Orthopedics

Feature Article 

Revision of Failed Resurfacing Hemiarthroplasty: Midterm Results, Survival, and Group Comparison

Pieter C. Geervliet, MD; Mike Houtveen, MD; Inger N. Sierevelt, MD; Cornelis P. J. Visser, MD, PhD; Arthur van Noort, MD, PhD

Abstract

Shoulder arthroplasty is a valuable option for treating glenohumeral osteoarthritis. Revision surgery for a failed shoulder arthroplasty is associated with difficult procedures, complications, and worse outcomes. Compared with a total joint arthroplasty, a resurfacing prosthesis has the supposed advantages of limited perioperative complications and little bone loss during revision. The aim of this study was to describe patient-reported outcome measures of revision surgery from failed uncemented Global CAP (DePuy, Warsaw, Indiana) resurfacing hemiarthroplasty to total shoulder or reverse shoulder arthroplasty. Eleven patients from 2 collaborating institutes had a failed resurfacing prosthesis. Revision surgery was performed to total shoulder prosthesis in 7 patients and to reverse shoulder prosthesis in 3 patients. Data were missing for 1 patient. Outcomes were monitored using the Constant–Murley score, Dutch Simple Shoulder Test, Short Form-12, visual analog scale for pain, and physical examination. Mean time to revision was 54 months (SD, 15.6 months). No perioperative complications occurred. At 42 months of follow-up (SD, 15.9 months), clinical and patient-reported outcomes were excellent. The Constant–Murley score improved a significant 29 points (P<.01). The visual analog scale pain score decreased from 55 to 5 points (P<.01), and the Dutch Simple Shoulder Test and Short Form-12 scores improved significantly (P≤.02). Five-year survival was 82.6% (95% confidence interval, 71.6%–93.6%). At 3.5-year follow-up, clinical and patient-reported outcome measures had satisfying results. [Orthopedics. 2019; 42(1):e111–e117.]

Abstract

Shoulder arthroplasty is a valuable option for treating glenohumeral osteoarthritis. Revision surgery for a failed shoulder arthroplasty is associated with difficult procedures, complications, and worse outcomes. Compared with a total joint arthroplasty, a resurfacing prosthesis has the supposed advantages of limited perioperative complications and little bone loss during revision. The aim of this study was to describe patient-reported outcome measures of revision surgery from failed uncemented Global CAP (DePuy, Warsaw, Indiana) resurfacing hemiarthroplasty to total shoulder or reverse shoulder arthroplasty. Eleven patients from 2 collaborating institutes had a failed resurfacing prosthesis. Revision surgery was performed to total shoulder prosthesis in 7 patients and to reverse shoulder prosthesis in 3 patients. Data were missing for 1 patient. Outcomes were monitored using the Constant–Murley score, Dutch Simple Shoulder Test, Short Form-12, visual analog scale for pain, and physical examination. Mean time to revision was 54 months (SD, 15.6 months). No perioperative complications occurred. At 42 months of follow-up (SD, 15.9 months), clinical and patient-reported outcomes were excellent. The Constant–Murley score improved a significant 29 points (P<.01). The visual analog scale pain score decreased from 55 to 5 points (P<.01), and the Dutch Simple Shoulder Test and Short Form-12 scores improved significantly (P≤.02). Five-year survival was 82.6% (95% confidence interval, 71.6%–93.6%). At 3.5-year follow-up, clinical and patient-reported outcome measures had satisfying results. [Orthopedics. 2019; 42(1):e111–e117.]

Shoulder arthroplasty has been proven to be clinically useful in patients with glenohumeral osteoarthritis during the past 6 decades.1 Over time, many designs of prosthesis have been used. Copeland popularized the resurfacing prosthesis in the 1980s,2,3 which required metal caps to be secured in place by a short central peg. The suggested advantages of this prosthesis include the preservation of the native head-shaft angle and center of rotation. Additionally, minimal resection of the humeral head is required to fit the prosthesis, which results in shorter operative time. Low prevalence of periprosthetic fractures is seen without the stress riser effect of a stem.4,5 Nevertheless, anatomical restoration is difficult because the humeral head is easily oversized and the design of the prosthesis may not replicate the native humeral head.6–8 Follow-up studies show positive functional and patient-reported results.4,5,9–13 Compared with conventional hemiarthroplasties, the resurfacing prosthesis has equivalent results; however, the revision rate is higher.14–17

Revision of conventional shoulder hemiarthroplasty is a time-consuming and difficult procedure in which extraction of the stem is prone to perioperative complications.18,19 Additionally, results are disappointing; up to 57% of the patients report unsatisfactory outcome measures and up to 27% need re-revision in 10 years.19,20 In case of revision of a resurfacing prosthesis, however, the removal of the implant is easily facilitated. Perioperative complications are rare, bone graft to compensate for lost humeral bone stock is seldom required, and less surgical time is needed.18,20 However, there are limited published data about the results of this revision, and to the authors' knowledge, follow-up has been described in only 3 series of patients with conflicting results.18,20–22

Therefore, the aim of this study was to report the clinical and functional outcomes of revision from the uncemented Global CAP resurfacing prosthesis (DePuy, Warsaw, Indiana) to a total shoulder prosthesis (TSA) or a reverse shoulder prosthesis (RSA). In addition, the authors performed a survivorship analysis and compared the baseline characteristics of the Global CAP revision and nonrevision groups to determine factors predictive of revision.

Materials and Methods

Patients

This study was performed as an extension to the ongoing follow-up study of patients treated with the uncemented Global CAP resurfacing shoulder prosthesis.10,17,23 The study received institutional review board approval, and all patients provided written informed consent.

Adult patients with osteoarthritis for whom conservative treatment failed were enrolled in this study and treated with un-cemented Global CAP resurfacing hemiarthroplasty between January 2007 and December 2009. This cohort consisted of 36 women and 12 men, with a mean age of 66 years (range, 54–84 years). The 48 shoulders (46 patients) that were included had intact rotator cuff, sufficient (>60%) bone stock of the proximal humerus, and type A1, A2, or B1 glenoid (Walch classification24) as assessed on radiographs and magnetic resonance imaging. Excluded patients had severe fatty infiltration (Goutallier grade 4)25 or paresis of rotator cuff muscles, wound healing or neuromuscular pathologies, or active infections.10,17

At a mean follow-up of 4.5 years, 11 patients (23%) had undergone revision surgery. Pain and poor function were caused by glenoid erosion in 4 patients (36%). Undefined pain and loss of function were found in 2 (18%) patients. Cuff arthropathy was found in 2 patients (18%), with 1 patient's prosthesis having anterior subluxations after a failed subscapularis tendon repair. Arthrofibrosis and painful glenoid without erosion were reasons for revision in 2 other patients. One patient (9%) had low-grade infection without loosening of the prosthesis; cultures showed Pantoea agglomerans, Staphylococcus epidermidis, and Propionibacterium acnes.23 Total shoulder arthroplasty was used in 8 patients. Three patients received a RSA, of whom 2 patients had an insufficient rotator cuff and 1 had excessive glenoid erosion (Figure 1, Table 1).

Anteroposterior radiographs of left shoulders with Global CAP (DePuy, Warsaw, Indiana) resurfacing prosthesis before revision (A), T.E.S.S. Total Shoulder Arthroplasty (Biomet, Valence, France) (B), Global AP Total Shoulder Arthroplasty (DePuy Synthes, Warsaw, Indiana) (C), and Delta Xtend Reverse Shoulder Arthroplasty (DePuy Synthes) (D).

Figure 1:

Anteroposterior radiographs of left shoulders with Global CAP (DePuy, Warsaw, Indiana) resurfacing prosthesis before revision (A), T.E.S.S. Total Shoulder Arthroplasty (Biomet, Valence, France) (B), Global AP Total Shoulder Arthroplasty (DePuy Synthes, Warsaw, Indiana) (C), and Delta Xtend Reverse Shoulder Arthroplasty (DePuy Synthes) (D).

Characteristics of Revision Patient Population (n=11)

Table 1:

Characteristics of Revision Patient Population (n=11)

During the revision procedures, the prostheses were easily removed from the proximal humerus. The bone density underneath the prosthesis was significantly decreased in all cases, although none of the prostheses were loosened. No revision required humeral osteotomy or humeral bone allograft. No perioperative complications occurred.

Rehabilitation consisted of pendulum exercises of the arm during the first 2 weeks. A period of 4 weeks with active assisted and passive motion within 90° of anteflexion and abduction and maximum of 30° of external rotation was advised for TSA patients. A sling was given for support during the first 6 weeks. Restricted range of motion and use of the supportive sling in RSA rehabilitation lasted 2 weeks. Additional physiotherapy was advised for 3 to 6 months for both TSA and RSA.

Study Design

Pre- and post-revision assessments were performed at the outpatient clinic. The Constant–Murley score was used as a guideline for shoulder function and was adjusted for sex and age.26 Secondary outcomes included pain measured by the visual analog scale27 and Short Form-1228 and shoulder function measured by the Dutch Simple Shoulder Test.29 Initial pre-resurfacing data were retrieved from the authors' study database. Baseline measurements of successful and revised Global CAP resurfacing prostheses were compared. The last orthopedic follow-up and date of death or revision were collected from all patient files to analyze the survival.

Statistics

Statistical analysis was performed with SPSS version 20.0 software (IBM, Armonk, New York). Nominal and ordinal outcomes were presented with frequencies and corresponding percentages. Continuous variables were presented as means and standard deviations or 95% confidence intervals. Pre- and postoperative pain, Constant–Murley, Short Form-12, and Dutch Simple Shoulder Test scores, and range of motion and strength were compared using paired t tests. Baseline characteristics of the patients with and without revision surgery were compared. For categorical variables, chi-square tests were performed; continuous variables were analyzed using t tests or Mann– Whitney U tests in case of non-normality. Kaplan–Meier curves were used for survival analysis, and a log-rank test was performed to compare survival of the prosthesis between male and female patients. Revision was defined as the endpoint, and dates of death or last follow-up were used as censuring dates. P<.05 was considered statistically significant.

Results

Post-revision assessments were achieved for 10 of the 11 revision patients. The 1 missing patient had emigrated and had revision surgery abroad. This patient did not reply to the survey. Assessments were made at a mean of 42 months (minimum follow-up, 21 months; maximum follow-up, 74 months; SD, 15.9 months) and showed good clinical and patient-reported outcome measures. The Constant–Murley score improved significantly, with a mean of 26 points (95% confidence interval, 9.6–43.0), and all patients scored above 80 points. Of 10 patients, 8 (80%) had no pain according to visual analog scale score. The partial Constant–Murley score for internal rotation resulted in a significant improvement from a median of 4 (reach to lumbosacral; inter-quartile range, 4–4) to 7 (reach between L3 and T12; interquartile range, 5.5–8) (P=.03). However, no significant improvement was observed for external rotation (P=.07). Both Dutch Simple Shoulder Test and Short Form-12 scores were significantly improved (Table 2).

Comparison of Assessments Before and After Revision

Table 2:

Comparison of Assessments Before and After Revision

Baseline characteristics of patients with and without revision are listed in Table 3 and Table 4. Goutallier et al25 grade fattening of the supraspinatus muscle was assessed on magnetic resonance imaging and was significantly higher in the non-revision CAP group (P<.01). No other significant preoperative differences were found between the 2 groups. Regression analyses showed a significant correlation between Constant–Murley score and sex (P<.01); therefore, the comparison between the revision and nonrevision group was corrected for sex.

Baseline Characteristics of Patients With and Without Revision

Table 3:

Baseline Characteristics of Patients With and Without Revision

Baseline Radiologicala Assessment of Patients With and Without Revision

Table 4:

Baseline Radiological Assessment of Patients With and Without Revision

Survival Analysis

In total, the 5-year survival of the Global CAP resurfacing prosthesis was 82.6% (95% confidence interval, 71.6%–93.6%). No significant difference was found between male and female patients (P=.40). Five-year survival was 85.3% (95% confidence interval, 73.3%–97.3%) for women and 75% (95% confidence interval, 50.5%–99.5%) for men. The Kaplan–Meier curves for all patients and for sex are shown in Figure 2.

Kaplan–Meier survival analysis for total group (A) and by sex (B). Five-year cut of time marked with vertical line. Abbreviations: F, female; M, male.

Figure 2:

Kaplan–Meier survival analysis for total group (A) and by sex (B). Five-year cut of time marked with vertical line. Abbreviations: F, female; M, male.

There were no re-revisions.

Discussion

The main finding of this study was the good outcome at midterm follow-up of shoulder arthroplasty after revision from the uncemented Global CAP resurfacing prosthesis. Comparable, good clinical outcomes were reported by Natera et al20 in 18 revisions of the Copeland resurfacing prosthesis. In contrast, Streubel et al21 found that only 4 of 11 (36%) patients had satisfactory results based on the modified Neer score. One re-revision (9%) had to be performed in their series.21 In the latest study, by Rasmussen et al,22 unsatisfactory outcomes were reported by 41% (n=33) of the 80 shoulder resurfacing revision patients from the Danish national register.

These various results could be explained by the presence of confounding variables such as the experience of the surgeon, age, prior surgery, differences between implants used, and underlying original pathology.21 Surgical volume has proven to be related to the outcome of shoulder prostheses.30 The implantation rates of TSA and RSA are rising1,31; therefore, surgical skill and experience should increase proportionately.

High-volume orthopedic surgeons (ie, more than 8 shoulder arthroplasties per year30) performed the revisions at the authors' institutions. The authors used 3 different prosthesis designs to revise the failed CAP resurfacing prosthesis (Table 1). The surgeons have extensive experience with these designs; the same prostheses used for primary stemmed TSA and RSA were used for the revision of the CAP prosthesis during this study. In contrast, Natera et al20 successfully used 1 specific type of RSA and reported that RSA was the best option in revision situations. There is limited evidence regarding the role of surgeon experience and prosthesis design in the outcome of revision surgery. The best prosthesis design to use for revision has yet to be determined. In the current authors' opinion, surgeon experience with the specific prosthesis design is most valuable.

For the treatment of glenohumeral osteoarthritis, TSA is the gold standard.32–35 However, the authors believe that a hemiprosthesis such as a resurfacing implant is still a valid treatment option in selected patients. The limited survival of the glenoid component in TSA is troubling. At midterm follow-up, the rate of glenoid loosening has been reported to be 39%.4,36–43 Factors such as rotator cuff failure, glenoid component malposition, and instability can lead to glenoid component loosening and failure.38,42,44

Young patients have been shown to have higher demands of their shoulder prostheses, and optimal shoulder function is needed for labor and physical activities.4,11 Patient-reported outcome measures are likely to be related to these demands.45 Hemiarthroplasties are prone to fail in young patients. The average age in the current series was 66 years; this older age could have been favorable for the outcomes.

Streubel et al21 stressed the importance of exposure in their revision surgeries when prior preservation of the rotator cuff was done. Owing to excessive scarring, a different approach was needed in 4 of their 11 cases. In the current study, only 1 patient had prior surgery (subscapularis tendon repair). Owing to the low prevalence of prior surgeries in this series, soft tissue damage and scarring were minimal. The extraction of the failed CAP prosthesis was easily accomplished after exposing the glenohumeral joint. During revision surgery, humeral osteotomy or humeral bone allograft was not necessary in all cases; this is in contrast to studies by Al-Hadithy et al46 and Alizadehkhaiyat et al.47 The current study did not show perioperative complications such as humeral fractures. With these advantages, Cisneros et al18 found that more than an hour of time was spared compared with revision of stemmed hemiarthroplasty, which is likely to minimize the perioperative complication hazard.

In the current study, the authors found a 5-year survival rate of 82.6%. Lebon et al48 found only a 41% survival rate of resurfacing prostheses at 5.5-year follow-up in 37 patients, which was significantly poorer than the 0 revisions in their stemmed hemiarthroplasty group. Levy et al11 reported a better 5-year survival rate of 97%. Clearly higher revision rates were reported beyond 5-year follow-up.11,31,48

There is certainly a discrepancy in the literature regarding the percentage of revision due to glenoid erosion and pain in resurfacing prostheses.11,47–52 Levy et al49 and Mullett et al50 reported 3% and 5% revision rates, respectively, at mid-term follow-up. Alizadehkhaiyat et al47 and Smith et al52 reported 21% and 22% revision rates at short-term and midterm follow-up, respectively. The current authors found a similar revision rate (23%) despite their careful inclusion criteria: glenohumeral osteoarthritis, intact rotator cuff, and glenoid type A1, A2, or B1.

In their initial series, 42% of the male and 17% of the female patients had a revision. However, a nonsignificant P value was found when comparing the sex-specific survival curves. Additionally, similar results were presented in the 2015 annual report of the Australian Orthopaedic Association, indicating no sex-specific differences in revision rate in 92 patients.16 A decrease in the use of resurfacing prostheses has been observed since 2006,31 with a probable decrease in surgical skill. Developments in resurfacing are therefore likely to diminish.

Although results varied, the indications for revision were comparable in all revision series the current authors reviewed.17,18,20–22 Hartel et al,53 Sajadi et al,54 and Dines et al55 showed inferior outcomes if revisions of hemiarthroplasty were due to soft tissue pathologies compared with glenoid erosion or component failure. Regarding resurfacing prostheses, the effect of indication for revision has not been investigated. However, glenoid erosion is a major concern in resurfacing hemiarthroplasty.56 Regarding the numbers available in their baseline comparison, the current authors conversely found significant lower Goutallier grades in the revision group, suggesting that good muscle condition could be a risk factor for early revision. This in contrast to Herschel et al,57 who found fatty infiltration of the rotator cuff to be a risk factor for glenoid erosion in hemiarthroplasty.

The CAP resurfacing prosthesis did not show signs of loosening on radiographs, and no loose prostheses were found during revision. However, perioperative observations indicated that there was significantly reduced bone density underneath the CAP prosthesis. These findings are similar to those described by Schmidutz et al,58 who reported that despite clear signs of stress shielding, adequate ingrowth of bone was observed to secure good stability of the prosthesis. The bone quality of the proximal humerus was not affected. Even a stemless prosthesis such as the T.E.S.S. (Biomet, Valence, France) could be firmly secured after the removal of the humeral head re-surfacing arthroplasty.

A limitation of this study was the small sample. Although a CAP resurfacing replacement was implanted in 48 shoulders, only 11 were revised and therefore available for this study. Another limitation of this study was the lack of a control group. A stemmed control group or primary TSA group like the studies of Natera et al20 and Rasmussen et al22 would yield valuable information and opportunities for comparison. Unfortunately, such data were not available. Despite the low therapeutic level of this study, it involved, to the authors' knowledge, the only cohort of revisions of this specific prosthesis described in the literature and showed good results.

Conclusion

At midterm follow-up, patient-reported outcome measures were satisfying after revision of the uncemented Global CAP resurfacing hemiprosthesis to TSA or RSA. Despite the limited, conflicting literature on this subject, the data of this study support the authors' opinion that TSA or RSA is a viable option when a re-surfacing hemiarthroplasty has failed.

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Characteristics of Revision Patient Population (n=11)

CharacteristicValue
Age at revision, mean±SD, y69±6.2
Survival, mean±SD, mo54±15.6
Sex, % male (male/female, No.)45.5% (5/6)
Side
  Dominant, % right (right/left, No.)81% (9/2)
  Operation, % right (right/left, No.)45.5% (5/6)
Reason for revision, No.
  Glenoid erosion4
  Pain and rROM2
  Cuff arthropathy2
  Arthrofibrosis2
  Infection1
Revision prosthesis, No.
  Global APa3
  T.E.S.S.b4
  Delta Xtendc3
  Unknownd1

Comparison of Assessments Before and After Revision

AssessmentMean±SDP

Before RevisionAfter Revision
Elevation111°±34°143°±24°.04
Abduction92°±34°113°±29°.09
Forcea22.3±3.522.0±3.4.92
Constant–Murley score, points67.1±26.096.1±7.2<.01
Visual analog scale score, points54.3±24.45.0±10.8<.01
Dutch Simple Shoulder Test score, points43.9±28.984.2±13.3<.01
Short Form-12 physical component score, points36.7±9.143.9±12.3.02
Short Form-12 mental component score, points42.6±9.955.5±10.6<.01

Baseline Characteristics of Patients With and Without Revision

CharacteristicRevision (n=11)No Revision (n=37)PSignificant Correlationa
Sex, % male (male/female, No.)45.5% (5/6)18.9% (7/30).11bNo
Age, mean±SD, y62.9±6.266.6±7.8.16No
Elevation, mean±SD97.0°±29.3°99.2°±35.6°.85.61
Abduction, mean±SD81.9°±32.2°81.9°±27.5°.99.64
Force,c mean±SD9.5±2.28.2±2.8.16.53
Constant–Murley score, mean±SD, points46.3±18.546.8±16.9.93.42
Visual analog scale score, mean±SD, points62.0±15.165.2±18.2.60.73
Short Form-12 mental component score, mean±SD, points51.7±10.848.1±12.3.39.58
Short Form-12 physical component score, mean±SD, points32.2±6.535.5±7.9.22.20
Dutch Simple Shoulder Test score, mean±SD, points27.6±27.520.0±21.3.34.57

Baseline Radiologicala Assessment of Patients With and Without Revision

AssessmentNo. (%)P

Revision (n=11)No Revision (n=37)
Goutallier fattening25<.01
  None9 (82)4 (11)
  Grade 12 (18)26 (70)
  Grade 20 (0)6 (16)
  Grade 30 (0)1 (3)
Glenoid type24.14
  A19 (82)17 (46)
  A21 (9)14 (38)
  B11 (9)6 (16)
Osteophytes.39
  None1 (9)1 (3)
  Little6 (55)14 (38)
  Moderate4 (36)19 (51)
  Severe0 (0)3 (8)
Cuff rupture.60
  Yes (<1 cm)0 (0)4 (11)
  No11 (100)33 (89)
Cuff calculations.11
  Yes5 (45)6 (16)
  No6 (55)31 (84)
Authors

The authors are from the Department of Orthopedic Surgery (PCG), Shoulder Unit, Northwest Clinics, Den Helder; the Department of Orthopedic Surgery (MH, INS, AvN), Spaarne Gasthuis, Hoofddorp; and the Department of Orthopedic Surgery (CPJV), Alrijne Hospital, Leiderdorp, the Netherlands.

Dr Geervliet, Dr Houtveen, and Dr Sierevelt have no relevant financial relationships to disclose. Dr Visser has received grants from DePuy Synthes and is a paid consultant for Johnson & Johnson. Dr van Noort has received grants from DePuy Synthes and is a paid consultant for Johnson & Johnson.

The original CAP study was funded by grants from DePuy Synthes to Spaarne Gasthuis (grant 116347) and Alrijne Hospital (grant 221090).

Correspondence should be addressed to: Pieter C. Geervliet, MD, Department of Orthopedic Surgery, Shoulder Unit, Northwest Clinics, Huisduinderweg 3, 1782 GZ, Den Helder, the Netherlands ( geervliet@gmail.com).

Received: October 10, 2017
Accepted: July 18, 2018
Posted Online: December 13, 2018

10.3928/01477447-20181206-02

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