Shoulder arthroplasty in patients aged fifty-five years or
younger with osteoarthritis
Robert Bartelt, MD, John W. Sperling, MD, Cathy D. Schleck, BS,
Robert H. Cofield, MD*
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
Background: The younger patient with glenohumeral arthritis presents a challenge because of concerns
about activity and frequency of failure. The purpose of this study was to define the results, complications,
and frequency of revision surgery in this group.
Materials and methods: Between 1986 and 2005, 46 total shoulder arthroplasties and 20 hemiarthroplas-
ties were performed in 63 patients who were aged 55 years or younger and had chronic shoulder pain due to
glenohumeral osteoarthritis. All 63 patients had complete preoperative evaluation, operative records, and
minimum 2-year follow-up (mean, 7.0 years) or follow-up until revision.
Results: Nine shoulders underwent a revision operation. The implant survival rate was 92% (95% confi-
dence interval, 77%-100%) at 10 years for total shoulder arthroplasty and 72% (95% confidence interval,
54%-97%) for hemiarthroplasty (Kaplan-Meier result). Patients who underwent total shoulder arthroplasty
had less pain (P ¼ .01), greater active elevation (P ¼ .05), and higher satisfaction (P ¼ .05) at final follow-
up compared with those who underwent hemiarthroplasty. Complete radiographs were available for
47 arthroplasties with a minimum 2-year follow-up or follow-up until revision (mean, 6.6 years). More
than minor glenoid periprosthetic lucency or a shift in component position was present in 10 of 34 total
shoulder arthroplasties. Moderate to severe glenoid erosion was present in 6 of 13 hemiarthroplasties.
Conclusions: This study indicates that there is intermediate- to long-term pain relief and improvement in
motion with shoulder arthroplasty in young patients with osteoarthritis. These results favor total shoulder
arthroplasty in terms of pain relief, motion, and implant survival.
Level of evidence: Level IV, Case Series, Treatment Study.
? 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Total shoulder arthroplasty; osteoarthritis; glenohumeral arthritis; young patient
The question of how to best treat the young patient with
glenohumeral osteoarthritis has been a challenging issue.
Better functional results have been shown for patients with
osteoarthritis after receiving total shoulder arthroplasty
to component loosening has been considered a relative
contraindication to performing total shoulder arthroplasty in
young patients with ostensibly higher physical demands.
This is in contrast to several studies that have not shown
with hemiarthroplasty in patients aged 50 years or
younger.3,19,20Because implant loosening is less common in
hemiarthroplasty, the equivalence is likely a result of the
number of early revision surgeries in patients receiving
hemiarthroplasties who had inadequate pain relief.15The
*Reprint requests: Robert H. Cofield, MD, Department of Orthopedic
Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
E-mail address: firstname.lastname@example.org (R.H. Cofield).
J Shoulder Elbow Surg (2011) 20, 123-130
1058-2746/$ - see front matter ? 2011 Journal of Shoulder and Elbow Surgery Board of Trustees.
experience of shoulder arthroplasty in young patients has
been marked by a high percentage of unsatisfactory
in the short term to midterm for total shoulder arthro-
plasty11,14and humeral head resurfacing.1
We are aware of only 1 study reporting the results of total
shoulder arthroplasty in similarly aged patients with osteo-
arthritis.14Therefore, we reviewed our experience over
a 20-year period with total shoulder arthroplasty and hemi-
arthroplasty in patients aged 55 years or younger with gle-
nohumeral osteoarthritis to assess the results, the risk factors
for an unsatisfactory outcome, and the rates of revision.
Materials and methods
The Mayo Clinic Institutional Review Board gave approval for
this study (No. 09-004605). No external source of funding was
used for any aspect of this study.
Between January 1, 1986, and December 31, 2005, 46 total
shoulder arthroplasties and 20 hemiarthroplasties were performed
in 63 patients aged 55 years or younger with primary or secondary
osteoarthritis. Patients were identified with the use of a comput-
erized database that contains the files of all patients having
undergone joint arthroplasty at our institution since 1969. During
this period, 1182 total shoulder arthroplasties and 231 hemi-
arthroplasties were performed at our institution for patients with
osteoarthritis, regardless of age. Our study represents 5% of these
patients, a similar rate to other institutions.16All total shoulder
arthroplasties and hemiarthroplasties were included in the Kaplan-
Meier survival analysis, with a revision procedure defined as the
endpoint. For clinical outcome assessment, all shoulders were
included in the analysis (including all revised shoulders as well as
those unrevised with at least 2 years of clinical follow-up). Thus,
46 total shoulder arthroplasties and 20 hemiarthroplasties with
complete preoperative evaluation,
minimum 2-year follow-up or follow-up until revision were
included in the clinical analysis (mean, 7.0 years; range, 9 months
to 20.2 years). For radiographic outcome assessment, 47 shoulders
met the inclusion criteria of complete radiographic records and
a minimum of 2 years of clinical and radiographic follow-up or
follow-up until revision. These comprised 34 total shoulder
arthroplasties and 13 hemiarthroplasties, with a mean radiographic
follow-up of 6.6 years (range, 9 months to 20.2 years). Indications
for implantation of a glenoid component were unchanged over the
duration of the study period. The decision to implant a glenoid
component was an individualized decision jointly made by the
patient and surgeon. Factors that weighed in this decision included
the patient’s wish for more complete assurance about pain relief,
the patient’s desired activity level, the structural status of the
glenoid, and the ability to balance the joint surface with or without
a glenoid component. None of the total shoulder arthroplasty
patients and four of the hemiarthroplasty patients had data
previously reported in a study of the outcomes of hemiarthroplasty
for osteoarthritis, regardless of age.15
Total shoulder arthroplasty
Themean ageof patients whounderwent totalshoulderarthroplasty
Twenty-one shoulders had undergone a previous procedure. The
previous procedures included 7 arthroscopic debridements, 3 SLAP
(superior labrum anterior-posterior) repairs (1 of which included
a concomitant rotator cuff repair, which was intact at the time of
arthroplasty), 3 subacromial decompressions with acromioplasty,
2 rotator cuff repairs (1 intact at arthroplasty and 1 with recurrent
and 1 Magnusson-Stack repair. In addition, 2 patients had a remote
history of proximal humeral fracture, neither of which resulted in
significant morphologic alteration of the glenohumeral joint as
viewed on standard radiographs.
complete preoperative evaluation, operative records, and minimum
2-year follow-up or follow-up until revision, the mean length of
clinical follow-up was 6.0 years, with less than 5 years offollow-up
The mean age of patients who underwent hemiarthroplasty was 49
years (range, 26-55 years). There were 4 women and 16 men. Four
shoulders had undergone a previous procedure. Previous surgical
procedures included 1 arthroscopic debridement, 1 Bristow proce-
dure, 1 procedure for instability (not otherwise specified), and
1 rotator cuff repair (repairable full-thickness tear noted at the time
of arthroplasty). The procedures for instability were performed
remotely from the arthroplasty.
Among the 20 shoulders having hemiarthroplasty and complete
preoperative evaluation, operative records, and minimum 2-year
follow-up or follow-up until revision, the mean length of clinical
follow-up was 9.3 years, with less than 5 years of follow-up in
6 shoulders, between 5 and 10 years in 5 shoulders, between 10 and
20 years in 8 shoulders, and greater than 20 years in 1 shoulder.
the surgeon as intact, thin (partial-thickness tear), or torn (presence
of a full-thickness tear). Among patients who underwent total
thin in 7 shoulders. Two patients had repairable full-thickness
tears at the time of arthroplasty. For patients undergoing hemi-
arthroplasty, the rotator cuff was intact in 12 shoulders and thin in
6 shoulders. Two patients had repairable full-thickness tears at the
follows: 42 Cofield humeral components, 41 of which were unce-
mented and 1 was cemented (Smith & Nephew, Memphis, TN);
4 Aequalis humeral components, all cemented (Tornier, Mon-
tbonnot, France); 40 Cofield glenoid components, 39 cemented and
1 ingrowth; 4 Aequalis glenoid components, all cemented; and
2 Neer glenoid components, both cemented (Kirschner Medical,
Fairlawn, NJ). The hemiarthroplasty implants were as follows:
13 Cofield humeral components, all uncemented; 5 Bio-Modular
components, all uncemented (Biomet, Warsaw, IN); 1 Neer
component, uncemented (3M, St Paul, MN); and 1 cemented
124R. Bartelt et al.
Howmedica stem (Mahwah, NJ). Bone grafting was performed
for the humerus in 1 shoulder receiving hemiarthroplasty and
1 receiving total shoulder arthroplasty. The glenoid was bone
grafted in 2 shoulders receiving total shoulder arthroplasty. Post-
operative rehabilitation was not different for the 2 groups, with
patients beginning physical therapy for initiation of passive
shoulder motion on the first postoperative day. Patients then began
active assisted motion at 4 to 6 weeks postoperatively and then
strengthening (isometrics, resistance bands) at 8 to 10 weeks.
Patients are asked to return for an examination, interview, and
radiographic evaluation at regular follow-up intervals. Patients
who are unable to return for evaluation are sent a standardized,
validated17questionnaire to evaluate their function and satisfac-
tion. In addition, patients are requested to have a local orthopaedic
surgeon send us the results of a clinical examination and recent
radiographs. For 32 patients, the most recent clinical information
was obtained via questionnaire.
At our institution, clinical assessment of all patients who have
undergone shoulder surgery is recorded by use of a standard
shoulder analysis sheet. Pain is graded according to scales previ-
ously published by Cofield5and Neer et al,12where 1 indicates
no pain; 2, slight pain; 3, pain after unusual activity; 4, moderate
pain; and 5, severe pain. Active abduction and passive external
rotation were recorded in degrees. Internal rotation was the
most posterior vertebral segment that could be reached by the
Three projections were used for radiographic analysis: an
axillary radiograph and 40?posterior oblique radiographs with
internal and external rotation of the humerus. We reviewed these,
and a consensus was reached. Radiographs for patients who
underwent total shoulder arthroplasty were reviewed to determine
the presence of glenohumeral subluxation, periprosthetic lucency,
and component shift in position. Radiographs for patients who
underwent hemiarthroplasty were reviewed to determine gleno-
humeral subluxation, periprosthetic lucency, component shift in
position, and glenoid erosion.
Preoperative glenoid morphology was assessed when possible
according to the method of Walch et al.21Among patients receiving
total shoulder arthroplasty, there were 12 with type A glenoid
glenoid, and 1 with a type C glenoid. Among those receiving hem-
iarthroplasty, 8 patients had type A glenoid morphology, 2 had type
B1, and 1 had type C.
Periprosthetic lucency was graded as follows: 0, none; 1, 1 mm
incomplete; 2, 1 mm complete; 3, 1.5 mm incomplete; 4, 1.5 mm
complete; or 5, 2 mm complete. Glenohumeral subluxation was
evaluated with regard to direction and degree and was graded as
follows: none, mild (center of prosthetic head translated <25%
relative to center of glenoid component), moderate (center of
prosthetic head translated 25%-50% relative to center of glenoid
component), or severe (center of prosthetic head translated >50%
relative to center of glenoid component). Glenoid erosion was
graded as none, mild (erosion into subchondral bone), moderate
(medialization of glenoid subchondral bone with hemispheric
conforming deformation of glenoid), or severe (complete hemi-
spheric deformation of glenoid with bone loss to base of coracoid
process). Component shift was either present or absent.
Descriptive statistics are reported as mean (range) for continuous
measures and number (percentage) for discrete assessments. All
shoulders were included in the estimation and followed from the
date of primary total shoulder arthroplasty or hemiarthroplasty to
either revisionorlastfollow-up.Weestimated implantsurvival free
of revision with the Kaplan-Meier method, reporting the estimate
and 95% confidence interval (CI). For clinical outcomes, all
66 shoulders were included in clinical outcome assessments (all
revised shoulders and those with at least 2 years of clinical follow-
up). A paired t test was used to compare preoperative versus post-
operative changes in pain, active abduction, and external and
internal rotation. Postoperative assessments were made at last
clinical contact. In patients with a revision, the last clinical infor-
mation before revision was used. The radiographic outcomes of
subluxation and humeral lucency were assessed in the same way as
for clinical outcomes. In these assessments, 47 shoulders were
included, 34 total shoulders and 13 hemiarthroplastiesdall revised
shoulders or those with at least 2 years of radiographic follow-up.
In patients with a revision, the last radiographic information
before revision was used. The a level was set at .05 for statistical
Complications and revisions
Five perioperative complications occurred in the forty-six
shoulders undergoing total shoulder arthroplasty. These
included 3 brachial plexopathies, 2 of which completely
resolved; 1 minimally displaced fracture of the glenoid seen
on postoperative radiographs treated in a spica cast; and
1 lower extremity deep vein thrombosis. There were 3 peri-
operative complications that occurred in the 20 shoulders
receiving hemiarthroplasty: 1 wound hematoma requiring
evacuation, irrigation, and debridement and 2 transient
brachial plexopathies, which recovered completely.
Three of the patients who underwent total shoulder
arthroplasty required revision surgery: one at 8.6 years for
coagulase-negative Staphylococcus infection, one at 11.9
years for an infection with Propionibacterium acnes, and
one at 12.3 years after index arthroplasty for glenoid
loosening. Six of the shoulders with hemiarthroplasty
required revision surgery. Five underwent revision for
painful glenoid arthritis to a total shoulder arthroplasty. The
mean time to revision for glenoid arthritis was 4.5 years
(range, 1.3-13.5 years). One patient in the hemiarthroplasty
group underwent revision at 9 months postoperatively for
infection with P acnes. This patient had a postoperative
wound hematoma requiring evacuation, irrigation, and
debridement. The estimated revision-free survival rate for
total shoulder arthroplasty was 100% at 5 years and 92%
(95% CI, 77%-100%) at 10 years. The estimated revision-
free survival rate for hemiarthroplasty was 85% (95% CI,
71%-100%) at 5 years and 72% (95% CI, 54%-97%) at 10
Shoulder arthroplasty in young patients125
years (Figure 1). There was not a statistically significant
difference in implant survival between total shoulder
arthroplasty and hemiarthroplasty (P ¼ .34). The 5 hemi-
arthroplasties revised to total shoulder arthroplasties had
Cofield components, and the total shoulder arthroplasty
revised for glenoid loosening had a Cofield cemented
Preoperativevariables were assessed for their association
with implant survival. No statistical association was seen for
gender (P ¼ .78), age at the time of surgery (P ¼ .58), status
of the rotator cuff (P ¼ .21), glenoid type (P ¼ .20), or prior
surgical procedure (P ¼ .64).
Pain and motion
Patients had significant pain relief and increases in shoulder
elevation and external rotation with shoulder arthroplasty.
Total shoulder arthroplasty patients had a mean decrease in
of 2.0 at most recent follow-up, with 7 patients having
moderateorseverepain at the timeof mostrecent follow-up.
Hemiarthroplasty patients had a mean decrease in pain score
of 1.5, from a mean of 4.5 preoperatively to a mean of 2.9 at
most recent follow-up, with 7 patients having moderate to
pain score was statistically different between patients
receiving total shoulder arthroplasty and hemiarthroplasty
(P ¼ .02) (Figure 2A).
For patients receiving total shoulder arthroplasty, the
mean improvements in motion were as follows: mean active
elevation of 46?, from 105?preoperatively to 151?at most
recent follow-up (Figure 2B), and mean external rotation of
24?, from 23?preoperatively to 48?at most recent follow-up
(Figure 2C). The mean improvements in motion for patients
receiving hemiarthroplasty were as follows: mean active
elevation of 9?, from 103?preoperatively to 114?at most
recent follow-up (Figure 2B), and mean external rotation of
14?, from 23?preoperatively to 38?at most recent follow-up
(Figure 2C). The mean improvements in motion were not
statistically different for patients receiving total shoulder
arthroplasty and hemiarthroplasty (P ¼ .06 for active
elevation and P ¼ .20 for external rotation). However, the
final mean active elevation was statistically greater for
patients receiving total shoulder arthroplasty (151?vs 114?,
P ¼ .005). Internal rotation was minimally increased after
surgery for both groups (sacrum to L4 for total shoulder
arthroplasty and sacrum to L5 for hemiarthroplasty).
Of the 5 patients who underwent revision from hemi-
arthroplasty to total shoulder arthroplasty, 4 had at least
1 year of clinical follow-up after revision (mean, 5.3 years;
range, 1-12 years). The mean active elevation for these
was 2.75 (range, 1-4).
At the time of their most recent follow-up, or last follow-up
before revision, 40 of the 46 patients receiving total
shoulder arthroplasty (87%) felt that they were better or
much better than preoperatively, compared with 13 of the
20 patients receiving hemiarthroplasty (65%). This differ-
ence was statistically significant (P ¼ .05).
Of the 34 total shoulder arthroplasty patients who had
both superior and posterior in 1), moderate in 4 shoulders
(posterior in 2, superior in 1, and anterior in 1), and severe in
1 shoulder (posterior). All shoulders with moderate or severe
subluxation had type B glenoid morphology. Nine of the
shoulders had humeral lucency; however, only two shoulders
had a 1.5-mm complete lucency or greater. One of these two
shoulders and one other shoulder had a shift of humeral
component position. Both of the humeral components that
showed tilt and/or subsidencewere uncemented. Twenty-one
of the glenoid components showed periprosthetic lucency;
this was 1.5-mm complete or greater in six shoulders. Two of
these shoulders and four others had tilting or migration of the
glenoid component. Five of the six patients with moderate or
severe glenoid periprosthetic lucency had type B glenoid
morphology preoperatively. A clinical example of radio-
graphic failure at midterm follow-up is shown in Figure 3. In
contrast, other patients have had excellent long-term radio-
graphic results, as shown in Figure 4.
years or younger receiving shoulder arthroplasty for glenohumeral
osteoarthritis. The estimated revision-free survival rate for total
shoulder arthroplasty (tsa) was 100% at 5 years and 92% (95% CI,
77%-100%) at 10 years. The estimated revision-free survival rate
for hemiarthroplasty (hemi) was 85% (95% CI, 71%-100%) at
5 years and 72% (95% CI, 54%-97%) at 10 years.
Kaplan-Meier survival curve for all patients aged 55
126R. Bartelt et al.
Pain scores after shoulder arthroplasty
Active elevation after shoulder arthroplasty
External rotation after shoulder arthroplasty
total shoulder arthroplasty (TSA) and hemiarthroplasty. Patients undergoing total shoulder arthroplasty had significantly less pain and
greater active elevation at final follow-up.
Preoperative and final postoperative results for pain (A), active elevation (B), and external rotation (C) for patients undergoing
Shoulder arthroplasty in young patients127
Of the 13 hemiarthroplasty patients who had complete
radiographic records for review, 7 had evidence of subluxa-
tion on the most recent films. It was classified as mild in
5shoulders(superiorin2 andposterior in3)andmoderate in
2 shoulders (superior in 1 and superior and posterior in 1).
One of the shoulders with moderate subluxation had type B
glenoid morphology preoperatively. Three of the shoulders
a 1.5-mm complete lucency or greater, and no shoulders
hadtilt orsubsidenceofthe implant. Allofthe shouldershad
erosion of the glenoid. Seven of the thirteen shoulders had
mild glenoid erosion. Erosion was graded as moderate in 4
in 8 shoulders, posterior in 3, and superior in 2. All patients
with posterior erosion had type B or C glenoid morphology.
There have been fewdataavailable toguide clinical decision
making for the young patient with glenohumeral osteoar-
thritis. Much of the previous work has addressed shoulder
arthroplasty for osteoarthritis regardless of age2,6,8,13,15,23or
Recent articles have reported favorable short-term to
midterm results for total shoulder arthroplasty in young to
middle-aged patients with osteoarthritis14or chondrolysis.11
patients receiving humeral head resurfacing with7,10,22or
present study reports on the clinical and radiographic results
as well as implant survival with intermediate- to long-term
follow-up (mean, 7.0 years) in patients aged 55 years or
younger with osteoarthritis who have undergone shoulder
There was a high rate of revision surgery or radiographic
failure in this group of patients, particularly for those
survival rate of implants was 72% for those receiving
hemiarthroplasty, based on Kaplan-Meier analysis. The
most common reason for revision surgery was progressive
glenoid arthritis in patients who had undergone hemi-
arthroplasty, with revision to a total shoulder arthroplasty,
similar to previous reports.15Three other patients under-
went revision for infection. One patient underwent revision
of total shoulder arthroplasty for component loosening.
These results argue against the idea that young patients
with osteoarthritis are poor candidates for total shoulder
arthroplasty because of progressive wear and failure of the
glenoid component. However, 6 of 34 patients receiving
total shoulder arthroplasty for whom complete radiographic
records were available did have moderate or severe lucency
100?, and passive external rotation of 30?. (B) and (C), Radiographs taken 5.5 years after surgery. The patient reported moderate pain and
showed 100?of active elevation and 40?of external rotation. Periprosthetic glenoid lucency and central migration are noted.
(A), Preoperative radiograph of a 49-year-old woman before total shoulder arthroplasty. She had severe pain, active elevation to
128R. Bartelt et al.
around the glenoid component and another 4 had tilting or
migration of the glenoid component, which is concerning
for impending clinical failure. The decision for revision of
a potentially loose glenoid component was based on patient
symptoms, not radiographic changes alone.
Shoulder arthroplasty seems to be rarely indicated in
young patients. Our relatively small study size and inter-
mediate- to long-term follow-up limit the conclusions that
may be drawn regarding the superiority of shoulder hemi-
arthroplasty versus total shoulder arthroplasty. However,
pain relief, satisfaction, and active elevation were superior
for those who underwent total shoulder arthroplasty. The
small number of revisions in the group (9) limits statistical
analysis of implant survival; however, our data favor the
survival of total shoulder arthroplasty. This is in agreement
of hemiarthroplasty to total shoulder arthroplasty because of
progressive glenoid arthritis15; however, other data suggest
that some patients undergoing hemiarthroplasty for gleno-
humeral osteoarthritis have excellent long-term implant
survival.23Analysis of our small subset of patients who
underwent revision of hemiarthroplasty to total shoulder
whom at least 1 year of clinical follow-up is available still
reporting moderate pain. This is consistent with previous
Limitations of the study include those inherent in retro-
spective reviews. In addition, complete radiographic follow-
of the duration of the data collection period and the tertiary
referral nature of our practice, with the difficulty some
patients have in returning for radiographs. This limited our
ability to analyze radiographic failure, which should corre-
late with and predict clinical failure. In addition, follow-up
was longer on average for hemiarthroplasty (9.3 years)
the data toward more failures in the hemiarthroplasty group.
for the total shoulder arthroplasty group, and longer-term
to revision. Another source of potential bias is the effect of
activity level on the outcome of the arthroplasty. Predicted
activity level is one of our preoperative considerations in the
decision to implant a glenoid component, with patients
having heavier physical demands being more likely to
receive a hemiarthroplasty. We were unable to study activity
level after surgery because of the retrospective nature of our
The data from this study indicate that there is satisfac-
tory intermediate- to long-term pain relief and improve-
ment in motion with shoulder arthroplasty in young patients
with osteoarthritis. However, there are frequent radio-
graphic changes affecting the glenoid component with
70?, and passive external rotation of 0?. (B) and (C), Radiographs taken 7.8 years after surgery. The patient reported pain only after unusual
activity and showed 140?of active elevation and 45?of external rotation. The glenoid component remained well fixed. However, proximal
humeral osteolysis was present, which is concerning for a young patient.
(A), Preoperative radiograph of a 48-year-old man before total shoulder arthroplasty. He had severe pain, active elevation to
Shoulder arthroplasty in young patients129
a relatively high rate of revision surgery, most commonly Download full-text
for progressive glenoid arthritis after hemiarthroplasty.
Young patients with glenohumeral arthritis should be
appropriately counseled regarding the favorable expecta-
tions for pain and function and the less favorable risk of
failure after either partial or total shoulder arthroplasty.
1. Shoulder arthroplasty for osteoarthritis in patients
aged 55 years or younger is rarely indicated, and
rates of revision and component loosening are high.
2. Better pain relief, motion, and patient satisfaction
were seen with total shoulder arthroplasty versus
Robert Cofield, MD, receives royalties from Smith &
Nephew and DJO/Aircast (Vista, CA). John W. Sperling,
MD, receives royalties from Biomet. However, no
outside funding was used for any part of this study.
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