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Arthroscopic Treatment of Degenerative Arthritis of the Shoulder
Despite the success of joint arthroplasty, the parallel search for alternative surgical treatments for arthritis continues with great fervor. Newly charted seas in the fields of autologous cartilage transplantation, allograft transplantation, and in vitro chondrocyte proliferation and implantation may ultimately pioneer arthritis surgery. Older techniques utilized by shoulder surgeons before prosthetic arthroplasty such as arthrodesis, resection arthroplasty, and osteotomies still have utility in the surgical armamentarium. Arthroscopic debridement and capsular release as a therapeutic surgical modality for glenohumeral arthritis is one alternative to arthroplasty that can provide significant benefit to properly selected patients. While arthroscopic treatment of arthritis has a long history, its role remains somewhat of a conundrum. Many surgeons use the technique variably and with individualized indications. Its role as a palliative treatment in patients who are not candidates to undergo prosthetic arthroplasty of the shoulder has been realized by surgeons anecdotally but sparsely documented by clinical studies. More clinical data to support the efficacy of arthroscopic debridement and lavage of glenohumeral arthritis is becoming available. These studies will further our understanding of proper patient selection, techniques, and outcomes for this procedure. The authors present the approach of the senior author’s (W.Z.B.) to arthroscopic debridement, lavage, and capsular release of the arthritic glenohumeral joint.
Indications
1. Physiologically young patients with restricted motion and moderate amount of pain.
2. Patients who have failed conservative management. This includes physical therapy, nonsteroidal medications, and therapeutic injections.
3. Patients medically unstable to endure a lengthy operation.
Physical Examination
1. Document the restriction of shoulder motion, both actively and passively.
2. An isolated injection of a local anesthetic (lidocaine) can help determine if the acromioclavicular (AC) joint is contributing to the patient’s symptoms.
3. Thorough evaluation for rotator cuff tears or nerve involvement/muscle atrophy should also be included.
4. Palpate the proximal biceps tendon with the shoulder internally rotated 20 degrees. Frequently there is an associated tenosynovitis.
Diagnostic Tests
1. Radiographic evaluation consisting of an anteroposterior view in external and internal rotation and an axillary view.
2. Magnetic resonance imaging to evaluate the status of the rotator cuff.
3. Computed tomography scan. Evaluate deformity, version, extent of bony erosion and subluxation.
4. Selective injections with a local anesthetic.
Special Considerations
1. A biconcave glenoid, as viewed on an axial radiograph, may require a more extensive surgical procedure (Fig. 34–1). Some authors have recommended an arthroscopic glenoidplasty with a burr to reestablish a more normal radius of curvature of the glenoid. This limits the posterior subluxation of the humeral head posteriorly.
2. Patients with an intact rotator cuff usually have less pain and respond better to arthroscopic treatment compared with those patients with rotator cuff tears.
Special Instruments
1. 10 cc syringe with 0.25% marcaine with epinephrine
2. 30 cc syringes with normal saline and an 18-gauge spinal needle
3. 5 mm plastic cannula with blunt trocar (have two available)
4. 30 degree arthroscope
5. Arthroscopic electrocautery (Oratec, Arthrocare, or Mitek), preferably with an insulated 90 degree hooked end
6. Arthroscopic 4 mm full-radius resector
7. Oscillating saw for distal claviculectomy
8. Osteotomes and self-retaining retractors
9. 4.2 mm arthroscopic burr if glenoidplasty is intended
Anesthetic Options
1. General anesthesia is required for full paralysis. Manipulation is more effective and the risk of an iatrogenic fracture is less.
2. Regional via a scalene block only if general anesthesia is contraindicated.
Patient and Equipment Position
1. Beach chair position; however, if the surgeon prefers, the patient can be positioned laterally.
2. The head is supported in a McConell (McConell Orthopedics, Plano, TX) or a Mayfield headrest.
3. The entire extremity is prepped and draped free and should allow access to the AC joint.
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