-and-socket design, was developed for patients with rheumatoid 8, and during 1974 and 1975 nine of these prostheses were used at the Mayo Clinic for patients * Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota with rheumatoid, osteo, or post-traumatic. In 1975, the records of these twenty-one patients were reviewed4, and two facts emerged. One was that complications from these operations were frequent: eleven reoperations had been necessary. The other fact was that the rotator cuff was variably involved, and its defects did not necessarily parallel the degree of intra-articular disease. Only six of the twenty-one shoulders had a rotator cuff tear. These facts led to the use of a less-constrained implant in the hope that there would be fewer complications, and the Neer prosthesis was chosen for most shoulders treated after Since then, 205 total shoulder arthroplasties with the Neer prosthesis have been done at the Mayo Clinic. The primary lesion was rheumatoid in seventy-seven shoulders, osteo in sixty-seven, traumatic in twenty-one, a cuff tear with secondary in sixteen, failed shoulder reconstruction in thirteen, avascular necrosis in four, ankylosing spondylitis in three, old sepsis in two, and radiation necrosis in two. In this report, I present a review of all patients in the three major diagnostic categories who were operated on between December 1975 and December The findings are compared with the results recently reported by Neer et. Materials and Methods There were sixty-five patients in the study: twenty-nine with osteo, twenty-four with rheumatoid, and twelve with traumatic secondary to an old fracture or fracture-dislocation (Table 1). 1 performed all of the operations, and the patients were followed as previously 1 The sixty-five patients had had seventy-three shoulder replacements and were followed for at least two years after arthroplasty. I excluded four other patients with four shoulder arthroplasties from the study because of inadequate follow-up. One patient died fourteen months after the operation, from causes unrelated to the shoulder surgery. Two elderly women in nursing homes reported that they were doing well but could not return for examination or radiography. The last exclusion was of a man who had had causalgia in addition to traumatic of the shoulder preoperatively. He still had causalgic symptoms postoperatively and refused to return for further evaluation or treatment. The follow-up of all sixty-five patients was carried out by me. To be included in this report, a patient had to have VOL. 66-A, NO. (. JULY

3 900 R. H. COFIELD TABLE I CHARA CTERISTICS 0 F THE PATIENTS Preo perativ e Evaluation Active External Sex No. with Abduction Rotation Range No. of No. of Age (Yrs.) (No.) Previous Pain (No.) (Degrees) (Degrees) Internal Patients Shoulders Av. Range F M Surgery Severe Moderate Av. Range Av. Range Rotation* of Osteo to to 50 LI to T7 Rheumatoid to to 80 LI to T6 Traumatic to to 70 GT to T6 Entire group to to 80 GT to T6 * LI = lateral part of the ilium and GT = greater trochanter. been examined at least one year after operation, to have been interviewed or have completed a questionnaire, and to have had radiographs made at least two years after the procedure. The most recent physical examination was done at an average of 3.3 years postoperatively (range, one to 6. 1 years): between one and two years postoperatively in thirteen shoulders, between two and three years in twenty-two, between three and four years in thirteen, between four and five years in fourteen, between five and six years in seven, and between six and seven years in four. The most recent follow-up by interview or questionnaire and radiographs was done at an average of 3.8 years postoperatively (range, two to 6.5 years): at two to three years in twenty-five shoulders, at three to four years in eleven, at four to five years in seventeen, at five to six years in fourteen, and at six to seven years in six. Of the entire study group, eight patients - five with rheumatoid, two with osteo, and one with traumatic - had a bilateral procedure. Forty-one prostheses were used in the right shoulder and thirty-two, in the left, and in thirty-eight shoulders the operation was done on the dominant extremity. Moderate or severe pain was the primary reason for operation in all patients. The average preoperative active and passive abduction, measured in the plane of the body of the scapula (approximately 45 degrees of horizontal flexion)6 2, was 76 degrees and 1 14 degrees, respectively. Preoperative passive external rotation with the arm at the side averaged 22 degrees. Active preoperative internal rotation was measured as the most cranial and posterior structure that could be reached by the index finger, and the median was to the level of the sacrum. At surgery, the pathological findings in the patients with osteo were rather constant #{176}. The humeral head and glenoid were flattened and sclerotic. There was formation of peripheral osteophytes on the humeral head, especially inferiorly. The anterior part of the capsule was contracted and scarred. There was a tendency to posterior humeral subluxation, and when this was present the glenoid was asymmetrically eroded, with more bone loss posteriorly. The rotator cuff and biceps tendon were usually intact (Table 11). In the patients with rheumatoid, the pathological findings at surgery varied considerably. Rheumatoid bursal or synovial proliferation was often present, as were varying degrees of osteopenia and central or central and superior glenoid erosion. The rotator cuff was normal in only five shoulders and the opposite shoulder was normal in only fourpatients. In seven patients, the opposite shoulder had an important degree of limitation of function. Additional ipsilateral impairments of the upper extremity also were common. Elbow function in five extremities was severely limited by disease, and function of the hand and wrist was limited in seven patients. Rheumatoid involvement of the lower extremities required full-time use of crutches by two patients and intermittent use by eight others. For the first eight weeks postoperatively the use of crutches was prohibited in order to protect the healing tendons and muscles. In the twelve patients with traumatic, there were only five involved shoulders with humeral tuberosities in normal or nearly normal position. In the remaining eight involved shoulders, the fractures of the greater tuberosity or tuberosities had malunited, so that osteotomy was necessary at surgery to reposition the tuberosity, with the tendon attached, behind the retroverted prosthetic humeral component. Surgical Technique and Postoperative Care The surgical techniques of this operation and the postoperative management have recently been described in detail3, but it is important to recognize that, additionally, different problems have to be individually addressed: the contractures and erosion of the posterior part of the glenoid in shoulders with osteo; the variability in rheumatoid shoulders, with soft-tissue destruction, osteopenia, or erosion of the glenoid medially; and the bone deformities or bone loss in traumatic lesions. The Neer prosthesis is designed to replace only lost cartilage and some subchondral humeral bone. Associated disease of the capsule, rotator cuff, tuberosity, biceps tendon, glenoid, acromion, or acromioclavicular joint must be identified and treated as a part of the surgical procedure. In the seventy-three shoulders, the operative time averaged two hours and fifty-one minutes (range, 105 to 315 minutes) and blood replacement averaged 2.3 units (range, THE JOURNAL OF BONE AND JOINT SURGERY

4 TOTAL SHOULDER ARTHROPLASTY WITH THE NEER PROSTHESIS 901 TABLE II LESIONS FOUND AT SURGERY Rotator Cuff No. of Minor Major Tuberosity Malunion Requiring Biceps Tendon Previously Ruptured or Shoulders Normal Thin Tear* Teart Osteotomy Normal Frayed Tenodesed Osteo Rheumatoid Traumatic I Entire group * Full-thickness fissuring in the supraspinatus tendon. t Full-thickness rotator-cuff tear running the width of the supraspinatus or larger. one to seven units). The anteromedial approach with release of the clavicular and anterior acromial origins of the deltoid was used in fifty-nine shoulders; a posterior approach was used in three; and, in the eleven shoulders treated recently, a long deltopectoral approach without release of the deltoid origin was used. The latter is now our preferred approach unless repair of a major rotator-cuff tear or osteotomy of a tuberosity is necessary. Acromioplasty for anterior acromial spurring was done in thirty-eight shoulders. The distal end of the clavicle was excised in twenty-three shoulders. When the rotator cuff was intact, no special treatment other than release of scar tissue of the anterior part of the capsule from the subscapularis was done. In the four shoulders with a split supraspinatus, the tendon was sutured. In six of the nine shoulders with a major rotator-cuff tear, the tendon was sutured and fixed to the cancellous bone of the proximal part of the humerus. In addition, three shoulders needed grafts of fascia lata. The long head of the biceps was sutured to the proximal portion of the humerus in only three, and in fifty-six it was left undisturbed at operation. The length ofthe prosthetic humeral head that we chose was the one that optimally restored normal tension to the rotator cuff. The size of the prosthetic humeral head used was small in forty-four shoulders and large in twenty-eight. A custom-made small humeral head was used in one shoulder in a patient with juvenile rheumatoid. The humeral prosthesis was placed in retroversion of 30 degrees if possible, and retroversion of between 20 and 40 degrees was recorded for seventy-one of the seventy-three shoulders. The humeral component was press-fitted into the humerus if the medullary fit was snug and if the metaphyseal cancellous bone was intact or had only a minor deficiency that could be eliminated by bone-grafting. Sixty-six components were press-fitted in this fashion. The other seven components required additional support with methylmethacrylate. The glenoid subchondral bone was roughened but was preserved as much as possible; the slot in the glenoid was just wide enough to accept the keel of the glenoid component. The subchondral plate of the glenoid was undermined to remove soft cancellous bone before introduction of the methylmethacrylate. The standard polyethylene glenoid cornponent was used in all shoulders. The arm was positioned in a shoulder immobilizer with the arm at the side and the forearm across the abdomen after fifty-three of the procedures. A humeral abduction splint was used for additional support after nineteen procedures, and a spica cast was applied for a rheumatoid patient with severe deficiencies of tendons who had undergone an cxtensive tendon repair. Physiotherapy was begun four to six days after surgery for all shoulders except the one in a spica cast. For the shoulders with an immobilizer, passive motion was not limited except for external rotation beyond 30 degrees (to protect the repair of the subscapularis tendon). For those in an abduction splint, the extremity was released from the arm-rest and passive motion was carried from the level of the arm-rest to 120 degrees of abduction, 30 degrees of rotation in each direction, and 30 degrees of flexion and 30 degrees of extension at the level of the arm-rest. Gentle isometric muscle-strengthening exercises were added at two weeks, and active or active assisted range-of-motion exercises were begun four to six weeks after surgery. Vigorous stretching and isotonic muscle-strengthening were usually possible by two to four months. Continuing improvement was the rule for as long as six months after surgery and occasionally into the second postoperative year. Cooperation with the rehabilitation program was excellent for fortyfour shoulders, was compromised because of poor general health or generalized rheumatoid disease for twenty-four, and was not possible to any degree for five because of the patients poor general health, very severe generalized arthritic disease, or attitudinal limitations. Pain Results Postoperatively there was no pain in twenty-nine shoulders and slight pain in thirty. Eight shoulders caused only slight pain but the patients felt moderate discomfort with unusually vigorous activities. These sixty-seven shoulders represent 92 per cent of the study group (Table III). Of the remaining six shoulders, three caused moderate pain and the other three caused severe pain. In two shoulders with moderate pain and one with severe pain the glenoid com- VOL. 66-A, NO. 6, JULY 1984

5 902 R. H. COFIELD TABLE III POSTOPERATIVE CLINICAL EVALUATION No. of Shoulders.. Active Abduction (Degrees). External Rotatlon (Degrees) Av. Range Change Av. Range Change Range of Internal Rotation* Osteo to to P1 to 15 Rheumatoid Traumatic to to P1 to to to LI to T4 Entire group to I to LI to T4 * P1 = posterior part of the ilium, and LI = lateral part of the ilium. ponent appeared to be loose on radiographs, and later they had a revision operation. In the third shoulder with moderate pain the glenoid component appeared to be loose on radiographs and at the time of this report the patient was considering surgical revision. One patient with severe pain had a rotator cuff repair at the time of shoulder replacement; by seven months after surgery it was apparent that there was recurrence of the tear in the rotator cuff, and at forty-one months the patient was considering a second operation. In the last patient with severe pain, a fifty-nine-year-old man who had osteo, no cause of the pain was discovered. The pain was located in the periscapular area. When the patient was examined fifty months postoperatively he had 180 degrees of active abduction, 60 degrees of external rotation, and normal strength. The radiographs showed no abnormalities except for an incomplete one-millimeter lucent line at the glenoid bone-cement junction. This line had appeared fourteen months after surgery and did not change thereafter. The patient also had complaints of pain in other areas of the body, and no cause for the pain could be discerned. This man had previously been declared disabled for his job because of ill health. Thus, of the six shoulders that caused moderate or severe pain postoperatively, four had a loosened glenoid component, one had a large tear of the rotator cuff, and one was in a patient who probably had a psychosocial basis for the pain. Motion For the entire study group, the preoperative active abduction averaged 76 degrees (Table I), with a gain of 44 degrees postoperatively to 120 degrees (range, 30 to 180 degrees) (Table III). Many of the patients with osteo attained normal or nearly normal active abduction, but the gains in patients with rheumatoid were less striking. The patients with traumatic varied considerably in their ability to regain active movement. For twenty shoulders, the range of active abduction that was achieved was less than 90 degrees. In eight of these twenty, the patients had severe, generalized, progressive rheumatoid and were unable to participate effectively in postoperative rehabilitation. Of the other twelve, in three the restriction was attributed to pain and a loosened glenoid component; in three, to a major rotator-cuff repair at the time of total shoulder arthroplasty; in two, to a postoperative rotator-cuff tear; and in one each, to non-union of an osteotomy, laceration of the axillary nerve at the time of surgery, and severe postoperative reflex dystrophy. For one shoulder, no apparent reason for the limitation of active motion could be identified. Complications aside, the amount of active abduction that was achieved postoperatively was clearly related to the condition of the rotator cuff at surgery. If the rotator cuff was normal or nearly so, the postoperative active abduction averaged 143 degrees; if the cuff was thin and scarred, as it often was in shoulders with advanced rheumatoid, the active abduction averaged 102 degrees; if an osteotomy or osteotomies of the tuberosity had been necessary, active abduction averaged 93 degrees; and if a major rotator-cuff tear had been repaired, the active abduction averaged 63 degrees. External rotation improved from an average of 22 degrees preoperatively to an average of 48 degrees postoperatively, and internal rotation also improved considerably. Function The function of seventy-one extremities after total shoulder arthroplasty was assessed on the basis of the patient s stated ability to perform seven common daily activities, both before and after surgery. For two extremities the assessment was not done preoperatively. The activities assessed were the ability to: eat with a knife, fork, or spoon held by the hand on the side that had been operated on; dress; tend to personal hygiene and toilet needs; sleep lying on the repaired limb without notable discomfort; lift and carry five to 7.5 kilograms with the involved extremity positioned near the side; do usual work; comb hair using the hand of the extremity that had been operated on; and use the hand for light work with the arm positioned at the level of the shoulder. Changes in functional capabilities were quite striking for all activities except for the patients ability to do their usual work. Whereas preoperatively between fourteen and thirty-one of the shoulders were rated as unable to perform the first five functions or activities listed, postoperatively the numbers had diminished to between one and ten. Of the seventeen patients who were not able to do their usual work preoperatively, postoperatively five achieved that goal and most of the others could do light tasks. Combing the hair also became possible (twenty-eight recorded this, in addition to the twenty-seven who could do THE JOURNAL OF BONE AND JOINT SURGERY

6 TOTAL SHOULDER ARTHROPLASTY WITH THE NEER PROSTHESIS 903 this task preoperatively). Using the arm at the level of the shoulder also became possible for some patients (eighteen could do so preoperatively and fifty-three, postoperatively). Patients Assessments According to the patients own assessments, fifty-one of the seventy-three shoulders were much better and sixteen were better. Four patients thought that the shoulder was essentially unchanged from its preoperative status, and two patients thought that it was worse. Of the six patients (six shoulders) that did not benefit, five had moderate or severe pain postoperatively: two with a loosened glenoid component who were later operated on again, one with radiographic evidence of loosening, one with a postoperative rotator-cuff tear, and the one whose pain probably had a psychosocial cause. The sixth shoulder that did not benefit was in a sixtytwo-year-old woman with rheumatoid. She had a thin, scarred rotator cuff and had moderate postoperative pain only with unusually vigorous activities. Although the shoulder had 90 degrees of active abduction and 20 degrees of external rotation postoperatively, she said that she had not benefited from the operation despite the fact that preoperatively she had had severe pain, active abduction of 40 degrees, and no external rotation. The shoulder was improved, but the continuing deterioration of the rheumatoid in the elbow, wrist, and hand of the ipsilateral extremity created hardships and did not improve the overall function of the extremity. Complications and Reoperations Fourteen complications of surgery occurred in thirteen patients. The one intraoperative complication was laceration of the axillary nerve in a sixty-five-year-old woman with an old, comminuted fracture of the proximal part of the humerus. She had had previous operations, and extensive scarring was evident. The laceration was recognized at the time of surgery; neurosurgical consultation was requested, and the nerve was repaired. However, there was no significant neural recovery. Because of a weak and scarred rotator cuff, a transfer of the trapezius muscle to the proximal part of the humerus was performed eight months after the initial operation. At seventy-three months of follow-up the patient had no pain, the shoulder was stable, and there were 35 degrees of active abduction, 90 degrees of external rotation, and internal rotation to the fifth lumbar level. The patient stated that she felt that she had benefited from the surgical procedure. One large wound hematoma had to be evacuated and one patient had a non-fatal pulmonary embolus. Swollen hands, moderate stiffness of the fingers, and vasomotor changes consistent with a reflex dystrophy developed in two patients. They had had peri of the shoulder early in the development of their osteo and had experienced more pain than usual during the early postoperative period. The symptoms in the hands resolved after two and four months of intensive physiotherapy, but both patients shoulders remained somewhat stiff. A recurrent rotator-cuff tear became apparent in five patients, none of whom have had a second operation to date. One patient with severe pain and 60 degrees of active abduction felt that the shoulder was worse than it had been before surgery, and he was considering further surgery at the time of this report. The other four with a recurrent rotator-cuff tear - two with an old fracture and traumatic requiring an osteotomy and repositioning of the tuberosity, one with osteo and a thinned rotator cuff at surgery, and one with rheumatoid and a massive rotator-cuff tear that required fascial reinforcement at surgery - had anterosuperior subluxation, weakness in ab- FIG. I-A FIG. 1-B Figs. 1-A and I-B: Migration of the glenoid component in a sixty-four-year-old man with osteo. Fig. 1-A: Forty-degree posterior oblique radiograph made two months after total shoulder arthroplasty. showing that the glenoid component is in good position and there are no definite lucent lines at the glenoid bone-cement junction. Fig. 1-B: Thirty-five months after total shoulder arthroplasty, there are both superior displacement of the humeral component secondary to a probable rotator-cuff tear and medial migration of the glenoid component with upward tilting of the prosthetic articular surface. VOL. 66-A, NO. 6. JULY 1984

7 904 R. H. COFIELD duction, and passive abduction in excess of active abduction. Although strength and active motion were compromised, none of these four patients had much pain, and all were pleased with the surgical result. One other patient had a non-union and displacement of an osteotomy of the tuberosity. She had only 60 degrees of active abduction but continued to have no pain and believed that she was much better. Three shoulders, in addition to the one with the axillary-nerve laceration and the shoulder with the wound hematoma, required a second surgical procedure. Of the total of eight patients with radiographic signs of loosening of the glenoid prosthesis, three patients with osteo had the development of severe pain, and they had to have a revision operation with cementing of a new glenoid component four to six years after the initial operation. This revision produced a satisfactory outcome for two of the three patients. Radiographic Analysis On follow-up, radiographs of the shoulder were made using three projections: a 40-degree posterior oblique radiograph with internal rotation of the humerus, a 40-degree posterior oblique radiograph with external rotation of the humerus, and an axillary radiograph. These projections allow good visualization of the glenoid prosthesis-cementbone interfaces, which are often not seen well on ordinary radiographs because of the obliquity of the glenoid component. Radiographs had also been made immediately after surgery (except for the external rotation radiograph) and at two weeks, one to two months, six months, one year, and two years postoperatively. Additional radiographs were made at other times if indicated. Radiographic features indicative of loosening of the glenoid component developed in eight patients (eight shoulders). Seven had a diagnosis of osteo and one, rheumatoid. All seven with osteo showed a shift in the position of the glenoid component on the scapula. The component and its surrounding cement had migrated medially into the scapula and had tilted, so that the articulating surface faced more superiorly than at operation (Figs. 1-A and 1-B). In six shoulders a lucent line was present at the glenoid bone-cement interface two months postoperatively and in one, thirty-five months after surgery. All of these lines progressed in thickness to one millimeter, but none exceeded 1.5 millimeters in width at the time of this report. In six shoulders the lucent line completely surrounded the cement and in one it was visible only in scattered areas. Three of these patients had a revision operation, as already mentioned, and for a fourth patient, who had modcrate pain, surgical revision was under consideration. The other three patients had either no pain or only slight pain, and no further treatment was indicated at the time of this report. A fifty-two-year-old woman with rheumatoid had extensive osteoporosis that precluded secure fixation of the glenoid component. A lucent line that completely surrounded the glenoid component and was two millimeters thick was apparent postoperatively, but it did not change in thickness in five years. At the most recent follow-up cxamination, the patient had moderate pain only with vigorous activity and had 90 degrees of active abduction. A lucent line did not develop in thirteen shoulders. Of the remaining fifty-two shoulders, a line at the glenoid bonecement interface (Fig. 2) developed at two weeks in fourteen shoulders, at one to two months in seventeen shoulders, and at six months or later in twenty-one shoulders. At the time of the last follow-up evaluation, it was less than one millimeter in width in twenty-five shoulders, was one millimeter wide in twenty-one, and was 1.5 millimeters wide in six. The entire bone-cement interface had a lucent line in twenty-four shoulders. In all ofthe remaining shoulders with a lucent line, the line involved only a portion ofthe interface. The line abutted the glenoid articular surface in ten shoulders and showed scattered areas of lucency at the interface in eighteen. Sequential radiographs showed that these lines continued to increase in width or extent in seventeen shoulders, whereas no changes were apparent in the other thirtyfive shoulders. Up to the time of this report, humeral component loosening had not been recognized clinically or radiographically. One of the seven shoulders in which cement had been used around the humeral component had a 1.5-millimeter lucent line surrounding a portion of the prosthetic stem. This patient did not have any pain. In the other six shoulders with a cemented humeral component, no lucent line developed. Of the sixty-six shoulders in which the humeral component was implanted without methylmethacrylate, forty-four did not have development of a lucent line. In the twenty-two shoulders that did have such a line, in six it was less than one millimeter thick; in seven it measured one millimeter; in five, 1.5 millimeters; and in four, two millimeters. None FIG. 2 Radiograph made seventy-two months after total shoulder arthroplasty in a twenty-eight-year-old man with rheumatoid. The lucent line at the glenoid bone-cement interface is 1.5 millimeters wide and abuts against the glenoid surface only. No lucent line was present in this patient until fifty-one months after surgery. THE JOURNAL OF BONE AND JOINT SURGERY

8 TOTAL SHOULDER ARTHROPLASTY WITH THE NEER PROSTHESIS 905 TABLE IV GRADING OF RESULTS No. of Shoulders Limited-Goals Full Exercise Program (No.) Rehabilitation (No.) Excellent Satisfactory Unsatisfactory Successful Unsuccessful Osteo 3 I Rheumatoid Traumatic Total (41%) 18 (25) 18 (25%) 4 3 of these humeral lucent lines surrounded the entire cornponent. Grading of Results The clinical results in the patients were graded as described by Neer et. If the rotator cuff was intact and functioning or had been well repaired, the patient participated in a full rehabilitation program, but in seven shoulders the major rotator-cuff tear could be repaired only tenuously, often supplemented with fascia lata grafting, and for them the program was less vigorous. Results in the sixty-six shoulders that went through the full rehabilitation program were graded as excellent, satisfactory, or unsatisfactory, whereas the other seven shoulders were graded as successful or unsuccessful. In an excellent result, the patient had no pain or slight pain, had active abduction within 35 degrees of normal and 90 per cent of normal external rotation, and was satisfied with the result. In a satisfactory result, the patient had no pain, slight pain, or moderate pain only with vigorous activities; active abduction of more than 90 degrees and 50 per cent of normal external rotation; and was satisfied with the procedure. In an unsatisfactory result, any one of these criteria was not met. In the shoulders in which a revision operation was necessary, the grade obtained was unsatisfactory. In the seven patients for whom limited rehabilitation goals were sought, the exercise program was directed at achieving a lesser range of motion but maintaming stability. If the patient had no pain, slight pain, or moderate pain only with vigorous activity and had active abduction of more than 70 degrees and external rotation of more than 20 degrees, the result was graded successful. The distribution of clinical ratings (Table IV) showed that seven unsatisfactory results occurred in the osteoarthritic group. Three ofthese shoulders had glenoid loosening and revision surgery; one, glenoid loosening and pain; one, a postoperative rotator-cufftear with decreased motion; one, reflex dystrophy with failure to regain motion; and one, unexplained pain. It is notable that of the twenty-nine shoulders with rheumatoid, five were in the limited-rehabilitation group because of a major rotator-cuff tear, two of which had required fascial supplementation. The two patients who did not meet the limited goals failed to do so because of the inability to obtain 70 degrees of active abduction. All seven unsatisfactory results were attributed to failure to obtam 90 degrees of active abduction. Among the thirteen shoulders with traumatic, there were four unsatisfactory results. One patient obtained only 80 degrees of active abduction. The other three patients had a complication that limited active motion: one had an axillary-nerve laceration; one, a non-union of a tuberosity osteotomy; and one, a postoperative rotator-cuff tear. Discussion In this series, the Neer total shoulder prosthesis was successful in the great majority of shoulders in relieving the moderate or severe pain that was the major indication for the surgical procedure. In five of the six shoulders that did not have relief of pain, an important complication occurred. Moreover, five of these six patients were those who did not think that they had benefited from the operation. Thus, in the absence of a postoperative complication, with rare cxceptions the results were predictably good. The amount of active abduction after surgery depended on three factors: the extent of the defect in the rotator cuff, the ability ofthe patient to participate fully in rehabilitation, and the absence of complications. A defect in the rotator cuff was less frequent in these shoulders than might have been anticipated. However, when a large rotator-cuff tear was present, final active abduction was nearly always cornpromised. In only one of eight such shoulders was more than 90 degrees of active abduction obtained. When there was severe generalized rheumatoid with malaise, involvement of other ipsilateral joints, or involvement of the opposite shoulder, the patient usually could not actively participate in the physiotherapy; special arrangements for continuing home therapy were necessary for them. In addition, the complications often resulted in muscle weakness or prevented full participation in the physiotherapy. Rotational movements of the arm depend more on a smooth glenohumeral articulation and absence of capsular contraction than on strength, and gains in those movements are the most important for the improved performance of many daily activities. There were striking improvements in the patients stated abilities to do common daily tasks. We compared our results with those in sixty-three shoulders in which a fusion had been done5. All of the tasks could be accomplished significantly better by the patients with a total shoulder arthroplasty than by the patients with a shoulder fusion. VOL. 66-A, NO. 6. JULY 1984

9 906 R. H. COFIELD As already stated, complications were the important cause of a poor result; that is, pain, an inadequate range of motion, and dissatisfaction with the procedure. Reflex dystrophy developed only in the two patients who had a history of a similar process preceding the total shoulder replacement. A recurrence of a tear in a rotator cuff after it is repaired can produce pain and weakness, but of the five patients in the series who had that complication only one had enough postoperative pain to consider further surgery. The remaining patients had satisfactory relief of pain and accepted the weakness and failure to gain as much abduction as they would have liked. Loosening of the glenoid component resulted in moderate or severe pain in four of the eight shoulders with this complication. The shortest interval between the index operation and the performance of a revision procedure was forty-eight months. Thus, the followup period for total shoulder-replacement arthroplasty apparently must be quite long before the outcome of the procedure can be definitely evaluated. Loosening ofthe humeral component has not been recognized as a clinical problem, and analysis of the humeral lucent lines did not suggest that this is likely to become a major problem in the future. A comparison of this study with that of Neer et shows that there are similarities and differences. The present study included fewer patients and was limited to the three major diagnostic categories, but the length of follow-up was similar in the two series, as were the indications for surgery and the surgical pathology in the diagnostic subgroups. In both series the surgery was difficult and involved many intraoperative variables, and an extensive rehabilitation program was mandatory. The relief of pain, the improvement in the range of motion, the complication rate, and the rate of surgical revision in the present report were about the same as those in that of Neer #{176}. The striking difference between the two series is in the type of complications that led to revision operation. Postoperative instability occurred in six shoulders in the series of Neer et but in none of our patients. Neer et al. reported no clinical or definite radiographic loosening of the glenoid component. In the present series, eight glenoid components were definitely loose and three required a revision operation. Of the shoulders without definite clinical signs of prosthetic loosening, 80 per cent showed a lucent line at the glenoid component-cement-bone interface, and 33 per cent of those lines were still increasing in thickness or extent at final follow-up. The time that the lines appeared during the follow-up period varied greatly. These radiographic findings contrast dramatically with those of Neer et al. : a lucent line was present in only 30 per cent of their patients, all were apparent postoperatively, and none were progressive during the period of follow-up. The findings in the present series suggest that the design of the glenoid component needs improvement. At present, I incorporate a metal backing and a more ample keel-like fixation device. The small volume of bone available for fixation of the implant in the glenoid of the scapula probably is the most limiting factor in total shoulder replacement, limiting both the indications for the procedure and the cxpectation of a good long-term result. Rotator cuff defects in the three diagnostic categories presented here have not been a large problem, but it has been reported that associated with cuff continues to be a problem when non-constrained total shoulder prostheses are used. However, the alternatives - more constrained implants - have a high frequency ofcomplications7 3. It is hoped that muscle and tendon-transposition techniques will be developed to substitute for the musculotendinous deficiencies of the rotator cuff. The outcome of the procedure of prosthetic replacement of the proximal end of the humerus without glenoid resurfacing for arthritic patients with loss of glenoid cartilage has not yet been well documented, and reports on that procedure in patients with have been infrequent 9 0. The present study, in addition to providing information on total shoulder-replacement arthroplasty, may serve as a basis for comparison with prosthetic replacements of the proximal end of the humerus done for osteo, rheumatoid, or traumatic. References 1. CLAYTON, M. L.; FERLIC, D. C.: and JEFFERS, P. D.: Prosthetic Arthroplasties ofthe Shoulder. Clin. Orthop., 164: , COFIELD, R. H.: The Bickel Glenohumeral Arthroplasty. In Joint Replacement in the Upper Limb, pp Institution of Mechanical Engineers Conference (Publication ). London, Mechanical Engineering Publications, COFIELD, R. H.: Unconstrained Total Shoulder Prostheses. Clin. Orthop., 173: , COFIELD, R. H.: Unpublished data. 5. COFIELD, R. H., and BRIGGS. B. 1. : Glenohumeral Arthrodesis. Operative and Long-Term Functional Results. J. Bone and Joint Surg., 61-A: , July JoHNSToN, T. B. : The Movements of the Shoulder-Joint. A Plea for the Use of the Plane of the Scapula as the Plane of Reference for Movements Occurring at the Humero-Scapular Joint. British J. Surg., 25: , LETTIN, A. W. F., and SCALES, J. 1.: Total Replacement of the Shoulder Joint (Two Cases). Proc. Roy. Soc. Med., 65: LETTIN, A. W. F.; COPELAND, S. A.: and SCALES, J. 1.: The Stanmore Total Shoulder Replacement. J. Bone and Joint Surg.. 64-B(I): MARMOR, LEONARD: Hemiarthroplasty for the Rheumatoid Shoulder Joint. Clin. Orthop.. 122: , NEER. C. S., II: Replacement Arthroplasty for Glenohumeral Osteo. J. Bone and Joint Surg.. 56-A: Jan NEER, C. S., II; WATSON, K. C.; and STANTON, F. J.: Recent Experience in Total Shoulder Replacement. J. Bone and Joint Surg., 64-A: , March POPPEN, N. K., and WALKER, P. 5.: Normal and Abnormal Motion of the Shoulder. J. Bone and Joint Surg., 58-A: ,March PosT, MELVIN; HASKELL, S. S. : and JABLON, MICHAEL: Total Shoulder Replacement with a Constrained Prosthesis. J. Bone and Joint Surg.. 62-A: April THE JOURNAL OF BONE AND JOINT SURGERY