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Surgeons offer pearls for the care of shoulder OA in young patients

Issue: March 2013

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Management of glenohumeral arthritis in young patients younger than 40 years remains one of the most challenging issues facing shoulder surgeons. We have assembled a world-renowned faculty who has extensive experience in the difficult decision-making and management of these patients’ complex shoulders. First, we review the evaluation of these patients and then delve into the myriad surgical options that have been described for these shoulders.

Joint preservation procedures are highlighted given the young age of these patients, but do not always lead to predictable outcomes. Arthroplasty, on the other hand, may be a better option but its long-term durability remains a concern. Our panel of distinguished surgeons share their experiences and insights with Orthopedics Today readers to help navigate this increasingly common and challenging clinical problem.

William N. Levine, MD
Moderator

William N. Levine, MD: Please go through your typical evaluation of a patient younger than age 40 years with glenohumeral osteoarthritis (OA).

Christopher S. Ahmad, MD: These patients present a clinical challenge, and evaluation is important. First, it is necessary to identify possible causes of early arthritis. The past surgical history can be enlightening, such as having undergone prior capsulorrhaphy procedures or the use of a pain pump or thermal device to the capsule from prior operative reports. Also, seek a history of trauma. Often an experience or sports-related trauma is recalled at an earlier age. Consider inflammatory arthritis and osteonecrosis as possible etiologies. It is important to identify the actual source of pain in the setting of radiographic evidence of OA, which may be related to other pathologies that may be more easily treated such as bursitis, AC joint arthritis, biceps tendinitis, etc.

The physical exam should assess limitations in passive and active range of motion and strength, and for coexisting pathologies (long head biceps, AC joint arthritis or bursitis) that may influence treatment. X-rays are evaluated for typical features of arthritis including degree of joint space narrowing, osteophytes, glenoid morpholology and bone stock. If surgery is being considered, a CT scan is obtained to better define bone deformity. MRI may be helpful in patients with a history of trauma or rotator cuff disease to better identify cartilage damage, which can be unipolar either on the humeral head or on glenoid.

Lastly, and especially critical, is understanding the patients’ expectations and activities they wish to continue, such as heavy labor or demanding sports such as boxing. Also, assess patients’ ability to modify their activities following surgery.

Peter J. Millett, MD, MSc: It is important to determine the cause of the OA — traumatic, post-surgical or iatrogenic (chondrolysis, hardware-related, etc.) and also to determine the principal complaint — pain, stiffness or both. I always obtain X-rays, evaluate bony anatomy and look at the joint space and any glenoid or humeral deformity.

J. Michael Wiater, MD: As you know, shoulder arthritis is exceedingly rare in patients younger than 40 years. While the basics of the work-up are no different than for an older patient, I am interested in answering the question of why the patient developed arthritis at such a young age. What are the predisposing factors? Is there a history of a previous arthroscopic procedure, fracture, chronic instability, steroid use, heavy labor or systemic inflammatory disease? While primary glenohumeral OA is the most common form of shoulder arthritis in the older patient, it is less common in the patient younger than 40 years.

Jon J.P. Warner, MD: The most important element of the evaluation is the patient’s subjective report of symptoms. Pain vs. stiffness and functional limitations are important to understand. It also is essential to understand relevant factors of prior surgery, such as rotator cuff integrity and placement of anchors. One should have proper orthogonal radiographs (true AP and lateral) to appreciate the shape of the humeral head and its relationship to the glenoid. A CT with contrast may be helpful to visualize articular surfaces in cases where isolated articular loss is an issue and also it may avoid artifact from prior metal anchors and give information about the rotator cuff.

An MRI is useful to assess rotator cuff integrity and quality of the rotator cuff muscles after prior surgery. Finally, it is important to rule out infection, so appropriate laboratory studies and aspiration may be necessary in some cases.

Physical examination should carefully distinguish between active and passive motion loss, and especially evaluate the subscapularis function in cases of prior open instability surgery. Careful neurological assessment is also necessary.

Levine: There are many surgical options for the young patient with glenohumeral arthritis. Please provide your algorithm for how you decide on the following options:

• arthroscopic debridement;
• resurfacing arthroplasty – humeral side;
• resurfacing arthroplasty – humeral side with glenoid reaming (“ream and run”);
• resurfacing arthroplasty – humeral side and glenoid resurfacing (Achilles allograft vs. meniscal allograft vs. graft jacket);
• hemiarthroplasty (stemmed);
• total shoulder arthroplasty (TSA); and
• other

Ahmad: Arthroscopic treatment is indicated ideally for those patients who demonstrate additional comorbidities that contribute to symptoms such as biceps tendinitis, AC joint arthritis and bursitis. For extremely young patients with traumatic cartilage lesions, arthroscopy can be used for diagnostic purposes prior to conversion to an open procedure, such as a partial resurfacing. Patients with early post-capsulorrhaphy arthropathy can also be treated with arthroscopic capsular release to improve pain, increase range of motion, and potentially alter the progression of the arthritis. Arthroscopy is also indicated for generalized early arthritis, and the procedure includes some combination of synovectomy, capsular release, chondroplasty, loose body removal and osteophyte resection. The results are inversely related to the degree and severity of the arthritis.

Humeral resurfacing arthroplasty can be performed as either partial resurfacing or complete resurfacing. When compared to stemmed hemiarthroplasty, resurfacing has the advantages of maintaining humeral bone stock, which may facilitate an easier future revision surgery and less alteration of normal proximal humeral anatomy with the procedure. The technique obviates the need for addressing humeral head offset. Surgical technique is important because it is still possible to place the prosthesis non-anatomically, and particular attention should be paid to avoid overstuffing the joint. Theoretically, bone will be preserved for revision surgery; however, surface coatings may make implant removal difficult and affect bone loss. The best indications are patients with a relatively normal glenoid and partial destruction of the humeral head such as an osteochondral defect, focal osteonecrosis or OA with mild bone deformity. Resurfacing can be especially useful when a stemmed implant is not easy to place, such as in the case of previous fracture and malunion, or other hardware in the humerus, such as prior elbow replacement.

Reaming the glenoid has several benefits. It creates a conforming surface to articulate with the humeral component. It may also create a biologic response with fibrous tissue development on the glenoid. “Ream and run” is, therefore, a reasonable approach to the young, active patient with observed glenoid deformity.

In an effort to avoid prosthetic resurfacing of the glenoid in the young patient with risk of component loosening, biologic resurfacing has been used. Technically, it can be challenging to obtain exposure to the glenoid necessary for glenoid preparation and secure fixation of the graft material. Initial results have been encouraging. However, my experience and recent reports on humeral arthroplasty and biologic resurfacing with an interpositional meniscus have shown the results to be variable, especially in the longer term. Failures especially occur in the setting of higher degrees of glenoid deformity. Because of the failure rate, I have limited indications for biologic resurfacing and consider it only for extremely young patients and patients with severe arthritis.

A stemmed implant is useful when there is inability to support a resurfacing prosthesis, and control of version is important. An example is a case of a locked posterior dislocation that requires a prosthesis because of significant humeral head bone loss and version restoration is critical to maintain stability.

Because pain relief is better with total shoulder replacement (TSR) compared to hemiarthroplasty, I prefer TSR for many young patients with OA despite the risk of glenoid component loosening, which we have observed to be low. The criteria for TSR are that the patient understand and comply with recommended modifications in postoperative activity that involves avoidance of repetitive and impact loading to the shoulder.

Millett: In most young patients, we opt for a joint-preserving approach. We have been interested in this as a way to preserve the joint surface and have found this particularly useful for active patients who have glenohumeral OA with joint stiffness. We typically perform an extensive debridement with a capsular release. We remove loose bodies and address concomitant biceps pathology with a biceps tenodesis. During the last 5 years, we have noticed an association with inferior humeral osteophytes and stiffness and posterior and lateral arm pain. We hypothesized that the spur could be leading to compression on the axillary nerve and have recently shown an association between spur size and fatty infiltration of the teres minor (a surrogate marker of axillary nerve dysfunction).

This has lead us to develop an arthroscopic procedure we call the Comprehensive Arthroscopic Management (CAM) procedure, which in addition to a debridement and capsular release, also includes arthroscopic excision of the inferior humeral osteophyte with axillary nerve neurolysis. Our initial results have been good, with 2-year survivorship now at 87% in a cohort of patients that we are following.

When this type of joint preserving approach fails, I usually prefer a traditional TSR, although in some cases, we use a short-stemmed humeral component to preserve bone stock for future revision procedures. I have found that hemiarthroplasty leads to incomplete pain relief and only use this in active patients who understand the risk of continued pain.

Wiater: My treatment algorithm for the younger patient is based on many factors including the patient’s occupation and hobbies, prior treatment, severity of symptoms and severity of disease. Since the ramifications of treatment choice can be tremendous, the young patient with an arthritic shoulder is faced with a significant life decision. My role as a clinician is to provide the patient with information on the various options available, including the benefits and risks of each, and to let the patient make an informed decision on what he or she feels is best for him or her. There is often more than one viable option. An important consideration that must be communicated to the patient is that no matter which operation is chosen, it will not be the last.

Arthroscopic debridement as a temporizing measure is a viable option for the young patient with mild arthritis. I might add a concomitant microfracture if there is a full thickness chondral defect. As with the older patient, when the joint is significantly bone-on-bone, arthroscopy is a waste of time.

Moving up the ladder of invasiveness, a partial surface replacement arthroplasty is an option for the young patient with a focal chondral defect who has failed an arthroscopic procedure. For young patients with more severe arthritis, the decision comes down to some form of hemiarthroplasty vs. TSA. I generally prefer a resurfacing hemiarthroplasty rather than a stemmed hemiarthroplasty in a young patient because it is bone preserving. If the patient has advanced arthritis and an occupation or hobby that makes him or her a poor candidate for implantation of a glenoid component, like the 35-year-old weightlifting firefighter I saw in the office this week, a good option is a resurfacing hemiarthroplasty. If the glenoid wear is concentric and the humeral head is centered, then I do not do anything to the glenoid. If the glenoid is worn posteriorly or biconcave, and the head is subluxed posteriorly, I will ream or contour the glenoid and spend time balancing the soft tissues to correct the deformity and center the head.

I have not had much success with biologic resurfacing of any kind in the shoulder and no longer consider it.

Patients who opt for a hemiarthroplasty must know they may have incomplete pain relief after surgery.

Without a doubt, TSA offers the best pain relief. The downside is the eventual wear and/or loosening of the glenoid component that may necessitate revision surgery. Despite that risk, TSA is a good option for a young patient with advanced arthritis and severe, unremitting pain, who is willing to make the necessary modifications in his or her life to allow the prosthesis to last as long as possible. For the young patient, I use a porous coated press-fit stemmed humeral component and an all-polyethylene moderately cross-linked pegged glenoid component with a large central fluted peg that allows for bone in-growth.

In the future, a stemless TSA may be available in the United States as it is in Europe, which may be well-suited to this patient population. There is currently an ongoing FDA Investigational Device Exemption trial of a stemless TSA design in the United States.

Warner: Before I can answer this question, it is important to take note that this is a heterogeneous group of patients. For example, a 22-year-old patient might present with painful arthritis as a consequence of mechanical damage from anchors placed into the joint for instability surgery, and this individual may or may not be stiff. We saw a number of such patients with painful shoulders after thermal capsulorrhaphy. This is different from the young patient with a dysplastic joint and severe retroversion who presents with a fixed posterior subluxation and painful glenoid erosion. To be sure, each is a difficult problem, but the options for solution may be different as well.

In the first case, it is reasonable to do an arthroscopic debridement with capsular release if the shoulder is stiff. Previous studies, while low level of evidence, have demonstrated a benefit from this kind of low risk surgery in such patients. That said, the evidence is not strong. In the latter situation with a fixed posterior subluxation, arthroscopic debridement is unlikely to be successful, and indeed no joint preserving surgery has been shown to be effective. While opening-wedge posterior osteotomy has been proposed for this kind of patient, there is no published data on its effectiveness and I have generally found it disappointing as it does not re-center the humeral head. For this patient, it seems only a conventional shoulder arthroplasty will provide reliable pain relief and re-center the humeral head on the glenoid.

Resurfacing arthroplasty with a stemless prosthesis for the humeral head may be attractive due to bone preservation and certainly seems to work in some patients. However, the Australian Joint Registry clearly demonstrates a worse survival curve for these patients than with conventional hemiarthroplasty or TSA.

Resurfacing arthroplasty with a stemmed or stem-less implant and glenoid reaming, the so-called “ream-and-run procedure,” has been offered as a way to avoid risk of glenoid loosening. Indeed, Matsen and colleagues have popularized this concept and Rockwood has also extolled the virtues of hemiarthroplasty. However, level 1 studies have clearly demonstrated that TSR is superior to hemiarthroplasty and longevity of TSA is also superior to hemiarthroplasty even in young patients. Nonetheless, if an individual anticipates high-impact loads, through work or sport, it is probably not appropriate to implant a glenoid component.

Resurfacing of the humeral head with a stemmed or stemless device and biological resurfacing of the glenoid with allograft has been suggested as a useful approach. Unfortunately, these assumptions are based on low levels of evidence and small cohorts of patients. Moreover, these studies are, in many cases, contradictory of each other. My personal opinion is that there is no role for this treatment in young patients as there is no evidence for the effectiveness of this method vs. hemiarthroplasty alone.

Levine: Shown are the radiographs of a 38-year-old right-hand dominant man who previously underwent a left shoulder arthroscopic labral repair (no thermal procedure was performed) 3 years ago and has had progressively worsening pain and corresponding loss of motion and function. Work-up has shown no signs of infection with normal lab studies. Examination shows intact rotator cuff with marked decrease range of motion – forward elevation 100°, external rotation at the side is 0° and internal rotation is to the side. What would you offer this patient and why?

True AP radiograph of a 38-year-old man with severe osteoarthritis in his left shoulder is shown here.

Images: Courtesy of Columbia Center for Shoulder, Elbow and Sports Medicine

Axillary radiograph of the same patient shows Walch B1 glenoid (severe posterior erosion and increased retroversion).

Ahmad: This patient has advanced degenerative post-capsulorrhaphy arthropathy with severe glenoid retroversion. Non-arthroplasty options include scope debridement and capsular release. The severe advanced bipolar global cartilage loss with glenoid retroversion suggests a poor outcome. Arthroplasty options include resurfacing with reaming of glenoid with or without biologic resurfacing and TSR. Despite his young age, the arthritis is in his non-dominant shoulder, I would recommend TSR with a smooth, uncemented stem and advise on avoidance of impact activities with the shoulder. The smooth stem is chosen to facilitate easier stem removal in the case of future revision.

Millett: I think the best option for a patient with this degree of joint destruction and deformity would be a TSA. If I were concerned about occult infection, then I would perform an arthroscopy and take deep tissue biopsies before implanting a prosthesis. One could consider a CAM procedure for this patient, but the degree of deformity is severe. We have found better results with the CAM procedure when there is at least 2 mm of joint space remaining.

Wiater: The arthritis is advanced. This is a Walch B2 glenoid in my opinion. There is a bit of native, normal glenoid remaining anteriorly, and severe biconcavity. The head is way out the back. We know from experience that hemiarthroplasty does not do well with this degree of arthritis and glenoid deformity. The best option would be a TSA, as long as the patient is informed and is not a heavy laborer or weightlifter. The glenoid would be tricky, requiring significant eccentric reaming.

Warner: The patient demonstrates classic OA with the humeral head centered on the glenoid. The humeral head is somewhat flattened on the axillary image, and there are large osteophytes present. I do not believe there is much value in an arthroscopic debridement and release as the humeral head is “out-of-round,” and this is unlikely to restore flexibility and alleviate pain. Neither do I believe resurfacing of the glenoid with allograft — with or without humeral head replacement — is likely to give a reproducible outcome. This patient should be informed that the options are hemiarthroplasty or TSR. The latter will be most likely to give a durable outcome with a high likelihood of minimal to no pain.

Levine: Share your pearls of arthroscopic management in patients with mild to moderate arthritis who you do not believe are indicated for shoulder arthroplasty?

Ahmad: Arthroscopic debridement is directed towards identifying all contributing causes of pain. Special attention should be paid to the degrees of capsular contracture that can be released and also some levels of bone deformity on the glenoid and humeral head that can be modified. If the biceps requires tenodesis, it may be beneficial to avoid large screw fixation into the humeral shaft since a stemmed implant may be chosen in the future.

Standard arthroscopy and a global synovectomy are performed. Loose bodies are removed and should be sought in the subscapularis recess. Chondroplasty is performed on loose flaps in the humeral head and glenoid. In the setting of common anterior capsular contracture with a loss of external rotation, capsular release is performed with either a radiofrequency probe above the superior half of the glenoid and more inferiorly use a biting instrument. The rotator interval and coracohumeral ligament is ablated. A posterior capsular release is used to avoid posterior subluxation of the humeral head. Glenoid osteophytes can be removed arthroscopically with the use of a burr or shaver. Similar to elbow arthroscopy for arthritis, retractors can be used to protect the soft tissues and gain exposure.

Millett: Arthroscopic management is helpful in the treatment of glenohumeral OA in young patients. We have had surprisingly good results in patients with rather advanced X-ray findings. We always perform a capsular release when the joint is stiff to restore mobility and use fluoroscopy to help with the excision of inferior osteophytes (Goat’s beard deformities). If you plan to excise an inferior spur, it is helpful to use a 7 o-clock portal and to keep the capsule intact while excising the spur as this protects the axillary nerve. It is also important to look for loose bodies in the subscapularis recess as these can also compress the brachial plexus and cause pain. In our initial series of the CAM procedure published in Arthroscopy, we found significant improvement in ASES scores, pain relief and patient satisfaction.

Wiater: Pick your patients carefully. Make sure patients know that arthroscopy will not give them a normal shoulder and will likely be a temporizing measure. Do not focus solely on the arthritis; remember to evaluate them preoperatively for other pathology that might need to be addressed at arthroscopy, such as rotator cuff tear, biceps disease, subacromial impingement and acromioclavicular arthritis. Do not be too aggressive with the debridement as you can leave the operating room with more arthritis than you started with.

Warner: In the past, I have had occasions to treat young individuals, teenagers and those older (but younger than 40 years), such as professional athletes who have retired with arthroscopic debridement. I tell them there is no strong evidence for the effectiveness of this approach, but it may be helpful in palliating their pain for some time. They must have a round humeral head and normal rotator cuff. Even so, the results are difficult to predict. I combine this approach with arthroscopic capsular release when necessary, but there is little literature in support of this method.

Levine: With all of the arthroplasties being performed on younger patients, share with us your experience in revision shoulder arthroplasty in the patient younger than age 40 years. What is the youngest patient in whom you have performed a revision to a reverse shoulder replacement? What is the role of arthrodesis in these young patients?

Ahmad: My experience with revision of young patients with failed arthroplasty is primarily patients who have had humeral resurfacing and biologic replacement of glenoid. Often, these cases are not difficult to revise. We prefer osteotomy of lesser tuberosity, which has great benefit if a prior subscap tenotomy and repair was performed. Once the head is removed, usually bone is preserved in a way that standard preparation for a stemmed prosthesis can be carried out. Patients I have counseled for shoulder arthrodesis are primarily those who have failed numerous instability operations who continue to have painful instability or fixed subluxation and required a definitive last surgery.

Millett: These are some of the toughest cases in my practice. I have performed TSR in a 20 year old and reverse TSR in a 22-year-old. These are exceptionally rare and complex cases, and I do not undertake them lightly or without lengthy discussions with the patients and their families about the potential consequences and complications associated with such approaches. I usually reserve fusions for end-stage instability patients and have had good success in the short-term with surprisingly high satisfaction rates for these challenging cases that have failed all other attempts at stabilization or that have otherwise totally destroyed glenohumeral joints.

Wiater: In my experience, revision shoulder arthroplasty in the young patient is usually performed for a failed hemiarthroplasty that was implanted for either severe OA or for the sequelae of severe trauma. Patients with an intact rotator cuff and glenoid arthrosis benefit from revision to a TSA. While converting a failed hemi to a total may sound easy, it is usually not due to subscapularis compromise, adhesions and glenoid erosion. In rare cases of severe rotator cuff deficiency or bone loss, revision to a reverse TSA may be the only viable option. The youngest patient I have revised to a reverse TSA was 38 years old at the time of revision. She slipped and fell exiting a hot tub and fractured her proximal humerus. The fracture was inadequately managed with a Rush rod. She developed a malunion, post-traumatic arthritis and rotator cuff deficiency, and underwent a poorly executed hemiarthroplasty. I revised her to a reverse TSA, and she is doing well. The primary indication for arthrodesis in the young patient would be for combined rotator cuff and deltoid paralysis.

Warner: The question of the patient with a failed shoulder arthroplasty is, unfortunately, one I face more and more. This is a byproduct of, in many cases, poor prior surgery and poor decision-making. It is an argument for specialty care, and a painful example of the consequence of such problematic initial treatments. In some cases, the revision to another prosthesis is not difficult. For example, a patient with a painful stemless humeral resurfacing with glenoid erosion has a relatively good chance for marked pain relief and improved function with conversion to a conventional TSA, assuming the rotator cuff (mainly the subscapularis) is functioning well.

Unfortunately, the patient I see most often is one in which there is a loss of rotator cuff function along with the failed prosthesis or even an infection. In the case of infection, these individuals are usually treated with a prostalac (DePuy Orthopaedics; Warsaw, Ind.) antibiotic spacer after removal of their prosthesis. Subsequent treatment with re-implantation may require a reverse prosthesis. I have treated some patients in their 40s with such an approach and, even though they are dramatically improved with pain relief and functional improvement, they are advised that durability of the implant will be an issue.

Individuals who are much younger present a real problem. Fusion after failed arthroplasty is a difficult problem, and I would strongly advise to readers that they should refer such a patient to a shoulder expert for care. Iannotti and colleagues have demonstrated that while fusion is possible to achieve, bone loss often requires multiple surgeries to achieve a solid union.