Late Results of Total Shoulder Replacement in Patients With Rheumatoid Arthritis

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1 CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 366, pp Lippincott Williams & Wilkins, Inc. Late Results of Total Shoulder Replacement in Patients With Rheumatoid Arthritis Jens 0. S@jbjerg, MD; Lars H. Frich, MD, PhD; Hans V. Johannsen, MD; and Otto Sneppen, MD, DMSC Rheumatoid arthritis of the shoulder is a progressive and destructive joint disease, and similar to arthritis in other joints, progression of the disease is unpredictable and may stop at any stage of involvement. Between 1983 and 1996, more than 500 shoulder prostheses were implanted in patients at the authors' institution. Total shoulder replacement yields satisfactory short and long term results even in patients with severely destructed joints. Pain relief is reliable and significant as reported in short and long term studies. In most patients the functional result is good or acceptable. Although range of motion is only slightly increased, a satisfactory overall range of motion is achieved by most patients because of the unaffected scapulothoracic motion. However, deteriorating results, emphasizing the complexity of shoulder arthroplasty, were seen with increasing observation time in patients with rheumatoid arthritis. Proximal migration of the humeral prosthesis attributable to rotator cuff failure, with secondary eccentric glenoid loading and progressive loosening, is latent in patients with chronic progressive rheumatoid disease and From the Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, University Hospital in Aarhus, Aarhus C., Denmark. Reprint requests to Jens 0. Sgjbjerg, MD, Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, University Hospital in Aarhus, Nerrebrogade 44 DK-8000 Aarhus City, Denmark. was by far the most common complication (42%) in the present series. In 1982, Neer et a18 introduced a nonconstrained total shoulder prosthesis, with a revised humeral part and a polyethylene glenoid component, because of an increasing number of reports about the deteriorating results after constrained shoulder arthroplasty. Their results proved this approach to be an effective method in the treatment of patients with glenohumeral arthritis, and since then the Neer prosthesis has been the gold standard of total shoulder replacement. Several authors have published short term results of total shoulder replacement in patients with rheumatoid arthritis and degenerative arthritis. Barrett et al,' Cofield,2 Frich et a14, and Kelly et a16 reported substantial pain relief in approximately 90% of their patients with rheumatoid arthritis, and the results in patients with degenerative arthritis were identical. The patients with degenerative arthritis had a better functional outcome. However, complication rates reported have differed, ranging from 5% to 25% in patients who had s~rgery.~ Only a few and inconsistent long term functional studies have been published.loj1 39

40 S~rjbjerg et al Clinical Orthopaedics and Related Research The present study reports the long term survival and complications after total shoulder replacement in patients suffering from severe

2 40 S~rjbjerg et al Clinical Orthopaedics and Related Research The present study reports the long term survival and complications after total shoulder replacement in patients suffering from severe rheumatoid arthritis, and reports whether the generally good short term results of patients who underwent total shoulder replacement are consistent or deteriorate with time. PATHOLOGY OF THE RHEUMATOID SHOULDER The incidence of rheumatoid arthritis in Scandinavia is approximately 1 % to 2%; it is highest in the northern part of the area.9 Shoulder joint involvement in patients suffering from rheumatoid arthritis is rather frequent, and probably involves as many as SO% of the patients. Rheumatoid arthritis of the shoulder is a progressive and destructive joint disease, and similar to arthritis in other joints, progression of the disease is unpredictable and may stop at any stage of involvement. For clinical purposes the authors have classified the rheumatoid shoulder according to three types of pathologic changes: the dry, the wet, and the resorptive rheumatoid shoulder. Figure 1 shows a rheumatoid shoulder of the dry type. The preoperative range of motion (ROM) usually is very limited because of severe fibrosis of the soft tissues around the shoulder, and during surgery extensive release often is necessary to obtain good motion of the joint. The bone quality in these patients tends to be good, offering sufficient support for glenoid and humeral components. In addition to cartilage destruction and erosions, the rheumatoid shoulder of the wet type is characterized by proximal migration of the humeral head (Fig 2). This is because of a rotator cuff deficiency that allows the humeral head to articulate with the undersurface of the acromion. These joints produce excessive amounts of synovial fluid, increasing the destruction of the soft tissues. The main surgical problem is reconstruction of the soft tissues. The rheumatoid shoulder of the resorptive type has a severe bone loss and medialization of the humeral head (Fig 3). A total shoulder replace- Fig 1. Radiograph of a shoulder with rheumatoid arthritis of the dry type. The characteristic appearance includes thinning of the cartilage, erosions, subchondral sclerosis, and osteopenia. In this type of shoulder abnormality the rotator cuff is intact, and the humeral head is reasonable centered against the glenoid, although a reduced acromiohumeral distance may be seen. ment can be difficult technically, because replacing the glenoid may be impossible. Rheumatoid arthritis of the shoulder joint covers a spectrum of pathologic changes of the joint and the destruction of the joint will vary considerably among patients. MATERIALS AND METHODS Between 1983 and 1996, more than 500 Neer (3M Inc, Glostrup, Denmark) shoulder prostheses were implanted in patients at the authors institution. The most common indications for surgery were rheu-

Number 366 September, 1999 Late Results of Total Shoulder Replacement 41 Fig 3. Radiograph of a shoulder with rheumatoid arthritis of the resorptive type.

$matoid arthritis (40%), osteoarthritis (20%), and fractures (30%), which accounted for approximately 90% of all the shoulder replacements.$

3 Number 366 September, 1999 Late Results of Total Shoulder Replacement 41 Fig 3. Radiograph of a shoulder with rheumatoid arthritis of the resorptive type. The humeral head and the glenoid are severely eroded and resorbed. Fig 2. Radiograph of a shoulder with rheumatoid arthritis of the wet type, showing the characteristic appearance of the proximal migrated humeral head caused by rotator cuff deficiency. matoid arthritis (40%), osteoarthritis (20%), and fractures (30%), which accounted for approximately 90% of all the shoulder replacements. Cuff tear arthropathy, avascular humeral head necrosis, tumors, and different arthritic conditions accounted for 10% of the shoulder replacements. All patients were examined 6 and 12 months after surgery and annually thereafter. At each examination, the patients were evaluated according to the Society of the American Shoulder and Elbow Surgeons5 evaluation form, and since 1990, the Constant and Murley? functional score including abduction strength measurements, also was used. Between 1981 and 1990,69 patients with rheumatoid arthritis underwent 86 Neer total shoulder arthroplasties at the authors institution. Most patients were in the limited goal category. All had severe destructions of the shoulder joint, with pain being the main indication for surgery. Thirteen pa- tients died within the first 4 postoperative years, and five patients were lost to followup, leaving 5 1 patients for inclusion in the study. There were 32 women and 19 men. Eleven patients had bilateral replacements (62 total shoulder arthroplasties). The average age of the patients at the time of surgery was 57 years, with a range from 31 to 75 years. All glenoid components and the majority of humeral components were cemented. Only 12 press fit humeral components were implanted. Rotator cuff tears were repaired when possible, but treatment often consisted of debridement alone. Minor tears were repaired in a routine fashion. Postoperative radiographic examination of the shoulder joint included anteroposterior (AP) projection with the arm in neutral position. Radiographs from the preoperative examination, the immediate postoperative examination, and the latest followup were compared and evaluated for signs of component loosening and proximal migration. Proximal migration of the humerus was evaluated by measuring the displacement of the inferior edge of the humeral prosthesis relative to the inferior edge of the glenoid, and by measuring the distance between the undersurface of the acromion and the top of the prosthetic head. Medial translation of the humeral component was calculated by measuring the displacement of the lateral edge of the humeral prosthesis relative to the lateral edge of the acromion.

Clinical Orthopaedics 42 Sajbjerg et al and Related Research LONG TERM RESULTS OF TOTAL SHOULDER REPLACEMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS Overall, 51 patients with 62 total shoulder

4 Clinical Orthopaedics 42 Sajbjerg et al and Related Research LONG TERM RESULTS OF TOTAL SHOULDER REPLACEMENT IN PATIENTS WITH RHEUMATOID ARTHRITIS Overall, 51 patients with 62 total shoulder replacements were evaluated with an average followup of 7.7 years (range, months). Pain relief at long term followup was good in 89% of patients; 25 patients (40%) were pain free, and slight or moderate pain after unusual activity was seen in 30 patients (48%). Six patients (10%) had moderate pain and only one patient (1.5%) had marked pain. Preoperative forward elevation averaged 44". The mean external rotation was 6" and internal rotation was measured by the patient's ability to reach the gluteal region. At followup, the mean forward elevation was 75", external rotation was 28", and internal rotation was measured by the patient's ability to reach the lower lumbar spine level. The observed differences between preoperative and postoperative ROM are highly significant (p < 0.OOOl). The mean preoperative American Shoulder and Elbow Surgeons function score was 13.4 points (range, 0-35 points). The average function score at followup was increased significantly (p < 0.001) to 24 points (range, 6-50 points). The mean abduction strength for the affected shoulders was 1.99 kg (range, kg). DISCUSSION Proximal migration of the humeral component was the most common complication in the current series of total shoulder replacement in patients with rheumatoid arthritis. Proximal migration indicates a rotator cuff tear or a poorly functioning rotator cuff. Superior subluxation of the humeral component causes subacromial impingement in some patients and pain relief is slightly less satisfactory in these patients. The incidence of progressive proximal migration after total shoulder replacement depends on the preoperative disease state of the shoulder joint. In rheuma- toid arthritis, rotator cuff failure has been reported in as many as 50% of In the current series a high degree of correlation was found between preoperative radiographic signs of rotator cuff failure and proximal migration of the humeral prosthesis at followup. Nineteen of 25 shoulders (76%) with a marked proximal subluxation preoperatively also had proximal migration at followup, whereas only 16 of the remaining 37 shoulders without initial proximal migration were subluxated cranially at followup. The overall incidence of proximal migration was 55% (34 shoulders) and it was progressive in 76% (26 shoulders). In rheumatoid arthritis, proximal migration is correlated to preoperative rotator cuff status and to the length of followup. A large percentage of patients have progressive proximal migration. Another major problem in total shoulder replacement is the significance of radiolucency to loosening of the implant. Lucent lines at the bone-cement interface related to the glenoid component are seen radiographically with an incidence of 50% to 80%. Lucent lines around the keel of the prosthesis seem to be indicative of clinical loosening, but whether this actually occurs still is not clear. Radiographic lucent lines present immediately after the operation are caused by insufficient cementing technique. The incidence of radiographic glenoid loosening depends on the amount of joint disease, but in patients with rheumatoid arthritis it may be as high as 30% to 50%.11 Although proximal migration is associated with moderately functional results and less reliable pain relief, the main problem with proximal migration is not decreased function but the increased risk of progressive glenoid loosening. Proximal subluxation of the humerus causes eccentric loading of the glenoid component, creating a rocking horse phenomenon that eventually may cause loosening of the glenoid (Fig 4). In the current series, 10 of 17 patients (58%) with eccentrically loaded glenoids had progressive glenoid loosening. With a centric loading progressive loosening was seen in only 15 patients (33%). In 10 patients

Number 366 September, 1999 Late Results of Total Shoulder Redacernent 43 mm, rarely extended beyond the superior 'h of the humeral stem, and none were progressive. There were no cases of subsidence.

5 Number 366 September, 1999 Late Results of Total Shoulder Redacernent 43 mm, rarely extended beyond the superior 'h of the humeral stem, and none were progressive. There were no cases of subsidence. However, when the Neer prosthesis was used as a press fit design, the incidence of clinical loosening was found unacceptably high; in the present series the incidence of clinical loosening was more than 40%. In the present series the overall revision rate was 4%, and 90% of the revisions of total shoulder arthroplasties were done because of glenoid loosening in patients with press fit humeral designs, and in patients with infections attributable to humeral component involvement (Fig 6). Selective glenoid revision Fig 4. (Right) Radiograph showing a prosthesis with initial eccentric loading superiorly of the glenoid. (Left) Three years later the radiograph shows glenoid loosening with a typical tilting of the glenoid in a caudal direction. The patient underwent revision surgery that reveated rotator cuff failure. the eccentric load was on the inferior margin of the glenoid, and progressive radiographic loosening was seen in seven of these patients, revealing a cranial tilt of the glenoid component. In the remaining seven patients the eccentric loading was centered on the superior margin, and three shoulders had glenoid loosening with the glenoid being shifted in a caudal direction. Overall, in the current series, 25 (40%) glenoid components had progressive radiographic loosening. In 16 of these shoulders (26%) the component was displaced (tilted or shifted) and in nine patients (14%) the component was dislocated from the glenoid bed (Fig 5). Contrary to the high incidence of glenoid loosening, the incidence of loosening of a cemented humeral prosthesis in the present series, as in other series, was very low: approximately 1 %.lo-* Radiolucent zones around the humeral stem were rare, all were less than 2 Fig 5. Radiograph showing radiolucent lines at the bone-cement interface related to the glenoid component. In this patient the lucency was progressive and indicated radiographic loosening.

44 Saibiera et al Fig 6. Radiograph obtained 7 years postoperatively in a patient with rheumatoid arthritis shows loosening of the glenoid component.

6 44 Saibiera et al Fig 6. Radiograph obtained 7 years postoperatively in a patient with rheumatoid arthritis shows loosening of the glenoid component. The uncemented humeral component has subsided considerable, indicating that revision surgery is required. is difficult technically, especially because of glenoid bone loss. In more than 1/2 of the patients who had revision surgery the glenoid was left unreplaced. In some patients severe bone destruction of humeral and glenoid bone renders revision arthroplasty technically impossible. In such patients the authors performed an arthrodesis of the joint, which is a far more demanding procedure. Total shoulder replacement yields satisfactory short and long term results even in patients with severely destructed joints. Pain relief is reliable and significant as reported in Clinical Orthopaedics and Related Research short and long term st~dies.~,~,~,~,'~,'~ In most patients the functional result is good or acceptable. Although ROM is increased only slightly, a satisfactory overall ROM is achieved by most patients because of the unaffected scapulothoracic motion. However, deteriorating results were seen with increasing observation time in patients with rheumatoid arthritis, which emphasized the complexity of shoulder arthroplasty. Proximal migration of the humeral prosthesis because of rotator cuff failure is latent in patients with chronic progressive rheumatoid disease and was by far the most common complication (42%) in the present series. Proximal migration with secondary eccentric glenoid loading and progressive loosening was seen in 25 patients (40%). This was the most common cause of implant failure in the present series. To reduce the high rate of complications the authors recommend proper timing of the surgery and life long clinical and radiographic followup examination for the patients. Early revision of shoulders with symptomatic progressive glenoid loosening or cuff failure may improve the results of revision surgery. Whenever possible, the patient should be operated on before severe destruction of bone and soft tissues has occurred and while the patient still has a reasonable range of glenohumeral motion. References 1. Barrett WP, Franklin JL, Jackins SE, et al: Total shoulder arthroplasty. J Bone Joint Surg 69A: , Cofield RH: Total shoulder arthroplasty with the Neer prosthesis. J Bone Joint Surg 66A: , Constant CR, Murley AGH: A clinical method of functional assessment of the shoulder. Clin Orthop 214: , Frich LH, Mdller BN, Sneppen 0: Shoulder arthroplasty with the Neer Mark I1 prosthesis. Arch Orthop Trauma Surg 107:liO-113, Hawkins RJ, Bokor DJ: Clinical Evaluation of Shoulder Problems. In Rockwood CA, Matzen FA (eds). The Shoulder. Vol 1. Ed 2. Philadelphia, WB Saunders Company , Kelly IG, Foster RS, Fisher WD: Neer total shoulder replacement in rheumatoid arthritis. J Bone Joint Surg 69B: , Miller SR, Bigliani L: Complications of Total Shoul-

Number 366 September, 1999 Late Results of Total Shoulder Replacement 45 der Replacement. In Bigliani L (ed). Complications of Shoulder Surgery. Baltimore, Williams and Wilkins 59-72, 1993. 8.

7 Number 366 September, 1999 Late Results of Total Shoulder Replacement 45 der Replacement. In Bigliani L (ed). Complications of Shoulder Surgery. Baltimore, Williams and Wilkins 59-72, Neer CS, Watson KC, Stanton FJ: Recent experience in total shoulder replacement. J Bone Joint Surg 64A: , Smith CA, Arnett FC: Epidemiologic aspects of rheumatoid arthritis. Clin Orthop 265:23-35, Sneppen 0, Fruensgird S, Johannsen, HV, et al: Total shoulder arthroplasty in rheumatoid arthritis. Proximal migration and loosening. J Shoulder Elbow Surg , Stewart MP, Kelly IG: Total shoulder replacement in rheumatoid disease: 7- to 13 year follow up of 37 joints. J Bone Joint Surg 79B:68-72, 1997.

Augmented Glenoid Component for Bone Deficiency in Shoulder Arthroplasty

Clin Orthop Relat Res (2008) 466:579 583 DOI 10.1007/s11999-007-0104-4 SYMPOSIUM: NEW APPROACHES TO SHOULDER SURGERY Augmented Glenoid Component for Bone Deficiency in Shoulder Arthroplasty Robert S. Rice