Clinical history

Patients who present in the office with glenohumeral arthritis and/or stiffness as a result of instability or after instability surgery have complaints similar to those with glenohumeral arthritis in general. These patients still present with pain that is deep and poorly localized within the shoulder. The quality is aching at rest, sharper with movements, and often occurs at night. Pain also can occur with motion in the midranges, which is a contrast to patients with subacromial impingement who complain of pain in the extremes of motion. The patient usually notices the stiffness or loss of motion, with external rotation most commonly affected. Patients also may report mechanical symptoms with occasional catching or locking. If the patient is still a competitive athlete even slight losses in range of motion (ROM) may cause significant deficits in performance. A thorough review of the patient’s past surgical history including review of previous operative reports can be very helpful.

Physical examination

Observation is the initial step in the physical. Comparison to the unaffected shoulder should begin immediately with both shoulders being free from clothing. The examiner must observe the patient from the front, side and back. At this time, it is easy to make note of all previous surgical scars. Surgical scars that are hypertrophic can be associated with increased scarring in the joint and scars that are widened may indicate a collagen abnormality. The examiner can make note of any abnormal contours of the shoulder, neck and back.

Active and passive ranges of motion should be measured objectively with a goniometer to detect subtle loss of motion. The presence of crepitus can be assessed at this time. Motor strength and neurovascular examinations are also important.

Palpation of certain key areas of the shoulder should be done. The neck also should be evaluated because shoulder pain may either be caused by cervical disease or may refer pain to the neck. Limited shoulder motion also can cause ipsilateral neck pain, tightness, and spasm as a result of strain in the compensatory periscapular muscles.

The use of local anesthetic without corticosteroid can be very helpful in the initial diagnosis of shoulder pathology. A diagnostic injection can further elucidate the area of pain and make physical exam easier to interpret.

Radiographic findings

Initial radiographic workup includes routine anteroposterior (AP) (neutral and external rotation views) and axillary lateral radiographs of the shoulder. X-rays are evaluated for evidence of previous bony injury (i.e., glenoid loss, Hill-Sachs lesion) and previous surgery (i.e., anchors, bony procedures). Evidence of glenohumeral arthritis includes loss of joint space; subchondral sclerosis; cysts; posterior glenoid wear; and osteophytes, which are typically present on the inferior aspect of the humeral or glenoid articular surfaces.

Samilson et al¹ originally described the radiographic appearance of arthritic glenohumeral joints after dislocation. Dislocation arthropathy is based on changes seen on the AP radiograph and classified into three groups based on the combined measurement of inferior osteophytes on both humerus and glenoid. Grade I (mild) arthritis measures less than 3 mm (Fig. 40-1, A), and grade II (moderate) arthritis measures between 3 and 7 mm with evidence of glenohumeral joint irregularity (Fig. 40-1, B). Grade III (severe) arthritis is greater than 7 mm with joint space narrowing and sclerosis (Fig. 40-1, C).

FIGURE 40-1 Samilson et al classification¹ for dislocation arthropathy. The classification is based on the combined size of humeral and glenoid osteophytes as seen on an anteroposterior (AP) radiograph. Grade 1 (mild, A) is <3 mm in combined measurement, grade 2 (moderate B) is 3 to 7 mm, and grade 3 (severe, C) is >8 mm.

Advanced imaging is an important adjunct in the radiographic evaluation of the postsurgical arthritic and/or stiff shoulder. Magnetic resonance imaging (MRI) can be helpful in evaluating articular cartilage, labrum, rotator cuff, and other soft tissue pathology. Computed tomography (CT) scanning is extremely useful for identifying joint incongruities, loose bodies, and bone abnormalities. Although more invasive by nature, the addition of intra-articular contrast to either MRI or CT imaging potentially adds invaluable information when investigating etiologies for postsurgical stiff shoulders.

Overtightening

The goal of instability surgery is to restore glenohumeral stability with near normal anatomy while still providing painless motion. Overtightening can lead to restricted ROM and pain and eventual degenerative changes in the joint space. Historical surgeries for instability (such as Magnuson-Stack and Putti-Platt procedures) or modern-day aggressive capsular shifts can overtighten the glenohumeral joint, leaving patients with both limited ROM and pain.

Inappropriate diagnosis

Another common cause of stiffness after instability surgery is an incorrect diagnosis and resultant surgery. Attempting to address posterior pathology when the direction of instability is anterior, or vice versa, can leave the shoulder stiff and painful. Unaddressed subacromial pathology also may be responsible for continued pain and stiffness. Rotator cuff tears may be missed when evaluating an unstable shoulder.

Another common differentiation that needs to be made is the difference between a shoulder that displays objective laxity and one that is subjectively unstable. Problems can arise when an objectively lax (otherwise asymptomatic) shoulder is stabilized and rendered painful and stiff.

Infection

When patients present with recalcitrant pain after previous surgery (especially if done with an open surgical technique), it is important to investigate for an underlying infection. Infectious indices should be drawn, and CT-guided shoulder aspiration can be performed to determine whether infection is the cause of pain after failed surgery. Such shoulder infections can be indolent, and cultures should be monitored for at least 10 days to identify slow-growing organisms such as Propionibacterium acnes.

Chondrolysis

Chondrolysis is a rare but catastrophic complication of arthroscopic shoulder instability surgery (Fig. 40-2). Multiple cases in the literature have been reported, but open surgical stabilization has not been associated with chondrolysis. Hence, there has been much speculation regarding the etiology of chondrolysis as a postarthroscopic phenomenon.

FIGURE 40-2 Coronal oblique magnetic resonance imaging (MRI) scan demonstrating chondrolysis after thermal capsular shrinkage.

Most commonly, chondrolysis has been associated with radiofrequency devices. Thermal capsulorrhaphy has had some use in the past to treat capsular laxity. Good et al² reported that eight patients developed chondrolysis after thermal energy was used. All eight had either thermal capsulorrhaphy or thermal capsular shrinkage in conjunction with labral repair for instability.

Postoperative pain pumps also have been associated with the development of chondrolysis. Intra-articular infusion of bupivacaine with or without epinephrine has been linked to chondrolysis in several studies. Laboratory studies have shown the cytotoxic effects of bupivacaine on chondrocytes. At this time, most literature recommends avoiding the use of intra-articular bupivacaine infusion pumps.

Arthritis after instability episodes

The incidence of glenohumeral arthritis after instability surgery is confounded by the degenerative changes that are often seen after recurrent instability even if no surgery is performed. It is impossible to determine how much of a role the number of instability episodes, the direction of injury, the age at time of injury, and the severity of instability trauma play in the development of arthritis.

Hovelius et al³ retrospectively evaluated long-term results after the open surgical Bristow-Latarjet procedure. Thirteen percent of patients who had a history of recurrent dislocation developed Samilson grade 2 or 3 arthritis, while only 6% without a history of recurrent dislocation demonstrated Samilson grade 2 or 3 arthritis.

In Samilson’s own series of 74 patients, only 16 developed arthritis. The older the patient at the time of initial dislocation, the more likely they were to develop arthritis. Shoulders with a posterior dislocation had a much higher incidence of grade 2 and 3 arthritis than those who were unstable anteriorly. There was no correlation with humeral or glenoid bone defects and the development of arthritis.

Arthritis after instability surgery

Multiple studies have demonstrated differing incidences of arthritis following instability surgery, especially with open surgical techniques. Neer et al⁴ reported that 7% of total shoulder arthroplasties were performed on patients with prior instability surgeries, and the average age was significantly younger in those patients. Rosenberg et al⁵ evaluated patients at 15 years following open Bankart repair, and 12% showed evidence of moderate to severe osteoarthritis. Other studies have demonstrated that anywhere from 12% to 17% of patients developed Samilson grade 2 to 3 arthritis after Bankart repair. In other soft tissue operations, a number of studies with follow-up from 9 to 26 years have demonstrated 11% to 30% incidence of moderate to severe arthritis after Putti-Platt capsulorrhaphy.

Procedures that address bone defects also have been associated with the variable development of arthritis. Bristow-Latarjet coracoid transfer procedures have demonstrated successful clinical outcomes. Banas et al⁶ reported that, at an average of 8.6-year follow-up, only 3% developed mild to moderate arthritis. In a long-term cohort, Hovelius et al³ found 14% with Samilson grade 2 to 3 changes at a mean 15-year follow-up. Similarly, Brox et al⁷ reported on 52 patients who underwent autograft iliac crest glenoid reconstruction with average follow-up of 14 years. Of those 4% had recurrence of instability and 53% of operated shoulders developed mild to moderate arthrosis.

There have been reports of complications from implants used for instability surgery. Zuckerman et al⁸ reported on 37 patients who developed complications after instability repair with screws or staples. Fourteen patients (41%) were noted to have significant injury to the articular cartilage at the time of reoperation. Obviously poor placement of metal, screws, pins, wires, and staples or even bioabsorbable material can damage the articular surface and lead to arthritic changes. However, even well-placed implants can cause a reaction leading to degeneration of the joint. Glenohumeral arthritis has been associated with increased use of certain bioabsorbable anchors. Freehill et al⁹ reported that 19% of patients developed delayed onset of synovitis including pain and progressive stiffness after use of poly-L-lactic acid tack at an average of 8 months after surgery.

Discussion with the patient

The first step in managing symptomatic stiffness and glenohumeral arthritis after instability surgery is educating the patient about the outcome and sharing expectations for future activity and treatment goals. Allowing the patient to take an active role is beneficial for compliance and fosters a sense of both partnership and control to the patient.

Anti-inflammatory medicine

Anti-inflammatory medication and analgesics are the mainstays of initial conservative treatment for the stiff, arthritic shoulder. A variety of nonsteroidal anti-inflammatory drugs (NSAIDs) can be used safely. However, care to educate on the possible gastric, renal, and hepatic side effects should be taken.

Corticosteroids

The risks and benefits of corticosteroid injections when used in the treatment of arthritis are still controversial. There is no peer-reviewed literature that demonstrates that cortisone injections are uniformly effective in the treatment of glenohumeral arthritis. Prospective randomized, blinded studies have found physiotherapy alone to be as effective as corticosteroid injection or a combination of both. Nevertheless, the judicious use of either oral corticosteroid medication or limited intra-articular corticosteroid injections may break the inflammatory pain cycle and allow other management modalities to be implemented.