Thursday, February 6, 2003
Biologic glenoid resurfacing can provide pain relief and a return to an active lifestyle for younger patients with glenohumeral arthritis, said authors of Scientific Paper 024 on Wednesday. They also reported that using allograft tissue can avoid possible sympathetic nerve pain associated with the capsular resurfacing procedure.
Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected younger patients with primary, post-traumatic or post-reconstruction glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and tendoachilles allograft, can be used and combined with an uncemented hemiarthroplasty. Based on 5- to 13-year results, the authors recommend either autogenous fascia lata or tendoachilles allograft.
From November 1988 to November 2001, 26 shoulders in 24 patients (22 men and 2 women) were followed prospectively. The average age of patients was 52 years (range 30 to 75 years). Fourteen of 26 shoulders had undergone previous surgery.
The diagnosis was primary glenohumeral osteoarthritis in nine shoulders, post-traumatic arthritis in four shoulders, avascular necrosis in one shoulder and post-reconstructive arthritis in the remaining 12 shoulders. Glenoid resurfacing was performed using the anterior capsule in seven shoulders, autogenous fascia lata in 12 shoulders and tendoachilles allograft in eight shoulders. A combination of sutures and anchors were used. All patients also had a cementless humeral head replacement.
The tendoachilles allograft was recommended as the resurfacing graft of choice because it reduces graft morbidity and increases tissue availability. The tendon can be folded back onto itself several times to create an appropriately sized glenoid shape, and sutured to itself to retain the shape. After creating a bleeding surface with a burr, the surgeon uses absorbable suture anchors to attach the graft to the glenoid. Sutures are individually passed through the contoured tendon graft in a mattress fashion. The graft is then pushed down the sutures and abutted against the glenoid, and the sutures are tied.
After the first year, annual Neer scores were performed on all patients and serial radiographs reviewed. Results were excellent in 12 shoulders (46 percent), satisfactory in nine shoulders (35 percent) and unsatisfactory in five shoulders (19 percent). Based on a visual analogue scale of 0 to 10, levels of pain decreased from 7.7 to 3.2. Glenoid erosion averaged 7.2 mm at the latest follow-up, stabilizing at approximately 5 years. Joint space averaged 1.3 mm. There were no revisions for humeral loosening. Twenty-one patients were able to return to their preoperative activities, which ranged from polo to firefighting to golf and tennis.
Complications included two infections, three cases of instability, one instance of brachial plexitis and one instance of upper extremity deep vein thrombosis. The use of the anterior capsule, infection, and early re-injury were all factors associated with unsatisfactory results. Three of the five poor results have been revised to a total shoulder arthroplasty, two with excellent results and one with a poor result. "The young patient with arthritis who has disabling pain and loss of motion but wants to return to active sporting activities or a job that requires heavy lifting or overhead arm movements poses a difficult treatment problem," note the authors. "Biologic glenoid resurfacing can provide pain relief similar to total shoulder arthroplasty for these diagnostic groups."
The paper's authors are Robert J. Nowinski, DO, of Newark, Ohio, and Wayne Z. Burkhead, MD, of Dallas, Texas. Funding was provided by Sulzer Medica and Centerpulse.
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