In young and active patients with glenohumeral osteoarthritis (OA), anatomic total shoulder arthroplasty (TSA) with an inlay glenoid coupled with a stemless ovoid humeral head may lead to long-term improved clinical outcomes and a high rate of return-to-activity over a shorter follow-up period, according to research results published in the Journal of Shoulder and Elbow Surgery.1
Researchers reported on the clinical outcomes as well as return-to-work and sporting activity data in a cohort of young and active patients who underwent an anatomic TSA with an inlay glenoid coupled with an ovoid humeral head component (Arthrosurface®).
Patients with glenohumeral (85.1%) and posttraumatic OA (14.9%) were pre and postoperatively evaluated using advanced MRI and/or computed tomography and true anteroposterior, scapular Y, and axillary lateral radiographs.
Researchers performed TSA with an inlay glenoid component on 27 shoulders in 24 patients, with a 2-year postsurgical follow-up. A total of 40.7% of patients underwent prior surgery on the ipsilateral shoulder, including arthroscopic rotator cuff repair, arthroscopic debridement and capsular release, subacromial decompression, instability procedures, biceps tenodesis or tenotomy, distal clavicle excision, superior labrum anterior-posterior repair, and glenohumeral microfracture.
Results showed significant improvements in American Shoulder and Elbow Surgeons score after TSA (mean, 39.5±20.8 to 85.7±16.1), with additional improvements in the functional component, the Single Assessment Numeric Evaluation score, the visual analog scale pain score, and the 12-Item Short Form physical score. Active range of motion was also increased in both forward flexion (107±24.5 to 155±16.6 degrees) and external rotation (23±7.5 to 55±15.1 degrees). Furthermore, 85% of patients were either satisfied or very satisfied with their shoulder after TSA with an inlay glenoid. No revision procedures were performed.
Overall, 74.1% of patients responded to and completed a custom return-to-work and -sports survey. A total of 92.59% of patients returned to work at an average of 3.7±5.2 months (range, 0-25 months), postoperatively. All survey respondents also reported participation in sporting activity before surgery; after surgery, 75% of respondents were able to return to ≥1 of the preoperative sports 9.1±4.3 months (range, 3-18 months) after the procedure. Only 2 patients were unable to return to sporting activity because of continued shoulder pain or stiffness.
We spoke with lead study author Gregory P Nicholson, MD, orthopedic surgeon at Rush University Medical Center in Chicago, Illinois, who provided an insight into the current applications of the novel joint preservation technology in patients who undergo TSA.
Could you give us the highlights of the novel joint preservation technology for glenohumeral OA?
Anatomic joint preservation arthroplasty procedures are becoming the preferred treatment method over traditional total joint replacements. As physical fitness and an active lifestyle become a high priority for many individuals, more patients reported wanting to return to normal activity as quickly as possible, postoperatively. Joint preservation procedures recreate the native shape of the joint, remove minimal bone, and minimize wear and loosening. Postoperative benefits make these procedures particularly appealing to patients who want to return to activities and sports that are typically prohibited after traditional total joint replacement.
While the demand for TSA in patients aged <55 years is projected to grow at a rate of 8.2% per year,1 clinical data for an anatomic TSA with inlay glenoid components has been lacking.
This study shows numerous benefits of using the Arthrosurface OVO® with Inlay Glenoid Shoulder Arthroplasty System as a primary solution for achieving pain relief and excellent functional improvements. Study results indicated that younger, more active adults who underwent a joint preservation procedure and received the [novel joint preservation technology] experienced excellent range of motion and improved clinical outcomes. Results were based on follow-up appointments conducted after an average of 40.4 months after the surgery.
In terms of clinical benefits, how can this joint preservation technology for glenohumeral OA be compared with traditional joint replacement methods?
Compared with traditional total joint replacements, this joint preservation procedure offers a range of benefits including a shorter operative and recovery time, excellent range of motion, improved clinical outcomes, no reoperations or radiographic loosening, and a high rate of return to occupational and sporting activity at follow-up.
We know that traditional stemmed TSA in younger patients, including those with hip and knee replacements, have a higher and earlier failure rate.2 However, this population is typically still in the workforce, and therefore has higher recreational activity levels that [patients] don’t want to give up. Thus, the use of polyethylene on the glenoid side was avoided in traditional shoulder arthroplasty procedures, as this was the “weak link” of being onlay.
But we now know that the best combination of pain relief and range of motion is with metal and plastic. The failure of standard onlay glenoid components was typically because of loosening from the edge load on 1 side and lift off on the opposite side, which creates surface wear, loosening, and overstuffing the joint.
Arthrosurface OVO with inlay glenoid is a modern TSA with 2 important features: the glenoid is inlayed into the subchondral bone level of the glenoid face and the humeral head component is aspherical or ovoid-shaped. This is much closer to the normal anatomy and has been shown to biochemically transmit force across the glenoid much better than traditional spherical heads.
Is this technology applicable to patients with inflammatory arthritis?
I would typically individualize my recommendation based on the status of the glenoid bone. If it is soft and cystic, the inlay may not be the best option. However, if a hemiarthroplasty is being considered, the OVOMotion® aspherical head would be a very suitable option with less force across the glenoid surface for these patients.
The study indicated improved clinical outcomes in younger, active patients who underwent TSA. What about older adults? Is there a subset of patients who are not recommended for this technology?
There is an option other than traditional stemmed TSA that can provide consistent pain relief and functional return, and allow a higher activity level. This can allow patients of all ages and walks of life to maintain a livelihood that they may not have been able to continue otherwise.
There are several factors used to determine which candidates are best for joint preservation procedures, including the degree of cartilage injury, age, and desired activity level. However, the Arthrosurface OVO with Inlay Glenoid Arthroplasty System is bone-sparing, has numerous biomechanical advantages, and the “symbiotic” relationship between the inlay glenoid component and the subchondral surface bone provides excellent pain relief, range of motion, and [facilitates] return-to-work and recreational activity. With this [novel technology], there is also no concern for early glenoid wear or loosening failure. [Overall], the system is a great option for the younger, active population as well as an older, less active demographic.
Advances and innovation like this anatomic joint preservation system [help] ensure that our aging population can maintain active, healthy lifestyles for years to come.
Disclosure: Dr Nicholson declared affiliations with Arthrosurface and Wright Medical, and has received research support from Wright Medical, SmithNephew, and Arthrex. Dr Nicholson is a board member of the American Shoulder and Elbow Surgeons. Please see the original references for a full list of authors’ disclosures.
1. Cvetanovich GL, Naylor AJ, O’Brien MC, Waterman BR, Garcia GH, Nicholson GP. Anatomic total shoulder arthroplasty with an inlay glenoid component: clinical outcomes and return to activity [published online December 31, 2019]. J Shoulder Elbow Surg. doi:10.1016/j.jse.2019.10.003
2. Maslow J, Wanner JP, Routman H, Byram I. The disappearing stem: The changing humeral side of shoulder arthroplasty. International Congress for Joint Reconstruction. Published February 21, 2019. Accessed April 13, 2020. https://icjr.net/articles/the-disappearing-stem-the-changing-humeral-side-of-shoulder-arthroplasty