The history and development of shoulder arthroplasty actually dates back to 1892 when Pean used a prosthesis in the shoulder to replace an infected tubercular joint. This was the first known joint replacement with a prosthesis, preceding the first prosthetic hip joint replacement by 26 years.
In the 1930s and 1940s, Wayne Z. Burkhead, MD, described the earliest use of acrylic prostheses used by several surgeons, including Baron and Senn, Lynn, Judet and De Anquin. Krueger created a Vitallium prosthesis in 1950 in conjunction with Austenal Laboratories of New York that was based on replicas of cadaver bones, and was used to treat a patient with avascular necrosis. In 1956, De Anquin modified his acrylic prosthesis to a metal component, which had fenestrations in the stem similar to Krueger’s design.
The modern era of shoulder arthroplasty began in the mid-1940s with Charles S. Neer II, MD. Dr. Neer graduated from Dartmouth University and the University of Pennsylvania School of Medicine, and was an orthopedic resident under William Darrach, MD, at New York Orthopaedic Hospital and Columbia Presbyterian Medical School.
Dr. Neer became disenchanted with the end results of patients with fractures of the proximal humerus treated with resection of the humeral head. He mentioned this to Dr. Darrach who said, “Smiley, why don’t you do something about it?” Before he could create anything, though, Dr. Neer went into the U.S. Army in early 1944. He served in both the European and Pacific theaters as a captain in the U.S. Medical Corps and was discharged in 1946. We should be very grateful to Dr. Darrach, who urged Dr. Neer to return to the staff at Columbia, for it was during that time he began his work in earnest to develop a shoulder prosthesis.
Neer’s first prosthesis
Charles S. Neer II pioneered the development of shoulder prostheses.
The first published photograph of Neer’s prosthesis appeared in an article in the American Journal of Surgery in 1953. His clinical series was first published in the Journal of Bone and Joint Surgery in 1955 and consisted of using his shoulder prosthesis in 12 cases. The original Neer I prosthesis was made of cast cobalt-chrome alloy called Vitallium. It had one stem size and the head boasted a 44-mm radius of curvature, which was the average of measurements of 50 dried bones. He used a hole in the lateral neck of the prosthesis to stabilize the fragments of the tuberosities in fracture cases. The top of the head was slightly flattened to avoid impingement on the supraspinatus tendon.
In 1953, the Neer I prosthesis became available in three stem sizes, and by 1955, that number increased to five. Each of the four fins had multiple fenestrations for bone ingrowth and stabilization. In his classic text, Shoulder Reconstruction, Neer reported that patients never had a problem with stem loosening as long as the device had been set firmly in the medullary canal at the time of insertion. He also noted that patients could engage in all types of activities, including farming and carpentry, without breakage, loosening or painful glenoid erosion. Furthermore, Neer continued to use the Neer I component without a glenoid prosthesis when the articular surface of the glenoid was normal.
He redesigned the humeral component in 1973 to conform to a polyethylene glenoid prosthesis. Zipple and Kenmore had independently designed and used a polyethylene glenoid with the original Neer I prosthesis. The Neer II prosthesis had the same radius of curvature of the head (44 mm) but had rounded edges to prevent encroachment on the glenoid component. The humeral component could be used with or without cement.
In his research, Dr. Neer experimented with different sizes and styles of glenoid components, including a metal-backed glenoid prosthesis. He also evaluated several different fixed fulcrum types of shoulder prostheses and was disappointed with all of them. The Neer prosthesis was originally marketed by Howmedica and later by 3-M as well as Kirschner. Today, the device is marketed by Biomet Inc. Neer continued to use the Neer II prosthesis until his retirement from Columbia University in New York in 1990.
A flurry of activity began in the 1950s and 1960s with the creation of new shoulder prosthesis designs. The designs were basically divided into three types: a fully-constrained prosthesis, a semi-constrained design and a non-constrained prosthesis. The fully-constrained or fixed-fulcrum prostheses included the designs of Bickel, Stanmore, Post, Kessel, Kolbel, Fenlin, Buechel, and Gristina. Some of the semi-constrained models included the designs from McNab-English, the DANA by Harlan Amstutz, and the Mathys. The primary indication for using a fixed-fulcrum prosthesis was when the patient had severe arthritis of the shoulder and destruction of the rotator cuff. It was basically a salvage procedure. The primary indication for using a semi-constrained model was to prevent superior subluxation of the humeral prosthesis when the patient had arthritis and rotator cuff insufficiency. Semi-constrained models have only been used sparingly, and most surgeons no longer use the fixed-fulcrum because of failure secondary to insecure fixation of the unit into the glenoid. In the 1970s, bipolar prostheses were designed by Swanson, Bateman and later by Worland. Simple resurfacing of the humeral head, a bone sparing procedure, was done by Bateman, Jonsson, Figgie and Copeland in the 1980s and 1990s.
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Neer prosthesis figure: The Neer I prosthesis, made of a cast cobalt-chrome alloy called Vitallium, was a revolutionary concept when it was introduced in the 1950s.
Courtesy of Charles
A. Rockwood, Jr.
In the 1980s, orthopedists turned to newer designs for unconstrained shoulder prostheses. In 1983, Robert Cofield, MD, while working with Richards Orthopaedic Co., introduced a humeral component with tissue ingrowth. A metal-backed glenoid with tissue ingrowth was introduced the following year. The Cofield shoulder was made available as a modular prosthesis in 1996 by Smith & Nephew Richards.
John Fenlin, MD, introduced the first modular shoulder prosthesis in North America in 1986, which was manufactured by Zimmer. The Biomodular prosthesis by Biomet was introduced in late 1986 by Russell Warren, MD, and David Dines, MD. It was the first modular shoulder prosthesis with a reverse Morse taper between the head and the body. Wayne Z. Burkhead, MD, introduced the “Select” modular prosthesis from Intermedics Orthopaedics, now Sulzer Medica Company, in 1987. The Global Shoulder prosthesis, another modular design which I designed with Rick Matsen, MD, became available from DePuy in 1990.
Other modular shoulder prostheses
Other modular shoulder prostheses were introduced in the mid-1990s, including the Foundation Shoulder by Richard Friedman, MD, for Encore; the Osteonics Total Shoulder System from Osteonics by Robert Bell, MD; and the Biangular prosthesis from Biomet by Richard Worland, MD. Other prostheses introduced within the past few years include the Atlas Shoulder and the Kirschner Modular IIC, designed by Edward Craig, MD, and originally marketed by Kirschner and now Biomet; and in 1999, the Bigliani-Flatow Shoulder from Zimmer by Louis Bigliani, MD, and Evan Flatow, MD. Many different prostheses have been introduced by prominent international shoulder surgeons such as Drs. Walch, Boileau, Gerber, Randelli, Copeland, Wallace and Mansat. Worldwide, there are probably more than 100 different shoulder prosthesis designs in use.
Ultimately, orthopedic surgeons and their patients owe a great deal to Dr. Neer for his pioneering work in the development of shoulder arthroplasty. He has been a great innovator, a great teacher and a great surgeon. Dr. Neer’s imagination, knowledge, skill and enthusiasm have created a shoulder arthroplasty legacy which will carry us into the new millennium.
Charles A. Rockwood Jr., MD, is professor and chairman emeritus of the department of orthopedic surgery at the University of Texas Health Science Center in San Antonio.