Management of Glenohumeral Joint Osteoarthritis

Michael Khazzam, MD, FAAOS; Albert O. Gee, MD, FAAOS; Michael Pearl, MD, FAAOS

Disclosures

J Am Acad Orthop Surg. 2020;28(19):790-794. 

In This Article

Overview and Rationale

The American Academy of Orthopaedic Surgeons (AAOS), with inputs from the representatives of the American Shoulder and Elbow Surgeons, the American College of Radiology, the American Society of Shoulder and Elbow Therapists, the American Academy of Physical Medicine and Rehabilitation, and the Arthroscopy Association of North America, recently published their clinical practice guideline (CPG), the Management of Glenohumeral Joint Osteoarthritis.[1] This clinical practice guideline was approved by the AAOS Board of Directors in March 2020. The purpose of this clinical practice guideline is to assist physicians, surgeons, and other healthcare professionals who care for patients with glenohumeral joint osteoarthritis in clinical decision-making for the nonsurgical and surgical management of these patients based on the best current available evidence.

Symptomatic primary glenohumeral joint osteoarthritis is a condition presenting with pain, reduced range of motion, and progressive loss of shoulder function. Glenohumeral joint osteoarthritis is characterized by progressive humeral head cartilage loss, adaptive changes to the subchondral bone, and development of inferior humeral head osteophytes. These changes result in a subsequent biomechanical change of the glenohumeral joint, joint space narrowing, and posterior humeral head subluxation, followed by progressive posterior glenoid bone loss. Although it has been hypothesized that there may be a genetic predisposition to disease progression, primary glenohumeral joint osteoarthritis has no specific causative factor that explains the etiology of the disease process other than the degenerative process that naturally occurs because of aging. Primary glenohumeral joint osteoarthritis can occur over a broad age range; it is most commonly seen in patients older than 60 years of age and more common in women. Radiographic data have found a prevalence rate of 94% in women and 85% in men over the age of 80 years.[2] Furthermore, Kerr et al[3] reported a 20% incidence of idiopathic glenohumeral joint osteoarthritis in patients older than 60 years who presented for shoulder symptoms. Although the true incidence and prevalence of glenohumeral joint osteoarthritis cannot be estimated currently, it is important to recognize it is common.

Chronic shoulder pain can result in notable dysfunction, disability, and increased healthcare costs. Shoulder pain has been reported as one of the most commonly affected joints for chronic pain, affecting 22.3 million patients older than 18 years in 2015.[4] It is estimated that shoulder pain affects 5% to 21% of the adult population in the United States, and glenohumeral joint arthritis affects nearly a third of the world's population older than 60 years.[5] The economic burden for the management of glenohumeral joint osteoarthritis is directly correlated with the duration of conservative management, surgical costs, perioperative complication rates as well as implant survivorship, and the need for revision shoulder arthroplasty. As the population ages, so does the disease burden of patients needing treatment of glenohumeral joint osteoarthritis. The reported annual increase of procedural volume from 2007 to 2015 has been estimated between 192% and 322%. Correspondingly, this will also result in an increased revision burden of approximately 4.5% to 7%.[6]

Therefore, the AAOS developed an evidence-based, CPG to aid practioners in the treatment of patients with glenohumeral joint osteoarthritis.[1] Furthermore, the CPG represents a resource demonstrating areas that need additional investigation to provide improved evidence-based guidelines for the treatment of glenohumeral joint osteoarthritis. An exhaustive literature search was conducted resulting initially in over 965 articles for full review. The articles were then graded for quality and aligned with the work group's patients, interventions, and outcomes of concern. For CPG PICO (ie, cohort, intervention, comparison, and outcome) questions that returned no evidence from the systematic literature review, the work group used the established AAOS CPG methodology to generate 16 companion consensus statements for procedural and clinical interventions including preoperative and postoperative physical therapy, alternative nonsurgical treatments, injectable biologics, opioid pain medication, biceps tenodesis and tenotomy, and the utilization of tranexamic acid.

In summary, the glenohumeral joint osteoarthritis guideline involved reviewing over 3,300 abstracts and more than 960 full-text articles to develop 13 recommendations supported by 69 research articles meeting stringent inclusion criteria. Each recommendation is based on a systematic review of the research-related topic which resulted in six recommendations classified as high, six recommendations classified as moderate, and one as limited. The strength of recommendation is assigned based on the quality of the supporting evidence. The strength of recommendation also takes into account the quality, quantity, and the trade-offs between the benefits and harms of a treatment; the magnitude of a treatment's effect; and whether there are data on critical outcomes.

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