Arthroscopic Management of Glenohumeral Arthritis

Rachel M. Frank, Geoffrey S. Van Thiel and Nikhil N. Verma

• Glenohumeral degenerative disease is a growing problem in the active patient population. Patient discomfort may be related to isolated articular cartilage disease, but may also result from other glenohumeral abnormalities, including labral, rotator cuff, and/or long head of the biceps tendon pathology. Although shoulder arthroplasty remains the gold standard for reducing pain in patients with advanced shoulder arthritis, it is typically not the most appropriate option for the relatively young patient who wishes to remain active without postoperative activity limitations. Therefore shoulder arthroscopy has become an increasingly popular treatment option for this challenging patient population, with a growing body of literature supporting its ability to improve pain and function while potentially delaying the need for arthroplasty.

Important Points

• Surgery may be indicated after failure of nonoperative management, including activity modification, physical therapy, nonsteroidal anti-inflammatory drugs, and/or injections.

• Examination may reveal crepitus, locking, or clicking.

• Decreased range of motion with pain at the extremes can often be addressed arthroscopically.

Clinical and Surgical Pearls

• Arthroscopic techniques include debridement, synovectomy, chondroplasty, capsular release, and subacromial decompression.

• For isolated lesions, microfracture can be considered.

• A complete capsular release will often provide good relief and improved range of motion.

• The lateral position allows for better access to the inferior aspect of the glenoid for a complete capsular release.

• The best surgical candidates include those with preserved joint space with a concentric glenoid and an absence of large osteophytes.

• Patients who respond to glenohumeral injections are more likely to respond to arthroscopic treatment.

Clinical and Surgical Pitfalls

• Patients with grade 4 bipolar disease, narrowed joint space (<2 mm), biconcave glenoid, and large osteophytes are at an increased risk of failure.

• When considering an isolated chondral lesion found at arthroscopy, it is crucial to determine if the lesion is truly responsible for the patient’s symptoms, or if it is simply incidental in nature.

• Care must be taken during an inferior capsular release, given the proximity of the axillary nerve.

Glenohumeral degenerative disease is a growing problem in the relatively young, active patient population. Patients with shoulder arthritis have increased pain and decreased function compared with patients with normal shoulder joints,¹ and such symptoms can certainly have a significant impact on quality of life, particularly at a younger age. However, given the complexity of the shoulder joint, it can be difficult to determine the exact pain generator (Fig. 29-1). Articular cartilage degradation can contribute to the patient’s symptoms, as can other shoulder pathologies including synovitis and capsulitis, labral tears, rotator cuff pathology, and long head of the biceps (LHB) tenosynovitis. Thus a comprehensive diagnostic and therapeutic approach is necessary.

Figure 29-1 Sources of pain in an arthritic glenohumeral joint. (Modified from Gartsman GM: Shoulder Arthroscopy. 2nd ed. Philadelphia: Elsevier; 2008.)

Nonoperative treatment techniques including activity modification, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and intra-articular injections of corticosteroids and/or hyaluronic acid solutions (off-label use) are typically effective as first-line options; however, their effects are often temporary.2,3 Surgical options are varied and range from simple arthroscopic debridement to total shoulder arthroplasty. Arthroplasty has certainly shown favorable outcomes with regard to pain relief; however, postoperative limitations and risks can be significant in an active patient.

Nonarthroplasty alternatives, including arthroscopic debridement, are increasingly attractive options in contemporary orthopedics.4–7 Shoulder arthroscopy and debridement is a commonly used initial surgical technique in the approach to treating patients with early glenohumeral degeneration, and several authors have demonstrated its potential for decreasing pain, improving function, and potentially delaying the need for eventual arthroplasty.^8–15 These debridement and arthroscopic procedures often include a combination of debridement, chondroplasty, synovectomy, capsular release, and subacromial decompression (SAD). However, it is important to keep in mind that the goal of arthroscopy at this stage is not to cure the underlying disease process (arthritis) but rather to provide symptomatic improvement and maintenance of function for as long as possible.