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Journal Club

September 2010

Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis:
A systematic review

Author: C Radnay, K Setter, L Chambers, W Levine, L Bigliani, C Ahmad

Journal : Journal of Shoulder and Elbow Surgery 2007

Introduction

• replacement surgery was introduced by Neer in the 1950’s for fractures
• It is most commonly used now for the treatment of G-H OA
• The goals are to reduce pain and improve function
• Failing non-operative treatment the options are a humeral head replacement or TSR

HHR

•          decreased operative time
•          decreased blood loss
•          less technically demanding
•          but... progression of glenoid OA & higher revision rate

TSR

•          likely better pain relief, ROM and strength
•          but... increased operative time
•          but... increased blood loss
•          but... technically more demanding
•          but... potential glenoid loosening & PE wear

AIMS

• perform a systematic review of the literature comparing HHR to TSR for the treatment of primary G-H OA
• Hypothesis : TSR is superior than HHR for the treatment of G-H OA

Methodology

• Medline & PubMed searches, 1966 - April 2004, English language, Primary G-H OA and TSR and HHR
• searched bibliographies and textbooks for further studies
• study quality rated using JBJS criteria
  • 1 - prospective RCT through to 5 - expert opinion
• relevant data extracted from the studies
  • age, pain, ROM, complications, revision rates

Exclusion criteria

• inflammatory
• post-trauma
• R-C arthropathy

Statistical methods

• pain scores were converted to a 100-point scale
• for continuous outcomes 2-sample t test
• for discrete outcomes two-by-two X2

Results

• 23 studies
• 1952 patients
• mean 43.4 month follow up
• mean age 66
• 1 prospective RCT
• 2 poorly controlled RT
• 22 case series

Pain Relief

•          14 studies, 1185 patients
•          TSR 85.8, HHR 77.6 p<0.0001

Range of Motion

•          15 studies, 1080 patients
•          FE - TSR141.4° HHR 124.9° p<0.0001
•          ER - TSR 42.7° HHR 42.1°  p=.74
•          gains in both FE&ER significantly more in TSR

Patient Satisfaction

•          12 studies, 969 shoulders
•          TSR 96.7% HHR 80.4% p<0.0001

Revision Surgery

•          13 studies, 1474 studies
•          TSR 6.5% HHR 10.2% p<0.025
•          8.1% of HHRs converted to TSR because of pain

Discussion

• The results of HHR appear to deteriorate with time
• The glenoid can deteriorate over time necessitating a TSR
• Conversion of HHR to TSR can leave up to 47% of patients unsatisfied

Pros of Study

• 1 prospective RCT
• able to pool data together to increase the power of analysis
• Louis U Bigliani

Cons of Study

• only 1 prospective RCT and this was with limited numbers
• only as good as the studies used
• limited follow up