Shoulder Arthritis

Glenohumeral Joint Arthritis

Treatment of Glenohumeral Osteoarthritis by Dr Navid Nazarian

Reviewed by

Dr Owen Mattern
BSc(hons), MBBS, PhD |
Orthopaedic Registrar

Definition

Aetiology

  • Osteoarthritis
    • posterior glenoid wear leading to relative retroversion
  • Inflammatory arthropathies
    • 91 % RA pts report shoulder pain
  • Post traumatic
    • Both from fracture and instability (1/10 recurrent instability will lead to arthritis within 10 years)
  • Cuff tear arthropathy
  • Others
    • post stabilisation
      • particularly anterior with over tightened anterior capsule leading to posterior directed joint forces.
    • Osteonecrosis
      • raumatic and nontraumatic.
    • Infective
    • Neuropathic

Epidemiology

  • Age 50-60 years

Anatomy

  • Ball and socket synovial joint
  • 4 basic characteristics for normal function
    • Motion (most mobile joint in the body. Capsule lax until extremes of ROM)
    • Stability (inherently unstable combated by: glenoid labrum, anatomically orientated humeral head: 130deg hea shaft angle 30 deg retroversion, extensive humeral articulation, anatomical glenoid 0-1 deg retroversion, net humeral joint reaction forces by all shoulder muscles working in synchronicity)
    • Strength (functional deltoid and RC)
    • Smoothness (smooth surfaces lubricated with synovial fluid)

Pathology

  • Progressive asymmetric narrowing of joint space, subchondral sclerosis, osteophyte formation, glenoid erosion
  • Painful, restricted ROM and crepitus
    • Rest pain worsened by activities

Classification

  • Frozen Shoulder
  • Chronic dislocation

History

  • Painful, restricted ROM and crepitus
    • Rest pain worsened by activities

Examination

  • Global painful restriction of ROM (particularly ER)
  • Progressive asymmetric narrowing of joint space, subchondral sclerosis, osteophyte formation, glenoid erosion
  • Painful, restricted ROM and crepitus
    • Rest pain worsened by activities

Investigations

Xray

  • Tear-drop osteophyte on inferior humeral head & glenoid
  • Posterior deficiency of glenoid bone stock (cf. medial loss in rheumatoid)
  • Proximal migration of humeral head & subacromial sclerosis with cuff arthropathy
  • Progressive asymmetric narrowing of joint space, subchondral sclerosis, osteophyte formation, glenoid erosion

Differential Diagnosis

Treatment

Non op

  • Analgesia
  • NSAIDS
  • Physiotherapy
    • ROM
    • Strengthening
    • Local adjuvant therapy

Operative

Arthrodesis

  • May be considered in young active patient
  • Doesn’t restore satisfactory shoulder function

Resection arthroplasty

  • 2/3 get pain relief
  • Active elevation of 70°

Arthroplasty

  • Procedure of choice in older patient
  • 9- Better pain relief if glenoid replaced
  • Repair cuff at same time
  • Hemiarthroplasty vs TSR
    • no absolute consensus
    • difference between the 2 is small
    • Advantages of Glenoid component
      • providing concentric glenoid bone support
      • prevention of continuous glenoid bone loss
      • improved range of motion
      • more reliable pain relef
      • revision of painful hemiarthroplasty to a TSA is more common than revision of TSA because of loose glenoid component
    • Disadvantages of Glenoid component
      • increased operating time
      • component expense
      • glenoid loosening
    • Do not use Glenoid Component with Rotator Cuff Tear
      • Edge loading
      • Rocking horse phenomenon
      • early loosening
       

Evidence

AAOS Guidelines

  • 16 recommendations based on published studies for GH OA (First considered RCT’s, then controlled trials, then prosepective comparative study then retrospective comparison study, then prospective case series)
    • Designed to combat bias, enhance transparency and promote reproducibility
    • Looked at non-surgical, surgical and prevention of complications
  • Criteria for inclusion
    • English language published report for treatment of GH OA
    • Not a retrospective case series, records review
    • >10 patients
    • 80% of patients had to have GH OA
    • 2 year minimum follow-up
  • 5 levels of recommendation
    • A: > 1 level I study with consistent findings
    • B: > 1 level II/III with consistent findings or a single level I study
    • C: > 1 level IV\V study or a single level II/III study
    • I: no evidence of conflicting evidence
    • Consensus with no supporting evidence
  • Did not pool data

Cochrane Review 2010

  • Benefit and harm for patients undergoing surgical procedures for GH OA
    • TSR, hemiarthroplasty, arthroscopic debridement, interpositional arthroplasty
  • Included
    • RCT’s and quasi-randomized trials
    • 7 studies included
      • 2 compared TSR – hemiarthroplasty – 24-36/12,
      • 3 compared pegged to keeled glenoid – 6week, 2 x 24/12,
      • 1 computer navigation to no navigation,
      • 1 cemented all poly to uncemented metal backed
  • Did not look at non-operative modalities

Physical Therapy, Pharmacotherapy and Injectable Steroids

  • AAOS
    • No studies of sufficient quality identified
    • Inconclusive evidence
    • Unable to recommend for or against

Injectable Viscosupplement

  • AAOS
    • 1 industry supported study with intra-articular sodium hyaluronate (IV evidence): Grade C
    • Weekly injections for 3/52
    • Improved pain relief, ROM and QOL – statistically significant at 1,3 and 6 months

Arthroscopic Debridment, Open Debridement or Interpositional Arthroplasty

  • AAOS
    • Inconclusive evidence
    • Unable to recommend for or against

TSA and Hemiarthroplasty

  • AAOS
    • TSA and hemiarthroplasty are options in treating GH OA: Grade C
    • TSA
    • Pain: 1 Level IV and 4 Level V Shoulder surgery improvement from baseline
    • Global Assessment: 1 Level IV and 4 Level V  Shoulder surgery improvement in pain and function
    • QOL: 9 Level V, Shoulder surgery imporvement in QOL in 7 studies
    • Hemiarthroplasty
      • Pain: 7 Level V Shoulder surgery improvement in pain
      • Global Assessment: 3 Level V Shoulder surgery improvement from baseline
      • Function: 6 Level V Shoulder surgery in 4 studies from baseline
      • QOL: 6 Level V evidence Shoulder surgery improvement

TSA vs Hemiarthroplasty

  • AAOS
    • TSA over hemiarthroplasty: Grade B Evidence
    • 2 Level II studies, Lo 2005, Gartsman 2000
    • TSA improved
      • Pain – Gartsman improved pain on ASES score and UCLA
      • Global health asseessment – 1/5 improvement
      • UCLA score of Gartsman
      • Others were not statistically powered
    • No difference in
      • Function, QOL
    • 14% revision rate hemiarthroplasty V 0% in TSA
  • Australian Registry
Hemi for OA467(613obs years)2.12/100 obs years
Resurfacing hemi*538(742)2.83/100 obs years
Total resurfacing333.71/100
TSR2303(2895)2.00/100 (OA)
Reverse TSR1005(1212)2.47/100 (OA)
  • *Jump in revision after 2 years – 4% -> 14%

TSA vs Hemiarthroplasty

  • Cochrane – same papers, meta-analysis showed
    • Pain:
      • improved
        • VAS improved 7.8 TSA not Shoulder surgery ,
        • Mc Gill pain score improved 1.8 not SS
    • Disability/Function:
      • improved
        • ASES improved 10.05 Shoulder surgery , UCLA improved 3.23 SS
    • QOL:
      • No difference
        • SF 36 physical or mental component or WOOS
    • Function:
      • ROM no difference
    • Safety:
      • No difference in adverse events, intraoperative fracture, infection, death. Trend towards higher revision rate

Surgeon Experience

  • AAOS
    • Grade C evidence of surgeons who are performing >2 shoulder arthroplasties a year had less immediate complications
    • 2 studies – Hammond 2003, Jain 2004 found Shoulder surgery increase in complications and longer length of hospital stay by low volume surgeons
      • Hammond OR 1.66 in surgeon 1-5 surgeries in 7 years compared to over 30 surgeries. No difference in 5-30 and > 30
      • Jain OR 1.85 Shoulder surgery in <2 compared to >/=5 and Shoulder surgery OR 1.52 in 2-4 compared to >5

VTE

  • AAOS
    • Consensus statement – no evidence
    • Recommend
      • Mechanical prophylaxis intra-operatively and chemoprophylaxis as weighed between embolic risk and bleeding risk

Keeled or Pegged Poly Glenoid

  • AAOS
    • Grade C either keeled or pegged all poly glenoids are option
    • Greater micro-motion over 2 years in keeled glenoids, with no impact on short-term outcome
    • Both showed Shoulder surgery improvement in VAS pain score, Constant-Murley score and ASES score

Keeled or Pegged Poly Glenoid

  • Cochrane
    • 3 studies
    • No differences in pain, disability/function, safety, QOL
    •  2 studies showed Shoulder surgery higher risk of radiolucencies in keeled compared to pegged glenoid group
      • 70 pts

GH OA with Irreparable RCT

  • AAOS
    • Consensus statement – no evidence
    • TSA should no be performed in the setting of irreparable RCT due to increased glenoid loosening associated with eccentric loading

What about the biceps or surgical approach

  • AAOS
    • Biceps tenotomy or tenodesis
      • Inconclusive
      • No evidence to support or refute this being performed
    • Subscap transtendinous VS LT osteotomy
      • Inconclusive
      • Non-healing/rupture of subscap is known complication with functional deficits and pain as potential side-effects
      • LT osteotomy union may be more reliable than tendon-tendon repair but there is no evidence to support this

Humeral design and fixation

  • AAOS
    • Inconclusive
    • No evidence to support cemented over uncemented or specific humeral design

Post OT Physical Therapy

  • AAOS
    • Inconclusive evidence
    • Common to be prescribed post operatively but no high quality data to confirm its benefit

Navigation vs Conventional

  • Cochrane
    • 1 RCT which found
    • Shoulder surgery retroversion angle with navigation (7.2 deg)
    • 31.5 min longer operative time with navigation
    • No complications in either group
    • No other clinical data

Cemented Poly vs Uncemented Metal Backed Glenoid

  • Cochrane
    • 1 RCT
    • Similar revision rate both groups
  • Systematic review Randay 2007
    • Revision rate for metal-backed glenoid was 6.8% compared to 1.7% for all poly glenoids

Prognosis

Complications of Arthroplasty

  • Longevity of Glenoid Component
    • radiolucent lines
      • common
      • often progressive
      • lead to failure
    • loose glenoid is primary reason for revision
    • Metal Backed Glenoid Components
      • durable fixation to bone
      • problems
        • polyethylene dissociation
        • wear

Take home message

  • Paucity of evidence for
    • Non-operative treatment options including:
      • analgesia,
      • physical therapy
      • intra-articular steroid injection
      • weak evidence for intra-articular viscosupplementation
    • Arthroscopic/open debridement and interpositional arthroplasty
    • DVT risk
    • Role of biecps
    • Surgical approach
    • Glenoid design
  • Both TSA and hemiarthroplasty improve outcomes
    • TSA better improvement than hemiarthroplasty
    • TSA lower revision rates in RCT
  • Both pegged and keeled glenoid components are options however the evidence is weak