Practice Guidelines Regarding Treatment of Shoulder Osteorthritis: My Commentary

[mtomaino]

On the Shoulder page of this website I recently attached an article from January's issue of the Journal of Bone and Joint Surgery. This article reflects the current consensus of the AAOS (American Academy of Orthopaedic Surgeons) regarding practice guidelines for Shoulder Osteoarthritis.
See the following link to take you directly there: http://www.rearmyourself.com/article...er-replacement

In what follows below, I have first copied the exact text from the article, in the order that the points are made, and after each point I provide my comment/opinion. One must remember that practice guidelines are largely predicated on "evidence" in the literature. Because there are many aspects of "practice" that we may know to be efficacious---from experience etc----even when not technically supported by "evidence in the literature" there will , at times, be conflict. My commentary is an attempt at reconciling these "conflicts".

AAOS Guidelines:
1. We are unable to recommend for or against physical therapy for the initial treatment of patients with osteoarthritis of the glenohumeral joint.
Strength of Recommendation: Inconclusive

MMT--I have seen PT help patients become more functional, therefore, in my practice, there is little downside to trying PT. PT does not cure the arthritis, but it may help decrease pain that may be coming from bursitis/rotator cuff. Further, PT may improve movement of your shoulder blade; in improving "scapulothoracic" motion, your functional range of motion--particularly over head as opposed to rotation--may improve.

2. We are unable to recommend for or against the use of pharmacotherapy in the initial treatment of patients with glenohumeral joint osteoarthritis.
Strength of Recommendation: Inconclusive

MMT--I agree. Nonsteroidals such as Aleve or Advil (Ibuprofen) may or may not help. Patients often ask whether taking Glucosamine will help. This is equally as random. May help--may not.


3.We are unable to recommend for or against the use of injectable corticosteroids when treating patients with glenohumeral joint osteoarthritis.
Strength of the Recommendation: Inconclusive

MMT-- I agree, however, in my experience, a corticosteroid injection often helps, even if transiently. Accordingly, I routinely offer this type of injection because it may truly help diminish pain.


4. The use of injectable viscosupplementation is an option when treating patients with glenohumeral joint osteoarthritis.
Strength of the Recommendation: Weak

MMT-- This is FDA approved for the Knee, but not in the shoulder. As a result, I have no experience with its use. The guidelines seem to indicate that it has limited efficacy, if any.


5. We are unable to recommend for or against the use of arthroscopic treatments for patients with glenohumeral joint osteoarthritis. These treatments include debridement, capsular release, chondroplasty, microfracture, removal of loose bodies, and biologic and interpositional grafts, subacromial decompression, distal clavicle resection, acromioclavicular joint resection, biceps tenotomy or tenodesis, and labral repair or advancement.
Strength of Recommendation: Inconclusive

MMT --In my experience this can help. Visit this link: http://www.rearmyourself.com/article...20arthroplasty

However, for this to be of potential benefit, usually one needs to have reasonable motion. Thus, it's main value is in trying to improve pain level in a shoulder with functional motion.


6.We are unable to recommend for or against open debridement and/or non-prosthetic or biologic interposition arthroplasty in patients with glenohumeral joint osteoarthritis. These treatments include:
d Allograft
d Biologic and Interpositional Grafts
d Autograft
Strength of Recommendation: Inconclusive

MMT-- This method of resurfacing the glenoid with tissue was originally advanced by Dr Wayne Burkhead (Dallas Tx). Few around the country have been able to duplicate his results. Recently Dr JP Warner (Boston), a former partner of mine when I was practicing in Pittsburgh, published a report which showed poor outcomes. In my practice I have not had good success with this approach. Accordingly, I am more inclined to perform either a hemiarthroplasty or total shoulder replacement, even in younger patients.


7. Total shoulder arthroplasty and hemiarthroplasty are options when treating patients with glenohumeral joint osteoarthritis.
Strength of Recommendation: Weak

MMT-- This is a true statement. However, the current evidence suggests that Totals do better than hemis.


8. We suggest total shoulder arthroplasty over hemiarthroplasty when treating patients with glenohumeral joint osteoarthritis.
Strength of Recommendation: Moderate

MMT--- As I mentioned above--pain relief and functional outcomes have been better in my experience, after Total replacement as opposed to hemiarthroplasty. But, Hemi is still a viable option, if glenoid replacement is not elected.


9. An option for reducing immediate postoperative complication rates is for patients to avoid shoulder arthroplasty by surgeons who perform less than two shoulder arthroplasties per year.
Strength of Recommendation: Weak

MMT--Though the evidence to support this statement exists, albeit weak, it is well understood that quality and quantity are linked. I do over 60 replacements each year---and often about 6-8 each month. If I did only 1-2 a year, I think that the potential for a complication would increase simply due to "less experience".

10. In the absence of reliable evidence, it is the opinion of this work group that physicians use perioperative mechanical and/or chemical VTE (venous thromboembolism)prophylaxis for shoulder arthroplasty patients.
Strength of Recommendation: Consensus

MMT-- I agree. It is part of our protocol to use devices on one's legs to prevent venous stasis during the pocedure. I do not use Coumadin or Aspirin .


11. The use of either keeled or pegged all polyethylene cemented glenoid components are options when performing total shoulder arthroplasty.
Strength of Recommendation: Weak

MMT--- agree that both are options. Up until the fall of 2010 I was using a keeled glenoid, and results have been good. But I have switched to a pegged glenoid as this is the newest type----which minimizes the use of cement, and allows for bone ingrowth--effectively improving the potential for long term surviveability.


12. In the absence of reliable evidence, it is the opinion of this work group that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear.
Strength of Recommendation: Consensus

MMT- Agree. In addition, if a patient has no tear, but weak, poorly functioning cuff muscle, outcomes may be unsatisfactory. In these cases, Reversed arthroplasty may be better than Anatomic replacement.


13. We are unable to recommend for or against biceps tenotomy or tenodesis when performing shoulder arthroplasty in patients who have glenohumeral joint osteoarthritis.
Strength of Recommendation: Inconclusive

MMT--In my experience, the long head of the biceps is degenerative in the vast majority of patients with arthritis. Leaving this tendon may result in pain. Therefore, I routinely perform a tenotomy--which means cutting it. I also routinely sew it to the pectoralis tendon (tenodesis) to keep the shape of the biceps muscle from bunching up. There is absolutely no loss of function with this practice.


14. We are unable to recommend for or against a subscapularis trans tendonous approach or a lesser tuberosity osteotomy when performing shoulder arthroplasty in patients who have glenohumeral joint osteoarthritis.
Strength of Recommendation: Inconclusive

MMT--There are a few different technical options regarding how to fix the subscapularis tendon, which is routinely cut to be able to gain access to the joint. If well executed, and the tendon heals, they are all valid. This tendon needs to be protected for 6 weeks after replacement, which is why we keep patients in a sling for 4-6 weeks and limit external rotation during tht period.


15. We are unable to recommend for or against a specific type of humeral prosthetic design or method of fixation when performing shoulder arthroplasty in patients with glenohumeral joint osteoarthritis.
Strength of Recommendation: Inconclusive

MMT--I agree that the evidence in inconclusive. However, I am a firm advocate of replicating one's own "anatomy". Therefore, I use an anatomic design which allows me to precisely replicate Humeral inclination, version and offset. In the final analysis, I believe (as do other advocates of anatomic designs) that this leads to better function after replacement.


16. We are unable to recommend for or against physical therapy following shoulder arthroplasty.
Strength of Recommendation: Inconclusive

MMT-- Agree that it is inconclusive; in fact I know of some colleagues who do no PT for 6 weeks. However, there is no contraindication to starting PT earlier than later so long as appropriate limitations are followed--such as limiting external rotation to allow the subscapularis to heal. The value of this inconclusive observation lies with understnding that when PT is not available or possible (for other reasons), it is unlikely to jeopardize outcome.