Glenohumeral Osteoarthritis in the Young Patient: Evaluation and Management 3030911896, 9783030911898

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Glenohumeral Osteoarthritis in the Young Patient Evaluation and Management Brian M. Grawe J. Gabriel Horneff III Joseph A. Abboud Editors

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Glenohumeral Osteoarthritis in the Young Patient

Brian M. Grawe  •  J. Gabriel Horneff III Joseph A. Abboud Editors

Glenohumeral Osteoarthritis in the Young Patient Evaluation and Management

Editors Brian M. Grawe Department of Orthopedic Surgery University of Cincinnati Medical Center Cincinnati, OH, USA

J. Gabriel Horneff III Department of Orthopaedics University of Pennsylvania Philadelphia, PA, USA

Joseph A. Abboud Rothman Institute Philadelphia, PA, USA

ISBN 978-3-030-91189-8    ISBN 978-3-030-91190-4 (eBook) https://doi.org/10.1007/978-3-030-91190-4 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Glenohumeral osteoarthritis is a chronic progressive disease that affects patients of all ages. Treatment of this condition in young patients poses a clinical challenge, as younger patients are often more active and high demand than their elderly counter parts. Therapeutic options often need to be personalized to both the patient and demand of the affected shoulder  – clinicians cannot utilize a one-size-fits-all approach for this disease process in the young patient. The purpose of this book was to break down, in a concise manner, the numerous modalities associated with successful treatment strategies in young patients that present with symptomatic glenohumeral osteoarthritis. Treatment options are presented in a stepwise fashion and cover non-surgical as well as surgical options. Spotlights on surgical techniques are highlighted when appropriate. Our mission was to deliver up-to-date treatment algorithms for this complex clinical diagnosis, highlighting how each option is altered based upon the patient being young and active. Chapter order was specifically chosen to sequentially increase based upon invasiveness. Each chapter is reinforced with up-to-date information and does not shy away from providing clinical rationale and evidence as to why the intervention can be successfully implemented in the young patient. We anticipate that the clinician reader will enjoy the content presented within. The production of the book was a heavy lift from many providers across the continent. Each chapter was carefully edited to ensure readability and meet the goals and purpose of the publication.



Cincinnati, OH, USA Philadelphia, PA, USA

Brian M. Grawe J. Gabriel Horneff III Joseph A. Abboud

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Contents

1 Burden of Glenohumeral Osteoarthritis in the Young Patient��������������   1 Timothy Leroux and David Drynan 2 Etiology of Glenohumeral Osteoarthritis in the Young Patient������������  15 Bradley L. Young and Bryan M. Saltzman 3 Evaluation of Glenohumeral Osteoarthritis in the Young Patient��������  31 Brandon J. Erickson and Anthony A. Romeo 4 Noninvasive Treatment Options for Glenohumeral Osteoarthritis in the Young Patient����������������������������������������������������������  43 Brandon D. Bushnell, Joseph K. Bell, William Gilbert, D. Hal Silcox IV, and Stephen A. Parada 5 Injection Therapies for Glenohumeral Osteoarthritis in the Young Patient ��������������������������������������������������������������������������������   59 J. Gabriel Horneff III and Jeffery Lu 6 Arthroscopic Treatment of Glenohumeral Arthritis in the Young Patient ����������������������������������������������������������������������������������  69 Adam J. Santoro, Daniel Hameed, and Luke S. Austin 7 Bone Preserving Resurfacing Treatment Options for Glenohumeral Osteoarthritis in the Young Patient��������������������������������  81 Anthony Miniaci and Michael J. Scarcella 8 Stemless Shoulder Arthroplasty for Glenohumeral Arthritis in a Young Patient����������������������������������������������������������������������  91 Nihar S. Shah and Brian M. Grawe 9 Ream and Run for Glenohumeral Arthritis in a Young Patient������������ 107 Corey J. Schiffman, Jason E. Hsu, and Frederick A. Matsen III 10 Total Shoulder Arthroplasty for Glenohumeral Arthritis in a Young Patient�������������������������������������������������������������������������������������� 119 J. Ryan Mahoney and Samer S. Hasan

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11 Reverse Shoulder Arthroplasty for Glenohumeral Arthritis in a Young Patient���������������������������������������������������������������������� 143 Adil Shahzad Ahmed, Kyle Gregory Achors, and Mark Alan Frankle 12 Arthrodesis for Glenohumeral Osteoarthritis in a Young Patient�������� 165 Nicholas P. Gannon, Edward V. Craig, and Michael L. Knudsen 13 Putting It All Together: What’s on the Horizon for a Young Patient with Glenohumeral Osteoarthritis?����������������������������������������   181 Joseph A. Abboud and Brian W. Hill Index�������������������������������������������������������������������������������������������������������������������� 193

Contributors

Joseph A. Abboud  Rothman Institute, Philadelphia, PA, USA Kyle  Gregory  Achors  Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA Adil  Shahzad  Ahmed  Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA Luke S. Austin  Rothman Orthopaedic Institute, Philadelphia, PA, USA Joseph K. Bell  Orthopedic Surgery, Franciscan Health, Olympia Fields, IL, USA Brandon D. Bushnell  Orthopedic Surgery, Harbin Clinic, LLC, Rome, GA, USA Edward  V.  Craig  University of Minnesota, Department of Orthopedic Surgery, Minneapolis, MN, USA David Drynan  The Children’s Hospital at Westmead, Sydney, NSW, Australia Brandon J. Erickson  Rothman Orthopaedic Institute, New York, NY, USA Mark  Alan  Frankle  Department of Orthopaedic Surgery, University of South Florida Morsani College of Medicine, Tampa, FL, USA Florida Orthopaedic Institute, Tampa, FL, USA American Shoulder and Elbow Surgeons, Tampa, FL, USA Nicholas P. Gannon  University of Minnesota, Department of Orthopedic Surgery, Minneapolis, MN, USA William  Gilbert  Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA Brian  M.  Grawe  Department of Orthopedic Surgery, University of Cincinnati Medical Center, Cincinnati, OH, USA D.  Hal  Silcox IV  Medical College of Georgia at Augusta University, Augusta, GA, USA Daniel Hameed  Rothman Orthopaedic Institute, Philadelphia, PA, USA

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Contributors

Samer S. Hasan  MercyHealth-Cincinnati Sportsmedicine and Orthopaedic Center, Cincinnati, OH, USA Brian W. Hill  Palm Beach Orthopaedic Institute, Palm Beach Gardens, FL, USA J. Gabriel Horneff III  Department of Orthopaedics, University of Pennsylvania, Philadelphia, PA, USA Jason  E.  Hsu  Orthopaedics & Sports Medicine, University of Washington, Seattle, WA, USA Michael L. Knudsen  University of Minnesota, Department of Orthopedic Surgery, Minneapolis, MN, USA Timothy Leroux  Orthopaedic Department, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada Jeffery Lu  Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA J. Ryan Mahoney  Cincinnati Shoulder and Elbow Fellowship, Cincinnati, OH, USA Frederick  A.  Matsen III  Orthopaedics & Sports Medicine, University of Washington, Seattle, WA, USA Anthony  Miniaci  FRCSC Sports Medicine, Cleveland Clinic, Garfield Heights, OH, USA Stephen A. Parada  Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA Anthony A. Romeo  Rothman Orthopaedic Institute, New York, NY, USA Bryan M. Saltzman  Department of Orthopaedic Surgery, OrthoCarolina, Sports Medicine Center, Atrium Health Musculoskeletal Institute (MSKI), Charlotte, NC, USA Adam J. Santoro  Rowan University School of Osteopathic Medicine, One Medical Center Drive, Stratford, NJ, USA Michael  J.  Scarcella  MD Sports Medicine, Cleveland Clinic, Garfield Heights, OH, USA Corey J. Schiffman  Orthopaedics & Sports Medicine, University of Washington, Seattle, WA, USA Nihar  S.  Shah  Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA Bradley L. Young  Department of Orthopaedic Surgery, Carolinas Medical Center, Atrium Musculoskeletal Institute, Charlotte, NC, USA

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Burden of Glenohumeral Osteoarthritis in the Young Patient Timothy Leroux and David Drynan

Introduction Age is the overriding risk factor for osteoarthritis [1]. As such, physicians and treatments have been elderly focussed, presenting the difficult scenario of the young patient with shoulder arthritis. Treating the under 55-year-old patient with glenohumeral arthritis encompasses primary osteoarthritis, post-traumatic, instability, iatrogenic and other secondary causes of arthritis leading to cartilage destruction, pain and limited function. The young patient, between 30 and 55 years old, with end-stage shoulder arthritis presents a unique treatment challenge given increased activity levels, higher expectations, and longer life expectancy. Young patients with arthritis can have their disease burden impact many phases of their life including affecting their working careers that may result in personal and financial implications.

Epidemiology Before understanding the epidemiology of glenohumeral joint osteoarthritis, a definition of the condition must be common for comparison. Along with glenohumeral joint osteoarthritis, like other joints, the disease is a continuum of degeneration, cartilage loss and joint dysfunction. The natural history of this condition in the young or early phases is difficult to accurately assess and, as yet, has not been fully reported in the literature. T. Leroux (*) Orthopaedic Department, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada e-mail: [email protected] D. Drynan The Children’s Hospital at Westmead, Sydney, NSW, Australia © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. M. Grawe et al. (eds.), Glenohumeral Osteoarthritis in the Young Patient, https://doi.org/10.1007/978-3-030-91190-4_1

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The epidemiology of arthritis is not well established in the literature for age, region or functional status. Arthritis of the young is a worldwide issue, demonstrated by the WHO confirming arthritic pain affecting 0.9–2.3% of 18–29-year-­ olds and 0.8–12.5% of 30–39-year-olds. Interestingly, this study reported 40–49 and 50–59-year-olds had a −0.3–3.3% and 0.7–11.5% symptom reporting rate respectfully, thus the true incidence is likely higher. Primary and secondary osteoarthritis of the shoulder are of concern and have a similar course. The rates are not well known, although larger studies of the post-­ instability arthropathy have been reported. Saltzman et al. have reported the rate of primary osteoarthritis of the shoulder is approximately 21% of those receiving total shoulder arthroplasty under 50 years of age, compared with 66% of those over 50, although this does not yield the overall incidence of shoulder arthritis in the young [2]. Several studies have assessed the long-term risk of arthritis against the natural history of the disease and following stabilisation interventions. The rate of shoulder instability is 8.2–21.9/100,000 persons and radiographic signs of arthritis to be 14–20% in 5-year follow-up studies [3–7]. Twenty-five-year follow-up data reported by Hovelius et al. described mild arthritis in 27% of patients following an instability event and moderate to severe in 34%. Plath and colleagues demonstrated that 69% will develop arthritis following arthroscopic Bankart repair for the treatment of anterior shoulder instability [8]. Although not all shoulder dislocations require surgical intervention, it does present a large burden of arthritic shoulders following instability, considering the peak incidence of first dislocation to be 41.5/100,000 in the 15–24-year age group [9, 10].

Definition Osteoarthritis, the clinical syndrome of joint pain and dysfunction caused by joint degeneration, affects more people than any other joint disease [1]. Primary OA or GH degenerative joint disease is a set of pathologies with a common pathophysiology – articular cartilage damage, dense subchondral bone, osteophytes, posterior glenoid erosion and posterior displacement of the humeral head [11]. Secondary osteoarthritis is due to conditions leading to abnormal cartilage loading or chondral damage, such as post-traumatic conditions, instability, chondrolysis or dysplasia. The diagnosis of this condition includes history, examination and imaging studies.

Clinical Diagnosis History and physical examination are important aspects of the workup for glenohumeral arthritis. Utilising a focussed history, the diagnosis, primary aims of the patient and potential barriers, and possible contraindications to specific management options are obtained. A clinical history is a tapestry of answers that increases the likelihood of the primary diagnosis, the sensitivity and specificity of individual questions is likely very low.

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History Questions • Age • Pain profile – location, character, radiation, associated features and aggravating and relieving factors, night pain • Joint profile – stiffness? Clicking? Locking? Swelling? • Functional profile – Able to dress? Comb hair? Hygiene? Work? Sports, recreational goals? Other demands for the function of the shoulder? • Medical history and medications including prior surgeries • Smoking – worse outcomes after arthroscopic rotator cuff surgery [12] • Handedness • Rehabilitation barriers – access to physiotherapy and care Examination • Look – scars, muscle bulk, wasting, swelling, erythema • Feel – assess range of motion; when limited, place the hand on the shoulder and assess active and passive ranges whilst assessing for crepitus; feel for effusions, swelling, warmth and tenderness • Move – A range of motion assessment shoulder be performed if not completed prior, flexion, abduction, internal rotation with radial styloid as guide, external rotation (sensitive sign for glenohumeral joint arthritis) assess scapular movement and look for dyskinesia • Assess rotator cuff strength for consideration of anatomic arthroplasty; assess deltoid strength for reverse total shoulder; assess stability if primary cause of arthritis; assess biceps tendon for concomitant symptomatic disease • Distal neurovascular exam • Cervical spine assessment for radicular pain

Radiographic Diagnosis Multiple diagnostic classifications exist for glenohumeral joint arthritis. Classification systems include Samilson-Prieto, Allain and Gerber modifications, Kellgren-­Lawrence, Weinstein, and Guyette. It is the author’s preference to use the Kellgren-Lawrence classification to grade GH OA, secondary to its ease of use and widespread acceptance as seen in Table 1.1. Schumaier et al. surveyed 26 shoulder surgeons to assess the inter- and intra-correlation coefficients for the KellgrenLawrence classification and found 0.79 and 0.84 respectfully [13]. Although developed in 1955 and described for rheumatoid arthritis, this classification system has been adopted for use throughout the body but has been shown to be a poor predictor of treatment when it comes to shoulder arthritis in the young [13–15]. Multiple radiographic parameters are discussed in the literature regarding the increased risk of osteoarthritis, such as the critical shoulder angle (CSA), the angle subtended from the inferior margin of the vertical axis of the glenoid to the lateral edge of the acromion. Although a common cause of increased cuff tear arthropathy, a recent literature review by Zaid et al. has not shown any correlation with CSA, acromial index (AI), lateral acromial angle (LAA) and glenoid inclination (GI) and osteoarthritis [16].

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Table 1.1  Kellgren-Lawrence classification and modification for shoulder [13, 14] Grade 0 1 2 3

Original description None Doubtful Mild Moderate

4

Severe

Shoulder modification No arthrosis Possible joint space narrowing, possible osteophyte lipping Definite osteophytes, definite joint space narrowing Multiple osteophytes, definite joint space narrowing, some sclerosis, possible deformity of bone contour Large osteophytes, joint space narrowing, severe sclerosis, definite deformity of bone contour

Ultrasound (US) Ultrasound is not utilised in the diagnosis of GH OA, although frequently patients arrive with US results from their local practitioner. It can be useful in diagnosing effusions and capsular changes with osteoarthritis, but as a primary diagnostic modality, it has limited value. US can be used to assess associated conditions with osteoarthritis, such as long head of bicep tendon pathology or rotator cuff tears lesions, although MRI is becoming more common where financially able to provide the service.

Computed Tomography (CT) CT is the gold standard for the diagnosis and classification of glenohumeral arthritis allowing for 3D imaging, interpretation and planning with printing and modelling. This modality has formed the basis for the Walch classification of glenoid morphology in glenohumeral osteoarthritis, shown in Figs. 1.1 and 1.2 [17]. Walch and colleagues have described the arthritic shoulder with 53.5–59% type A, 32–39.5% type B and 5–9% type C, although the average age groups were greater than 60 years and may not pertain to the young active patient [17, 18]. Osteoarthritis is evident with CT scanning of the shoulder, allowing for advanced knowledge of the subtle signs and early changes of arthritis that may be missed with standard 2D imaging (see below). CT scanning offers highly accurate diagnostic value and can globally define the disease burden to the joint; furthermore, it is a modality that is widely available at most centres. The 3D assessment of the joint has allowed industry partners to develop 3D modelling of prostheses, surgical planning software and predictive range of motion modelling. 3D printing has allowed patient-­ specific implant guides to be manufactured for additional assistance and accuracy with surgical steps and intraoperative navigation. CT findings for osteoarthritis Humerus: • Subchondral sclerosis • Subchondral cysts • Osteophytes

1  Burden of Glenohumeral Osteoarthritis in the Young Patient

A1

5

C B1

A2 B2

Fig. 1.1  Walch et  al. 1999, original classification of glenoid morphology in osteoarthritis. (Reproduced with permission [17])

A1

B1

A2

B2

C

D

B3

Fig. 1.2  Modified Walch classification by Bercik et al. 2016. Including type B3 and D utilising CT. (Reproduced with permission [19])

• Deformity and collapse • Version and varus/valgus alignment • Prior implant assessment Glenoid: • Subchondral sclerosis • Subchondral cysts • Osteophytes

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• Deformity/version/wear pattern/inclination • Prior anchor placement and bone loss Joint: • Joint loss • Effusion • Loose bodies • “Subluxation” Associated: • ACJ arthritis • Loose bodies • Cuff integrity tears and muscle bulk • Prior soft tissue procedures/bony procedures • Planning for implant – vault assessment, bone loss, humeral resection, balancing Walch et al. have shown the breakdown of glenoid types in their published classification utilising CT scans [17]. This research group demonstrated a high interand intra-correlation coefficient and updated breakdown of shoulder arthritis demographics with respect to glenoid morphology, as seen in Table 1.2. These findings have been corroborated across the literature [18].

Magnetic Resonance Imaging (MRI) A recent study has utilised MRI descriptors to classify and predict shoulder arthroplasty outcomes. Cartilage thickness, oedema, glenoid bone loss and version changes with arthritis are easily seen with MRI. These descriptors are used to determine the severity of the arthritis along with cuff pathllogy, ACJ assessment, labral and biceps pathology. Osteoarthritis grading for knee MRI has been developed, including Whole-Organ Magnetic Resonance Imaging Score, Knee Osteoarthritis Scoring System and Boston Leeds Osteoarthritis Knee Score, allowing for Table 1.2  Inter- and intra-reliability with glenoid classifications [17, 19–22] Study Pajolli et al. 2019 Lowe et al. 2017 Bercik et al. 2016 Kidder et al. 2012 Nowak et al. 2010 Walch et al. 1999

Inter-observer reliability 0.132

Intra-observer reliability 0.305–0.545

0.26–0.34 0.23–0.26 0.391 0.703 0.545

0.47–0.6 0.61–0.73 0.604 0.882 0.874

0.508

0.611

Original Walch classification Original Walch with MRI Original Walch classification Modified with A2, B3 and D Partial Walch classification, A, B, C only Original Walch classification

0.65–0.7

0.65–0.7

Original Walch classification

Classification Original Walch classification

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crossover of MRI descriptors for arthritic changes to be used along with Shoulder Osteoarthritis Severity (SOAS) Score [23]. There is no shoulder-specific MRI classification for osteoarthritis. Cartilage thickness, oedema, glenoid bone loss and version changes with arthritis are easily seen with MRI. These descriptors are used to determine the severity of the arthritis with MRI reporting, but no specific grading exists for the shoulder. Osteoarthritis grading for knee MRI has been developed, including Whole-Organ Magnetic Resonance Imaging Score, Knee Osteoarthritis Scoring System and Boston Leeds Osteoarthritis Knee Score, allowing for crossover of MRI descriptors for arthritic changes. Fluid-sensitive MRI slices are best used to determine marrow oedema and early changes in the cartilage, especially fat-suppressed images. Current research evaluating novel MRI sequences and technology include Cartilage Quantification and Composition Assessment to yield better assessment of the cartilage. MRI has been compared to CT for the assessment of osteoarthritis of the shoulder. Lowe et al. assessed the inter- and intra-observer reliability of MRI and Walch classification, finding good reliability for type A1, A2, B1 glenoid, but poor with B2 and C glenoid morphology [20].

Nuclear Medicine (NM) Bone scans and positron emission tomography are rarely used in the clinical setting of investigating arthritis, but will show increased uptake and bone turnover in the arthritis setting, but with minimal bone architectural changes.

Arthroscopic Diagnosis Diagnosis during arthroscopy may be an expected or unexpected event. The expected diagnosis may be confirmation when performing a joint salvage procedure. The unexpected diagnosis may occur as when performing a stabilisation procedure or addressing other soft tissue concerns. During these procedures, the arthroscopic evaluation may confirm cartilage lesions or diffuse arthritis. The difficulty in the second situation is to the management and decision making intraoperatively. The specific treatment and decision making will be determined by the clinical history, examination, symptoms and other soft tissue findings. These treatment options will be addressed in later chapters.

Trends in Diagnosis The diagnosis of symptomatic GH OA in the young and active population is increasing in prevalence. This fact is in part due to increased knowledge of the condition, increased sporting uptake and increased use and availability of advanced imaging, such as MRI.  The sensitivity of MRI allows for the early diagnosis of cartilage

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lesions and osteoarthritis when investigating other pathology, such as instability, that is the likely primary cause of the secondary glenohumeral osteoarthritis.

Financial Burden The economic burden of shoulder arthritis is significant, to the individual, health care practitioner and the health care system as a whole. The US Department of Labor Statistics, 2018 published data regarding days of work missed due to shoulder conditions to be over 68,000 days. Arthritis specifically coded 20 days’ work lost due to shoulder OA. Of the 68,000 shoulder injuries and loss of work days in 2018, the average time away from work was 27 days, almost 32,000 days of work lost from injuries or exacerbation of shoulder conditions [24]. This lost time from work results in a significant impact on the patients’ function, income, work abilities, hobbies, lifestyle and quality of life. Additionally, it can impact individuals around them.

The Health Care System Obtaining accurate numbers of cost are difficult with the myriad of treatment options, pathogenesis for the disease, patient follow-up and outcome reporting. Several investigators have assessed the cost of shoulder arthroplasty with respect to other total joint arthroplasty and subsets of shoulder arthroplasty. Bhat et al. have assessed the cost of total shoulder arthroplasty and hemiarthroplasty in the young arthritic shoulder in both a literature review and economic model. They showed for the 5279 young arthritic shoulders reported in the literature, a total shoulder arthroplasty would cost the health care system $125.5mil and hemiarthroplasty $132.5mil, including projected revisions and longevity of prostheses. This figure is for those reported in the literature, a small percentage of those young patients with glenohumeral arthritis. The expectation for demand of total shoulder arthroplasty is to increase 8.2% per year in the under 55-year-old population and increase 333.3% between 2011 and 2030 [25].

The Patient The impact on the patient includes employment options, hobbies, lifestyle, home life, chronic pain, quality of life and financial strains. The economic impact for patients has been difficult to quantify in the literature, but quality of life assessments have been made. Financial impacts can be extrapolated from employment data from the US Department of Labor, showing 32,000 days’ missed work due to shoulder injuries, with a high percentage being in manual labour occupations [24, 26]. The financial impact is not only due to income loss but also expenditure for treatment. Mulieri et  al. showed no change with formal physiotherapy following

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shoulder arthroplasty compared to physician and patient directed rehabilitation, although their estimates included 1 hour appointments with a physiotherapist for rehabilitation to be approximately US$100. With additional travel, physician visits, allied health input and decreased income during the recovery, the personal financial impact is significant [27]. The overall impact of shoulder arthritis is not just financial; Gartsman et al. published self-assessment data regarding the impact of shoulder pain, including arthritis, that showcased the impact on par with diabetes mellitus, depression and congestive heart failure [28]. The increased demands, expectations, goals and limited options confirm glenohumeral arthritis in the under 55-year-olds is a very difficult problem to manage.

Age-Related Concerns Treatment of shoulder arthritis in the elderly has a tried-and-true algorithm, with arthroplasty displaying predictable results. A specific treatment is less well defined in the young and active patient. The physical demands are increased, the activity levels are elevated, the longevity of the implants is predictability less, whilst the underlying pathology is often more complex [2, 29]. Total shoulder arthroplasty outcomes are less reliable with post-traumatic osteonecrosis as the primary cause for the osteoarthritis, along with decreased range of motion and humeral head subluxation, all of which are increased in osteoarthritis of the young [30, 31]. The concerns with arthroplasty are the functional goals of the patient and if the prosthesis can yield predictable results that maintain longevity of the implant. Due to these limitations with current arthroplasty, alternative treatments such as arthroscopic debridement, chondral treatments, injection therapy and biologic resurfacing and arthroplasty are considered.

Functional Demands Patients under 55 have a higher functional demand and are less often willing to settle for activity modification as a treatment option for their shoulder arthritis. These demands include occupation, physical muscle bulk, activity level, sporting and hobby activities and the financial demands of young active people in the workforce with a chronic condition. The increased functional demands, functional goals and the duration of survival of the intervention lead to further management difficulties with glenohumeral arthritis in the young patient.

Joint Salvage Outcomes Multiple interventions including pain-relieving procedures such as injections, debridement and joint preservation procedures including cartilage grafting and

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biologic resurfacing have their indications and limitations. Biologic resurfacing has been shown to improve shoulder function, particularly constant scores, although the radiographic arthritis progression is evident at an 8-year follow-up [32]. The proven longevity for these interventions is not yet well established, and the possible compromise of future primary total shoulder arthroplasty is a consideration in the young arthritic patient.

Arthroplasty Longevity Outcomes The longevity of current prostheses is a primary reason for the difficulty in managing young patients with glenohumeral osteoarthritis. The functional demands and activity goals for patients under 55 years are increased compared with the elderly arthroplasty practice and prosthesis candidates. This factor may be why Sperling et al. found only 50% of patients with a total shoulder arthroplasty under the age of 50 were satisfied [33]. Although a dated reference, it does highlight the increased expectations of prostheses, function, feel and demands of the younger person with glenohumeral arthritis. Bartelt et al. showed that in patients younger than 55 years, 87% of patients felt better or much better than they were preoperatively, but did not mention the patient’s overall satisfaction rate with the shoulder prosthesis [34]. Newer interventions such as a pyrocarbon interposition arthroplasty have shown a 90% survival at almost 4 years, but almost 80% had progression of disease with humeral medialisation and pain [35]. In this cohort, 10% were revised to reverse total shoulder replacements at an average of 38 months (20–60 months) [35]. Several case series and cohort studies have assessed the survival rate of total shoulder arthroplasty in the under 50-year-old patient and shown results as high as 97% at 10 years for total shoulder arthroplasty [33]. This rate has not been matched in many other longitudinal studies, or the arthroplasties in the young are from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). According to the AOANJRR, the survivorship of hemi-resurfacing for osteoarthritis in patients less than 40 years of age is 77.2% at 9 years, with 80% of those hemi-resurfacings being converted to total shoulder arthroplasty. Total shoulder arthroplasty has improved survival and functional results compared to hemiarthroplasty. Hemiarthroplasty, specifically resurfacing of the humerus, in both less than 40 years old and the 40–55-year groups displays a revision rate of 22.8% at 9 years. A slightly higher revision rate can be found in the stemmed prosthesis in patients under 40 years of age. Total shoulder arthroplasty in the less than 40-year-­ old and 40–55-year groups has relatively high revision rates, 20.7% revision at 8 years for less than 40, and 19.1% at 10 years for 40–55-year age group. This is higher than the cumulative rate of revision at 12 years of 14.8% for stemmed total shoulder arthroplasty and 6.4% for reverse total shoulder arthroplasty at 10 years [36, 37]. Reverse total shoulder arthroplasty in the young has a high revision rate, with insufficient data for less than 40-year subset and 4.7% at 5 years for the 40–55-­ year group [37].

1  Burden of Glenohumeral Osteoarthritis in the Young Patient 100% 90%

HR - adjusted for gender 40-55 vs 5%) with posterior glenoid erosion Narrowing of the posterior joint space, subchondral sclerosis, osteophyte formation Biconcave glenoid secondary to erosion Dysplastic glenoid with glenoid retroversion of more than 25°

Table 3.2  Favard classification of glenoid morphology in the coronal plane Favard category E0 E1 E2

Description Superior humeral head migration without glenoid erosion Concentric glenoid erosion Erosion that is limited to the superior portion of the glenoid

E3 E4

Erosion that extends to the inferior portion of the glenoid Erosion is predominantly at the inferior portion of the glenoid

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Magnetic Resonance Imaging (MRI) While X-rays and CT scans are useful at evaluating bony anatomy, MRI is the imaging modality of choice to better understand soft tissue structures. MRI provides significant information regarding the rotator cuff, articular cartilage of both the glenoid and humeral head, labrum, biceps, capsule, and bony edema/cyst formation within the glenoid and humeral head. The history and physical exam will help the clinician hone in on specific aspects of the MRI to better evaluate the patient’s symptoms and shoulder disease. The MRI is typically done in three planes and has fluid-sensitive sequences and non-fluid-sensitive sequences. Non-fluid-sensitive sequences such as T1 are useful to determine normal anatomy. Fluid-sensitive sequences such as T2 are ideal for evaluating pathological variants including edema within the humeral head or glenoid, cyst formation, etc. The proton density (PD) sequence along with T1ρ is ideal for evaluating the status of the articular cartilage on both the humeral head and glenoid. Evaluating the cartilage is one of the most important functions of the MRI in young patients with shoulder arthritis as subtle changes can occur from various traumas. While significant glenohumeral arthritis is best defined with X-ray and CT, focal chondral defects can be nicely detected on MRI. Furthermore, status of the cartilage from trauma can be nicely delineated on MRI. Saxena et al. evaluated T1ρ MRI values for glenoid and humeral head cartilage in nine patients who sustained a primary shoulder dislocation and compared these findings to five healthy controls without a history of dislocation [18]. The authors found that the humeral head cartilage sustained greater damage than the glenoid cartilage following a primary dislocation. They also found the T1ρ values were higher in glenohumeral zones associated with Bankart and Hill-Sachs lesions and therefore concluded that this widespread cartilage damage from a dislocation could predispose patients to glenohumeral arthropathy. While information regarding the overall cartilage status of the shoulder is important, understanding the quality of the patient’s rotator cuff is also critical. The clinician most understands whether each rotator cuff tendon is intact and what the status of each rotator cuff muscle is, regarding the presence or absence of atrophic changes. It also involves evaluating any prior surgical changes that occurred to the shoulder [19]. The integrity of the rotator cuff tendons can be seen on multiple views. The authors commonly use the axial views to evaluate the subscapularis and the coronal and sagittal views to evaluate the supraspinatus, infraspinatus, and teres minor (Fig. 3.4a, b). Although cuff integrity is important, muscle bulk and status are also extremely important. Goutallier et al. initially described a five-stage grading system muscular fatty degeneration using CT scans in 63 patients who underwent rotator cuff repair (Table 3.3) [20]. Although initially described on CT scans, as MRI is more commonly performed to evaluate the status of the rotator cuff, this classification system has now been validated on MRI. The authors commonly use the sagittal

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b

Fig. 3.4 (a, b) Axial (a) and coronal (b) MRI slices demonstrating an intact subscapularis (red arrow) and supraspinatus (white arrow)

Table 3.3 Original Goutallier classification system for grading fatty atrophy in rotator cuff musculature

Stage 0 1 2 3 4

Description Normal muscle without fatty streaks Some fatty streaks Significant fatty infiltration but with more muscle than fat Equal amounts of fat and muscle More fat than muscle

MRI slices to evaluate the muscle bulk of the rotator cuff muscles (Fig. 3.5). Lippe evaluated the interobserver reliability of the Goutallier classification system and found it to be moderate [21]. Warner et al. also described a method to measure rotator cuff muscle health and fatty degeneration on MRI [22]. The authors used the oblique sagittal plane MRI slice that was medial to the level of the coracoid process and drew lines from the edge of the coracoid to the inferior scapular tip, from the inferior tip of the scapula to the spine, and from the scapular spine to the coracoid process. They then created a grading scale based on how the rotator cuff muscle bellies occupied the space. Their system was broken down into no atrophy, where the muscle completely fills its fossa, and the outer contour is convex (above the previously drawn lines); minimal atrophy, where the muscle’s outer contour is flat compared with its fossa; moderate atrophy, where the muscle’s outer contour is concave into the fossa; and severe atrophy, where the muscle is barely apparent in its fossa. Whatever grading system one uses, it is important to understand the quality of the rotator cuff before deciding on specific treatment.

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Fig. 3.5  Sagittal MRI slice used to determine muscle bulk of the rotator cuff musculature. No significant fatty infiltration is seen

Summary Glenohumeral arthritis in young patients is a difficult problem to manage. Proper treatment can only be rendered once a thorough understanding of the patient’s symptoms and imaging findings are synthesized. As such, obtaining a detailed history, performing a comprehensive physical exam, and obtaining proper imaging in the form of X-rays and advanced imaging modalities including CT and MRI are critical to properly treating young patients with glenohumeral arthritis.

References 1. Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis: implications for research. Clin Orthop Relat Res. 2004;427 Suppl:S6–15. 2. Matsen FA 3rd, Ziegler DW, DeBartolo SE. Patient self-assessment of health status and function in glenohumeral degenerative joint disease. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et al]. 1995;4(5):345–51. 3. Saltzman BM, Leroux TS, Verma NN, Romeo AA. Glenohumeral osteoarthritis in the young patient. J Am Acad Orthop Surg. 2018;26(17):e361–e70. 4. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et  al]. 2016;25(3):390–7.

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5. Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37(9):1840–7. 6. Chalmers PN, Cvetanovich GL, Kupfer N, Wimmer MA, Verma NN, Cole BJ, et al. The champagne toast position isolates the supraspinatus better than the Jobe test: an electromyographic study of shoulder physical examination tests. J Shoulder Elbow Surg/ American Shoulder and Elbow Surgeons [et al]. 2016;25(2):322–9. 7. Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2006;22(10):1076–84. 8. Taylor SA, Newman AM, Dawson C, Gallagher KA, Bowers A, Nguyen J, et al. The "3-pack" examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: a prospective study. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2017;33(1):28–38. 9. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplast. 1999;14(6):756–60. 10. Nowak DD, Gardner TR, Bigliani LU, Levine WN, Ahmad CS.  Interobserver and intraobserver reliability of the Walch classification in primary glenohumeral arthritis. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et al]. 2010;19(2):180–3. 11. Bercik MJ, Kruse K 2nd, Yalizis M, Gauci MO, Chaoui J, Walch G. A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-­ dimensional imaging. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et al]. 2016;25(10):1601–6. 12. Levigne C, Boileau P, Favard L, Garaud P, Mole D, Sirveaux F, et al. Scapular notching in reverse shoulder arthroplasty. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et al]. 2008;17(6):925–35. 13. Erickson BJ, Bohl DD, Cole BJ, Verma NN, Nicholson G, Romeo AA, et al. Reverse total shoulder arthroplasty: indications and techniques across the world. Am J Orthop. 2018;47(9) 14. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg/ American Shoulder and Elbow Surgeons [et al]. 2015. 15. Erickson BJ, Harris JD, Romeo AA. The effect of humeral inclination on range of motion in reverse total shoulder arthroplasty: a systematic review. Am J Orthop. 2016;45(4):E174–E9. 16. Boileau P, Cheval D, Gauci MO, Holzer N, Chaoui J, Walch G. Automated three-dimensional measurement of glenoid version and inclination in arthritic shoulders. J Bone Joint Surg Am. 2018;100(1):57–65. 17. Levigne C, Garret J, Boileau P, Alami G, Favard L, Walch G.  Scapular notching in reverse shoulder arthroplasty: is it important to avoid it and how? Clin Orthop Relat Res. 2011;469(9):2512–20. 18. Saxena V, D'Aquilla K, Marcoon S, Krishnamoorthy G, Gordon JA, Carey JL, et al. T1rho magnetic resonance imaging to assess cartilage damage after primary shoulder dislocation. Am J Sports Med. 2016;44(11):2800–6. 19. Erickson BJ, Ling D, Wong A, Eno JJ, Dines JS, Dines DM, et al. Does having a rotator cuff repair prior to reverse total shoulder arthroplasty influence the outcome? The bone & joint journal. 2019;101-B(1):63–7. 20. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC.  Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83.

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21. Lippe J, Spang JT, Leger RR, Arciero RA, Mazzocca AD, Shea KP.  Inter-rater agreement of the Goutallier, Patte, and Warner classification scores using preoperative magnetic resonance imaging in patients with rotator cuff tears. Arthroscopy: the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2012;28(2):154–9. 22. Warner JJ, Higgins L, Parsons IM, Dowdy P.  Diagnosis and treatment of anterosuperior rotator cuff tears. J Shoulder Elbow Surg/American Shoulder and Elbow Surgeons [et  al]. 2001;10(1):37–46.

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Noninvasive Treatment Options for Glenohumeral Osteoarthritis in the Young Patient Brandon D. Bushnell, Joseph K. Bell, William Gilbert, D. Hal Silcox IV, and Stephen A. Parada

Introduction As life expectancy continues to increase and the population ages, the incidence of glenohumeral joint osteoarthritis (GHOA) and subsequent glenohumeral joint arthroplasty has also increased. For the elderly patient with arthritis, total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) are reliable options to restore function and improve pain. Shoulder arthritis occurring in young patients, however, is more likely to be due to post-traumatic changes or related to chronic instability [1–3]. Due to the high incidence of anterior shoulder instability events, recurrent instability constitutes a leading cause of advancing arthritis in the young patients following both initial operative or nonoperative intervention [4–9]. Chondrolysis, advancing to osteoarthritic breakdown, can occur as a feared complication after surgery [10, 11]. Reports of glenohumeral arthroplasty in active younger patients demonstrate higher reoperation rates, lower return to activities, and decreased satisfaction rates [1, 12–19]. Because of these known limitations in outcomes and increased complication rates in the young patient, every attempt should be made to utilize nonoperative treatment modalities for GHOA in this cohort. The American Academy of B. D. Bushnell (*) Orthopedic Surgery, Harbin Clinic, LLC, Rome, GA, USA e-mail: [email protected] J. K. Bell Orthopedic Surgery, Franciscan Health, Olympia Fields, IL, USA W. Gilbert Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA D. Hal Silcox IV Medical College of Georgia at Augusta University, Augusta, GA, USA S. A. Parada Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. M. Grawe et al. (eds.), Glenohumeral Osteoarthritis in the Young Patient, https://doi.org/10.1007/978-3-030-91190-4_4

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Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPG) for management of GHOA address options such as physical therapy, acupuncture, dry needling, cannabis, cannabidiol (CBD) oil, capsaicin, shark cartilage, glucosamine and chondroitin, cupping, cryotherapy, or transcutaneous electrical nerve stimulation (TENS) [20, 21]. Unfortunately, no significant evidence exists in favor of many of these treatments. Preoperative function has been found to have a moderate quality of evidence leading to improved outcomes following arthroplasty [20], and many of the aforementioned treatment modalities may play a part in increasing preoperative function. As such, while noninvasive treatments do not “cure” GHOA, they can potentially ameliorate symptoms and contribute to a better postoperative result if and when the patient eventually has surgery. It is important for the treating physician to have a discussion with each patient so that they can make a shared, informed decision regarding their nonoperative treatment options for GHOA. It is also essential during this discussion that the provider relay the varying levels of evidence, or lack thereof, of treatment options while still encouraging the patient that individual results may vary. The lack of randomized data demonstrating an overall positive impact of noninvasive treatment across all patient types for GHOA is likely affected by the heterogeneity within this patient cohort. Anecdotally, many providers have seen patients report success with many different types of treatment even when there is a lack of consensus scientific evidence in support of that treatment. Physicians should counsel patients to evaluate critically the risks of each treatment as well as the cost, as many of these treatment options can become very costly. This chapter will review the available nonoperative, noninvasive treatment options for the young patient with symptomatic GHOA. The nonoperative but invasive option of injection therapy will be discussed in detail in the following chapter.

Nutrition – Diet Diets designed to treat or prevent chronic medical conditions, such as obesity, cardiovascular disease, and rheumatoid arthritis, have become more popular and heavily promoted. Some foods have been hypothesized to contain compounds with anti-inflammatory properties. When applied to the treatment of osteoarthritis, these foods are thought to affect well-known inflammatory pathways, such as the arachidonic acid pathway and production of interleukins. The Mediterranean diet, well known for prevention of cardiovascular diseases, has been hypothesized to treat chronic diseases including rheumatoid and osteoarthritis [22]. The main components of the Mediterranean diet include an abundance of vegetables, fruits, whole grains, olive oil, fish, and poultry while limiting the intake of red meat. The fats found within this diet are rich in polyunsaturated fatty acids, which contain compounds linked to anti-inflammatory properties. Oleic acid, found within various meats, dairy products, and nuts, has been found to modulate signal transduction pathways and cytokine production. Secoiridoid oleocanthal, a phenol present in virgin olive oil, was found to have a strong anti-inflammatory potential by

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downregulating cytokines associated with joint inflammation, such as IL-6 and TNF-alpha, within activated macrophages and chondrocytes [23]. Oleuropein aglycone, a similar phenol compound found in olive oil, has been shown to modulate the inflammatory response in collagen-induced arthritic mice [24]. Foods containing these compounds are rich in polyunsaturated fatty acids with low omega-6 to omega-3 fatty acid ratios, and extra-virgin olive oil is also known to have a high content of monounsaturated fatty acids [22]. While the Mediterranean diet has proven clinical benefits in cardiovascular disease and knee osteoarthritis, there have been no clinical trials directly evaluating its effectiveness in patients with GHOA. Curcuma, a component found in turmeric (Curcuma longa), has a long history of being used in alternative medicine for various chronic diseases. Curcuma longa is a spice commonly used in curry powders and provides the yellow pigment to some mustards, broth, and other foods. Curcuma is believed to inhibit pro-inflammatory signals such as prostaglandins and leukotrienes. There have been no clinical trials to evaluate the effectiveness of turmeric in shoulder osteoarthritis; however, it has been noted to be safe when consumed as a spice in foods and short term for medicinal purposes [25]. Dietary fruits such as blueberries, pomegranates, strawberries, and cranberries have been postulated to contain anti-inflammatory properties. The bioactive polyphenols concentrated in these fruits have been shown in animal studies as well as human studies to elicit antioxidant activity. The polyphenol compounds responsible for this activity are primarily phenolic acids and flavonoids, with the most studied compound being the flavonoid anthocyanin. Basu and colleagues found darker colored berries, such as blueberries and black raspberries, have higher concentrations of anthocyanin than lighter berries such as strawberries, dried cranberries, and red raspberries [26]. Pomegranate has been shown to possess the highest antioxidant activity when compared to other fruits [27]. In spite of this generalized data regarding inflammation, the clinical relevance of antioxidant activity has not been directly evaluated in patients with GHOA.  The potential of these easily accessible fruits being a treatment modality for patients with shoulder arthritis warrants further clinical investigation.

Nutrition – Supplements In addition to well-targeted dietary choices, supplements, per their name, represent an additional level of nutrition that can have direct effects on the clinical outcomes of GHOA. Almost all studies surrounding the benefits of these supplements usually do not specifically involve the health of the cartilage within the glenohumeral joint. However, since most supplements are taken orally, they can logically be assumed to have relatively similar impacts across all joints throughout the body. Glucosamine and chondroitin are probably the most well-recognized supplements utilized for the treatment of osteoarthritis. A task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis specifically includes prescription glucosamine sulfate and chondroitin sulfate as a

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preliminary step in the treatment of osteoarthritis [28]. Multiple studies for each of these supplements have shown promise in relieving pain and bolstering function of the affected joints on a short-term basis. A 2018 meta-analysis by Gregori and colleagues suggested that glucosamine sulfate could have the highest probability of being the best long-term treatment for osteoarthritis, even above the use of celecoxib, a NSAID [29]. However, this meta-analysis did have a high risk of bias as the authors had conflicts of interest with Rottapharm, a manufacturer of glucosamine sulfate [30]. A 2017 meta-analysis by Liu and coworkers showed that glucosamine, chondroitin, and methylsulfonylmethane (MSM) had significant standard mean differences (SMD) in outcome for both pain and function. Among these three supplements, MSM had the highest SMD for pain and function (−0.47 and −1.10) [31]. These results mirror those of in vitro studies involving MSM [32]. MSM was shown to mediate the NF-κB pathway, which regulates inflammation by mitigating IL-1β. However, only three studies involving MSM (n  =  148) qualified for the meta-­ analysis by Liu et al., and therefore more clinical studies should be conducted to confirm these benefits [31]. The results regarding chondroitin from the meta-­ analysis by Liu et al. are also mirrored in findings by a meta-analysis conducted by Zhu et  al. which concluded that oral chondroitin is effective in the treatment of osteoarthritis [33]. Other notable results from the meta-analysis by Liu and colleagues are the long-­ term benefits of vitamin D supplementation [31]. Vitamin D showed larger SMD values than both glucosamine and chondroitin for both pain relief and physical function (−0.19 and −0.36). Neither of the SMD values met the minimum clinically important difference (MCID) of −0.37 SMD. However, vitamin D is a supplement that could be considered as a relatively inexpensive and noninvasive treatment of GHOA. Calcium supplementation has also been recognized as a possible method of maintaining healthy cartilage. However, this supplementation has only been recommended when coupled alongside a supplement of vitamin D [34]. Additionally, most of the research surrounding calcium and vitamin D supplementation deals with osteoporosis and osteoarthritis in elderly patients rather than young patients. Therefore, most of this research is not directly applicable to the treatment of GHOA in patients under the age of 50, but it can be extrapolated as useful information for the treatment of younger patients, as arthritic physiology likely remains relatively constant. Magnesium has been suggested as another supplement that could aid in the prevention or treatment of osteoarthritis. However, recent research does not show that supplemental magnesium intake can prevent osteoarthritis within the knee. Therefore, one can extrapolate that supplementation of magnesium would not aid in the prevention or treatment of GHOA.  The only observed benefit of magnesium supplementation was the decreased incidence of fracture within patients with osteoarthritis of the knee [35]. Thus, this benefit could translate to the prevention of fractures surrounding the glenohumeral joint and subsequent post-traumatic osteoarthritis.

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In addition to these conventionally accepted supplements for cartilage health, new alternatives are also emerging for the treatment of osteoarthritis. Collagen hydrolysate, passion fruit peel extract, and Boswellia serrata extract all exhibited efficacy in the reduction of pain and restoration of function in osteoarthritic joints [31]. However, very few randomized clinical trials involving these supplements exist at present. Additionally, the number of participants in the trials that have been performed thus far have been insufficient to justify the widespread prescription of these supplements. Proteoglycans derived from bramble shark cartilage have been shown to have anti-osteoarthritic properties [36]. The efficacy and safety of these proteoglycans are unknown as they have yet to be studied in humans; however, early investigations using animal models (rats) have shown promising results. The osteoarthritic rats showed less cartilage erosion and neovascularization in the affected joints when treated with shark proteoglycans. Moreover, supplementation with these proteoglycans should be revisited after the safety and efficacy of this supplement have been verified through randomized clinical trials.

Medications Medications represent the foundation of noninvasive treatment for osteoarthritis across all joints. Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and steroids are typically used before any invasive therapies are considered. NSAIDs usually represent the first choice among these medications for osteoarthritis. In contrast, paracetamol (acetaminophen) has questionable effectiveness in treating inflammatory conditions [37]. A 2018 meta-analysis by Rasmussen found that paracetamol did not display an effective MCID for pain relief or restoration of physical function. The same meta-analysis concluded that the best NSAIDs for pain management were diclofenac (150 mg/day), rofecoxib (50 mg/day), and etoricoxib (90 mg/day or 60 mg/day). Among these, only diclofenac (150 mg/day) and rofecoxib (25 mg/day) had a clinically important effect on physical function. These conclusions align relatively well with another meta-analysis performed by Zeng and colleagues that investigated the benefits and risks associated with topical NSAIDs [38]. The authors concluded that diclofenac patches could be the most effective NSAID for pain relief. Although diclofenac patches represented the highest efficacy for pain relief, topical piroxicam showed the highest efficacy in the restoration of physical function. Finally, another important finding of this particular meta-analysis was that topical NSAIDs, apart from salicylic acid, were not associated with adverse events in the kidneys or the gastrointestinal tract. A 2018 meta-analysis by Gregori et al. concluded that celecoxib was the only NSAID to provide long-term pain improvement for osteoarthritis [29]. However, this meta-analysis also concluded that efficacy was only seen when the studies with a high risk of bias were included in the analysis. One should note that this meta-­ analysis also showed that celecoxib did not show any improvements with respect to physical function.

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The long-term consumption of NSAIDs can result in upper gastrointestinal events and carry some risk in patients with concomitant cardiovascular disease. When celecoxib was directly compared to naproxen and ibuprofen, it was not found to carry any additional cardiovascular risk [39]. Further investigation of cardiovascular safety of celecoxib found that the risk of myocardial infarction did not occur within the first 7 days of taking the medication but instead only after continuously using celecoxib for 30 days or more [40]. Additionally, the risk of adverse gastrointestinal events was significantly lower in celecoxib than in naproxen and ibuprofen [39]. There was also a significant decrease in adverse renal events when using celecoxib compared to ibuprofen; however, this decrease was not found when comparing celecoxib to naproxen. Additionally, nonselective NSAIDs have been shown to carry a higher risk of acute kidney injury rather than selective NSAIDs [40]. Therefore, celecoxib may represent the best medication option among these commonly used NSAIDs in the treatment of osteoarthritis. One should note that most if not all of the literature on NSAIDs focus on the use of these medications in the short term or on an intermittent basis for pain relief but not used as a long-term medication. Therefore, any long-term use of these medications for GHOA must be carefully evaluated on an individualized basis. Steroids and opioids should be considered in the treatment of osteoarthritis only in the advent of an acute and sudden increase in pain. In this clinical setting, the use of these powerful medications should be viewed with caution. An in vitro study of methylprednisolone showed toxic effects against chondrocytes and that the steroid did not reduce the effects of IL-1β [41]. Therefore, the use of methylprednisolone in the treatment of acute inflammation may result in more long-term damage to the osteoarthritic joint, even as it relieves short-term symptoms. Opioids can also be considered as an acute-phase treatment option, but their use should be limited and judicious – as their abuse has been well documented [42].

Physical Therapy Physical therapy (PT) is regularly integrated in the nonoperative treatment of a myriad of musculoskeletal conditions, including GHOA. Physical therapy encompasses many therapeutic modalities including exercise, manual therapy, electrical stimulation, and temperature (thermo/cryo) therapy. The ultimate goal of these combined modalities is to improve range of motion and to strengthen muscles controlling glenohumeral movement. Though PT remains a mainstay in most treatment programs, there is an absence of reliable direct evidence describing a structured treatment model and physical therapy is often incorporated in a multimodal treatment plan driven through expert opinion and group consensus [43–45]. Despite the deficiency of quality evidence, PT programs have shown to be reliable and efficient for patients with GHOA [46, 47]. Especially in young patients who are not good candidates for arthroplasty due to concerns for implant survivorship, PT can help optimize mobility and function and minimize pain [44]. When these patients then progress to surgery, the concept of such “pre-hab” can be helpful in optimizing postoperative results [45].

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Glenohumeral joint arthritis is commonly accompanied by stiffness related to contracture and adhesions involving the glenohumeral capsule and weakness of surrounding cuff muscles [46]. Therefore, PT should be targeted to increase the patient’s ROM and strengthen the cuff muscles which provide the appropriate forces to compress and center the humeral head in the glenoid fossa, keeping the glenohumeral joint dynamically stable [48]. In addition to the cuff muscles, the scapulothoracic muscles are also important in maintaining scapulohumeral rhythm [48–50]. Scapulothoracic function and fitness vary widely from patient to patient, making it important to establish the rehabilitation plan on an individualized basis [51]. In GHOA, losses of shoulder motion typically follow a pattern of limited external rotation, abduction, internal rotation, and active forward flexion [46, 52]. PT should be driven to increase ROM through stretching and strengthening exercises targeting these motions in gradual increments. The patients most likely to benefit from physical therapy are those with specific motion deficits who are not severely stiff and those where the joint architecture remains well preserved without flattening of the humeral head [3]. Typically, capsular tightness should be corrected with stretching prior to strengthening. It is important that these movements are performed slowly as acutely robust and aggressive movements to regain mobility can accelerate the disease process and worsen pain symptoms. Rockwood and Matsen suggest that capsular stretches be held for 2 minutes allowing time for muscles to relax appropriately and for capsular tissue to be plastically deformed [53]. Gentle ROM can begin with pendulum movements where the patient leans over a surface with the affected arm hanging to gravity. Gently, the patient can move their arm front to back, side to side, and clockwise/ counterclockwise to encourage generalized shoulder motion. Active-assisted ROM can be used to further accomplish other movements such as flexion, extension, and internal and external rotation of the shoulder.

 ome Exercise Programming H and Physician-Directed Rehabilitation Home Exercise Programming (HEP) and Physician-Directed Rehabilitation (PDR) are some of the most common and most economical nonoperative treatment options utilized for patients with all kinds of osteoarthritis. Osteoarthritic patients typically have pain and decreased range of motion compared to their normal unaffected shoulder, but often cannot participate in formal therapy programs due to time constraints, transportation barriers, financial restraints, or other issues. Rehabilitation programs serve as an initial treatment modality with the ability to increase patient range of motion as well as reduce pain, and as discussed above, these programs for cases of GHOA can bypass formal PT and proceed through HEP or PDR. HEP/PDR protocols should target joint mobilization through active and passive means, as well as a specific capsular stretching program. The directions of glenohumeral mobilization should include flexion, abduction, adduction, internal and external rotation, and extension. This can be accomplished with the help of a family member or other assisting individual, or it can be done unaccompanied with the

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assistance of a cane/stick, towel, or the patient’s unaffected extremity. The program should be advanced slowly and to the patient’s tolerances. The stretching program should aim to improve elasticity of the muscles, tendons, and ligaments involved with the shoulder. The targeted muscles should include the deltoid, rotator cuff, trapezius, latissimus dorsi, and biceps [43]. The setting where these exercises should be performed should be made on an individual basis between physician and patient. HEP/PDR offers the benefits of schedule flexibility and decreased costs, in comparison to formal PT. The greatest benefit of formal, supervised therapy is the expert guidance through exercises to ensure proper technique and prevent injury, but this expertise often comes at increasing costs in the modern world of managed medicine. When evaluating a patient as a candidate for HEP/PDR, the greatest concerns are patient compliance and adequate technique. The literature comparing noninvasive/nonoperative outcomes of patients with GHOA treated with formal PT versus HEP is deficient. Studies have shown, however, that postoperative results after total shoulder replacement can be similar when HEP/PDR is used after surgery in comparison to formal PT [54, 55]. Further investigation is thus warranted to compare a similar scenario for nonoperatively managed patients.

Acupuncture Acupuncture is a traditional Eastern medicine treatment technique that involves the insertion of thin needles through the skin at specific points on the body. This technique has become more popular in the United States for a variety of conditions, and it is most often utilized to treat pain and stress. The efficacy of acupuncture has been examined in patients with knee and hip osteoarthritis, where it was found to improve the severity of arthritic symptoms and improve quality of life in combination with conventional treatments versus conventional therapy alone [56]. This perceived clinical benefit in these patients was evident at 3 and 6 months following the treatment protocols, demonstrating acupuncture’s potential for short-term therapeutic intervention. Not only does acupuncture possess a clinical benefit that has been shown in patients with knee osteoarthritis, but also a measurable physiologic response has been observed in patients undergoing acupuncture therapy. Patients who received electroacupuncture reported having decreased levels of pain intensity while also measuring lower serum levels of beta-endorphin and cortisol [57]. The majority of acupuncture side effects seem to be mild and reversible, including nausea, vomiting, fainting, bleeding, bruising, and pain at needle site [58]. The physiologic alteration, clinical improvement, and high tolerance for these techniques may serve as the basis for future, more extensive clinical trials for acupuncture treatment in osteoarthritic patients – including those with GHOA. The effects of acupuncture for patients with shoulder arthritis are less studied than patients with knee arthritis. Patients with a diagnosis of rotator cuff tear or GHOA treated with real acupuncture have been shown to clinically improve from a pain aspect when compared with those receiving a “sham acupuncture” treatment

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[59]. However, the extrapolation of these findings should be reserved due to the possibility of rotator cuff tear patients skewing the findings in this study. There is a shortage of evidence supporting the effectiveness of acupuncture for GHOA and has led to the American Academy of Orthopaedic Surgeons (AAOS) neither recommending in favor nor against the use of acupuncture as a treatment option in the shoulder [45]. Due to the relatively few side effects encountered with acupuncture, further clinical studies should be conducted evaluating the efficacy of acupuncture in cases of GHOA.

Electrical Stimulation Electrical stimulation (E-Stim) is another therapeutic modality now being used in many physical rehabilitation programs. There are multiple types of E-Stim, including transcutaneous electrical nerve stimulation (TENS), interferential current (IFC), and neuromuscular electrical stimulation (NMS) [60]. Each one of these E-Stim modalities targets different tissue types including soft tissue, nerves, and muscle groups. The method of effectiveness of E-Stim is thought to be twofold. The first is through pain control and the second through muscle group facilitation. TENS and IFC are the two modalities which target pain control, and have been largely studied in the acute phase of rehabilitation. Their function is based on the “gate control” pain theory where electrical impulses reduce pain through activation of descending inhibitory pathways. These modalities have been most extensively studied in the treatment of low-back pain, and there are no current studies on treatment in young patients with GHOA.  Studies have shown that as part of a multimodal treatment plan, TENS and IFC have been attributed to better pain control, but the studies are limited because they cannot effectively evaluate the confounding effect of other therapeutic modalities [60–63]. NMS for muscle rehabilitation uses electrodes over the peripheral nerves controlling certain muscle groups and allows for reeducation and muscle strengthening in the rehab process. NMS has largely been studied in postoperative recovery scenarios associated with ACL reconstruction and total knee arthroplasty [60, 64]. Though these electrical stimulation modalities could theoretically play a role in nonoperative management of GHOA, there is no current evidence supporting its role in this area. As such, the AAOS has been unable to recommend for or against its use in GHOA [45], and this lack of data warrants further study.

Ultrasound Ultrasound is growing immensely in multiple fields of medicine as both a diagnostic and therapeutic modality. This modality is noninvasive, and its reliability continues to improve as more technicians and providers are training with the technology. Cooled radiofrequency ablation (CRFA) is an ultrasound technique that has been utilized as a minimally invasive option for pain control in osteoarthritis of the knee

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[65]. CRFA involves utilizing a transcutaneous needle that can ablate various afferent sensory pathways in order to provide pain relief to the innervated area. CRFA targeting the genicular nerves of the knee has been shown to provide 12 months of analgesia in patients with knee pain from osteoarthritis [66]. In a study by Davis and colleagues, patients with chronic osteoarthritis who underwent CRFA showed improved reduction in baseline pain when compared to those who received intra-­ articular steroid injection [67]. While the evidence shows support for ultrasound as an adjunct treatment in knee osteoarthritis, there are significantly fewer studies examining the effects of ultrasound on shoulder osteoarthritis. A systematic review examined seven trials of therapeutic ultrasound for treating shoulder osteoarthritis, of which all seven trials demonstrated reduction in pain. However, four of these trials showed therapeutic ultrasound was still inferior to the comparator modality [68]. The most recent shoulder arthritis management guidelines produced by the AAOS do not provide a recommendation on the strength of evidence for ultrasound treatment in GHOA patients [45]. Additional clinical trials with larger patient pools are needed to establish more conclusive evidence of the role ultrasound may serve as an adequate therapeutic modality for shoulder osteoarthritis.

Iontophoresis Iontophoresis is a method for drug delivery that utilizes an electric motive gradient to facilitate the absorption of medication into a localized area, such as the shoulder. Iontophoresis would seem to be a natural consideration in the treatment of GHOA due to its proven ability to deliver ionized medications such as lidocaine, dexamethasone, hyaluronate, and others. The Food and Drug Administration (FDA) has approved the use of this technology for localized analgesic drug delivery [69]. The use of iontophoresis for non-analgesic drug delivery is currently under additional investigation in animal models but has yet to be tested in human trials or be formally approved by the FDA. For example, iontophoresis was shown to increase the delivery of topical celecoxib in rats [70]. Iontophoresis has also been used in rats to deliver other prodrugs for pain relief [71]. Thus, iontophoresis may have a future clinical application in treating GHOA, but further clinical trials will be necessary to justify the use of iontophoresis.

Kinesiology Tape Kinesiology taping (KT or K-tape) is another therapeutic tool proposed to alleviate pain and improve healing through dynamic support, proprioceptive facilitation, and reducing muscle fatigue [72–74]. This special tape is designed to mimic the physical quality of human skin with the ability to be stretched and applied over the affected joint [75]. The stretch theoretically enhances feedback with movement and joint position through proprioceptive enhancement of cutaneous neuroreceptors

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[76]. Depending on how the tape is applied, it also increases muscle facilitation for increased contractile forces. Thelen and colleagues looked at K-taping in young athletes with shoulder pain and found that it decreased pain with shoulder abduction compared to patients with sham taping [77]. Similarly, Hsu and coworkers looked at amateur baseball players with the diagnosis of shoulder impingement and found elastic taping resulted in positive changes in scapular motion and muscle performance [72]. In theory, K-tape might be utilized as part of a multimodal approach to help reduce a patient’s pain in order to advance range of motion, strength, and function [74]. In on our review, there is currently no evidence that directly investigates K-tape in GHOA specifically, and therefore its use can only be based upon expert opinion and shared decision-making [75].

Blood Flow Restriction Blood flow restriction therapy (BFRT) has been a recent area of interest for the strengthening of muscle groups surrounding osteoarthritic joints. Blood flow restriction therapy allows patients to perform exercises at low to moderate loads while gaining strength comparable to heavy-load strength rehabilitation training [78]. Therefore, this methodology provides the patient with the ability to gain strength and stability without significantly increasing the loading of joints and thereby putting them at risk of injury. Although this method of physical therapy shows promise, almost all the research involved in low load blood flow restriction therapy involves the knee joint rather than the glenohumeral joint [79]. Blood flow restriction therapy requires an occlusion wrap to be applied near the top of the leg or arm. Therefore, this method of treatment would not necessarily be applicable to the care of GHOA since properly occluding muscle groups around the affected shoulder would present many difficulties. In addition to the aforementioned challenges, blood flow restriction therapy should be used with caution until further investigation of the risks and benefits of this novel treatment can be fully understood.

Temperature Therapy Thermotherapy and cryotherapy often serve as an adjunctive therapy in pain relief in a young patient [3]. Cryotherapy, the application of cold temperature, and thermotherapy, the application of heat, can be harnessed through many modalities including ice/hot packs, immersion, cryotherapy devices, convection, and radiation [60]. Their use is largely anecdotal with minimal evidence supporting their efficacy alone, especially in young patients with GHOA [45]. Despite this lack of evidence, they are regularly incorporated in rehabilitation programs for both GHOA and many other shoulder conditions. Local temperature change leads to improvements in pain modulation, edema control, delayed onset muscle soreness, and tissue extensibility [60]. Cryotherapy specifically helps increase local vasoconstriction, thus decreasing edema and swelling in addition to improving local pain control. Alternatively,

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thermotherapy increases tissue extensibility and range of motion through increased blood flow, tissue metabolism, and connective tissue elasticity [80]. Several authors have investigated thermotherapy in ROM exercises and found that heat and stretching are more effective than stretching alone [81, 82]. Overall, both heating and cooling therapies can contribute to pain control in patients and can be useful with limited risk. Their use in GHOA in a young patient, specifically, is not described well in the literature, but based on their utility in other musculoskeletal conditions, they can logically be incorporated in a multimodal therapeutic approach.

Conclusion This chapter has reviewed the various nonoperative, noninvasive options for treatment of GHOA in the young patient. If any singular theme emerges, it is the lack of direct, well-designed studies providing evidence in support of these treatment choices specific to the young GHOA cohort. Most of these treatments, however, pose minimal risk – especially in comparison to those risks associated with invasive and operative treatments such as injections, arthroscopy, reconstruction techniques, and partial or total joint replacement surgery. While each patient’s treatment should be individualized, the low-risk nature of these various noninvasive options mandates their inclusion as a foundational aspect of any treatment plan.

References 1. Kusnezov N, Dunn JC, Parada SA, Kilcoyne K, Waterman BR. Clinical outcomes of anatomical total shoulder arthroplasty in a young. Active Population Am J Orthop (Belle Mead NJ). 2016;45(5):E273–82. 2. Cole BJYA, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elb Surg. 2007;16(5 Supp):S231–S40. 3. Chong PY, Srikumaran U, Kuye IO, Warner JJ. Glenohumeral arthritis in the young patient. J Shoulder Elb Surg. 2011;20(2 Suppl):S30–40. 4. Waterman BR, Kilcoyne KG, Parada SA, Eichinger JK. Prevention and management of post-­ instability glenohumeral arthropathy. World J Orthop. 2017;8(3):229–41. 5. Taylor DCAR. Pathologic changes associated with shoulder dislocations. Am J Sports Med. 1997;25(3):306–11. 6. Galvin JW, Ernat JJ, Waterman BR, Stadecker MJ, Parada SA. The epidemiology and natural history of anterior shoulder instability. Curr Rev Musculoskelet Med. 2017;10(4):411–24. 7. Samilson RLPV.  Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983;65(4):456–60. 8. Reineck JRKS, Burkhead WZ.  Early glenohumeral arthritis in the competing athlete. Clin Sports Med. 2008;27(4):803–19. 9. Hovelius LOA, Sandstrom B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Nowak J, Sennerby U. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five year follow­up. J Bone Joint Surg Am. 2008;90(5):945–52. 10. Hansen BPBC, Beck EP, Townsley RW. Postarthroscopic glenohumeral chondrolysis. Am J Sports Med. 2007;35(10):1628–34.

4  Noninvasive Treatment Options for Glenohumeral Osteoarthritis in the Young…

55

11. Scheffel PTCJ, Lynch JR, Warme WJ, Bertelsen AL, Matsen FA. Glenohumeral chondrolysis: a systematic review of 100 cases from the English language literature. J Shoulder Elb Surg. 2010;19(6):944–9. 12. A W.  Management of glenohumeral osteoarthritis in the young adult. Shoulder Elbow. 2010;2:1–8. 13. Elser FBS, Dewing CB, Millett PJ. Glenohumeral joint preservation: current options for managing articular cartilage lesions in young, active patients. Arthroscopy. 2010;26(5):685–96. 14. Bartelt R, Sperling JW, Schleck CD, Cofield RH. Shoulder arthroplasty in patients aged fifty-­ five years or younger with osteoarthritis. J Shoulder Elb Surg. 2011;20(1):123–30. 15. Denard PJ, Raiss P, Sowa B, Walch G. Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis. J Shoulder Elb Surg. 2013;22(7):894–900. 16. Magnussen RA, Mallon WJ, Willems WJ, Moorman CT 3rd. Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. J Shoulder Elb Surg. 2011;20(2):281–9. 17. McCarty EC, Marx RG, Maerz D, Altchek D, Warren RF. Sports participation after shoulder replacement surgery. Am J Sports Med. 2008;36(8):1577–81. 18. 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(6):764–9. 19. Schumann K, Flury MP, Schwyzer HK, Simmen BR, Drerup S, Goldhahn J. Sports activity after anatomical total shoulder arthroplasty. Am J Sports Med. 2010;38(10):2097–105. 20. Group ABGMR, Ricchetti ET, Khazzam MS, Denard PJ, Dines DM, Edwards TB, et  al. Reliability of the modified Walch classification for advanced Glenohumeral osteoarthritis using three-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group. J Shoulder Elb Surg. 2020;30:736. 21. Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, et al. Treatment of glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010;18(6):375–82. 22. Oliviero FSP, Fiocco U, Ramonda R, Sfriso P, Punzi L.  How the Mediterranean diet and some of its components modulate inflammatory pathways in arthritis. Swiss Med Weekly. 2015;145:w14190. 23. Scotece MGR, Conde J, Lopez V, Gomez-Reino JJ, Lago F, Smith AB, Gualillo O. Further evidence for the anti-inflammatory activity of oleocanthal: inhibition of MIP-1a and IL-6 in J774 macrophages and in ATDC5 chondrocytes. Life Sci. 2012;91(23-24):1229–35. 24. Impellizzeri DEE, Mazzon E, Paterniti I, DiPaola R, Morittu VM, Procopio A, Britti D, Cuzzocrea S. Oleuropein aglycone, an olive oil compound, ameliorates development of arthritis caused by injection of collagen type II in mice. J Pharmacol Exp Ther. 2011;339(3):859–69. 25. Gregory PJSM, Wilson AF.  Dietary supplements for osteoarthritis. Am Fam Physician. 2008;77(2):177–84. 26. Basu ARM, Lyons TJ.  Berries: emerging impact on cardiovascular health. Nutr Rev. 2010;68(3):168–77. 27. Kalaycioglu ZEF. Total phenolic contents, antioxidant activities, and bioactive ingredients of juices from pomegranate cultivars worldwide. Food Chem. 2017;221:496–507. 28. Bruyère O, Cooper C, Pelletier JP, Branco J, Luisa Brandi M, Guillemin F, et  al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum. 2014;44(3):253–63. 29. Gregori D, Giacovelli G, Minto C, Barbetta B, Gualtieri F, Azzolina D, et al. Association of pharmacological treatments with long-term pain control in patients with knee osteoarthritis: a systematic review and meta-analysis. JAMA. 2018;320(24):2564–79. 30. Eriksen P, Bartels EM, Altman RD, Bliddal H, Juhl C, Christensen R.  Risk of bias and brand explain the observed inconsistency in trials on glucosamine for symptomatic relief of osteoarthritis: a meta-analysis of placebo-controlled trials. Arthritis Care Res (Hoboken). 2014;66(12):1844–55.

56

B. D. Bushnell et al.

31. Liu X, Machado GC, Eyles JP, Ravi V, Hunter DJ. Dietary supplements for treating osteoarthritis: a systematic review and meta-analysis. Br J Sports Med. 2018;52(3):167–75. 32. Cheleschi S, Fioravanti A, De Palma A, Corallo C, Franci D, Volpi N, et  al. Methylsulfonylmethane and mobilee prevent negative effect of IL-1β in human chondrocyte cultures via NF-κB signaling pathway. Int Immunopharmacol. 2018;65:129–39. 33. Zhu X, Sang L, Wu D, Rong J, Jiang L. Effectiveness and safety of glucosamine and chondroitin for the treatment of osteoarthritis: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2018;13(1):170. 34. Harvey NC, Biver E, Kaufman JM, Bauer J, Branco J, Brandi ML, et  al. The role of calcium supplementation in healthy musculoskeletal ageing : an expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF). Osteoporos Int. 2017;28(2):447–62. 35. Wu Z, Yang J, Liu J, Lian K.  The relationship between magnesium and osteoarthritis of knee: A MOOSE guided systematic review and meta-analysis. Medicine (Baltimore). 2019;98(45):e17774. 36. Ajeeshkumar KK, Vishnu KV, Navaneethan R, Raj K, Remyakumari KR, Swaminathan TR, et al. Proteoglycans isolated from the bramble shark cartilage show potential anti-­osteoarthritic properties. Inflammopharmacology. 2019;27(1):175–87. 37. Rasmussen S. NSAIDs are superior to paracetamol for osteoarthritic pain and function in a network meta-analysis. BMJ Evid Based Med. 2018;23(1):40–1. 38. Zeng C, Wei J, Persson MSM, Sarmanova A, Doherty M, Xie D, et al. Relative efficacy and safety of topical non-steroidal anti-inflammatory drugs for osteoarthritis: a systematic review and network meta-analysis of randomised controlled trials and observational studies. Br J Sports Med. 2018;52(10):642–50. 39. Nissen SE, Yeomans ND, Solomon DH, Lüscher TF, Libby P, Husni ME, et al. Cardiovascular safety of celecoxib, naproxen, or ibuprofen for arthritis. N Engl J Med. 2016;375(26):2519–29. 40. Cooper C, Chapurlat R, Al-Daghri N, Herrero-Beaumont G, Bruyère O, Rannou F, et al. Safety of Oral non-selective non-steroidal anti-inflammatory drugs in osteoarthritis: what does the literature say? Drugs Aging. 2019;36(Suppl 1):15–24. 41. Seshadri V, Coyle CH, Chu CR. Lidocaine potentiates the chondrotoxicity of methylprednisolone. Arthroscopy. 2009;25(4):337–47. 42. Alamanda VK, Wally MK, Seymour RB, Springer BD, Hsu JR.  Prevalence of opi oid and Benzodiazepine prescriptions for osteoarthritis. Arthritis Care Res (Hoboken). 2020;72(8):1081–6. 43. Macias-Hernandez SI, Morones-Alba JD, Miranda-Duarte A, Coronado-Zarco R, Soria-­ Bastida MLA, Nava-Bringas T, et  al. Glenohumeral osteoarthritis: overview, therapy, and rehabilitation. Disabil Rehabil. 2017;39(16):1674–82. 44. Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Wiater JM, et al. American academy of orthopaedic surgeons clinical practice guideline on: the treatment of glenohumeral joint osteoarthritis. J Bone Joint Surg Am. 2011;93(2):203–5. 45. Khazzam MS, Pearl ML.  AAOS clinical practice guideline: Management of Glenohumeral Joint Osteoarthritis. J Am Acad Orthop Surg. 2020;28:790. 46. Carfagno DG, Ellenbecker TS. Osteoarthritis of the glenohumeral joint: nonsurgical treatment options. Phys Sportsmed. 2002;30(4):19–30. 47. Marinko LN, Chacko JM, Dalton D, Chacko CC. The effectiveness of therapeutic exercise for painful shoulder conditions: a meta-analysis. J Shoulder Elb Surg. 2011;20(8):1351–9. 48. Reinold MM, Escamilla RF, Wilk KE. Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. J Orthop Sports Phys Ther. 2009;39(2):105–17. 49. Cools AM, Dewitte V, Lanszweert F, Notebaert D, Roets A, Soetens B, et al. Rehabilitation of scapular muscle balance: which exercises to prescribe? Am J Sports Med. 2007;35(10):1744–51. 50. Ebaugh DD, McClure PW, Karduna AR. Scapulothoracic and glenohumeral kinematics following an external rotation fatigue protocol. J Orthop Sports Phys Ther. 2006;36(8):557–71.

4  Noninvasive Treatment Options for Glenohumeral Osteoarthritis in the Young…

57

51. Wyss JP. In: Wyss JF, ADP, editors. A. Therapeutic programs for musculoskeletal disorders. New York: Demos Medical Pub; 2013. 52. Gerber A, Lehtinen JT, Warner JJ. Glenohumeral osteoarthritis in active patients: diagnostic tips and complete management options. Phys Sportsmed. 2003;31(4):33–40. 53. Matsen FA, Lippitt SB, Rockwood CA, Wirth MA. Glenohumeral arthritis and its management. Rockwood and Matsen's the shoulder. 5th ed. Elsevier; 2017. p. 831–1042. 54. Eriksson LLB, Gard G, Lysholm J. Physiotherapy at a distance: a controlled study of rehabilitation at home after a shoulder joint operation. J Telemed Telecare. 2009;15(5):215–20. 55. Mulieri PJHJ, Dunning P, Pliner M, Bogle RK, Pupello D, Frankle MA. Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis? J Shoulder Elb Surg. 2010;19(4):570–9. 56. Witt CMJS, Brinkhaus B, Liecker B, Wegscheider K, Willich SN.  Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm. Arthritis Rheum. 2006;54(11):3485–93. 57. Ahsin SSS, Bhatti AM, Iles RK, Aslam M. Clinical and endocrinological changes after electro-­ acupuncture treatment in patients with osteoarthritis of the knee. Pain. 2009;147(1-3):60–6. 58. Sanders MGO.  The use of glucosamine, devil's claw (Harpagophytum procumbens), and acupuncture as complementary and alternative treatments for osteoarthritis. Altern Med Rev. 2011;16(3):228–38. 59. Lathia ATJS, Chen LX. Efficacy of acupuncture as a treatment for chronic shoulder pain. J Altern Complement Med. 2009;15(6):613–8. 60. Logan CA, Asnis PD, Provencher MT. The role of therapeutic modalities in surgical and nonsurgical management of orthopaedic injuries. J Am Acad Orthop Surg. 2017;25(8):556–68. 61. Rutjes AW, Nuesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2009;2009(4):CD002823. 62. Fuentes JP, Armijo Olivo S, Magee DJ, Gross DP. Effectiveness of interferential current therapy in the management of musculoskeletal pain: a systematic review and meta-analysis. Phys Ther. 2010;90(9):1219–38. 63. Khadilkar A, Odebiyi DO, Brosseau L, Wells GA.  Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;2008(4):CD003008. 64. Nussbaum EL, Houghton P, Anthony J, Rennie S, Shay BL, Hoens AM. Neuromuscular electrical stimulation for treatment of muscle impairment: critical review and recommendations for clinical practice. Physiother Can. 2017;69(5):1–76. 65. Oladeji LOCJ. Cooled radio frequency ablation for the treatment of osteoarthritis-related knee pain: evidence, indications, and outcomes. J Knee Surg. 2019;32(1):65–71. 66. Bellini MBM. Cooled radiofrequency system relieves chronic knee osteoarthritis pain: the first case-series. Anaesthesiol Intensive Ther. 2015;47(1):30–3. 67. Davis TLE, DePalma M, Hunter C, Lindley D, Patel N, Choi D, Soloman M, Gupta A, Desai M, Buvanendran A, Kapural L.  Prospective, multi-center, randomized, crossover clinical trial comparing the safety and effectiveness of cooled radiofrequency ablation to corticosteroid injection in the management of knee pain from osteoarthritis. Reg Anesth Pain Med. 2018;43(1):84–91. 68. Aiyer RNS, Chang KV, Jung B, Rasheed A, Bansal N, Ottestad E, Gulati A.  Therapeutic ultrasound for chronic pain management in joints: a systematic review. Pain Med. 2020;21(7):1437–48. 69. Dixit N, Bali V, Baboota S, Ahuja A, Ali J. Iontophoresis - an approach for controlled drug delivery: a review. Curr Drug Deliv. 2007;4(1):1–10. 70. Tavakoli N, Minaiyan M, Heshmatipour M, Musavinasab R. Transdermal iontophoretic delivery of celecoxib from gel formulation. Res Pharm Sci. 2015;10(5):419–28. 71. Lobo S, Yan G. Evaluation iontophoretic delivery of a cationic ketoprofen prodrug for treating nociceptive symptoms in monosodium iodoacetate induced osteoarthritic rat model. Int J Pharm. 2019;569:118598.

58

B. D. Bushnell et al.

72. Hsu YH, Chen WY, Lin HC, Wang WT, Shih YF.  The effects of taping on scapular kinematics and muscle performance in baseball players with shoulder impingement syndrome. J Electromyogr Kinesiol. 2009;19(6):1092–9. 73. Gonzalez-Iglesias J, Fernandez-de-Las-Penas C, Cleland JA, Huijbregts P, Del Rosario G-VM. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: a randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(7):515–21. 74. Shamus JL, Shamus EC.  A taping technique for the treatment of acromioclavicular joint sprains: a case study. J Orthop Sports Phys Ther. 1997;25(6):390–4. 75. Kelly T. Bassett SALaRFE. The use and treatment efficacy of kinaesthetic taping for musculoskeletal conditions: a systematic review. N Z J Physiother. 2010;38(2):56. 76. Riemann BL, Lephart SM.  The sensorimotor system, part II: the role of proprioception in motor control and functional joint stability. J Athl Train. 2002;37(1):80–4. 77. Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial. J Orthop Sports Phys Ther. 2008;38(7):389–95. 78. Hughes L, Paton B, Rosenblatt B, Gissane C, Patterson SD. Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis. Br J Sports Med. 2017;51(13):1003–11. 79. Minniti MC, Statkevich AP, Kelly RL, Rigsby VP, Exline MM, Rhon DI, et al. The safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: a systematic review. Am J Sports Med. 2020;48(7):1773–85. 80. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med. 2015;127(1):57–65. 81. Nakano J, Yamabayashi C, Scott A, Reid WD.  The effect of heat applied with stretch to increase range of motion: a systematic review. Phys Ther Sport. 2012;13(3):180–8. 82. Bleakley CM, Costello JT. Do thermal agents affect range of movement and mechanical properties in soft tissues? A systematic review. Arch Phys Med Rehabil. 2013;94(1):149–63.

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Injection Therapies for Glenohumeral Osteoarthritis in the Young Patient J. Gabriel Horneff III and Jeffery Lu

Introduction While total shoulder arthroplasty (TSA) remains an appealing treatment option in the elderly, there remains considerable concern about offering this treatment in younger patients with higher functional demand, greater functional expectations, and the need for longer implant longevity [1, 2]. Nonoperative treatment should be the initial treatment option for younger patients who present with glenohumeral arthritis. Nonoperative management encompasses physical therapy, activity modification, anti-inflammatory medication, and intra-articular injections [1–3]. Intra-­ articular injections, including corticosteroids, hyaluronic acid, platelet-rich plasma (PRP), and stem cells, may be beneficial when other nonoperative management fails [1, 4, 5] (Table 5.1). It is important to counsel patients that nonoperative treatment does not alter the disease course; however, it can help reduce pain and increase range of motion, extending time before surgery is required [6]. This is an ideal approach to treat younger patients with the hope that they can delay arthroplasty treatment until they are at an age where the expectations of TSA are more in line with their daily demands. Exploring these various injection therapies requires that the treating surgeon and patient understand the benefits, risks, and expected outcomes with each option.

J. G. Horneff III (*) Department of Orthopaedics, University of Pennsylvania, Philadelphia, PA, USA J. Lu Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. M. Grawe et al. (eds.), Glenohumeral Osteoarthritis in the Young Patient, https://doi.org/10.1007/978-3-030-91190-4_5

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Table 5.1  Nonoperative intra-articular injections Corticosteroids

Hyaluronic acid (HA)/ viscosupplementation

Platelet-rich plasma (PRP)

Stem cells

Description Corticosteroids are both anti-inflammatory and immunosuppressive, decreasing erythema, swelling, and heat in joints

Types/brands Kenalog (triamcinolone), methylprednisolone, betamethasone, dexamethasone Orthovisc, Monovisc, Euflexxa

HA is a naturally occurring glycosaminoglycan in joints that reduces stress and friction on articular cartilage. HA concentrations are decreased in osteoarthritis and supplementing HA in an arthritic joint may decrease pain and inflammation Leukocyte rich, PRP is made from a patient’s own blood, leukocyte poor containing platelet growth factors and other fibrin scaffolds. PRP injections are proposed to provide supraphysiologic levels of growth factors to stimulate the natural healing cascade and induce tissue regeneration at the site of the injection Stem cells are undifferentiated cells with the potential of differentiating into more mature cell types (muscles, cartilage, bone, etc.)

Approach to Injections Accessing the glenohumeral joint for an intra-articular injection can generally be performed in either that anterior (Fig.  5.1) or posterior (Fig.  5.2) approach. The treating practitioner should examine patient imaging to assess for any significant osteophyte formation or joint subluxation that may prevent access from one approach over the other. Additionally, the severity of osteoarthritis may determine whether the injection can be safely performed without the use of image guidance. Some practitioners are experienced with the use of ultrasound guidance to improve the chances of placing an injection intra-articularly. If not, referral to interventional radiology may be necessary. Regardless, sterile technique should always be utilized with any injection by preparing the skin with either an alcohol-based or iodine-­ based topical antiseptic. Patients should also be educated on warning signs for potential infection following an injection and given ready access to follow-up care if necessary.

Corticosteroid Injections Intra-articular corticosteroid injections are a commonly used treatment for shoulder pain, which may provide pain relief in patients with glenohumeral arthritis [7]. In a Cochrane review, Buchbinder et al. concluded that there was little overall evidence

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Fig. 5.1 Surface landmarks and approach for anteriorly placed intra-articular injection of the glenohumeral joint

to support the use of steroid injections for shoulder pain; however, no study directly evaluated the use of corticosteroid injections in shoulder arthritis [8]. To our knowledge, only one retrospective controlled trial has been conducted that evaluated corticosteroid injections in the treatment of shoulder arthritis. Merolla et  al. demonstrated that patients with shoulder arthritis treated with corticosteroid injection had a significant reduction of baseline pain and nighttime pain at 1  month. However, the reduction in pain at 3 and 6 months was not statistically significant [9]. They found that the maximum effect of corticosteroid injection was in the first 15 days and that patient satisfaction improved at 1 month but did not have lasting effects at 3 and 6 months [9]. The majority of information on intra-articular steroid injection usage comes from literature regarding knee arthritis. A Cochrane review of 28 trials found steroid injection to be more effective than placebo. Effects were seen up to 4 weeks, but there was little effect seen beyond 4 weeks [10]. The review concluded that short-­ term effects were well established but long-term benefits had not been confirmed. It is also important to note that the use of corticosteroids is not without side effects. Wernecke et al. noted high doses of intra-articular steroid injections (>3 mg/dose or 18–24 mg/total cumulative dose in vivo) were significantly associated with gross cartilage damage and chondrocyte toxicity [11]. Dragoo et  al. demonstrated a

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Fig. 5.2 Surface landmarks and approach for posteriorly placed subacromial injection of the shoulder. A posterior approach can also be performed for an intra-articular injection with the needle aimed more inferior

significant decrease in chondrocyte viability with 9-day and 14-day trials of knee corticosteroid injections [12]. Braun et al. reported significant chondrotoxicity with 1% lidocaine or 0.25% bupivacaine in combination with corticosteroids compared to lidocaine alone [13]. These findings suggest intra-articular corticosteroid injections should be used judiciously and should be used at a maximum of every 4 months, if effective. When approaching a younger patient with shoulder arthritis, this potential damage to the cartilage must be considered so as not to place the patient at any greater acceleration of the arthritic process. Denard et al. even recommended no more than three corticosteroid injections in a single joint, barring special circumstances so as to avoid this potential acceleration [2]. In patients with shoulder arthritis, corticosteroid injections may be beneficial, but it is important to keep the side effects on articular cartilage in mind.

Hyaluronic Acid Hyaluronic acid (HA) is a long polysaccharide chain made up of repeating chains of N-acetyl-glucosamine and glucuronic acid, providing both viscous and elastic properties which are essential for normal joint function [14, 15]. In arthritic joints, HA

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concentration can decrease by 33–50% due to inflammatory effusions, abnormal synoviocytes, and molecular fragmentation, leading to distorted joint mechanics [15, 16]. Decrease in lubrication further worsens the degeneration of articular cartilage, potentially increasing pain symptoms and leading to more mechanical symptoms and stiffness [15, 17]. HA has demonstrated both analgesic and chondroprotective properties [14]. Additionally, HA therapies can be classified into high molecular weight (HMW), between 620 and 3200  kDa, and low molecular weight (LMW), between 500 and 730 kDa [18]. In 1974, Peyron et al. studied the use of hyaluronic acid injections as treatment for knee osteoarthritis and demonstrated an improvement in symptoms at 4 months in the treatment group compared to the control group [19]. Hyaluronic acid has since been classified as a medical device by the Food and Drug Administration and has been approved as a treatment option for knee osteoarthritis [20]. Research has since turned to investigate its treatment potential in shoulder arthritis. In 2007, in an industry-sponsored study of 30 patients diagnosed with shoulder osteoarthritis, investigators found a significant improvement at 6  months in the Visual Analogue Scale (VAS) pain scale, Simple Shoulder Test (SST), and UCLA score when treated with hyaluronic acid injections [21]. In a meta-analysis of 15 studies with five level I randomized controlled trials, Zhang et al. found a significant reduction in VAS at 3 months and 6 months in patients with glenohumeral arthritis treated with HA injection [17]. However, they found an improvement in pain scores in control and other intervention groups as well. Side effects were minimal with the most common being pain at injection site and effusion. The review was not able to comment on the efficacy of HMW versus LMW HA injections, and so there is little evidence to support one formulation over the other. The authors concluded that intra-articular HA injection is safe and improves pain for patients with glenohumeral arthritis but that further randomized controlled trials are necessary to evaluate the efficacy of HA [17]. Since then, multiple types of hyaluronic acid injections have become available on the market. In 2018, Bowman et al. reported at least 14 different HA injections available for the treatment of osteoarthritis [22]. Weick et al. reported when evaluating only payments specific to the treatment of knee osteoarthritis (excluding imaging which was considered evaluative), HA injections emerged as the largest expenditure, accounting for 25.2% of payments. Additionally, they found that knee HA injections were the second highest knee osteoarthritis-related healthcare expenditure, behind only imaging [23]. The FDA has not approved the use of HA injections for the treatment of glenohumeral arthritis, further increasing the cost per injection. This is important to discuss with patients who may be seeking an alternative to corticosteroid injections. The treating physician must make the patient aware of the financial implications of using HA injections. Overall, HA injections are a safe treatment for glenohumeral arthritis shown to decrease pain; however, cost of injection should be factored in when treating patients. Further research is required to determine the efficacy and optimal molecular weight of HA injections in younger patients with shoulder arthritis.

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Platelet-Rich Plasma Platelet-rich plasma (PRP) is an autologous biologic treatment made from a patient’s own plasma, containing growth factors released from platelets and endogenous fibrin scaffolds [24]. The rationale behind PRP injections is that supraphysiologic levels of platelet-derived growth factors may directly stimulate the natural healing cascade and tissue regeneration at the site of treatment [25]. Other research studies have proposed that PRP contains anabolic growth factors which enhance the biosynthesis of the cartilage and the bone matrix as well as inhibiting catabolic factors which are pro-inflammatory and have nociceptive properties [26]. As with HA injections, there have been limited studies performed examining the use of PRP in glenohumeral arthritis. In 2014, a case report was published of a 62-year-old woman with glenohumeral arthritis who was treated with three PRP injections over 3 weeks. The patient had improvement of pain and function at 8 weeks that continued with VAS improving from 6 to 0 and DASH score improving from 65 to 5 at 42 weeks [27]. Like with hyaluronic acid, PRP injections have been studied more rigorously in the knee literature. In a prospective, double-blind randomized controlled trial, researchers reported a significant improvement in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire within 2–3 weeks and lasting until the final 6-month follow-up. Additionally, they reported that WOMAC scores were not significantly different between patients receiving one PRP injection compared to patients who received two PRP injections 3 weeks apart [28]. A similar randomized controlled trial comparing PRP to HA injections found that WOMAC pain scores were not significantly different at any follow-up time points, although both injections were associated with an improvement in pain scores. Patients treated with PRP injections, however, were found to have significantly lower VAS pain scores compared to patients treated with HA injections at both 24- and 52-week follow-up [26]. A meta-analysis performed by Dai et al. reported no significant difference in WOMAC pain and functional scores at 6 months in patients treated with PRP compared to those treated with HA but found a significant difference in WOMAC pain and functional scores at 12 months. In addition, researchers found that PRP was more effective for pain relief and functional improvement compared to placebo (saline injection) at 6 and 12  months post-injection and PRP did not increase the risk of adverse events compared to HA or saline [29]. Another meta-­ analysis noted that most adverse events reported are nonspecific, including pain, stiffness, dizziness, headache, syncope, nausea, gastritis, sweating, and tachycardia. No severe complications were recorded, and all events were self-resolved in days [30]. In summary, there is a paucity of research investigating PRP injection use in the treatment of glenohumeral osteoarthritis. Studies in knee osteoarthritis have demonstrated efficacy in improving pain and function. PRP injection may be helpful in treating glenohumeral arthritis in the young patient, but more research is required to make a conclusive determination.

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Stem Cells In the past few decades, stem cells have emerged as a potential treatment option for a vast number of medical conditions including knee arthritis and rotator cuff tears [31, 32]. The number of true stem cell therapies that meet formal criteria is very small with currently available, minimally manipulated cells [33]. It is important to note that ex vivo culture expansion is currently not allowed in the United States and almost all current “stem cell” therapies contain very few true stem cells by formal criteria [34]. In addition, stem cells may change behavior after being transferred from their native environment. The new environment often lacks the proper growth signals to induce differentiation of stem cells. Currently, two of the more popular “stem cell” therapies include bone marrow aspirate concentrate (BMAC) and adipose-­derived mesenchymal stem cells [34]. However, there is a paucity of research investigating the use of BMAC and adipose-derived mesenchymal stem cells (MSC) in glenohumeral osteoarthritis. Even current available studies have high risk of bias and lack of control groups [31, 35]. In a study of 115 patients with symptomatic glenohumeral osteoarthritis with or without a rotator cuff tear, Centeno et  al. reported improved pain and Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 1 month and up to 2 years post-injection (BMAC) when compared to pre-­injection levels. However, the authors acknowledged a lack of a control group as well as a large, heterogeneous study population, which potentially confounded their findings [35]. No significant treatment-related adverse events were reported [35]. In knee literature, a recent systematic review of five randomized controlled trials and one nonrandomized trial reported that all trials had high risk of bias, resulting in downgrading of evidence to level III. But the authors did report that all five randomized controlled trials reported superior efficacy for patient-reported outcomes (VAS, WOMAC, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Lequesne) compared to controls at final follow-up, ranging from 24 to 48 months. Superior radiographic and histological outcomes were found that favored stem cell injection. No serious adverse events were reported in all randomized controlled trials analyzed [31]. Despite these conclusions, the authors concluded that they do not recommend stem cell therapy for the treatment of knee osteoarthritis [31]. To summarize, there are limited studies available evaluating stem cell therapy for the treatment of glenohumeral osteoarthritis. Current available studies in both shoulder and knee literature have a high risk of bias or did not have control groups. More randomized controlled trials are necessary to assess the efficacy of stem cell therapy for the treatment of glenohumeral arthritis in the young patient.

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Conclusion Glenohumeral arthritis in the young patient remains a difficult condition for many orthopedic surgeons to treat. Alternatives to total shoulder arthroplasty have represented an important area of research for orthopedic surgeons. Injection therapies have emerged as a potential alternative treatment option for glenohumeral arthritis, improving pain and function in these patients. Corticosteroid injections remain a highly used injection therapy for glenohumeral arthritis demonstrating a significant reduction in pain at 1 month post-injection. However, chondrocyte toxicity and cartilage damage remain the serious adverse effects that require consideration when treating patients with corticosteroid injections. Hyaluronic acid injections have been shown to cause a significant reduction in pain and improvement in function at 3 and 6 months post-injection with relatively low rates of adverse events. While HA injections may be effective, cost of HA injections should be factored in when considering treatment. PRP is a relatively new therapy with few studies conducted in the treatment of glenohumeral osteoarthritis. One case report described an improvement in VAS and DASH scores at 42 weeks post-injection. More research is necessary to determine the efficacy of PRP injections in the treatment of glenohumeral osteoarthritis. Stem cell therapy, like PRP, is a new therapy with few studies determining its efficacy. The vast majority of stem cell therapies contain very few true stem cells that meet the minimum criteria. Questions remain on whether stem cells remain viable once removed from their native environment. Future randomized controlled trials are required to determine the true efficacy of stem cell therapies in the treatment of shoulder osteoarthritis.

References 1. Barlow JD, Abboud J. Surgical options for the young patient with glenohumeral arthritis. Int J Shoulder Surg. 2016;10(1):28–36. 2. Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93(9):885–92. 3. Ansok CB, Muh SJ. Optimal management of glenohumeral osteoarthritis. Orthop Res Rev. 2018;10:9–18. 4. Strauss EJ, Hart JA, Miller MD, Altman RD, Rosen JE. Hyaluronic acid viscosupplementation and osteoarthritis: current uses and future directions. Am J Sports Med. 2009;37(8):1636–44. 5. Gross C, Dhawan A, Harwood D, Gochanour E, Romeo A. Glenohumeral joint injections: a review. Sports Health. 2013;5(2):153–9. 6. van der Meijden OA, Gaskill TR, Millett PJ. Glenohumeral joint preservation: a review of management options for young, active patients with osteoarthritis. Adv Orthop. 2012;2012:160923. 7. Izquierdo R, Voloshin I, Edwards S, Freehill MQ, Stanwood W, Michael Wiater J, et  al. Treatment of glenohumeral osteoarthritis. J Am Acad Orthop Surg. 2010;18(6):375–82. 8. Buchbinder R, Green S, Youd JM.  Corticosteroid injections for shoulder pain. Cochrane Database Syst Rev. 2003;2003(1):CD004016. 9. Merolla G, Sperling JW, Paladini P, Porcellini G.  Efficacy of Hylan G-F 20 versus 6-­methylprednisolone acetate in painful shoulder osteoarthritis: a retrospective controlled trial. Musculoskelet Surg. 2011;95(3):215–24.

5  Injection Therapies for Glenohumeral Osteoarthritis in the Young Patient

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10. Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005328. 11. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163. 12. Dragoo JL, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012;20(9):1809–14. 13. Braun HJ, Wilcox-Fogel N, Kim HJ, Pouliot MA, Harris AHS, Dragoo JL.  The effect of local anesthetic and corticosteroid combinations on chondrocyte viability. Knee Surg Sports Traumatol Arthrosc. 2012;20(9):1689–95. 14. Brockmeier SF, Shaffer BS.  Viscosupplementation therapy for osteoarthritis. Sports Med Arthrosc Rev. 2006;14(3):155–62. 15. Conduah AH, Baker CL, Baker CL. Managing joint pain in osteoarthritis: safety and efficacy of hylan G-F 20. J Pain Res. 2009;2:87–98. 16. Moreland LW.  Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action. Arthritis Res Ther. 2003;5(2):54–67. 17. Zhang B, Thayaparan A, Horner N, Bedi A, Alolabi B, Khan M. Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis. J Shoulder Elb Surg. 2019;28(3):596–606. 18. Abate M, Pulcini D, Iorio A, Schiavone C.  Viscosupplementation with intra-articular hyaluronic acid for treatment of osteoarthritis in the elderly. Curr Pharm Des. 2010;16(6):631–40. 19. Peyron JG, Balazs EA.  Preliminary clinical assessment of Na-hyaluronate injection into human arthritic joints. Pathol Biol. 1974;22(8):731–6. 20. Watterson JR, Esdaile JM. Viscosupplementation: therapeutic mechanisms and clinical potential in osteoarthritis of the knee. J Am Acad Orthop Surg. 2000;8(5):277–84. 21. Silverstein E, Leger R, Shea KP.  The use of intra-articular hylan G-F 20  in the treatment of symptomatic osteoarthritis of the shoulder: a preliminary study. Am J Sports Med. 2007;35(6):979–85. 22. Bowman S, Awad ME, Hamrick MW, Hunter M, Fulzele S. Recent advances in hyaluronic acid based therapy for osteoarthritis. Clin Transl Med. 2018;7:6. 23. Weick JW, Bawa HS, Dirschl DR. Hyaluronic acid injections for treatment of advanced osteoarthritis of the knee: utilization and cost in a national population sample. J Bone Joint Surg (Am Vol). 2016;98(17):1429–35. 24. Sánchez M, Anitua E, Azofra J, Aguirre JJ, Andia I. Intra-articular injection of an autologous preparation rich in growth factors for the treatment of knee OA: a retrospective cohort study. Clin Exp Rheumatol. 2008;26(5):910–3. 25. McArthur BA, Dy CJ, Fabricant PD, Gonzalez Della Valle A. Long term safety, efficacy, and patient acceptability of hyaluronic acid injection in patients with painful osteoarthritis of the knee. Patient Prefer Adherence. 2012;6:905–10. 26. Cole BJ, Karas V, Hussey K, Pilz K, Fortier LA. Hyaluronic acid versus platelet-rich plasma. Am J Sports Med. 2017;47(2):347–54. 27. Freitag J. The effect of photoactivated platelet-rich plasma injections in the novel treatment of shoulder osteoarthritis. Int J Case Rep Images. 2014;5(8):546. 28. Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis. Am J Sports Med. 2013;41(2):356–64. 29. Dai WL, Zhou AG, Zhang H, Zhang J.  Efficacy of platelet-rich plasma in the treat ment of knee osteoarthritis: a meta-analysis of randomized controlled trials. Arthroscopy. 2017;33(3):659–70. 30. Shen L, Yuan T, Chen S, Xie X, Zhang C. The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-­ analysis of randomized controlled trials. J Orthop Surg Res. 2017;12:16. 31. Pas HI, Winters M, Haisma HJ, Koenis MJ, Tol JL, Moen MH. Stem cell injections in knee osteoarthritis: a systematic review of the literature. Br J Sports Med. 2017;51(15):1125–33.

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32. Jo CH, Chai JW, Jeong EC, Oh S, Kim PS, Yoon JY, et al. Intratendinous injection of autologous adipose tissue-derived mesenchymal stem cells for the treatment of rotator cuff disease: a first-in-human trial. Stem Cells. 2018;36(9):1441–50. 33. Jones IA, Chen X, Evseenko D, Vangsness CT. Nomenclature inconsistency and selective outcome reporting hinder understanding of stem cell therapy for the knee. J Bone Joint Surg Am. 2019;101(2):186–95. 34. Carr JB, Rodeo SA.  The role of biologic agents in the management of common shoulder pathologies: current state and future directions. J Shoulder Elb Surg. 2019;28(11):2041–52. 35. Centeno CJ, Al-Sayegh H, Bashir J, Goodyear SH, Freeman D, M. A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. J Pain Res. 2015;8:269–76.

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Arthroscopic Treatment of Glenohumeral Arthritis in the Young Patient Adam J. Santoro, Daniel Hameed, and Luke S. Austin

Introduction Glenohumeral osteoarthritis (GHOA) is defined as destruction of the humeral and glenoid articular surfaces, often leading to shoulder pain, decreased range of motion (ROM), and loss of function. Collectively, osteoarthritis is a leading cause of disability in the United States, with GHOA affecting one in five elderly patients [1, 2]. Initial treatment of glenohumeral arthritis consists of nonsurgical measures such as nonsteroidal anti-inflammatories, activity modification, physical therapy, viscosupplementation, and steroid injections. When conservative treatment modalities fail, surgical interventions are often necessary to mitigate the effects of GHOA. Total shoulder arthroplasty (TSA) is considered the gold standard for treating glenohumeral arthritis and has shown to provide significant pain relief, improved function, and range of motion [3–8]. However, shoulder arthroplasty may not be the right procedure for every patient. Younger patients with shoulder arthritis who pursue arthroplasty may be at risk for early component loosening and need for multiple revision surgeries, while older patients and those with multiple medical comorbidities may not be ideal candidates for a major joint replacement surgery [9–13]. In this subset of patients, alternative surgical interventions may be more appropriate. Glenohumeral arthrodesis and soft tissue interposition arthroplasty are surgical options that are associated with numerous complications, high rates of revision, and poor clinical outcomes in younger patients [14–16]. This chapter will evaluate the varying arthroscopic treatment options for glenohumeral arthritis.

A. J. Santoro Rowan University School of Osteopathic Medicine, One Medical Center Drive, Stratford, NJ, USA D. Hameed · L. S. Austin (*) Rothman Orthopaedic Institute, Philadelphia, PA, USA e-mail: [email protected]; [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. M. Grawe et al. (eds.), Glenohumeral Osteoarthritis in the Young Patient, https://doi.org/10.1007/978-3-030-91190-4_6

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When Is Surgical Arthroscopy the Right Answer? Patient age is of paramount importance when counselling patients on treatment options for GHOA. Younger patients are often looking for pain relief and a return to normalcy postoperatively. Consequently, this population is also more often active, which places greater strain on their shoulders leading to potential early failure and revision in the setting of shoulder replacement surgery [9]. Bartelt et al. [17] found that one-third of patients under 55 undergoing TSA returned at a 2-year follow-up with prosthetic loosening and risk for clinical failure. Another study by Dillon et al. retrospectively reviewed 3000 patients undergoing TSA and found patients under 59 had twice the rate of revision than those older than 59 at their 2-year follow-up [10]. The literature shows us that there are excellent early survival rates of TSA in patients under 55; however, up to 40% of patients may need revision for component loosening after 10 years [9]. Not only is the durability of shoulder replacement in question for younger patients, but pain relief is not guaranteed. Younger patients undergoing shoulder replacement report a higher rate of residual pain and up to one in five are unhappy with their postoperative limitations [18]. In this population, surgical arthroscopy provides a viable treatment option when conservative measures fail, and patients may be simply too young for joint replacement surgery. Periprosthetic joint infection (PJI) is another factor that can lead to catastrophic failure following shoulder arthroplasty. Young patients, especially males, are at higher risk for PJI, specifically C. acnes, following shoulder arthroplasty [19]. PJIs result in significant morbidity, financial burden, and potential mortality [19, 20]. These effects may be amplified in the younger patient population. Similarly, older patients are looking for pain relief and quick return to their hobbies. These patients may have multiple medical comorbidities and not be ideal candidates for shoulder arthroplasty. The literature has shown inferior outcomes with potentially unacceptable risks in patients with the elderly, especially those with obesity, cardiac and/or renal failure, or diabetes [11, 21–24]. Arthroscopy provides the benefit of having lower complication rates and quicker return to normal activity compared to arthroplasty, thus making this an appealing treatment option for this subset of patients [25, 26]. Understanding patients’ symptoms, goals, and expectations can also help elucidate whether or not arthroscopy is appropriate. Patients experiencing mechanical symptoms such as locking, catching, clicking, and decreased range of motion may benefit from arthroscopic debridement and removal of impinging structures (i.e., bone spurs and loose bodies) with acceptable outcomes. Furthermore, other pathologies are often associated with glenohumeral arthritis, such as labral tears, SLAP lesions, rotator cuff tears, and subacromial impingement. Arthroscopy can provide a diagnostic and therapeutic means to treat these patients [26–28]. Arthroscopy is not for everyone. Multiple studies have looked at patient-specific factors to guide surgical decision making and found high-grade Kellgren-Lawrence OA, bipolar GH joint disease, 30 and patients over the age of 45 in the knee literature [43]. More studies are needed to determine if these, and other, prognostic indicators hold true in the shoulder. Microfracture is not for everyone. Millet et al. [41] looked at microfracture in 30 patients with full-thickness chondral lesions. He found a negative correlation between the size of the lesion and postoperative ASES score, with the worst results in bipolar disease. Furthermore, patients with large chondral lesions or glenohumeral instability may have extensive damage to the subchondral bony architecture leading to failure of the fibrocartilage regenerative process necessary for microfracture to work [40].

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a

d

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c

e

Fig. 6.2 (a–e) Intraoperative arthroscopic images demonstrating bipolar cartilage lesions (a, top left), debridement of bipolar cartilage lesion (b, top middle), pre-microfracture (c, top right) and post-microfracture (d, bottom left), and removal of loose body (e, bottom right)

Postoperatively, rehabilitation is designed to maximize stem cell migration and differentiation into the appropriate cell line. This is done by a consistent physical therapy program focused on joint motion. Ultimately, regular motion will maintain lubrication and nutrition as well as provide mechanical stimuli to the regenerating tissue [40]. Postoperatively, patients are restricted from heavy overhead lifting for 3 months, and gentle stretching and strengthening exercises are recommended. In 4 months, patients can anticipate return to full activity with exception of competitive overhead athletes who require restriction for 6 months [40]. Microfracture has been proven to be an effective, short-term treatment option for the management of chondral defects [42, 44, 45]. However, there is a scarcity of data on its long-term success. Wang et al. studied 16 patients 10 years after undergoing microfracture surgery and found 21.4% of patients were converted to arthroplasty within 10 years [46]. For now, microfracture appears to be an adjunct to other procedures when treating glenohumeral arthritis, and more data is needed to determine its durability.

Arthroscopic Biologic Resurfacing and Interposition Shoulder resurfacing was developed as an alternative to shoulder replacement for young patients who have an active lifestyle [47]. Unlike arthroplasty, which excises the humeral and glenoid arthritic bone, the objective of glenohumeral resurfacing is to preserve the native glenohumeral joint by interposing synthetic or biological scaffolds that are high in tensile strength and can permit repopulation of host cells. The treatment can be performed arthroscopically and is synonymous with interposition arthroplasty. There are multiple options that can act as the interposition

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material such as silicone, nylon, skin, lyophilized human dura mater, anterior capsule, fascia lata, meniscal allograft, and animal membranes [48]. Popularized by Burkhead and Hutton, the concept involves covering the glenoid with natural biologic substances [47]. By creating grafts from the anterior glenoid capsule and fascia lata, they were able to find good pain relief and improved ROM with positive patient-reported outcomes 7 years post-op. As this technique became more popular, other studies started using grafts from the Achilles tendon and lateral meniscal allografts [49–51]. They believed that bulkier material would have better load-bearing characteristics, and they found similar results to Burkhead and Hutton. Arthroscopic techniques are used that allow resurfacing glenohumeral interposition arthroplasty without the need to take down the subscapularis to gain visibility of the joint [51]. Bhatia describes an arthroscopic technique that has the advantage of preserving the anatomy and soft tissue planes for future prosthetic arthroplasty, in case it becomes necessary. “The arthroscopic technique can resurface the glenoid with any interposition membrane or tissue that can be passed into the glenohumeral joint through a 10-mm cannula.” This technique eliminates the use of suture anchors for tissue fixation. This procedure has been performed in several patients with early and advanced glenohumeral arthritis and has produced safe and reproducible results [51, 52]. Potential benefits of resurfacing compared to traditional shoulder arthroplasty are that it is a less traumatic surgery requiring minimal bone resection and no osteotomy, as well as shorter rehabilitation time. Data also suggests that there is a significantly low prevalence of humeral periprosthetic fractures overall [51, 53]. Despite the upsides of resurfacing, studies have not shown positive long-term outcomes. Strauss et al. reported on 41 patients with 31 lateral meniscal allografts and found a “clinical failure rate of 45% at 3.4 years in the lateral meniscus group” [50]. Another study by Hammond et al. compared a group of patients undergoing hemiarthroplasty with a group undergoing biologic glenoid resurfacing [53]. They found better pain relief and functional outcome in the hemiarthroplasty group. More studies are needed to validate the efficacy of resurfacing and to further define its role in the management of glenohumeral arthritis.

 imitations of Surgical Arthroscopy When Managing L Glenohumeral Arthritis There are several limitations of arthroscopic management for the treatment of glenohumeral arthritis. For starters, studies have shown that patients with bipolar disease, joint space narrowing