Treatment of Glenohumeral Joint Osteoarthritis
We are unable to recommend for or against physical therapy for the initial treatment of patients with osteoarthritis of the glenohumeral joint.Despite an exhaustive review of the literature, there was insufficient evidence to make conclusions either in favor of or against the efficacy of physical therapy. This includes the modalities of massage, joint mobilization, joint manipulation, exercise, phonophoresis, iontophoresis, ultrasound, laser, acupuncture, and/or electrical stimulation, in the treatment of patients with osteoarthritis of the shoulder. Further, no studies of sufficient quality were found that addressed massage therapy, hydrotherapy, manual therapy and/or mobilization and manipulation.
We are unable to recommend for or against the use of pharmacotherapy in the initial treatment of patients with glenohumeral joint osteoarthritis.Conservative management of pain secondary to osteoarthritis frequently includes pharmacologic treatment. Non steroidal anti-inflammatories, acetaminophen, opioids, and over–the-counter supplements are routinely used. Despite an exhaustive literature review, there is insufficient evidence to support or refute the use of the pharmacologic treatments for shoulder arthritis.
We are unable to recommend for or against the use of injectable corticosteroids when treating patients with glenohumeral joint osteoarthritis.There is no evidence to support or refute the use of intra-articular steroid injection for the treatment of osteoarthritis of the shoulder, whether performed with or without fluoroscopic, ultrasound or CT guidance.
Corticosteroid injections are used widely in clinical practice for patients with shoulder pain of all etiologies, and occasionally they are employed in conjunction with physical therapy as an initial treatment for patients with shoulder pain. Intra-articular injections are used for the treatment of osteoarthritis in other joints. The current literature does not support or refute the use of intra-articular steroid injection for the treatment of glenohumeral osteoarthritis.
The use of injectable viscosupplementation is an option when treating patients with glenohumeral joint osteoarthritis.Currently we have one, industry supported, study 5 that met the inclusion criteria supporting the use of intra-articular injection of sodium hyaluronate preparations in patients with shoulder pain. Hyaluronic acid injections have been evaluated in the treatment of shoulder osteoarthritis, demonstrating a statistically significant benefit in pain relief, range of motion and quality of life as measured by the VAS, SST, and UCLA outcome measures.
We are unable to recommend for or against the use of arthroscopic treatments for patients with glenohumeral joint osteoarthritis.There is a concern for performing shoulder arthroplasty in patients under the age of 50 because of potential risk of increased prosthetic loosening and decreased survivorship of the prosthesis in this patient population. Patients with early stages of osteoarthritis may not have symptoms severe enough to warrant or be willing to undergo shoulder arthroplasty procedure. For this reason, arthroscopic options in the treatment of glenohumeral osteoarthritis are of interest. The role for arthroscopic surgical intervention in the treatment algorithm for osteoarthritis of the glenohumeral joint is inconclusive. Despite an exhaustive review of literature, there was insufficient evidence to make conclusions either in favor or against the efficacy of arthroscopic treatment, including glenohumeral debridement, capsular release, chondroplasty, microfracture, removal of loose bodies, biologic and interposition grafts, subacromial decompression, distal clavicle resection, biceps tenotomy or tenodesis, and labral repair or advancement in the treatment of the glenohumeral arthritis of the shoulder. This review was limited to the treatment of glenohumeral arthrosis and does not pertain to subacromial bursitis, acromio-clavicular arthrosis or impingment nor rotator cuff tendonopathy.
We are unable to recommend for or against open debridement and/or non-prosthetic or biologic interposition arthroplasty in patients with glenohumeral joint osteoarthritis. These treatments include: Allograft, Biologic and Interpositional Grafts, Autograft.There is a concern for performing shoulder arthroplasty in younger patients because of potential risk of increased prosthetic loosening and decreased survival of the prosthesis. The role for open debridement and non-prosthetic and /or interposition arthroplasty in the treatment algorithm for osteoarthritis of the glenohumeral joint is inconclusive. Despite an exhaustive review of literature, there was insufficient evidence to make conclusions either in favor or against the efficacy of open debridement and non-prosthetic and /or interposition arthroplasty, including osteoarticular allograft, interpositional soft tissue allograft, and autograft in the treatment of the glenohumeral arthritis of the shoulder.
Total shoulder arthroplasty and hemiarthroplasty are options when treating patients with glenohumeral joint osteoarthritis.The body of evidence4, 16, 17, 18, 19 , 20, 21 supports the use of total shoulder arthroplasty or hemiarthroplasty for glenohumeral osteoarthritis. However, there is no reliable evidence for the use of humeral resurfacing in the existing literature for the treatment of glenohumeral joint osteoarthritis. Total shoulder arthroplasty or hemiarthroplasty provide significant improvements in pain, global health assessment, function, and quality of life scores 4, 16, 17, 18, 19, 20, 21. The majority of studies 4, 18, 21 supported the use of hemiarthroplasty when performed in patients with naturally concentric glenoids or those reamed to concentricity.
We suggest total shoulder arthroplasty over hemiarthroplasty when treating patients with glenohumeral joint osteoarthritis.There were only two studies of sufficient quality to meet our inclusion criteria comparing total shoulder arthroplasty to hemiarthroplasty.18, 25 The largest of these studies reported that global health assessment scores and pain relief were statistically significantly better after total shoulder arthroplasty. Function and quality of life outcome measures in both studies showed no statistically significant differences between groups. No total shoulder arthroplasty required revision to hemiarthroplasty. However, 14% of patients treated with a hemiarthroplasty required revision to a total shoulder arthroplasty because of progressive glenoid arthrosis and pain. This difference in revision rates must be considered when contemplating shoulder arthroplasty and the possibility of a second operative exposure.
An option for reducing immediate postoperative complication rates is for patients to avoid shoulder arthroplasty by surgeons who perform less than two shoulder arthroplasties per year.Two studies26, 27 reported increased early postoperative complication rates and increased length of stay when shoulder arthroplasty is performed by low volume surgeons. Low volume was defined as surgeons who perform less than two shoulder arthroplasties per year. Complications were only defined in one study and included mortality, wound dehiscence, early postoperative infection, pulmonary embolism, deep vein thrombosis, and “operative mishaps”. Complications following discharge were not assessed in either study when comparing the low volume and high volume surgeons. No patient outcome measurements or clinical assessments were reported in either study.
In the absence of reliable evidence, it is the opinion of this work group that physicians use peri-operative mechanical and/or chemical VTE (venous thromboembolism) prophylaxis for shoulder arthroplasty patients.Venous thromboembolism and pulmonary embolism are recognized potentially catastrophic complications faced by all patients who undergo shoulder arthroplasty. Despite the paucity of evidence to support or refute the use of embolic prophylaxis in shoulder arthroplasty patients, the consensus opinion of our work group is to employ its routine use. Mechanical prophylaxis for shoulder arthroplasty patients intra-operatively and during the immediate postoperative period places the patient at minimal additional risk or discomfort and may help prevent pulmonary embolism. Each patient should be assessed for the risk of pulmonary embolism and the addition of chemical prophylaxis considered if appropriate. The level of embolic risk must be weighed against the potential bleeding risk in these patients as well. We believe these actions are consistent with the current practice of most Orthopaedic surgeons. The AAOS has produced a guideline for the prevention of pulmonary embolus in lower extremity surgery, which can also serve as a reference; however, the risks for lower extremity surgery are reported to be higher than shoulder surgery.28 As such these guidelines may not be applicable to this patient population.
The use of either keeled or pegged all polyethylene cemented glenoid components are options when performing total shoulder arthroplasty.Studies have demonstrated that total shoulder arthroplasty provides improved outcomes in terms of pain relief and function (see Recommendation 7). The concept of performing a pegged or keeled glenoid has been studied extensively from a biomechanical standpoint, but limited data has been available regarding the clinical outcome, durability, and component stability when comparing the two types of resurfacing designs. As such, design considerations have long been considered an important variable when applied to the glenoid component.
One study29 has evaluated the objective outcome and implant stability when comparing the keeled and pegged implant. The authors revealed there was no statistically significant difference between the designs in terms of pain relief and functional improvement in patients following total shoulder arthroplasty. The radiostereometric analysis performed at regular intervals during a two-year follow-up demonstrated greater micromotion in the keeled design group. Although this did not have an impact on short-term outcomes, this may suggest long-term implications with regards to implant loosening and progressive clinical symptoms.
In the absence of reliable evidence, it is the opinion of this work group that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.In the setting of an irreparable rotator cuff tear, glenoid component loosening is a potential complication of total shoulder arthroplasty due to the increased eccentric rim loading of the glenoid component that can occur. This has been termed the rocking horse phenomenon. Loosening and failure of the glenoid component can lead to pain and decreased function and may ultimately necessitate revision surgery. Currently, no reliable studies exists comparing clinical or radiographic results of total shoulder arthroplasty in patients with and without irreparable rotator cuff tears. Despite this, the current “best medical practice” is to perform total shoulder arthroplasty in patients with glenohumeral osteoarthritis who have intact or reparable rotator cuffs. No studies of sufficient quality have been identified which examine TSA in patients with glenohumeral osteoarthritis with and without an intact rotator cuff.
We are unable to recommend for or against biceps tenotomy or tenodesis when performing shoulder arthroplasty in patients who have glenohumeral joint osteoarthritis.Currently, some surgeons routinely sacrifice the biceps tendon at the time of arthroplasty and others preserve it, however these practice habits are either anecdotal or based on “experience”. Because of the paucity of the current body of literature and the variety of techniques used to address the biceps tendon at the time of shoulder arthroplasty, we are unable to support either routine biceps tenotomy or tenodesis. No studies of sufficient quality have been identified which examine TSA in patients with glenohumeral osteoarthritis with and without an intact rotator cuff.
We are unable to recommend for or against a subscapularis trans tendonous approach or a lesser tuberosity osteotomy when performing shoulder arthroplasty in patients who have glenohumeral joint osteoarthritis.Non-healing or rupture of the subscapularis tendon repair following total shoulder arthroplasty is a recognized complication of the transtendinous approach. Deficiency of the subscapularis tendon can lead to poor results after total shoulder arthroplasty. Patients may complain of pain and difficulty with simple tasks like reaching the contralateral axilla or getting the arm behind the back to tuck in a shirt or reach into a back pocket. In addition, instability of the prosthesis, ranging from subluxations to overt dislocation, may occur. This has prompted some investigators to study osteotomy of the lesser tuberosity during surgical approach in shoulder arthroplasty. Lesser tuberosity osteotomy repair results in bone-to-bone healing, which may be more reliable than tendon-to-tendon or tendon-to-bone healing. While several studies have been published examining results of lesser tuberosity osteotomy following total shoulder arthroplasty in patients with glenohumeral osteoarthritis, they did not meet our inclusion criteria. Thus, the current available literature is insufficient to recommend for or against a lesser tuberosity osteotomy over a trans tendonous approach.
We are unable to recommend for or against a specific type of humeral prosthetic design or method of fixation when performing shoulder arthroplasty in patients with glenohumeral joint osteoarthritis.Following Neer’s original humeral design in the 1950’s with monoblock stems in three sizes, over 70 different shoulder arthroplasty systems have been developed. Modern prosthetic design has evolved to include expanded sizes and increased modularity. Prostheses have become more anatomic, with features like variable neck-shaft angles and eccentric heads to allow the surgeon to more closely replicate the patient’s normal anatomy. Surgeons can choose between prostheses designed for cemented or uncemented use. Purported advantages of one prosthetic design over another have been claimed. Despite this, no clinical studies of sufficient quality comparing different designs and fixation options were identified. Thus, the current available literature is insufficient to recommend for or against a specific type of humeral prosthetic design or method of fixation when performing shoulder arthroplasty in patients with glenohumeral osteoarthritis.
We are unable to recommend for or against physical therapy following shoulder arthroplasty.Formal physical therapy has been a consistent recommendation following shoulder arthroplasty. Despite this common practice there are no high quality studies that address whether physical therapy improves outcomes following shoulder arthroplasty.
Guideline Work Group:
Rolando Izquierdo, MD, Chair
Ilya Voloshin, MD, Vice-Chair
Sara Edwards, MD
Michael Q. Freehill, MD
Walter Stanwood, MD
J. Michael Wiater, MD
AAOS Guidelines and Technology Oversight Committee:
William C. Watters III, MD, Chair
Michael J. Goldberg, MD, Vice Chair
AAOS Evidence Based Practice Committee:
Michael Keith, MD, Chair
Charles M. Turkelson, PhD, Director of Research and Scientific Affairs
Janet L. Wies, MPH, Manager, Clinical Practice Guidelines
Sara Anderson, MPH, Lead Research Analyst
Kevin Boyer, MPH, Research Analyst
Laura Raymond, MA, Research Analyst
Patrick Sluka, MPH, Research Analyst
Kristin Hitchcock, MSI, Medical Research Librarian