Go for the Glenoid! Seitz vs. Galatz in Shoulder Debate

“Take the high road, ” said Dr. Bill Seitz.  “You don’t want to burn any bridges.”  “Au contraire!” countered Dr. Leesa Galatz. Go low and “go for the glenoid.”

The Orthopaedic Crossfire® debate was “Surface Arthroplasty in Middle Age: Maintaining Your Options.” For the proposition was Dr. William Seitz, Jr. of Cleveland Clinic who argued that surface replacement provides good pain relief and good motion for certain patients. Against the proposition was Dr. Leesa Galatz of Barnes Jewish Hospital in St. Louis who championed total shoulder replacement where you have an intact cuff, good function, and good glenoid bone stock.

Dr. Seitz: “Surface arthroplasty preserves bone stock. It’s useful in the types of arthritis that younger people get, in avascular necrosis, some rheumatoids who have multiarticular problems, and in young people with osteoarthritis, and specifically in active people with cuff tear arthropathy (CTA). The successful use of surface replacement has been well documented in multiple studies. It utilizes a resurfacing providing an ingrowth or ongrowth surface for which the bone underneath adheres to the cup implant. It resects very little bone so it’s conservative and it burns no bridges, something important in the young patient who may need revision later.”

“The special conditions are in CTA with a contained (not escaped) humeral head; with avascular necrosis; in isolated head-split fracture; in some rheumatoids with good bone stock who may have a bad elbow; in patients with existing hardware which may be difficult to remove, and in the physiologically younger patient. But that’s a moving target…and today’s younger patients are different than the younger patients several generations ago.”

“Taking the example of a 50-year-old laborer with avascular necrosis, a lot of pain and low function…good candidate for a resurfacing without taking away any bone stock or doing an ablative procedure where we have to put a stem down.”

“Contraindications are poor bone stock, an unstable joint, inadequate peripheral support such as in a more complex fracture. Sometimes these are older patients with osteopenic bone; they do have massive cuff tears and poor tissue that’s not reparable. They have glenoid erosion, the biceps is frequently damaged, and there’s been a superior migration. However, if the head is contained within the arch, this patient is a good candidate for replacement.”

“Whether you’re doing an anatomic resurfacing or a cuff tear, it comes down to replacing that portion where the anatomy is distorted. In a CTA, you do this in a hypervalgus position where the cup fits over the tuberosities. Technical issues are that by preserving the head, if you need to reach the glenoid it can be tricky. One caveat is that these folks frequently have scar tissue below the lower glenoid which can be mobilized off the capsule and brought up and used as a soft tissue resurfacing.”

“This technique can give very good pain relief and surprisingly good motion. We can take cases with severe erosion, and without having to take away any significant bone stock in a younger patient, be able to improve their anatomy. So conservative frequently is good. We don’t want to waste what we don’t need to waste, and we don’t want to burn any bridges…Leesa?”

Dr. Galatz: “I’m going to oppose surface replacement in middle age, and my talk will focus on the middle-aged person with an intact rotator cuff and why we would probably want to address the glenoid—something not easily done with resurfacing. Our main goals are pain relief and function. What are some of the cited advantages? Bone preservation, you preserve your fusion option, and you avoid glenoid loosening.”

“Disadvantages of surface arthroplasty: there is failure to re-establish joint congruence, and this can lead to further subluxation and asymmetric glenoid wear—and the incomplete pain relief of a hemiarthroplasty…and there are no long-term results of surface replacement. Looking at a total shoulder where any kind of arthroplasty you do addresses the glenoid, this gives you pain relief, functional restoration…this is established in the literature.”

“Some of the cited disadvantages are that a glenoid is technically difficult, and that there are concerns of loosening and failure. In looking at an argument for resurfacing you could say that the pain relief is as good as a total shoulder, that glenoids fail early, and that you can just convert to a total shoulder later. In a young patient population, age 50 or younger in a study in 2004 with a minimum 15-year follow-up, there was significant long-term pain relief and motion improvement in both patients. However, glenoid erosion was present in 72% of the hemiarthroplasties, so I would argue that this is not necessarily protective or joint preserving, especially in a younger person.”

“In terms of asymmetric glenoids, an interposition arthroplasty is not a good option for bringing back congruence to a glenoid. Often when we do a resurfacing of glenoids we look at maintaining joint space, however with final follow-up we see a loss of joint space and posterior subluxation, which becomes an increasingly difficult problem to deal with. There are some indications for soft tissue interposition, however, but looking at this as a bone sparing procedure, the bone spared is in the humeral shaft, not the humeral head. When you have to revise this you make a cut and essentially you’re back where you would have started with a total shoulder.”

“So I’m advocating for a total shoulder replacement where you have an intact cuff, good function, good glenoid bone stock. The literature does not substantiate the longevity of surface arthroplasty, or that it offers durable pain relief, or long-term prevention of glenoid erosion. The literature does not support elimination of a total shoulder due to concerns such as technical difficulties, radiolucencies, or early glenoid failure.”

Moderator Thornhill: “Now I’m in my usual state of confusion, but I’m afraid we may be mixing a few things up. When we talk about surface replacement I got the sense that you [Dr. Seitz] were talking about putting a stem down the humerus, and that you could either resurface the glenoid or not. Are you talking about just hemiarthroplasty?”

Dr. Seitz: “I’m talking about resurfacing of the humerus with or without doing a resurfacing on the other side.”

Moderator Thornhill: “And Leesa, you’re talking about total shoulder versus hemiarthroplasty?”

Dr. Galatz: “Right.”

Moderator Thornhill: “Let’s say that Bill’s doing the glenoid, the only difference would be the bone down the humeral shaft because as you said the humeral head’s going to go anyway. Is that bone in the hole of the humeral shaft really important? I don’t see humeral loosening as a big thing, particularly if it’s uncemented.”

Dr. Seitz: “It can be not a big thing if it’s uncemented. But even some of the uncementeds will have a very tight fit, and if you did have to revise that, you frequently have to slot the bone in order get it out. Preserving the humeral head makes it easier for a secondary procedure.”

Moderator Thornhill: “But you’re not preserving the humeral head. It’s going for resurfacing anyway—most of it.”

Dr. Seitz: “You’re basically not taking it away.”

Moderator Thornhill: “Leesa, let’s assume there’s a rod there, and you can’t or don’t want to get it out. As long as you resurface the glenoid, can he go ahead and do one of his surface things on that case?”

Dr. Galatz: “From a realistic standpoint it’s very difficult to do a resurfacing arthroplasty and put a glenoid in. There have been reports of doing a superior approach, but you have to take the deltoid down, which adds substantial morbidity. It’s very difficult to do any type of resurfacing, especially a polyethylene glenoid, when you have the humeral head there.”

Moderator Thornhill: “Bill, let’s assume you’re going to do a meniscal allograft or some sort of interposition, also reported to be harder with a surface replacement.”

Dr. Seitz: “It is technically challenging to reach the glenoid, but it’s doable without removing/releasing any more of the rotator cuff than you would for a standard total. The retractor instruments are important, and if you have well shaped ones you can still get in there. My preference—I don’t use meniscal allograft—I use the patient’s own tissue to take down some of the capsule and suture it up…if it’s a robust posterior labrum or through the drill holes. But I have done a number of these with a glenoid resurfacing. I agree with Leesa’s concept that if you’ve got bi-articular osteoarthritis you have to address it. I’m not saying don’t use a total, but this is a conservative procedure which has merit.”

Moderator Thornhill: “Leesa, soon I have to revise a surface hemiarthroplasty to a total. He’s had progressive loss of glenoid bone and intractable pain. Any tips other than a plane ticket to St. Louis?”

Dr. Galatz: “To get these out you just—if it’s positioned appropriately—cut the bone and end up where you would have started, hopefully, with a total shoulder. Making sure that you preserve the cuff and manage any glenoid bone defects.”

Moderator Thornhill: “You’re using all polyethylene…pegged or keeled glenoids?”

Dr. Galatz: “Pegged.”

Moderator Thornhill: “What kind of poly? Does it matter?”

Dr. Galatz: “Probably. One of the limitations in the shoulder literature is that we don’t have a lot of long-term follow-up that focuses on those things, so as time goes on we’ll answer those questions. The forces are certainly different in the shoulder and forces in the hip and knee are compression forces and in the shoulder it’s shear forces—may or may not make a difference in longevity.”

Moderator Thornhill: “Thank you both.”

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