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Glenohumeral Arthritis

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Topic updated on 06/01/16 4:07pm
Introduction
  • Glenohumeral degenerative joint disease has many causes including 
    • osteoarthritis
    • rheumatoid arthritis 
      • is most prevalent form of inflammatory process affecting the shoulder with >90% developing shoulder symptoms
      • is commonly associated with rotator cuff tears
        • 25%-50% have full thickness tears
    • connective tissue diseases
    • spondyloarthropathies
  • Epidemiology
    • demographics
      • more common in the elderly
      • may be associated with throwing athletes at younger age 
  • Pathoanatomy
    • primary osteoarthritis
      • no known cause
      • rotator cuff tears rare (5%-10%) 
    • secondary osteoarthritis
      • trauma
      • previous surgeries
        • overtightening of anterior capsule during reconstruction of shoulder
        • hardware in and around shoulder 
      • instability
        • rotator cuff disease
  • Associated conditions
    • chondrolysis 
      • which has been associated with the use of intra-articular local anesthetic infusion pumps after surgery
Anatomy
  • Glenohumeral joint 
Classification

Walch classification of glenoid wear associated with primary OA
Type A Concentric wear, no subluxation, well centered
A1 minor erosion
A2 deeper central erosion
Type B Biconcave glenoid, asymmetric glenoid wear and head subluxated posteriorly
B1 narrowing of posterior joint space, subchondral sclerosis, osteophytes
B2 posterior wear, biconcave glenoid 
Type C

C Glenoid retroversion of more than 25 degrees (dysplastic in origin) and posterior subluxation of humerus


Presentation
  • Symptoms
    • pain at night
    • pain with activities involving shoulder motion
  • Physical exam
    • tenderness at GH joint
    • flattening of the anterior shoulder contour 
      • due to posterior subluxation of the humeral head
    • functional limitations at GH joint
      • decreased range of motion
        • limited external rotation
    • painful shoulder range of motion 
Imaging
  • Radiographs
    • recommended views 
      • AP, true AP and axillary 
    • findings
      • subchondral sclerosis
      • osteophytes at inferior aspect of humeral head ("goat's beard")
      • look for superior migration of head to indicate cuff deficiency
      • look for evidence of previous surgery (staples)
      • look for medialization that occurs in inflammatory arthritis
        • may preclude glenoid resurfacing if severe 
      • posterior glenoid wear  
      • posterior humeral head subluxation
  • CT 
    • indicated in inflammatory arthritis if large bony defects are present on radiographs
  • MRI
    • may be indicated to evaluate rotator cuff tendon
Treatment
  • Nonoperative
    •  NSAIDS, DMARDs for RA, physical therapy, corticosteroid injections
      • first line of treatment in all cases 
  • Operative
    • total shoulder arthroplasty
      • indications
        • unresponsive to nonoperative treatment 
        • progressive pain
        • decreased ROM
        • inability to perform activities of daily living
      • contraindications
        • deltoid dysfunction
        • insufficient glenoid stock
        • rotator cuff arthropathy
      • outcomes
        • literature shows decreased rate of revision surgery when compared to hemiarthroplasty  
    • hemiarthroplasty
      • indications
        • osteoarthritis
        • rheumatoid arthritis
          • when large, irreparable RC tears are present 
          • if there is inadequate bone stock to support glenoid prosthesis 
        • post-traumatic arthritis
    • reverse ball prosthesis
      • contraindications
        • deltoid deficiency
    • fusion
      • indications
        • rotator cuff deficiencies
        • deltoid deficiencies
        • rarely indicated for OA  
      • positioning
        • 30/30/30: flexion, internal rotation, abduction
    • arthroscopic debridement 
      • indications
        • temporizing measure
Techniques
  • Total shoulder arthroplasty   
  • Hemiarthroplasty 
  • Reverse ball prosthesis 

 

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Qbank (5 Questions)

TAG
(OBQ11.27) A 65-year-old man presents with chronic right shoulder pain and crepitus. On physical exam his rotator cuff strength is 5/5. He has pain with both passive and active range of motion. Radiographs are shown in Figures A and B. An MRI is performed and shows no evidence of a rotator cuff tear. When comparing TSA versus hemiarthroplasty as a treatment option in this patient, hemiarthroplasty results in which of the following? Topic Review Topic
FIGURES: A   B        

1. Improved pain relief
2. Increased rate of revision surgery
3. Increased blood loss
4. Increased postoperative instability
5. Increased postoperative infection rates

PREFERRED RESPONSE ▶
TAG
(OBQ09.22) A 61-year-old laborer presents for total shoulder arthroplasty for primary osteoarthritis. What is his chance of having a concomitant full-thickness supraspinatus tear? Topic Review Topic

1. less than 10%
2. 10 to 20%
3. 20 to 30%
4. 30 to 40%
5. greater than 40%

PREFERRED RESPONSE ▶
TAG
(OBQ09.42) In comparison to patients with osteoarthritis, patient with inflammatory arthritis undergoing shoulder arthroplasty are more likely to have? Topic Review Topic

1. Large inferior humeral osteophyte
2. Medialization of the glenohumeral joint line
3. Posterior humeral head subluxation
4. Sclerotic glenoid
5. Posterior glenoid wear

PREFERRED RESPONSE ▶
TAG
(OBQ06.142) A 72-year-old man reports progressive pain and restriction of motion in his left shoulder. His active and passive motion are restricted to 90 degrees of forward elevation and neutral external rotation. Based on his radiograph shown in Figure A and physical exam, where is glenoid wear most likely to exist? Topic Review Topic
FIGURES: A          

1. Anterior
2. Posterior
3. Superior
4. Inferior
5. Central

PREFERRED RESPONSE ▶



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