JORT Journal

Introduction

Sickle Cell Disease (SCD) is a commonest inherited blood disorder in Oman (3.5-4.7/1,000) [1]. It is an autosomal recessive disease resulting from a point mutation in the 13-globin gene. Pa- tients with SCD have a variety of clinical manifestations, and the most common are chronic haemolytic anaemia and vaso-occlusive disease. Avascular Necrosis (AVN) of the humeral head is reported to have a prevalence of around 5% in SCD patients [2]. The Co- peland Shoulder Resurfacing Arthroplasty (CSRA) was developed in the early 1980s by Copeland and his colleagues. It is a cement- less, pegged Humeral Head (HH) surface replacement [3]. There are several advantages of CSRA: shorter operation time, preserva- tion of humeral bone stock, and lower risk of periprosthetic frac- tures [4]. However, very little is known about the results of shoul- der resurfacing arthroplasty in sickle cell patients with humeral head avascular necrosis. Therefore, this study aims to evaluate the outcome of Copeland Shoulder Resurfacing Arthroplasty (CSRA) in Sickle Cell Disease (SCD) patients with humeral Avascular Ne- crosis (AVN).

Methods

Patient Population

This study is a retrospective observational study that includes all patients with Copeland shoulder resurfacing arthroplasty for Humeral avascular necrosis due to SCD from 2010 to 2014 at Sultan Qaboos University Hospital (SQUH), Oman.

Surgical Technique

All surgical procedures were performed by a single experience shoulder surgeon under general anesthesia with an interscalene block on a beach chair position. Surgical approach was a standard Deltopectoral approach with Subscapularis tenotomy approximately 1 cm from its insertion. Tenodesis of long head of biceps below the groove. Special attention was given to the humeral preparation to carefully expose the anatomical neck of the humerus and ensure correct positioning of the prosthesis. circumferential removal of all osteophytes. A humeral drill guide of the correct size as determined by its fit to the native HH was placed with its free edge parallel to the anatomic neck .No procedure was performed on the glenoid and there was no posterior capsular release Trans-osseous repair of the subscapularis was performed using nonabsorbable sutures. The Copeland Mark IV (Biomet Orthopaedic Ltd) hydroxyapatite coated prothesis was used for all cases.

Clinical and Radiological Assessment

Functional outcome assessment using the Oxford shoul-der score (OSS) (scale 1–48, 48 = optimal functioning shoulder) was used only in post-operatively. Six patients completed the OSS scores post-operatively. Pain (no pain, mild, moderate and severe) and satisfaction level (Satisfied, somehow satisfied, unsatisfied) were assessed in the follow-up. Complications (infection, periprosthetic fracture, stiffness, glenoid erosion, instability, aseptic loosening) were evaluated. Follow-up radiographs including anterolateral and axillary views were taken preoperatively, immediate postoperatively, 3 months, 6 months then annually. AVN of humeral head was staged based on the Ficat and Arlet classification, modified by Cruess for the shoulder [5].

Results

Eleven CSRAs were performed in eight patients from 2010 to 2014 at SQUH. There were 2 males (%) and 6 females (%). The mean age was 31.6 years (range 21-51 years) and the mean followup was 4.1 years (range 3.1-8.3). There were five shoulders in Humeral head AVN stage III (Figure1), three shoulders are stage IV, and three shoulders in stage V. Table 1 demonstrated the clinical and complications result according to AVN humeral head stage. During follow-up, three CSRA (27.3%) underwent revision to a total anatomical shoulder arthroplasty due to significant progressive glenoid erosion (Figure 2) and One shoulder developed stiffness that required arthroscopic capsular release (after 18 months). One patient with proximal migration and rotator cuff tear, reluctant to go to further surgery.

Figure 1: SCD patient with stage III humeral head AVN of left shoulder underwent Copeland shoulder resurfacing arthroplasty.

Figure 2: SCD patient with stage IV humeral head AVN of the right shoulder underwent Copeland shoulder resurfacing arthroplasty and underwent revision to a total anatomical shoulder arthroplasty due to significant progressive glenoid erosion.

Discussion

There are few published data currently on the outcomes from shoulder arthroplasty in sickle cell patients. Lau et al [6] reported the outcome of 8 shoulder arthroplasties (7 hemiarthroplasty and one TSA) in sickle cell patients with a mean of 51 months follow-up. Results are variable for both function and pain relief. Three patients had complications (intraoperative rotator cuff tear, stiffness and infection) and One patient with a hemiarthroplasty underwent revision to TSA.

In the largest HHAVN arthroplasty studies Schoch et all [7] performed retrospective study comparing the outcome between HA & TSA in (141) patients with atraumatic AVN with 9.3-year mean follow-up. Results reported significant improvements in pain, ROM and satisfaction in all patients (HA & TSA). However, eleven percent of HA had moderate to severe glenoid erosion at follow-up, and 25% of glenoid components of TSA were radiographically at risk. Although the Copeland prosthesis has been used since 1986, very few case series have been published. Alizadehkhaiyat et al [8], reported a result of series of 102 consecutive CRSA in OA (47.1%), RA (40.2%), RCA (8,8%) and AVN (3.9%). The best results were obtained in OA patients, then RA group and AVN. RCA patients having the poorest outcome. 12.9% revision rate. In another study, Rai et al reported a long-term follow up (12.0 years) outcome of 46 CRSA in mixed patient groups. OA (40 shoulder), 2 with RA, one with instability and one with AVN. The OSS and SF-12 scores were good for all pathologies except rotator cuff disease. 3.6 % revision rate.

Our series showed that the best results of CRSA in SCD patients were in patient with early stage of AVN (stage 3). However, pain was persistence after arthroplasty in almost all patients This is can be explained due to ongoing vascular occlusion events from SCD and Other joints involvement. In our study, the main complication and reason of revision were glenoid erosion. One major limitation of our study is the small number of patients.

Conclusion

Treatment of humeral head AVN in SCD patients is challenging. CSRA may provide improvement in pain and function in selected SCD patients with early stages of humeral head AVN. However, further studies with larger number of patients and longer follow-up are required

References

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