Glenohumeral arthritis in the young patient

Subscapular sparing approach for total shoulder arthroplasty: a systematic review and meta-analysis of comparative studies

Background

Total shoulder arthroplasty has been effective in treating primary glenohumeral arthritis surgically. However, the subscapularis (SSC) tendon must be released as part of the surgery's conventional approach, which could lead to postoperative problems and later tendon failure. Using a procedure that spares the tendon, Lafosse et al reported improved postoperative SSC performance. This meta-analysis will compare this approach to the standard one.

Methods

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched till October 2022. The clinical outcomes consisted of the postoperative pain, adverse events, and range of motion.

Results

Only 3 studies were included in this meta-analysis. The subscapularis sparing approach tended to have better postoperative internal rotation (P = .06) and shoulder elevation (P = .1); however, the results were marginally statistically insignificant.

Conclusion

This is the first meta-analysis to compare the subscapularis sparing to the standard approach in total shoulder arthroplasty. Showing better postoperative range of motion (elevation and internal rotation), the SSC approach might be considered as a good substitute to the standard one. However, it is limited by the potentially limited exposure making it harder to use in muscular and obese patients. More randomized clinical trials are needed to reach more significant results and establish clearer indications of this approach.

The role of the anterior shoulder joint capsule in primary glenohumeral osteoarthritis

The pathogenesis of primary glenohumeral arthritis (GHOA) is mediated by a complex interaction between osseous anatomy and the surrounding soft tissues. Recently, there has been growing interest in characterizing the association between the anterior shoulder joint capsule and primary GHOA because of the potential for targeted treatment interventions. Emerging evidence has shown substantial synovitis, fibrosis, and mixed inflammatory cell infiltrate in the anterior capsule of osteoarthritic shoulders. In addition, increased thickening of the anterior shoulder joint capsule has been associated with greater posterior glenoid wear and humeral head subluxation. While these findings suggest that anterior capsular disease may play a causative role in the etiology and progression of eccentric GHOA, further studies are needed to support this association. The purpose of this article is to review the pathogenesis of primary GHOA, contextualize current hypotheses regarding the role of the anterior capsule in the disease process, and provide directions for future research.

Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival

Background

To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid.

Methods

All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes.

Results

The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients.

Conclusion

Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.

Shoulder Arthroplasty Options for Glenohumeral Osteoarthritis in Young and Active Patients (<60 Years Old): A Systematic Review

Aim

This study aims to describe the shoulder arthroplasty options for young and active patients (<60 years old) with glenohumeral osteoarthritis.

Methods

A systematic review of the literature was conducted by searching on Pubmed database. Studies that reported outcomes of patients with glenohumeral arthritis, younger than 60 years, that underwent shoulder arthroplasty [(Hemiarthroplasty (HA), Hemiarthroplasty with biological resurfacing (HABR), Total shoulder arthroplasty (TSA), Reversed total shoulder arthroplasty (RSA)] were included. Data include patient characteristics, surgical technique, range of motion, pain relief, outcome scores, functional improvement, complications, need for and time to revision.

Results

A total of 1591 shoulders met the inclusion criteria. Shoulder arthroplasty provided improvements in terms of ROM on the 3 plains, forward flexion (FF), abduction (Abd) and external rotation (ER), in different proportions for each type of implant. Patients submitted to RSA had lower preoperative FF (p = 0.011), and the highest improvement (Δ) in Abd, but the worst in terms of ER (vsTSA, p = 0.05). HA had better ER postoperative values (vsRSA p = 0.049). Pain scores improved in all groups but no difference between them (p = 0.642). TSA and RSA groups had the best CS Δ (p = 0.012). HA group had higher complication rates (21.7%), RSA (19.4%, p = 0.034) and TSA (19.4%, p = 0.629) groups the lowest, and HABR had the highest rate of revisions (34.5%).

Conclusions

HA had the highest rate of complications and HABR unacceptable rates of revision. These implants have been replaced by modern TSAs, with RSA reserved for complex cases. Surgeons should be aware of the common pitfalls of each option.

Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review

Background

Novel approaches for anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) that spare the subscapularis (SSC) have recently been described. Outcomes for the SSC-sparing approach were evaluated through this systematic review.

Methods

Medline, Embase, PubMed, and CENTRAL were searched.

Results

From 2051 citations, 8 studies were included (aTSA group, n = 241; rTSA group, n = 68). SSC-sparing aTSA and rTSA were associated with significant postoperative improvements in shoulder function and range of motion at 12- to 24-month follow-up.

Conclusion

The SSC-sparing approach may provide a safe alternative for up to two years post-surgery. Evidence for long-term use remains inconclusive.

Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study

BACKGROUND

Most anatomic total shoulder arthroplasty (ATSA) techniques release and reattach the subscapularis tendon. The risk of failed healing is a widely recognized complication. The purpose of this study was to radiographically compare a traditional deltopectoral (DP) approach and a superolateral subscapularis sparing (SSS) technique through the rotator interval.

METHODS

A single, independent, blinded, reviewer analyzed preoperative and postoperative radiographs of patients undergoing ATSA performed by a single surgeon. The reviewer assessed humeral head height, humeral head medial offset, humeral head diameter, head-neck angle, humeral head centering, and coracohumeral offset, and used the anatomic reconstruction index (ARI) to evaluate overall reconstruction quality.

RESULTS

There were 70 SSS and 20 DP patients included. When comparing preoperative with postoperative differences, we found that there was no difference between groups in humeral head height (P = .19), humeral head medial offset (P = .38), and coracohumeral offset (P = .07). The DP group had a mean humeral head diameter oversizing of 1.4 mm, whereas the superolateral group had an undersizing of 2.8 mm (P < .001). The head-neck angle difference of the SSS approach was 2° greater than that found with the DP group (P < .001). The humeral head centering in the DP group was 7% displaced vs. 12% with the SSS group (P = .001) relative to the glenoid size. The ARI was 7.35 for the DP group and 6.93 for the SSS group (P = .50).

DISCUSSION AND CONCLUSIONS

Radiographic comparison of these 2 ATSA techniques identified no statistical significant difference in 4 of 7 radiographic measurements and ARI. The SSS ATSA is a reasonable approach that yields similar radiographic measurements as a traditional DP total shoulder arthroplasty approach.

Glenohumeral Osteoarthritis in the Young Patient

Glenohumeral osteoarthritis in the young patient (aged <60 years) is a difficult condition, given both age and functional demands. Primary osteoarthritis is the most common etiology in this patient demographic, but secondary causes include osteonecrosis, previous trauma (eg, fracture-dislocation), previous infection (eg, septic arthritis), previous capsulorrhaphy, previous arthroscopic surgery (eg, chondrolysis), and glenoid dysplasia. Nonsurgical modalities, including activity modification, pharmacotherapy, physical therapy, and intra-articular injections, are the mainstay of management; however, in young patients who have exhausted nonsurgical management, surgical options include arthroscopic débridement, humeral head replacement with or without glenoid treatment (ie, biologic glenoid resurfacing, glenoid reaming), and total or reverse total shoulder arthroplasty. Unfortunately, failure rates after surgical management are considerably higher in young patients compared with those observed in older, more sedentary patients. Here, we focus on the etiology, evaluation, and management of young patients with glenohumeral osteoarthritis, with a focus on clinical outcomes.

Glenohumeral kinematics after soft tissue interposition graft and glenoid reaming: A cadaveric study

BACKGROUND

The management of young patients with glenohumeral arthritis is controversial. Resurfacing of the glenoid with biologic interposition and reaming of the glenoid have been suggested as potential treatment options. The goal of this study was to determine the change in glenohumeral contact pressures in interposition arthroplasty, as well as glenoid reaming in an arthritis model. We hypothesized that interposition with meniscal allograft will lead to the best normalization of contact pressure throughout the glenohumeral range of motion.

MATERIALS AND METHODS

Eight fresh-frozen cadaveric shoulders were tested in static positions of humeral abduction with a compressive load. Glenohumeral contact area, contact pressure, and peak force were determined sequentially for (1) intact glenoid (2) glenoid with cartilage removed (arthritis model) (3) placement of lateral meniscus allograft (4) placement of Achilles allograft (5) arthritis model with reamed glenoid.

RESULTS

The arthritis model demonstrated statistically higher peak pressures than intact glenoid and glenoid with interpositional allograft. Meniscal and Achilles allograft lowered mean contact pressure and increased contact area to a level equal to or more favorable than the control state. In contrast, the reamed glenoid did not show any statistical difference from the arthritis model for any of the recorded measures.

CONCLUSION

Glenohumeral contact pressure is significantly improved with interposition of allograft at time zero compared to an arthritic state. Our findings suggest that concentric reaming did not differ from the arthritic model when compared to normal. These findings favor the use of allograft for interposition as a potential treatment option in patients with glenoid wear.

Biologic resurfacing of the glenoid with humeral head resurfacing for glenohumeral arthritis in the young patient

BACKGROUND

Resurfacing of the glenoid with an interposition soft tissue graft in conjunction with humeral head arthroplasty has been proposed as an option to improve glenohumeral arthritis in young patients while avoiding the potential complications associated with total shoulder arthroplasty. There currently exist minimal outcomes data for this procedure, and the results have not been consistent. The purpose of this study was to report on the outcomes in our cohort of patients aged younger than 55 years.

METHODS

A multicenter review of 16 patients who had undergone humeral head arthroplasty with soft tissue interposition grafting of the glenoid was performed. All patients had a minimum follow-up time of 24 months, unless revision surgery was required because of failure of the procedure.

RESULTS

At a mean follow-up of 60 months, the patients showed improvement in the visual analog scale score for pain from 8.1 to 5.8 (P < .05), and the American Shoulder and Elbow Surgeons score improved from 23.2 to 57.7 (P < .05). Forward elevation improved from 128° to 134° (P = .33), and external rotation improved from 28° to 32° (P = .5). Internal rotation showed no improvement. Conversion to a total shoulder arthroplasty was performed in 7 patients (44%) at a mean of 36 months.

CONCLUSIONS

The optimal management for the young patient with arthritis has not yet been established. Because of the limited improvement in patient outcomes and the relatively high revision rate, biologic resurfacing of the glenoid with humeral head resurfacing is no longer our primary treatment option for young patients and should be used with caution.

Videoarthroscopic treatment of glenohumeral osteoarthritis

Objetive

To evaluate possible benefits obtained through the use of surgical videoarthrosco- py in the management of glenohumeral osteoarthritis.

Methods

We evaluated 37 patients (38 shoulders) who underwent through surgical videoar- throscopy in the period between November 1999 and May 2009 (minimum follow-up of two years). Twenty five patients attend for revaluation and thirteen were interviewed by telephonic contact. Functional assessments were performed (UCLA, Constant, and measu- rement of range of motion -ROM-), as well as pre and post surgical radiographics. We eva- luated the influence of the following factors in the final results: the presence of chondral lesions, joint space narrowing, osteophyte presence, associated injuries (rotator cuff torn or instability), and follow-up. Among those patients interviewed by phone we evaluated the satisfaction level and if they would submit themselves again to the surgical procedure.

Results

It was observed significant gain towards to the function (UCLA) and the internal rotation, as well as the association between dissatisfaction and pre surgical joint space reduced. Among the operated patients, 84% were satisfied with the results and 86.6% would repeat the procedure.

Conclusion

Surgical videoarthroscopy presents a relevant role in management of the glenohumeral osteoarthritis, providing improvement of functional results and high levels of satisfaction.

Arthroscopic treatment of early glenohumeral arthritis

Background

The articular cartilage of the shoulder is not endowed with intrinsic repair abilities, so the detection of chondral lesions during arthroscopy may indicate that additional articular procedures are needed. The aim of the current study was to evaluate the benefits of arthroscopy in patients with early shoulder arthritis, and to assess which clinical and radiological features are correlated with better arthroscopic outcomes.

Materials and methods

Out of a total of 2,707 shoulders, 61 arthroscopies were performed on patients aged 30–55 years suffering from a painful early arthritic shoulder. We performed a retrospective study of 47 of those 61 patients with osteoarthritis at Samilson–Prieto stage I or II. SST and Constant score were used as outcome measures. Arthroscopic circumferential capsulotomy was performed to release the soft tissues and increase the joint space. Glenoid chondral lesions were caregorized according to location (anterior, posterior, centered) and size (small, large, total) and treated with microfractures; in the last 11 patients, we placed a engineered hyaluronic acid membrane, Hyalograft^® C, on the surface of the glenoid. Postoperative care included mobilization the day after surgery, with the arm protected in a sling for two weeks. Follow-up examinations were performed at 3, 6, 12, and 24 months after surgery. The clinical and radiographic data collected were compared with those obtained at the last examination.

Results

The mean Constant score increased from 43.8 points to 79.1, and the mean SST score increased from 4.9 points to 9.4 points. Clinical outcomes improved significantly in 44 patients (93.6 %). The three patients (6.4 %) with the lowest scores showed progression of arthritis. Age, gender, glenohumeral distance, and presence of engineered hyaluronic acid membrane were not related to clinical scores. Recovery of range of motion as well as small and centered cartilage lesions were statistically associated with improved outcome.

Conclusion

The main finding was that soft tissue procedures (including capsulotomy and synovectomy) associated with glenoid microfractures are only suitable for patients with early arthritis and preserved humeral head shape, particularly in cases with small and centered glenoid cartilage lesions.

Recent advances in shoulder research

Shoulder pathology is a growing concern for the aging population, athletes, and laborers. Shoulder osteoarthritis and rotator cuff disease represent the two most common disorders of the shoulder leading to pain, disability, and degeneration. While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option for a number of pathologic conditions in the shoulder. Rotator cuff disease has been a significant focus of research activity in recent years, as clinicians face the challenge of poor tendon healing and irreversible changes associated with rotator cuff arthropathy. Future treatment modalities involving biologics and tissue engineering hold further promise to improve outcomes for patients suffering from shoulder pathologies.