The young patient with end-stage glenohumeral arthritis who wants to return
to active sports activities or manual labor poses a difficult treatment
challenge. Traditionally, these patients, especially those requiring the
shoulders for overhead use, have been denied total shoulder arthroplasty
because of concern about failure of the glenoid
component1.
Accelerated loosening of polyethylene glenoid components and increased
polyethylene wear are theoretical concerns regarding total shoulder
arthroplasty in younger
patients2-8.
One alternative is to perform an isolated humeral hemiarthroplasty in these
patients. However, in several large series, hemiarthroplasty was found to be
inferior to total shoulder arthroplasty with regard to pain relief, range of
motion, strength, and eventual functional
outcome9-13.
In an effort to offer these young active patients the clinical benefits of
total shoulder arthroplasty without the complications attendant to
conventional glenoid components, we have utilized a technique combining
prosthetic humeral hemiarthroplasty with biologic resurfacing of the
glenoid.
The patient is placed in a modified beach-chair semisupine position with
the head of the operating table elevated 20°. A limited deltopectoral
approach is performed through a 2-in (5-cm) skin incision paralleling the path
of the cephalic vein (Fig. 1).
Once the clavipectoral fascia is identified and the conjoined tendon is
retracted, the axillary nerve is identified crossing the belly of the
subscapularis muscle from superomedial to inferolateral. The biceps tendon is
identified in the intertubercular groove and is released from the supraglenoid
tubercle for later tenodesis.
At this time, the three borders of the subscapularis (superior, lateral,
and inferior) are identified and the subscapularis is released with a small
"fleck" of bone from the lesser tuberosity
(Fig. 2). This bone
"fleck" is generally 2 cm long, 1 cm wide, and 3 to 4 mm thick.
The subscapularis is released in continuity with the underlying capsule from
the humeral neck and then mobilized on its superior, posterior, and inferior
surfaces. We do not resect the anteriorinferior aspect of the capsule but
rather incise this part of the capsule to both increase excursion of the
subscapularis and improve the glenohumeral range of motion.
After removal of the ring of osteophytes from the humeral head, a humeral
osteotomy is performed along the true anatomic neck. At this time, prior to
humeral preparation, attention is turned to the glenoid. A single Darrach
retractor is placed along the posterior-inferior glenoid margin to retract the
humeral head, and a classic Rowe or Bankart retractor is placed along the
anterior aspect of the glenoid neck to retract the subscapularis and anterior
aspect of the capsule. Once the glenoid is exposed, care is taken to preserve
the circumferential glenoid labrum for graft fixation. Glenoid version is now
corrected with motorized reamers until the glenoid surface is perpendicular to
the scapula (neutral version) (Figs. 3-A
and 3-B). Several 2.0-mm drill-holes are placed in the prepared
glenoid surface in order to create a bleeding bed for the biologic graft
(Fig. 3-C). Once the glenoid
surface has been prepared, four double-loaded absorbable suture anchors with
nonabsorbable sutures are placed at the "cruciate corners" of the
glenoid—the positions on the glenoid that correspond to the positions on
a clock face of 12, 3, 6, and 9 o'clock
(Fig. 4).
Next, the Achilles tendon allograft for biologic resurfacing is prepared.
From the beginning of the surgical procedure, the graft has been thawing in
warm saline solution. The calcaneal osseous attachment is resected from the
thawed tendon prior to preparation of the graft
(Fig. 5). The fascial portion
of the tendon is now folded on itself two or three times (depending on the
graft length) to create a glenoid shape of appropriate size, and the shape is
maintained by suturing the periphery of the graft with a running mattress
suture of heavy nonabsorbable material
(Fig. 6-A). The final prepared
graft is approximately 6 to 8 mm thick
(Fig. 6-B).
The graft is now inset by passing all sutures from the suture anchors
through the graft in a horizontal mattress fashion
(Fig. 7). Once all sutures are
passed, the graft is reduced to the glenoid surface (the
"parachute" maneuver), and all sutures are tied. The remaining
tail of the graft is used to pull on the inset graft in order to test
fixation, and then this remaining calcaneal portion of the graft is removed.
If further fixation is necessary, four number-2 nonabsorbable sutures are
placed at the glenoid labral rim midway between each anchor, and these sutures
are passed through the graft in a simple fashion
(Fig. 8).
Once biologic resurfacing of the glenoid is completed, we perform the
humeral hemiarthroplasty. We utilize a third-generation humeral component
(fixed with or without cement) that respects the anatomic center of rotation
of the proximal humeral articular surface (Aequalis Shoulder System; Tornier,
St. Ismier, France). The subscapularis bone "fleck" is reduced and
is fixed with eight transosseous heavy nonabsorbable sutures in a
biomechanically validated dual-row fashion
(Figs. 9-A, 9-B, and 9-C). The
rotator interval is closed with the arm held in 30° of external rotation,
and a biceps soft-tissue tenodesis is performed with a locking suture in the
rotator interval region. Routine wound closure is completed, and no drains are
utilized. Postoperative radiographs are used to confirm proper positioning of
the arthroplasty (Fig.
10).
Postoperatively, all patients are treated as if they had had a standard
total shoulder arthroplasty—i.e., with a Velpeau arm sling for four
weeks and supine passive range-of-motion exercises immediately. The sling is
removed after four weeks, and a full active range of motion is begun, with
resistance exercises started during the eighth postoperative week. Full
activity (including sports and/or manual labor) is allowed between three and
six months after the surgery, depending on functional recovery.
CRITICAL CONCEPTSINDICATIONS:A young, active patient, less than sixty years of age, with nonconcentric
posterior glenoid wearPosttraumatic, postoperative, or primary glenohumeral arthritis in an
individual who performs strenuous manual laborFailed hemiarthroplasty or total shoulder arthroplasty requiring glenoid
salvage and precluding implantation of a conventional glenoid componentCONTRAINDICATIONS:Active infectionA history of graft-versus-host diseasePITFALLS:The main pitfall, as with any total shoulder arthroplasty, is related to
exposure and preparation of the glenoid. Failure to achieve proper exposure
prevents the consistent preparation of the glenoid that is required for
successful placement and fixation of the graft. We believe that adequate
exposure is greatly facilitated by proper patient positioning and appropriate
soft-tissue releases. This technique is applicable in any situation requiring
glenoid resurfacing, and it is particularly useful in cases of deficient
glenoid bone stock such as is found in revision total shoulder
arthroplasty.AUTHOR UPDATE:Although it is as yet investigational, we currently favor allograft human
dermis for our glenoid resurfacing. Our experience with this tissue is still
short-term (maximum, two years), but we have found this graft to be less
bulky, which reduces the chances of lateralizing the joint center of rotation.
We have successfully utilized dermal allograft in more than twenty glenoid
resurfacing procedures, and we continue to investigate the potential for
incorporation and metaplasia that this tissue may provide. Furthermore, with
the advent of double-loaded suture anchors, we no longer routinely augment our
anchor fixation with transosseous Bankart sutures. Our anecdotal experience
indicates that double-loaded anchors placed in a cruciate pattern are
adequate, although we do not hesitate to place the peripheral glenoid labral
sutures if necessary.
CRITICAL CONCEPTS
INDICATIONS:
A young, active patient, less than sixty years of age, with nonconcentric
posterior glenoid wearPosttraumatic, postoperative, or primary glenohumeral arthritis in an
individual who performs strenuous manual laborFailed hemiarthroplasty or total shoulder arthroplasty requiring glenoid
salvage and precluding implantation of a conventional glenoid component
A young, active patient, less than sixty years of age, with nonconcentric
posterior glenoid wear
Posttraumatic, postoperative, or primary glenohumeral arthritis in an
individual who performs strenuous manual labor
Failed hemiarthroplasty or total shoulder arthroplasty requiring glenoid
salvage and precluding implantation of a conventional glenoid component
CONTRAINDICATIONS:
Active infectionA history of graft-versus-host disease
Active infection
A history of graft-versus-host disease
PITFALLS:
The main pitfall, as with any total shoulder arthroplasty, is related to
exposure and preparation of the glenoid. Failure to achieve proper exposure
prevents the consistent preparation of the glenoid that is required for
successful placement and fixation of the graft. We believe that adequate
exposure is greatly facilitated by proper patient positioning and appropriate
soft-tissue releases. This technique is applicable in any situation requiring
glenoid resurfacing, and it is particularly useful in cases of deficient
glenoid bone stock such as is found in revision total shoulder
arthroplasty.
AUTHOR UPDATE:
Although it is as yet investigational, we currently favor allograft human
dermis for our glenoid resurfacing. Our experience with this tissue is still
short-term (maximum, two years), but we have found this graft to be less
bulky, which reduces the chances of lateralizing the joint center of rotation.
We have successfully utilized dermal allograft in more than twenty glenoid
resurfacing procedures, and we continue to investigate the potential for
incorporation and metaplasia that this tissue may provide. Furthermore, with
the advent of double-loaded suture anchors, we no longer routinely augment our
anchor fixation with transosseous Bankart sutures. Our anecdotal experience
indicates that double-loaded anchors placed in a cruciate pattern are
adequate, although we do not hesitate to place the peripheral glenoid labral
sutures if necessary.