The role of arthroscopy in the evaluation and management of glenohumeral arthritis

Background of glenohumeral arthritis

Osteoarthritis is the most common cause of disability in the United States; Buckwalter et al. determined that the condition affects nearly 10% of the population older than the age of 60 years. Although hip and knee arthritides remain the joints most commonly addressed with arthroplasty surgery, such treatment of glenohumeral osteoarthritis (GHOA) has become an increasingly performed procedure in orthopedic surgery. Multiple studies have found that the utilization of shoulder arthroplasty has been increasing since the new millennium, with the rate of utilization increase equal to or greater than that of hip and knee arthroplasty utilization increases. ^, Considering that the incidence of osteoarthritis increases with age and the population is living longer and with more active lifestyles, there is a growing burden of patients dealing with symptomatic shoulder arthritis. It has been estimated that osteoarthritis across all joints costs the United States economy approximately $60 billion per year.

Among older patients, the option of glenohumeral arthroplasty is a reliable and effective treatment method. However, there is concern for such treatment options when it comes to the younger and more active patient. In a systematic review from 2017, Roberson et al. found that total shoulder arthroplasty (TSA) in patients younger than the age of 65 years resulted in a revision rate of 17% and a complication rate of nearly 10%. ^, In addition, when looking at radiographs, more than half of patients (54%) demonstrated glenoid lucencies. Although TSA in this younger population was a reliable source of pain relief and improved function, these numbers were far inferior to the older population that traditionally undergoes TSA. Denard et al. reported on 50 patients younger than the age of 55 years old who underwent TSA with a keeled glenoid component and found that the survivorship of implants dropped precipitously from 98% at 5 years to only 62.5% at 10 years. ^, Hemiarthroplasty in young patients has also had questionable long-term durability, with studies from the Mayo Clinic showing declining implant survival rates (82% at 10 years, 75% at 20 years) along with patient satisfaction scores (Neer rating 40% at 15 years and 27% at 20 years). ^, More than a quarter of the patients in those studies required revision surgery within 20 years. With studies demonstrating a decline in longer-term outcomes, the option of treating young patients with shoulder arthroplasty should give treating surgeons pause. As such, other surgical options that can delay joint replacement should be considered.

Etiology of glenohumeral arthritis

There are numerous causes of arthritis in the shoulder. Osteoarthritis or degenerative joint disease is the most common form of glenohumeral arthritis in which articular cartilage surfaces of the humerus and glenoid are worn from either repetitive overuse, minor trauma, or underlying structural deformities. For patients with a high-demand occupation or who engage in significant recreational weight training, this is the type of arthritis that is often encountered. As stated before, because of the increased activity level of aging patients who are living longer, this form of arthritis is on the rise.

Capsulorrhaphy arthritis is often encountered in younger patients with a prior history of repairs for glenohumeral instability. Historical surgical procedures such as the Putti-Platt and Magnuson-Stack procedures for recurrent anterior instability often resulted in overtightening of the shoulder, which could lead to a larger compressive force across the glenohumeral joint ( Fig. 61.1 ). In severe cases, such anterior tightening could cause posterior subluxation of the humerus with respect to the glenoid and lead to increased posterior glenoid wear patterns ( Fig. 61.2 ). More modern surgical techniques such as arthroscopic Bankart repair should theoretically lead to less excessive tightening of the shoulder capsule but can still result in prominent glenoid anchors and sutures that may lead to focal or even global cartilage damage ( Fig. 61.3 ). In addition, the rise of coracoid bone transfer procedures may also expose patients to the risk of arthritis from prominent screws or laterally overhanging graft placement. Let us not forget that iatrogenic surgical causes of arthritis are also a common source of osteoarthritis, which can oftentimes be due to a poorly performed surgical intervention.

Inflammatory arthritis of the shoulder remains yet another cause for glenohumeral arthritis. Although earlier diagnosis and more effective drug treatments have helped to decrease the progression of rheumatoid and other inflammatory arthropathies, patients may have progression that requires surgical management. In general, the use of joint arthroplasty has seen a dramatic decrease in juvenile idiopathic arthritis and mild decrease in rheumatoid arthritis. However, the utilization of shoulder arthroplasty has seen a rise from 2002 to 2011, with some authors suggesting that the use of reverse TSA has increased for rheumatoid patients with cuff disease. ^, Regardless, as patients with inflammatory arthritis live longer lives that are more active due to the suppression of their disease, the demand for treatment of shoulder conditions remains.

Other types of shoulder arthritis are also seen. Avascular necrosis (AVN) can result from the use of steroids, antiretroviral medications or alcohol, or from prior trauma. In this condition, the subchondral bone will often display signs of collapse, and deformity of the humeral head will ensue ( Fig. 61.4 ). In addition to potentially leading to AVN, posttraumatic arthritis can accelerate arthritic changes because of direct damage to articular cartilage itself or because of joint force changes seen in malunion and nonunion of fractures. Cuff tear arthropathy, although typically seen in older patients, can still be a concern in younger patients with inflammatory disease that degenerates cuff tissue or in long-standing rotator cuff defects. Proximal migration of the humeral head may result in a superior wear pattern of the glenoid as the counteracting force of the intact cuff tissue is lost against the proximally directed force of the deltoid muscle ( Fig. 61.5 ). Such arthritic conditions are more difficult to treat because both the joint surface and the rotator cuff function must be addressed. This is particularly difficult for young patients where the use of the reverse TSA is less desirable. Lastly, conditions such as syringomyelia and neuropathic arthritides can be seen with substantial proximal humeral bone loss and decreased shoulder girdle motor function.

Although all of these conditions can result in damage to the joint surface, they respond differently to the available treatment options.

Diagnostic evaluation

Patients suspected of having glenohumeral arthritis should be thoroughly evaluated with three minimum pillars of orthopedic examination: history of present illness, physical examination, and radiographic evaluation.

History of present illness

It is important to have the patient describe in his or her own words what symptoms he or she feels in the affected shoulder. Patients should be asked what activities (including those of daily living) incite symptoms, the severity of their symptoms, the duration of their symptoms, and what treatments have already been attempted to alleviate the condition. Any history of prior trauma or surgery is crucial to help elucidate the etiology of the arthritic condition. In addition, the patient’s handedness, occupation, and preferred recreational activities are also important so that a treatment plan suitable for expectations can be created mutually with the treating physician.

Physical examination

After completing a history of the present illness, a thorough physical examination is paramount to evaluating shoulder arthritis. It is important not to rely solely on the patient’s history because he or she may not recall a previous surgical procedure or may be unaware of other abnormal findings in upper extremity function. The examination should begin with inspection of the shoulder to evaluate for any prior surgical scars, muscle atrophy, scapular winging, or even signs of infections (increased swelling, warmth, redness). Palpation of various anatomic landmarks, including the acromioclavicular joint, clavicle, and cervical spine, can determine the location of patient pain. General tenderness about the anterior, lateral, or posterior region of the glenohumeral joint may be nonspecific but can shed light on conditions such as nerve hypersensitivity, capsulitis, or infection. It is not uncommon for patients with glenohumeral arthritis to deny any palpable pain as they feel their symptoms deeper within the joint.

Next, range of motion of the shoulder should be assessed both actively and passively. Patients should demonstrate motion in forward elevation, abduction, external rotation with the arm at the side, and internal rotation behind the back. Additional motions such as internal and external rotation with the arm abducted to 90 degrees can also be assessed. It is important to always compare the motion of the symptomatic shoulder to the contralateral side. Patients with shoulder arthritis will often have decreased motion compared with the contralateral side in either one or possibly all planes of motion. In addition, unlike a rotator tear or neurologic weakness presentation (in which the shoulder may have limited active motions but full or even hypermobile passive motions), the active and passive motions of an arthritic shoulder will often be similar. In addition to the actual degrees of motion, the examiner should also note any pain or crepitus symptoms that are typically seen in the setting of an arthritic joint. In general, patients will often present with decreased motion highlighted by pain and “grinding” sensation.

Specific shoulder testing maneuvers can then also be added to the examination to assess stability, cuff integrity, or other concurrent conditions such as impingement or tendinitis. Lastly, a thorough neurovascular examination of the axillary nerve, spinal accessory nerve, long thoracic nerve and distal extremity, and cervical spine should be performed to rule out any pathology in those regions.

Radiographic evaluation

The third important component for evaluating shoulder arthritis is proper radiographic imaging. At the very minimum, it is important for the patient to have good-quality plain film radiographs to examine the shoulder joint in the anteroposterior (AP) and axillary planes. AP radiographs including true AP and Grashey views are important to determine the relationship of the humerus and glenoid in terms of proximal migration (which may be seen in long-standing cuff disease), humeral head collapse (severe disease or AVN), and medialization of the glenoid. Axillary views with the arm positioned in forward elevation in the plane of the scapula can help with determining humeral head subluxation, cartilage wear, glenoid bone loss, and glenoid wear patterns (particularly useful in Walch B2, B3, and C type glenoids). With quality films in these two directions, most surgeons should be able to garner enough information to begin formulating a proper surgical treatment plan.

Certainly, in cases of more severe disease or concern for soft tissue injury (i.e., rotator cuff tears or inflammatory arthritis), more advanced imaging studies such as computed tomography and magnetic resonance imaging can help with ensuring that a proper surgical plan is created.

Along with these three components to patient evaluation, certain presentations may require other studies such as laboratory markers (infection and inflammatory disease), cultures (infection), or electrodiagnostic testing (neurogenic arthropathies).

Surgical decision making

The surgical treatment of glenohumeral arthritis should be considered only once all of the nonsurgical options, including activity modification, antiinflammatory medication, therapy, and injections, have been exhausted. A thorough discussion with the patient to identify his or her goals of surgical treatment is then critical to the shared decision-making process. When nonsurgical treatment fails, the operative options range from arthroscopic debridement, including a combination of synovectomy, capsular release, osteophyte resection, interposition arthroplasty, and hemiarthroplasty, to total shoulder replacement. A clear understanding of the patient’s symptoms and goals may allow for successful treatment aligning the patient’s and surgeon’s expectations.

Patients sometimes inquire, “Why can’t you just use an arthroscope to clean the arthritis out of my shoulder?” Multiple studies have demonstrated that arthroscopic management of glenohumeral arthritis may reduce pain and improve function, but the relief may be brief, and the failure rates have been reported as high as 30%. ^, TSA is the most reliable option with regard to pain relief and improvement in range of motion in patients with GHOA. However, in the younger, more active patient, TSA has demonstrated increased polyethylene wear and implant loosening with higher revision rates compared with older cohorts. Denard et al. reported the 10-year implant survival rate to be only 62.5% in young patients who underwent TSA with a keeled glenoid component. For this reason, arthroscopic treatment of glenohumeral arthritis may be a reasonable option for the appropriate patient.

The indications for arthroscopic management of glenohumeral arthritis continue to evolve as our understanding is improved and new techniques are developed. Using a Markov decision-making model, a recent decision analysis suggested that arthroscopic management for glenohumeral arthritis may be the preferred treatment strategy in patients younger than 47 years. Therefore the “ideal” patient is younger and active and has a greater likelihood to place a greater demand if a joint prosthesis is chosen, which may result in early loosening ( Table 61.1 ). Importantly, arthroscopic management of glenohumeral arthritis may not prevent the progression of osteoarthritis, but it may provide a period of improved symptoms and function before deterioration of the joint leads to a more substantial operation, such as joint replacement.

TABLE 61.1

Indications and Contraindications for Arthroscopic Management of Glenohumeral Osteoarthritis

Indications

Physiologically young patient

Active lifestyle

Symptomatic glenohumeral osteoarthritis

Failed nonsurgical management

Contraindications

Nonconcentric glenoid wear

< 2-mm joint space

Bipolar grade IV chondral lesions

Kellgren-Lawrence grade III or IV

Prior studies have attempted to find associations between the radiographic appearance of glenohumeral arthritis treated arthroscopically with patient outcomes. Several studies have reported poorer outcomes and shorter survivorship of arthroscopic management with conversion to joint replacement in patients with grade IV Kellgren-Lawrence radiographic glenohumeral arthritis. Clinicians should also evaluate the preoperative radiographs for joint space less than 2 mm on true AP radiographs because this has been an indicator for poorer outcomes. ^, The size and location of the articular lesion are also critical in the decision-making process. Cameron et al. demonstrated that osteochondral lesions involving greater than 2 cm had less resolution of pain. Kerr and McCarty, along with others, noted bipolar Outerbridge grade IV cartilage lesions fared worse when compared with those having monopolar lesions that were less severe. ^, Finally, patients with large osteophytes requiring resection or those with nonconcentric wear patterns (i.e., Walch B2 or C) have demonstrated poorer outcomes with arthroscopic management and are not ideal candidates for the procedure. ^, ^,

Early reports of arthroscopic management of glenohumeral osteoarthritis

Although there have been numerous advances with respect to arthroscopy in general, the arthroscopic treatment of GHOA is in its relative infancy. Published in 1983, Cofield described arthroscopic evaluation of eight patients with arthritic shoulder disease. He performed a synovectomy in one with presumed rheumatoid disease, but the others were visualized only through an arthroscope prior to prescribing further recommendations. However, in 1986, Ogilvie-Harris and Wiley were the first to report their findings after arthroscopic debridement of the arthritic shoulder. Of the 54 patients the authors identified with GHOA, two-thirds improved with debridement if the lesions consisted of articular cartilage damage only, whereas only one-third of patients improved if there was severe arthritis or subchondral bone exposed. Ellman et al. later, in 1992, described their findings of 18 patients with impingement syndrome and coexisting glenohumeral arthritis treated with a subacromial decompression and arthroscopic debridement of the joint. Weinstein et al. assisted with a further understanding of arthroscopic debridement in their study of 25 patients with early GHOA. Their treatment consisted of an arthroscopic lavage, debridement, loose body removal, partial synovectomy, possible osteophytectomy, and bursectomy. Based on resolution of pain, 21 patients reported excellent outcomes at a minimum of 1-year follow-up. In addition, 10 of 12 (83%) of the patients with preoperative stiffness had improvement in their range of motion. The authors were unable to find associations between the preoperative radiographs or intraoperative findings to their study results.

Not all of the early results of arthroscopic treatment of glenohumeral arthritis were promising; risk factors for poor results began to be identified ( Fig. 61.6 ). Cameron et al. described their outcomes after arthroscopic debridement of 61 patients with grade IV osteochondral lesions at a minimum of 1-year follow-up. Significant improvement in pain and function was obtained in 88% of all patients; however, pain relief was nonsignificant or returned in 85% of the shoulders with osteochondral lesions greater than 2 cm or in 61% of the shoulders with bipolar lesions (both on glenoid and humerus). The authors also added capsular release in 22 patients with preoperatively defined stiff shoulders (≥15 degrees loss of motion). They found significant improvements to external rotation at the side and internal rotation in these selective patients. Guyette et al. confirmed these findings in their arthroscopic evaluation of patients treated for impingement syndrome. The authors evaluated the outcomes of 36 patients diagnosed with subacromial impingement with concomitant glenohumeral arthritis treated with subacromial decompression and debridement. The poorest outcomes were seen in patients with bipolar lesions and those with advanced cartilage lesions identified arthroscopically.