2.2. Resection and interposition arthroplasty

When the glenohumeral joint destruction occurs and patient suffers from severe pain, at this point arthroplasty becomes the treatment of choice. But first generation of shoulder arthroplasties had resulted with high rate of loosening, thus patients' morbidity increased [51]. Till the advancement of shoulder prosthesis, resection and interposition arthroplasty was preferred by several authors because of the preservation of glenoid and humeral head bone stock and enabling further revisions [52]. This procedure is mostly selected for high life expectant patients with advanced glenohumeral arthritis suffering from severe pain [51].

Principle of this procedure, damaged cartilages of glenoid and humeral head are resected, radical open synovectomy is performed and soft tissues are interpositioned between articulations, ultimately a new joint is formed [52]. Historically, porcine bladder was used as the soft tissue [53] and in time skin, fascia, tendon, muscle [54] and eventually dura mater [52] were used as membranes for interposition. Porcine bladder was mostly used in temporomandibular joint interposition surgeries and dura mater was used in elbow, temporomandibular joint interposition surgeries [55–57].

Milbrink et al. advocated functional outcome of resection interposition arthroplasty was even better than prosthetic arthroplasty. Although the operation fails in time, as the remaining bone stock was well preserved, conversion to arthroplasty or arthrodesis was still possible [52]. But the advancements in shoulder arthroplasty had nullified this statement [51].

Fink et al. observed 53 shoulders for a mean follow-up of 8.2 years. They stated that after 10 years, the functional outcome of resection interposition arthroplasty decreases dramatically. This phenomenon is explained by the medialization of joint's center of rotation because of progressive resorption of humeral head [51]. As Strauss et al. stated, the medialization of joint center by resection interposition surgery deltoid abduction lever arm decreases by 35% resulting in poor functional outcomes [58]. They supported indication for resection interposition arthroplasty for the group of very young-aged patients because of preservation of bone stock and delay the need for prosthesis [51]. But the pain relief is controversial, maximum active abduction is mostly limited to 60–80 and moderate weakness can persist even though the rotator cuff was sutured [59].

In conclusion; with the advancement of shoulder prosthesis, the indication for resection interposition arthroplasty is declined in time, but theoretically for the young-aged patients with advanced glenohumeral arthritis may be the candidates for resection and interposition arthroplasty due to the preservation of glenohumeral joint and thus delaying the need of prosthetic reconstruction, but practically we saw that newest shoulder resection and interposition surgery literature is from year of 2001, that is because surgeons began to prefer arthroplasty for arthritic patients [50]. The postoperative functional status, complications and revision to arthroplasty are summarized in Table 3.

#### 2.3. Resurfacing arthoplasty

The idea for resurfacing arthroplasty was to correct deformed humeral head with minimal bone loss. The need for this idea was because of reported high incidence of glenoid loosening with Publications

Milbrink

13 N/A

 6 months

%100

 N/A

 N/A

 48

N/A

None

 Resection results are even superior to some

endoprosthetic

enable adequate bone stock for total

shoulder

needed.

arthroplasty

 if revision is

reconstructions

 and also

interposition

arthroplasty's

(prognostic)

et al. [52] Fink et al.

42 47.9

98.4 months

Constant:

Constant:

27.5

2.39

1 (rotator cuff

Even though functions after resection

interposition

arthroplasty

deterioration

 of the scores

 improve in

tear, painful

shoulder)

the long-term

was witnessed.

may be logical candidates

bone stock for total shoulder

arthroplasty

 revision in the future

 Form. The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 177

Young-aged

 patients

 for reserving

N/A

42.33

SAS: N/A

SAS:

26.43

[51]

(range

(range 42–

18–68)

Abbreviations:

Table 3.

Summary of previous

publications

 about resection and

interposition

arthroplasty

 in RA patients.

 ER, external rotation; FF, forward flexion; SAS, Society of American Shoulder and Elbow Surgeons Basic Shoulder Evaluation

210)

 n Age

Follow-up

Satisfaction

 Pre-op

Post-op

Improvement

Improvement

Complication

 Conclusion

score

score

in FF

in ER

(mean)

(mean)


2.2. Resection and interposition arthroplasty

tion surgeries [55–57].

176 Advances in Shoulder Surgery

When the glenohumeral joint destruction occurs and patient suffers from severe pain, at this point arthroplasty becomes the treatment of choice. But first generation of shoulder

[51]. Till the advancement of shoulder prosthesis, resection and interposition arthroplasty was preferred by several authors because of the preservation of glenoid and humeral head bone stock and enabling further revisions [52]. This procedure is mostly selected for high life expectant patients with advanced glenohumeral arthritis suffering from severe pain [51].

Principle of this procedure, damaged cartilages of glenoid and humeral head are resected, radical open synovectomy is performed and soft tissues are interpositioned between articulations, ultimately a new joint is formed [52]. Historically, porcine bladder was used as the soft tissue [53] and in time skin, fascia, tendon, muscle [54] and eventually dura mater [52] were used as membranes for interposition. Porcine bladder was mostly used in temporomandibular joint interposition surgeries and dura mater was used in elbow, temporomandibular joint interposi-

Milbrink et al. advocated functional outcome of resection interposition arthroplasty was even better than prosthetic arthroplasty. Although the operation fails in time, as the remaining bone stock was well preserved, conversion to arthroplasty or arthrodesis was still possible [52]. But

Fink et al. observed 53 shoulders for a mean follow-up of 8.2 years. They stated that after 10 years, the functional outcome of resection interposition arthroplasty decreases dramatically.

progressive resorption of humeral head [51]. As Strauss et al. stated, the medialization of joint center by resection interposition surgery deltoid abduction lever arm decreases by 35% resulting in poor functional outcomes [58]. They supported indication for resection interposition arthroplasty for the group of very young-aged patients because of preservation of bone stock and delay the need for prosthesis [51]. But the pain relief is controversial, maximum

In conclusion; with the advancement of shoulder prosthesis, the indication for resection interposition arthroplasty is declined in time, but theoretically for the young-aged patients with advanced glenohumeral arthritis may be the candidates for resection and interposition arthroplasty due to the preservation of glenohumeral joint and thus delaying the need of prosthetic reconstruction, but practically we saw that newest shoulder resection and interposition surgery literature is from year of 2001, that is because surgeons began to prefer arthroplasty for arthritic patients [50]. The postoperative functional status, complications and revision to

The idea for resurfacing arthroplasty was to correct deformed humeral head with minimal bone loss. The need for this idea was because of reported high incidence of glenoid loosening with

–80

.

the advancements in shoulder arthroplasty had nullified this statement [51].

This phenomenon is explained by the medialization of joint

active abduction is mostly limited to 60

arthroplasty are summarized in Table 3

2.3. Resurfacing arthoplasty

the rotator cuff was sutured [59].

' morbidity increased

's center of rotation because of

and moderate weakness can persist even though

arthroplasties had resulted with high rate of loosening, thus patients

Table 3.Summary of previous publications about resection and interposition arthroplasty in RA patients.

unpredicted bony erosion during revision surgery after stemmed arthroplasty. Also the application of stems with cement intraoperatively might result in cracking osteopenic humerus shaft of rheumatoid patients. Postoperatively as intramedullary stem leads to stress rise at the tip of the prosthesis, RA patients are prone to fractures around the stem of prosthesis and are hard to manage [60, 61].

the bone stock for a possible revision surgery and enabling to restore the individual height,

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 179

Fuerst et al. published their results of 35 shoulders for a follow-up of at least 5 years in patients with RA. Three revisions were mentioned. These were due to need of conversion to a larger implant, glenoid erosion and loosening. Over the 5-year follow-up, superior migration of the humeral head encountered in 63% and the glenoid depth increased in 31%. Clinically, no difference between the patients with massive rotator cuff tear and smaller tear or no tear was found. Also they suggested magnetic resonance imaging prior to surgery, not only to evaluate soft tissues like rotator cuff, but also to detect the quality of bone, cysts, necrotic areas and

Although most of the results of RA patients with resurfacing arthroplasty are good in the literature given above, Mansat et al. reported worst results in RA patients. In his group of mixed patients, four rheumatoid shoulders gave worst results among them. And concluded that, the resurfacing arthroplasty does not resolve the problem of long-term results of

Available data on the long-term survival of shoulder arthroplasty is limited. Because of high functional demands of the younger patients; prosthesis may result in a limited life span and the need for a revision surgery during their lifetime is probable [50]. Recently, Levy et al. published their minimum 10 year results of surface replacement arthroplasty in patients younger than 50 years. This is the longest follow-up result of young-aged RA patients' series. Twenty of 49 patients have RA and 4 of 10 revisions were performed in RA patients. The superior migration of the humeral head was more prevalent in these patients. The revisions were done due to rotator cuff failure and loosening at 8–14 years after surgery [71]. They found decreased pain, high satisfaction, good percentage of back to work and sporting activities. As of our own clinical experience and literature review had shown, resurfacing arthroplasty is more demanding for the surgeon, with its advantages of minimal resection and functional

The first hemiarthroplasty series were published by Neer. They reconstructed three and four part humerus proximal fractures and took the attention to good functional outcomes [72]. In the following years, hemiarthroplasty was begun to be preferred for osteoarthritis, RA, cuff tear arthropathies and fracture sequelae (Figure 1). But superior migration (Figure 2) due to cuff tear arthropathies led to diminished functions which had shown that hemiarthroplasty was not the optimal solution for cuff tear arthropathies, thus reverse shoulder arthroplasty

Still there is no consensus on preference of hemiarthroplasty or TSA especially in the cases of young-aged rheumatoid patients. The main complication of hemiarthroplasty is glenoid erosion which results in medialization of the joint which was seen in 98% of the patients in a study by Sperling et al. with a mean follow-up of 11.3 years [74], but the risk of glenoidal component

version and offset are important advantages for surface arthroplasty [68].

other defects of the humeral head [69].

2.4. Hemiarthroplasty

(RSA) was designed [73].

hemiarthroplasty, even it mimics the normal anatomy [70].

outcomes in rotator cuff intact patients, making it a favorable choice.

The advantages of resurfacing arthroplasty are short operative time, low risk of intraoperative or postoperative periprosthetic fractures and minimal bone resection. The disadvantages are difficulty in correction of the anatomical fitting in cases with extremely deformed humeral head [62, 63].

Rydholm and Sjögren published their mid-term clinical results in 72 rheumatoid shoulders with 94% pain relief and 82% improved mobility. Patients were followed-up for 4.2 years and were evaluated radiographically and functionally. About 25% of patients had shown loosening of the cup. But interestingly, no relationship was found between the position of the cup and the clinical outcomes of the patients. Neither superior migration of the humeral head in 38% nor central attrition of the glenoid in 22% showed any relation to gain of mobility, pain nor functional scores [64]. A counter-argument against resurfacing arthroplasty is that progressive erosion of the glenoid will make future arthroplasty more difficult and the need for total shoulder arthroplasty (TSA) will be earlier and harder as would be advocated for hemiarthroplasty. But in this series of patients they found no relation between the central glenoid erosion and the patient clinical outcomes [64].

Ålund et al. published their 2–6 year results in 33 RA patients. Their findings also showed no correlation between clinical results and radiographic superior migration of the humeral head with or without glenoid erosion. About 25% of the patients showed radiographic signs of cup loosening. They found good pain relief in 27 of the shoulders. The remaining six shoulders were still painful at follow-up [65].

Levy and Copeland published their results with the Copeland Mark-2 Prosthesis with 5–10 year results. In this series, 41 patients out of 94 were RA. There was no difference between the RA and primary osteoarthritis patients in terms of functional clinical scores. Only one RA patient revised to TSA due to loosening. About 93.9% of the patients were satisfied by this procedure [61, 66]. RA patients had better functional results when compared to groups of rotator cuff tear and instability arthropathy.

Fink et al. published the results of 45 RA patients. The patients were divided into three groups according to the cuff pathology: intact, partial tear and total tear. In all three groups, there was significant increase of the functional scores. But the least increase was observed in total rotator cuff tear group. They experienced no complications like component loosening or change in the cup position. Therefore, cup arthroplasty was stated as a good alternative to other arthroplasty solutions in rheumatic patients [67].

Thomas et al. reported their outcome of 56 patients followed-up for at least 2 years. A total of 26 out of 56 patients were RA patients. They reported good clinical outcomes in RA patients when compared to the other indications. The survival analysis showed no variance from acceptable standards for shoulder arthroplasty during the study period. The preservation of the bone stock for a possible revision surgery and enabling to restore the individual height, version and offset are important advantages for surface arthroplasty [68].

Fuerst et al. published their results of 35 shoulders for a follow-up of at least 5 years in patients with RA. Three revisions were mentioned. These were due to need of conversion to a larger implant, glenoid erosion and loosening. Over the 5-year follow-up, superior migration of the humeral head encountered in 63% and the glenoid depth increased in 31%. Clinically, no difference between the patients with massive rotator cuff tear and smaller tear or no tear was found. Also they suggested magnetic resonance imaging prior to surgery, not only to evaluate soft tissues like rotator cuff, but also to detect the quality of bone, cysts, necrotic areas and other defects of the humeral head [69].

Although most of the results of RA patients with resurfacing arthroplasty are good in the literature given above, Mansat et al. reported worst results in RA patients. In his group of mixed patients, four rheumatoid shoulders gave worst results among them. And concluded that, the resurfacing arthroplasty does not resolve the problem of long-term results of hemiarthroplasty, even it mimics the normal anatomy [70].

Available data on the long-term survival of shoulder arthroplasty is limited. Because of high functional demands of the younger patients; prosthesis may result in a limited life span and the need for a revision surgery during their lifetime is probable [50]. Recently, Levy et al. published their minimum 10 year results of surface replacement arthroplasty in patients younger than 50 years. This is the longest follow-up result of young-aged RA patients' series. Twenty of 49 patients have RA and 4 of 10 revisions were performed in RA patients. The superior migration of the humeral head was more prevalent in these patients. The revisions were done due to rotator cuff failure and loosening at 8–14 years after surgery [71]. They found decreased pain, high satisfaction, good percentage of back to work and sporting activities. As of our own clinical experience and literature review had shown, resurfacing arthroplasty is more demanding for the surgeon, with its advantages of minimal resection and functional outcomes in rotator cuff intact patients, making it a favorable choice.
