2.4. Hemiarthroplasty

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

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

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

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

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

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

glenoid erosion and the patient clinical outcomes [64].

were still painful at follow-up [65].

rotator cuff tear and instability arthropathy.

solutions in rheumatic patients [67].

manage [60, 61].

178 Advances in Shoulder Surgery

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 (RSA) was designed [73].

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

Figure 1. Hemiarthroplasty surgery to a defective glenoid. (A) Preoperative AP plain radiography. (B) Preoperative axial CT scan. (C) Preoperative coronal CT scan. (D) Early postoperative AP plain radiography.

TSA series performed on rheumatoid arthritic shoulders. Because the press-fit technique had shown 40% (5 in 12 patients) loosening, in comparison to cemented humeral components had

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 181

Because of rotator cuff insufficiency to overwhelm superior migration of the prosthesis, Rozing et al. conducted a study of rotator cuff repair for shoulder arthroplasty in 1998 including 40 patients (11 were hemiarthroplasty). The follow-up was ranging from 2 to 13 years. They stated that rotator cuff repair was effective because proximal migration was seen in only 6 of 40 patients. For the surgical technique, if rotator cuff repair is planned, posterosuperior incision should be preferred because the osteotomization of the posterior acromion was not restricting the postoperative rehabilitation in contrast to superior approach which requires an osteotomy

Cofield et al.'s study of hemiarthroplasty included 32 rheumatoid shoulders and 35 osteoarthritis shoulders and followed up for 9.3 years. They stated that pain relief was achieved in 78% of the patients, external rotation and forward flexion range increased by 26 and 24, respectively. Although the functional results seemed to be satisfying, the patients' self-evaluation had shown that 49% of the patients were satisfied. About 12% of the patients required a revision to TSA because of intractable pain of glenoid arthritis and postoperative pain relief evaluations were satisfying. They supported the indication of hemiarthroplasty in inadequate glenoid bone stock

Sperling et al. compared the hemiarthroplasty and TSA patients below 50 years of age between the years of 1976 and 1985. Hemiarthroplasty was performed in 74 shoulders, TSA was performed in 34 shoulders. The radiolucent line adjacent to TSA was 53% for humeral, 59% for

which cannot bear an implant and young aged or active life expectant patients [78, 79].

shown none (0 in 50 patients) [76, 77].

Figure 2. Plain radiography of hemiarthroplasty superior migration.

including large portion of acromion [75].

loosening in TSA and decreased glenoidal bone stock is another concern for the indication for young-aged patients. Thus, hemiarthroplasty is widely accepted for patients with intact rotator cuff and minimal glenoid erosion [73].

As for RA, indications of arthroplasty are glenohumeral joint destruction with severe pain and restriction of movements [75]. But this must be kept in mind that, the RA in shoulder differs from osteoarthritic patients in many ways, such as glenoid is osteopenic, rotator cuff is torn or thinned and internal rotation is increased due to medial side of glenoid is eroded rather than posterior as seen in osteoarthritis [75]. Smith et al. described the changes and effect on functional outcomes of arthroplasty performed on rheumatoid shoulders. They mentioned that TSA was mostly preferred in their practice, because of the prevention of medial erosion of glenoid by resurfacing and better comfort. Although the advantages of TSA seemed to be better, due to mentioned changes in glenoid might cause an obstacle for insertion of glenoid component, thus hemiarthroplasty might be performed which had a similar functional outcome and pain relief. Also they supported the cementation of humeral component in Sneppen et al.'s

Figure 2. Plain radiography of hemiarthroplasty superior migration.

loosening in TSA and decreased glenoidal bone stock is another concern for the indication for young-aged patients. Thus, hemiarthroplasty is widely accepted for patients with intact rota-

Figure 1. Hemiarthroplasty surgery to a defective glenoid. (A) Preoperative AP plain radiography. (B) Preoperative axial

CT scan. (C) Preoperative coronal CT scan. (D) Early postoperative AP plain radiography.

As for RA, indications of arthroplasty are glenohumeral joint destruction with severe pain and restriction of movements [75]. But this must be kept in mind that, the RA in shoulder differs from osteoarthritic patients in many ways, such as glenoid is osteopenic, rotator cuff is torn or thinned and internal rotation is increased due to medial side of glenoid is eroded rather than posterior as seen in osteoarthritis [75]. Smith et al. described the changes and effect on functional outcomes of arthroplasty performed on rheumatoid shoulders. They mentioned that TSA was mostly preferred in their practice, because of the prevention of medial erosion of glenoid by resurfacing and better comfort. Although the advantages of TSA seemed to be better, due to mentioned changes in glenoid might cause an obstacle for insertion of glenoid component, thus hemiarthroplasty might be performed which had a similar functional outcome and pain relief. Also they supported the cementation of humeral component in Sneppen et al.'s

tor cuff and minimal glenoid erosion [73].

180 Advances in Shoulder Surgery

TSA series performed on rheumatoid arthritic shoulders. Because the press-fit technique had shown 40% (5 in 12 patients) loosening, in comparison to cemented humeral components had shown none (0 in 50 patients) [76, 77].

Because of rotator cuff insufficiency to overwhelm superior migration of the prosthesis, Rozing et al. conducted a study of rotator cuff repair for shoulder arthroplasty in 1998 including 40 patients (11 were hemiarthroplasty). The follow-up was ranging from 2 to 13 years. They stated that rotator cuff repair was effective because proximal migration was seen in only 6 of 40 patients. For the surgical technique, if rotator cuff repair is planned, posterosuperior incision should be preferred because the osteotomization of the posterior acromion was not restricting the postoperative rehabilitation in contrast to superior approach which requires an osteotomy including large portion of acromion [75].

Cofield et al.'s study of hemiarthroplasty included 32 rheumatoid shoulders and 35 osteoarthritis shoulders and followed up for 9.3 years. They stated that pain relief was achieved in 78% of the patients, external rotation and forward flexion range increased by 26 and 24, respectively. Although the functional results seemed to be satisfying, the patients' self-evaluation had shown that 49% of the patients were satisfied. About 12% of the patients required a revision to TSA because of intractable pain of glenoid arthritis and postoperative pain relief evaluations were satisfying. They supported the indication of hemiarthroplasty in inadequate glenoid bone stock which cannot bear an implant and young aged or active life expectant patients [78, 79].

Sperling et al. compared the hemiarthroplasty and TSA patients below 50 years of age between the years of 1976 and 1985. Hemiarthroplasty was performed in 74 shoulders, TSA was performed in 34 shoulders. The radiolucent line adjacent to TSA was 53% for humeral, 59% for glenoid component in spite of 24% which was seen in humeral component of hemiarthroplasty. In contrary, prosthesis survival analysis revealed at 10 year of follow-up, revision rates of hemiarthroplasties were increased significantly (17% for hemiarthroplasties, 3% for TSA). Pain and functional outcome comparison revealed no significant results [80].

In contrary, Collins et al. published a prospective multi-centered study for the comparison of arthroplasties in RA patients. They stated the hemiarthroplasty indication as young aged, high activity level anticipated, osteopenic, rotator cuff tear already present, extensive poorly controlled systemic disease. A total of 61 shoulder arthroplasties were included (36 hemiarthroplasty, 25 TSA) and followed up for 38 months for hemiarthroplasty, 39 months for TSA. The results of functional scores and pain assessments had shown a slight advantage for TSA, but patient selection criteria were worse for hemiarthroplasty. The choice for TSA was advised for the patients with intact or reparable rotator cuff and adequate glenoid bone stock. Because even the patients' condition was worse for selection of hemiarthroplasty, functional outcome and pain relief were increased when compared to preoperative status. Also another concern for better functional outcome and pain relief criteria was stated as the glenohumeral alignment which could be achieved better in TSA [81].

Sperling et al.'s 195 TSA and 108 hemiarthroplasty included with 11.3 year follow-up is the largest patient population. Their comparison of hemiarthroplasty and TSA revealed important factors for decision. For hemiarthroplasty and TSA, the results for pain relief and functional outcome were significantly improved. But if the results were evaluated for rotator cuff intact or reparable and rotator cuff torn patients separately, the rotator cuff intact patients' survival of prosthesis, pain relief, functional outcome results were superior to hemiarthroplasty. But for the rotator cuff deficient shoulders, the results remained the same. As for the main complication of the prosthesis choice, TSA's glenoid loosening rates were lower than hemiarthroplasty's painful glenoid arthritis [73].

Rees et al.investigated the primary shoulder hemiarthroplasties for osteoarthritis and RA, but they subgrouped RA so that the results were clear. Thirty-one patients were evaluated with Oxford Shoulder Score and transition and satisfaction questions. As for Oxford Shoulder Scores, a statistically significant improvement was seen, but for the patient satisfaction test the results had shown that 33.3% of the RA patients were worse or the same and 29.6% were not pleased [82].

Rozing et al. conducted a study to describe the prognostic factors in arthroplasty for rheumatoid shoulders. They included 66 TSA and 75 hemiarthroplasty. They stated that hemiarthroplasty was affected by the preoperative acromioclavicular joint arthrosis and medial migration. But as for the rotator cuff repair status, proximal migration progression hemiarthroplasty's Hospital for Special Surgery clinical score were not affected as much as TSA. Also they stated that 11 patients who had both hemiarthroplasty and TSA, in their 2nd year follow-up score functional results had shown no significant difference. They concluded that in the patients with poor glenoid bone stock and moderate or lower quality rotator cuff repair, hemiarthroplasty was a good treatment choice [83].

Etiology-based evaluation study by Gadea et al. for hemiarthroplasty resulted with improved Constant-Murley score and 100% survival of prosthesis [73]. Although this study had a minimum Publication

Cofield

32 N/A

 9.3

 %49

 N/A

 N/A

 26

24

N/A

Patients with inadequate high-level activity expectancy

candidates

 for

hemiarthroplasty

 glenoid bone stock or

 might be proper

et al. [78]

Watson

4 71 (range

5.9

%100

 HSS:

HSS:

25

30

None

 Bipolar spacer prosthesis might be a good surgical

option for the treatment of advanced

glenohumeral

encountered

sleeve might restrict joint movements.

 loss of low-friction

 properties of the

 arthritis, but the eventually

13

41.75

et al. [79]

Sperling

28 39 (range

11.7

 %66

 VAS:

VAS:

24

44

N/A

Shoulder relief and motion aged patients (<50) care should be taken to assess

the appropriate

prosthesis.

 choice due to low survival of

arthroplasty

 provides long-term pain

improvement,

 but in young-

4.6

2.4

19–50

et al. [80]

Collins

36 58 (range

3.1

N/A

 N/A

 N/A

 15

N/A

N/A

By

range of motion are expected when sufficient

glenoidal and humeral bone stock are present

hemiarthroplasty,

 pain relief and improved

> et al. [81]

Sperling

95 54 (range

12.1

 N/A

 Pain

Pain

18

32

10 (8 glenoid

Shoulder relieves pain and improves shoulder joint range of

arthroplasty

 in rheumatoid

 arthritis

> erosion, 2

loosening)

motion, but with the presence of intact rotator

cuff, total shoulder

shown superiority

arthroplasty's

 results had

score:

score:

4.8

2.4

et al. [74]

Rees et al.

31 63.5

 11.9 4.37

%70.4

 OSS:

OSS:

N/A

N/A

N/A

Rheumatoid

with their

may be rectified by their systemic pathology where the joint pain improved but bodily and limb

function did not.

 arthritis patients less likely satisfied

hemiarthroplasty

 operation. This fact

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

13.7

28

(range

3–8)

[82]

Abbreviations:

available.

Table 4.

Summary of previous

publications

 comparing

hemiarthroplasty

 and total shoulder

arthroplasty

 in RA patients. 183

 ER, external rotation; FF, forward flexion; OSS, Oxford Shoulder Score; HSS, Hospital for Special Surgery Score; VAS, Visual Analogue Scale; N/A, not

21–77)

30–84)

(range

2–6)

70–73)

(range

2.5–10)

 N Age

Followup

Satisfaction

 Pre- op

Postop

Improvement

Improvement

Complication

 Conclusion

> in ER

> in FF

> > score

score

(mean)


glenoid component in spite of 24% which was seen in humeral component of hemiarthroplasty. In contrary, prosthesis survival analysis revealed at 10 year of follow-up, revision rates of hemiarthroplasties were increased significantly (17% for hemiarthroplasties, 3% for TSA). Pain

In contrary, Collins et al. published a prospective multi-centered study for the comparison of arthroplasties in RA patients. They stated the hemiarthroplasty indication as young aged, high activity level anticipated, osteopenic, rotator cuff tear already present, extensive poorly controlled systemic disease. A total of 61 shoulder arthroplasties were included (36 hemiarthroplasty, 25 TSA) and followed up for 38 months for hemiarthroplasty, 39 months for TSA. The results of functional scores and pain assessments had shown a slight advantage for TSA, but patient selection criteria were worse for hemiarthroplasty. The choice for TSA was advised for the patients with intact or reparable rotator cuff and adequate glenoid bone stock. Because even the patients' condition was worse for selection of hemiarthroplasty, functional outcome and pain relief were increased when compared to preoperative status. Also another concern for better functional outcome and pain relief criteria was stated as the glenohumeral alignment

Sperling et al.'s 195 TSA and 108 hemiarthroplasty included with 11.3 year follow-up is the largest patient population. Their comparison of hemiarthroplasty and TSA revealed important factors for decision. For hemiarthroplasty and TSA, the results for pain relief and functional outcome were significantly improved. But if the results were evaluated for rotator cuff intact or reparable and rotator cuff torn patients separately, the rotator cuff intact patients' survival of prosthesis, pain relief, functional outcome results were superior to hemiarthroplasty. But for the rotator cuff deficient shoulders, the results remained the same. As for the main complication of the prosthesis choice, TSA's glenoid loosening rates were lower than hemiarthroplasty's

Rees et al.investigated the primary shoulder hemiarthroplasties for osteoarthritis and RA, but they subgrouped RA so that the results were clear. Thirty-one patients were evaluated with Oxford Shoulder Score and transition and satisfaction questions. As for Oxford Shoulder Scores, a statistically significant improvement was seen, but for the patient satisfaction test the results had shown

Rozing et al. conducted a study to describe the prognostic factors in arthroplasty for rheumatoid shoulders. They included 66 TSA and 75 hemiarthroplasty. They stated that hemiarthroplasty was affected by the preoperative acromioclavicular joint arthrosis and medial migration. But as for the rotator cuff repair status, proximal migration progression hemiarthroplasty's Hospital for Special Surgery clinical score were not affected as much as TSA. Also they stated that 11 patients who had both hemiarthroplasty and TSA, in their 2nd year follow-up score functional results had shown no significant difference. They concluded that in the patients with poor glenoid bone stock and moderate or lower quality rotator cuff repair, hemiarthroplasty was a good treatment

Etiology-based evaluation study by Gadea et al. for hemiarthroplasty resulted with improved Constant-Murley score and 100% survival of prosthesis [73]. Although this study had a minimum

that 33.3% of the RA patients were worse or the same and 29.6% were not pleased [82].

and functional outcome comparison revealed no significant results [80].

which could be achieved better in TSA [81].

painful glenoid arthritis [73].

182 Advances in Shoulder Surgery

choice [83].

Table 4. Summary of previous publications comparing hemiarthroplasty and total shoulder arthroplasty in RA patients. 8 year follow-up, Sperling et al.'s study for survival of prosthesis was more dependable because of its large numbers but as the survival of hemiarthroplasty decreased, after 20th year, it seized to deteriorate and the lines of hemiarthroplasty and TSA intersected [80]. Thus, they concluded that hemiarthroplasty was a better treatment option for the young patients (<50 years of age) [73].

In conclusion, hemiarthroplasty provides a painless shoulder with good functional outcomes. But the literature about comparison of TSA and hemiarthroplasty confirmed that its survival rate is inferior to TSA. Glenoid bone stock preservation which is enabling future revision surgeries, good functional outcomes and survival of prosthesis according to Gadea et al. [73] minimum 8 year and even same survival rate as TSA in long-term as supported by Sperling et al. [74] are in favor for young RA patients, but the conflict of optimal treatment between the use of TSA and hemiarthroplasty in recent literature, mostly limit the indication to elderly patients with insufficient glenoid bone stock and rotator cuff deficient patients [50]. The literature comparing hemiarthroplasty and TSA are summarized in Table 4.

#### 2.5. The ream and run technique

The glenoid component complications of the TSA created concerns about the indications for young-aged active patients [80, 84]. The Ream and Run technique, first described by Clinton et al., is a form of hemiarthroplasty with the reaming of the glenoid. This technique is also called non-prosthetic reconstruction of the glenoid [85, 86]. Reamed glenoidal surface was examined on canine model and demonstrated that the reamed glenoid articular surface heals with smooth and concentric fibrocartilage [86].

achieved superiorly in TSA, especially in the patient group whose age is older than 50 which

Figure 3. Total shoulder arthroplasty surgery. (A) Preoperative AP plain radiography. (B) Preoperative axial CT scan. (C)

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 185

The assessment of rotator cuff status preoperatively is essential to avoid proximal migration and consequently the rocking horse phenomenon. The survival of the glenoidal component has a strong negative correlation with the fatty degeneration of the rotator cuff that can be seen by ultrasonography and magnetic resonance imaging or decreased subacromial space seen in

Neer's nonconstrained TSA had achieved pain relief and low complication rates in rheumatoid shoulders. But the poor bone stock, irreparable rotator cuff tears, soft tissue constraints demonstrated an underestimated potential risk for arthroplasty [95–97]. Due to these factors of rheumatoid shoulder, high rate of radiographic lucent lines, ranging from 30 to 93% which was correlated with physical loosening of the components, created concerns about the long-term survival of the TSA [95, 98]. Hambright's study of perioperative status comparison between rheumatoid and non-rheumatoid shoulders that had undergone TSA revealed no significant difference among mortality and complications. Also, interestingly, even the hospital costs per day were higher in rheumatoid shoulder patients; due to low hospital stay, overall in-hospital costs were lower in comparison to non-rheumatoid patients. This fact was tried to be explained

by the RA patients' experience of managing chronic disease and the pain [31, 99, 100].

Boileau et al. [101] and Martin et al. [102] studied the results of metal backed hydroxyapatite covered uncemented glenoidal components for osteoarthritic patients with a follow-up of 3 and 7.5 years, respectively. Glenoidal component loosening was encountered in 20% of Boileau et al.'s and 11% of Martin et al.'s patients, so considered as unfavorable and uncemented glenoidal component was abandoned. Against these statements, Clement et al. investigated the results of hydroxyapatite covered metal backed glenoid components in rheumatoid patients. A total of 36 shoulders were evaluated for 132 months and 1 out of 5 complication was seen as glenoidal loosening and survival of prosthesis in 10 years was found

was accepted as a predictor of pain relief and better functional outcome [92–94].

the plain x-ray [33].

Postoperative 6th month AP plain radiography.

One of the advantages of this technique is the preservation of the labrum during the periglenoid capsular release that results with improved glenohumeral stability and concentrically loading of the joint. If there is a need for a correction of glenoid version, this may also be done by ream and run procedure. But if there is severe posterior wear, this condition may not be appropriate for Ream and Run technique [87, 88].

Ream and run technique is suitable for primary glenohumeral arthritis patients who agree on slow recovery to avoid glenoid loosening and medial erosion in the long-term. Even though, the results were satisfying, due to the requirement of healing process in the glenoid for 12–18 months in non-RA patients, rheumatoid shoulders with destructive pattern are not seemed to be suitable candidates, but this assumption was not proven according to our best of our knowledge because the Ream and Run technique's functional outcome has not been evaluated on rheumatoid shoulders yet [87–91].

## 2.6. Anatomical total shoulder arthroplasty

Indications for TSA in rheumatoid shoulders are for the patients with intractable pain, endstage disease with extensive glenohumeral joint destruction, intact rotator cuff and yet with sufficient bone stock and soft tissue balance to stabilize the prosthetic articulations (Figure 3) [92]. The presence of mentioned factors makes the TSA superior treatment choice rather than hemiarthroplasty. Because medial erosion of the glenoid which affects glenoid bone stock may complicate the revision surgeries of hemiarthroplasty. Also the glenohumeral alignment can be

8 year follow-up, Sperling et al.'s study for survival of prosthesis was more dependable because of its large numbers but as the survival of hemiarthroplasty decreased, after 20th year, it seized to deteriorate and the lines of hemiarthroplasty and TSA intersected [80]. Thus, they concluded that hemiarthroplasty was a better treatment option for the young patients (<50 years of age) [73].

In conclusion, hemiarthroplasty provides a painless shoulder with good functional outcomes. But the literature about comparison of TSA and hemiarthroplasty confirmed that its survival rate is inferior to TSA. Glenoid bone stock preservation which is enabling future revision surgeries, good functional outcomes and survival of prosthesis according to Gadea et al. [73] minimum 8 year and even same survival rate as TSA in long-term as supported by Sperling et al. [74] are in favor for young RA patients, but the conflict of optimal treatment between the use of TSA and hemiarthroplasty in recent literature, mostly limit the indication to elderly patients with insufficient glenoid bone stock and rotator cuff deficient patients [50]. The

The glenoid component complications of the TSA created concerns about the indications for young-aged active patients [80, 84]. The Ream and Run technique, first described by Clinton et al., is a form of hemiarthroplasty with the reaming of the glenoid. This technique is also called non-prosthetic reconstruction of the glenoid [85, 86]. Reamed glenoidal surface was examined on canine model and demonstrated that the reamed glenoid articular surface heals

One of the advantages of this technique is the preservation of the labrum during the periglenoid capsular release that results with improved glenohumeral stability and concentrically loading of the joint. If there is a need for a correction of glenoid version, this may also be done by ream and run procedure. But if there is severe posterior wear, this condition may not

Ream and run technique is suitable for primary glenohumeral arthritis patients who agree on slow recovery to avoid glenoid loosening and medial erosion in the long-term. Even though, the results were satisfying, due to the requirement of healing process in the glenoid for 12–18 months in non-RA patients, rheumatoid shoulders with destructive pattern are not seemed to be suitable candidates, but this assumption was not proven according to our best of our knowledge because the Ream and Run technique's functional outcome has not been evaluated

Indications for TSA in rheumatoid shoulders are for the patients with intractable pain, endstage disease with extensive glenohumeral joint destruction, intact rotator cuff and yet with sufficient bone stock and soft tissue balance to stabilize the prosthetic articulations (Figure 3) [92]. The presence of mentioned factors makes the TSA superior treatment choice rather than hemiarthroplasty. Because medial erosion of the glenoid which affects glenoid bone stock may complicate the revision surgeries of hemiarthroplasty. Also the glenohumeral alignment can be

literature comparing hemiarthroplasty and TSA are summarized in Table 4.

2.5. The ream and run technique

184 Advances in Shoulder Surgery

with smooth and concentric fibrocartilage [86].

be appropriate for Ream and Run technique [87, 88].

on rheumatoid shoulders yet [87–91].

2.6. Anatomical total shoulder arthroplasty

Figure 3. Total shoulder arthroplasty surgery. (A) Preoperative AP plain radiography. (B) Preoperative axial CT scan. (C) Postoperative 6th month AP plain radiography.

achieved superiorly in TSA, especially in the patient group whose age is older than 50 which was accepted as a predictor of pain relief and better functional outcome [92–94].

The assessment of rotator cuff status preoperatively is essential to avoid proximal migration and consequently the rocking horse phenomenon. The survival of the glenoidal component has a strong negative correlation with the fatty degeneration of the rotator cuff that can be seen by ultrasonography and magnetic resonance imaging or decreased subacromial space seen in the plain x-ray [33].

Neer's nonconstrained TSA had achieved pain relief and low complication rates in rheumatoid shoulders. But the poor bone stock, irreparable rotator cuff tears, soft tissue constraints demonstrated an underestimated potential risk for arthroplasty [95–97]. Due to these factors of rheumatoid shoulder, high rate of radiographic lucent lines, ranging from 30 to 93% which was correlated with physical loosening of the components, created concerns about the long-term survival of the TSA [95, 98]. Hambright's study of perioperative status comparison between rheumatoid and non-rheumatoid shoulders that had undergone TSA revealed no significant difference among mortality and complications. Also, interestingly, even the hospital costs per day were higher in rheumatoid shoulder patients; due to low hospital stay, overall in-hospital costs were lower in comparison to non-rheumatoid patients. This fact was tried to be explained by the RA patients' experience of managing chronic disease and the pain [31, 99, 100].

Boileau et al. [101] and Martin et al. [102] studied the results of metal backed hydroxyapatite covered uncemented glenoidal components for osteoarthritic patients with a follow-up of 3 and 7.5 years, respectively. Glenoidal component loosening was encountered in 20% of Boileau et al.'s and 11% of Martin et al.'s patients, so considered as unfavorable and uncemented glenoidal component was abandoned. Against these statements, Clement et al. investigated the results of hydroxyapatite covered metal backed glenoid components in rheumatoid patients. A total of 36 shoulders were evaluated for 132 months and 1 out of 5 complication was seen as glenoidal loosening and survival of prosthesis in 10 years was found for 89%. Their findings showed that the use of pegged which is more stable than keeled component, thin metal back with thicker polyethylene because the polyethylene wear was stated as the major factor for revision surgeries [103].

The radiographic evaluation of TSA revealed that 72% of the patients had radiolucent lines around glenoid component, in contrast to hemiarthroplasty's glenoid erosion which occurred in 98% of the patients. Even the presence of radiolucency rates was higher for TSA, in the 10th year of follow- up; TSA's survival was 92.9% and with an intact rotator cuff survival was increased to 96.7%. In contrary, hemiarthroplasty's 10 year survival was 87.9% but with an intact cuff survival was decreased to 75.8%. They stated that even the glenoidal component loosening is a catastrophic complication; with the presence of an intact rotator cuff, the sur-

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 187

Glenoid loosening also depends on the morphology of the glenoid. Walch et al. identified five types glenoid morphology (A1, A2, B1, B2, C) in 113 patients' computed tomography scans. A1, A2 and B1 represents a lesser risk for glenoid component insertion and long-term loosening in contrast to B2 and C type glenoids. Key feature of the morphology of B2, C glenoids is the excessive retroversion [110]. Surgical techniques vary depending on the morphology but all technique has its disadvantage. Anatomical glenoid correction by reaming may be performed but as a result, the joint will be medialized, thus the lever arm of the surrounding muscle will decrease [111]. Also due to excessive reaming, glenoid bone stock will be lost and while inserting the component, the pegs may perforate the cortex which will result as loosening, fracture and in the long-term the revision surgery will be complicated. To protect the bone stock, glenoid may be reamed retrovertly without correcting version, but this technique represents a threat for perforation of anterior cortex by the inserted pegs and also more than 10 of retroversion increases the subluxation and instability of the prosthesis. To fill the defect of eroded area by bone graft in the posterior glenoid is another choice, but cemented glenoid components carry the risk of graft osteolysis. Metal backed hydroxyapatite covered components may be chosen. The advancement of prosthesis technology created posterior augmented glenoid designs. This component's augment fits on the defected glenoid, thus the reaming of anterior glenoid will be prevented [111, 112]. Kersten et al. compared the standard glenoid component with wedge and stepped posterior augmented glenoid component. Posterior augmented glenoid components confirmed that bone loss in glenoid is decreased significantly according to standard type glenoid components. Also comparison of the subgroups of posterior augmented components, the wedge-shaped required lesser reaming, thus bone stock removal was lesser than the stepped glenoid component and as a result lower risk for glenoid loosening might be achieved with wedged-shaped posterior augmented glenoid component [111]. Also Greiner et al. investigated the radiolucent line occurrences according to morphology. B2 and C glenoid types showed significantly higher radiolucent lines around glenoidal component after a follow-up of approximately 5 years [112]. Although these studies were performed on mostly primary osteoarthritis, surgical technique choices may give clues about

In conclusion, as the advancement in prosthesis and improvement in surgical techniques, recent literature supports TSA for young- and old-aged patients with an intact or reparable rotator cuff. Rotator cuff deficiency and poor glenoid bone stock are the main perioperative challenges of TSA, but with the repair of rotator cuff and adjusting the glenoidal component by trimming had shown statistically significant pain relief and also improved functional outcomes. The identification of the glenoid morphology carries great importance to assess the

vival of the prosthesis is superior to hemiarthroplasty [109].

patient specific approach.

Also, Betts et al.'s study included 14 rheumatoid shoulders with a follow-up of 19.8 years. They reported their functional outcomes, pain relief and complication rates. With the increase in follow-up duration, radiolucencies around glenoidal and humeral component and rotator cuff deficiency were progressed. But even with the presence of these radiological findings, functional outcomes and satisfactory pain relief were especially achieved in elderly, non-demanding patients. They managed their personal care and their sleep was undisturbed. Additionally, they stated that proximal humeral migration was strongly relevant to glenoidal component loosening. This phenomenon was explained by the rocking horse movements of the humeral component on the glenoidal component which causes the eccentric loading on the glenoid component. The exacerbating factors of the proximal migration were described as instability and rotator cuff deficiency. Even the rotator cuff repair was performed; in the long-term, rotator cuff deficiency was stated as inevitable [104].

In 1987, Kelly et al. reported their experience in Neer's TSA in rheumatoid shoulders. After a follow-up of 36 months; even the patients' forward flexion (75) and abduction (68) were moderate; because of the improvement in external (40) and internal rotation, patients managed their daily living, thus the functional scores were satisfactory. But the main concern was the glenoidal radiolucent lines that started to happen after 2 weeks of operation [105], but their second updated publication in 1997 with a 9.5 year follow-up, revealed that even 23 of 37 glenoidal components had shown radiolucencies, only 24% were progressed and required further evaluation for revision. The range of motion in the long-term was not significantly different from their previous study [106].

Sneppen et al. published the long-term results of TSA in terms of complications in a rheumatoid patient group. Sixty-two shoulders were included and followed up for about 7 years. In the total group, 54% of the patients showed proximal migration. Especially the patients with preoperative Larsen grade V lesions had shown 69% proximal migration. But interestingly, the occurrence of proximal migration did not influence the functional outcome of the patients. About 89% of the patients achieved acceptable pain relief. Forward flexion and abduction were significantly increased according to the preoperative state. They also stated that because of the glenoid's poor bone stock, the glenoidal component's keel might be trimmed to achieve a proper fitting. Thus, the use of metal back components might not be the suitable choice for these patients. The authors also advised the use of cemented humeral component because even the perioperative state of humerus was seemed to be in good shape, 5 out of 12 patients had shown humeral component loosening in contrary of 50 patients with cemented humeral component which had shown no sign of radiolucency [107]. In contrary, Trail et al. supported the uncemented humeral component in their study (n = 144) because 13% of the patients had shown the radiolucent lines around the humeral component but it was neither progressive nor symptomatic [108]. Barlow et al.'s updated study about arthroplasty series in rheumatoid shoulder included largest patient population in literature. A total of 195 anatomical total shoulders and 108 hemiarthroplasty was included in study and followed up for 13.8 years. The radiographic evaluation of TSA revealed that 72% of the patients had radiolucent lines around glenoid component, in contrast to hemiarthroplasty's glenoid erosion which occurred in 98% of the patients. Even the presence of radiolucency rates was higher for TSA, in the 10th year of follow- up; TSA's survival was 92.9% and with an intact rotator cuff survival was increased to 96.7%. In contrary, hemiarthroplasty's 10 year survival was 87.9% but with an intact cuff survival was decreased to 75.8%. They stated that even the glenoidal component loosening is a catastrophic complication; with the presence of an intact rotator cuff, the survival of the prosthesis is superior to hemiarthroplasty [109].

for 89%. Their findings showed that the use of pegged which is more stable than keeled component, thin metal back with thicker polyethylene because the polyethylene wear was

Also, Betts et al.'s study included 14 rheumatoid shoulders with a follow-up of 19.8 years. They reported their functional outcomes, pain relief and complication rates. With the increase in follow-up duration, radiolucencies around glenoidal and humeral component and rotator cuff deficiency were progressed. But even with the presence of these radiological findings, functional outcomes and satisfactory pain relief were especially achieved in elderly, non-demanding patients. They managed their personal care and their sleep was undisturbed. Additionally, they stated that proximal humeral migration was strongly relevant to glenoidal component loosening. This phenomenon was explained by the rocking horse movements of the humeral component on the glenoidal component which causes the eccentric loading on the glenoid component. The exacerbating factors of the proximal migration were described as instability and rotator cuff deficiency. Even the rotator cuff repair was performed; in the long-term, rotator cuff deficiency

In 1987, Kelly et al. reported their experience in Neer's TSA in rheumatoid shoulders. After a follow-up of 36 months; even the patients' forward flexion (75) and abduction (68) were moderate; because of the improvement in external (40) and internal rotation, patients managed their daily living, thus the functional scores were satisfactory. But the main concern was the glenoidal radiolucent lines that started to happen after 2 weeks of operation [105], but their second updated publication in 1997 with a 9.5 year follow-up, revealed that even 23 of 37 glenoidal components had shown radiolucencies, only 24% were progressed and required further evaluation for revision. The range of motion in the long-term was not significantly different

Sneppen et al. published the long-term results of TSA in terms of complications in a rheumatoid patient group. Sixty-two shoulders were included and followed up for about 7 years. In the total group, 54% of the patients showed proximal migration. Especially the patients with preoperative Larsen grade V lesions had shown 69% proximal migration. But interestingly, the occurrence of proximal migration did not influence the functional outcome of the patients. About 89% of the patients achieved acceptable pain relief. Forward flexion and abduction were significantly increased according to the preoperative state. They also stated that because of the glenoid's poor bone stock, the glenoidal component's keel might be trimmed to achieve a proper fitting. Thus, the use of metal back components might not be the suitable choice for these patients. The authors also advised the use of cemented humeral component because even the perioperative state of humerus was seemed to be in good shape, 5 out of 12 patients had shown humeral component loosening in contrary of 50 patients with cemented humeral component which had shown no sign of radiolucency [107]. In contrary, Trail et al. supported the uncemented humeral component in their study (n = 144) because 13% of the patients had shown the radiolucent lines around the humeral component but it was neither progressive nor symptomatic [108]. Barlow et al.'s updated study about arthroplasty series in rheumatoid shoulder included largest patient population in literature. A total of 195 anatomical total shoulders and 108 hemiarthroplasty was included in study and followed up for 13.8 years.

stated as the major factor for revision surgeries [103].

was stated as inevitable [104].

186 Advances in Shoulder Surgery

from their previous study [106].

Glenoid loosening also depends on the morphology of the glenoid. Walch et al. identified five types glenoid morphology (A1, A2, B1, B2, C) in 113 patients' computed tomography scans. A1, A2 and B1 represents a lesser risk for glenoid component insertion and long-term loosening in contrast to B2 and C type glenoids. Key feature of the morphology of B2, C glenoids is the excessive retroversion [110]. Surgical techniques vary depending on the morphology but all technique has its disadvantage. Anatomical glenoid correction by reaming may be performed but as a result, the joint will be medialized, thus the lever arm of the surrounding muscle will decrease [111]. Also due to excessive reaming, glenoid bone stock will be lost and while inserting the component, the pegs may perforate the cortex which will result as loosening, fracture and in the long-term the revision surgery will be complicated. To protect the bone stock, glenoid may be reamed retrovertly without correcting version, but this technique represents a threat for perforation of anterior cortex by the inserted pegs and also more than 10 of retroversion increases the subluxation and instability of the prosthesis. To fill the defect of eroded area by bone graft in the posterior glenoid is another choice, but cemented glenoid components carry the risk of graft osteolysis. Metal backed hydroxyapatite covered components may be chosen. The advancement of prosthesis technology created posterior augmented glenoid designs. This component's augment fits on the defected glenoid, thus the reaming of anterior glenoid will be prevented [111, 112]. Kersten et al. compared the standard glenoid component with wedge and stepped posterior augmented glenoid component. Posterior augmented glenoid components confirmed that bone loss in glenoid is decreased significantly according to standard type glenoid components. Also comparison of the subgroups of posterior augmented components, the wedge-shaped required lesser reaming, thus bone stock removal was lesser than the stepped glenoid component and as a result lower risk for glenoid loosening might be achieved with wedged-shaped posterior augmented glenoid component [111]. Also Greiner et al. investigated the radiolucent line occurrences according to morphology. B2 and C glenoid types showed significantly higher radiolucent lines around glenoidal component after a follow-up of approximately 5 years [112]. Although these studies were performed on mostly primary osteoarthritis, surgical technique choices may give clues about patient specific approach.

In conclusion, as the advancement in prosthesis and improvement in surgical techniques, recent literature supports TSA for young- and old-aged patients with an intact or reparable rotator cuff. Rotator cuff deficiency and poor glenoid bone stock are the main perioperative challenges of TSA, but with the repair of rotator cuff and adjusting the glenoidal component by trimming had shown statistically significant pain relief and also improved functional outcomes. The identification of the glenoid morphology carries great importance to assess the surgical technique for overwhelming the most common complication of the TSA. In the longterm follow-up, the radiolucencies around components had created concerns about loosening, but the progression of radiolucencies is more trustworthy for this diagnosis [50]. Summary of the literature for TSA can be found in Table 5.
