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Early Osteoarthritis

Separate consideration should be given to the arthroscopic management of the early osteoarthritic shoulder. The disease in young patients is a challenging clinical problem. Non-surgical treatment options include physical therapy, therapeutic modalities, intra-articular corticosteroid injections, activity modification, and nonsteroidal anti-inflammatory medications .

There is a substantial amount of literature to support the use of the arthroscope in these patients; however, the proper indications must be present to obtain good, predictable results. The routine use of the arthroscope for symptomatic relief of osteoarthritis is simply not substantiated in the literature.

Indications for arthroscopic debridement of shoulder osteoarthritis include young patients with early to moderate disease, preserved range of motion (>120 degree elevation, >20 degree external rotation at the side), concentric glenoid wear without evidence of subluxation, and minimal osteophyte formation.

In the athlete and young patient with osteoarthritis, arthroscopy allows recognition and treatment of coexisting pathologies in which procedures such as subacromial decompression and capsular release have proven to be of benefit. In fact, arthroscopy is the most sensitive method for diagnosing early osteoarthritis.

Disorders such as rotator cuff tendinopathy, impingement syndrome, adhesive capsulitis, and biceps tendonitis often mimic osteoarthritis and are difficult to separate clinically. Through the use of arthroscopy, the proper diagnosis and specific treatment may be applied, thus maximizing the patient’s opportunity for improvement.

The goals of arthroscopic debridement are primarily to relieve pain and secondarily to improve function. The removal of loose tissues that cause pain and impingement helps to achieve these goals. In some situations, the microfracture technique of subchondral bone perforation can be a useful adjunct in order to induce fibrocartilage formation over areas of exposed bone .

Although the technique has not been specifically analyzed with respect to the shoulder, there is certainly a substantial amount of literature to support its use in the knee with studies showing that it improves symptoms, reduces defect size, and allows earlier return to activity in patients with osteochondral defects.

It should be kept in mind, however, that the duration of relief is highly variable and the procedure is at best a temporizing one . It can be highly advantageous, though, in the young active patient that desires to postpone prosthetic replacement.

An important component of the decision-making process for this procedure is radiographic analysis. The proper views are critical to allow an appropriate diagnosis and these include an anteroposterior (AP) view in internal rotation, an AP view in the scapular plane with the arm in external rotation and slight abduction and an axillary view .

The scapular AP and the axillary view are the critical ones because they are orthogonal to the plane of the joint. To improve sensitivity, the AP view may be obtained with the patient in 45 degrees of abduction while contracting the deltoid. This procedure provides joint compressive force and helps delineate joint space narrowing that can be underrepresented in standard views. A useful classification system that is applicable to this patient population has been devised by Walch et al.

A Grade A lesion shows a centralized humeral head, Grade B has posterior subluxation of the humeral head, and Grade C has a glenoid retroversion of >25 degrees. In this scheme, radiographic progression beyond a grade of A is a relative contraindication for arthroscopic debridement.

The typical arthroscopic debridement in these patients includes a thorough assessment of their motion and stability under anesthesia, as well as a thorough diagnostic arthroscopy including the subacromial space and the acromioclavicular joint

An area that deserves particular mention is that of capsular release. In many of these patients, shoulder range of motion is significantly limited not only as a result of the degenerative changes, but also as a result of the capsular contractures that are often present. Certainly, part of the procedure would include a complete capsular release to improve the passive range of motion. The technique is described in other sections of this book, and the reader is directed to the appropriate references.

With regards to outcome, there are several studies in the literature that support the use of arthroscopy to improve the symptoms associated with degenerative shoulder joints. One study evaluated 25 patients at an average of 34 months follow-up. The overall results were rated as excellent in 2 patients, good in 19 patients, and unsatisfactory in 5 (20%).

Two patients had complete pain relief and 18 had only occasional mild pain. Notably, of the 12 patients with marked stiffness preoperatively, 83% had improvement in range of motion. Of note in this population was the coexistence of significant intra-articular findings in 32% of the patients. This included labral tears, loose bodies, SLAP lesions, and partial cuff tears. Interestingly, there was no correlation between the radiographic grade and the clinical outcome.

Another study evaluated the results of arthroscopic debridement with or without capsular release in a group of sixty-one patients . At follow-up with 45 patients having a minimum of 2 years, 87% of patients indicated that they would have the surgery again. Most patients noted the onset of pain relief within 5 weeks of surgery, and obtained a duration of pain relief of 28 months or greater.

The addition of concomitant procedures, such as acromioplasty, distal clavicle resection, and labral debridement or repair did not have a negative impact on the functional results. They did note, however, that lesions greater than 2 cm appeared to be associated with a return of pain and failure of the procedure.

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