User login
Osteoporosis Drugs Compared for Side Effects, Efficacy
A study comparing the efficacy and tolerability of 2 popular osteoporosis drugs, denosumab and zoledronic acid, found that denosumab had a significantly greater effect on increasing spine bone mineral density and zoledronic acid caused more flu-like symptoms. These findings were presented recently at the American Society for Bone and Mineral Research’s annual meeting.
Lead author Kellen Sheedy, a medical student at Loyola University’s Strich School of Medicine, and colleagues performed a retrospective chart review and survey of 107 patients to compare the efficacy, patient satisfaction, cost, and known adverse effects of denosumab versus zoledronic acid, including muscle pain, back pain, and flu-like symptoms. At 1 year, the denosumab and zoledronic acid groups were statistically similar in all areas except spine bone mineral density (increased 0.060 g/cm2 versus 0.021 g/cm2, respectively) and flu-like symptoms (none versus 29% of patients).
Regarding costs, all of the zoledronic acid treatments were covered by insurance and only 2 participants had a copayment ($150 and $1,500); 93% of the denosumab treatments were covered by insurance and 3 participants had a copayment ($70, $200, and $1,800 for 2 treatments).
Overall, the denosumab group (51 patients) had a higher mean increase in spine bone mineral density and the zoledronic acid group (56 patients) had a higher incidence of flu-like symptoms but the 2 groups were statistically similar in patient satisfaction, the researchers reported.
The FDA approved denosumab in 2010 for postmenopausal women with osteoporosis. It is injected subcutaneously (60 mg) every 6 months. The treatment works by inhibiting bone loss and fracture risk.
Zoledronic acid was approved by the FDA in 2007 for osteoporosis. This treatment is administered intravenously (5 mg) once every 12 months. It is the most potent of the drugs in its class, and it works by interfering with the bone-breakdown process.
“This study helped us quantify the efficacy and adverse effects of these 2 drugs providing further guidance for physicians who prescribe these treatments,” said Pauline Camacho, MD, lead study investigator and Director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Health System. “While this was the first head-to-head comparison of these 2 treatments, larger prospective studies will be needed to confirm these findings.”
Sheedy K, Camara I, Camacho P. Comparison of efficacy, adverse effects and cost of zoledronic acid and denosumab in the treatment of osteoporosis. J Bone Miner Res. 2014;28(Suppl 1). Available at www.asbmr.org/education/AbstractDetail?aid=f66c3659-3ede-47df-a321-1d8a2c75f587. Accessed February 14, 2014.
A study comparing the efficacy and tolerability of 2 popular osteoporosis drugs, denosumab and zoledronic acid, found that denosumab had a significantly greater effect on increasing spine bone mineral density and zoledronic acid caused more flu-like symptoms. These findings were presented recently at the American Society for Bone and Mineral Research’s annual meeting.
Lead author Kellen Sheedy, a medical student at Loyola University’s Strich School of Medicine, and colleagues performed a retrospective chart review and survey of 107 patients to compare the efficacy, patient satisfaction, cost, and known adverse effects of denosumab versus zoledronic acid, including muscle pain, back pain, and flu-like symptoms. At 1 year, the denosumab and zoledronic acid groups were statistically similar in all areas except spine bone mineral density (increased 0.060 g/cm2 versus 0.021 g/cm2, respectively) and flu-like symptoms (none versus 29% of patients).
Regarding costs, all of the zoledronic acid treatments were covered by insurance and only 2 participants had a copayment ($150 and $1,500); 93% of the denosumab treatments were covered by insurance and 3 participants had a copayment ($70, $200, and $1,800 for 2 treatments).
Overall, the denosumab group (51 patients) had a higher mean increase in spine bone mineral density and the zoledronic acid group (56 patients) had a higher incidence of flu-like symptoms but the 2 groups were statistically similar in patient satisfaction, the researchers reported.
The FDA approved denosumab in 2010 for postmenopausal women with osteoporosis. It is injected subcutaneously (60 mg) every 6 months. The treatment works by inhibiting bone loss and fracture risk.
Zoledronic acid was approved by the FDA in 2007 for osteoporosis. This treatment is administered intravenously (5 mg) once every 12 months. It is the most potent of the drugs in its class, and it works by interfering with the bone-breakdown process.
“This study helped us quantify the efficacy and adverse effects of these 2 drugs providing further guidance for physicians who prescribe these treatments,” said Pauline Camacho, MD, lead study investigator and Director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Health System. “While this was the first head-to-head comparison of these 2 treatments, larger prospective studies will be needed to confirm these findings.”
Sheedy K, Camara I, Camacho P. Comparison of efficacy, adverse effects and cost of zoledronic acid and denosumab in the treatment of osteoporosis. J Bone Miner Res. 2014;28(Suppl 1). Available at www.asbmr.org/education/AbstractDetail?aid=f66c3659-3ede-47df-a321-1d8a2c75f587. Accessed February 14, 2014.
A study comparing the efficacy and tolerability of 2 popular osteoporosis drugs, denosumab and zoledronic acid, found that denosumab had a significantly greater effect on increasing spine bone mineral density and zoledronic acid caused more flu-like symptoms. These findings were presented recently at the American Society for Bone and Mineral Research’s annual meeting.
Lead author Kellen Sheedy, a medical student at Loyola University’s Strich School of Medicine, and colleagues performed a retrospective chart review and survey of 107 patients to compare the efficacy, patient satisfaction, cost, and known adverse effects of denosumab versus zoledronic acid, including muscle pain, back pain, and flu-like symptoms. At 1 year, the denosumab and zoledronic acid groups were statistically similar in all areas except spine bone mineral density (increased 0.060 g/cm2 versus 0.021 g/cm2, respectively) and flu-like symptoms (none versus 29% of patients).
Regarding costs, all of the zoledronic acid treatments were covered by insurance and only 2 participants had a copayment ($150 and $1,500); 93% of the denosumab treatments were covered by insurance and 3 participants had a copayment ($70, $200, and $1,800 for 2 treatments).
Overall, the denosumab group (51 patients) had a higher mean increase in spine bone mineral density and the zoledronic acid group (56 patients) had a higher incidence of flu-like symptoms but the 2 groups were statistically similar in patient satisfaction, the researchers reported.
The FDA approved denosumab in 2010 for postmenopausal women with osteoporosis. It is injected subcutaneously (60 mg) every 6 months. The treatment works by inhibiting bone loss and fracture risk.
Zoledronic acid was approved by the FDA in 2007 for osteoporosis. This treatment is administered intravenously (5 mg) once every 12 months. It is the most potent of the drugs in its class, and it works by interfering with the bone-breakdown process.
“This study helped us quantify the efficacy and adverse effects of these 2 drugs providing further guidance for physicians who prescribe these treatments,” said Pauline Camacho, MD, lead study investigator and Director of the Osteoporosis and Metabolic Bone Disease Center at Loyola University Health System. “While this was the first head-to-head comparison of these 2 treatments, larger prospective studies will be needed to confirm these findings.”
Sheedy K, Camara I, Camacho P. Comparison of efficacy, adverse effects and cost of zoledronic acid and denosumab in the treatment of osteoporosis. J Bone Miner Res. 2014;28(Suppl 1). Available at www.asbmr.org/education/AbstractDetail?aid=f66c3659-3ede-47df-a321-1d8a2c75f587. Accessed February 14, 2014.
Osteoporosis Screening Recommendations May Miss Two-Thirds of Women Ages 50 to 64 Years
The U.S. Preventive Services Task Force (USPSTF) recommends osteoporosis screening for women younger than 65 years whose 10-year predicted risk of major osteoporotic fracture is 9.3% or greater. For identifying screening candidates among women between the ages of 50 to 65 years, however, it is uncertain how the USPSTF strategy compares with the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE).
Carolyn Crandall, MD, Professor of Medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA, and colleagues examined data from 1994 to 2012 from 5,165 Women’s Health Initiative participants ages 50 to 64 years. Their findings were published in the January 2014 issue of the Journal of Bone and Mineral Research. According to the researchers, the USPSTF strategy would identify only 34% of women who actually had bone mineral density in the osteoporosis range.
For the USPSTF (FRAX major fracture risk ≥ 9.3% calculated without bone mineral density), the OST (score < 2), and SCORE (score > 7) strategies, the researchers assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck T-scores of -2.5 or less. Sensitivity, specificity, and AUC for identifying femoral neck T-scores of -2.5 or less were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX); 79.8%, 66.3%, and 0.73 for OST; and 74%, 70.8%, and 0.72 for SCORE.
“The USPSTF strategy identified about one-third of women ages 50 to 64 years with femoral neck T-scores of -2.5 or less,” the researchers wrote. “Among women ages 50 to 64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without femoral neck T-scores of -2.5 or less.” As a result, the researchers said, following the USPSTF strategy may lead to missed opportunities to decrease fracture risk in at-risk women.
Crandall CJ, Larson J, Gourlay ML, et al. Osteoporosis screening in postmenopausal women 50–64 years old: comparison of U.S. Preventive Services Task Force strategy and two traditional strategies in the Women’s Health Initiative. J Bone Miner Res. 2014; Jan 16 [epub ahead of print].
The U.S. Preventive Services Task Force (USPSTF) recommends osteoporosis screening for women younger than 65 years whose 10-year predicted risk of major osteoporotic fracture is 9.3% or greater. For identifying screening candidates among women between the ages of 50 to 65 years, however, it is uncertain how the USPSTF strategy compares with the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE).
Carolyn Crandall, MD, Professor of Medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA, and colleagues examined data from 1994 to 2012 from 5,165 Women’s Health Initiative participants ages 50 to 64 years. Their findings were published in the January 2014 issue of the Journal of Bone and Mineral Research. According to the researchers, the USPSTF strategy would identify only 34% of women who actually had bone mineral density in the osteoporosis range.
For the USPSTF (FRAX major fracture risk ≥ 9.3% calculated without bone mineral density), the OST (score < 2), and SCORE (score > 7) strategies, the researchers assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck T-scores of -2.5 or less. Sensitivity, specificity, and AUC for identifying femoral neck T-scores of -2.5 or less were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX); 79.8%, 66.3%, and 0.73 for OST; and 74%, 70.8%, and 0.72 for SCORE.
“The USPSTF strategy identified about one-third of women ages 50 to 64 years with femoral neck T-scores of -2.5 or less,” the researchers wrote. “Among women ages 50 to 64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without femoral neck T-scores of -2.5 or less.” As a result, the researchers said, following the USPSTF strategy may lead to missed opportunities to decrease fracture risk in at-risk women.
Crandall CJ, Larson J, Gourlay ML, et al. Osteoporosis screening in postmenopausal women 50–64 years old: comparison of U.S. Preventive Services Task Force strategy and two traditional strategies in the Women’s Health Initiative. J Bone Miner Res. 2014; Jan 16 [epub ahead of print].
The U.S. Preventive Services Task Force (USPSTF) recommends osteoporosis screening for women younger than 65 years whose 10-year predicted risk of major osteoporotic fracture is 9.3% or greater. For identifying screening candidates among women between the ages of 50 to 65 years, however, it is uncertain how the USPSTF strategy compares with the Osteoporosis Self-Assessment Tool (OST) and the Simple Calculated Osteoporosis Risk Estimate (SCORE).
Carolyn Crandall, MD, Professor of Medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA, and colleagues examined data from 1994 to 2012 from 5,165 Women’s Health Initiative participants ages 50 to 64 years. Their findings were published in the January 2014 issue of the Journal of Bone and Mineral Research. According to the researchers, the USPSTF strategy would identify only 34% of women who actually had bone mineral density in the osteoporosis range.
For the USPSTF (FRAX major fracture risk ≥ 9.3% calculated without bone mineral density), the OST (score < 2), and SCORE (score > 7) strategies, the researchers assessed sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) to discriminate between those with and without femoral neck T-scores of -2.5 or less. Sensitivity, specificity, and AUC for identifying femoral neck T-scores of -2.5 or less were 34.1%, 85.8%, and 0.60 for USPSTF (FRAX); 79.8%, 66.3%, and 0.73 for OST; and 74%, 70.8%, and 0.72 for SCORE.
“The USPSTF strategy identified about one-third of women ages 50 to 64 years with femoral neck T-scores of -2.5 or less,” the researchers wrote. “Among women ages 50 to 64 years, the USPSTF strategy was modestly better than chance alone and inferior to conventional SCORE and OST strategies in discriminating between women with and without femoral neck T-scores of -2.5 or less.” As a result, the researchers said, following the USPSTF strategy may lead to missed opportunities to decrease fracture risk in at-risk women.
Crandall CJ, Larson J, Gourlay ML, et al. Osteoporosis screening in postmenopausal women 50–64 years old: comparison of U.S. Preventive Services Task Force strategy and two traditional strategies in the Women’s Health Initiative. J Bone Miner Res. 2014; Jan 16 [epub ahead of print].
Irreducible Posterolateral Elbow Dislocation
No Difference in 90-Day Complications Between Bilateral Unicompartmental and Total Knee Arthroplasty
Treatment of Postoperative Infection After Posterior Spinal Fusion and Instrumentation in a Patient With Neuromuscular Scoliosis
Fracture of the Radial Styloid and Concomitant First Dorsal Compartment Musculotendinous Injuries
Acute Host Reaction After Anterior Cruciate Ligament Reconstruction
An Isolated Iliac Wing Stress Fracture in a Marathon Runner
Safety and Usefulness of Free Fat Grafts After Microdiscectomy Using an Access Cannula: A Prospective Pilot Study and Literature Review
Is There a Role for Arthroscopy in the Treatment of Glenohumeral Arthritis?
This issue of The American Journal of Orthopedics focuses on the treatment of shoulder and elbow pathology in 2014. Treatment of shoulder arthritis in young or high-demand patients remains a significant challenge. Total shoulder arthroplasty (TSA) for glenohumeral arthritis can provide excellent pain relief and improved function in elderly, lower demand patients. In younger or higher demand patients, the long-term outcomes are less favorable—failure rates are higher, and revision surgery outcomes are unpredictable. Sperling and colleagues1 reported a survival rate of only 61% for TSA in patients younger than 50 at 10-year follow-up. In addition, postarthroplasty activity restrictions may be unacceptable for these younger, active patients. Concerns about poor shoulder arthroplasty durability and patient expectations of high activity have led to considerations for nonarthroplastic surgical options for shoulder arthritis in this patient population.
Some consider hemiarthroplasty an appropriate treatment option for shoulder arthritis in young patients and in patients who are too active for TSA, as hemiarthroplasty does not involve implantation of a glenoid component. However, compared with TSA, hemiarthroplasty is generally associated with inferior outcomes. Furthermore, when hemiarthroplasty fails and TSA revision becomes necessary, the outcomes of this revision are often inferior to those of primary TSA in the same population. For these reasons, hemiarthroplasty is considered a less optimal option for primary shoulder arthritis.
Biological resurfacing of the glenoid once was an exciting treatment alternative to TSA. Biological resurfacing includes interposition of soft tissue, whether fascia lata,
Achilles tendon, or lateral meniscus allograft, onto the native glenoid with a hemiarthroplasty of the humerus. Initial short-term outcomes of biological resurfacing were encouraging, but midterm outcomes were unsatisfactory, and attempts to reproduce initial published results were unsuccessful. Biological resurfacing has a very limited role now and is largely reserved for patients with localized humeral head articular cartilage loss with minimal involvement of the glenoid. In general, the glenoid remains the most significant treatment challenge in this group, and, other than for “ream and run” procedures, most biological
solutions for the glenoid are seldom used because of technical difficulty, surgical morbidity, and overall high failure rates.
Arthroscopic treatment of shoulder arthritis has emerged as an alternative to shoulder arthroplasty. Originally reported in 1982, initial attempts consisted mostly of arthroscopic joint lavage and loose body removal.2 More recently, arthroscopic procedures for the treatment of shoulder arthritis have been expanded to include extensive joint debridement with synovectomy and circumferential capsular release, chondroplasty, osteophyte excision, and treatment of associated pathology, such as biceps tendinopathy, subacromial bursitis, acromioclavicular arthrosis, and even neurolysis of the axillary nerve.
Published results of shoulder arthroscopy for arthritis are encouraging. In a recent systematic literature review, Namdari and colleagues3 found a clear trend of significant pain relief and improved function after shoulder arthroscopy for arthritis, despite lack of high-level evidence. Millett and colleagues4 reported 85% survivorship at 2-year follow-up for 30 shoulders (23 men, 6 women; mean age,
52 years). Overall, patients reported significant pain relief with daily activities, athletic or work activity, and ability to rest comfortably. Similarly, Van Thiel and colleagues5 reported excellent pain relief and improved validated shoulder and elbow scores at 27-month follow-up. In both studies, patients with severe joint-space narrowing (<2 mm on radiographs) or severe arthritic deformity had
inferior outcomes, but severity of arthroscopic grade of arthritis was not prognostic of clinical outcomes. Chondroplasty and osteophyte excision were shown to be helpful in reestablishing range-of-motion (ROM) and providing pain relief, but larger osteophytes associated with worse glenohumeral arthritis had poorer outcomes. In general, it should be assumed that, if the humeral head shape is preserved, if glenoid wear is concentric, and if the joint space is visible on radiographs, then the patient is likely to have improved pain and function with arthroscopic treatment.
Properly addressing associated shoulder pain generators at time of arthroscopic surgery is important. Patients with significant arthritic stiffness can have prolonged improvement in ROM and function after arthroscopic debridement and circumferential capsular release. Patients with symptoms of biceps tendinopathy should undergo biceps tenodesis or tenotomy. Acromioclavicular joint pain should
receive a distal clavicle excision. Subacromial debridement should be performed for subacromial symptoms, while acromioplasty can be reserved for type III acromion morphology. With careful preoperative evaluation, the clinician should be able to identify all possible pain generators in the arthritic shoulder and address these concomitantly to optimize pain relief and improved function.
In summary, shoulder arthroscopy should be considered a surgical alternative to shoulder arthroplasty in young or high-demand patients with mild to moderate arthritis. Pathology most responsive to shoulder arthroscopy includes shoulder stiffness caused by capsular tightness, chondral lesion less than 2 cm,3 less severe arthritis with preserved humeral head shape, and properly addressed associated
pathology, such as synovitis, biceps tendinopathy, and subacromial bursitis or acromioclavicular arthrosis. Although high-level evidence is lacking, study trends show improved ROM and pain relief and overall high patient satisfaction at short to midterm follow-up. Ultimately, more data are needed to provide precise surgical indications and prognostic factors. Currently, however, it appears that shoulder arthroscopy can play an important role in the treatment of shoulder arthritis and can provide high satisfaction in appropriately selected patients.
References
1. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer
total shoulder arthroplasty in patients fifty years old or less. Long-term
results. J Bone Joint Surg Am. 1998;80(4):464-473.
2. McGinty JB. Arthroscopic removal of loose bodies. Ortho Clin North
Am. 1982;13(2):313-328.
3. Namdari S, Skelley N, Keener JD, Galatz LM, Yamaguchi K. What is the
role of arthroscopic debridement for glenohumeral arthritis? A critical
examination of the literature. Arthroscopy. 2013;29(8):1392-1398.
4. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic
management (CAM) procedure: clinical results of a joint-preserving
arthroscopic treatment for young, active patients with advanced shoulder
osteoarthritis. Arthroscopy. 2013;29(3):440-448.
5. Van Thiel GS, Sheehan S, Frank RM, et al. Retrospective analysis of
arthroscopic management of glenohumeral degenerative disease.
Arthroscopy. 2010;26(11):1451-1455.
This issue of The American Journal of Orthopedics focuses on the treatment of shoulder and elbow pathology in 2014. Treatment of shoulder arthritis in young or high-demand patients remains a significant challenge. Total shoulder arthroplasty (TSA) for glenohumeral arthritis can provide excellent pain relief and improved function in elderly, lower demand patients. In younger or higher demand patients, the long-term outcomes are less favorable—failure rates are higher, and revision surgery outcomes are unpredictable. Sperling and colleagues1 reported a survival rate of only 61% for TSA in patients younger than 50 at 10-year follow-up. In addition, postarthroplasty activity restrictions may be unacceptable for these younger, active patients. Concerns about poor shoulder arthroplasty durability and patient expectations of high activity have led to considerations for nonarthroplastic surgical options for shoulder arthritis in this patient population.
Some consider hemiarthroplasty an appropriate treatment option for shoulder arthritis in young patients and in patients who are too active for TSA, as hemiarthroplasty does not involve implantation of a glenoid component. However, compared with TSA, hemiarthroplasty is generally associated with inferior outcomes. Furthermore, when hemiarthroplasty fails and TSA revision becomes necessary, the outcomes of this revision are often inferior to those of primary TSA in the same population. For these reasons, hemiarthroplasty is considered a less optimal option for primary shoulder arthritis.
Biological resurfacing of the glenoid once was an exciting treatment alternative to TSA. Biological resurfacing includes interposition of soft tissue, whether fascia lata,
Achilles tendon, or lateral meniscus allograft, onto the native glenoid with a hemiarthroplasty of the humerus. Initial short-term outcomes of biological resurfacing were encouraging, but midterm outcomes were unsatisfactory, and attempts to reproduce initial published results were unsuccessful. Biological resurfacing has a very limited role now and is largely reserved for patients with localized humeral head articular cartilage loss with minimal involvement of the glenoid. In general, the glenoid remains the most significant treatment challenge in this group, and, other than for “ream and run” procedures, most biological
solutions for the glenoid are seldom used because of technical difficulty, surgical morbidity, and overall high failure rates.
Arthroscopic treatment of shoulder arthritis has emerged as an alternative to shoulder arthroplasty. Originally reported in 1982, initial attempts consisted mostly of arthroscopic joint lavage and loose body removal.2 More recently, arthroscopic procedures for the treatment of shoulder arthritis have been expanded to include extensive joint debridement with synovectomy and circumferential capsular release, chondroplasty, osteophyte excision, and treatment of associated pathology, such as biceps tendinopathy, subacromial bursitis, acromioclavicular arthrosis, and even neurolysis of the axillary nerve.
Published results of shoulder arthroscopy for arthritis are encouraging. In a recent systematic literature review, Namdari and colleagues3 found a clear trend of significant pain relief and improved function after shoulder arthroscopy for arthritis, despite lack of high-level evidence. Millett and colleagues4 reported 85% survivorship at 2-year follow-up for 30 shoulders (23 men, 6 women; mean age,
52 years). Overall, patients reported significant pain relief with daily activities, athletic or work activity, and ability to rest comfortably. Similarly, Van Thiel and colleagues5 reported excellent pain relief and improved validated shoulder and elbow scores at 27-month follow-up. In both studies, patients with severe joint-space narrowing (<2 mm on radiographs) or severe arthritic deformity had
inferior outcomes, but severity of arthroscopic grade of arthritis was not prognostic of clinical outcomes. Chondroplasty and osteophyte excision were shown to be helpful in reestablishing range-of-motion (ROM) and providing pain relief, but larger osteophytes associated with worse glenohumeral arthritis had poorer outcomes. In general, it should be assumed that, if the humeral head shape is preserved, if glenoid wear is concentric, and if the joint space is visible on radiographs, then the patient is likely to have improved pain and function with arthroscopic treatment.
Properly addressing associated shoulder pain generators at time of arthroscopic surgery is important. Patients with significant arthritic stiffness can have prolonged improvement in ROM and function after arthroscopic debridement and circumferential capsular release. Patients with symptoms of biceps tendinopathy should undergo biceps tenodesis or tenotomy. Acromioclavicular joint pain should
receive a distal clavicle excision. Subacromial debridement should be performed for subacromial symptoms, while acromioplasty can be reserved for type III acromion morphology. With careful preoperative evaluation, the clinician should be able to identify all possible pain generators in the arthritic shoulder and address these concomitantly to optimize pain relief and improved function.
In summary, shoulder arthroscopy should be considered a surgical alternative to shoulder arthroplasty in young or high-demand patients with mild to moderate arthritis. Pathology most responsive to shoulder arthroscopy includes shoulder stiffness caused by capsular tightness, chondral lesion less than 2 cm,3 less severe arthritis with preserved humeral head shape, and properly addressed associated
pathology, such as synovitis, biceps tendinopathy, and subacromial bursitis or acromioclavicular arthrosis. Although high-level evidence is lacking, study trends show improved ROM and pain relief and overall high patient satisfaction at short to midterm follow-up. Ultimately, more data are needed to provide precise surgical indications and prognostic factors. Currently, however, it appears that shoulder arthroscopy can play an important role in the treatment of shoulder arthritis and can provide high satisfaction in appropriately selected patients.
References
1. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer
total shoulder arthroplasty in patients fifty years old or less. Long-term
results. J Bone Joint Surg Am. 1998;80(4):464-473.
2. McGinty JB. Arthroscopic removal of loose bodies. Ortho Clin North
Am. 1982;13(2):313-328.
3. Namdari S, Skelley N, Keener JD, Galatz LM, Yamaguchi K. What is the
role of arthroscopic debridement for glenohumeral arthritis? A critical
examination of the literature. Arthroscopy. 2013;29(8):1392-1398.
4. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic
management (CAM) procedure: clinical results of a joint-preserving
arthroscopic treatment for young, active patients with advanced shoulder
osteoarthritis. Arthroscopy. 2013;29(3):440-448.
5. Van Thiel GS, Sheehan S, Frank RM, et al. Retrospective analysis of
arthroscopic management of glenohumeral degenerative disease.
Arthroscopy. 2010;26(11):1451-1455.
This issue of The American Journal of Orthopedics focuses on the treatment of shoulder and elbow pathology in 2014. Treatment of shoulder arthritis in young or high-demand patients remains a significant challenge. Total shoulder arthroplasty (TSA) for glenohumeral arthritis can provide excellent pain relief and improved function in elderly, lower demand patients. In younger or higher demand patients, the long-term outcomes are less favorable—failure rates are higher, and revision surgery outcomes are unpredictable. Sperling and colleagues1 reported a survival rate of only 61% for TSA in patients younger than 50 at 10-year follow-up. In addition, postarthroplasty activity restrictions may be unacceptable for these younger, active patients. Concerns about poor shoulder arthroplasty durability and patient expectations of high activity have led to considerations for nonarthroplastic surgical options for shoulder arthritis in this patient population.
Some consider hemiarthroplasty an appropriate treatment option for shoulder arthritis in young patients and in patients who are too active for TSA, as hemiarthroplasty does not involve implantation of a glenoid component. However, compared with TSA, hemiarthroplasty is generally associated with inferior outcomes. Furthermore, when hemiarthroplasty fails and TSA revision becomes necessary, the outcomes of this revision are often inferior to those of primary TSA in the same population. For these reasons, hemiarthroplasty is considered a less optimal option for primary shoulder arthritis.
Biological resurfacing of the glenoid once was an exciting treatment alternative to TSA. Biological resurfacing includes interposition of soft tissue, whether fascia lata,
Achilles tendon, or lateral meniscus allograft, onto the native glenoid with a hemiarthroplasty of the humerus. Initial short-term outcomes of biological resurfacing were encouraging, but midterm outcomes were unsatisfactory, and attempts to reproduce initial published results were unsuccessful. Biological resurfacing has a very limited role now and is largely reserved for patients with localized humeral head articular cartilage loss with minimal involvement of the glenoid. In general, the glenoid remains the most significant treatment challenge in this group, and, other than for “ream and run” procedures, most biological
solutions for the glenoid are seldom used because of technical difficulty, surgical morbidity, and overall high failure rates.
Arthroscopic treatment of shoulder arthritis has emerged as an alternative to shoulder arthroplasty. Originally reported in 1982, initial attempts consisted mostly of arthroscopic joint lavage and loose body removal.2 More recently, arthroscopic procedures for the treatment of shoulder arthritis have been expanded to include extensive joint debridement with synovectomy and circumferential capsular release, chondroplasty, osteophyte excision, and treatment of associated pathology, such as biceps tendinopathy, subacromial bursitis, acromioclavicular arthrosis, and even neurolysis of the axillary nerve.
Published results of shoulder arthroscopy for arthritis are encouraging. In a recent systematic literature review, Namdari and colleagues3 found a clear trend of significant pain relief and improved function after shoulder arthroscopy for arthritis, despite lack of high-level evidence. Millett and colleagues4 reported 85% survivorship at 2-year follow-up for 30 shoulders (23 men, 6 women; mean age,
52 years). Overall, patients reported significant pain relief with daily activities, athletic or work activity, and ability to rest comfortably. Similarly, Van Thiel and colleagues5 reported excellent pain relief and improved validated shoulder and elbow scores at 27-month follow-up. In both studies, patients with severe joint-space narrowing (<2 mm on radiographs) or severe arthritic deformity had
inferior outcomes, but severity of arthroscopic grade of arthritis was not prognostic of clinical outcomes. Chondroplasty and osteophyte excision were shown to be helpful in reestablishing range-of-motion (ROM) and providing pain relief, but larger osteophytes associated with worse glenohumeral arthritis had poorer outcomes. In general, it should be assumed that, if the humeral head shape is preserved, if glenoid wear is concentric, and if the joint space is visible on radiographs, then the patient is likely to have improved pain and function with arthroscopic treatment.
Properly addressing associated shoulder pain generators at time of arthroscopic surgery is important. Patients with significant arthritic stiffness can have prolonged improvement in ROM and function after arthroscopic debridement and circumferential capsular release. Patients with symptoms of biceps tendinopathy should undergo biceps tenodesis or tenotomy. Acromioclavicular joint pain should
receive a distal clavicle excision. Subacromial debridement should be performed for subacromial symptoms, while acromioplasty can be reserved for type III acromion morphology. With careful preoperative evaluation, the clinician should be able to identify all possible pain generators in the arthritic shoulder and address these concomitantly to optimize pain relief and improved function.
In summary, shoulder arthroscopy should be considered a surgical alternative to shoulder arthroplasty in young or high-demand patients with mild to moderate arthritis. Pathology most responsive to shoulder arthroscopy includes shoulder stiffness caused by capsular tightness, chondral lesion less than 2 cm,3 less severe arthritis with preserved humeral head shape, and properly addressed associated
pathology, such as synovitis, biceps tendinopathy, and subacromial bursitis or acromioclavicular arthrosis. Although high-level evidence is lacking, study trends show improved ROM and pain relief and overall high patient satisfaction at short to midterm follow-up. Ultimately, more data are needed to provide precise surgical indications and prognostic factors. Currently, however, it appears that shoulder arthroscopy can play an important role in the treatment of shoulder arthritis and can provide high satisfaction in appropriately selected patients.
References
1. Sperling JW, Cofield RH, Rowland CM. Neer hemiarthroplasty and Neer
total shoulder arthroplasty in patients fifty years old or less. Long-term
results. J Bone Joint Surg Am. 1998;80(4):464-473.
2. McGinty JB. Arthroscopic removal of loose bodies. Ortho Clin North
Am. 1982;13(2):313-328.
3. Namdari S, Skelley N, Keener JD, Galatz LM, Yamaguchi K. What is the
role of arthroscopic debridement for glenohumeral arthritis? A critical
examination of the literature. Arthroscopy. 2013;29(8):1392-1398.
4. Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic
management (CAM) procedure: clinical results of a joint-preserving
arthroscopic treatment for young, active patients with advanced shoulder
osteoarthritis. Arthroscopy. 2013;29(3):440-448.
5. Van Thiel GS, Sheehan S, Frank RM, et al. Retrospective analysis of
arthroscopic management of glenohumeral degenerative disease.
Arthroscopy. 2010;26(11):1451-1455.
