Surgeons offer pearls for the care of shoulder OA in young patients
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
- William N. Levine, MD
- New York
- Christopher S. Ahmad, MD
- New York
- Peter J. Millett, MD, MSc
- Vail, Colo.
- Jon J. P. Warner
- J. Michael Wiater, MD
- Royal Oak, Mich.
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.
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
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.
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.
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.
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: Share your pearls of arthroscopic management in patients with mild to moderate arthritis who you do not believe are indicated for shoulder arthroplasty?
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.
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?
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.
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For more information:
William N. Levine, MD, can be reached at Columbia at New York-Presbyterian Hospital, 622 West 168th St., PH 11, New York, NY 10032; email: email@example.com.
Peter J. Millett, MD, MSc, can be reached at The Steadman Clinic, 181 W Meadow Dr., Vail, CO 81657; email: firstname.lastname@example.org.
J. Michael Wiater, MD, can be reached at Beaumont Health System, Department of Orthopaedic Surgery, 3535 W. Thirteen Mile Rd., Royal Oak, NI 48073; email: email@example.com.
Disclosures: Ahmad is a consultant for Arthrex Inc.; Levine is a consultant for Zimmer and receives research support from the National Institutes of Health; Millett has no relevant financial disclosures; Wiater is a consultant for Zimmer, DePuy-Synthes, and Tornier, and receives research support from Zimmer, DePuy-Synthes, Stryker, and Tornier; Warner receives fellowship support from Mitek, Arthrex, Smith & Nephew, DJO, BREG, a royalty on a rotator cuff repair implant from Tornier, and has stock in Orthospace Company and VuMedi.