New glenohumeral osteoarthritis guidelines recommend arthroplasty

Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty in the treatment of patients who have glenohumeral osteoarthritis (GHOA) in the strongest of 16 recommendations in a new evidence-based clinical practice guideline developed by the American Academy of Orthopaedic Surgeons (AAOS). The AAOS guideline is designed to help physicians improve treatment of patients with shoulder pain by applying the best current evidence in making clinical decisions about GHOA.

The surgical management of GHOA has seen tremendous growth in the past decade, according to the AAOS. The surgical options have expanded and there are new techniques to address the condition in young patients and to prevent various complications that may be associated with shoulder arthroplasty. Whether TSA or hemiarthroplasty is the better treatment for patients with GHOA has been controversial. Nonsurgical treatment options in the clinical practice guideline include physical therapy, pharmacotherapy, injectable corticosteroids, and viscosupplementation. Surgical options include arthroscopy, open debridement and nonprosthetic/biologic interposition arthroplasty, hemiarthroplasty, and TSA. The recommendations also cover treatment options for preventing the complications associated with shoulder arthroplasty (eg, deep venous thrombosis [DVT], glenoid loosening, pain associated with biceps disease, and subscapularis insufficiency) and with postsurgical rehabilitation.

Other recommendations in the clinical practice guideline for the treatment of patients with GHOA include the following:
•To reduce immediate postoperative complication rates, avoidance of TSA by surgeons who perform fewer than 2 TSAs per year.
•The use of keeled or pegged all-polyethylene cemented glenoid components when the TSA procedure is performed.
•The use of injectable viscosupplementation.

Because of a poor overall level of quality of evidence in the guideline, the AAOS was unable to recommend whether to use physical therapy or pharmacotherapy for the initial treatment of patients with GHOA or to use injectable corticosteroids. No recommendation was made for or against the use of arthroscopic treatments (eg, debridement, capsular release, chondroplasty, microfracture, removal of loose bodies, biologic and interpositional grafts, subacromial decompression, distal clavicle resection, acromioclavicular joint resection, biceps tenotomy or tenodesis, and labral repair or advancement); open debridement and nonprosthetic or biologic interposition arthroplasty (eg, allograft, biologic and interpositional grafts, and autograft); when TSA is performed, biceps tenotomy or tenodesis, a subscapularis transtendinous approach or a lesser tuberosity osteotomy, or a specific type of humeral prosthetic design or method of fixation; or physical therapy after TSA.

The AAOS work group concluded that the quality of the scientific data on the management of GHOA can be improved significantly and that future studies on the effectiveness of various treatment strategies are needed. The areas that would benefit most from high-quality studies include the following:
•The roles of physical therapy, pharmacotherapy, injectable corticosteroids, and injectable viscosupplementation in nonsurgical treatment of patients with GHOA.
•The roles of arthroscopy, open debridement, and nonprosthetic arthroplasty/interposition graft.
•The risk of DVT after shoulder arthroplasty and the need for DVT prophylaxis.
•The role of the biceps as a potential pain generator after shoulder arthroplasty.
•Surgical techniques for subscapularis repair after shoulder arthroplasty.

The work group strongly recommended that physicians consult the full guideline and evidence report rather than rely solely on the summary. Treatment decisions for a patient should be based on that patient’s specific circumstances and mutual communication between the patient and the treating physician, they noted.

For more information on the GHOA guideline, visit the AAOS Web site at http://www.aaos.org/guidelines. Or, contact the organization at AAOS at 6300 North River Rd, Rosemont, IL 60018-4262; telephone: (847) 823-7186; fax (847) 823-8125.