Osteoarthritis

 

Shoulder OA

 

Epidemiology

 

Usually after 50-60 years of age

 

Aetiology

 

Primary 90% of cases

 

Secondary

- AVN

- trauma

- instability

 

Pathology

 

Cuff & biceps intact as rule

 

Inferior beard osteophytes

 

Beard osteophyte

 

Retroversion of glenoid due to posterior wear

 

Glenoid retroversion and posterior wear

 

Posterior subluxation not uncommon

 

Shoulder OA Posterior Subluxation

 

Tight anterior capsule & subscapularis limiting external rotation

 

Post traumatic

- always soft tissue contracture

- rotator interval contracted

- malunion of tuberosities leads to impingement and offset of normal cuff action

- non-union results in extensive shortening of cuff

- scarring about axillary nerve

 

Shoulder OA post trauma

 

Post-traumatic OA

 

Signs

 

Global painful restriction of range of movement 

- due to incongruity of joint surfaces

- crepitus

- limitation of ER

 

DDx Limitation ER

- Frozen Shoulder

- Chronic posterior dislocation

- Arthrodesis

 

X-ray

 

Typical changes of OA

1. Teardrop / beard osteophytes on inferior head & glenoid

2. Osteochondral loose bodies

 

Shoulder OAShoulder OA Xray

 

Beard osteophytes

 

Shoulder Loose Body

 

Osteochondral loose body

 

DDx

 

Cuff arthopathy

- proximal migration of head

- subacromial sclerosis

 

Rotator cuff arthropathy

 

Arthroscopy

 

Shoulder OA GlenoidShoulder OA Debridement

 

Management

 

Non-operative

 

ELMPOPI

 

Education

Lifestyle modification

Pharmaceuticals - simple analgesia

Physiotherapy

Injections

 

Injections

 

Hyaluronic Acid

 

Zhang et al. JSES 2019

- systematic review and meta-analysis

- no statistical difference in outcomes between HA and placebo

 

Bone Marrow Aspirate

 

Dwyer et al. Arthros Sports Med Rehab 2021

- RCT cortisone versus bone marrow aspirate for shoulder OA

- 25 shoulders

- improved QuickDASH and EQ5D but not WOMAC at 12 months post injection

 

Platelet rich plasma

 

Randomized trials on clinicaltrials.gov

None published yet

 

Operative

 

Options

 

Arthroscopic debridement

Glenoid resurfacing with glenoid biological resurfacing

Arthrodesis

Replacement

 

1.  Arthroscopic Debridement

 

Shoulder OA Synovitis

 

Technique

 

A.  Glenohumeral joint

- deal with biceps tendon pathology if present (tenotomy / tenodesis)

- synovectomy

- capsular release

- chondroplasty

- remove beard osteophyte

 

B.  Subacromial space

- acromioplasty

- CA ligament left intact

- ACJ resection

 

Results

 

Mitchell et al. AJSM 2016

- 49 shoulders mean age 52 at 5 year follow up

- 26% progressed to total shoulder at mean of 2.6 years

- otherwise significant improvements in clinical outcomes

 

Arner et al. AJSM 2021

- 38 shoulders mean age 53 at 10 year follow up

- 63% 10 years survival

- humeral head flattening and severe joint incongruency risk factors for TSA

 

2. Humeral head replacement with glenoid biological resurfacing

 

Meaike et al. Should Elbow 2020

- 11 studies, 268 shoulders

- revision rate 34%

- another 10% unsatisfactory

 

3.  Arthrodesis

 

Indication

 

May be considered in very young active patient

 

Issues

 

Limited movement

Difficult to perform

 

4.  Arthroplasty

 

Options

 

Hemiarthroplasty (young patient or insufficient glenoid bone stock)

Anatomical TSA

Reverse TSA

 

Results

 

Australian Joint Registry 2021

- 8000 stemmed anatomic TSR

- 15% revision rate at 14 years