20 studies that have influenced my approach to shoulder arthritis.

Deconflicting use of the term "subluxation". 

Most orthopaedic surgeons use the word subluxation to refer to separation of the surfaces of a joint, as in patello-femoral subluxation

In this classic article, Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis,   the authors defined subluxation of the shoulder in a manner consistent with the standard use of the term:  decentering of the humeral head with respect to the perpendicular bisector of the plane of the glenoid face.

Thus, this humeral head is not subluxated.

Neither is this one where the humeral head is centered with respect to the perpendicular bisector of the plane of the glenoid face (even though the glenoid is retroverted with respect to the plane of the scapula). Today, we would identify this as a B3 glenoid.

In the example below, however, the humeral head is posteriorly decentered (subluxated) with respect to the plane of the glenoid face. This is a classic B2 glenoid,

Consistent with Walch's classic article, the authors of Quantitative Measurement of Osseous Pathology in Advanced Glenohumeral Osteoarthritis  defined subluxation in terms of "humeroglenoid alignment" or HGA, and found that the humeral head was relatively well centered in the retroverted B3 type compared with the type B2 glenoid.

However, as pointed out in Subluxation in the Arthritic Shoulder many authors have recently confused the use of the word "subluxation" by using it to refer to alignment of the humeral head with the scapular axis, rather than with respect to the plane of the glenoid face. The relationship of the humeral head to the plane of the scapula is mostly determined by glenoid retroversion and is not a measure of glenohumeral subluxation.

Interestingly, the authors of Progression of Glenoid Morphology in Glenohumeral Osteoarthritis  found that arthritic shoulders that started out with the humeral head centered with respect to the plane of the glenoid face rarely progressed to becoming subluxated (i.e. decentered).

Does glenoid version need "correcting" 

If humeral head decentering on the glenoid face is not driven by glenoid retroversion, is it necessary to "correct" glenoid retroversion when performing a shoulder arthroplasty?

The authors of Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review  found that "there is currently insufficient evidence that pre- or postoperative glenoid version influences postoperative outcomes independent of other morphologic factors such as joint line medialization. Given that noncorrective reaming demonstrated favorable postoperative outcomes, and that postoperative glenoid version was not significantly and consistently found to impact outcomes, there is inconclusive evidence that correcting glenoid retroversion is routinely required."

Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at a minimum 5-year follow-up found that the results of TSA with conservative glenoid reaming without attempt at version correction were favorable at a minimum 5- year, and mean 8-year, follow-up. There were no differences in clinical and radiographic outcomes between patients with eccentric and concentric wear patterns. Incomplete glenoid component seating was the greatest predictor of glenoid component radiolucency.

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty?  noted that postoperative glenoid retroversion was not associated with inferior clinical results at 2 years after surgery. 

Glenoid subchondral bone density distribution in male total shoulder arthroplasty subjects with eccentric and concentric wear  pointed out that attempts to correct glenoid version may result in loss of the dense glenoid bone that contributes to good fixation of a glenoid component.

The authors Management of intraoperative posterior decentering in shoulder arthroplasty using anteriorly eccentric humeral head components  showed that decentering of the humeral head with respect to the plane of the glenoid face could be corrected without changing glenoid version through the use of an anteriorly eccentric humeral head component

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How do anatomic and reverse total shoulders compare in the treatment of glenohumeral arthritis with an intact cuff?

A comparative analysis of anatomic total shoulder arthroplasty versus reverse shoulder arthroplasty for posterior glenoid wear patterns noted that patients with shoulder osteoarthritis and posterior glenoid wear patterns with an intact rotator cuff who underwent TSA had similar outcomes as RSA. The TSA group had superior active external rotation and internal rotation at 2 years postoperative compared with RSA.

Treatment of B2 Type Glenoids with Anatomic versus Reverse Total Shoulder Arthroplasty: A Retrospective Review found that anatomic and reverse total shoulder arthroplasty can produce good results in patients with B2 glenoid morphology with low rates of revision with appropriate patient selection. Anatomic total shoulder arthroplasty may result in improved range of motion.

 

Survivorship of shoulder arthroplasty in young patients with osteoarthritis: an analysis of the Australian Orthopaedic Association National Joint Replacement Registry  noted that instability/dislocation were the leading causes of revision for RTSA (41.7%) For TSA, the majority of revisions were for either instability/dislocation (20.6%) or loosening (18.6%).The high early dislocation rate associated with RTSA, as well as the lack of revision options available to address this, indicates that careful selection of patients and a greater appreciation of anatomic risk factors are needed in the future.

Total Shoulder Arthroplasty Versus Reverse Shoulder Arthroplasty in Primary Glenohumeral Osteoarthritis With Intact Rotator Cuffs: A Meta-Analyses  in the setting of primary glenohumeral osteoarthritis with an intact cuff reverse total shoulder were found to be non-inferior to the TSA.

The Influence of Rotator Cuff Disease on the Results of Shoulder Arthroplasty for Primary Osteoarthritis demonstrated that minimally retracted or nonretracted rotator cuff tears limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in total shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.

Reverse total shoulder challenges

Development, Evolution, and Outcomes of More Anatomical Reverse Shoulder Arthroplasty  presents the evolution of RSA design, particularly the development of a lateralized center of rotation constructs, which aimed to address the disadvantages associated with the Grammont-style design and more closely reproduce the native anatomy in order to improve patient outcomes in an expanded context of pathologies. 

Glenoid morphology in reverse shoulder arthroplasty: Classification and surgical implications showed that abnormal glenoid morphology has a significant effect on anatomical and surgical factors which can necessitate adjustments in surgical technique for reverse shoulder arthroplasty including the use or the alternative spine centerline.

Implant-Positioning and Patient Factors Associated with Acromial and Scapular Spine Fractures After Reverse Shoulder Arthroplasty noted that while the original indication for a reverse total shoulder was cuff tear arthropathy with pseudoparalysis, patients with this condition have inferior outcomes in comparison to those with intact rotator cuffs. Poor bone density and rotator cuff deficiency appear to be the strongest predictors of acromial and scapular spine fractures after RSA. To a lesser degree, increased humeral lateralization appear to be associated with lower fracture rates while glenoid-sided and global lateralization are associated with higher fracture rates. However, glenoid lateralization may improve shoulder stability, range of motion and function while reducing the risk of unwanted prosthesis-bone contact with associated limitations in range of motion and scapular notching.

An alternative approach to cuff tear arthropathy.

Cuff Tear Arthropathy: Pathogenesis, Classification, and Algorithm for Treatment  showed that the use of an extended humeral head prosthesis for Types-IA, IB, and IIA cuff tear arthropathy revealed substantial improvement in pain relief, range of motion, and functional goals. 

Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty showed that for patients having cuff tear arthropathy with retained active elevation, an extended head humeral hemiarthroplasty yielded clinically important improvement in comfort and function while avoiding the complications of dislocation and acromial/spine fracture that can be associated with a reverse total shoulder. 

New technologies

Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty The analysis did not identify evidence that the results of TSA were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Technique or Technology? Shoulder arthritis in a 68 year old active woman: 16 year followup

A 68 year old woman presented with a stiff painful shoulder and these radiographs.

After discussion of the alternatives, including a reverse total shoulder, she elected to proceed with an anatomic total shoulder.  No preoperative CT was obtained and no 3D planning was carried out. The procedure was performed under general anesthesia without a nerve block. The long head tendon of the biceps was preserved. A standard length, thin,  smooth stem was fixed with impaction autografting. A standard all-polyethylene glenoid component with an ingrowth central peg was inserted with careful seating and minimal cement.

Six months after her right shoulder arthroplasty she presented with painful arthritis of her left shoulder requesting a similar procedure

At 16 years after her arthroplasties, she returned with excellent comfort and function of both shoulders and the x-rays below showing no evidence of stress shielding of the humerus and excellent bony ingrowth into the central peg (arrows)

Of note, as is typical for our practice, the costs of CT scans, plexus blocks, special components and a reverse total shoulder were avoided without compromise of the clinical outcome.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

What is the preferred treatment of a 58 year old woman with post-dislocation arthritis.

A 58 year old woman presents with painful stiffness of her shoulder after a dislocation 25 years ago (treated non operatively). She is physically active and has increased pain in the shoulder after using it.

Her Simple Shoulder Test results are shown below.

Her shoulder was strong, but stiff - much of the motion was scapulothoracic.

Her x-rays at the time of presentation are shown below.

What is the appropriate treatment for this patient?

Comments welcome at shoulderarthritis@uw.edu

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/


Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Sleep and shoulder arthroplasty

 

Sleeplessness is a prominent complaint of individuals with shoulder arthritis. Shown below are the percentages of the 12 functions of the Simple Shoulder Test that were performable by over 3,000 patients presenting with glenohumeral osteoarthritis. Note that 90% of these patients were unable to sleep comfortably.

The authors of Improvement in Sleep Disturbance Following Anatomic and Reverse Shoulder Arthroplasty used the Simple Shoulder Test and other measures to assess sleep impairment prior to shoulder arthroplasty as well as the recovery of the ability to sleep comfortably after shoulder arthroplasty for glenohumeral arthritis. They identified 1,405 patients treated with shoulder arthroplasty: 698 who underwent anatomic shoulder arthroplasty (TSA) and 707 who underwent reverse total shoulder (RSA). 97%) of those who underwent TSA and 95% of those who underwent RSA reported sleep disturbance prior to surgery. 

517 who underwent TSA and 472 who underwent RSA were studied with a median follow-up of 36 months for the TSA group and 25 months for the RSA group. 

Postoperatively, significant improvements in the average ability to sleep comfortably and sleep on the affected side were observed in both the TSA group and the RSA group. The ability to sleep comfortably returned faster than the ability to sleep on the affected side, with the ability to sleep comfortably reaching a plateau at 3 months and the ability to sleep on the affected side reaching a plateau at 6 months. Despite improvements in terms of sleep disturbance, at the time of most recent follow-up, 13.2% of patients in the TSA group and 16.0% of those in the RSA group could not sleep comfortably and 31.4% of those in the TSA group and 36.8% of those in the RSA group could not sleep on the operative side.

Comment: This is an informative study. While it answers some clinically important questions, it does not answer the question "why do 1/3 of patients not regain their ability to sleep on the operative side after arthroplasty?" It would be of interest, for example, to know if the shoulders of the "unable to sleep" patients were stiffer than the others. This information could help inform the details of surgery (e.g. how tight the soft tissues should be) and the details of the post operative rehabilitation (e.g. how soon and what type of exercises should be implemented after surgery).

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Shoulder arthritis - second opinion,

Patients are encouraged to get a second opinion regarding the management of their shoulder arthritis.

Here's an example.

An active man in his late 60's presents with pain in his shoulder, but is still doing bench press with 30 pounds and has retained active elevation.  These CT images were obtained at his initial surgical consultation.

He was presented with the sole option of a reverse total shoulder (see this link) to help improve his shoulder performance.

    

This patient has clinical and radiographic findings that are commonly successfully managed with an anatomic total shoulder (see this link) or a ream and run procedure (see this link), should he continue to have disabling symptoms after a trial of rehabilitation exercises (see this link) and non-steroidal anti-inflammatory medications. A discussion of the pros and cons of these options is warranted.

You can support cutting edge shoulder research and education that are leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Primary glenohumeral arthritis: treatment with the ream and run in comparison to total shoulder arthroplasty - 10 year followup

Glenohumeral arthritis in shoulders with an intact rotator cuff is the most common indication for shoulder arthroplasty. 

The safety, effectiveness and durability of anatomic arthroplasty - the ream and run (RnR) or the anatomic total shoulder (TSA) - is widely recognized. 

The authors of Minimum 10-year Follow-up of Anatomic Total Shoulder Arthroplasty and Ream-and-Run Arthroplasty for Primary Glenohumeral Osteoarthritis studied the patients and the minimum 10-year outcomes for the RnR (n=34) and TSA (n=29). In this practice, the patients chose their surgical procedure after a discussion of the risks and benefits of each.

The two groups differed in a number of important preoperative characteristics. The RnR patients were significantly younger than the TSA patients (60 ± 7 vs 68 ± 8, p<0.001), predominantly male (97% vs 41%, p<0.001), and were healthier as reflected by the American Society of Anesthesiologists score (p=0.018). 

Patient-assessed preoperative and postoperative function was documented by the Simple Shoulder Test (SST)

The preoperative and the postoperative SST scores were higher for the patients having the ream and run procedure than for those having total shoulders.

Total shoulder

In the TSA group, the pain score decreased from a preoperative average of 6.6 ± 2.2 to 1.2 ± 2.3 (p < 0.001), and the SST score improved from and average of 3.8 ± 2.6 to 8.9 ± 2.6 at 10-year follow-up. (p < 0.001). The percent of maximum possible improvement averaged 64%. No patient in the TSA group required reoperation; notably there were no cuff tears or glenoid loosenings.

Ream and Run

In the RnR group, the pain score decreased from a preoperative average of 6.5 ± 1.9 to 0.9 ± 1.3 (p < 0.001), while the SST score improved from and average of 5.4 ± 2.4 to 10.3 ± 2.1 at 10-year follow-up (p < 0.001).  The percent of maximum possible improvement averaged 83%. 

Four patients  underwent single-stage exchange to another hemiarthroplasty because of painful stiffness. Two of these 4 patients had positive cultures for Cutibacterium. One patient required manipulation under anesthesia. No patients had conversion to a TSA or reverse total shoulder. 

At followup, a larger percentage of RnR patients could perform high-level shoulder functions: SST questions 7, 8, 9, 10, and 12.

As an example, a 15-year post RnR followup x-ray of the shoulder shown at the beginning of this post is shown below. Note the stable humeral fixation and the seating of the humeral head centered in the healed glenoid concavity.

This patient (now 71 years old) continues to use his arm for heavy physical work and recreation. He has excellent range of motion, comfort and function and now returns for an RnR on his opposite shoulder.

 

Comment: Patients with glenohumeral osteoarthritis and their surgeons have the choice of the ream and run and anatomic total shoulder. This is one of the few long term studies of the patients having each of the procedures. It is notable that young, healthy, male patients preferred the ream and run procedure after a discussion of the pros and cons of each. The RnR patients had higher levels of function both before and after surgery - particularly for the more demanding activities assessed by the Simple Shoulder Test.

As is necessary for all clinical outcome studies, this article reported the number of patients enrolled in the database and the number and reasons groups of patients were not included in the final analysis. This is the standard "Figure 1", which seems absent in many reports.

This figure shows the challenge in achieving long term followup on a high percentage of patients.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

The ream and run - the shoulder joint replacement for active individuals.

The ream and run shoulder arthroplasty is an established shoulder replacement procedure for active individuals with disabling shoulder arthritis (see this link). In this procedure the rough arthritic joint surface of the humerus is replaced with a securely fixed, smooth metal implant, while the irregular arthritic glenoid socket is conservatively reamed to a smooth concavity (see this link).

This procedure is an option for active individuals who wish to avoid the risks and limitations associated with the plastic socket used in conventional total shoulder replacement. It is useful in addressing severe arthritis in the shoulders of young individuals, including those having failed prior shoulder surgery. 

Below are the preoperative x-rays from a 40 year old athlete showing displacement of the humeral head on the glenoid, severe arthritis and retained hardware from a previous operation.

As is our practice, the ream and run is performed without preoperative MRI or CT scans, preoperative 3-D planning, intraoperative navigation, augmented reality, cement, plastic, ingrowth component, or nerve block -  making it a cost-effective procedure.

His postoperative x-rays are shown below

This man was vigorous in his rehabilitation. Here's his assisted motion the morning after surgery.

He pursued his dedicated rehabilitation. He shared this video at five months after surgery

Recently he reported: "16 months post ream and run and I can play basketball again. Able to shoot long range 3-pointers, dribble, make hook shots and do a chest pass with no problem. My shoulder hasn’t felt this good in 25 yrs." He kindly gave us permission to share this recent video

Results such as this do not come automatically after the ream and run, but rather result from dedicated, persistent adherence to the defined rehabilitation program (see this link). Patients must "do the work".

Patients provide frequent followup to their surgeon with videos such as those shown below for two patients in the first two weeks after their ream and run procedures (shared with their permission).

Comment: A successful outcome after a ream and run procedure depends on four things:

(1) informed selection of the right procedure for the right patient

(2) excellent surgical technique 

(3) patient dedication to the rehabilitation program

(4) frequent communication between the surgeon and the patient during the recovery.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).