Management of the Younger Arthritic Shoulder

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Conflict of Interest Slide Management of the Younger Arthritic Shoulder Gerald R.

Fenlin, Jr, MD Professor of Shoulder and Elbow Surgery Royalties Depuy: shoulder arthroplasty DJO:

Tornier, Depuy, Synthasome Stock Ownership: In vivo therapeutics, CrossCurrent Business Analytics,

decision making Treatment options Personal approach Conclusions Surena Namdari, MD Young Definition

1 Conflict of Interest Slide Management of the Younger Arthritic Shoulder Gerald R. Williams, Jr, MD John M. Fenlin, Jr, MD Professor of Shoulder and Elbow Surgery Royalties Depuy: shoulder arthroplasty DJO: shoulder arthroplasty Walters Kluwer: shoulder texts IMDS/Cleveland Clinic: arthroplasty Research: Tornier, Depuy, Synthasome Stock Ownership: In vivo therapeutics, CrossCurrent Business Analytics, LLC, OBERD, LLC, Force Therapeutics Thanks Agenda Background Definition Epidemiology Factors affecting decision making Treatment options Personal approach Conclusions Surena Namdari, MD Young Definition Epidemiology Demand in patients 55 and younger increasing substantially Living longer More active Age is just a number loose proxy for activity 50 is a common threshold for TSR One revision gets them to 80. maybe 1

Epidemiology Factors Affecting Decision making 60% 40% 20% 0% Relative %

revision burden cost Age/activity level Patient expectations Stiffness

Factors Affecting Decision making Subtler problems deserve subtler

Injections Cortisone HA (off label, not FDA approved) Stem cells, PRP, etc.

com Treatment Options Surgical Joint Sparing Joint Sacrificing Soft tissue

interposition Arthroscopic Open Osteotomy Glenoid Humeral Arthrodesis

2 Epidemiology Factors Affecting Decision making 60% 40% 20% 0% Relative % of Hemiarthroplasties Performed % % % Increasing revision burden cost Age/activity level Patient expectations Stiffness Cuff integrity Prior surgery Infection Bone deformity Humerus Glenoid Factors Affecting Decision making Subtler problems deserve subtler solutions Factors Affecting Decision making Activity modification NSAIDS Injections Cortisone HA (off label, not FDA approved) Stem cells, PRP, etc. Therapy Treatment Options MDHealth.com Treatment Options Surgical Joint Sparing Joint Sacrificing Soft tissue release, debridement,synovectomy Arthroscopic Open Soft tissue interposition Arthroscopic Open Osteotomy Glenoid Humeral Arthrodesis Resection arthroplasty Joint replacement Resurfacing Partial Complete Hemiarthroplasty +/ concentric glenoid reaming Total shoulder Mini (in lay) Standard 2

Treatment Options Surgical A Continuum Treatment Options

Injection Viscosupplementation anti inflammatory analgesic

acute local reactions flare up of pseudogout pseudosepsis

in their knee, more likely to help shoulder NOT FDA

3 Treatment Options Surgical A Continuum Treatment Options Surgical Last Resort Arthroscopy Arthroplasty Cortisone Injection Viscosupplementation anti inflammatory analgesic effects precise mechanism for pain relief is not known acute local reactions flare up of pseudogout pseudosepsis (acute systemic reactions) Anecdotally if it worked well in their knee, more likely to help shoulder NOT FDA APPROVED Viscosupplementation Viscosupplementation Viscosupplementation 3

Stem cells and PRP Minimal data Cash payment Popular among professional athletes Apparently lucrative N =

6 points Surgical (Joint Preserving) Arthroscopy Less severe deformity Arthroscopic debridement

months (range 12-63 months) 19 males, 6 females Treatment: Lavage, debridement, capsular release

Patients Total =23 Excellent No pain, Full ROM, nml strength 2 (8%) Good Occasional pain Elevation > 130

5 (21 73) F/U avg 34 months (range 12 74 months) 41 males, 20 females Treatment: debridement, capsular

8% converted to arthroplasty (mean 16 months) Predictor: lesion >2cm 2 Systematic Review 5 studies; 212

4 Stem cells and PRP Minimal data Cash payment Popular among professional athletes Apparently lucrative N = 34 OA patients Mean 7 months Stem cells and PRP Dash Improvement: 18.7 points Pain scale improvement: 1.6 points Surgical (Joint Preserving) Arthroscopy Less severe deformity Arthroscopic debridement Arthroscopic capsular release Arthroscopic interposition N= 23 patients, mean age 46 (27-72) F/U avg 34 months (range months) 19 males, 6 females Treatment: Lavage, debridement, capsular release Description No. Patients Total =23 Excellent No pain, Full ROM, nml strength 2 (8%) Good Occasional pain Elevation > 130 Nml strength 19 (72%) Unsatisfactory Lack of above 5 (20%) Case #1 N= 61 patients, mean age 49.5 (21 73) F/U avg 34 months (range months) 41 males, 20 females Treatment: debridement, capsular release (n=22), acromioplasty (n=18) 9.8% converted to arthroplasty (mean 16 months) Predictor: lesion >2cm 2 Systematic Review 5 studies; 212 patients Mean age 49 years (18 87) Mean follow up 34 months (12 152) Improvements in pain relief, motion, function 13% conversion to arthroplasty Unable to identify predictors for successful outcome Insufficient evidence to support routine use of arthroscopic debridement/capsular release for GH DJD AAOS CPG 4

Surgical (Joint Sparing) Arthroscopic Interposition Mild deformity mild humeral osteophytes, concentric joint Mild to moderate stiffness Capsular release increases difficulty Release alone might be

5 Surgical (Joint Sparing) Arthroscopic Interposition Mild deformity mild humeral osteophytes, concentric joint Mild to moderate stiffness Capsular release increases difficulty Release alone might be adequate Meniscus Pennington, W. T., and Bartz, B. A. Arthroscopy, 21(12): , Dermis-- Steinmann, Bhatia, D. N.; van Rooyen, K. S.; du Toit, D. F.; and de Beer, J. FArthroscopy, 22(5): 570 e1-5, Surgical (Joint sparing) Arthroscopic Interposition Porcine Intestine Basement membrane (Restore by Depuy) 23 patients (mean age 32) F/u 3 6 years 3 lost to f/u 5 converted to arthroplasty (resurfacing) 75% satisfaction rate Acellular dermal scaffold 32 patients 28% failure 5 converted to arthroplasty Surgical (Joint sparing) Arthroscopic Interposition Surgical (Joint Sparing) Open Debridement +/ Interposition Stiff shoulder More deformity than appropriate for arthroscopic release No biconcavilty Very active (young) Do everything I would do in a TSR except replace the joint : 1-4 yr f/u, 6 pts Table 1. Pre- and Post-op Range of Motion : 1-4 yr f/u, 6 pts Table 2. Mean Outcome Measurements ROM Mean Pre-op AROM Mean Post-op AROM AROM Percent Increase AROM FF ER ER IR >100 Penn Shoulder Score 100 pts maximum Mean Preop Score Mean Postop Score Score Percent Increas e Score Pain: Satisfaction: Function: Total Score:

6 Open Release/Debridement Soft Tissue Interposition 27 yo male weight lifting coach for a high school football team Open debridement No interposition 35 y o RHD union carpenter Two year history of right shoulder pain Motion 120º elevation 30º external rotation L5 internal rotation 6

7 Surgical (Joint sacrificing) Hemiarthroplasty +/ concentric glenoid reaming Hemiarthroplasty (stemmed or stemless) Resurfacing Concentric reaming only with biconcave glenoid Done without resurfacing Head removal facilitates glenoid exposure Hemiarthroplasty Hemiarthroplasty -N=28 shoulders years mean f/u (13-21) revision rate = 29% - Levine et al 17% - Rispoli et al, 32 % mod-severe pain 2% - Wirth et al Ream and Run Ream and Run Lynch et al. J Bone Joint Surg Am, 2007 Jun 01;89(6):

Ream and Run 55 and under 65 shoulders in patients 55 and under Minimum 2 yr f/u 22 with radiographic f/u Avg. medial erosion of 1.

Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 2011;20:609 15.

9) SANE=74.5%; PSS=82.9; SST 10.4 Correlated with motion and age Getz CL, Kearns KA, Padegimas EM, Johnston PS, Lazarus MD, Williams GR, Jr.

8 Ream and Run 55 and under 65 shoulders in patients 55 and under Minimum 2 yr f/u 22 with radiographic f/u Avg. medial erosion of 1.1 mm at 44 months 14% revision rate at 2 years or less Saltzman MD, Chamberlain AM, Mercer DM, Warme WJ, Bertelsen AL, Matsen FA, 3rd. Shoulder hemiarthroplasty with concentric glenoid reaming in patients 55 years old or less. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 2011;20: Ream and Run 24 shoulders 21 were 55 or younger Reamers inconsistent, excised labrum Minumum 2 yr f/u 6 (25%) required revision within 2 yrs The remaining 15 shoulders followed 3.7 yrs ( ) SANE=74.5%; PSS=82.9; SST 10.4 Correlated with motion and age Getz CL, Kearns KA, Padegimas EM, Johnston PS, Lazarus MD, Williams GR, Jr. Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid. The Journal of the American Academy of Orthopaedic Surgeons 2017;25: Hemiarthroplasty + biologic resurfacing Hemiarthroplasty + biologic resurfacing No to minimal posterior subluxation Minimal glenoid deformity Wirth, et. al. Biologic Interposition Excel Satis Unsatis Neer Criteria Wirth M. A. J Bone Joint Surg 2009:91: Krishnan S. G., Burkhead W. Z., et.al. J Bone Joint Surg 2008:90:9-19 8

Biologic Interposition Elhassan B., Warner J. JP., et.

Arthroplasty Better than hemiarthroplasty in older

revision HHR Glenoid erosions 68 72% Survival estimates

Unsatisfactory Hemis and Totals will both Fail 1) 46 vs

yrs) Hemiarthroplasty Glenoid erosion often asymmetric

augmented component never as good as initial total

bone loss usually central Often cannot be revised to 2

9 Biologic Interposition Elhassan B., Warner J. JP., et.al. J Bone Joint Surg 2009:91: Total Shoulder Arthroplasty Better than hemiarthroplasty in older patients Concern for glenoid longevity Concern for revision HHR Glenoid erosions 68 72% Survival estimates less than Glenoid lucency 59 76% For All: > 50% Unsatisfactory Hemis and Totals will both Fail 1) 46 vs 20 hemiarthroplasties 2) Minimum f/u 2 years (mean 7 yrs) Hemiarthroplasty Glenoid erosion often asymmetric with subluxation Often require structural bone graft or augmented component never as good as initial total would have been Total Shoulder Arthroplasty Glenoid bone loss usually central Often cannot be revised to 2 nd anatomic glenoid at 1 st revision May have humeral bone loss from polyethylene wear 9

Hemi to Total Hemi to Total Follow up 5.

3%) Follow up ~5 years Complications (45%) Reoperations (21%) How do we

cost and effectiveness of hemiarthroplasty and total shoulder arthroplasty in

10 Hemi to Total Hemi to Total Follow up 5.5 years Unsatisfactory Outcome (47%) Reoperations (33.3%) Follow up ~5 years Complications (45%) Reoperations (21%) How do we decide? Value Based Decision Making Purpose: Clin Orthop Relat Res Nov;474(11): Functional Outcome Cost Survival To create decision model that could evaluate cost and effectiveness of hemiarthroplasty and total shoulder arthroplasty in a cohort of young patients (US population yrs at risk Monte Carlo simulation). Methods Markov chain decision tree model to age 70 Hemi Hemi Annual Cohort Size = 5,279 Decision Hemi Death Hemi T 10

Threshold Analysis Implications How could Hemis be made to equal totals? total reimbursement of hemi to 16,600k/case (from 17.8k) 10 years survival rate of hemi to 90.

11 Threshold Analysis Implications How could Hemis be made to equal totals? total reimbursement of hemi to 16,600k/case (from 17.8k) 10 years survival rate of hemi to 90.7% (from 82%) Treatment of glenohumeral arthritis in patients aged 30 to 50 in the United States with total shoulder arthroplasty, instead of hemiarthroplasty, would results in: 1. Greater cost savings 2. Avoid a substantial number of revision surgeries 3. Greater years with a satisfactory outcome Disclaimer: per case patient selection for treatment remains important Personal Approach Personal Approach Accept that all patients will need revision Minimize the number aim for 1 2 Choose least invasive option with any hope of success Preserve joint if possible When sacrificing the joint, preserve as much bone as possible especially glenoid Include patient in the process shared decision making Every patient gets initial nonoperative management Primarily injections and activity modification Arthroscopic debridement Concentric joint, mild to moderate deformity, mild to moderate stiffness Arthroscopic capsular release Concentric joint, no to mild deformity, moderate to severe stiffness Arthroscopic interposition Rarely used extremely young, concentric glenoid, bad glenoid, minimal deformity, mild to moderate stiffness Open debridement/capsulectomy Extremely young/active, concentric joint, no longer use interposition, motivated patient Hemiarthroplasty Most lifters, ream if biconcave, motivated patient, no longer use resurfacing, stemless good option Total shoulder Concentric joint in lay glenoid Biconcave augmented component Conclusions There are no right answers. There are only individualized decisions Thank You No treatment is life-long No treatment is curative Consider the revision surgery Tremendous opportunity for innovation 11

Shoulder DJD in Athletic patient. What is Athletic? McCarty University of Colorado Fall Sports Medicine Symposium. Oct. 3, 2008

Shoulder DJD in Athletic patient. What is Athletic? McCarty University of Colorado Fall Sports Medicine Symposium. Oct. 3, 2008 Indications for Shoulder Arthroplasty in Athletic Patients Eric C. McCarty, M.D. Associate Professor, Dept. of Orthopaedics Chief, Sports Medicine and Shoulder Surgery Head Team Physician, University of