Should Hemiarthroplasty Be the Index Procedure in Younger Patients with Shoulder Pathology?
Dr. Timothy Reish and Dr. Hunter Hamilton comment on a recently published study on revision of failed hemiarthroplasty to anatomic total shoulder arthroplasty, making the case that hemiarthroplasty may actually be more beneficial than shoulder replacement as the first surgery in a younger patient population.
Timothy G. Reish, MD, and D. Hunter Hamilton, MD
Sheth MM, Sholder D, Abboud J, Lazarus MD, Ramsey ML, Williams, GR, Namdari S. Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2018 Oct;27(10):1884-1890. doi: 10.1016/j.jse.2018.03.018. Epub 2018 May 10.
Sheth et al retrospectively evaluated indications, results, implant survival rates, and complications among patients who were revised from hemiarthroplasty (HA) to anatomic total shoulder arthroplasty (aTSA) for glenoid arthrosis and had a minimum of 2 years of follow-up.
Retrospective chart review identified 28 patients with a mean age of 52 ± 12 years (age range, 30 to 75 years) at the time of the index procedure who met the inclusion criteria for the study. Osteoarthritis and osteonecrosis were the primary indications for surgery. Operative reports were reviewed to assess rotator cuff status, adjuvant procedures, and complications. Postoperatively, implant survival, reoperations, and complications were evaluated by retrospective chart review and direct patient contact.
The time from the index procedure to the revision procedure was 4.9 ± 3.7 years in patients with a mean age of 57 ± 12 years (age range, 33 to 77 years). At the time of revision, 3 patients had small repairable rotator cuff tears and 1 patient had non-union of a prior lesser tuberosity fracture. Cemented all-polyethylene glenoid components were used in the revisions, 3 with an all-polyethylene posterior augmented component.
The overall complication rate was 46%, with 3 intraoperative and 10 postoperative complications. Two- and 5-year survival rates were 93% and 86%, respectively, and 6 patients required reoperation, 4 of which were for revision of components. Two of the 3 patients who had a rotator cuff tear at the time of aTSA had implant survival at 84 and 40 months after surgery; the third patient required revision to reverse total shoulder arthroplasty (rTSA).
Overall, 81% of the patients were happy with their surgery, 10% were neutral, and 10% were dissatisfied.
As implant technology improves, our indications for aTSA and rTSA have expanded. But questions remain: What is the best treatment for younger adults with shoulder pathology? Is shoulder HA still a treatment option for them? If revision of shoulder HA is indicated, should the surgeon convert to aTSA or to rTSA?
The most common indication for HA revision is symptomatic glenoid arthrosis. Furthermore, there is concern regarding the wear pattern with posterior glenoid wear and deformity. Given the concern for excessive glenoid wear, many surgeons would consider rTSA over aTSA. Hartel et al  compared rTSA to aTSA and found a higher complication rate (25% vs 14%, respectively) and lower patient satisfaction with rTSA. Conversion from HA to aTSA was associated with a high complication rate (46%) in the study by Sheth et al, with fracture and rotator cuff tear at the time of surgery and subscapularis failure found to be the most common postoperative complications. Three patients required a glenoid component with a posterior augment. Despite the concern for early failure secondary to glenoid wear, the most common cause of re-operation at 5 years was stem revision and cuff failure.
Many recent studies have demonstrated superior pain relief and range of motion with aTSA compared with HA with or without glenoid reaming or biologic interposition. As a result, more physicians have favored reconstruction with aTSA over HA in the younger patient population. Despite these superior outcomes, the lifespan of aTSA implants in younger patients leads us to question whether a more bone preserving approach to the index surgery would be of greater benefit.
Glenoid component loosening is the most common failure mode in aTSA. Reported survivorship of aTSA implants in patients 55 years or younger has varied greatly, ranging from 63% to 92% and compared with 72% in HA. This patient population will likely require revision arthroplasty at some point. Reverse total shoulder arthroplasty is known to result in decreased range of motion and, ultimately, decreased satisfaction with the procedure in younger patients. If we perform an aTSA as the index surgery in these younger patients, we may be predestined to perform an rTSA as the revision procedure, thus limiting our options in the case of re-revision surgery.
In the current climate, cost, efficiency, quality, and outcomes must all be taken into account when determining the best treatment modality for the patient. Although Sheth et al did not compare costs between HA and aTSA, a recent report from Cleveland Clinic evaluated the cost of HA versus rTSA. At their institution, an HA prosthesis cost $4160 compared with $13,300 for an rTSA implant. When these costs were coupled with hospital and physical therapy cost, rTSA was found to have a significantly higher cost than HA: $40,000 for rTSA compared with $22,000 for HA. Not only did HA have a lower cost, but it was also associated with better patient-reported outcomes. Sheth et all did obtain patient-reported outcomes.
Sheth et al demonstrated good short-term (2 years) and mid-term (5 years) implant survival when converting younger patients with an HA to aTSA for symptomatic glenoid arthrosis. Their complication rate was high, but it was similar to complication rates reported for conversion to rTSA. Although this is a retrospective study with inherent limitations, Sheth et al provide compelling evidence that HA is a reasonable option for the younger patient population. With HA as the index surgery, we are able to preserve bone stock for likely future revisions, preventing the need for a salvage procedure as the next surgery, and provide cost-effective care for a challenging patient population.
Timothy G. Reish, MD, is the Director of the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine and Associate Professor, Department of Orthopedic Surgery, NYU Langone Health, New York, New York. D. Hunter Hamilton, MD, is an Adult Reconstruction Fellow, Department of Orthopaedic Surgery, Insall Scott Kelly Institute/NYU Langone Health, New York, New York.
Dr. Reish has disclosed that he is a consultant with Conmed and Arthrex and that he serves on the design team with Catalyst Orthoscience. Dr. Hamilton has no disclosures relevant to this article.
- Hartel BP, Alta TD, Sewnath ME, Willems WJ. Difference in clinical outcome between total shoulder arthroplasty and reverse shoulder arthroplasty used in hemiarthroplasty revision surgery. Int J Shoulder Surg. 2015 Jul-Sep;9(3):69-73. doi: 10.4103/0973-6042.161426.