No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head

Philip M Parel; Shu Lin; Amil R Agarwal; Mark Haft; R Timothy Kreulen; Arhum Naeem; Zachary Pressman; Matthew J Best; Zachary R Zimmer; Uma Srikumaran

doi:10.1016/j.jse.2024.03.046

No Difference in 10-Year Survivorship of Total Shoulder Arthroplasty Versus Hemiarthroplasty for Avascular Necrosis of the Humeral Head

J Shoulder Elbow Surg. 2024 May 10:S1058-2746(24)00324-0. doi: 10.1016/j.jse.2024.03.046. Online ahead of print.

Authors

Affiliations

¹ The George Washington University School of Medicine and Health Sciences, Washington, DC, USA. Electronic address: pmparel2018@gwmail.gwu.edu.
² Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL, USA.
³ The George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁵ The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

PMID: 38735634
DOI: 10.1016/j.jse.2024.03.046

Abstract

Introduction: Avascular necrosis of the humeral head (AVN) is characterized by osteonecrosis secondary to disrupted blood flow to the glenohumeral joint. Following collapse of the humeral head, arthroplasty, namely total shoulder arthroplasty (TSA) or humeral head arthroplasty (hemiarthroplasty) is recommended standard of care. The literature is limited to underpowered and small sample sizes in comparing arthroplasty modalities. Therefore, the aims of this study were (1) to compare the 10-year survivorship of TSA and hemiarthroplasty in the treatment of AVN of the humeral head and (2) to identify differences in their revision etiologies.

Methods: Patients who underwent primary TSA and hemiarthroplasty for AVN were identified using the PearlDiver database. TSA patients were matched by age, gender, and Charlson Comorbidity Index (CCI) to the hemiarthroplasty cohort in a 4:1 ratio since TSA patients were generally older, sicker, and more often female. The 10-year cumulative incidence rate of all-cause revision was determined using Kaplan-Meier survival analysis. Multivariable analysis was conducted using Cox Proportional Hazard modeling. Chi-squared analysis was conducted to compare the indications for revisions between matched cohorts including periprosthetic joint infection (PJI), dislocation, mechanical loosening, broken implants, periprosthetic fracture, and stiffness.

Results: In total, 4,825 patients undergoing TSA and 1,969 patients undergoing hemiarthroplasty for AVN were included in this study. The unmatched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 7.0% and 7.7%, respectively. The matched 10-year cumulative incidence of revision for patients who underwent TSA and hemiarthroplasty was 6.7% and 8.0%, respectively. When comparing the unmatched cohorts, TSA patients were at significantly higher risk of 10-year all-cause revision (HR: 1.39; P = 0.017) when compared to hemiarthroplasty patients. After matching, there was no significant difference in risk of 10-year all-cause revision (HR: 1.29; P = 0.148) and no difference in the observed etiologies for revision (P > 0.05 for all).

Conclusion: After controlling for confounders, only 6.7% of TSA and 8.0% hemiarthroplasties for humeral head AVN were revised within 10-years of index surgery. The demonstrated high and comparable long-term survivorship for both modalities supports the utilization of either for the AVN induced humeral head collapse.

Keywords: Level of Evidence: Level III; Retrospective Cohort Comparison using Large Database; Treatment Study; avascular necrosis; hemiarthroplasty; humeral head; survivorship; total shoulder arthroplasty.