Abstract
Background: While there have been numerous reports concerning glenohumeral arthrodesis for many indications, there is little available information specific to glenohumeral arthrodesis performed after failed prosthetic shoulder arthroplasty. The purpose of this study was to report the outcomes of glenohumeral arthrodesis in the setting of severe glenohumeral bone loss and deltoid muscle and rotator cuff insufficiency following failed prosthetic shoulder arthroplasty.
Methods: We retrospectively reviewed clinical and radiographic data on seven consecutive patients treated with glenohumeral arthrodesis following a failed prosthetic shoulder arthroplasty between 1997 and 2004. The average duration of clinical follow-up was four years (range, 1.5 to eight years).
Results: Five of the seven patients demonstrated an intact fusion at the time of the latest follow-up. Four of the seven patients had undergone additional bone-grafting procedures in an effort to obtain union. Two of these patients ultimately had a persistent nonunion despite the additional procedures for bone-grafting and revision of the fixation hardware. Overall, the average subjective clinical outcome score (Penn Shoulder Score) improved significantly from 17 points (range, 8 to 33 points) to 58 points (range, 31 to 77 points) (p = 0.008). The most common complication was delayed union requiring additional procedures for bone-grafting and revision of the fixation hardware.
Conclusions: Treatment of a failed prosthetic shoulder arthroplasty with concomitant extensive glenohumeral bone loss and soft-tissue deficiencies is extremely challenging. The results of this study suggest that glenohumeral arthrodesis can yield satisfactory clinical outcomes. However, both the patient and the surgeon should be aware of the complex nature of this surgery and the frequent need for additional surgical procedures to obtain fusion.
Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Prosthetic glenohumeral arthroplasty is an established and effective treatment for glenohumeral arthrosis. The rate of survival of shoulder replacements has been reported to be 87% at fifteen years1-5. When failure occurs, the principal reasons include joint infection, aseptic loosening of the glenoid or humeral component, rotator cuff tears, stiffness, instability, and component malposition resulting in adverse shoulder mechanics2-6.
In most cases, the causes of the failed shoulder arthroplasty can be addressed during revision surgery, at which time insertion of new prosthetic components may be necessary. In the setting of a failed arthroplasty, every effort should be made to maintain the function of the glenohumeral joint. However, in rare cases, severe glenohumeral bone loss with absent rotator cuff and deltoid muscle function may occur as a consequence of multiple prior operations, removal of prosthetic components, joint infection, or axillary nerve injury. In this situation, the chance of a successful outcome with a revision arthroplasty may be unacceptably low. Removal of the prosthetic components either without prosthetic reimplantation (resection arthroplasty) or with glenohumeral arthrodesis remains a surgical option.
The results of glenohumeral arthrodesis for non-prosthesis-related shoulder problems have been reported previously7-28. To our knowledge, functional and anatomic data regarding arthrodesis for treatment of a failed prosthetic arthroplasty in the setting of severe rotator cuff and deltoid deficiency are lacking. The purpose of this retrospective review was to report patient outcomes at a minimum of two years after glenohumeral arthrodesis done following a failed prosthetic shoulder arthroplasty associated with severe soft-tissue and bone deficiency.
All patients in whom a glenohumeral arthrodesis had been performed after removal of a failed shoulder arthroplasty prosthesis and who had been followed clinically for at least eighteen months were included in this study. Between 1997 and 2004, glenohumeral arthrodesis was performed for the treatment of a failed prosthetic arthroplasty in eight patients. One patient was lost to follow-up after only three months and was therefore not included in this review. The seven remaining patients (three men) with a mean age of forty-seven years (range, twenty to sixty-five years) were available for follow-up. Of these seven patients, one (Case 5) was lost to follow-up after eighteen months. Information from this patient's family indicated that she had died six years after the fusion surgery but had maintained the same painless function that was present at the time of her latest clinical follow-up. The mean time to follow-up for the seven patients was four years (range, 1.5 to eight years). Detailed patient data are presented in Table I.
Immediate preoperative and postoperative clinical and radiographic data on all patients were collected. Except for one patient (Case 5), all returned for clinical examination, at which time they completed subjective questionnaires and new radiographs (anteroposterior, true anteroposterior, and axillary views of the shoulder as well as anteroposterior and lateral views of the humerus) were made.
A previously validated subjective shoulder outcome questionnaire stratifying pain, satisfaction, and function (the Penn Shoulder Score) was administered preoperatively and at the time of the most recent follow-up29-31. Statistical analysis of this scoring system demonstrated that it has high reliability with good correlation of its total scores with the Constant-Murley and American Shoulder and Elbow Surgeons (ASES) shoulder scores32. The Penn Shoulder Score also has demonstrated better precision than the ASES score and the Simple Shoulder Test throughout all score ranges29. Subjective outcome questionnaire data were not available for one patient (Case 5), but clinical information was obtained at the eighteen-month follow-up examination of that patient.
Four patients had a failed total shoulder arthroplasty, and three patients had a failed humeral head replacement. The indication for arthrodesis in six of the seven patients included a painful, poorly functioning shoulder prosthesis and absence of a functional rotator cuff and deltoid muscle. The remaining patient had a painful and poorly functioning humeral head replacement with aseptic loosening and migration and a deficient rotator cuff but had intact deltoid muscle function. For this patient, the arthrodesis was performed before a reverse total shoulder prosthesis had been approved for use in the United States. Had this device been available, this patient may have been a candidate for its use considering the intact deltoid muscle function. Active infection was not present in any of the patients. Patient data were collected and analyzed in accordance with and approval of our institutional review board. Our institutional review board deemed that individual patient consent was not required because the study was a retrospective chart review.
Differences between the preoperative and postoperative outcome scores were evaluated with use of the paired Student t test. Nonparametric tests were used when the data were not normally distributed.
Surgical Technique
Glenohumeral arthrodesis following a failed prosthetic replacement is a technically demanding procedure. The need for and type of bone graft were determined preoperatively. The volume of bulk structural graft that was typically needed was not obtainable from the patient's iliac crest, and thus a femoral head allograft was utilized preferentially. In three patients, in whom the tuberosities were missing or not attached to the humeral shaft and a large portion of the proximal part of the humerus was deficient, a vascularized fibular autograft was used to provide a reconstructive solution for this extent of bone loss.
General anesthesia was combined with an interscalene regional block. The patient was positioned in a beach-chair configuration, with the involved shoulder brought over the edge of the table, allowing a full range of motion of the shoulder and global surgical access. When a vascularized fibular graft was used, both lower limbs were prepared from the groin to the toes.
The incision was made over the spine of the scapula, curving anteriorly over the acromion. The scar from previous deltopectoral incisions was incorporated as the distal extent of the arthrodesis incision. The deltopectoral interval was dissected to the clavicle while the remaining portions of the anterior and middle deltoid were detached subperiosteally from the clavicle and acromion. With the detached deltoid retracted distally, the entire proximal part of the humerus was exposed. The prosthetic components were removed. In two patients (Cases 1 and 4), this required a longitudinal osteotomy of the humerus. After the humeral stem was removed, the remaining bone stock and soft-tissue defects were evaluated. Scar and detritus in the surgical bed were completely removed to expose the bone surfaces. The entire glenoid fossa, rim, and vault walls were exposed to define the best placement of the fibular graft or proximal part of the humerus. In the patients with a failed total shoulder arthroplasty, the glenoid component was removed and the soft tissues and debris were removed from the surrounding glenoid vault.
The optimal position of the fused shoulder is controversial9,11,12,17. In a fusion following a failed arthroplasty, the position that will allow proper function needs to be balanced with the position of the remaining humeral and glenoid bone that will optimize bone-to-bone contact, stability, and ultimately osseous union. The position of fusion that we chose for all patients was 10° to 20° of abduction, 10° to 20° of flexion, and 35° to 45° of internal rotation. This position generally allows the patient to reach the mouth, waist, back pocket, and contralateral shoulder, thus facilitating activities of daily living.
When the tuberosities were intact, they were shaped with minimal bone removal and were fit around the glenoid. Given that the tuberosities have a blood supply, the potential for fusion is enhanced. Fixation of the tuberosities to the glenoid was done separately with large cancellous screws inserted through the intact tuberosity and into the glenoid vault. Soft tissue from the underside of the acromion was removed, and its undersurface was planed to provide a flat surface for fusion while an attempt was made to remove as little bone as possible. After initial fixation with screws, the structural allograft was cut to fit between the tuberosities, the acromion, and the humeral shaft. A large-fragment pelvic reconstruction plate was contoured to the spine of the scapula, the acromion, the bone graft, and the humeral shaft distally (Fig. 1).
As mentioned, a vascularized fibular autograft was used in three patients in this series. The decision to use the fibular graft was based on the preoperative evaluation of the radiographs by the senior author (J.P.I.) and the assumption that this method offered a way to accommodate massive bone loss with biologic tissue. In general, if both tuberosities were no longer attached in any manner to the humeral shaft and there was =5 cm of proximal humeral bone loss, a fibular autograft was employed. For these cases, the medullary canal of the humerus was prepared so that the fibula could be placed within it, and at least two cortical (4.5-mm) screws were placed through the humeral shaft, transfixing the fibula. A glenoid slot was prepared such that the proximal end of the fibula could be inserted like a dowel into the glenoid vault with good side-to-side contact with the vault. Two 4.5-mm cortical screws were placed into the proximal part of the fibula and then into the glenoid vault. A large-fragment pelvic reconstruction plate was contoured as described above and fixed with cortical and cancellous screws. The fibular graft was then revascularized by the microvascular surgical team.
Postoperatively, the shoulder was immobilized in a shoulder spica cast for at least twelve weeks (range, twelve to fifteen weeks) or until radiographic evidence of fusion was present. Scapular range-of-motion and strengthening exercises were initiated after immobilization.
Details regarding the results and characteristics of the seven patients are presented in Table I. The average duration of follow-up was fifty months (range, eighteen to ninety-six months). All patients had undergone multiple surgical procedures (average, five; range, two to fifteen) prior to the first fusion surgery.
Rate of Union
Five of the seven patients had union of the fusion site at the time of the most recent follow-up. In three patients (Cases 1, 2, and 3), union was achieved after one attempt. In two patients (Cases 4 and 5), union was obtained after additional bone-grafting procedures performed separately from the initial arthrodesis surgery. Union was diagnosed when orthogonal radiographs of the fusion site were free of lucent lines and the patient had no pain at the fusion site.
Two patients (Cases 6 and 7) had a persistent nonunion at the time of the most recent follow-up. In both of these patients, a vascularized free fibular graft had been used to address massive humeral bone loss. In one of these patients (Case 6), the arthrodesis, performed when he was twenty years of age, was done with an intercalary vascularized free fibular graft following failure of two prior surgical procedures in which a custom total shoulder tumor prosthesis had been used with a large segmental allograft (Fig. 2). The initial arthroplasty was performed at the age of seven years for the treatment of an osteosarcoma. Because of serial radiographic evidence of minimal bone-healing, the patient underwent revision of both fusion sites with iliac crest bone graft three months after the initial fusion attempt. Although clinical and radiographic evidence twelve months after the bone-grafting suggested union at both fusion sites, this patient presented later with a painless, fibrous nonunion at the proximal fusion site thirty-seven months following the initial fusion surgery.
The other patient with a nonunion (Case 7) at the time of the most recent follow-up had had multiple procedures for treatment of a four-part proximal humeral fracture. She ultimately had a failed proximal humeral replacement with a large degree of proximal humeral cortical bone loss and absent tuberosities. The arthrodesis procedure incorporated a vascularized free fibular graft to accommodate the cortical bone loss. A pseudarthrosis developed at the proximal fusion site and persisted despite revision of the fixation hardware and additional autologous bone-grafting. Removal of the failed, symptomatic hardware at sixty-five months resulted in a resection arthroplasty with a decreased level of shoulder discomfort, but function remained poor (Fig. 3).
Results of the Free Fibular Graft
In four patients (Cases 2, 5, 6, and 7), a vascularized free fibular graft was used in order to address massive humeral bone loss. In one of these patients (Case 2), the tuberosities were absent along with 4 cm of the humeral shaft. A vascularized free fibular graft was attempted, but the vascular anastomoses to the fibula were compromised intraoperatively, essentially resulting in a nonvascularized free fibular graft. Union was still obtained in this patient without additional surgical intervention. This patient was followed for eight years.
Another patient (Case 5) in whom a vascularized fibular graft had been utilized to accommodate severe proximal humeral bone loss had an additional autogenous iliac crest bone-grafting procedure as treatment for a delayed union at three months after the fusion surgery. At twelve months, the arthrodesis hardware, which had become symptomatic, was removed. Intraoperative evaluation of the fusion site at that time demonstrated it to be fully healed, with the fibula incorporated and stable. This patient was lost to follow-up eighteen months after the index arthrodesis. At the last clinical follow-up visit, the patient was able to perform normal activities of daily living without pain. The family reported that, at the time of her death six years after the fusion surgery, the shoulder was pain-free and she had not had any deterioration of function after her last clinical follow-up examination. The Penn Shoulder Score was not available for this patient.
Although a vascularized fibular graft was utilized in Cases 6 and 7 to accommodate massive proximal humeral bone loss, they each presented with a nonunion at the time of the most recent follow-up. No vascular studies were performed in these patients postoperatively to verify patency of the vascularized graft.
Clinical Outcome Measures
The 100-point Penn Shoulder Score has three components: pain (maximum, 30 points), satisfaction (maximum, 10 points), and function (maximum, 60 points). Five of the six patients had improvement in two (pain and function) of the three components of the Penn Shoulder Score. The average pain score improved from 8 points (range, 2 to 16 points) to 26 points (range, 21 to 29 points) (p = 0.001), the average satisfaction score improved from 2 points (range, 0 to 7 points) to 7 points (range, 0 to 10 points) (p = 0.06), and the average function score improved from 8 points (range, 0 to 16 points) to 26 points (range, 10 to 38 points) (p = 0.03). The average total Penn Shoulder Score improved from 17 points (range, 8 to 33 points) to 58 points (range, 31 to 77 points) (p = 0.008).
Additional Procedures
Five of the seven patients required additional procedures after the initial fusion surgery (Table I). Two (Cases 1 and 5) required removal of symptomatic hardware eight and twelve months, respectively, after the index arthrodesis. Four patients (Cases 4 through 7) required additional bone-grafting and revision of loose fixation hardware to treat delayed union of the fusion site. One patient (Case 4) underwent two such procedures, at seven and nine months, and eventually obtained a solid union. Bone-grafting was performed at six months in Case 5. Two patients (Cases 6 and 7) did not demonstrate union at the time of final follow-up despite the bone-grafting and revision of loose fixation hardware (at four and six months, respectively). In Case 4, a superficial wound infection developed following the last bone-grafting procedure and was treated successfully with débridement and antibiotics. No deep infections occurred in this series.
Arthrodesis following a failed prosthetic shoulder arthroplasty is usually undertaken as a salvage procedure when additional reconstructive options are not possible. Accordingly, this procedure should be viewed as having limited goals. Providing pain relief and a stable platform for elbow and hand function as well as allowing some active elevation of the shoulder through scapulothoracic motion are the primary objectives of glenohumeral arthrodesis. Outcomes of glenohumeral arthrodesis for indications other than failed prosthetic shoulder arthroplasty have been reported previously7-28. However, to our knowledge, peer-reviewed information relative to arthrodesis following failed shoulder arthroplasty is scarce9,14,19,33.
The results of forty-three shoulder arthrodeses, two of which were performed following removal of a failed shoulder prosthesis, were reported by Rühmann et al.19. Pseudarthrosis was observed in one of the patients in whom bone graft had not been used. The authors suggested that bone graft be used in the setting of bone loss to help secure a solid fusion.
The results of fifty-seven glenohumeral arthrodeses were reviewed in another series, by Richards et al.14. Included were two patients for whom this procedure was performed subsequent to a failed total shoulder arthroplasty. One of these patients had a nonunion and required revision surgery and bone-grafting before fusion was obtained.
Given that only a small proportion of the glenohumeral arthrodeses described in the literature were done for the treatment of a failed prosthetic shoulder arthroplasty, the indications for and specific results following this procedure are difficult to assemble. In our series, the indication for arthrodesis was a painful, failed shoulder prosthesis with severe osseous and soft-tissue deficiencies in a patient who wished to obtain function beyond what a resection arthroplasty was likely to provide and for whom alternative reconstructive options would not have provided benefit.
Of the six patients for whom preoperative and postoperative subjective clinical outcome measures were available, five showed substantial improvement. The remaining patient, who had a symptomatic nonunion, had similar total preoperative and postoperative Penn Shoulder Scores (33 compared with 31 points). These results suggest that, when union occurs, subjective improvements in pain and function scores can be expected. Although the average total postoperative score was 58 of a possible 100 points, it should be remembered that this is a salvage procedure and that the average preoperative score was only 17 points. By way of comparison, analysis of our shoulder surgery registry revealed that seventy-six patients in whom a primary total shoulder arthroplasty had been performed for treatment of osteoarthritis had an average improvement in the total Penn Shoulder Score from 32 ± 15 points preoperatively to 80 ± 22 at a minimum of two years postoperatively. Thus, severe pain and very low functional scores were greatly improved in five of our six patients.
The decision to utilize a vascularized free fibular graft was based on extensive (>5-cm) humeral cortical bone loss and absence of both tuberosities. No postoperative vascular studies of the grafts were performed to verify their vascularity. Therefore, the extent to which the grafts remained vascularized postoperatively and how this may have influenced the chances of eventual union are unknown.
One patient (Case 7) presented initially with a failed hemiarthroplasty following failed osteosynthesis of a four-part proximal humeral fracture. At the time of the arthrodesis in 2001, a reverse-type shoulder prosthesis was not available for wide use in the United States. Use of such a prosthesis may have been a viable surgical option in this case, considering that the deltoid muscle remained functional.
The most frequent complication encountered in this series was delayed union or nonunion of the fusion site. This underscores the challenging nature of these procedures when compared with shoulder arthrodeses for other, non-prosthesis-related indications, which have been reported to have high union rates7,9,10,12,14,15,19.
This review has limitations inherent to its retrospective nature and the size of the study population. Furthermore, only limited follow-up (eighteen months) was available for one patient. However, we believe that it is the largest series specific to arthrodesis for failed prosthetic arthroplasty reported to date.
Arthrodesis does present a salvage option for some selected cases in which other reconstructive options would probably provide little benefit. Resection arthroplasty, however, may be a more appropriate option for older, lower-demand patients, in whom a complex arthrodesis procedure, extensive bone-grafting, and prolonged immobilization would typically be inappropriate. In a study of seven patients with recalcitrant periprosthetic infection, Braman et al. showed that resection arthroplasty can allow maintenance of sufficient function to perform activities of daily living34. Although overall shoulder function was poor in that study, with an average elevation of only 28°, the patients were satisfied with the result. Other authors have demonstrated similar outcomes and defined narrow indications for resection arthroplasty as a salvage procedure35,36.
Glenohumeral arthrodesis following a failed prosthetic arthroplasty is a salvage procedure requiring realistic expectations from both the patient and the surgeon. The operative indications for this procedure should be appropriately narrow to include only patients in whom additional reconstructive options would not be likely to provide a benefit. Also, some patients with remaining deltoid muscle function may preferentially be candidates for revision arthroplasty with use of the currently available reverse-type total shoulder prosthesis. The challenges of obtaining a fusion and the likelihood of the need for additional bone-grafting procedures should be prominent in discussions with the patient regarding the anticipated results of glenohumeral arthrodesis following a failed prosthetic arthroplasty. Although this operation should be considered a salvage procedure, with proper patient selection it can be an alternative when other revision options are not likely to provide a favorable outcome. 
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