Shoulder Arthritis
Osteoarthritis is a progressive degeneration of the joints. It results when the protective surface (cartilage) that allows the joint to move smoothly is damaged. Over time this cartilage is worn away, and adjacent bones are remodelled as the joint becomes increasingly abnormal and ‘rusty’, resulting in pain and stiffness.
Osteoarthritis of the shoulder is less common than many other joints, principally the hips, knees, and hands. It is nonetheless a debilitating problem and can have a significant impact on the patient’s life.
Incidence
• increases with age
◦ more likely in patients over 60
• Demographics
◦ more common in women
• Risk factors
◦ 56% of patients who had primary anterior dislocation have arthrosis at 25 years follow up.
Causes
Traditionally thought of as a ‘wear and tear’ phenomenon, the cause of osteoarthritis is generally unknown; however, several contributing factors have been identified. It can be primary osteoarthritis. It can be secondary to trauma, dislocation, inflammatory/crystalline arthritis, avascular necrosis, rotator cuff arthropathy, prior shoulder surgery, history of trauma, and shoulder overuse—individuals who engage in high-intensity overhead activities such as weightlifters and racquet sport players are at increased risk.
Symptoms
Patients with arthritis of the shoulder will classically complain of a stiff and painful shoulder, with a limited range of movement. Description of pain and stiffness that intensifies with use is standard as is painful interruption of sleep. “Catching” and “noise” heard during movement is another routine finding.
Presentation
• Shoulder pain
◦ worse with activities involving shoulder motion
◦ often no pain at rest
◦ Loss of range of motion
◦ especially external rotation due to anterior capsule contraction
◦ difficulty sleeping
• Functional limitations at glenohumeral joint
◦ decreased range of motion
◦ variable and more active patients have better range of motion (ROM)
◦ crepitus
◦ catching/squeaking with articulation
Diagnosis
Osteoarthritis is usually diagnosed by a combination of clinical examination and history of the presenting complaint. Before proceeding with treatment, X-rays may be taken to evaluate the extent of any damage which may help decide upon the most appropriate treatment. Similarly, a CT scan of the shoulder may also be requested if it is decided that surgical management would be the most suitable option.
Treatment
Surgical Management
The form of surgery chosen should be the least invasive approach required to provide long term pain relief and restore function.
Surgical Management
Arthroscopic treatment of the shoulder for osteoarthritis is primarily a temporary therapy in which the joint is “tidied up.” The surgeon removes unwanted material and smoothes off the joint, hopefully providing relief of symptoms.
Shoulder Replacement
Non-operative Management
Non-operative treatment should always be exhausted prior to proceeding with any form of surgery. Possible non-operative options available include:
1. Physiotherapy – to prevent any further stiffness and regain range of motion
2. Painkillers and anti-inflammatories – mild/ moderate pain killers and anti-inflammatory medications may be taken to provide symptomatic relief. However, these drugs are in no way curative and will not alter the course of the disease.
3. Injections – mainly short-term benefit only
4. Steroid injections – are often given to provide short-term relief to the patient, though this period is unpredictable due to the wide variability of the disease. Repeated injections should not be given as a long term cure as they can cause further damage to the joint.
5. Hyaluronan injections have been shown to be beneficial for early arthritis and where surgery is contraindicated. They seem to provide more extended benefit than steroid injections with fewer side effects. However, they are more costly.
6. Platelet-rich plasma and stem cell injections.
Ultimately in cases of severe non-resolvable pain or previously failed treatment options, shoulder replacement (arthroplasty) is indicated. There are several variations of shoulder replacements available, some more invasive than others. The choice of replacement depends on several criteria. These include age, activity level, a form of arthritis, and the amount of bone affected.
Arthroplasty Options
Hemiarthroplasty
Hemiarthroplasty involves a prosthetic metal implant being placed into the upper bone in the arm (humerus) which forms half of the shoulder joint. Whilst in total shoulder arthroplasty both sides of the joint are replaced. Depending on the condition of your shoulder, your surgeon may replace only the ball. This procedure is called a hemiarthroplasty. In a traditional hemiarthroplasty, the head of the humerus is replaced with a metal ball and stem, similar to the component used in a total shoulder replacement. This is called a stemmed hemiarthroplasty.
Resurfacing Hemiarthroplasty
Resurfacing hemiarthroplasty involves replacing just the joint surface of the humeral head with a cap-like prosthesis without a stem. With its bone preserving advantage, it offers those with arthritis of the shoulder an alternative to the standard stemmed shoulder replacement.
Total Shoulder replacement
The typical total shoulder replacement involves replacing the arthritic joint surfaces with a highly polished metal ball attached to a stem and a plastic socket. Patients with bone-on-bone osteoarthritis and intact rotator cuff tendons are generally good candidates for conventional total shoulder replacement.
Reverse Shoulder Replacement
Another type of shoulder replacement is called reverse total shoulder replacement. Reverse total shoulder replacement is used for people who have:
• Completely torn rotator cuffs with severe arm weakness
• The effects of severe arthritis and rotator cuff tearing (cuff tear arthropathy)
• had a previous shoulder replacement that failed
Reverse shoulder replacement is a type of shoulder replacement in which the glenohumeral joint’s normal ball and socket relationship is reversed, creating a more stable joint with a fixed fulcrum. This form of shoulder replacement is utilized in situations where conventional shoulder replacement surgery leads to poor outcomes and high failure rates. The combination of improved design features and excellent clinical outcome data has led to reverse shoulder replacement instead of other types to primary manage various shoulder problems. We have published our results as part of a multicentre clinical study looking at 159 reverse shoulder replacement results with five years of follow-up. We reported that reverse total shoulder arthroplasty restores the function in the shoulder with significant improvements in function and moderate complications with significant improvement in clinical functions.
Prevention
- Keep doing as much of your regular routine as possible.
- Maintain a healthy weight
- Remain active to keep muscle strength from diminishing. If you work up to a well-designed exercise program, you can keep or even improve joint flexibility.
- Keep repetitive overhead activity to a minimum
- Rest only when joints are very painful.