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Early Glenohumeral Arthritis in the Competing Athlete
Early Glenohumeral Ar thritis in the Competing Athlete John R. Reineck, MD, Sumant G. Krishnan, MD*,W.Z. Burkhead, MD KEYWORDS Glenohumeral Arthritis Athlete
Early glenohumeral degeneration is, at best, a difficult condition for the competing athlete. This is especially true of athletes who participate in overhead sports of baseball, tennis, swimming, and volleyball. However, competitors in football, basketball, and soccer may also find themselves saddled with severe posttraumatic, post-reconstruction, or primary cartilage loss in their shoulders. Unfortunately, this may lead to impeded performance, and, ultimately, derailed careers. Fortunately, for the orthopedic surgeon, this is not a common condition. However, those who have been involved in the care of the performing athlete with early arthritis can attest that the problem is vexing and the best possible treatment unclear. Although total shoulder arthroplasty in older, more sedentary individuals has been shown to reliably relieve pain and improve function, this is not an ideal procedure for the competitive athlete due to concerns about implant longevity, not to mention altered biomechanics. This therapeutic challenge has spurred the development of alternative approaches to treat glenohumeral arthritis in competing athletes. These approaches include various conservative management strategies as well as arthroscopic procedures, partial or total humeral surface replacement, interposition, and glenoid biologic resurfacing. These approaches, together with traditional arthroplasty, make up the armamentarium of options for the treatment of glenohumeral arthritis in the young athlete. The challenge lies in deciding which option is best for each situation. CLINICAL PRESENTATION
The clinical presentation of early osteoarthritis (OA) in the competitive athlete can be similar to that seen in the general population. The patient may complain of a deep, aching-type pain localized to the glenohumeral joint that is often present at night. Loss of varying degrees of range of motion (ROM) and occasional locking from
Shoulder and Elbow Service, W.B. Carrell Memorial Clinic, 9301 North Central Expressway, Suite 400, Dallas, TX 75231, USA * Corresponding author. E-mail address: [email protected] (S.G. Krishnan). Clin Sports Med 27 (2008) 803–819 doi:10.1016/j.csm.2008.07.004 sportsmed.theclinics.com 0278-5919/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
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intra-articular loose bodies may also be present. However, competitive athletes are unique in that they may be functionally disabled by symptoms that may not affect the average sedentary individual. High performance is born of high demand on the glenohumeral anatomy. Therefore, if the anatomy of the shoulder is unable to meet this demand, performance will consequently suffer. Thus, slight losses of ROM virtually unnoticed by the general population may be devastating to the competitive athlete. As a result, one must pay particular attention to the complaints of these athletes, as delay in diagnosis may have career-ending implications. For instance, pain in the mid-ROM is more suggestive of cartilage degeneration than that at the extremes, as found in the more common entity of impingement and cuff pathology. RADIOGRAPHS
One should obtain routine anteroposterior and axillary lateral radiographic views in all competing athletes complaining of shoulder pain. Radiographic changes of primary and secondary osteoarthritis include joint space narrowing, subchondral sclerosis and cysts, and osteophytic spurring of the inferior humeral and glenoid articular surfaces, with a posterior-inferior erosion pattern of the humeral head on the glenoid. The Samilson and Prieto classification,1 originally described for post-dislocation arthropathy, is based on these changes seen on an AP radiograph and is graded as mild, moderate, or severe. Mild arthrosis is characterized by a less than 3 mm spur projecting off of the humerus, glenoid, or both. Moderate arthrosis displays osteophytes measuring between 3 and 7 mm off of the humerus, glenoid, or both, with slight glenohumeral joint irregularity. Severe arthrosis has osteophytes measuring greater than 8 mm off of the humerus, glenoid, or both, with joint space narrowing and sclerosis (Fig. 1). Studies have shown this classification system to be reliable.2–5 Additional x-ray films, such as the apical oblique view and the Stryker notch view, may be helpful in identifying degenerative changes in the anteroinferior glenoid and humeral head notching, respectively. Furthermore, computed tomographic (CT) scans
Fig. 1. Grade 3 Samilson and Prieto classification of severe arthritis.
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may be helpful in defining the extent of posterior glenoid wear, whereas magnetic resonance imaging (MRI) has been useful in demonstrating isolated cartilage lesions. NONOPERATIVE MANAGEMENT Education
An initial explanation of the arthritic process and discussion of its probable future implications constitute an important first step in treating all patients, especially the competing athlete. This helps ensure that the athlete’s expectations are consistent with the prognosis. Education and encouragement also promote compliance, with appropriate exercise and avoidance of detrimental activities. The goals of treatment and anticipated improvements should also be discussed. Unfortunately, this may mean that the patient adjust his or her expectations or, in extreme cases, career direction. Patients with arthritis must be taught to interpret their own symptoms to provide information important in determining appropriate therapy. They contribute to the exercise plan and assume responsibility for its implementation. The patient’s active contribution to treatment fosters a sense of control over the effects of the disease. This approach will help physicians teach patients how to manage and best enjoy the highest quality of life that is possible through the technologic achievements of present-day operative and nonoperative interventions for their arthritic shoulders. Anti-inflammatory and Analgesic Medications
Oral analgesics, such as salicylates, acetaminophen, and codeine, can be very effective in treating arthritic pain. The role of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating patients with symptomatic inflammatory arthropathies is well established. These drugs are also commonly used in the setting of noninflammatory osteoarthritis. Regardless of the anti-inflammatory or analgesic medication used, patients should be counseled as to the potential renal, hepatic, or gastric side effects of these drugs. Corticosteroids
Local anesthetic injections are of great value in diagnosing shoulder conditions by localizing the anatomic site of the pain generators. Appropriate steroid injections have also been documented to have significant therapeutic value.6 Although the use of intra-articular steroids can be effective in abating symptoms in joints afflicted with rheumatoid arthritis (RA), they are generally of comparatively limited value in osteoarthritis (OA), typically providing relatively short-term relief of symptoms. Dacre and colleagues7 studied the prospective, randomized, blinded results of local steroid injections or physiotherapy in treating patients with painful or stiff shoulders with RA. Sixty consecutive patients of similar age, sex, diagnosis, and disease severity were allocated into 3 groups to receive either local steroids, 6 weeks of physiotherapy, or both. Results showed that physiotherapy alone was just as effective as local steroid injections or a combination of these 2 methods. In the uncomplicated case, a local steroid injection was the most cost-effective treatment. Similarly, recently published meta-analyses of the peer-reviewed literature regarding the use of corticosteroid injections used for periarticular and intra-articular shoulder pain document variable success.6,8 Patients with subacromial pathology (such as rotator cuff disease) and those with varying degrees of stiffness/capsulitis statistically benefited from the use of corticosteroid injections. Results for treatment of OA remained difficult to interpret. Anecdotally, the authors have found that if a single intra-articular water-soluble corticosteroid injection is helpful, then another can be
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performed at a 6-month interval (no more often than 2 injections per year). If the first injection provides minimal relief (assuming a truly intra-articular position of the injection—if there is any doubt, fluoroscopic imaging should be considered), then further corticosteroid injections are likely to have little potential benefit.
Viscosupplementation
Peer-reviewed publications over the past decade have documented the apparent statistical benefit of intra-articular injections of hyaluronic acid in the treatment of knee and hip OA for pain relief. Unfortunately, neither in vitro nor in vivo studies have demonstrated a chondroprotective effect of either low- or high-molecular weight hyaluronic acid, and the probable effect of these substances on the human joint (if any) appears to be symptomatic relief of joint pain by an unknown mechanism. Further work is in progress regarding the use of intra-articular glucosamine and whether it is of any value from a pain-relieving and/or chondroprotective standpoint. Viscosupplementation of the glenohumeral joint has demonstrated much more variable clinical results. There remains no peer-reviewed, double-blinded, prospective, randomized clinical trial documenting any benefit of such injections when compared with simple corticosteroid injections in the shoulder. Nevertheless, as with any other treatment modality, there may still be a benefit in certain patients who seek to avoid operative treatment for their glenohumeral arthritis. These indications have not been clarified, as yet because there are currently no specific published data regarding glenohumeral viscosupplementation in the competing athlete.
Physical Therapy General principles
Although nearly all patients with glenohumeral arthritis will benefit from physical therapy, those who benefit most begin with decreased ROM and weakness in the presence of minor roentgenographic findings. Occasionally, an initial period of rest may be beneficial. However, an excessive period of rest can contribute to muscle atrophy, joint contractures, and worsening functional abilities. The aim of physical therapy is to increase ROM and strength. Nevertheless, therapy should not be considered a failure if the result is only the maintenance of the existing ROM. Exercises are designed specifically for the needs of each patient—this includes gentle passive motion and isometric strengthening. Preferential strengthening of specific muscle groups is especially beneficial for patients with mild OA and generalized ligamentous laxity. Although acting in nearly diametric ways, heat and cold are therapeutically useful when employed at appropriate times in chronic and acute phases of inflammatory pain. Cold treatment is useful in treatment of acute inflammatory flare-ups; the analgesic effects have been attributed to the ability of cold to depress the excitability of nerve fibers and muscle spindles, thereby increasing the pain threshold. Cutaneous vasoconstriction and resulting reduction in blood flow reduce edema even in deeper tissues. When inflammatory pain is chronic, then the application of heat, usually in the dry form, is useful in temporizing pain and enhancing joint motion by increasing tissue elasticity. Increased tissue metabolic activity also accompanies the increased blood flow resulting from vasodilatation. Heat can be delivered superficially by using hot packs, hot water, or convective fluid therapy, while therapeutic ultrasound can be used for deeper penetration (see later section).
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Hydrotherapy
The therapeutic efficacy of water therapy cannot be overstated. This remains a mainstay in the rehabilitation of any glenohumeral joint, especially in the arthritic one. Buoyancy effects of water help to reduce stress exerted on muscles and joints during therapeutic shoulder exercises. The patient’s exertion can also be regulated because of the direct relation between the speed of movement and the resistance encountered. Adjustments in water temperature and agitation enhance the beneficial effects of hydrotherapy. Therapeutic ultrasound
The clinical usefulness of therapeutic ultrasound is based primarily on its capacity to increase blood circulation and temperature in deep tissues. Tissue temperature can be elevated at depths up to 5 cm from the point of application on the patient’s skin, and peak temperatures occur in bone. When the treatment objective is to heat muscle tissue, the most effective modality currently available is shortwave diathermy. Application of heat and cold, hydrotherapy, ultrasound, and ROM and strengthening exercises are commonly used modalities for helping restore mobility to the stiff shoulder. These and other nonoperative therapeutic interventions are contraindicated in patients who have severe pain and a rapidly deteriorating condition, because this scenario could imply concomitant occult sepsis.
Exercises
Functional limitations are second only to pain in the frequency of complaints in patients with glenohumeral arthritis. However, the functional goals of the competitive athlete are decidedly different from those of the general population, with livelihood depending on such activities as maintaining pitch velocity, pass accuracy, or serving strength. Physical therapists, especially occupational therapists attuned to the needs of competitive athletes, can assist these patients by instructing them in particular exercises that promote increased ROM and increased strength while facilitating scapular stabilization. Specifically, strengthening of the rotator cuff, with emphasis on scapular stabilization, will help reduce shear forces across the glenohumeral joint, thus reducing pain and further degeneration. Examples of specific exercises aimed at promoting ROM include capsular stretching, wall walks, and pulley exercises (Fig. 2). Exercises aimed at scapular stabilization include scapular pinches and scapular rows (Fig. 3). Finally exercises that focus on strengthening and plyometrics are used (Fig. 4).
Authors’ Preferred Treatment Regimen
For any athlete with radiographic evidence of glenohumeral arthritis and symptoms of pain and decreased function, a course of therapy is begun that includes antiinflammatory agents, activity modification, intra-articular cortisone injection, and physical therapy. Corticosteroid injections are offered only twice a year. If the patient returns within 6 months of the second steroid injection, a course of viscosupplementation is offered. If he or she continues to have pain and progression of arthritis characterized by further loss of motion and radiographic changes after completing this course of conservative therapy, nonoperative treatment is considered a failure, and surgical management options are discussed.
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Fig. 2. (A) Pectoralis minor stretching. (B) Posterior capsular stretching. (C) Wall walks with exercise ball. This also works on the scapular stabilizing musculature. (D) Pulley exercises.
Fig. 3. (A) Standing rows, (B) Sitting rows. This can be combined with weights for strength training.
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Fig. 4. Plyometric exercises.
OPERATIVE MANAGEMENT Arthroscopic Techniques Debridement /capsular release
Arthroscopic debridement or lavage for arthritis has been successfully used in the weight-bearing joints of the lower limb, particularly the knee. In many cases, this may be the result of a strong placebo effect. In contrast to the knee, the benefits of, and indications for, arthroscopic debridement in the shoulder are not as clear, especially with reference to the athlete’s shoulder. However, there is some evidence in the general population that arthroscopic debridement may be of some benefit. According to Cameron and colleagues,9 the ideal candidate for arthroscopic debridement is one with a congruent, well-centered joint, little or no osteophyte formation, mild or no subchondral sclerosis or cyst formation, and an osteochondral lesion that does not exceed 2 cm2. Krishnan and colleagues10 agree that patients should have a congruent glenoid but have also commented on the importance of having at least 20 of external rotation and congruity of the glenohumeral articulation. There have been some encouraging reports in the literature regarding the results of arthroscopic debridement for early arthritis. In the report by Cofield11 on 8 patients who underwent arthroscopic debridement for previously unrecognized arthritis, all 8 patients improved postoperatively. Johnson12 later stated that the results of arthroscopic debridement for osteoarthritis would depend on the degree of involvement of the joint. Ogilive-Harris and Wiley13 followed 54 patients treated with arthroscopic debridement for osteoarthritis for 3 years. They concluded that the more severe changes were associated with poorer results. Patients with mild changes had a successful outcome two thirds of the time, whereas only one-third of patients with severe change had successful outcomes. A favorable outcome was associated with removal of osteoarthritic debris, restoration of motion, and debridement of degenerative labral tears, which they likened to degenerative tears of the meniscus in the knee. Weinstein and colleagues14 reported on 27 patients who underwent arthroscopic debridement for a diagnosis of degenerative joint disease. Treatment included joint lavage, loose body removal, degenerative cartilage debridement, labral and/or soft
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tissue debridement, and subacromial space bursectomy. An average follow-up of 30 months showed 78% satisfactory results, with 67% of patients able to return to their previous level of activities. In a later report, Weinstein and colleagues15 performed glenohumeral lavage, labral and chondral debridement, loose body removal, partial synovectomy, and subacromial bursectomy in 26 patients. Twenty-one patients had good or excellent results. Optimum results were achieved in patients with a concentric joint and visible joint space on an axillary radiograph. The authors reported on 37 patients with a mean 2-year follow-up.10 Their approach included acromioplasty, biceps tenodesis or tenotomy, capsular releases, debridement, and excision of the distal clavicle. Preoperatively, mean active ROM was 82 of elevation, 5 of external rotation (ER) (range, 35–80 ), and internal rotation (IR) to the sacroilliac (SI) joint. Mean simple shoulder test (SST) score was 5.8. Pain level averaged 6.3 (0 5 no pain; 10 5 worst pain). Postoperatively, mean active ROM was 124 of elevation, 37 of ER, and IR to L3. Mean SST score was 8.5 and pain level averaged 2.8. (P<.01 for all measures). Good or excellent results by the SST score occurred in 77% of patients. Mean patient satisfaction score was 8.3 (0 5 unsatisfied; 10 5 completely satisfied). Eighty percent of patients stated that they would undergo this procedure again. Nineteen percent of these patients (3/37) required revision to total shoulder arthroplasty. All 3 of these patients were noted to have biconcave glenoids (Walsh B1 or B2) before arthroscopic debridement. However, extrapolation of these generally good results to an athletically active population is difficult, because there were no individuals identified as athletes within these groups. As the arthritic process advances, the anterior capsule becomes constricted, restricting external rotation, effectively causing increased forces to be placed onto the articular cartilage as a result of the abnormal glenohumeral motion. Hawkins and Angelo16 recognized this entity in 10 patients (11 shoulders) who had had PuttiPlatt capsulorrhaphies for anterior shoulder instability with an overly tightened anterior capsule. Most of these patients responded to conservative treatment measures, whereas 4 underwent surgical release of the anterior capsule with good results. They theorized that relieving the pressure on the chondral surfaces from the tight anterior capsule could delay the progression of arthritis. Therefore, it has been suggested that capsular releases be performed in patients with loss of motion, especially in external rotation, associated with mild to moderate OA. Obviously, this has the potential to affect the throwing and/or hitting mechanics in the overhead athlete. For this reason, a detailed discussion regarding expectations is paramount before surgery. In the study by Ogilvie-Harris and Wiley,13 14 of the 54 patients they treated with arthroscopic debridement had an associated frozen shoulder. Lysis of adhesions or manipulation under anesthesia was used to restore motion in cases of severe motion restriction. If a loss of more than 20 of passive motion of the shoulder was apparent, compared with the contralateral side, arthroscopic capsular releases were performed with good results. The authors have also reported on the use of capsular releases combined with other arthroscopic procedures for glenohumeral arthritis.10 Overall, all patients had improvements in pain and function postoperatively. Average postoperative ROM improved by 42 in forward flexion and 32 in external rotation. Competitive athletes with glenohumeral degenerative changes often have concomitant subacromial pathology. Often, impingement-type lesions and proliferative bursae are secondary to altered biomechanics coupled with excessive demand on the joint. Therefore, subacromial decompression is often coupled with debridement and capsular release in this patient population.
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Guyette and colleagues17 performed a retrospective review of 36 patients with glenohumeral degenerative joint disease who underwent arthroscopic subacromial decompression and were followed an average of 5 years. Patients with Outerbridge grades I, II, or III demonstrated equal or improved ROM postoperatively. Only 1 of 10 patients with Outerbridge grade IV lesions showed improvement. Two of these patients went on to receive hemiarthroplasty. Ellowitz and colleagues18 reported on 21 patients who were found to have grade IV osteoarthritic changes at the time of arthroscopic subacromial decompression. Follow-up of 19 of their patients for an average of 37 months revealed improvement in ROM, strength, pain relief, and ability to return to their sport of choice in all patients. Likewise, Cameron and colleagues9 also reported on patients with grade IV lesions. They performed arthroscopic debridement, with or without arthroscopic capsular release, acromioplasty, distal clavicle resection, and labral debridement or repair in 61 patients. Forty-five patients were available for 2-year follow-up. Pain and function were improved in 88% of all patients. Lesions greater than 2 cm2 were predictive for return of pain and ultimate failure of the procedure. Conversion to hemiarthroplasty occurred in 6 patients. All had lesions greater than 2 cm2. Authors’ preferred treatment Indications The authors proceed with arthroscopic management when the patient
meets the following criteria: 1. 2. 3. 4. 5.
Failure of nonoperative treatment Preservation of the joint line on axillary lateral radiograph Minimal to no biconcave pattern of glenoid erosion Maintained acromiohumeral distance greater than 6 mm External rotation of at least 20 .
The following procedures are preferred, combined with debridement of the glenohumeral joint: 1. 2. 3. 4.
Intra-articular debridement/synovectomy Capsular releases Subacromial decompression Distal clavicle resection (if there is clinical and radiographic evidence of arthrosis).
Technique After induction of general anesthesia, the patient is placed in the beach
chair position. The posterior and anterior portals are created. The anterior portal is placed for easy access for later distal clavicle resection. A cannula is inserted into the anterior portal, and the joint is lavaged to remove all loose bodies. At this point, performing the capsular releases is preferred, if indicated, so that the articular cartilage in tight joints is not injured, while attempting joint inspection. An ablation device is inserted into the anterior cannula and used to release the tight rotator interval from the anterior edge of the supraspinatus to the superior edge of the subscapularis tendon until the fibers of the coracoacromial ligament can be seen. The anterior capsule is released adjacent to the labrum to expose the fibers of the subscapularis to approximately the 5-o’clock position to increase external rotation. The inferior capsule is left alone to protect the axillary nerve. The arthroscope is then switched to the anterior portal for release of the posterior capsule, but only if there is no evidence of posterior subluxation of the humerus on the glenoid both radiographically or arthroscopically, and if there is a lack of internal rotation compared with the contralateral side. An angled incisor blade is then placed into the posterior portal and used to resect approximately 1 cm of posterior capsule adjacent to the labrum. The ablation
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device is then placed into the posterior portal and the release is completed to the 7-o’clock position. On completion of the capsular release, the articular surfaces are inspected for degenerative changes, including marginal osteophytes, eburnated cartilage, and posterior wear of the glenoid, which can create a biconcave surface. All loose bodies are removed from the axillary pouch. The trocar and cannula are then passed through the posterior portal into the subacromial space and out the anterior portal just lateral to the coracoacromial ligament. A cannula is slipped over the trocar and the arthroscope is placed through the cannula in the posterior portal. The arthroscope is slid backward out of the anterior cannula, and the undersurface of the anterolateral corner of the acromion is visualized. A spinal needle is used to establish a lateral portal, usually 2 finger-breadths distal and lateral to the anterolateral corner of the acromion. The ablation device is used to debride the coracoacromial ligament and periosteum off of the anterior acromion. An arthroscopic 4.0-mm full-radius Acromionizer burr (Dyonics, Smith & Nephew Inc., Andover, Massachusetts) is used to flatten the undersurface of the acromion. The arthroscope is transferred to the lateral portal and the burr to the posterior portal. The remaining medial spur is visualized and resected with the burr. The 4.5-mm shaver is then placed into the posterior portal, and the bursectomy is performed. Attention is then turned to the acromioclavicular (AC) joint, if there is preoperative evidence of AC joint degeneration. The arthroscope is placed into the lateral portal. The ablation device is placed into the anterior portal and the capsule and periosteum are cleaned off of the joint, making sure not to detach the deltoid fibers. The burr is then used to resect approximately 7 mm in males and 5 mm in females of the distal clavicle and approximately 2 mm off of the medial acromion to create a space of approximately 1 cm, leaving the superior capsule intact to control the anterior-toposterior translation of the remaining distal clavicle. The subacromial space is then irrigated and all portals are closed. The shoulder is then manipulated throughout a full ROM in flexion, abduction, external rotation, and internal rotation, with the arm in 90 of abduction, to obtain any final degrees of motion. Postoperatively, the patient is allowed passive motion immediately. No sling is used. The patient is sent home with instructions for passive motion with pendulum, pulley, stick, and internal rotation up the back to be performed 3 to 5 times a day. At 3 weeks, the patient is started on active-assisted exercises. At 8 weeks, Thera-Band (Hygenic, Akron, Ohio) low-resistance exercises are begun in internal and external rotation only. These exercises are to be performed every other day. At 12 weeks, resistance exercises are progressed to all planes. Outcome
The results of a combined arthroscopic procedure, including debridement, capsular releases, subacromial decompression, and AC joint excision for glenohumeral arthritis, have been reported.10 Thirty-three consecutive patients with a mean age of 62 years and minimum 2-year follow up were evaluated. Excellent results were reported in 15 patients (46%) and good results in 10 patients (31%). Overall, 77% achieved a satisfactory outcome (excellent or good result). Five patients (15%) reported fair results, and 3 patients (8%) reported poor results. Three patients required revision to arthroplasty at an average of 28 months (range, 12–48 months) after arthroscopy. All 3 cases initially presented with a biconcave glenoid as diagnosed by axillary radiographs. The mean patient pain score (0 5 no pain; 10 5 worst pain) improved from 6.3 preoperatively to 2.8 at final follow-up, with 80% of patients indicating that they would have the surgery again. Average postoperative motion increased
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for forward elevation by 42 and for external rotation by 32 . Workers’ compensation patients obtained inferior subjective results overall; however, improvements in pain and function were found in all patients. OPERATIVE MANAGEMENT Arthroplasty
Unfortunately, there are those competitive athletes for whom the procedures stated here are either not indicated (eg, biconcave glenoid) or not efficacious. This presents a significant therapeutic dilemma to both the patient and the surgeon. Arthroplasty in all its forms (resurfacing, hemiarthroplasty, biologic resurfacing, and total joint arthroplasty) can reliably provide pain relief. However, this is often at the expense of the high functional level demanded by the competing athlete. Furthermore, concerns of implant longevity are amplified. Therefore, decisions to proceed with arthroplasty must be carefully made between the patient and surgeon, while ensuring full understanding of the implications and subsequent expectations of performance. Humeral Surface Replacement (Copeland)
Originally developed in 1979 and instituted clinically in 1986, the cementless surface replacement arthroplasty has been used for all types of arthritis in various situations. It involves a small, press-fit, metallic resurfacing of the humeral head, which requires minimal resection of the humeral head and no reaming of the humeral canal (Fig. 5). Hydroxyapatite coating was added in 1993 to increase the ingrowth potential. There are many potential advantages to using this stemless prosthesis. Because there is no stem in the shaft of the humerus, stress risers and the risk of subsequent fractures at the end of the prosthesis are avoided. Revision surgery to either a total shoulder arthroplasty or arthrodesis can be done with ease in light of the substantial remaining bone stock and the lack of cement fixation. In Copeland and colleagues’ recent report in patients 50 years or younger, the results were comparable to traditional, stemmed prostheses.19 Average follow-up was 8.2 years (2.0–14.8 years). Twenty-two hemiarthroplasties and 17 total shoulder
Fig. 5. Humeral resurfacing implant.
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arthroplasties were performed. The average Constant score improved by 41 points. Active elevation improved in all patients, most dramatically for patients with avascular necrosis. Radiolucent lines less than 1 mm were seen in 73% of glenoid components and 7% of humeral components. No lucencies greater than 1 mm were noted. Two patients required conversion to arthrodesis, secondary to active infection in one and persistent instability in the other. Thomas and colleagues20 reported encouraging follow-up in the short term on close to 3-year follow-up on 52 patients with isolated humeral resurfacing. The mean age was 70 years (range, 34–84 years). They demonstrated significant improvement in the Constant score (16.4 preoperatively to 54 postoperatively), with only 1 case of aseptic loosening requiring revision to a stemmed component. Similarly, Bailie and colleagues21 reported on 36 patients with a mean age of 42.3 years and an average of 38-month follow-up. He demonstrated no radiographic evidence of loosening and significant improvement in American Shoulder and Elbow Surgeons (ASES) scores. Interpositional Arthroplasty and Biologic Glenoid Resurfacing Introduction
The concept of using biologic materials for the resurfacing of articular surfaces is not a new one. As early as 1860, Veneriel described a fascial arthroplasty of the temporomandibular joint.22 In 1904, Murphy performed fascial arthroplasty of the knee and elbow as well as the shoulder,23 using the fat that remained attached to the fascia to further decrease the coefficient of friction. MacAusland, in a 1921 review, detailed all of the materials that had been used to realign human joints.24 Attempts using nonabsorbable materials included the use of ivory pegs, magnesium sheets, wood, celluloid, gutta percha, gauze packing, yellow wax and lanolin, cellophane, nylon, and rubber. Techniques using autograft were also numerous and included attempts using periosteum, fascial and muscle flaps, bursal flaps, fat, cartilage transfers, and skin. Xenograft with chromatized pig bladder has also been described.25 Currently, uncemented or cemented humeral hemiarthroplasty with biologic resurfacing of the glenoid in young, active individuals with post-reconstruction, posttraumatic, and primary osteoarthritis is favored. Resurfacing of the glenoid is achieved with either autograft or allograft materials. Ipsilateral anterior capsule or autogenous fascia lata have been used extensively in the early reports documenting the non-prosthetic biologic resurfacing of the glenohumeral joint. Unpredictable outcomes and concerns regarding the durability of those tissues have led to a predominance of allograft usage for either interposition arthroplasty or biologic resurfacing. Classically, the allograft of choice has been Achilles tendon. Tendo Achilles allograft is durable, low cost, and readily available. The collagen makeup of the Achilles tendon lends itself very well to beneficial wear characteristics on the glenoid surface. Recent work has demonstrated the significant intermediate- and longer-term wear characteristics of the tendo Achilles allograft in resisting glenoid erosion and maintaining glenohumeral joint space.26 However, technical considerations and concerns for overstuffing or lateralizing the joint have led some to abandon the use of bulky materials in favor of more manageable materials, such as allograft meniscus. Ball and colleagues26 were the first to describe the use of this type of allograft. In addition to less bulk, theoretical advantages include an established history of synovial healing when used in the knee and a wedge shape that compensates for pre-existing posterior glenoid wear. Ball and colleagues reported that their initial results in 6 shoulders at an average 24-month follow-up showed promising patient satisfaction, pain relief, and significant improvements in ROM. Radiographic results in these patients were also promising with no glenoid
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erosion and maintenance of the glenohumeral joint space. More recent reports have also demonstrated similar success in the short term.27,28 Furthermore, a current biomechanical study suggests that these grafts are durable under physiologic and pathologic loads across the shoulder joint.29 Unfortunately, this graft choice is more expensive, less readily available, and there are no peer-reviewed reports documenting long-term outcomes with regard to progressive glenoid erosion. Another alternative is human dermal collagen allograft (GraftJacket). Although these grafts incur a larger expense, the potential gain is a durable surface much like the tendo Achilles graft that is easier to handle and work with in the surgical setting. The reduced bulk of this type of graft choice, when compared with the tendo Achilles allograft, may promote a more anatomic restoration of glenohumeral anatomy (Fig. 6). Nevertheless, the durability of this graft over time is still unknown. Additionally, Williams has reported on interpositional arthroplasty alone for the treatment of young patients with end-stage glenohumeral arthritis.30 He reported good pain relief and improved function in a series of 6 patients treated between 1997 and 2000. In 5 of these patients, anterior capsule was used. In all cases, the humeral head was debrided of osteophytes but otherwise left unchanged. The 6 patients in his series were an average 38 years of age, and all had a chief complaint of incapacitating pain secondary to degenerative arthritis. At average 27-month follow-up, patients showed improvement in ROM, with improved postoperative PENN shoulder score and all patients rating their shoulders as being good/excellent according to the UCLA end-result score. Furthermore, Bhatia and colleagues31 and Brislin and colleagues32 have explored performing interpositional arthroplasty without hemiarthroplasty using arthroscopic techniques, demonstrating encouraging results in the short term. Although arthroscopic in nature, the underlying principles nonetheless are the same as those in open surgery: there is restoration of the glenoid version as necessary (with an arthroscopic burr), preparation of the glenoid surface (with microfracture), and suturing of the interpositional graft to the labrum and capsule (arthroscopically). Conversely, the recent work of Matsen et al33 suggests that good results may be achieved without interpositional graft at all. Using a canine model, they performed humeral hemiarthroplasty combined with reaming of the glenoid and no resurfacing. At 10 weeks, the glenoid was partially covered with a fibrous tissue and there was bone formation at the margins, with maintenance of the concavity of the glenoid. At
Fig. 6. Glenoid resurfaced with human allograft dermis.
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24 weeks, there was considerably more healing, with formation of a thick fibrocartilaginous layer covering the glenoid.33 Their early clinical results are also encouraging, demonstrating improvement in the simple shoulder test scores at 2- to 4-year follow-up.34 The author’s longer-term, 2- to 15-year outcomes of biologic resurfacing of the glenoid with humeral hemiarthroplasty for the treatment of glenohumeral arthritis were recently published.35 Thirty-four patients (36 shoulders) were treated between 1988 and 2003. Patient age averaged 51 years with a predominant diagnosis of primary glenohumeral arthritis (18/36). Post-reconstructive arthritis (12/36), posttraumatic arthritis (5/36), and avascular necrosis (1/36) comprised the remainder of the cases. Biologic resurfacing with cemented or cementless humeral head replacement was performed in all cases. A variety of biologic surfaces, including anterior capsule (7 cases), autogenous fascia lata (11 cases), and tendo Achilles allograft (18 cases), were used, reflecting the evolution of the technique over time. Patients treated with the senior author’s (J.R.R.) current, preferred technique, using allograft dermis GraftJacket, were not included in this particular series. Patients were evaluated clinically before and after surgery with the ASES score and improved on average from a score of 39 preoperatively to a score of 91 postoperatively. Average active anterior elevation improved from a mean of 70 preoperatively to a mean of 140 postoperatively. There was likewise improvement in external rotation from 5 preoperatively to 50 postoperatively, and internal rotation improved an average of 6 spinal levels. By Neer’s criteria, there were 18 excellent, 13 satisfactory, and 5 unsatisfactory results. Unsatisfactory results were associated with infection, early re-injury, and the use of capsule as an interposition material. Of the 5 poor results, 4 had undergone resurfacing with anterior capsule and 1 with autologous fascia lata. None of the patients resurfaced with Achilles tendon allograft had an unsatisfactory result. The reason for failure was pain and instability in 3 patients treated with anterior capsule. Infection was the reason for failure in the remaining 2 patients with unsatisfactory results. This included 1 patient treated with autologous fascia lata who failed. In addition, 1 case of brachial plexitis and 1 upper extremity deep vein thrombosis represented the complications associated with this series. Radiographic evaluation showed stable humeral components in all cases both with cemented and cementless stems. Glenoid erosion averaged 7.2 mm but appeared to stabilize at approximately 5 years. Glenohumeral joint space was obliterated in all cases preoperatively. Immediately postoperatively, this improved to an average of 2.9 mm. The final mean joint space was measured at 1.3 mm. Traditional Arthroplasty
Shoulder arthroplasty is currently the gold standard for the treatment of end-stage glenohumeral arthritis in the general population with severe pain and dysfunction unrelieved by conservative measures. However, the active competitive athlete who undergoes this procedure is at greater risk of failing secondary to the likelihood of decreased longevity of the prosthesis. Therefore, if these patients cannot change their lifestyle to compensate for the extra precautions of shoulder replacement, other forms of treatment should be sought. Sperling et al36 have conducted the most extensive review of shoulder arthroplasty in patients younger than 50 years. Their first report included 114 patients followed for a minimum of 5 years (mean, 12.3 years). They performed 78 hemiarthroplasties and 36 total shoulder arthroplasties for glenohumeral arthritis. Both procedures resulted in long-term pain relief and improved abduction and external rotation. Yet, almost half of
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the patients had an unsatisfactory result. Radiolucent lines were seen around the humeral component in 16 (24%) of the hemiarthroplasties and 17 (53%) of the total shoulders. Nineteen (59%) of the total shoulders displayed radiolucent lines around the glenoid component. Erosion of the glenoid was seen in 46 (68%) of hemiarthroplasties. The most common cause of revision in the hemiarthroplasty group was painful glenoid arthrosis. The authors cautioned surgeons in using hemiarthroplasty or total shoulder arthroplasty in patients 50 years or younger. A follow-up to this study was later performed with a minimum follow-up of 15 years (mean, 16.8 years).37 The results were similar. Sixty percent of hemiarthroplasties and 48% of total shoulders demonstrated unsatisfactory results. Radiolucent lines were evident around the humeral component in 60% of total shoulders and 34% of hemiarthroplasties. Glenoid periprosthetic lucency was present in 76% of total shoulders, and glenoid erosion was seen in 72% of hemiarthroplasties. Again, surgeons were urged to use great care and consider alternative methods of treatment before proceeding with either hemiarthroplasty or total shoulder arthroplasty in patients 50 years or younger. SUMMARY
Glenohumeral arthritis in the competitive athlete can be a devastating condition. Fortunately, it is rare. The mainstay of treatment is conservative and involves NSAIDSs injections, and physical therapy focusing on maintenance of ROM and strength. However, this approach is often unsuccessful, as these individuals depend on a high level of function to maintain their livelihood or active lifestyle. For these patients, arthroscopic debridement and capsular release may provide short-term pain relief and improvement in ROM. Failing this, the athlete needs to make a decision of lifestyle/ livelihood modification versus glenohumeral arthroplasty. If arthroplasty is chosen, various biologic resurfacing options are available and encouraged. Barring this, total shoulder arthroplasty using a standard polyethylene component will reliably provide pain relief and restore function; however, longevity and survival issues preclude recommending this as a first line of treatment. REFERENCES
1. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am 1983;65:456–60. 2. Brox JI, Lereim P, Merckoll E, et al. Radiographic classification of glenohumeral arthrosis. Acta Orthop Scand 2003;74(2):186–9. 3. Davis MA, Ettinger WH, Neuhaus JM, et al. Correlates of knee pain among US adults with and without radiographic knee osteoarthritis. J Rheumatol 1992;19: 1943–9. 4. Johnson LL. Diagnostic and surgical arthroscopy of the shoulder. St Louis (MO): Mosby; 1993. 239–48. 5. Moseley JB Jr, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am J Sports Med 1996;24:28–34. 6. Blair B, Rokito AS, Cuomo F, et al. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78:1685–9. 7. Dacre JE, Beeney N, Scott DL. Injections and physiotherapy for the painful stiff shoulder. Ann Rheum Dis 1989;48:322–5. 8. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003;(1):CD004016.
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9. Cameron BD, Galatz LM, Ramsey ML, et al. Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint. J Shoulder Elbow Surg 2002; 11(1):25–32. 10. Krishnan SG, Nowinski RJ, Burkhead WZ. Combined arthroscopic capsular release, acromioplasty, and distal clavicle resection for end-stage glenohumeral arthritis. Poster presentation at American Shoulder and Elbow Surgeons Closed Meeting, Oct. 8–11, 2003. Dana Point, California. 11. Cofield RH. Arthroscopy of the shoulder. Mayo Clin Proc 1983;58:501–8. 12. Johnson L. The shoulder joint: an arthroscopist’s perspective of anatomy and pathology. Clin Orthop 1987;223:113–25. 13. Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder: a general appraisal. J Bone Joint Surg Br 1986;68-B(2):201–7. 14. Weinstein D, Bucchieri J, Pollock R. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 1993;9:366. 15. Weinstein DM, Bucchieri JS, Pollock RG, et al. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 2000;16(5):471–6. 16. Hawkins R, Angelo R. Glenohumeral osteoarthrosis: a late complication of PuttiPlatt repair. J Bone Joint Surg Am 1990;72:1193–7. 17. Guyette TM, Bae H, Warren RF, et al. Results of arthroscopic subacromial decompression in patients with subacromial impingement and glenohumeral degenerative joint disease. J Shoulder Elbow Surg 2002;11(4):299–304. 18. Ellowitz AS, Rosas R, Rodosky MW, et al. The benefit of arthroscopic decompression for impingement in patients found to have unsuspected glenohumeral osteoarthritis. Presented at: American Academy of Orthopedic Surgeons Annual Meeting; February 13–17, 1997; San Francisco, CA. 19. Copeland SA, Levy O, Brownlow HC. Resurfacing arthroplasty of the shoulder. Techniques in Shoulder and Elbow Surgery 2003;4(4):199–210. 20. Thomas SR, Wilson AJ, Chambler A, et al. Outcome of Copeland surface replacement shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:485–91. 21. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in patients less than 50 years of age. J Bone Joint Surg Am 2008;90:110–7. 22. Verneriel. Arch Med 1860. 23. Murphy JB. Ankylosis: arthroplasty-clinical and experimental. Transactions of the American Surgical Association 1904;22:215. 24. MacAusland WR. Mobilization of the elbow by free fascia transplantation with report of thirty-one cases. Surg Gynecol Obstet 1921;33:223–45. 25. Baer WS. Arthroplasty with the aid of an animal membrane. Am J Orthop Surg 1918;16. 26. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty for the arthritic shoulder: description of a new surgical technique. Tech Shoulder Elbow Surg 2001;2:247–54. 27. Nicholson GP, Goldstein JL, Romeo AA, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elbow Surg 2007;17. 28. Themistocleous GS, Zalavras CG, Zachos VC, et al. Biologic resurfacing of the glenoid using a meniscal allograft. Tech Hand Up Extrem Surg 2006;10(3): 145–9. 29. Creighton RA, Cole BJ, Nicholson GP, et al. Effect of lateral meniscus allograft on shoulder articular contact areas and pressures. J Shoulder Elbow Surg 2007; 16(3):367–72.
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30. Williams GR, Font-Rodriguez D, Baghian S. Soft-tissue interposition without hemiarthroplasty as an alternative for degenerative shoulder arthritis in young, active patients. Presented at Closed Meeting of American Shoulder and Elbow Surgeons. Pebble Beach, California, October 2002. 31. Bhatia DN, van Rooyen KS, duToit DF, et al. Arthroscopic technique of interposition arthroplasty of the glenohumeral joint. The Arthroscopy 2006;22(5):570. e1–5. 32. Brislin KJ, Savoie FH, Field LD, et al. Surgical treatment for glenohumeral arthritis in the young patient. Tech Shoulder Elbow Surg 2004;5(3):165–9. 33. Matsen FA, Clark JM, Titelman RM, et al. Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model. J Orthop Res 2005;23:18–26. 34. Lynch JR, Franta AK, Montgomery WH Jr, et al. Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming. Journal of Bone & Joint Surgery Am 2007;89(6):1284–92. 35. Krishnan SG, Nowinski RJ, Harrison DK, et al. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: 2–15 year outcomes. J Bone Joint Surg Am 2007;89:727–34. 36. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. J Bone Joint Surg 1998; 80-A(4):464–73. 37. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg 2004;13(6):604–13.
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Early glenohumeral degeneration is, at best, a difficult condition for the competing athlete. This is especially true of athletes who participate in overhead sports of baseball, tennis, swimming, and volleyball. However, competitors in football, basketball, and soccer may also find themselves saddled with severe posttraumatic, post-reconstruction, or primary cartilage loss in their shoulders. Unfortunately, this may lead to impeded performance, and, ultimately, derailed careers. Fortunately, for the orthopedic surgeon, this is not a common condition. However, those who have been involved in the care of the performing athlete with early arthritis can attest that the problem is vexing and the best possible treatment unclear. Although total shoulder arthroplasty in older, more sedentary individuals has been shown to reliably relieve pain and improve function, this is not an ideal procedure for the competitive athlete due to concerns about implant longevity, not to mention altered biomechanics. This therapeutic challenge has spurred the development of alternative approaches to treat glenohumeral arthritis in competing athletes. These approaches include various conservative management strategies as well as arthroscopic procedures, partial or total humeral surface replacement, interposition, and glenoid biologic resurfacing. These approaches, together with traditional arthroplasty, make up the armamentarium of options for the treatment of glenohumeral arthritis in the young athlete. The challenge lies in deciding which option is best for each situation. CLINICAL PRESENTATION
The clinical presentation of early osteoarthritis (OA) in the competitive athlete can be similar to that seen in the general population. The patient may complain of a deep, aching-type pain localized to the glenohumeral joint that is often present at night. Loss of varying degrees of range of motion (ROM) and occasional locking from
Shoulder and Elbow Service, W.B. Carrell Memorial Clinic, 9301 North Central Expressway, Suite 400, Dallas, TX 75231, USA * Corresponding author. E-mail address: [email protected] (S.G. Krishnan). Clin Sports Med 27 (2008) 803–819 doi:10.1016/j.csm.2008.07.004 sportsmed.theclinics.com 0278-5919/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
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intra-articular loose bodies may also be present. However, competitive athletes are unique in that they may be functionally disabled by symptoms that may not affect the average sedentary individual. High performance is born of high demand on the glenohumeral anatomy. Therefore, if the anatomy of the shoulder is unable to meet this demand, performance will consequently suffer. Thus, slight losses of ROM virtually unnoticed by the general population may be devastating to the competitive athlete. As a result, one must pay particular attention to the complaints of these athletes, as delay in diagnosis may have career-ending implications. For instance, pain in the mid-ROM is more suggestive of cartilage degeneration than that at the extremes, as found in the more common entity of impingement and cuff pathology. RADIOGRAPHS
One should obtain routine anteroposterior and axillary lateral radiographic views in all competing athletes complaining of shoulder pain. Radiographic changes of primary and secondary osteoarthritis include joint space narrowing, subchondral sclerosis and cysts, and osteophytic spurring of the inferior humeral and glenoid articular surfaces, with a posterior-inferior erosion pattern of the humeral head on the glenoid. The Samilson and Prieto classification,1 originally described for post-dislocation arthropathy, is based on these changes seen on an AP radiograph and is graded as mild, moderate, or severe. Mild arthrosis is characterized by a less than 3 mm spur projecting off of the humerus, glenoid, or both. Moderate arthrosis displays osteophytes measuring between 3 and 7 mm off of the humerus, glenoid, or both, with slight glenohumeral joint irregularity. Severe arthrosis has osteophytes measuring greater than 8 mm off of the humerus, glenoid, or both, with joint space narrowing and sclerosis (Fig. 1). Studies have shown this classification system to be reliable.2–5 Additional x-ray films, such as the apical oblique view and the Stryker notch view, may be helpful in identifying degenerative changes in the anteroinferior glenoid and humeral head notching, respectively. Furthermore, computed tomographic (CT) scans
Fig. 1. Grade 3 Samilson and Prieto classification of severe arthritis.
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may be helpful in defining the extent of posterior glenoid wear, whereas magnetic resonance imaging (MRI) has been useful in demonstrating isolated cartilage lesions. NONOPERATIVE MANAGEMENT Education
An initial explanation of the arthritic process and discussion of its probable future implications constitute an important first step in treating all patients, especially the competing athlete. This helps ensure that the athlete’s expectations are consistent with the prognosis. Education and encouragement also promote compliance, with appropriate exercise and avoidance of detrimental activities. The goals of treatment and anticipated improvements should also be discussed. Unfortunately, this may mean that the patient adjust his or her expectations or, in extreme cases, career direction. Patients with arthritis must be taught to interpret their own symptoms to provide information important in determining appropriate therapy. They contribute to the exercise plan and assume responsibility for its implementation. The patient’s active contribution to treatment fosters a sense of control over the effects of the disease. This approach will help physicians teach patients how to manage and best enjoy the highest quality of life that is possible through the technologic achievements of present-day operative and nonoperative interventions for their arthritic shoulders. Anti-inflammatory and Analgesic Medications
Oral analgesics, such as salicylates, acetaminophen, and codeine, can be very effective in treating arthritic pain. The role of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating patients with symptomatic inflammatory arthropathies is well established. These drugs are also commonly used in the setting of noninflammatory osteoarthritis. Regardless of the anti-inflammatory or analgesic medication used, patients should be counseled as to the potential renal, hepatic, or gastric side effects of these drugs. Corticosteroids
Local anesthetic injections are of great value in diagnosing shoulder conditions by localizing the anatomic site of the pain generators. Appropriate steroid injections have also been documented to have significant therapeutic value.6 Although the use of intra-articular steroids can be effective in abating symptoms in joints afflicted with rheumatoid arthritis (RA), they are generally of comparatively limited value in osteoarthritis (OA), typically providing relatively short-term relief of symptoms. Dacre and colleagues7 studied the prospective, randomized, blinded results of local steroid injections or physiotherapy in treating patients with painful or stiff shoulders with RA. Sixty consecutive patients of similar age, sex, diagnosis, and disease severity were allocated into 3 groups to receive either local steroids, 6 weeks of physiotherapy, or both. Results showed that physiotherapy alone was just as effective as local steroid injections or a combination of these 2 methods. In the uncomplicated case, a local steroid injection was the most cost-effective treatment. Similarly, recently published meta-analyses of the peer-reviewed literature regarding the use of corticosteroid injections used for periarticular and intra-articular shoulder pain document variable success.6,8 Patients with subacromial pathology (such as rotator cuff disease) and those with varying degrees of stiffness/capsulitis statistically benefited from the use of corticosteroid injections. Results for treatment of OA remained difficult to interpret. Anecdotally, the authors have found that if a single intra-articular water-soluble corticosteroid injection is helpful, then another can be
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performed at a 6-month interval (no more often than 2 injections per year). If the first injection provides minimal relief (assuming a truly intra-articular position of the injection—if there is any doubt, fluoroscopic imaging should be considered), then further corticosteroid injections are likely to have little potential benefit.
Viscosupplementation
Peer-reviewed publications over the past decade have documented the apparent statistical benefit of intra-articular injections of hyaluronic acid in the treatment of knee and hip OA for pain relief. Unfortunately, neither in vitro nor in vivo studies have demonstrated a chondroprotective effect of either low- or high-molecular weight hyaluronic acid, and the probable effect of these substances on the human joint (if any) appears to be symptomatic relief of joint pain by an unknown mechanism. Further work is in progress regarding the use of intra-articular glucosamine and whether it is of any value from a pain-relieving and/or chondroprotective standpoint. Viscosupplementation of the glenohumeral joint has demonstrated much more variable clinical results. There remains no peer-reviewed, double-blinded, prospective, randomized clinical trial documenting any benefit of such injections when compared with simple corticosteroid injections in the shoulder. Nevertheless, as with any other treatment modality, there may still be a benefit in certain patients who seek to avoid operative treatment for their glenohumeral arthritis. These indications have not been clarified, as yet because there are currently no specific published data regarding glenohumeral viscosupplementation in the competing athlete.
Physical Therapy General principles
Although nearly all patients with glenohumeral arthritis will benefit from physical therapy, those who benefit most begin with decreased ROM and weakness in the presence of minor roentgenographic findings. Occasionally, an initial period of rest may be beneficial. However, an excessive period of rest can contribute to muscle atrophy, joint contractures, and worsening functional abilities. The aim of physical therapy is to increase ROM and strength. Nevertheless, therapy should not be considered a failure if the result is only the maintenance of the existing ROM. Exercises are designed specifically for the needs of each patient—this includes gentle passive motion and isometric strengthening. Preferential strengthening of specific muscle groups is especially beneficial for patients with mild OA and generalized ligamentous laxity. Although acting in nearly diametric ways, heat and cold are therapeutically useful when employed at appropriate times in chronic and acute phases of inflammatory pain. Cold treatment is useful in treatment of acute inflammatory flare-ups; the analgesic effects have been attributed to the ability of cold to depress the excitability of nerve fibers and muscle spindles, thereby increasing the pain threshold. Cutaneous vasoconstriction and resulting reduction in blood flow reduce edema even in deeper tissues. When inflammatory pain is chronic, then the application of heat, usually in the dry form, is useful in temporizing pain and enhancing joint motion by increasing tissue elasticity. Increased tissue metabolic activity also accompanies the increased blood flow resulting from vasodilatation. Heat can be delivered superficially by using hot packs, hot water, or convective fluid therapy, while therapeutic ultrasound can be used for deeper penetration (see later section).
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Hydrotherapy
The therapeutic efficacy of water therapy cannot be overstated. This remains a mainstay in the rehabilitation of any glenohumeral joint, especially in the arthritic one. Buoyancy effects of water help to reduce stress exerted on muscles and joints during therapeutic shoulder exercises. The patient’s exertion can also be regulated because of the direct relation between the speed of movement and the resistance encountered. Adjustments in water temperature and agitation enhance the beneficial effects of hydrotherapy. Therapeutic ultrasound
The clinical usefulness of therapeutic ultrasound is based primarily on its capacity to increase blood circulation and temperature in deep tissues. Tissue temperature can be elevated at depths up to 5 cm from the point of application on the patient’s skin, and peak temperatures occur in bone. When the treatment objective is to heat muscle tissue, the most effective modality currently available is shortwave diathermy. Application of heat and cold, hydrotherapy, ultrasound, and ROM and strengthening exercises are commonly used modalities for helping restore mobility to the stiff shoulder. These and other nonoperative therapeutic interventions are contraindicated in patients who have severe pain and a rapidly deteriorating condition, because this scenario could imply concomitant occult sepsis.
Exercises
Functional limitations are second only to pain in the frequency of complaints in patients with glenohumeral arthritis. However, the functional goals of the competitive athlete are decidedly different from those of the general population, with livelihood depending on such activities as maintaining pitch velocity, pass accuracy, or serving strength. Physical therapists, especially occupational therapists attuned to the needs of competitive athletes, can assist these patients by instructing them in particular exercises that promote increased ROM and increased strength while facilitating scapular stabilization. Specifically, strengthening of the rotator cuff, with emphasis on scapular stabilization, will help reduce shear forces across the glenohumeral joint, thus reducing pain and further degeneration. Examples of specific exercises aimed at promoting ROM include capsular stretching, wall walks, and pulley exercises (Fig. 2). Exercises aimed at scapular stabilization include scapular pinches and scapular rows (Fig. 3). Finally exercises that focus on strengthening and plyometrics are used (Fig. 4).
Authors’ Preferred Treatment Regimen
For any athlete with radiographic evidence of glenohumeral arthritis and symptoms of pain and decreased function, a course of therapy is begun that includes antiinflammatory agents, activity modification, intra-articular cortisone injection, and physical therapy. Corticosteroid injections are offered only twice a year. If the patient returns within 6 months of the second steroid injection, a course of viscosupplementation is offered. If he or she continues to have pain and progression of arthritis characterized by further loss of motion and radiographic changes after completing this course of conservative therapy, nonoperative treatment is considered a failure, and surgical management options are discussed.
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Fig. 2. (A) Pectoralis minor stretching. (B) Posterior capsular stretching. (C) Wall walks with exercise ball. This also works on the scapular stabilizing musculature. (D) Pulley exercises.
Fig. 3. (A) Standing rows, (B) Sitting rows. This can be combined with weights for strength training.
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Fig. 4. Plyometric exercises.
OPERATIVE MANAGEMENT Arthroscopic Techniques Debridement /capsular release
Arthroscopic debridement or lavage for arthritis has been successfully used in the weight-bearing joints of the lower limb, particularly the knee. In many cases, this may be the result of a strong placebo effect. In contrast to the knee, the benefits of, and indications for, arthroscopic debridement in the shoulder are not as clear, especially with reference to the athlete’s shoulder. However, there is some evidence in the general population that arthroscopic debridement may be of some benefit. According to Cameron and colleagues,9 the ideal candidate for arthroscopic debridement is one with a congruent, well-centered joint, little or no osteophyte formation, mild or no subchondral sclerosis or cyst formation, and an osteochondral lesion that does not exceed 2 cm2. Krishnan and colleagues10 agree that patients should have a congruent glenoid but have also commented on the importance of having at least 20 of external rotation and congruity of the glenohumeral articulation. There have been some encouraging reports in the literature regarding the results of arthroscopic debridement for early arthritis. In the report by Cofield11 on 8 patients who underwent arthroscopic debridement for previously unrecognized arthritis, all 8 patients improved postoperatively. Johnson12 later stated that the results of arthroscopic debridement for osteoarthritis would depend on the degree of involvement of the joint. Ogilive-Harris and Wiley13 followed 54 patients treated with arthroscopic debridement for osteoarthritis for 3 years. They concluded that the more severe changes were associated with poorer results. Patients with mild changes had a successful outcome two thirds of the time, whereas only one-third of patients with severe change had successful outcomes. A favorable outcome was associated with removal of osteoarthritic debris, restoration of motion, and debridement of degenerative labral tears, which they likened to degenerative tears of the meniscus in the knee. Weinstein and colleagues14 reported on 27 patients who underwent arthroscopic debridement for a diagnosis of degenerative joint disease. Treatment included joint lavage, loose body removal, degenerative cartilage debridement, labral and/or soft
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tissue debridement, and subacromial space bursectomy. An average follow-up of 30 months showed 78% satisfactory results, with 67% of patients able to return to their previous level of activities. In a later report, Weinstein and colleagues15 performed glenohumeral lavage, labral and chondral debridement, loose body removal, partial synovectomy, and subacromial bursectomy in 26 patients. Twenty-one patients had good or excellent results. Optimum results were achieved in patients with a concentric joint and visible joint space on an axillary radiograph. The authors reported on 37 patients with a mean 2-year follow-up.10 Their approach included acromioplasty, biceps tenodesis or tenotomy, capsular releases, debridement, and excision of the distal clavicle. Preoperatively, mean active ROM was 82 of elevation, 5 of external rotation (ER) (range, 35–80 ), and internal rotation (IR) to the sacroilliac (SI) joint. Mean simple shoulder test (SST) score was 5.8. Pain level averaged 6.3 (0 5 no pain; 10 5 worst pain). Postoperatively, mean active ROM was 124 of elevation, 37 of ER, and IR to L3. Mean SST score was 8.5 and pain level averaged 2.8. (P<.01 for all measures). Good or excellent results by the SST score occurred in 77% of patients. Mean patient satisfaction score was 8.3 (0 5 unsatisfied; 10 5 completely satisfied). Eighty percent of patients stated that they would undergo this procedure again. Nineteen percent of these patients (3/37) required revision to total shoulder arthroplasty. All 3 of these patients were noted to have biconcave glenoids (Walsh B1 or B2) before arthroscopic debridement. However, extrapolation of these generally good results to an athletically active population is difficult, because there were no individuals identified as athletes within these groups. As the arthritic process advances, the anterior capsule becomes constricted, restricting external rotation, effectively causing increased forces to be placed onto the articular cartilage as a result of the abnormal glenohumeral motion. Hawkins and Angelo16 recognized this entity in 10 patients (11 shoulders) who had had PuttiPlatt capsulorrhaphies for anterior shoulder instability with an overly tightened anterior capsule. Most of these patients responded to conservative treatment measures, whereas 4 underwent surgical release of the anterior capsule with good results. They theorized that relieving the pressure on the chondral surfaces from the tight anterior capsule could delay the progression of arthritis. Therefore, it has been suggested that capsular releases be performed in patients with loss of motion, especially in external rotation, associated with mild to moderate OA. Obviously, this has the potential to affect the throwing and/or hitting mechanics in the overhead athlete. For this reason, a detailed discussion regarding expectations is paramount before surgery. In the study by Ogilvie-Harris and Wiley,13 14 of the 54 patients they treated with arthroscopic debridement had an associated frozen shoulder. Lysis of adhesions or manipulation under anesthesia was used to restore motion in cases of severe motion restriction. If a loss of more than 20 of passive motion of the shoulder was apparent, compared with the contralateral side, arthroscopic capsular releases were performed with good results. The authors have also reported on the use of capsular releases combined with other arthroscopic procedures for glenohumeral arthritis.10 Overall, all patients had improvements in pain and function postoperatively. Average postoperative ROM improved by 42 in forward flexion and 32 in external rotation. Competitive athletes with glenohumeral degenerative changes often have concomitant subacromial pathology. Often, impingement-type lesions and proliferative bursae are secondary to altered biomechanics coupled with excessive demand on the joint. Therefore, subacromial decompression is often coupled with debridement and capsular release in this patient population.
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Guyette and colleagues17 performed a retrospective review of 36 patients with glenohumeral degenerative joint disease who underwent arthroscopic subacromial decompression and were followed an average of 5 years. Patients with Outerbridge grades I, II, or III demonstrated equal or improved ROM postoperatively. Only 1 of 10 patients with Outerbridge grade IV lesions showed improvement. Two of these patients went on to receive hemiarthroplasty. Ellowitz and colleagues18 reported on 21 patients who were found to have grade IV osteoarthritic changes at the time of arthroscopic subacromial decompression. Follow-up of 19 of their patients for an average of 37 months revealed improvement in ROM, strength, pain relief, and ability to return to their sport of choice in all patients. Likewise, Cameron and colleagues9 also reported on patients with grade IV lesions. They performed arthroscopic debridement, with or without arthroscopic capsular release, acromioplasty, distal clavicle resection, and labral debridement or repair in 61 patients. Forty-five patients were available for 2-year follow-up. Pain and function were improved in 88% of all patients. Lesions greater than 2 cm2 were predictive for return of pain and ultimate failure of the procedure. Conversion to hemiarthroplasty occurred in 6 patients. All had lesions greater than 2 cm2. Authors’ preferred treatment Indications The authors proceed with arthroscopic management when the patient
meets the following criteria: 1. 2. 3. 4. 5.
Failure of nonoperative treatment Preservation of the joint line on axillary lateral radiograph Minimal to no biconcave pattern of glenoid erosion Maintained acromiohumeral distance greater than 6 mm External rotation of at least 20 .
The following procedures are preferred, combined with debridement of the glenohumeral joint: 1. 2. 3. 4.
Intra-articular debridement/synovectomy Capsular releases Subacromial decompression Distal clavicle resection (if there is clinical and radiographic evidence of arthrosis).
Technique After induction of general anesthesia, the patient is placed in the beach
chair position. The posterior and anterior portals are created. The anterior portal is placed for easy access for later distal clavicle resection. A cannula is inserted into the anterior portal, and the joint is lavaged to remove all loose bodies. At this point, performing the capsular releases is preferred, if indicated, so that the articular cartilage in tight joints is not injured, while attempting joint inspection. An ablation device is inserted into the anterior cannula and used to release the tight rotator interval from the anterior edge of the supraspinatus to the superior edge of the subscapularis tendon until the fibers of the coracoacromial ligament can be seen. The anterior capsule is released adjacent to the labrum to expose the fibers of the subscapularis to approximately the 5-o’clock position to increase external rotation. The inferior capsule is left alone to protect the axillary nerve. The arthroscope is then switched to the anterior portal for release of the posterior capsule, but only if there is no evidence of posterior subluxation of the humerus on the glenoid both radiographically or arthroscopically, and if there is a lack of internal rotation compared with the contralateral side. An angled incisor blade is then placed into the posterior portal and used to resect approximately 1 cm of posterior capsule adjacent to the labrum. The ablation
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device is then placed into the posterior portal and the release is completed to the 7-o’clock position. On completion of the capsular release, the articular surfaces are inspected for degenerative changes, including marginal osteophytes, eburnated cartilage, and posterior wear of the glenoid, which can create a biconcave surface. All loose bodies are removed from the axillary pouch. The trocar and cannula are then passed through the posterior portal into the subacromial space and out the anterior portal just lateral to the coracoacromial ligament. A cannula is slipped over the trocar and the arthroscope is placed through the cannula in the posterior portal. The arthroscope is slid backward out of the anterior cannula, and the undersurface of the anterolateral corner of the acromion is visualized. A spinal needle is used to establish a lateral portal, usually 2 finger-breadths distal and lateral to the anterolateral corner of the acromion. The ablation device is used to debride the coracoacromial ligament and periosteum off of the anterior acromion. An arthroscopic 4.0-mm full-radius Acromionizer burr (Dyonics, Smith & Nephew Inc., Andover, Massachusetts) is used to flatten the undersurface of the acromion. The arthroscope is transferred to the lateral portal and the burr to the posterior portal. The remaining medial spur is visualized and resected with the burr. The 4.5-mm shaver is then placed into the posterior portal, and the bursectomy is performed. Attention is then turned to the acromioclavicular (AC) joint, if there is preoperative evidence of AC joint degeneration. The arthroscope is placed into the lateral portal. The ablation device is placed into the anterior portal and the capsule and periosteum are cleaned off of the joint, making sure not to detach the deltoid fibers. The burr is then used to resect approximately 7 mm in males and 5 mm in females of the distal clavicle and approximately 2 mm off of the medial acromion to create a space of approximately 1 cm, leaving the superior capsule intact to control the anterior-toposterior translation of the remaining distal clavicle. The subacromial space is then irrigated and all portals are closed. The shoulder is then manipulated throughout a full ROM in flexion, abduction, external rotation, and internal rotation, with the arm in 90 of abduction, to obtain any final degrees of motion. Postoperatively, the patient is allowed passive motion immediately. No sling is used. The patient is sent home with instructions for passive motion with pendulum, pulley, stick, and internal rotation up the back to be performed 3 to 5 times a day. At 3 weeks, the patient is started on active-assisted exercises. At 8 weeks, Thera-Band (Hygenic, Akron, Ohio) low-resistance exercises are begun in internal and external rotation only. These exercises are to be performed every other day. At 12 weeks, resistance exercises are progressed to all planes. Outcome
The results of a combined arthroscopic procedure, including debridement, capsular releases, subacromial decompression, and AC joint excision for glenohumeral arthritis, have been reported.10 Thirty-three consecutive patients with a mean age of 62 years and minimum 2-year follow up were evaluated. Excellent results were reported in 15 patients (46%) and good results in 10 patients (31%). Overall, 77% achieved a satisfactory outcome (excellent or good result). Five patients (15%) reported fair results, and 3 patients (8%) reported poor results. Three patients required revision to arthroplasty at an average of 28 months (range, 12–48 months) after arthroscopy. All 3 cases initially presented with a biconcave glenoid as diagnosed by axillary radiographs. The mean patient pain score (0 5 no pain; 10 5 worst pain) improved from 6.3 preoperatively to 2.8 at final follow-up, with 80% of patients indicating that they would have the surgery again. Average postoperative motion increased
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for forward elevation by 42 and for external rotation by 32 . Workers’ compensation patients obtained inferior subjective results overall; however, improvements in pain and function were found in all patients. OPERATIVE MANAGEMENT Arthroplasty
Unfortunately, there are those competitive athletes for whom the procedures stated here are either not indicated (eg, biconcave glenoid) or not efficacious. This presents a significant therapeutic dilemma to both the patient and the surgeon. Arthroplasty in all its forms (resurfacing, hemiarthroplasty, biologic resurfacing, and total joint arthroplasty) can reliably provide pain relief. However, this is often at the expense of the high functional level demanded by the competing athlete. Furthermore, concerns of implant longevity are amplified. Therefore, decisions to proceed with arthroplasty must be carefully made between the patient and surgeon, while ensuring full understanding of the implications and subsequent expectations of performance. Humeral Surface Replacement (Copeland)
Originally developed in 1979 and instituted clinically in 1986, the cementless surface replacement arthroplasty has been used for all types of arthritis in various situations. It involves a small, press-fit, metallic resurfacing of the humeral head, which requires minimal resection of the humeral head and no reaming of the humeral canal (Fig. 5). Hydroxyapatite coating was added in 1993 to increase the ingrowth potential. There are many potential advantages to using this stemless prosthesis. Because there is no stem in the shaft of the humerus, stress risers and the risk of subsequent fractures at the end of the prosthesis are avoided. Revision surgery to either a total shoulder arthroplasty or arthrodesis can be done with ease in light of the substantial remaining bone stock and the lack of cement fixation. In Copeland and colleagues’ recent report in patients 50 years or younger, the results were comparable to traditional, stemmed prostheses.19 Average follow-up was 8.2 years (2.0–14.8 years). Twenty-two hemiarthroplasties and 17 total shoulder
Fig. 5. Humeral resurfacing implant.
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arthroplasties were performed. The average Constant score improved by 41 points. Active elevation improved in all patients, most dramatically for patients with avascular necrosis. Radiolucent lines less than 1 mm were seen in 73% of glenoid components and 7% of humeral components. No lucencies greater than 1 mm were noted. Two patients required conversion to arthrodesis, secondary to active infection in one and persistent instability in the other. Thomas and colleagues20 reported encouraging follow-up in the short term on close to 3-year follow-up on 52 patients with isolated humeral resurfacing. The mean age was 70 years (range, 34–84 years). They demonstrated significant improvement in the Constant score (16.4 preoperatively to 54 postoperatively), with only 1 case of aseptic loosening requiring revision to a stemmed component. Similarly, Bailie and colleagues21 reported on 36 patients with a mean age of 42.3 years and an average of 38-month follow-up. He demonstrated no radiographic evidence of loosening and significant improvement in American Shoulder and Elbow Surgeons (ASES) scores. Interpositional Arthroplasty and Biologic Glenoid Resurfacing Introduction
The concept of using biologic materials for the resurfacing of articular surfaces is not a new one. As early as 1860, Veneriel described a fascial arthroplasty of the temporomandibular joint.22 In 1904, Murphy performed fascial arthroplasty of the knee and elbow as well as the shoulder,23 using the fat that remained attached to the fascia to further decrease the coefficient of friction. MacAusland, in a 1921 review, detailed all of the materials that had been used to realign human joints.24 Attempts using nonabsorbable materials included the use of ivory pegs, magnesium sheets, wood, celluloid, gutta percha, gauze packing, yellow wax and lanolin, cellophane, nylon, and rubber. Techniques using autograft were also numerous and included attempts using periosteum, fascial and muscle flaps, bursal flaps, fat, cartilage transfers, and skin. Xenograft with chromatized pig bladder has also been described.25 Currently, uncemented or cemented humeral hemiarthroplasty with biologic resurfacing of the glenoid in young, active individuals with post-reconstruction, posttraumatic, and primary osteoarthritis is favored. Resurfacing of the glenoid is achieved with either autograft or allograft materials. Ipsilateral anterior capsule or autogenous fascia lata have been used extensively in the early reports documenting the non-prosthetic biologic resurfacing of the glenohumeral joint. Unpredictable outcomes and concerns regarding the durability of those tissues have led to a predominance of allograft usage for either interposition arthroplasty or biologic resurfacing. Classically, the allograft of choice has been Achilles tendon. Tendo Achilles allograft is durable, low cost, and readily available. The collagen makeup of the Achilles tendon lends itself very well to beneficial wear characteristics on the glenoid surface. Recent work has demonstrated the significant intermediate- and longer-term wear characteristics of the tendo Achilles allograft in resisting glenoid erosion and maintaining glenohumeral joint space.26 However, technical considerations and concerns for overstuffing or lateralizing the joint have led some to abandon the use of bulky materials in favor of more manageable materials, such as allograft meniscus. Ball and colleagues26 were the first to describe the use of this type of allograft. In addition to less bulk, theoretical advantages include an established history of synovial healing when used in the knee and a wedge shape that compensates for pre-existing posterior glenoid wear. Ball and colleagues reported that their initial results in 6 shoulders at an average 24-month follow-up showed promising patient satisfaction, pain relief, and significant improvements in ROM. Radiographic results in these patients were also promising with no glenoid
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erosion and maintenance of the glenohumeral joint space. More recent reports have also demonstrated similar success in the short term.27,28 Furthermore, a current biomechanical study suggests that these grafts are durable under physiologic and pathologic loads across the shoulder joint.29 Unfortunately, this graft choice is more expensive, less readily available, and there are no peer-reviewed reports documenting long-term outcomes with regard to progressive glenoid erosion. Another alternative is human dermal collagen allograft (GraftJacket). Although these grafts incur a larger expense, the potential gain is a durable surface much like the tendo Achilles graft that is easier to handle and work with in the surgical setting. The reduced bulk of this type of graft choice, when compared with the tendo Achilles allograft, may promote a more anatomic restoration of glenohumeral anatomy (Fig. 6). Nevertheless, the durability of this graft over time is still unknown. Additionally, Williams has reported on interpositional arthroplasty alone for the treatment of young patients with end-stage glenohumeral arthritis.30 He reported good pain relief and improved function in a series of 6 patients treated between 1997 and 2000. In 5 of these patients, anterior capsule was used. In all cases, the humeral head was debrided of osteophytes but otherwise left unchanged. The 6 patients in his series were an average 38 years of age, and all had a chief complaint of incapacitating pain secondary to degenerative arthritis. At average 27-month follow-up, patients showed improvement in ROM, with improved postoperative PENN shoulder score and all patients rating their shoulders as being good/excellent according to the UCLA end-result score. Furthermore, Bhatia and colleagues31 and Brislin and colleagues32 have explored performing interpositional arthroplasty without hemiarthroplasty using arthroscopic techniques, demonstrating encouraging results in the short term. Although arthroscopic in nature, the underlying principles nonetheless are the same as those in open surgery: there is restoration of the glenoid version as necessary (with an arthroscopic burr), preparation of the glenoid surface (with microfracture), and suturing of the interpositional graft to the labrum and capsule (arthroscopically). Conversely, the recent work of Matsen et al33 suggests that good results may be achieved without interpositional graft at all. Using a canine model, they performed humeral hemiarthroplasty combined with reaming of the glenoid and no resurfacing. At 10 weeks, the glenoid was partially covered with a fibrous tissue and there was bone formation at the margins, with maintenance of the concavity of the glenoid. At
Fig. 6. Glenoid resurfaced with human allograft dermis.
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24 weeks, there was considerably more healing, with formation of a thick fibrocartilaginous layer covering the glenoid.33 Their early clinical results are also encouraging, demonstrating improvement in the simple shoulder test scores at 2- to 4-year follow-up.34 The author’s longer-term, 2- to 15-year outcomes of biologic resurfacing of the glenoid with humeral hemiarthroplasty for the treatment of glenohumeral arthritis were recently published.35 Thirty-four patients (36 shoulders) were treated between 1988 and 2003. Patient age averaged 51 years with a predominant diagnosis of primary glenohumeral arthritis (18/36). Post-reconstructive arthritis (12/36), posttraumatic arthritis (5/36), and avascular necrosis (1/36) comprised the remainder of the cases. Biologic resurfacing with cemented or cementless humeral head replacement was performed in all cases. A variety of biologic surfaces, including anterior capsule (7 cases), autogenous fascia lata (11 cases), and tendo Achilles allograft (18 cases), were used, reflecting the evolution of the technique over time. Patients treated with the senior author’s (J.R.R.) current, preferred technique, using allograft dermis GraftJacket, were not included in this particular series. Patients were evaluated clinically before and after surgery with the ASES score and improved on average from a score of 39 preoperatively to a score of 91 postoperatively. Average active anterior elevation improved from a mean of 70 preoperatively to a mean of 140 postoperatively. There was likewise improvement in external rotation from 5 preoperatively to 50 postoperatively, and internal rotation improved an average of 6 spinal levels. By Neer’s criteria, there were 18 excellent, 13 satisfactory, and 5 unsatisfactory results. Unsatisfactory results were associated with infection, early re-injury, and the use of capsule as an interposition material. Of the 5 poor results, 4 had undergone resurfacing with anterior capsule and 1 with autologous fascia lata. None of the patients resurfaced with Achilles tendon allograft had an unsatisfactory result. The reason for failure was pain and instability in 3 patients treated with anterior capsule. Infection was the reason for failure in the remaining 2 patients with unsatisfactory results. This included 1 patient treated with autologous fascia lata who failed. In addition, 1 case of brachial plexitis and 1 upper extremity deep vein thrombosis represented the complications associated with this series. Radiographic evaluation showed stable humeral components in all cases both with cemented and cementless stems. Glenoid erosion averaged 7.2 mm but appeared to stabilize at approximately 5 years. Glenohumeral joint space was obliterated in all cases preoperatively. Immediately postoperatively, this improved to an average of 2.9 mm. The final mean joint space was measured at 1.3 mm. Traditional Arthroplasty
Shoulder arthroplasty is currently the gold standard for the treatment of end-stage glenohumeral arthritis in the general population with severe pain and dysfunction unrelieved by conservative measures. However, the active competitive athlete who undergoes this procedure is at greater risk of failing secondary to the likelihood of decreased longevity of the prosthesis. Therefore, if these patients cannot change their lifestyle to compensate for the extra precautions of shoulder replacement, other forms of treatment should be sought. Sperling et al36 have conducted the most extensive review of shoulder arthroplasty in patients younger than 50 years. Their first report included 114 patients followed for a minimum of 5 years (mean, 12.3 years). They performed 78 hemiarthroplasties and 36 total shoulder arthroplasties for glenohumeral arthritis. Both procedures resulted in long-term pain relief and improved abduction and external rotation. Yet, almost half of
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the patients had an unsatisfactory result. Radiolucent lines were seen around the humeral component in 16 (24%) of the hemiarthroplasties and 17 (53%) of the total shoulders. Nineteen (59%) of the total shoulders displayed radiolucent lines around the glenoid component. Erosion of the glenoid was seen in 46 (68%) of hemiarthroplasties. The most common cause of revision in the hemiarthroplasty group was painful glenoid arthrosis. The authors cautioned surgeons in using hemiarthroplasty or total shoulder arthroplasty in patients 50 years or younger. A follow-up to this study was later performed with a minimum follow-up of 15 years (mean, 16.8 years).37 The results were similar. Sixty percent of hemiarthroplasties and 48% of total shoulders demonstrated unsatisfactory results. Radiolucent lines were evident around the humeral component in 60% of total shoulders and 34% of hemiarthroplasties. Glenoid periprosthetic lucency was present in 76% of total shoulders, and glenoid erosion was seen in 72% of hemiarthroplasties. Again, surgeons were urged to use great care and consider alternative methods of treatment before proceeding with either hemiarthroplasty or total shoulder arthroplasty in patients 50 years or younger. SUMMARY
Glenohumeral arthritis in the competitive athlete can be a devastating condition. Fortunately, it is rare. The mainstay of treatment is conservative and involves NSAIDSs injections, and physical therapy focusing on maintenance of ROM and strength. However, this approach is often unsuccessful, as these individuals depend on a high level of function to maintain their livelihood or active lifestyle. For these patients, arthroscopic debridement and capsular release may provide short-term pain relief and improvement in ROM. Failing this, the athlete needs to make a decision of lifestyle/ livelihood modification versus glenohumeral arthroplasty. If arthroplasty is chosen, various biologic resurfacing options are available and encouraged. Barring this, total shoulder arthroplasty using a standard polyethylene component will reliably provide pain relief and restore function; however, longevity and survival issues preclude recommending this as a first line of treatment. REFERENCES
1. Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am 1983;65:456–60. 2. Brox JI, Lereim P, Merckoll E, et al. Radiographic classification of glenohumeral arthrosis. Acta Orthop Scand 2003;74(2):186–9. 3. Davis MA, Ettinger WH, Neuhaus JM, et al. Correlates of knee pain among US adults with and without radiographic knee osteoarthritis. J Rheumatol 1992;19: 1943–9. 4. Johnson LL. Diagnostic and surgical arthroscopy of the shoulder. St Louis (MO): Mosby; 1993. 239–48. 5. Moseley JB Jr, Wray NP, Kuykendall D, et al. Arthroscopic treatment of osteoarthritis of the knee: a prospective, randomized, placebo-controlled trial. Results of a pilot study. Am J Sports Med 1996;24:28–34. 6. Blair B, Rokito AS, Cuomo F, et al. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78:1685–9. 7. Dacre JE, Beeney N, Scott DL. Injections and physiotherapy for the painful stiff shoulder. Ann Rheum Dis 1989;48:322–5. 8. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev 2003;(1):CD004016.
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9. Cameron BD, Galatz LM, Ramsey ML, et al. Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint. J Shoulder Elbow Surg 2002; 11(1):25–32. 10. Krishnan SG, Nowinski RJ, Burkhead WZ. Combined arthroscopic capsular release, acromioplasty, and distal clavicle resection for end-stage glenohumeral arthritis. Poster presentation at American Shoulder and Elbow Surgeons Closed Meeting, Oct. 8–11, 2003. Dana Point, California. 11. Cofield RH. Arthroscopy of the shoulder. Mayo Clin Proc 1983;58:501–8. 12. Johnson L. The shoulder joint: an arthroscopist’s perspective of anatomy and pathology. Clin Orthop 1987;223:113–25. 13. Ogilvie-Harris DJ, Wiley AM. Arthroscopic surgery of the shoulder: a general appraisal. J Bone Joint Surg Br 1986;68-B(2):201–7. 14. Weinstein D, Bucchieri J, Pollock R. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 1993;9:366. 15. Weinstein DM, Bucchieri JS, Pollock RG, et al. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 2000;16(5):471–6. 16. Hawkins R, Angelo R. Glenohumeral osteoarthrosis: a late complication of PuttiPlatt repair. J Bone Joint Surg Am 1990;72:1193–7. 17. Guyette TM, Bae H, Warren RF, et al. Results of arthroscopic subacromial decompression in patients with subacromial impingement and glenohumeral degenerative joint disease. J Shoulder Elbow Surg 2002;11(4):299–304. 18. Ellowitz AS, Rosas R, Rodosky MW, et al. The benefit of arthroscopic decompression for impingement in patients found to have unsuspected glenohumeral osteoarthritis. Presented at: American Academy of Orthopedic Surgeons Annual Meeting; February 13–17, 1997; San Francisco, CA. 19. Copeland SA, Levy O, Brownlow HC. Resurfacing arthroplasty of the shoulder. Techniques in Shoulder and Elbow Surgery 2003;4(4):199–210. 20. Thomas SR, Wilson AJ, Chambler A, et al. Outcome of Copeland surface replacement shoulder arthroplasty. J Shoulder Elbow Surg 2005;14:485–91. 21. Bailie DS, Llinas PJ, Ellenbecker TS. Cementless humeral resurfacing arthroplasty in patients less than 50 years of age. J Bone Joint Surg Am 2008;90:110–7. 22. Verneriel. Arch Med 1860. 23. Murphy JB. Ankylosis: arthroplasty-clinical and experimental. Transactions of the American Surgical Association 1904;22:215. 24. MacAusland WR. Mobilization of the elbow by free fascia transplantation with report of thirty-one cases. Surg Gynecol Obstet 1921;33:223–45. 25. Baer WS. Arthroplasty with the aid of an animal membrane. Am J Orthop Surg 1918;16. 26. Ball CM, Galatz LM, Yamaguchi K. Meniscal allograft interposition arthroplasty for the arthritic shoulder: description of a new surgical technique. Tech Shoulder Elbow Surg 2001;2:247–54. 27. Nicholson GP, Goldstein JL, Romeo AA, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elbow Surg 2007;17. 28. Themistocleous GS, Zalavras CG, Zachos VC, et al. Biologic resurfacing of the glenoid using a meniscal allograft. Tech Hand Up Extrem Surg 2006;10(3): 145–9. 29. Creighton RA, Cole BJ, Nicholson GP, et al. Effect of lateral meniscus allograft on shoulder articular contact areas and pressures. J Shoulder Elbow Surg 2007; 16(3):367–72.
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30. Williams GR, Font-Rodriguez D, Baghian S. Soft-tissue interposition without hemiarthroplasty as an alternative for degenerative shoulder arthritis in young, active patients. Presented at Closed Meeting of American Shoulder and Elbow Surgeons. Pebble Beach, California, October 2002. 31. Bhatia DN, van Rooyen KS, duToit DF, et al. Arthroscopic technique of interposition arthroplasty of the glenohumeral joint. The Arthroscopy 2006;22(5):570. e1–5. 32. Brislin KJ, Savoie FH, Field LD, et al. Surgical treatment for glenohumeral arthritis in the young patient. Tech Shoulder Elbow Surg 2004;5(3):165–9. 33. Matsen FA, Clark JM, Titelman RM, et al. Healing of reamed glenoid bone articulating with a metal humeral hemiarthroplasty: a canine model. J Orthop Res 2005;23:18–26. 34. Lynch JR, Franta AK, Montgomery WH Jr, et al. Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming. Journal of Bone & Joint Surgery Am 2007;89(6):1284–92. 35. Krishnan SG, Nowinski RJ, Harrison DK, et al. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: 2–15 year outcomes. J Bone Joint Surg Am 2007;89:727–34. 36. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. J Bone Joint Surg 1998; 80-A(4):464–73. 37. Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg 2004;13(6):604–13.
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