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Shoulder Arthritis

  • Signs of advanced shoulder arthritis
    • decreased external rotation 
    • crepitus
  • Normal bony anatomy

    • neck shaft angle 130 degrees
    • retroversion 30 degrees from transepiocndylar distance
  • Etiology

    • primary OA
    • capsulorrphay arthropathy
    • post-traumatic
    • osteonecrosis
    • inflammatory arthritis
  • History

    • pain, stiffness, crepitation, worse at night and with activity
  • Subjective Shoulder Value (SSV)
    • patient’s subjective assessment of shoulder function (0-100%)
    • patients with OA often report this value to be around 30%
  • X-rays

    • get a true AP (Grashey view) and axillary view 
    • posterior wear on the glenoid, best viewable on the axillary
    • inferior humeral head osteophyte on the AP view
    • early on may appear to have good joint space on the AP view, but it is because the wear is more in the weightbearing/superior zone on the humerus and more posteriorly on the glenoid, which you cannot see on the AP view but do see better on the axillary
  • Advanced imaging
    • CT and CT arthrogram
  • Walch Classification

    • best seen on CT scan, more difficult to pick up on radiographs or MRI scan (Lin’s group, JSES study, “can glenoid wear be accurately assessed using x-ray imaging” shows radiographs are poor)
    • Levine et al. paper, JSES 1997, glenoid wear affects outcomes in shoulder hemiarthroplasty
    • A1
    • A2
    • B1
    • B2
    • C
  • Treatment

    • 1st line of treatment nonoperative
      • NSAIDS, activity modification, physical therapy, injections
      • AAOS clinical practice guidelines provide no good insight
    • Early operative Intervention
      • early progressive glenoid bone wear
      • marked asymmetric posterior wear may not be correctible with reaming alone and may require osseous augmentation
    • Decision Making
      • patient age
        • arthroplasty in patients <59 years is double (Dillon et. al, JSES 2015)
      • occupation
      • activity level
      • extent of disease
      • previous surgery
        • 38% of glenoid components fail at 10 years in patients with previous instability surgery (Sterling et. al, JBJS 2002)
        • newer techniques and technology have probably improved this
      • concomitant shoulder pathology
    • Chondral injuries
      • goal is to re-estabilish hyaline or hyaline like cartilage
      • multiple techniques
    • Shoulder arthroplasty

      • predictable improvements in pain and function
      • unlike THA and TKA as there are not the same bony constraints providing stability
    • Hemiarthroplasty vs TSA

      • indications for hemi
        • glenoid “too good”
          • osteonecrosis, fractures, tumor reconstruction
        • glenoid “too bad”
          • e.g. rheumatoid arthritis
        • relative: young laborer where glenoid loosening would be a concern
      • argument against hemiarthroplasty
        • progressive glenoid wear
        • lower 10 and 15 year survival rate compared to TSA
      • in general most studies show better pain relief for TSA
    • Anatomic Total Shoulder Arthroplasty

      • let anatomy guide you
      • appropriate soft tissue tensioning is the key
      • management of net humeral reaction force
        • intrinsic pull of shoulder musculature
        • prevent edge loading of the glenoid
      • aim for
        • 40 ER with arm at side, 50% posterior translation, 60 IR with arm abducted
      • correct version of glenoid back to neutral
        • 1-2 mm of posterior wear, ream high side down
        • 3-5 mm can ream down some and accept some retroversion
        • > 5mm, consider augments 
    • Stemless implants with TSA

      • advantages include preservation of humeral bone stock, possibly technically easier
      • JBJS Churchill et al., patients did well
        • 157 patients with 2 year follow-up
        • 3 patients need revisions
        • significant improvement in patient reported outcomes and pain
    • Reverse Total Shoulder Arthroplasty

      • can use in cases of cuff insufficiency
    • Subscap management
      • peel versus lesser tuberosity osteotomy (LTO) versus sparring versus tenotomy
      • LTO better in biomechanics studies
    • Arthroscopic treatment of shoulder arthritis

      • arthroscopy, chondroplasty, capsular release, biceps tenodesis, SAD, MUA, micro fracture
      • Peter Millett has published on this
        • Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis, AJSM 2017
        • 107 shoulders – TSA candidates
        • 15.8% went on to total shoulder arthroplasty (TSA) at a mean of 2 years
          • factors associated with failure
            • 1.3 vs 2.6mm of joint space
            • higher Kellgren-Lawrence grade
            • age > 50
            • Walch B2 and C glenoid
      • more effective in young people with mild to moderate OA

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