John W. Sperling
Osteoarthritis is recognized as the most common type of glenohumeral arthritis. It is characterized by a progressive arthropathy with loss of articular cartilage and hypertrophic changes in the subchondral bone. In treating the patient with glenohumeral osteoarthritis, multiple facets need to be incorporated to formulate a successful treatment plan. The process begins with a thorough understanding of the severity of the patient's symptoms, functional demands, and ability to comply with postoperative restrictions. Appropriate imaging studies, in conjunction with a careful examination, allow the physician to outline a proper treatment plan for the patient.
Pathogenesis
Osteoarthritis of the shoulder is significantly less common than that of the hip or knee. There is a progressive increase in the incidence with increasing age. Subclinical stages of osteoarthritis may exist for decades. Subchondral cysts may be present in both the humeral head as well as the glenoid. The typical pathologic findings of osteoarthritis include thinning or complete loss of cartilage on the humeral head. In addition, the humeral head may flatten with progressive sclerotic changes. Osteophytes frequently develop at the margin of the articular surface in a circumferential pattern. These osteophytes may increase tension on the capsule with resultant loss of shoulder motion.
One of the characteristics that differentiates osteoarthritis from rheumatoid arthritis and other inflammatory types of glenohumeral arthritis is the typical preservation of the rotator cuff. Multiple studies have demonstrated that the rotator cuff is intact in 90% to 95% of patients with osteoarthritis.
Also typical of osteoarthritis is the posterior glenoid wear pattern frequently present. This disease pattern results in posterior glenoid wear with associated posterior humeral subluxation. There is progressive stretching of the posterior capsule with thickening and contracture of the anterior capsule.
Patient Evaluation
History
Evaluation of the patient with glenohumeral arthritis begins with taking a thorough history. It is critically important to understand the severity of the patient's symptoms and functional demands. It is essential to understand the primary complaint of the patient—is it weakness, pain, or loss of motion?
One should determine how long the shoulder pain has been present as well as whether there was a specific traumatic event. Patients are asked to rate their pain on a 1 to 10 scale at rest, with activities, and at night. Alleviating and aggravating factors are determined. Patients are asked to specifically localize the pain. Does the pain occur in the superior-lateral aspect of the shoulder? Does the pain occur in a radicular pattern down the arm, possibly consistent with a neurologic cause?
One should ask about prior evaluations and treatment. What studies have been performed in the past and what were the results? Has the patient had a trial of physical therapy? Has the patient had prior injections? If so, what was the location and response? Has there been prior shoulder surgery? If so, what was the indication, postoperative therapy, and outcome? Were there any problems with wound healing?
Review of Systems
A focused review of systems should be documented. Is there a history of metabolic or rheumatologic disease? Does the patient have a history of other joint involvement, and in what order should they be addressed? Is there a history of neurologic symptoms or neck pain?
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One needs to determine whether there is a history of cough, shortness of breath, or weight loss. Although uncommon, patients may present with shoulder pain as a symptom of lung cancer. A list of medications and associated medical problems should also be compiled to assist with planning of medical clearance prior to surgery.
Physical Examination
The first step in the physical examination is inspection with evaluation for atrophy and appearance of prior incisions. One examines for atrophy associated with long-standing rotator cuff disease as well as evidence of deltoid deficiency. Palpation begins at the cervical spine. Cervical motion is evaluated, and testing for potential cervical radiculopathy is performed with a Spurling test. Examination is bilateral and should include the wrist, elbow, and shoulder. Examination of the upper extremities includes assessment of reflexes, strength, and sensation.
Shoulder range of motion and strength is carefully assessed. Active and passive shoulder abduction is recorded. One needs to determine whether there is a component of anterior-superior humeral head escape or altered scapular motion with shoulder elevation. External rotation and internal rotation are recorded. Typically, shoulder strength is graded on a 1 to 5 scale for internal rotation, external rotation, flexion, extension, and abduction. Deltoid and periscapular muscles are also tested.
Radiographic Studies
Three shoulder views are routinely obtained: an axillary view and 40- degree posterior oblique views with internal and external rotation. On the anteroposterior (AP) view, one evaluates both the medial-lateral and superior-inferior acromiohumeral distance. Among patients with glenoid erosion, there is a decrease in the amount of humeral head offset from the lateral border of the acromion. Specifically, among patients with significant glenoid erosion, the lateral border of the humeral head is medial to the lateral edge of the acromion. In patients with rotator cuff deficiency, which is less common in osteoarthritis, there may be superior subluxation of the humeral head with a decrease in the acromial-humeral distance. One caveat is that with posterior subluxation that is frequently present in osteoarthritis, there can be the false appearance of superior humeral head subluxation.
The AP radiographs are also helpful in determining the overall degree of osteopenia, thickness of the cortices, and size of the humeral canal. Serial radiographs taken over time will allow one to confirm the diagnosis of osteoarthritis compared with other diagnoses that may include rheumatoid arthritis, osteonecrosis, cuff tear arthropathy, and traumatic arthritis. The axillary view allows assessment of glenoid erosion and glenohumeral subluxation. CT scans have become an extremely valuable tool in evaluating the patient prior to consideration of operative intervention, especially total shoulder arthroplasty. In the setting of glenoid erosion, CT scans provide important information concerning glenoid version and quantifying the amount of bone loss (Fig. 44-1). Three-dimensional CT is a new development that can further assist in evaluating the humerus and glenoid.
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Figure 44-1 Preoperative CT scan used to evaluate degree of glenoid erosion. |
Treatment
After integrating the information obtained from the history, physical exam, and imaging studies, one determines the specific diagnosis and can present treatment options to the patient. In the setting of glenohumeral arthritis, conservative therapy plays an important role in the early stages of disease. Nonsteroidal anti-inflammatories and intra-articular steroid and/or hyaluronic acid injections may provide temporary pain relief. A physical therapy program that focuses on restoring and maintaining range of motion and strength may be tried. Heat and cold therapy as well as ultrasound may reduce the inflammatory response and provide pain relief.
Although many patients with early shoulder osteoarthritis can be successfully treated with nonoperative modalities, patients with more advanced disease may require surgical intervention. In determining the most appropriate treatment, it is critical to clearly understand the patient's goals. Patients must be accepting of the postoperative restrictions and comply with the rehabilitation. The gold standard for severe osteoarthritis is total shoulder arthroplasty; however, in the young active patient or those patients who are unable to accept the restrictions associated with a prosthesis, this option may not be suitable. In these select cases, arthroscopic treatment or interposition arthroplasty may provide symptomatic relief.
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Arthroscopic Treatment
The ideal candidate for arthroscopic debridement is a young, active, high-demand patient with isolated Outerbridge grade I to III chondral lesions. In addition, ideal candidates have congruent joint surfaces and minimal osteophyte formation. A thorough arthroscopic lavage may help remove inflammatory enzymes and proteins from the joint fluid. In addition, debridement of surface irregularities, displaced chondral flaps, and labral tears with removal of loose bodies may alleviate mechanical symptoms. Capsular contractures can also be released to help restore motion.
There have been limited reported results of arthroscopic treatment of arthritis. Ogilvie-Harris and Wiley were the first to report results of arthroscopic debridement for glenohumeral arthritis. The authors reported that 60% of patients with mild disease had improvement; however only 30% of patients with moderate to severe disease had relief. Weinstein et al. evaluated the extent and duration of pain relief after arthroscopic debridement for stages I to III glenohumeral arthritis. Among the 25 patients with a mean follow-up of 34 months, there were 2 excellent, 18 good, and 5 unsatisfactory results. A trend was noted toward worse results with increasing severity of cartilage changes. The authors also reported that 10 of 12 patients with marked preoperative stiffness had significant improvement of motion. Patients with large osteophytes and/or nonconcentric joints had worse results.
Cameron et al. reported on arthroscopic debridement and capsular release among patients with Outerbridge grade IV lesions. There were 45 patients with a minimum 2-year follow-up. Patient satisfaction scores improved significantly with 87% of patients indicating they would have the surgery again. Osteochondral lesions >2 cm2 were associated with earlier return of pain and failure of the procedure.
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Figure 44-2 Preoperative (A) and postoperative (B) radiographs. |
Biologic Resurfacing
In the setting of osteoarthritis, biologic resurfacing of the glenoid alone or in combination with hemiarthroplasty has been reported to provide good pain relief. Traditionally these patients, especially heavy laborers, have been considered candidates for glenohumeral fusion. Although fusion results are satisfactory in 80% of cases, persistent scapulothoracic muscle pain and significant loss of motion make this an unattractive option for many active patients.
Techniques described usually involve an open approach; however, an all-arthroscopic resurfacing technique has recently been published. The goals of interposition arthroplasty and hybrid interposition arthroplasty are pain relief and restoration of function while preserving bone stock for future procedures. Several different materials have been described for use as an interposition material including anterior capsule, fascia lata autograft, and allografts of Achilles tendon, lateral meniscus, dura mater, and purified porcine submucosa.
Hybrid arthroplasty combining biologic resurfacing of the glenoid and hemiarthroplasty was first described by Burkhead and Hutton in 1995. A recent review of Burkhead's long-term results (5 to 13 years) of 26 shoulders that underwent interposition arthroplasty demonstrated excellent results in 12 of 26 (46%), 9 of 26 a satisfactory result (35%), and 5 of 26 an unsatisfactory result (19%) using Neer's criteria.
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Shoulder Arthroplasty
Total shoulder arthroplasty is the gold standard treatment for osteoarthritis of the shoulder (Fig. 44-2). Several studies have been published that demonstrate the superiority of total shoulder arthroplasty compared with hemiarthroplasty for osteoarthritis of the shoulder. The chance of good to excellent pain relief with total shoulder arthroplasty is >90% whereas it is 80% to 85% with hemiarthroplasty.
In addition to retrospective reviews, prospective studies have been performed demonstrating superior pain relief with total shoulder arthroplasty. Gartsman et al. performed a prospective study of 51 shoulders with osteoarthritis, a concentric glenoid, and an intact rotator cuff. The shoulders were randomly assigned to hemiarthroplasty or total shoulder arthroplasty (TSA). Total shoulder arthroplasty had significantly better pain relief. In addition, there were no revisions in the TSA group and three revisions in the hemiarthroplasty group for painful glenoid arthritis.
Conclusion
Arthroscopic debridement for glenohumeral arthritis may be indicated in young active patients with mild to moderate disease or in carefully selected patients with advanced disease who do not want prosthetic replacement. Debridement of chondral and labral lesions, loose body removal, and capsular releases are the goals of arthroscopic treatment. Long-term results of arthroscopic debridement are unknown, but in patients with mild disease, short-term results are encouraging. Biologic resurfacing of the glenoid alone, or in combination with hemiarthroplasty, may provide a reasonable option in the young patient with glenohumeral arthritis. Total shoulder arthroplasty, however, remains the gold standard for treatment of end-stage glenohumeral osteoarthritis.
Suggested Readings
Brislin KJ, Savoie FH III, Field LD, et al. Surgical treatment for glenohumeral arthritis in the young patient. Tech Shoulder Elbow Surg. 2004; 5:165-169.
Burkhead WZ, Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg. 1995; 4:263-270.
Cameron BD, Galatz LM, Ramsey ML, et al. Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint. J Shoulder Elbow Surg. 2002; 11:25-32.
Cofield RH. Shoulder arthrodesis and resection arthroplasty of the shoulder. Instr Course Lect. 1985; 34:268-277.
Gartsman GM, Roddey TS, Hammerman SM. Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis. J Bone Joint Surg. 2000; 82:26-34.
Nowinski RJ, Burkhead WZ Jr. Hemiarthroplasty with biologic glenoid resurfacing: 5-13 year outcomes. 70th Annual Meeting, New Orleans, LA, February 5-9, 2003.
Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder: a general appraisal. J Bone Joint Surg. 1986; 68B:201-207.
Weinstein DM, Bucchieri JS, Pollock RG, et al. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy. 2000; 16:471-476.