High Yield Topics

Shoulder/Glenohumeral Arthritis

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Shoulder/Glenohumeral Arthritis

Shoulder/Glenohumeral Arthritis
Jason W. Hammond MD
Basics
Description
Progressive loss of glenohumeral joint space with
thinning of articular cartilage, formation of osteophytes, and
progressive deformity
Epidemiology
  • Females are more likely than males to have primary glenohumeral osteoarthritis.
  • Patients >60 years old are more likely to have it than are younger patients.
Incidence
  • ~0.4% in the general population (1)
  • Can reach 4.6% in patients with concomitant shoulder diseases (1)
Risk Factors
  • Age >60 years
  • Excessive joint loading (e.g., throwing athletes and manual laborers)
  • Joint injury
  • Excessively tight capsulorrhaphy
Genetics
No known genetic component
Etiology (2)
  • Osteoarthritis
  • Rheumatoid arthritis
  • Secondary degenerative joint disease
    • Repetitive and major trauma
    • End-stage AVN
    • Rotator cuff tear arthropathy
    • Capsulorrhaphy arthritis
Associated Conditions
  • Rotator cuff tear
  • Biceps tendinitis
Diagnosis
Signs and Symptoms
  • Activity-related pain in the shoulder
  • Decreased ROM
History
  • Progressive shoulder pain and stiffness
  • Previous shoulder surgery
  • Previous diagnosis of rheumatoid arthritis
  • Shoulder trauma
  • Osteonecrosis
  • Cuff tear arthropathy
Physical Exam
  • Assess ROM of the glenohumeral joint, scapulothoracic motion, and cervical spine.
  • Test muscle strength, especially of deltoid, rotator cuff, and biceps.
  • Perform a full neurologic examination of the upper extremity to differentiate cervical disc or brachial plexus disease.
  • Palpate the surrounding structures, including the AC joint and biceps tendon.
  • In active rheumatoid arthritis of the
    glenohumeral joint, an adduction and internal rotation deformity of the
    joint is produced by protective muscle spasm.
Tests
Lab
  • If clinically indicated, the workup for rheumatoid arthritis should include:
    • ESR, C-reactive protein, serum rheumatoid factor
    • Complete blood count, ESR, and C-reactive protein to be obtained if septic arthritis is suspected
  • Joint fluid analysis may help with diagnoses other than osteoarthritis.
Imaging
  • Radiography (1):
    • AP and axillary radiographs of the affected shoulder are essential.
    • Joint space narrowing, osteophytes, subchondral sclerosis, and cyst formation are hallmark signs of osteoarthritis.
    • Posterior wear of the glenoid may be seen
      in osteoarthritis, and symmetric joint space narrowing may be seen in
      rheumatoid arthritis.
    • Superior subluxation of the humeral head may indicate an associated rotator cuff tear.
    • Athletes also may have a thrower’s exostosis on the posterior inferior glenoid, visualized on the Stryker notch view.
  • MRI, arthrography, and ultrasound can be used to assess rotator cuff integrity.
    • Mild cartilage loss and other lesions may be visualized on MRI if not seen on plain films.
  • CT can be used to assess bone stock for surgical planning.
Diagnostic Procedures/Surgery
Lidocaine injection of the subacromial space or joint may help with the diagnosis.
Differential Diagnosis
  • Rotator cuff tear
  • AC joint arthritis
  • Isolated chondral lesion
  • PVNS
  • Synovial chondromatosis
  • AVN
  • Septic arthritis
  • Lyme disease
  • Inflammatory arthropathies
  • Posttraumatic conditions
  • Metastatic disease
  • Cervical radiculopathy
Treatment
General Measures
  • Nonoperative treatments should aim to optimize shoulder flexibility, maintain muscle function, and reduce inflammation and pain.
  • Activity modification is helpful but often difficult in the active patient.
Special Therapy
Physical Therapy
An exercise program to maintain ROM and to strengthen the rotator cuff is an important 1st step in management (3).
Medication
First Line
NSAIDs, acetaminophen, aspirin
Second Line
  • Joint injection with corticosteroid
    should be considered after other therapeutic interventions (such as
    NSAIDs, physical therapy, and activity modification) have failed.
    • Indications for glenohumeral joint injection include osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.

P.399


Surgery
  • Arthroscopy with associated débridement
    and synovectomy can relieve pain, improve function, and delay
    progression of the disease for inflammatory arthropathies.
  • Arthroscopic procedures addressing
    osteoarthritis consist of débridement, loose body removal,
    chondroplasty or abrasion of the glenoid and humeral head, and capsular
    release (4).
  • An inferior humeral osteophyte that blocks motion in athletes may be removed arthroscopically.
  • Arthroscopic glenoidplasty allows the
    humeral head to be centered in the glenoid by reestablishing a more
    normal radius of curvature of the glenoid (4).
    • This procedure has been recommended for severe posterior glenoid wear that may cause posterior subluxation of the humeral head.
  • Prosthetic shoulder replacement is a highly reliable surgery for pain relief (5).
    • A hemiarthroplasty replaces the humeral head; a total shoulder arthroplasty also replaces the glenoid.
    • Shoulder replacement should not be expected to restore normal shoulder motion (2).
    • For patients with primary osteoarthritis,
      total shoulder arthroplasty provides better results than
      hemiarthroplasty for pain, mobility, and activity.
    • It is an easy, economical, and dependable method of treating shoulders severely affected by rheumatoid arthritis.
  • Arthrodesis can be functionally
    preferable to shoulder arthroplasty for the physical laborer with
    painful arthritis who is not required to perform overhead lifting.
Follow-up
Prognosis
  • Osteoarthritis pain and progression vary widely among patients, but most patients are unlikely to improve with time.
  • Shoulder arthroplasty has good long-term results.
Complications
  • Complications of arthroplasty include:
    • Loosening of the glenoid component
    • Infection
    • Dislocation
    • Nerve injury
Patient Monitoring
Patients are treated nonoperatively until activities of daily living become compromised or pain becomes unmanageable.
References
1. Nakagawa Y, Hyakuna K, Otani S, et al. Epidemiologic study of glenohumeral osteoarthritis with plain radiography. J Shoulder Elbow Surg 1999;8:580–584.
2. Azar
FM, Wright PE, II. Arthroplasty of shoulder and elbow. In: Canale ST,
ed. Campbell’s Operative Orthopaedics, 10th ed. St. Louis: Mosby,
2003:483–533.
3. Parsons IM, Weldon EJ, III, Titelman RM, et al. Glenohumeral arthritis and its management. Phys Med Rehabil Clin North Am 2004;15:447–474.
4. Bishop JY, Flatow EL. Management of glenohumeral arthritis: A role for arthroscopy? Orthop Clin North Am 2003;34:559–566.
5. Edwards
TB, Kadakia NR, Boulahia A, et al. A comparison of hemiarthroplasty and
total shoulder arthroplasty in the treatment of primary glenohumeral
osteoarthritis: Results of a multicenter study. J Shoulder Elbow Surg 2003;12: 207–213.
Additional Reading
Lehtinen
JT, Kaarela K, Belt EA, et al. Incidence of glenohumeral joint
involvement in seropositive rheumatoid arthritis. A 15-year endpoint
study. J Rheumatol 2000;27:347–350.
Miscellaneous
Codes
ICD9-CM
716.91 Glenohumeral arthritis
Patient Teaching
  • Shoulder arthroplasty can substantially improve symptoms of pain, but patients cannot be expected to regain normal motion.
  • Physical therapy before and after surgery is beneficial to maximize strength and ROM.
FAQ
Q: What are the expectations for shoulder hemiarthroplasty or total arthroplasty for glenohumeral arthritis patients?
A:
Patients can expect pain relief from shoulder arthroplasty with removal
of osteophytes and repair of rotator cuff tendons. Patients can expect
modest improvement in ROM, but it will not be full. Patients can expect
improved function in activities of daily living.

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