Choose the Best Surgical Option for These 2 Patients - Clinical Pain Advisor

Choose the Best Surgical Option for These 2 Patients

Slideshow

  • Anteroposterior radiograph of the left shoulder of Patient A, a 70-year-old man who has had pain in that shoulder for several years.

    Slide

    Anteroposterior radiograph of the left shoulder of Patient A, a 70-year-old man who has had pain in that shoulder for several years.

  • Anteroposterior radiograph of the right shoulder of Patient B, a 74-year-old man with several years of pain and weakness in that location.

    Slide

    Anteroposterior radiograph of the right shoulder of Patient B, a 74-year-old man with several years of pain and weakness in that location.

Patient A is a 70-year-old man who has been treated for several years for left shoulder pain. Intra-articular steroid injections, rest, and nonsteroidal anti-inflammatory drugs have provided short-term relief. On examination, the patient has good range of motion of the shoulder both passively and actively. Magnetic resonance imaging taken 1 month earlier shows an intact rotator cuff.

Patient B is a 74-year-old man with several years of right shoulder pain and weakness. His medical history includes a chronically torn rotator cuff that was debrided arthroscopically a few years earlier. On examination, the patient has near full passive range of motion but isolated supraspinatus muscle testing reveals weakness. Conservative treatment with intra-articular steroid injections, rest, and nonsteroidal anti-inflammatory drugs have failed to provide relief.

This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.

Arthritis of the shoulder, or glenohumeral joint, can cause significant pain, loss of motion, and disability. There are several causes of shoulder arthritis, including primary and secondary osteoarthritis, rotator cuff arthropathy, rheumatoid arthritis, avascular necrosis, and connective tissue disorders. Primary...

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Arthritis of the shoulder, or glenohumeral joint, can cause significant pain, loss of motion, and disability. There are several causes of shoulder arthritis, including primary and secondary osteoarthritis, rotator cuff arthropathy, rheumatoid arthritis, avascular necrosis, and connective tissue disorders. Primary arthritis is age-related cartilage degeneration that occurs over time, and secondary arthritis is caused by a prior injury that results in a degenerative cascade. Shoulder arthritis and rotator cuff pathology are prevalent in more than 90% of people with rheumatoid arthritis. Common symptoms include night pain; decreased range of motion, particularly external rotation; and painful range of motion.1,2

First-line treatment for everyone who presents with shoulder arthritis includes nonsteroidal anti-inflammatory drugs, disease-modifying antirheumatic drugs for rheumatoid arthritis, activity modification, physical therapy, and intra-articular injections. The 3 primary surgical options available once conservative treatments have failed are hemiarthroplasty, total shoulder arthroplasty, and reverse total shoulder arthroplasty. Important factors to consider when choosing the best treatment option include patient age and activity level, degree of arthritis on the humeral surface and glenoid, and the integrity of the rotator cuff on magnetic resonance imaging.

Younger patients who place a higher demand on the shoulder, such as laborers or athletes, are more prone to complications with total shoulder arthroplasty. Younger patients are also more likely to have chondral wear on the humeral surface and not on the glenoid, which makes hemiarthroplasty (replacement or resurfacing of the humeral side only) a good option for this patient population.

Patients with arthritis on both the humeral and glenoid surfaces who have an intact or repairable rotator cuff are good candidates for total shoulder arthroplasty. Because fewer than 10% of those who present with shoulder arthritis have a rotator cuff tear, total shoulder arthroplasty is the most commonly performed procedure of these 3 surgical options. In total shoulder arthroplasty, the rotator cuff keeps the humerus depressed in the glenoid and allows for active shoulder motion.

Total shoulder replacement will likely fail in patients who have a deficient rotator cuff, as the humerus tends to migrate superiorly and forward elevation of the shoulder is lost (pseudoparesis). Therefore, those with a deficient rotator cuff or rotator cuff arthropathy are considered for a reverse total shoulder procedure. Reverse total shoulder replacement relies on the deltoid to move the shoulder as the deficient rotator cuff no longer can. Reverse total shoulder replacement is indicated for patients aged older than 70 years who have severe rotator cuff arthropathy and for patients in whom total shoulder arthroplasty has failed.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

  1. Wiater JM, Fabing MH. Shoulder arthroplasty: prosthetic options and indications. J Am Acad Orthop Surg. 2009;17:415-425.
  2. Denard PJ, Wirth MA, Orfaly RM. Management of glenohumeral arthritis in the young adult. J Bone Joint Surg Am. 2011;93:885-892.