Shoulder and Elbow cases glenohumeral osteoarthritis
A 61-year-old, right-hand-dominant female presents with 5 years of gradually worsening right shoulder pain. The pain is worse at night and she is finding it gradually more difficult to perform certain activities such as combing her hair, putting on a coat, and reaching for objects on high shelves. Past medical history includes hypertension and hyperlipidemia, both well controlled with medication. Physical examination reveals that the right shoulder appears flatter in contour compared with the contralateral side. She has diffuse tenderness to palpation about the right shoulder glenohumeral joint; range of motion of the shoulder decreased in external rotation; and 5/5 strength in the rotator cuff muscles. Imaging is shown in
Figures 2–48 and 2–49.
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Figure 2–48
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Figure 2–49
Based on the information and imaging, what is the most likely diagnosis?
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Traumatic rotator cuff tear
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Osteoarthritis of the glenohumeral joint
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Cuff tear arthropathy
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Degenerative labral tear
Discussion
The correct answer is (B). The patient’s chronic pain, difficulty with external rotation, flattened appearance, combined with the imaging showing narrowed joint space, subchondral sclerosis, and osteophytes at the inferior aspect of the humeral head lead to the diagnosis of glenohumeral osteoarthritis. In addition, the patient has no signs of cuff deficit on examination and no history of trauma, so Answer A is incorrect. Cuff tear arthropathy (Answer C) would also be less likely given her lack of weakness combined with imaging showing typical signs of osteoarthritis without a high-riding humeral head as would be characteristic of a massive cuff tear with resulting arthropathy. Finally, Answer D is incorrect because, even though it is probable a person her age would have a labral tear, it would manifest more as mechanical symptoms and/or instability.
The patient says she has been taking ibuprofen daily with little to no relief. Based on the diagnosis, what would you recommend at this point?
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Physical therapy to strengthen the rotator cuff muscles, corticosteroid injection into the subacromial space.
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Total shoulder arthroplasty
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Physical therapy to improve shoulder range of motion and corticosteroid injection into the glenohumeral joint
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Reverse total shoulder arthroplasty
Discussion
The correct answer is (C). Conservative management is the first step in treating glenohumeral osteoarthritis, which consists of physical therapy to improve range of motion so the patient is better able to complete activities of daily living (ADLs) and corticosteroid injection into the glenohumeral joint. Should this fail to adequately relieve pain, the next choice would be B, total shoulder arthroplasty. Answer D is incorrect not only because the first step is conservative management, but also because the patient’s rotator cuff is intact, and reverse total shoulder arthroplasty is indicated for glenohumeral arthritis with cuff deficiency and an intact deltoid. Finally, Answer A would be more appropriate for a patient with a rotator cuff tear and subacromial bursitis, as opposed to this patient whose pathology is focused on the glenohumeral joint.
Eight months later, the patient has completed a course of physical therapy and undergone two corticosteroid injections into the glenohumeral joint. The first injection relieved her pain for about 3 months, but her second injection only worked
for a few weeks. The patient now says the pain and disability have returned to levels prior to the injections. You decide to proceed with operative treatment with a total shoulder arthroplasty (TSA).
What is the next step in preoperative planning?
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CT of the right shoulder to evaluate glenoid bone stock and glenoid version
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MRI of the right shoulder to evaluate the rotator cuff
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MR-arthrogram of the right shoulder to evaluate for labral tears
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X-ray of the left shoulder to evaluate for contralateral glenohumeral osteoarthritis
Discussion
The correct answer is (A). CT would aid in preoperative planning by determining glenoid bone stock and glenoid version and is therefore the best choice. Glenoid bone stock is especially important as there must be sufficient bone stock in order to be able to place the glenoid component. The Walch classification (Table 2–5, Fig. 2–50) describes the progression of glenoid wear found in glenohumeral arthritis. “B” is incorrect because, although an intact rotator cuff is a requirement for TSA, it is assumed at this point the status of the cuff has been evaluated, and the exact nature of rotator cuff morphology is not necessary for preoperative planning. “C” is incorrect since the quality of the labrum has no effect on pre-operative planning for TSA. “D” is incorrect because osteoarthritis in the contralateral shoulder is not an important factor in preoperative planning, however, in the case of rheumatoid arthritis clinical function of other extremities does have an effect on operative decision making.
Table 2–5 WALCH CLASSIFICATION OF GLENOID WEAR
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Type A |
Concentric wear, no subluxation, well centered A1-minor erosion A2-deeper, central erosion |
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Type B Biconcave glenoid, asymmetric glenoid wear, posterior subluxation of humeral head B1-narrowed posterior joint space, subchondral sclerosis B2-posterior wear with biconcave glenoid |
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Type C |
Glenoid retroversion >25 degrees (of dysplastic origin), ± posterior subluxation of humeral head |
From Walch G, et al. Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis. Journal of Arthroplasty 1999;14(6):756–760.
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Figure 2–50 Reproduced with permission from Walch G, et al. Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis. Journal of Arthroplasty 1999;14(6):756–760.
The patient undergoes a total shoulder arthroplasty via deltopectoral approach. At her 2-week postoperative visit, the incision is healing well and her pain is controlled with 1 to 2 tablets of hydrocodone-acetaminophen daily. You give her a prescription for physical therapy. Four weeks later, the patient returns to clinic complaining of an increase in shoulder pain as well as weakness for the past 3 days, especially when getting dressed. She does not recall any traumatic event. On examination her incision remains clean, dry, and intact; there is a positive finding of weakness when resistance is applied to the arm in an adducted and internally rotated position behind the back. X-rays are shown in Figure 2–51.
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Figure 2–51
What is the most likely explanation?
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Loosening of the humeral component
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Infection of the shoulder joint with P. acnes
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Tearing of the subscapularis tendon
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Axillary nerve palsy from intraoperative injury
Discussion
The correct answer is (C). During the deltopectoral approach, the subscapularis tendon is detached from the anterior humerus so the humeral head may be exposed. The tendon is reattached after placement of the components, and there is a postoperative risk of repair failure, especially during rehabilitation. Precautions to avoid in rehabilitation include limiting external rotation of the shoulder and avoiding such movements as pushing out of a chair. Pendulum exercises and passive range of motion supervised by physical therapy are advised, and active range of motion of the elbow, wrist, and hand should be encouraged to avoid stiffness. Choice “A” is incorrect because the patient’s symptoms are more consistent with subscapularis tear, and there is no radiographic evidence of loosening. Choice “B” is incorrect because infection is more associated with loosening. Choice “D” is incorrect because axillary nerve palsy would likely present as weakness with shoulder abduction and/or sensory changes in the skin around the deltoid.
Objectives: Did you learn...?
Recognize the clinical presentation of glenohumeral osteoarthritis? Treat a patient with glenohumeral osteoarthritis?
Manage a patient after total shoulder arthroplasty?