When a younger patient presents with glenohumeral osteoarthritis (OA), what is the best course of action?
Speaking at the International Congress for Joint Reconstruction’s 2nd Annual Las Vegas Shoulder Course, Joseph D. Zuckerman, MD, expressed his preference for initial non-operative treatment, progressing to total shoulder arthroplasty (TSA) with non-cemented glenoid component when non-operative treatment fails.
Dr. Zuckerman emphasized , though, that a number of treatment options are available for the young patient with OA of the shoulder. The problem is, the literature does not provide much evidence for one option over another. What’s clear, he said, is that the treatment plan must be individualized for each patient.
At NYU Langone Medical Center in New York, Dr. Zuckerman manages hip, knee, and shoulder patients. He said that compared with OA in hip and knee joints, OA of the glenohumeral joint can generally be treated more effectively with non-operative options. These include:
Non-steroidal anti-inflammatory drugs
All these are, to a varying degree, effective temporizing measures.
When a patient is ready to move beyond non-operative measures, arthroscopic treatment offers the option of removing chondral flaps, stabilizing cartilage lesions, and reducing the chances of further delamination.
Arthroscopic treatment is sometimes combined with adjunct procedures for pain relief, Dr. Zuckerman said, such as:
Acromioclavicular joint resection
However existing research has yet to confirm whether any of these adjunct procedures contribute to pain relief. And although arthroscopic treatment has the potential to delay the need for shoulder replacement, the prognosis is not good for patients with:
< 2mm joint space remaining
Presence of grade IV bipolar arthritic changes
Outcomes reported in the literature vary, Dr. Zuckerman said, and it is difficult to compare patient groups with regard to severity of disease and procedures performed. But in studies showing best outcomes, 80% of patients improved for up to 3 years. The worst outcomes showed little, if any, improvement, as well as increased stiffness and more symptoms.
Arthroscopic cartilage reparative techniques are another option. However there are still very limited outcomes data to support those techniques. Cartilage restorative techniques are applicable to small, local, full-thickness chondral lesions, Dr. Zuckerman said. But, again, there are limited clinical outcomes data.
When looking at prosthetic replacement, treatment options can be divided into humeral-side-only and humerus and glenoid resurfacing.
Partial humerus replacement: "Ream and run"
Partial humerus replacement (PHR): “Ream and run”
Limited resurfacing (hemicap)
PHR with biologic resurfacing
Humerus and glenoid
Humeral resurfacing with glenoid component
TSA with cemented glenoid
TSA with uncemented glenoid
In the short term, humeral-side resurfacing alone may be a temporizing option to allow glenoid resurfacing to be done when the patient is older.
In the literature, combining PHR with reshaping of the glenoid to better center the humeral head has shown variable results, Dr. Zuckerman said. But some large series have shown results comparable to TSA, only with slower recovery and with better prognosis in older males and in patients with good preoperative function.
When looking at PHR vs. resurfacing vs. hemicap, the decision is mostly based on surgeon experience, and the outcomes primarily depend on operative technique and degree of glenoid degeneration. When done correctly, the results of humeral-side-only resurfacing may rival those of TSA, but at this point the research is not as robust as it should be.
Humeral replacement can be combined with a biologic resurfacing of the glenoid using lateral meniscus, Achilles tendon, or fascia lata. The outcome studies for these procedures vary greatly, with good results at up to 7 years of follow-up in one study, vs. 51% clinical failures in another.
Total shoulder arthroplasty
When total shoulder arthroplasty becomes necessary, Dr. Zuckerman prefers an uncemented glenoid. The advantages of TSA are:
Improved pain relief
The possibility of correcting glenoid morphology vs. the “ream-and-run” procedure
The possible downside to a TSA with uncemented glenoid may be problems with glenoid failure in the long term, Dr. Zuckerman said.
Dr. Zuckerman’s presentation from the 2nd Annual Las Vegas Shoulder Course is available on ICJR.net.