Abstract cause it preserves rather than removes the humer al head With a less invasive surgery there is the promise of better function as well as a less difcult revision if it is later need ID: 157585
Download Pdf The PPT/PDF document "Shoulder resurfacing is an attractive co..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Long-termresultsandpatientsatisfactionaftershoulderJamesW.Pritchett,MDOrthopedicsInternational,Seattle,WA,USAShoulderresurfacinghasregainedpopularityinrecentyears.Thisreportpresentsthelong-term⠀20years)resultsofthisprocedurewithregardtopatientsatisfactionandimplantsurvival.Materialsandmethods:Wefollowedup61patientswhounderwentshoulderresurfacingprocedures(74shoulders)foraminimumof20yearsoruntildeath⠀7additionalpatientswerelosttofollow-up).Themeanpatientageatthetimeofsurgerywas58years.Therewere41totalresurfacingproceduresand33hemi-resurfacingprocedures.Thehumeralcomponentconsistedofacupwithashortcentralpegthatwasplacedeitherwithorwithoutcement.Theglenoidwasresurfacedwithacementedpolyeth-yleneorpolyurethanecomponent.Results:Patientsatisfactionwas95%,andthesurvivorshipofthehumeralprostheseswas96%.Therewerenoperiprostheticfractures,dislocations,orinfections.Twohumeralcomponentswererevisedtostemmedprostheses(oneforlooseningandoneforunexplainedpain),andonewasrevisedfromacement-lesstoacementedresurfacingprosthesis.Twelvecementedpolyethyleneglenoidprostheseshadradiolu-cencies,butonlythreeproducedsymptomsrequiringrevisionsurgery;threepolyurethaneglenoidprosthesesshowedseverewearradiographically,butnonewaslooseorrequiredrevisionsurgery.Therewere7revisionprocedures,6withgoodresults.Shoulderresurfacingisasuccessfulprocedureforthemajorityofpatients,withhighratesofpatientsatisfaction,long-termsurvivorshipofthehumeralprosthesis,andfewcomplications.Levelofevidence:LevelIV,CaseSeries,TreatmentStudy.2011JournalofShoulderandElbowSurgeryBoardofTrustees.Shoulder;shoulderresurfacing;humeralimplantTheÞrsttotalshoulderresurfacingprocedureisbelievedtohavebeenperformedbyDrCharlesO.Townleyin1958usingametalhumeralcomponentandapolyurethanegle-noid.Subsequentshoulderresurfacingprocedureswereperformedbyuseofsmallhipresurfacingprostheses.Zippelin1975wastheÞrstinvestigatortopublishareportdescribingtheuseofametallicsurfacereplacementofthehumeralhead.However,withtheadventofstem-supportedshoulderprostheses,shoulderresurfacingwaslargelyabandoned,withtheexceptionofafewsurgeons.Recently,cementlesshemi-resurfacingandtotalshoulderresurfacingprostheseshaveagainbecomepopular,andresultsatmidtermfollow-uphavebeenfavorable.ShoulderresurfacingmayofferseveralproceduralbeneÞtstoboththesurgeonandpatient.Thehumeralheadisretained,theoreticallyfacilitatingcorrectversion,offset,andinclinationoftheprosthesisduringsurgery.supportedtotalshouldarthroplastyisareliabletreatmentfordegenerativeconditionsoftheglenohumeraljoint,andreportssuggestpainreliefandimplantsurvivorshipof84% *Reprintrequests:JamesW.Pritchett,MD,OrthopedicsInternational,901BorenAve,Ste800,Seattle,WA90104.E-mailaddress:bonerecon@aol.comJShoulderElbowSurg(2011)20,771-777 www.elsevier.com/locate/ymse 1058-2746/$-seefrontmatter2011JournalofShoulderandElbowSurgeryBoardofTrustees.10.1016/j.jse.2010.08.014 to96%at12years.However,forthehumerus,shoulderresurfacingmaybeeasierthanpreparingthepatientforandinsertingastemmedsupportedpros-thesis,althoughglenoidexposurecanbedifÞcultwhenthehumeralheadisnotresected.Inaddition,ashoulderresurfacingprosthesiscanbeusedonahumeruswithinsituimplantedÞxationoradeformitythatwouldprecludetheplacementofahumeralstem.Thisstudywasconductedtodeterminethelong-term20years)outcomeofshoulderresurfacingbyassessingthefollowingprimaryandsecondaryoutcomes:(1)patientsatisfactionand(2)thesurvivorshipoftheimplant.MaterialsandmethodsInstitutionalreviewboardapprovalwasnotrequiredatthetimethepatientswereenrolledinthestudy.Noneofthepatientshadundergonepriorimplantarthroplasty,although18patientshadundergonepriorsurgerytotreatafracture,dislocation,impinge-mentsyndrome,orrotatorcufftear.Allpatientshadbeentreatedextensivelybutunsuccessfullywithnonoperativemethods.AllpatientsweredissatisÞedwiththeirshoulderfunctionandwereunwillingtocontinuetoenduretheirsymptomsofseverepainandlimitationsinfunction.Allpatientsoptedforsurgicaltreatmentevenwhenadvisedbythesurgeonsthattherewasnocertaintyofasuccessfuloutcome.Theinitialstudypopulationconsistedof68adultpatients(84shoulders)whounderwentshoulderresurfacingsurgerywiththeTotalArticularReplacementArthroplastyprosthesis(DePuyOrthopaedics[Warsaw,IN]andHowmedica[Rutherford,NJ])between1958and1990⠀Fig.1).TheÞnalstudypopulationdescribedinthisreportconsistedof61adultpatients(74shoul-ders),because7patientswerelosttofollow-upandwere,thus,notincluded.Therewere32womenand29menwithameanageof58years(range,32-71years).Preoperativediagnosesincludedosteoarthritis(37shoulders[50%]),post-traumaticarthritis(20shoulders[27%]),inßammatoryarthritis(12shoulders[16%]),andosteonecrosis(5shoulders[7%]).Theindicationforsurgerywasseverepainassociatedwithlimitationsinfunctionforallpatients.Exclusioncriteriawerepriorinfectionoftheshoulder,severedeformityofthehumeralhead,andneurologicinjuries.RotatorcuffinsufÞciencywasacceptedintheabsenceofsuperiorhumeralheadescape.Becausepatientdataincludedinthisreportbegantobecollectedmorethan50yearsago,itisnotpossibletoreportwithaccuracythenumberofpatientswhounderwentashoulderarthroplastyotherthanresurfacing;however,aroughestimatewouldbe3to4timesasmanythanunderwentresur-facing.Patientswhomettheinclusioncriteriawereofferedtheoptionofundergoingtheresurfacingprocedure.Patientswerefollowedupprospectivelyandaskedtoreturnat1year,2years,and5yearsandthenevery5yearsthereafter.Todeterminepatientsatisfaction,atthefollow-upexaminations,patientswereaskedabouttheiractivityandwhethertheirresur-facedshoulderlimitedanyoftheiractivities.AnylimitationswerespeciÞctothatparticularpatientÕslifegoals.DatareportedinthisstudyconsistedofthepatientsÕself-reportedsatisfactionatthe20-yearfollow-upvisit.Alldeceasedpatientshadafollow-upvisitwithin4yearsoftheirdeath(range,4-46months);datawerederivedfromtheirself-reportedsatisfaction(ie,theirverbalresponsesof퐀ÔverysatisÞed,픀픀퐀ÔsatisÞed,픀픀퐀ÔsomewhatsatisÞed,픀픀퐀Ôsomewhatdisappointed,픀픀or퐀ÔverydisappointedÕ픀thatwerenotedontheirmedicalrecordsduringtheirÞnalvisit).Patientswereaskedwhetheranyadditionalsurgeryhadbeenperformedaftertheirresurfacingprocedure.ImplantsurvivalwasdeÞnedasimplantsforwhichrevisionwasnotperformedorrecommended.Allpatientswerefollowedupforaminimumof20yearsoruntilPostoperativeradiographswereassessedbytheauthorretro-spectivelyforthepresenceorabsenceofradiolucentlinesandtheirwidthinrelationtotimeafterresurfacing.DeÞnitelooseningwasdeÞnedasachangeinthepositionofthecomponent,andpossiblelooseningwasdeÞnedasanunchangedpositionbutprogressiveradiolucentlinesinvolvingallpartsofacomponent.Becauseradiographswerenotstandardized(ie,differenttechni-ciansanddifferentandvastlyimprovedtechniquesandequipmentovermanyyears),nospeciÞcradiographicmeasurementsofthehumeralcomponentweremade.WeusedthegradingsystemdescribedbyFranklinetalfortheglenoid.Toallowcomparisontootherstudies,wealsousedtheConstantscore.Inaddition,noneofthecurrentlyavailablefunctionalscoringsystemswereused, Figure1TotalArticularReplacementArthroplastycomponents.Thecobaltchromiumhumeralcomponenthasacentralstem.Theglenoidismadefrompolyethyleneandhasacentralkeel. J.W.Pritchett becausetheÞrstsuchsystemwasdevelopedin1987andnearlyallpatientsinthisreporthadbeentreatedbythattime.quently,subjectivepostoperativeresultsasratedbythepatientsarepresented.OperativeprocedureEachoperationwasperformedby1of2surgeons(J.W.P.orCharlesO.Townley,MD).Adeltopectoralapproachwasusedforallprocedures.Thesubscapularistendonwasincisedvertically1cmmedialtothelessertuberosity,isolatedfromthejointcapsule,andretractedmedially.Theshoulderwasdislocatedanteriorlybyexternalrotation.Thelabrumwasdebridedasnecessary,andanycontractureswerereleased.Thehumeralheadwasmeasuredandpreparedwithamillingdevicetoacceptthehumeralcup.Thehumeralprosthesiswiththebestheadcoveragewasplacedinanatomicversion,andananatomicrepairofthesubscapulariswasperformed.Weplaced3oftheearliesthumeralcomponentswithoutcementusingaboltthroughthelateralhumeralcortex,30humeralcomponentswereplacedwithoutaboltandwithoutcement,37humeralcomponentswerecementedwithpolymethylmethacrylate(Simplex;Howmedica),and4humeralcomponentswerecementedwithpolyurethanecement(Ostamer;WilliamS.Merrell,Cincin-nati,OH).Thepolyurethanepolymerwaspreparedbymixingthepre-polymerwithresinandacatalystatthetimeofsurgeryandmoldingitinsituoronthebacktabletothehumeralprosthesis.Thehumeralprostheseswereallmadeofcobaltchromium(DePuyOrthopaedicsandHowmedica)⠀Fig.2Therewere41glenoidsimplanted.Theglenoidcomponentswerealwayscementedinplace.Polyurethanecementwasusedforthepolyurethaneglenoidcomponents,butthepolyethyleneglenoidprostheseswerecementedwithpolymethylmethacrylate.Thepolyethyleneglenoidprosthesesbecameavailablein1971andhadacentralkeel(HowmedicaandDePuyOrthopaedics).Polyurethaneglenoidprostheseswereusedfrom1958until1962,whenthevendorstoppedsellingtheproduct.Noreamingorpreparationofthegle-noidisdonewhenahemiarthroplastyisperformed.PostoperativeprotocolPatientsusedastandardslingontheoperatedextremityfor6weekspostoperatively.HomeexerciseswerestartedontheÞrstpostoperativedayandconsistedofpassivecircumductionandpendulums,aswellasactiverange-of-motionexercisessuchassaws(ie,back-and-forthmotionofthearminthecoronalplanewitha�xedelbow).Externalrotationwasallowedtowithin30ofthatobtainedintraoperativelyaftersubscapularisrepair.Patientsparticipatedineitheraformalphysicaltherapyprogramoratherapist-directedhomeprogramforanadditional6weeks.NolimitationswereplacedonpatientsÕactivitiesafter3monthspostoperatively.BythetimeofÞnalfollow-up,42patients(69%⤀haddiedatameanageof81years(range,59-92years).Themeanfollow-upwas28years(range,20-41years)⠀TableITherewere41totalresurfacingproceduresand33hemi-arthroplasties.Totalarthroplastieswereperformedwhensubstantialglenoiderosionwaspresent.Excludingthepatientswhounderwentrevisionsurgery,95%ofthepatientsweresatisÞedwiththeirshoulderresurfacingprocedure;TableIIshowsthepatient-reportedresults.Ofthepatientsassessedforpostsurgicalactivity,39%partic-ipatedinstrenuousathleticsorworkandonly2weredissatisÞedwiththeirfunction;overall,92%ofpatientswerenotlimitedintheiractivities.TableIIIshowstheshouldermotionafterresurfacing,andTableIVshowsthepreoperativeandpostoperativeConstantscores.Therewerenodifferencesinsatisfactionorfunctionaccordingtowhetherthepatienthadahemi-resurfacingortotalresur-facingprocedure. Figure2Anteroposteriorshoulderradiographs.,Preoperativeimagewithadvancedglenohumeralarthritis.,Postoperativeimagetakenafterinsertionoftotalresurfacingprosthesis. Long-termresultsofshoulderresurfacing Therewerenoinfections,subluxations,orperiprostheticfractures.Therewere2temporarynervepalsies,1involvingtheentirebrachialplexusand1involvingtheaxillarynerveonly.Theradiographicfollow-upperiodaveraged24years(range,20-36years).Of41glenoidcomponentsimplanted,3wererevised,thusleaving38glenoidprosthesesavailableforÞnalreview.Radiographicreviewshowedgrade0in2,grade1in7,grade2in8,grade3in8,grade4in12,andgrade5in1;the3thatwererevisedweregrade5.Asmentionedpreviously,theproceduresinthisreportbeganmorethan50yearsago,andearlyradiographicqualitywasfarpoorerthanmorerecentradiographicdata.Ofthepolyethyleneglenoidprostheses,12wereloose(deÞnitely,n4;possibly,n8)butonly4weresymptomatic.Threeoffourpolyurethanecomponentsshowedwearthroughbutnoneloosenedorrequiredrevi-sion,andallfourofthesepatientscontinuedtoreportasatisfactoryoutcome.Afterthepolyurethaneworeaway,theseshouldersseemedtofunctionashemiarthroplasties.Therewere7revisionsurgeries,6withultimategoodoutcomes.Oneoftheearliestcementlesshemi-resurfacingcomponentswasrevisedtoacementedtotalresurfacingprosthesisbecauseoflooseningofthehumeralcomponentandglenoidwear.Afterrevision,thispatientreportednopainandnoactivitylimitationsandwassatisÞedwiththeprocedure.Anotherhemiarthroplastywasrevisedtoastem-supportedhemiarthroplastyforpersistentpain.Thisimplantwasnotlooseatthetimeofrevision;theglenoidappearednormal,andnosourceofpaincouldbeidentiÞed.ThepatientcontinuedtohavepainafterrevisionandwasdissatisÞedwiththeprocedure.OneresurfacinghumeralprosthesiswasplacedonaninsufÞcienthumeralhead.ThepatientwassatisÞedinitiallyandcontinuedtobehighlyactivefor2years;however,theprosthesisbecameloose,requiringrevisiontoastemmedprosthesis,afterwhichthepatientresumedhighactivitylevelsandwaspainfreeFig.3).Anotherhemiarthroplastywasrevisedtoatotalresurfacingprosthesisbytheadditionofaglenoidpros-thesis.ThispatientwashighlyactiveandsatisÞedafterrevisionsurgery.Twoloosepolyethyleneglenoidpros-theseswereremovedandonewasrevised;allthreepatientsreportedasatisfactoryoutcomeandhadnolimitationsaftertheirindexprocedurefor3to5yearsbeforepaindevel-oped.All3weresatisÞedandhadnoactivitylimitationsaftertheirrevisionprocedures.Onelooseglenoidprosthesiswaspainful,butthepatientdidnotelecttoundergorevisionsurgery.Sevenpatientswerelosttofollow-upandarenotincludedintheresults.Inrecentyears,shoulderresurfacinghasgainedfavorbysurgeonsandpatientsforseveralreasons.Theprimaryreasonisthatthehumeralheadisretained,asopposedtototalshoulderarthroplasty,whichremovestheentirehumeralhead.Inaddition,becausetheheadisretained,thereisnoneedtore-createthehead/shaftangle.Treatingcomplicationsofshoulderarthroplastymaybeeasierwithresurfacingprosthesesascomparedwithstemmedpros-theses.Forexample,treatinganinfectionwouldbeeasierwithalimitedamountofimplantedmaterial.Ifaninfectionorjointinstabilityoccurred,thejointmaybeamenableto TableIIPatient-reportedpostoperativeresults(61patients[74shoulders])Self-reportedoutcomesNo.ofpatients/shoulders(%ofpatients)None52/63(85%)Slight7/9(11%)Moderate1/1(2%)Severe1/1(2%)Highlyactive(strenuoussportsorjob)24/29(39%)Active(nolimitations)31/38(51%)Moderatelyactive4/5(7%)2/2(3%)VerysatisÞed31/36(50%)22/27(36%)SomewhatsatisÞed4/7(9%)Somewhat/verydisappointed4/4(5%) TableISurvivorshipof61patientsYearssincesurgeryNo.(%)MeanageatdeathorÞnalfollow-upy(range)Deceased42(69%)81(59-92)20-302330-401740219(31%)75(54-94) TableIIIMeanshouldermotionafterresurfacing(increase)HemiarthroplastyTotalNo.ofshoulders1033Abduction⠀⤀178105(47)109(46)Flexion⠀⤀170112(41)119(45)rotation⠀6443(26)44(27)InternalrotationL22L4 J.W.Pritchett arthrodesis,whichmaynotbeanoptionafterinfectionand/orinstabilitywithastemmedshoulderprosthesis.Intheeventoffailure,revisionofahumeralprosthesismaybeeasierwhenalltheproximalhumeralboneremains.Inaddition,periprostheticfracturesmaybelesscommonandtreatedmoreeasilyintheresurfacedshoulderascomparedwithtotalshoulderarthroplastywithastemintheintra-medullarycanal.Forthepatient,postoperativesatis-factioniscomparabletothatachievedwithtotalshoulderarthroplasty.Patientsmayenjoyeasierpostoperativereha-bilitationaftershoulderresurfacingversusshoulderreplacement.Therearealsotheoreticadvantagestoresurfacing,suchasthepossibilitythatproprioceptivefeedbackispreserved,leadingtobetterfunction.However,aswithanyprocedure,theremaybelimitationsassociatedwithshoulderresurfacing.Ithasbeensuggestedthathumeralresurfacingprosthesescanloosenandfailmorecommonlyovertimethanstem-supportedprosthesesbecausetheyhavelessÞxationarea.Inaddition,thereisfearthathumeralneckfractureorhumeralheadcollapsemayoccurinasimilarmannertowhatoccurswithhipresurfacing,althoughtheshoulderjointsupportslowerloadsthanthehipjoint.Insomepatients,however,totalshoulderresurfacingcanbemoretechnicallydemandingthantotalshoulderreplacement,becauseaccessforprepa-rationoftheglenoidismoredifÞcultwithoutremovalofthehumeralhead.Ifthereisnotenoughhumeralheadremaining,astemmeddeviceisneeded.Weandothershavefoundthatif70%ofthehumeralheadremainsbasedonintraoperativeassessmentofthesurfacearea,itisadequatetosupportaresurfacingprosthesis.Burgessetalthatintheirexperience,60%issufÞcientwithbonegrafting.Contemporaryshoulderresurfacingbeganagainin1986withacementlesshydroxyapatite-coatedprosthesis.Atmidtermfollow-up,therevisionrateforthishumeralprosthesisis1%to2%.Whenaglenoidprosthesisisused,looseningoccursinupto10%ofpatients.Ninety-Þvepercentofpatientsreportasatisfactoryfunctionaloutcomewithshoulderresurfacing.favorableresultsare,nodoubt,partiallybecauseoftheabilitytoobtaincorrectversion,inclination,offset,andsize.Thesefactorsarejudgedeasilyandrelatedirectlytotheanatomy.Infractureandreplacementcases,thehumeralheadhasbeenremovedandversionisestimatedeitherindirectlyorfromguidesduringsurgery.Itisreportedthat30%ofunsatisfactoryresultsaftershoulderreplacementsareduetocomponentmalpositioning.Thelong-termdebateaboutwhetheratotalarthroplastyorhemiarthroplastyprocedureisbestisnotsolvedwithourwork.Instemmedtotalshoulderreplacement,therateofconversionfromahemiarthroplastytoatotalshoulderreplacementisupto12%.Theconversionratemaybelesswithresurfacing.Weattributeatleastsomeofthesuccessofourhemi-resurfacingprocedurestoreleasingsoft-tissuecontracturesandrestoringthenormalhumeral TableIVPreoperativeandpostoperativeConstantscoresPreoperativelyPostoperativelyHemi-resurfacingTotalresurfacingHemi-resurfacingTotalresurfacingConstantscore(range)21.412.3(11-33)19.211.2(8-30)59.816.5(56-83)63.713.2(51-85)Age-andsex-adjustedConstantscore(range)(%)13.3(21-47)30.49.1(18-39)71.230.5(52-101)75.217.1(47-109) Figure3Anteroposteriorshoulderradiographs.,Preoperativeimagewithlargehumeralheaddefectfromanteriordislocation.Postoperativeimageafterinsertionofcementedhemi-resurfacingprosthesis.,Postoperativeimageafterrevisionofresurfacingprosthesistocementedstem-supportedhumeralprosthesis. Long-termresultsofshoulderresurfacing contours.Thislikelyimprovesthekinematicsofshoulderfunction.Becausetheversionandspacingofthejointareimproved,lesssubsequentglenoidpainandwearmayresult.Thismaysuggestperformingahemiarthroplastyinmanycases.Theshoulderresurfacingprosthesisinthisstudyach-ieveditsgoalofreducingpainandimprovingfunction.Thepatientsatisfactionresultsinourstudyareasgoodasorbetterthanthosereportedwithaconventionalstemmedhumeralprosthesis.Patientsatisfactioninourserieswas95%;LevyandCopelandin2001reportedthat94%oftheir94patients(103shoulders)feltthatthe퐀Ôshoulderwasimproved.픀픀In2004,theyreportedthatof71patients(79shoulders),90%ofthepatientsconsideredthe퐀Ôshouldertobebetter.픀픀Thesurvivalofthehumeralprosthesisinourstudyisverysatisfactory,at96%butinagreementwithotherstudies,wefoundthattheglenoidcomponentremainsvulnerabletowearandloosening.Amongthe41glenoidcomponentsimplantedand38availableforradiographicreview,wefoundradiolucenciesin12cementedpolyethyleneglenoidprostheses,yetonly3requiredrevision.Radiographically,3ofourpolyurethaneglenoidprostheseswereseverelyworn,althoughnonewaslooseorrequiredrevision.Therewerefewcomplicationsinourseries.Therewerenoinstancesofsubluxationordislocation.Therewerenoperiprostheticfractures,possiblybecauseofthelackofstressshieldingwithresurfacing.Implantinstabilityisareportedcomplicationoftotalshoulderreplace-ment.17,18,21,22,26Therewere2casesofhumeralprosthesislooseningthatrequiredrevision(1wasanearly-generationcementlessprosthesisattachedwithaboltthroughthelateralhumeralcortex,adesignthatwediscontinuedusingafter3cases).TheotherhumeralprosthesisthatbecameloosewasimplantedonadeÞcienthumeralhead.Therewerenoinfectionsinourseries.Therearelimitationstothisstudy.Thepatientpop-ulationreportedissmallbut,nonetheless,comparabletootherpublishedstudiesofshoulderresurfacing(ie,SteffeeandMoore,53patients;LevyandCopeland,patients;LevyandCopeland,71patients;andBailieetal,36patients).Nevertheless,smallcasenumberssuggestcautionininterpretingtheincidenceofuncommoncomplications,suchasperiprostheticfractureandinfection.OurstudyinvestigatestheTotalArticularReplacementArthroplastyprosthesisthatwasinevolutionasitwasbeingimplanted.BothcementedandcementlesshumeralÞxa-tionswereused,butweareunabletodrawconclusionsaboutthisvariable.Therewerenoautopsyretrievalsorpathologicspecimensevaluated.Otherlimitationsarethatthe2surgeonsinvolvedperformedtheclinicalandradio-graphicanalyses.However,theprimaryoutcome(patientsatisfactionof95%)andthesecondaryoutcome(implantsurvivalof96%)areknownforallbut7patientswhowerelosttofollow-up.Becausethisisasingle-procedureseries,thereisnocomparisontoresultsofusingstemmedhumeraldevices,althoughotherinvestigatorshavereportedessen-tiallyequalresultswithregardtopatientsatisfac-Ourstudysoughttoreportpatientsatisfactionandprosthesissurvivalaftershoulderresurfacing.Totalshoulderresurfacingisavalidprocedureand,liketotalshoulderreplacement,willresultinexcellentpainreliefandrestorationoffunction.However,theproblemofglenoidlooseningremains.ThedifÞcultieswithtotalshoulderresurfacingareprimarilyontheglenoidside;well-performedhumeralresurfacingrarelyfailsovertime,withorwithouttheuseofcement.Theresultsofrevisionsurgeryaftershoulderresurfacingweregenerallyfavorableaswell.Thelong-termresultsofstem-supportedtotalshoulderreplacementsupportitsuseasareliableprocedurefortreatingdegenerativeconditionsoftheglenohumeraljoint.Publishedreportsindicatethattheprocedureprovidespainreliefandresultsinimplantsurvivorshipof84%to96%at12years.However,shoulderresur-facingisanattractiveoptionfortreatingshoulderarthritis.Itcanbeusedinthetreatmentofosteoarthritis,rheuma-toidarthritis,post-dislocationarthritis,andosteonec-Itworkswell,isboneconserving,andavoidssomeoftheconcernsassociatedwithastem-supportedprosthesis.Inaddition,therearemoresalvageoptionsintherareeventofafailure.Shoulderresurfacingisareasonableoptionforayoung,activepatient.Thisstudyshowedthatshoulderresurfacinginourpatientpopulationresultedinafunctionalpatientsatisfactionrateof95%,with92%ofthepatientshavingnolimitationsintheiractivities.Thesurvivorshipofthehumeralprosthesiswas96%ataminimum20-yearfollow-up(mean,28years;range,20-41years).Moreover,therewerefewcomplicationsinthisseriesof74shoulders,and6ofthe7revisionproceduresresultedinagoodÞnaloutcome.TheauthoracknowledgesthelateCharlesO.Townley,MD,whoperformedsomeoftheoperativeproceduresincludedinthisstudy.HediedonDecember23,2006.TheauthoracknowledgestheeditorialassistanceofJanetL.Tremaine,ELS,TremaineMedicalCommuni-cations,Dublin,Ohio.Theauthor,hisimmediatefamily,andanyresearchfoundationwithwhichheisafÞliateddidnotreceiveany J.W.Pritchett �ancialpaymentsorotherbeneÞtsfromanycommer-cialentityrelatedtothesubjectofthisarticle.Nooutsidefundingorgrantswereassociatedwiththisstudy.1.BailieSD,LlinasPJ,EllenbeckerTS.CementlesshumeralresurfacingarthroplastyinactivepatientslessthanÞfty-Þveyearsofage.JBoneJointSurgAm2008;90:110-7.doi:10.2106/JBJS.F.015522.BurgessD,McGrathM,BonuttiP,MarkerD,DelanoisR,MontM.Currentconceptsreview:shoulderresurfacing.JBoneJointSurgAm2009;91:1128-238.doi:10.2106/JBJS.H.010823.CofeldRH.TotalshoulderarthroplastywiththeNeerprosthesis.JBoneJointSurgAm1984;66:899-906.4.ConstantC,MurleyA.Aclinicalmethodoffunctionalassessmentoftheshoulder.ClinOrthopRelatRes1987;160-4.5.CopelandS.Thecontinuingdevelopmentofshoulderreplacement:퐀Ôreachingthesurface.픀픀JBoneJointSurgAm2006;88:900-5.doi:10.2106/JBJS.F.000246.EgundN,JonssonE,LidgrenL,KellyI,PettersonH.Computedtomographyofhumeralcuparthroplasties.ActaRadiol1987;28:S71-3.doi:10.3109/028418587091773117.FranklinJL,BarrettWP,JackinsSE,MatsenFAIII.Glenoidlooseningintotalshoulderarthroplasty.AssociationwithrotatorcuffdeÞciency.JArthroplasty1988;3:39-60.doi:10.1016/SO883-5403(88)80051-28.FurstM,FinkB,RutherW.TheDUROMcuphumeralsurfacereplacementinpatientswithrheumatoidarthritis.JBoneJointSurgAm2007;89:1756-62.doi:10.2106/JBJS.F.012909.GartsmanGM,RoddeyTS,HammermanSM.Shoulderarthroplastywithorwithoutresurfacingoftheglenoidinpatientswhohaveosteoarthritis.JBoneJointSurgAm2000;82:26-34.10.HasanSS,LeithJM,CampbellB,KapilR,SmithKL,MatsenFAIII.Characteristicsofunsatisfactoryshoulderarthroplasties.JShoulderElbowSurg2002;11:432-41.doi:1067/mse.2002.12580611.JohnsonE,EgundN,KellyI,RydholmU,LidgrenL.Cuparthroplastyoftherheumatoidshoulder.ActaOrthopScand1986;57:542-6.doi:10.3109/1745367860901479012.JonssonE,LidgrenL,MjobergB,RydholmU,SelvicG.HumeralcupÞxationinrheumatoidshoulders.ActaOrthopScand1990;61:116-7.13.KumarS,SperlingJW,HaidukewychGH,CoÞeldRH.Periprosthetichumeralfracturesaftershoulderarthroplasty.JBoneJointSurgAm2004;86:680-9.14.LevyO,CopelandSA.Cementlesssurfacereplacementarthro-plasty⠀CopelandCSRA)forosteoarthritisoftheshoulder.JShoulderElbowSurg2004;13:266-71.doi:10.1016/j.jse.2004.0100515.LevyO,CopelandSA.Cementlesssurfacereplacementarthroplastyoftheshoulder.5-to10-yearresultswiththeCopelandMark-2pros-thesis.JBoneJointSurgBr2001;83:213-21.doi:10/1302/0301-620X.16.LevyO,FunkL,SforzaG,CopelandSA.Copelandsurfacereplace-mentarthroplastyoftheshoulderinrheumatoidarthritis.JBoneJointSurgAm2004;86:512-8.17.NeerCS.Articularreplacementforthehumeralhead.JBoneJointSurgAm1955;37:215-28.18.NeerCS,WatsonKC,StantonFJ.Recentexperienceintotalshoulderreplacement.JBoneJointSurgAm1982;64:319-37.19.OrrTE,CarterDR.Stressanalysisofjointarthroplastyintheproximalhumerus.JOrthopRes1985;3:360-71.doi:10.1002/jor.20.PritchettJW.Curved-stemhipresurfacingminimum20-yearfollow-up.ClinOrthopRelatRes2008;466:1177-85.doi:10.1007/S11999-21.PritchettJW.Inferiorsubluxationofthehumeralheadaftertraumaorsurgery.JShoulderElbowSurg1997;6:356-9.doi:10.1016/S1058-2746(97)90003-322.PritchettJW,ClarkJM.Prostheticreplacementforchronicunreduceddislocationsoftheshoulder.ClinOrthopRelatRes23.RydholmU.Surfacereplacementofthehumeralheadinrheumatoidshoulder.JShoulderElbowSurg1993;2:286-95.doi:10.1016/1058-2746(93)90074-Q24.SettergrenCR.TotalshoulderarthroplastywiththeNeerprosthesis:longtermresults.JShoulderElbowSurg1997;6:495-505.25.SteffeeAD,MooreRW.Hemi-resurfacingarthroplastyoftheshoulder.ContempOrthop1984;9:51-9.26.TorchiaME,Co�ldRH,SettergrenCR.TotalshoulderarthroplastywiththeNeerprosthesis:long-termresults.JShoulderElbowSurg1997;6:495-505.doi:10.1016/S1058-2746(97⤀90081-127.WalkerPS.Somebioengineeringconsiderationsofprostheticreplacementfortheglenohumeraljoint.In:InglishAE,editor.Symposiumonthetotaljointreplacementoftheupperextremity.StLouis:Mosby;1975.p.25-32.28.WeissAP,AdamsMA,MooreJR,WeilandAJ.Unconstrainedshoulderarthroplasty;aÞve-yearaveragefollow-upstudy.ClinOrthopRelatRes1990;86-90.29.ZippelJ.Dislocation-proofshoulderprosthesismodelBME[inGerman].ZOrthopIhreGrenzgeb1975;113:454-7. Long-termresultsofshoulderresurfacing