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Copeland Surface Replacement Arthroplasty of the Shoulder in Rheumatoid Arthritis
Ofer Levy, MD, MCh(Orth)1; Lennard Funk, MSc, FRCS(Tr and Orth)2; Giuseppe Sforza, MD3; Stephen A. Copeland, FRCS4
1 Reading Shoulder Unit, Royal Berkshire Hospital, Reading RG1 5AN, United Kingdom. E-mail address: oferlevy@readingshoulderunit.com
2 Hope Hospital, Manchester M6 8HD, United Kingdom
3 Unita di Ortopedia, Ospedale “S. Maria delle Grazie,” Matera 70125, Italy
4 Reading Shoulder Unit, Berkshire Independent Hospital, Reading RG1 6UZ, United Kingdom
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. S.A. Copeland received royalties from a commercial entity (Biomet Merck, Ltd.). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Reading Shoulder Unit, Royal Berkshire Hospital, Reading, United Kingdom

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):512-518
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Background: 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.

Methods: 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.

Results: 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° in the hemiarthroplasty group and 47° in the total shoulder replacement group to 101° and 104°, 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.

Conclusions: 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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    James W. Pritchett
    Posted on April 06, 2004
    Copeland Surface Replacement Arthroplasty

    To The Editor:

    I read with great interest the article entitled “Copeland Surface Replacement Arthroplasty of the Shoulder in Rheumatoid Arthritis”(2004; 86:512-518) by Levy et al. The long- term results of the Total Articular Replacement Arthroplasty (TARA) corroborate the authors’ findings. The TARA prosthesis with its characteristic curved stem was developed and commonly used as a femoral head surfacing prosthesis starting in 1952.1,2 The humeral prosthesis had a shorter stem and was first used in 1957 by the innovator Charles O. Townley of Port Huron, MI.

    Since neither polyethylene nor polymethylmethacrylate was readily available the prosthesis was used as a press fit hemiarthroplasty. Starting in 1960 polyurethane was occasionally used to resurface the glenoid and if the humeral fixation was in doubt polyurethane was used as cement. More than 100 humeral TARA prostheses were implanted with a follow-up interval as long as 33 years.

    When a hemiarthroplasty was performed the glenoid was prepared, just as the authors report for the Copeland prosthesis, by drilling to encourage fibrous tissue in growth. The implant, therefore, functions as an articular barrier assisting the formation of a self lubricating, soft, mobile, pseudobiological fibrous joint. In the cases where polyurethane was used it fragmented and ultimately disappeared radiographically. The joint then functioned as a hemiarthroplasty. There was neither apparent adverse reaction to polyurethane debris in patients nor were adverse changes found at necropsy in dogs.

    Many of the patients also had hip arthritis and received a TARA hip prosthesis. The size of the humeral and femoral surfacing prosthesis was the same. A ceramic resurfacing prosthesis became available in 1995. Like resurfacing operations for the hip, the technique of resurfacing arthroplasty of the shoulder is demanding and critical to the long-term success of the procedure.

    James W. Pritchett, MD 1101 Madison #400 Seattle, WA 98104

    JimP@PacMed.org 206 505 1043

    1. Freeman M: Total surface hip arthroplasty. Clin Orthop 134:2-4, 1978.

    2. Townley CO: Hemi and total articular replacement arthroplasty of the hip with a

    fixed femoral cup. Orthop Clin North Amer 13:869-894, 1982.

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