TOTAL SHOULDER ARTHROPLASTY
Strong evidence supports that anatomic total shoulder arthroplasty demonstrates more favorable function and pain relief in the short- to mid-term follow-up when compared to hemiarthroplasty for the treatment of glenohumeral osteoarthritis

Rationale

There were 2 high quality (Gartsman et al. 2000 & Lo et al. 2005), one moderate quality (Mann et al. 2014), and 13 low quality (Garcia et al. 2016, Edwards et al. 2003, Iannotti et al. 2003, Virk et al. 2018, Razmjou et al. 2014, Gowd et al. 2019, Krukenberg et al. 2018, Werthel et al. 2018, Rasmussen et al. 2018, Levy et al. 2004, Clinton et al. 2007, and Orfaly et al. 2003, Schairer et al. 2014) studies evaluating and comparing the outcomes of anatomic total shoulder arthroplasty to hemiarthroplasty.

Gartsman et al. 2000, performed a prospective randomized trial and found significantly better pain relief (p=0.002), internal rotation (p=0.003) and lower revision rates (3 subjects in hemiarthroplasty group underwent reoperation for conversion tot total shoulder arthroplasty) with anatomic total shoulder arthroplasty. Both ASES and UCLA scores were also significantly better for the anatomic total shoulder arthroplasty group.

Lo et al. 2005, performed a prospective randomized double-blind study comparing anatomic total shoulder to hemiarthroplasty. The total shoulder arthroplasty group had better postoperative ASES, UCLA, WOOS quality of life, Constant scores at two years follow up but these values did not reach statistical significance. There were 4 patients in the hemiarthroplasty group considered as failures 3 of which due to progressive glenoid erosion and one due to rotator cuff deficiency with poor function and increased pain. Two went on to revision surgery and conversion to anatomic total shoulder arthroplasty.

Meta-analysis was performed favoring anatomic total shoulder arthroplasty with regards to improvement in ASES score (Gartsman et al. 2000, Iannotti et al. 2003, Lo et al. 2005, Razmjou et al. 2014, Virk et al. 2018), functional scale (Clinton et al. 2007, Gowd et al. 2019, Lo et al. 2005, Virk et al. 2018), pain scale (Garcia et al. 2016, Iannotti et al. 2003, Lo et al. 2005, Virk et al. 2018), range of motion (specifically external rotation)(Virk et al. 2018, Razmjou et al. 2014), patient satisfaction (Edwards et al. 2003, Garcia et al. 2016, Gowd et al. 2019, Werthel et al. 2018) and lower complication rate (Garcia et al. 2016, Mann et al. 2014, Werthel et al. 2018).

Longer follow-up is needed to determine if these findings maintain over time especially related to implant survivorship, patient reported outcomes, pain, function, and quality of life.  Additionally, prior studies did not adequately stratify patients by parameters that are now understood important such as glenoid morphology type and rotator cuff integrity.

 

Strength of Evidence (quality of evidence): Strong

 

Benefits & Harms:

There are no harms with implementation of this recommendation.

 

Outcome Importance:

Methods to optimize predictable postoperative outcomes following shoulder arthroplasty will decrease complication rates, increase implant survivorship as well as patient function improvements and satisfaction.

 

Cost Effectiveness/Resource Utilization:

Evidence based decisions regarding implant choice will ideally result in decreased long term costs by decreasing the need for revision surgery, decrease need for prolonged treatment with physical therapy and decreased risk of long-term pain related issues.

 

Acceptability:

Anatomic total shoulder arthroplasty is already an acceptable commonly used procedure for the treatment of glenohumeral joint arthritis.

 

Feasibility:

Again, anatomic total shoulder arthroplasty is a well-established surgical treatment for glenohumeral joint arthritis.

 

Future Research:

Additional research is needed to determine long term follow-up of the outcomes of shoulder arthroplasty. Currently, the studies which have met inclusion criteria for this document as well as that are available are at best medium-term follow-up. Although there are case series in the literature with >10-year follow-up this is not sufficient to make evidence-based decisions regarding treatment. It is important to understand the long-term outcomes, survivorship as well as consequences of failure from issues such as glenoid failure (i.e. bone loss, erosion, implant loosening), rotator cuff pathology, humeral implant failure or stress shielding.


LEARN MORE ABOUT AAOS

The Future of OrthoGuidelines

FIND OUT MORE

The OrthoGuidelines Process