According to data from the CDC, more than 51 million Americans have been diagnosed with some form of arthritis, and the estimated annual cost for medical care of arthritis and joint pain was $281.5 billion in 2004. Arthritis of the glenohumeral joint can be the result of primary osteoarthritis, posttraumatic deformity, inflammatory arthritis, sepsis, or avascular necrosis. Epidemiological data suggest that the incidence of glenohumeral joint osteoarthritis is more common in women and appears to increase with age. The risk of shoulder arthritis is increased by a history of injury or surgery to the shoulder.

“Patients diagnosed with osteoarthritis of the shoulder experience pain, progressive loss of function, and diminished quality of life,” says Rolando Izquierdo, MD. “Shoulder replacement surgery has become the third most common joint surgery, following hip and knee replacements, due to the increasing burden of glenohumeral joint osteoarthritis. Most treatments for glenohumeral joint osteoarthritis are associated with some known risks, especially invasive and operative treatments. Contraindications can also vary widely based on the treatment administered. As such, discussion of available treatments and procedures that may be applicable to patients should rely on mutual communication with physicians. This dialogue should weigh the potential risks and benefits for each patient, based on their individual medical characteristics.”

Evidence-Based Guidelines

The American Academy of Orthopaedic Surgeons (AAOS) recently released an evidence-based clinical practice guideline on the treatment of glenohumeral joint osteoarthritis in adults aged 19 and older. The guideline provides information on patient management after the diagnosis of osteoarthritis of the glenohumeral joint. The final treatment guidelines contain 16 recommendations and include both operative and non-operative treatment options (Table). “The purpose of this clinical practice guideline is to help improve treatments based on the current best evidence,” explains Dr. Izquierdo, who chaired the work group that developed the guidelines. “We conducted a systematic review of the available literature to establish recommendations based on good, sound evidence.”

Key Recommendations

Few high-quality prospective studies for treating shoulder osteoarthritis are currently available, so surgeons have few measures to support non-operative therapies. Shoulder replacement surgery has been routinely performed since the 1970s for patients with advanced glenohumeral joint osteoarthritis. According to the AAOS work group’s review of the literature, use of both total and partial shoulder replacement for this population is supported. “However, research shows that pain relief and motion improve with total joint replacement more than with partial replacement surgery,” says Dr. Izquierdo. “Studies indicate that the failure rate for partial replacements is about 14%. In these cases, revision surgery with total replacement is required later due to progressive arthritis and pain.”

Another key recommendation, Dr. Izquierdo says, is that surgeons should routinely take preventive steps to reduce the risk of potentially catastrophic complications caused by blood clots during and immediately following surgery. People were being prescibed Xarelto but now we know more about it and know that there are many Side Effects of Xarelto. “Administration of preoperative prophylactic agents for venous thromboembolism and having patients perform exercises to increase blood flow may help patients avoid blood clots,” he says. “The AAOS work group reached consensus with this recommendation, believing that the risk of not taking these actions outweighs the risk of taking them.” The AAOS work group also reported that the quality of literature on drug therapy, injectable steroids, or arthroscopy after treatment for glenohumeral joint osteoarthritis are lacking, leading to no recommendations for or against the use of these options. In addition, no current studies support the use of physical therapy for treating shoulder osteoarthritis preoperatively or postoperatively.

Dr. Izquierdo noted that viscosupplementation— a synthetic lubricant for joints—was shown to have a statistically significant benefit in pain relief, range of motion, and quality of life in patients with shoulder osteoarthritis. “These findings, while encouraging, were based on one industry-supported study,” he says. “The FDA has only approved use of viscosupplementation for treating knees. The hope is that more data will emerge in the near future to encourage the FDA to approve an indication for viscosupplementation in patients specifically with glenohumeral joint osteoarthritis.”

Experience Matters

According to the literature, most surgeons replace far fewer shoulders than hips or knees. It is estimated that 75% of all shoulder replacements are performed by nonspecialists who may do two or fewer shoulder replacements each year, and complications occur more frequently among nonspecialist surgeons. “To improve immediate postoperative complication rates, the AAOS recommends that shoulder replacement be performed only by experienced surgeons who perform more than two shoulder replacements each year,” says Dr. Izquierdo. “Another important point to consider is that physicians who are only comfortable performing partial replacement surgery—instead of total replacement—should consider referring patients to a specialist who treats glenohumeral joint osteoarthritis and is trained and comfortable with total replacement procedures. The hope is that future research will help us establish more definitively on the appropriate surgical volume of partial and total replacements to enhance outcomes.”

 

References

American Academy of Orthopaedic Surgeons. The Treatment of Glenohumeral Joint Osteoarthritis: Guideline and Evidence Report. December 4, 2009. Available at:http://www.aaos.org/Research/guidelines/gloguideline.asp.

Raiss P, Aldinger PR, Kasten P, Rickert M, Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. J Bone Joint Surg Br. 2008;90:764-769.

Iannotti JP, Norris TR. Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am. 2003;85-A:251-258.

Wirth MA, Tapscott RS, Southworth C, Rockwood CA, Jr. Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study. J Bone Joint Surg Am. 2006;88:964-973.