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Arthroscopic management of glenohumeral osteoarthritis


OVERVIEW

Chapter synopsis

Osteoarthritis resulting in pain and functional limitations is a significant and growing problem with an aging population. Many treatment options exist, ranging from conservative treatment and physical therapy to total shoulder arthroplasty. Although arthroplasty procedures are effective in reducing pain and improving function, the longevity of total shoulder implants makes this a less desirable option in younger and more active individuals. As a consequence, other arthroscopic surgical techniques have been developed to target the primary pain generators and limited range of motion to help provide symptom relief, improve shoulder function, and potentially delay the need for total shoulder arthroplasty.

Important points

  • A comprehensive course of conservative management should be trialed prior to surgical intervention, including activity modification, physical therapy, and pain-relieving medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and/or intra-articular steroid injections.

  • Patients should be appropriately screened and counseled preoperatively based on current evidence that suggested certain preoperative radiographic parameters (joint space < 2 mm, Walch Class B2/C) and patient demographics (age > 50) that may place patients at increased risk of subsequent conversion to arthroplasty

Clinical and surgical pearls

  • Arthroscopic techniques frequently utilized include debridement, capsular release, biceps tenodesis, subacromial decompression, and other procedures for contributing intra-articular pathologies.

  • Performing a complete capsular release often results in significant pain relief and improved range of motion. During a capsular release, the inferior glenoid is more accessible from the lateral position.

  • Patients who are responsive to nonoperative management with glenohumeral injections may have a greater likelihood of benefiting from arthroscopic treatment.

Clinical and surgical pitfalls

  • Patients with joint space of less than 2 mm, biconcave glenoid (Walch classification type B2/C), and age 50 years or older at the time of surgery are at a greater risk of failure and subsequent conversion to arthroplasty.

  • Ensure separation of the axillary nerve from surrounding tissue during an inferior capsule release to avoid iatrogenic damage to the nerve.

  • Considering that isolated chondral lesions of the glenohumeral joint are not uncommon, it is critical to distinguish between lesions contributing to the patient’s symptoms and those that are merely discovered incidentally during arthroscopy.

  • Multiple pain generators may exist within the shoulder, such as impingement/bursitis, AC joint pain, and biceps tendonitis. Alternate sources of pain should be carefully identified pre-operatively and managed intra-operatively.

Video available

  • : Arthroscopic circumferential capsulotomy and axillary nerve release.

Introduction

Glenohumeral osteoarthritis (GHOA) is a growing problem with both an aging and increasingly active population, with significant impacts on function and quality of life due to both pain and reduced range of motion. A spectrum of escalating interventions exists to treat the pain and functional limitations of GHOA, ranging from activity modification, therapy, oral and intraarticular anti-inflammatories, and analgesics to total shoulder arthroplasty. Total shoulder arthroplasty remains the gold standard for definitive treatment of symptomatic GHOA; however, the inherent limitations of implant durability and function make this a less desirable option in younger and active populations. Given this limitation, a range of arthroscopic techniques and temporizing procedures have been developed from simple debridement to more comprehensive management of multiple pain generators. The goal of this section is to outline the preoperative evaluation of patients with symptomatic GHOA, identify the surgical indications and contraindications for arthroscopic management of GHOA, detail the steps of the procedure, and briefly summarize the current outcomes within the literature.

Pre-operative considerations

History

Patients with symptomatic GHOA typically present with diffuse pain and limited range of motion. Given the progressive nature of GHOA, it is more common in older patients and those with a history of other known precipitating activities such as weightlifting. Patient history often describes a gradual onset and increasing severity of symptoms, often including pain at night. The onset, characteristics, and location of the pain are also valuable. Acute onset can possibly indicate the exacerbation of underlying pathology. Pain exclusively at the extremes of motion is more suggestive of adhesive capsulitis rather than arthritis. Other characteristics of the pain, including clicking, catching, or popping, can be indicative of loose bodies or chondral degeneration. Location of the pain is also helpful, with GHOA presenting posteriorly, or more globally, while more localized pain, such as the anterior aspect of the shoulder, may be more suggestive of biceps tendinitis. The following symptoms are commonly reported by patients with glenohumeral arthritis:

  • Progressive, and often posterior, shoulder pain that worsens with upper extremity activity

  • Shoulder pain that also occurs at rest and is an impediment to sleep at night

  • Complaints of functional limitations and reduced motion due to shoulder stiffness

In addition to the onset and progression of symptoms, providers should also solicit a history of any treatment course, including activity modification, physical therapy, medications, injections, and any prior surgical interventions. Prior activity levels and future goals should also be determined to assess if the patient’s activity levels would be sufficiently addressed with an arthroplasty procedure or if an arthroscopic procedure should be attempted first to delay the need for arthroplasty.

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