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

Guideline Summary

The recommendations developed are meant to aid in the clinical decision-making process for the treatment of patients presenting with symptomatic primary glenohumeral joint osteoarthritis. Use of these guidelines helps physicians determine appropriate interventions which are most likely to provide predicable beneficial outcomes before recommending surgery. This set of updated CPGs is very different than the previous guidelines published in 2009.[7] The previous iteration presented 16 statements and only one of these statements provided moderate evidence for support of the recommendation. Fifteen of 16 recommendations were based on either level IV evidence, expert opinion (level V), or work group consensus. Fortunately, many of these factors/questions prompted investigation providing improved quality of the literature published, allowing for more definitive guideline recommendations.

The recommendation for the use of total shoulder arthroplasty (TSA) over hemiarthroplasty has now been upgraded to strong because of increases in supporting evidence. The growth in the body of literature allows for meta-analysis to strengthen this recommendation and demonstrate that anatomic TSA provides markedly better improvement regarding pain, range of motion, patient satisfaction, patient-reported outcomes, and lower complication rates. Additional follow-up is still needed to determine whether these findings maintain over time specifically related to implant survivorship.

Similarly, the strength of recommendations has been updated related to the use of either pegged or keeled all-polyethylene glenoid implants with the current strong recommendation now stating "strong evidence supports the use of pegged or keeled glenoid components with a well-functioning rotator cuff." Interestingly, two of the four studies[8,9] which met our work groups inclusion criteria had been published at the time of the previous CPG. A pooled data analysis of the studies which met the inclusion criteria found lower incidence of radiolucent lines for the pegged implants, but these findings did not influence patient outcomes, nor implant survivorship. These studies presented only short-term follow-up; therefore, long-term follow-up is needed (>8 to 10 years) to determine whether there will be a notable difference between these glenoid implant designs related to clinical outcome and implant survivorship. Currently, based on the best available evidence, this work group leaves it at the description of the surgeon as to what works best in their hands.

Management of the subscapularis was challenging in the 2009 CPG, with an inconclusive recommendation stating "unable to recommend for or against subscapularis transtendinous approach or lesser tuberosity osteotomy."[7] The addition of evidence from moderate-quality studies has allowed for strengthening this recommendation to a moderate and stating that surgeons can use subscapularis peel, lesser tuberosity osteotomy, or tenotomy when performing a shoulder arthroplasty. The results of the included studies have demonstrated no notable difference with healing or clinical outcomes comparing all three techniques.

This work group felt important to emphasize and make recommendations against the use of noncemented metal-backed glenoid implants with anatomic TSA because of the poor survivorship, high revision rates, and 76% failure rate. These implants have currently been abandoned and removed from the market in the United States. Future studies and improved implant design, specifically related to the interest in convertibility from anatomic to reverse TSA may solve this problem, but currently, this not an option for clinical use.

Recommendations on the influence of patient-related factors on predictors of postoperative complications, outcomes, and implant survivorship such as age, obesity, nicotine use, sex, mental health, and medical comorbidities are useful to guide surgeons to provide an optimal outcome. This current CPG addressed these factors with three strong statements regarding the influence on the number of patient medical comorbidities, sex, and body mass index (BMI) and how these influence surgical outcomes after a TSA. In addition, three moderate statements regarding patient age, depression, and tobacco use were also made as to how these factors influence the postoperative outcomes.

Interestingly, neither BMI nor sex has been shown to affect the outcomes after a TSA in the early postoperative period. For clarification, the studies which met the inclusion criteria to formulate the recommendations regarding the influence of BMI with the risk of postoperative complications only report the first 30 days after surgery. Similarly, the studies which met the inclusion criteria for sex only provide 30 and 90 day postoperative follow-up. The influence of these factors in the long-term complication rates, patient-reported outcomes, and survivorship cannot be extrapolated by these results in the early postoperative period, and future long-term, high-quality studies are needed to be able to formulate a stronger CPG recommendation.

The current CPG makes a strong recommendation against the use of hyaluronic acid injections as a modality during nonsurgical management of glenohumeral joint osteoarthritis indicating that the added costs provide no additional benefit. In addition, the use of viscosupplementation injections for the shoulder is not an approved by the FDA and therefore is off-label use.

The increase in humeral implant design has led to several options now available including stemmed (both long and short), stemless, or humeral head resurfacing prosthesis. Evidence supporting humeral implant choice provides a limited recommendation for the use of any of these humeral prostheses. The biggest limitation of the studies which met the inclusion criteria for this recommendation is that they do not make direct comparison of stemmed, stemless, and resurfacing as well as mixed the results of hemiarthroplasty and anatomic TSA. This work group recommends that although all are safe and effective options, these implants (especially the newer stemless prostheses) be used with caution because there are no long-term outcome studies of the survivorship or complications. High-quality prospective randomized trials or prospective cohort studies with a long-term follow-up (>10 years) which compare stemmed, stemless, and humeral resurfacing for both hemiarthroplasty and anatomic TSA are needed to provide evidence supporting how humeral implant type influences patient outcome, pain relief, and survivorship.

Strength of Recommendation Overall Strength of Evidence Description of Evidence Quality Strength Visual
Strong Strong Evidence from two or more "high"-quality studies with consistent findings for recommending for or against the intervention. Also, this requires no reasons to downgrade from the EtD framework ****
Moderate Moderate or Strong Evidence from two or more "moderate"-quality studies with consistent findings or evidence from a single "high"-quality study for recommending for or against the intervention. Also, this requires no or only minor concerns addressed in the EtD framework. ***
Limited Limited, Moderate, or Strong Evidence from one or more "low"-quality studies with consistent findings or evidence from a single "moderate"-quality study recommending for or against the intervention. Also, higher strength evidence can be downgraded to limited because of major concerns addressed in the EtD Framework. **
Consensus No reliable evidence There is no supporting evidence, or higher quality evidence was downgraded because of major concerns addressed in the EtD framework. In the absence of reliable evidence, the guideline work group is making a recommendation based on their clinical opinion. *

There are still many areas of uncertainty that the current CPG could not answer as is exemplified by the need for this work group to include 16 consensus recommendations. Questions still exist related to timing, duration, and formal versus a supervised home program for both preoperative and postoperative physical therapy. Although widely used in clinical practice, currently no reliable evidence exists to support or guide these modalities. Most of what is currently used is based on expert opinion, and one retrospective case-control study[10] found no difference between a home-based physician-directed versus a standard formal physical therapy program. Future research needs to be focused on the type of protocol, timing, duration, and method of delivery (ie, home-based physician-directed or formal physical therapist-directed). The use of injectable orthobiologics (platelet-rich plasma, bone marrow aspirate, and mesenchymal stem cells) continues to be an area of controversy with benefits and possible associated potential harm with the use of these unregulated materials. High-quality studies are needed to provide the safety profile, cost-benefit profile, and efficacy in glenohumeral osteoarthritis.

Imaging of the shoulder starting with radiographs with utilization of advanced imaging including CT scan may provide a more detailed assessment of glenoid bone morphology. Known preoperative risk factors for poor functional outcomes and increased risk of implant loosening with implant failure include large full-thickness rotator cuff tears, notable posterior glenoid bone loss, notable joint line medialization, and notable posterior humeral head subluxation.[11,12] Use of 3D CT reconstructions and possible use of preoperative planning software allows for detailed preoperative surgical planning to identify, understand, and correct these deformities. Further investigation is needed to determine how these modalities affect the patient outcome and implant survivorship.

Many additional areas related to nonarthroplasty options such as arthroscopic débridement or biologic resurfacing, use of polyethylene-metal hybrid glenoid implants, management of the head biceps, same day discharge, use of postoperative cryotherapy, multimodal pain management, and tranexamic acid are all areas that warrant future research to provide high strength recommendations because there still remains a notable gap in knowledge in these areas.

It is clear that as best available evidence continues to grow more definitive guidance can be provided for the treatment of glenohumeral joint osteoarthritis.

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