65 y/o With Limited OA of the Glenoid: Why You Really Need to Put in - - PowerPoint PPT Presentation

65 y/o With Limited OA of the Glenoid: Why You Really Need to Put in a Glenoid

Lawrence V. Gulotta, MD

Director of Research, Sports Medicine and Shoulder Service Co-Medical Director, Leon Root Motion Analysis Laboratory Attending Surgeon, Sports Medicine and Shoulder Service Hospital for Special Surgery New York, NY

Why TS A is Better Than Hemi for OA

Disclosures

Zimmer-Biomet, Inc – Speaking and Consulting

Perspective

• Change the scenario:
• 65 y/o male with groin pain:

“ Let’s do a hip hemiarthroplasty”

• said no arthroplasty surgeon in the last 20 years

Perspective

• 65 y/o with enough OA to justify shoulder arthroplasty,

but with “limited OA of the glenoid”.

Utilization of Hemiarthroplasty

• Kim et al. JBJS

2011

Utilization of Hemiarthroplasty

2011 United S tates

• 66,485 S

houlder Arthroplasties

• 44%

TS A

• 38%

RS A

• 23%

Hemi

Why Hemiarthroplasty

• Hemi attractive due to:
• Don’t have to expose the glenoid
• Technically easier
• Shorter OR time
• Encouraging short term data
• No fear of eventual glenoid loosening
• Especially in young, active patients
• Lower surgical costs

Hemiarthroplasty – Encouraging Short Term

Despite Promising S hort Term Clinical Results All S tudies S how Glenoid Erosion

Hemiarthroplasty – Encouraging Short Term

• All had glenoid erosions
• Revision 37% for painful

glenoid erosion

• 38 Shoulders
• F/U 65.4 months

No Fear of Glenoid Loosening Just Fear of Glenoid Erosion

Hemiarthroplasty – Encouraging Short Term

1997

• 74%

with S atisfactory Results

• 86%

S atisfactory when Glenoid Wear Concentric

• 63%

S atisfacdtory when Eccentric Wear

Hemiarthroplasty – Encouraging Short Term

“ On the basis of these results hemiarthroplasty can be an effective treatment for both primary and secondary arthritis but should be reserved for patients with a concentric glenoid which affords a better fulcrum for glenohumeral motion”

Hemiarthroplasty – Encouraging Short Term, but…

• 25% Satisfied
• 26% Revision Rate
• Concentric did better than

eccentric

• But both deteriorated over

time.

• 31 Shoulders
• F/U 17.2 years

Hemiarthroplasty – Encouraging Short Term, but…

• 25% Satisfied
• 26% Revision Rate
• Concentric did better than

eccentric

• But both deteriorated over

time.

• 31 Shoulders
• F/U 17.2 years

“ Patients with concentric glenoid wear and primary osteoarthritis have better outcomes than those with eccentric glenoid wear and secondary osteoarthritis do, but patients in both groups experienced deterioration of results over time”

What About Glenoid Survival with TSA?

• Glenoid loosening

worsens with time

• 63 TSA’s
• Very durable for 10 years

JBJS , 2014

• Clinical glenoid failure rare
• 151 TSA’s
• Humerus seldom loose (3%)
• Radiographic glenoid

loosening common

JS ES , 2013

What About Glenoid Survival with TSA?

• Clinical glenoid failure rare
• Importance of meticulous glenoid

preparation

• 151 TSA’s
• Humerus seldom loose (3%)
• Radiographic glenoid

loosening common

• Factors associated with

glenoid loosening

• Radiolucent lines at time

zero (OR 4.6)

• Poor glenoid seating at time
• f surgery

JS ES , 2013

What About Glenoid Survival with TSA?

• 125 TSA’s
• End-point revision
• All Glenoids

JS ES , 2009

• All-poly glenoids outperform

metal-backed

What About Glenoid Survival with TSA?

Glenoid Survival – Related to Humeral Position

• 52 TSA’s
• All under 55 years old

JS ES , 2013

• Poorly implanted humeral

component led to glenoid loosening

What Does All This Data Tell Us?

• Glenoid is the weak link
• It requires meticulous preparation

and implantation

• Humeral position is important too

because malposition starts a chain reaction that leads to glenoid loosening.

• Cuff failure
• Rocking horse
• Glenoid failure

S urgical Technique Directly Relates to Long Term Outcomes Can Be Difficult, But Worth Putting In

Hemiarthroplasty vs TSA

• Revisions:
• HHR 10.2%
• TSR 6.5%
• All poly glenoid = 1.7%
• 23 Studies, mean f/u 43

months

• Better outcomes in TSR

compared to HHR

• Pain relief
• ROM
• Pt Satisfaction

Hemiarthroplasty vs TSA

20% of hemi’s were converted to TSA

Hemiarthroplasty vs TSA

TS A Hemi

Hemiarthroplasty vs TSA – Young Patients

• Sperling et al, JBJS 1998
• Patients under 50y/o
• Neer hemi and Neer TSA
• TSA starts to separate at 10 Years

Over time – more likely to have revision to put in a glenoid for failed hemi, than to revise a glenoid for failed TS A

Hemiarthroplasty vs TSA – Active Patients

• Garcia et al. AJSM, 2016 (HSS)
• 40 Hemi vs 40 TSA, matched
• F/U of 62 months
• Patients with TSA had:
• Better Pain Relief (VAS 0.6 vs 2.2)
• More satisfaction (100% vs 70%)
• Better return to sports (97.3% vs 65.5%)

Reality is that patients are better able to return to sports after TS A vs Hemi

What About Cost?

• When considering a higher revision rate for

hemiarthroplasty compared to TSA, TSA is more cost- effective, even in young patients.

Hemiarthroplasty vs TSA

Conclusions

• TSA outperforms Hemi for OA – that’s a fact
• However, glenoid is weak link in TSA
• While radiographic failure is common, clinical failure is

rare

• Your surgical technique matters and it affects long term
• utcomes
• Know how to see and prepare the glenoid
• Appreciate glenoid morphology and know how to correct deformity
• Meticulous bone preparation and cement technique
• Cemented, all-polyethylene pegged or keeled glenoids are

standard of care.

• Anatomic humeral restoration is critical
• Provides concentric articulation
• Limits cuff failure, which can lead to glenoid loosening
• While technically challenging, putting in a glenoid is worth

the effort

Thank You