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Saturday, February 26, 2005

TSA better then hemiarthroplasty for glenohumeral osteoarthritis

By Carolyn Rogers

Total shoulder arthroplasty (TSA) demonstrates superior results for pain relief, range of motion and patient satisfaction when compared to hemiarthroplasty for patients with primary glenohumeral osteoarthritis, according to researchers who presented Paper 381, a meta-analysis comparing the two procedures.

Because the optimal treatment choice for primary osteoarthritis remains controversial, the researchers performed a meta-analysis to determine differences in pain relief, range of motion, revision surgery and satisfaction in primary glenohumeral osteoarthritis patients treated with TSA as compared to hemiarthroplasty.

The investigators searched computerized databases for clinical studies published between 1966 and 2004 that reported on shoulder arthroplasty for glenohumeral arthritis. Twenty-four studies were identified, with a total of 1,941 patients and an average follow-up of 61.6 months (range: 27-147 months). The studies were graded one (prospective randomized) through five (expert opinion) for level of evidence. The average level of evidence was 3.73.

Among the 24 studies, eight different outcome instruments were used. For this reason, the researchers had to convert the pain data into a 100-point pain score, based on a rating system developed by Neer and Cofield. Of the 24 studies, 15 (n=1,425 patients) reported levels of pain relief, 15 (n=1,367 patients) reported range of motion, 15 (n=1,425 patients) reported patient satisfaction, and 14 (n=1,347 patients) reported revision surgery.

Normal test statistics were performed on the pooled data and demonstrated that TSA, compared to hemi-arthroplasty, provided significantly greater pain relief (p<.001), forward elevation (p<.001), gain in forward elevation (p<.001), gain in external rotation (p=.0014), and patient satisfaction (p<.001). Furthermore, 10.2 percent of the shoulders that underwent hemiarthroplasty required another procedure, as compared to 7.7 percent of total shoulder arthroplasties. Only 1.7 percent of all-polyethylene glenoid components required revision.

"Despite the increased technical difficulty and potential problems associated with placement of a glenoid component, TSA maintains low rates of glenoid loosening and revision surgery especially when all polyethylene glenoid components are used," said lead researcher Christopher S. Ahmad, MD. "Total shoulder arthroplasty appears to be the surgical treatment of choice for patients with end-stage primary glenohumeral osteoarthritis."

An additional finding of the meta-analysis was that the studies identified and reviewed were of poor quality, as quantified by the Journal of Bone and Joint Surgery levels of evidence for primary research questions. The level of evidence for these studies was poor and the outcome instruments used were uneven, suggesting the need for standardization of outcome instruments and improved study design in the future, the paper stated.

In addition to Dr. Ahmad, the researchers included Craig S. Radnay, MD, MPH; Kevin J. Setter, MD; Locky Chambers; William N. Levine, MD; and Louis U. Bigliani, MD-all of New York City.

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