Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to fifteen-year outcomes.

BACKGROUND: Biologic glenoid resurfacing was developed in 1988 as an alternative to total shoulder arthroplasty in selected (usually younger) patients with primary, posttraumatic, or postreconstructive glenohumeral arthritis. A variety of biologic surfaces, including anterior capsule, autogenous fascia lata, and Achilles tendon allograft, have been combined with a humeral hemiarthroplasty. METHODS: From November 1988 to November 2003, thirty-four patients (thirty-six shoulders) who were managed with biologic glenoid resurfacing and humeral head replacement either with cement (ten shoulders) or without cement (twenty-six shoulders) were followed prospectively. The study group included thirty men and four women with an average age of fifty-one years. The diagnoses included primary glenohumeral osteoarthritis (eighteen shoulders), postreconstructive arthritis (twelve), posttraumatic arthritis (five), and osteonecrosis (one). Anterior capsule was used for seven shoulders, autogenous fascia lata for eleven, and Achilles tendon allograft for eighteen. All shoulders were assessed clinically and with serial radiographs. RESULTS: The mean American Shoulder and Elbow Surgeons score was 39 points preoperatively and 91 points at the time of the most recent follow-up. According to Neer's criteria, the result was excellent for eighteen shoulders, satisfactory for thirteen, and unsatisfactory for five. Glenoid erosion averaged 7.2 mm and appeared to stabilize at five years. There were no revisions for humeral component loosening. Complications included infection (two patients), instability (three patients), brachial plexitis (one patient), and deep-vein thrombosis (one patient). Factors that appeared to be associated with unsatisfactory results were the use of capsular tissue as the resurfacing material and infection. CONCLUSIONS: Biologic resurfacing of the glenoid can provide pain relief similar to total shoulder arthroplasty. It allows selected younger patients to maintain an active lifestyle, including weight-lifting and manual work, without the risk of polyethylene wear. On the basis of this and previous reviews, we currently recommend Achilles tendon allograft as the preferred resurfacing material when this option is chosen. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Rehabilitation of the arthrofibrotic knee.

This paper describes the postoperative rehabilitation of the arthrofibrotic knee, with specific emphasis on modern rehabilitation techniques. The significance of prevention and early recognition is discussed. The importance of early motion and patellar mobility is emphasized and specific exercises to prevent and treat stiffness are described. Continuous passive motion, bracing, and exercise--on the stationary bicycle, on the treadmill, and in water--are adjuncts in the program. Strengthening is added when motion is re-established and there is no swelling or pain. Sport-specific activities are added if progress is satisfactory and motion is maintained. If pain, swelling, or stiffness develops, exercises should be discontinued. Modalities such as cryotherapy, ultrasound, electrical stimulation, rest, and manipulation can be used judiciously. Anti-inflammatory and analgesic medications should be used to prevent inflammation, to control pain, and to allow more aggressive rehabilitative exercises.