MANAGING THE ARTHRITIC SHOULDER: BEFORE THE FALL

Abstract

1. Introduction

   • Pathophysiology of glenohumeral arthritis differs depending upon type of arthritis

     1. Osteoarthritis

     2. Post-traumatic arthritis

     3. Inflammatory arthritis (i.e. RA)

     4. Arthritis of instability

     5. Crystalline arthritis (Milwaukee shoulder, cuff tear arthropathy)

     6. Avascular necrosis

   • Natural history as well as response to treatment are both pathology dependent

     1. Soft-tissue involvement

        1. Rotator cuff tear

        2. Soft tissue contracture

     2. Secondary osseous deformity

        1. Regional osteopenia

        2. Glenoid wear (concentric versus eccentric)

        3. Humeral collapse

   • Surgical options

     1. Joint-sparing techniques

        1. Arthroscopic capsular release/ joint debridement/synovectomy

        2. Open debridement, subscapularis lengthening

        3. Open capsular interposition

        4. Osteotomy

           1. Glenoid

           2. Humeral

     2. Cartilage transplantation

     3. Arthrodesis

     4. Resection arthroplasty

     5. Joint replacement

        1. Unconstrained

           1. Hemiarthroplasty

           2. Total shoulder replacement

        2. Constrained

2. Joint-sparing Techniques

   • These techniques are only useful in patients with early changes or who are too young and active for joint replacement

   • Arthroscopic debridement or capsular release

     1. Young patients

     2. Normal joint alignment

     3. Severe asymmetric capsular contracture (i.e. arthritis of instability)

   • Open debridement

     1. Large humeral osteophytes

     2. Subscapularis lengthening

   • Open capsular interposition

     1. Lateral edge of anterior capsule sutured to posterior labrum

     2. Less severe degrees of contracture, subscapularis must be repaired anatomically

   • Osteotomy

     1. Only useful in situations where there is abnormal humeral or glenoid alignment

     2. Glenoid – posterior opening wedge for osteoarthritis in combination with posterior glenoid hypoplasia or increased retroversion

     3. Humeral – most useful for post-fracture deformity (i.e. varus of the surgical neck)

3. Cartilage Transplantation

   • Very early experience and really only attempted in any numbers in the knee

   • Chondrocyte transplantation very expensive and tedious

   • Currently, the most popular techniques involve transplanting plugs or cores of articular cartilage, subchondral bone, and cancellous bone

     1. Autograft- harvest from non-weight-bearing or less weight-bearing area the same or different bone

        1. Lateral femoral condyle

        2. Posterolateral humeral head

     2. Allograft

        1. Early attempts limited by chondrocyte viability after harvest

        2. Improved processing techniques have recently improved chondrocyte survival to 60–70%

        3. Offers the desirable option of being able to preoperatively match radii of curvature of implant to donor site

4. Arthrodesis

   • Fortunately, rarely indicated. Patients miss the ability to rotate the humerus

   • Indications

     1. Brachial plexus injury

     2. Combined deltoid and rotator cuff deficiency

     3. Young heavy labourer

     4. Sepsis

     5. Severe bone loss

   • Requires functional trapezius and serratus anterior

5. Resectional Arthroplasty (Jones Procedure)

   • Even more rarely indicated than arthrodesis

   • Function is better if rotator cuff is attached to proximal humerus

   • Indications

     1. Sepsis

     2. Failed arthroplasty

     3. Combined deltoid and rotator cuff deficiency

6. Conclusions

   • Hemiarthroplasty or total shoulder replacement with unconstrained implants is the surgical treatment of choice in the vast majority of patients with glenohumeral arthritis

   • Joint-sparing procedures are indicated in young patients with early, less extensive changes

   • Arthrodesis and resection arthroplasty are rarely indicated, except under unusual circumstances of soft-tissue deficiency, nerve injury, or sepsis

   • Cartilage transplantation shows promise in very select patients