Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Shoulder/Glenohumeral Arthritis

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
  • Can reach 4.6% in patients with concomitant shoulder diseases
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
  • 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:
    • 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 .
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.
Surgery
  • Arthroscopy with associated debridement and synovectomy can relieve pain, improve function, and delay progression of the disease for inflammatory arthropathies.
  • Arthroscopic procedures addressing osteoarthritis consist of debridement, loose body removal, chondroplasty or abrasion of the glenoid and humeral head, and capsular release.
  • 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.
    • 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.
    • 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.
    • 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.

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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