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Background and Aims: Osteoarthritis (OA) is the world’s most common joint disease and there is currently no cure. Glenohumeral osteoarthritis (GHOA) accounts for an estimated 5%–17% of patients with shoulder complaints. The etiology of GHOA is multifactorial, and we review the various non-specific and specific risk factors and further sub-classify them into local and systemic factors. Materials and Methods: Data for this review article were identified by searches of MEDLINE, PubMed, and references from relevant articles using search terms such as “glenohumeral,” “osteoarthritis,” “epidemiology,” “etiology,” “imaging,” and “pathophysiology.” Only articles published in English, German, and Finnish between 1957 and 2017 were included. Results: The prevalence of radiological shoulder OA has been estimated to be as high as 16%–20% in the middle-aged and elderly population, but the concordance between structural findings and symptoms seems to be weak, as many of these individuals are asymptomatic. The vast majority of GHOA is related to non-specific factors, namely advancing age, while specific risk factors are commonly found in young patients. Diagnosis of GHOA is made when typical clinical features and defined radiological findings overlap in an individual. Conclusion: Conclusion: Ultimately the determinants of shoulder pain in GHOA remain incompletely understood. Improved understanding of the etiology and diagnosis of GHOA will enable clinicians to better determine which patients will benefit from different treatment modalities, as well as provide new avenues to potential treatments.

Background Arthritic glenoids are susceptible to vault perforation during total shoulder arthroplasty. We investigated the effects of glenoid perforation and subsequent cement extrusion on the suprascapular nerve and on the glenoid cement infiltration. Methods Total shoulder arthroplasty using three-pegged glenoid components were performed on 10 cadaveric shoulders assigned to two groups (perforation vs. control). In perforation group, the glenoids were reamed eccentrically and intentionally perforated medially through the central peg hole, whereas control group received perpendicular reaming with no perforation. Bone cement was applied to each peg. Spatial relationship between the extruded cement and the suprascapular nerve, and the amount of cement infiltration into the cancellous bone were evaluated. Results In perforation group, five specimens were perforated anteriorly, and two posteriorly. In the two posteriorly perforated specimens, the suprascapular nerve was in direct contact with extruded cement at the spinoglenoid notch. Perforation group showed significantly less cement infiltration into the cancellous bone than control group ( p = 0.008). Conclusions Glenoid perforation decreases the volume of cement infiltration into the cancellous bone potentially compromising glenoid component fixation. Glenoid perforation tends to occur anteriorly rather than posteriorly in arthritic glenoids; however, if perforation occurs posteriorly, the suprascapular nerve is at immediate risk from the extruded cement. Level of evidence: Basic science study.

BACKGROUND: Return to work after shoulder arthroplasty for glenohumeral osteoarthritis (OA) is an important consideration for an aging workforce. QUESTIONS/PURPOSES: The aim of this study was to compare the shoulder function, pain levels, and rate of return to work in patients treated with anatomic total shoulder arthroplasty (aTSA) versus humeral hemiarthroplasty (HHA). METHODS: A retrospective review of consecutive HHA patients was performed of our institution’s shoulder arthroplasty registry. Inclusion criteria were pre-operative diagnosis of end-stage OA and more than 2 years’ follow-up. HHA patients were statistically matched to aTSA patients and then screened for pre-operative work status; 26 HHA and 23 aTSA patients worked before surgery. There was no difference in average age (HHA, 62.4 years; aTSA, 61.7 years) or follow-up (HHA, 67.5 months; aTSA, 66.9 months). RESULTS: Average American Shoulder and Elbow Surgeons (ASES) scores (HHA, 37.6 to 70.3; aTSA, 35.6 to 80.1) and visual analogue scale (VAS) for pain scores (HHA, 6.1 to 2.3; aTSA, 6.5 to 0.6) improved in both groups. However, HHA patients had worse final VAS scores, and aTSA patients were more satisfied (100% vs 77%); 61.5% of HHA patients returned to work post-operatively versus 87.0% of aTSA patients. There was no difference in time to return to work (HHA, 1.9 ± 2.3 months; aTSA, 1.3 ± 1.0 months). CONCLUSION: Patients with shoulder OA undergoing aTSA have higher rates of return to work, function, and satisfaction than those undergoing HHA. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09692-0) contains supplementary material, which is available to authorized users.

Background Chronic obstructive pulmonary disease patients have been shown in orthopedic literature to have poorer outcomes and higher rates of complications from surgery. In this retrospective review, medical complications, length of stay, and costs were obtained to explore the effects of chronic obstructive pulmonary disease on patients undergoing primary total shoulder arthroplasty. Methods Total shoulder arthroplasty cases from January 2005 to March 2014 were queried and analyzed from a nationwide database. Study patients were matched 1:5 to controls by age, sex, and medical comorbidities associated with chronic obstructive pulmonary disease. In-hospital length of stay, 90-day medical complications, day of surgery, and total global 90-day episode of care costs were obtained for comparison. Results Chronic obstructive pulmonary disease patients were found to have higher incidence and odds (53.91 vs. 11.95%; OR: 3.58, 95%CI: 3.18–3.92, p Discussion Chronic obstructive pulmonary disease patients undergoing primary total shoulder arthroplasty have higher rates of medical complications, in-hospital length of stay, and costs of care. This represents an important factor that will allow orthopedic surgeons to adequately manage expectations and educate chronic obstructive pulmonary disease patients of the potential complications which may occur following total shoulder arthroplasty.

BackgroundWe report functional outcomes at six years in patients with varying degrees of fatty infiltration and atrophy of the rotator cuff muscles who have undergone anatomic total shoulder replacement.MethodsA retrospective analysis of case notes and magnetic resonance imaging scans of patients undergoing total shoulder replacement for primary glenohumeral arthritis was performed. Patients were grouped based upon their pre-operative magnetic resonance imaging findings for fatty infiltration, muscle area and tendinopathy. Post-operative functional outcomes were assessed using the Oxford Shoulder Score and Quick Disabilities of the Arm, Shoulder and Hand score. Post-operative measurements were made for active shoulder movements.ResultsThirty-two patients were reviewed at a mean of 67 months following surgery. All patients demonstrated fatty infiltration on their pre-operative magnetic resonance imaging scan. Muscle atrophy was shown in 22 patients and 12 had tendinopathy. Multiple regression analysis showed no correlation between the Oxford Shoulder Score (p = 0.443), the Quick Disabilities of the Arm, Shoulder and Hand score (p = 0.419), forward flexion (p = 0.170), external rotation (p = 0.755) and any of the pre-operative independent variables.DiscussionThe degree of fatty infiltration, muscle atrophy and tendinopathy of the rotator cuff muscle on pre-operative magnetic resonance imaging scanning is not associated with functional outcome score or functional movement at medium-term follow-up following total shoulder replacement.Level of evidenceIV

Background: Management of anterior shoulder instability (ASI) aims to reduce risk of future recurrence and prevent complications via nonoperative and surgical management. Machine learning may be able to reliably provide predictions to improve decision making for this condition. Purpose: To develop and internally validate a machine-learning model to predict the following outcomes after ASI: (1) recurrent instability, (2) progression to surgery, and (3) the development of symptomatic osteoarthritis (OA) over long-term follow-up. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: An established geographic database of >500,000 patients was used to identify 654 patients aged Results: Of the 654 included patients, 443 (67.7%) experienced multiple instability events, 228 (34.9%) underwent surgery, and 39 (5.9%) developed symptomatic OA. The ensemble gradient-boosted machines achieved the best performances based on discrimination (via area under the receiver operating characteristic curve [AUC]: AUCrecurrence = 0.86), AUCsurgery = 0.76, AUCOA = 0.78), calibration, decision curve analysis, and Brier score (Brierrecurrence = 0.138, Briersurgery = 0.185, BrierOA = 0.05). For demonstration purposes, models were integrated into a single web-based open-access application able to provide predictions and explanations for practitioners and researchers. Conclusion: After identification of key features, including time from initial instability, age at initial instability, sports involvement, and radiographic findings, machine-learning models were developed that effectively and reliably predicted recurrent instability, progression to surgery, and the development of OA in patients with ASI. After careful external validation, these models can be incorporated into open-access digital applications to inform patients, clinicians, and researchers regarding quantifiable risks of relevant outcomes in the clinic.

Background The Walch B3 glenoid is theorized to be a progression of the B2 biconcave pattern. The present study aimed to compare glenoid indices between B2 and B3 patterns. We hypothesized that the B3 pattern would have significantly worse retroversion, inclination and medialization. Methods Computed tomography scans of 50 patients with B2 erosions [mean (SD) age 68 (9) years; 25 male] and 50 patients with B3 erosions [mean (SD) age 72 (8) years; 22 males] were converted into three-dimensional reconstructions. Retroversion, inclination, medialization and humeral head subluxation were compared. Results The data demonstrated no statistically significant differences [mean (SD)] between groups when assessing retroversion: B2 = 21 (8)°, B3 = 24 (7)° ( p = 0.602); glenoid inclination: B2 = 9 (6)°, B3 = 8 (6)° ( p = 0.967); or medialization: B2 = 12 (4) mm, B3 = 14 (4) mm ( p = 0.384). In the B2 group, the mean (SD) humeral head subluxation was 80% (10%) according to the scapular plane and 55% (9%) according to the glenoid plane, which was not statistically different from the B3 group with a mean (SD) humeral head subluxation of 81% (7%) according to the scapular plane ( p = 0.680) and 54% (7%) according to the glenoid plane ( p = 0.292). Conclusions These results demonstrated no significant differences between the B2 and B3 erosion patterns, with respect to the glenoid indicies measured. The aetiology of the B3 glenoid cannot be completely explained by progression of wear in a B2 glenoid.

Background: Patient selection is critical when choosing between arthroscopic joint preservation and total shoulder arthroplasty in young patients with glenohumeral osteoarthritis (GHOA). Purpose: To identify prognostic factors predictive of early failure in patients undergoing comprehensive arthroscopic management (CAM) for GHOA. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 107 shoulders in 98 patients with minimum 2-year follow-up who underwent CAM were identified and evaluated. All shoulders met clinical and radiographic criteria for total shoulder arthroplasty (TSA), but the patients opted for joint preservation with arthroscopic management. Radiographic and preoperative factors were analyzed to determine predictors of early failure, defined as progression to TSA within the study period. Results: There were 72 men and 26 women with a mean age of 52 years (range, 29-77 years). Seventeen (15.8%) of 107 shoulders progressed to TSA at a mean of 2 years (range, 0.46-8.2 years). Shoulder status for the rest had a mean follow-up of 3.9 years (range, 2-9.4 years). There were a number of radiographic features that were correlated with early failure. Patients who failed had significantly less preoperative joint space than did those who succeeded (1.3 vs 2.6 mm; P = .004). Higher Kellgren-Lawrence grades for osteoarthritis and age older than 50 were also associated with failure. Shoulders with Walch type B2 and C glenoid were significantly more likely to fail than were Walch types A1, A2, and B1 ( P < .05). Conclusion: The CAM procedure has been shown to reliably improve pain and function in active patients with advanced GHOA; however, it is important to inform patients about the limitations of the procedure. Patients with less joint space and abnormal posterior glenoid shape were significantly more likely to progress to early failure.

A thorough assessment and understanding of glenoid morphology is critical prior to shoulder arthroplasty for primary glenohumeral osteoarthritis. This is due to the fact that multiple studies have demonstrated the importance of reestablishing the native glenoid anatomy on the long-term survivability of the polyethylene glenoid component. In 1999, Walch et al. created a classification system for primary glenohumeral osteoarthritis based upon glenoid erosion and retroversion, and humeral head posterior subluxation. Since its original publication, the Walch classification has been the most widely used classification system for primary glenohumeral arthritis. However, after its initial publication in 1999, additional modifications have been made to the classification to clarify various definitions as well as further characterize other glenoid morphopathology seen in primary glenohumeral osteoarthritis. This article will discuss the original and modified Walch classification, the key differences between the two and the importance of these differences on the classification of the “B2 glenoid.”

BackgroundCementless surface replacement hemiarthroplasty (CSRHA) is an established treatment for glenohumeral osteoarthritis; however, studies evaluating its role in arthritis with rotator cuff deficiency are limited. This study reviews the outcomes of CSRHA for glenohumeral osteoarthritis with and without rotator cuff tears.Methods41 CSRHA (Mark III Copeland prosthesis) were performed for glenohumeral osteoarthritis with intact rotator cuffs ( n = 21) and cuff-deficient shoulders ( n = 20). Patients were assessed using Oxford and Constant questionnaires, patient satisfaction, range of motion measurements and by radiography.ResultsMean age and follow-up were 75 years and 5.1 years, respectively. Functional gains were significantly higher in patients with intact rotator cuffs compared to cuff-deficient shoulders, with Oxford Shoulder Score improving from 18 to 37.5 and 15 to 27 and forward flexion improved from 60° to 126° and 44° to 77° in each group, respectively. Two patients with deficient cuffs had deficient subscapularis tendons; one of which was dislocated anteriorly.ConclusionsCSRHA provides significant improvements in pain and function in patients with glenohumeral osteoarthritis. In patients with deficient cuffs, functional gains are limited, and should be considered in low-demand patients where pain is the primary problem. Caution should be taken in patients with a deficient subscapularis as a result of the risk of dislocation.

Background Shoulder osteoarthritis is characterized by progressive wear of the joint. To grade the degree of joint deformity, the Walch classification of glenohumeral arthritis has been proposed. This classification is based on five categories (A1, A2, B1, B2, C), although its validity has been questioned. Methods The present study proposed a new classification in three categories and compared it in terms of inter- and intra-observer reliability with the complete Walch classification and regroup classification (A, B, C). Results One hundred and sixteen computed tomography scans of patients with shoulder arthritis were revised by three independent evaluators and were classified according to the three classifications. The kappa statistics were identical between the new classification and the complete Walch classification (0.87 and 0.874). The regroup Walch classification (A, B, C) demonstrated higher reliability (kappa = 0.92). Most of the disagreement between observers was observed between glenoid B1 and B2. Discussion We report the first study on the Walch classification to use a large number of patients and challenge its reliability. According to the results obtained, there is no advantage in changing the classification. Therefore, surgeons must be aware of higher risk of mistake for glenoid type B. The superiority of a classification in terms of the prediction of surgical decisions and outcome has to be determined.

The development of degenerative joint disease in the young active patient is an increasing and difficult problem. In this review, evidence for the role of nonoperative and operative treatment strategies is assessed with the objective of establishing guidelines for management, and identifying areas for future research. Glucosamine and chondroitin supplements, as well as steroid and hyaluronan injections are probably useful early in the disease. Arthroscopic debridement, capsular release, and microfracture are temporizing measures that can provide pain relief and defer more invasive surgery. Attempts to restore the cartilage surface with osteochondral autologous transplants or autologous chondrocyte implantation may be suitable as second-line therapy for focal defects, although resurfacing of more extensive lesions with biological membranes has proven more difficult. Because prosthetic arthroplasty is relatively contraindicated in young patients, particularly contact athletes, the search for an ideal solution remains elusive, and more clinical and basic science research is needed.

Objectives: We previously reported clinical improvement and pain relief following arthroscopic management of glenohumeral osteoarthritis (GHOA) at 2 years. The purpose of this study was to determine 5 year survivorship for the comprehensive arthroscopic management (CAM) procedure for the treatment of GHOA. Methods: This study had prior IRB approval. The CAM procedure was performed on a consecutive series of 42 young patients (44 shoulders) with GHOA who otherwise met criteria for shoulder arthroplasty but instead opted for joint preservation. The procedure included glenohumeral chondroplasty, capsular release, and synovectomy, humeral osteoplasty, axillary nerve neurolysis, subacromial decompression, loose body removal, microfracture and biceps tenodesis. Only patients who were a minimum of 5 years out from surgery were included in the study. Patients completed a subjective questionnaire, and further surgical intervention of the index shoulder was noted for survivorship analysis. Failure was defined as progression to TSA. Kaplan Meier survivorship analysis was performed. Results: Forty-two patients (with 44 shoulders) underwent a CAM procedure between 1/2006-12/2009 and were included. All patients were self-described recreational athletes. Seven patients were former collegiate or professional athletes. Mean follow-up was 5.9 years (range, 5 years to 8.1 years). Mean age at surgery was 52 (range 27- 68) years old in 13 women and 29 men. Eleven shoulders (26%) failed and progressed to TSA at a mean of 2.9 years (1.0-5.4 years). Shoulder status (progression to TSA or not) at minimum 5 years (range 5.3 - 9.4 years) was known for 95% (42/44). One patient progressed to another surgery for stiffness at a mean of 5.6 months and another patient underwent a revision CAM procedure at 7.9 years. From this cohort, Kaplan Meier survivorship was 92% at 1 year, 85.7% at 3 years, and 75.3% survivorship at 5 years. Conclusion: The long term durability of arthroscopic management for symptomatic GHOA is not well studied. Glenohumeral debridement and capsular release may not be enough to address all the pain generating pathology in the osteoarthritic shoulder. After the CAM procedure we found an 84% survivorship at 3 years and 72% survivorship at 5 years. Predictors of success were not known in the early years for this patient cohort. We have since found that factors such as joint space > 2 mm, glenoid morphology (A1, A2, B1) and CSA > 30o are associated with better outcomes. The 72% survivorship at 5 years demonstrated in this study can serve as a benchmark. Hopefully, with better patient selection, excluding those with negative predictive factors, outcomes and survivorship after the CAM procedure for GHOA can be improved.

Background: Return to activity is a commonly used indication for shoulder hemiarthroplasty (HA) compared with total shoulder arthroplasty (TSA). Despite clinical studies demonstrating better functional outcomes after TSA, the literature has failed to show a difference in return to sports. Purpose: To compare rates of return to sports in a matched cohort of TSA and HA patients with a preoperative diagnosis of glenohumeral osteoarthritis (OA). Study Design: Cohort study; Level of evidence, 3. Methods: A prospectively collected registry was queried retrospectively for consecutive patients who underwent HA. Inclusion criteria were preoperative diagnosis of OA and more than 2 years of follow-up. After meeting the inclusion criteria, all HA patients were statistically matched to a TSA patient. All patients had end-stage OA with significant glenohumeral joint space narrowing. Results: At final follow-up, 40 HA patients and 40 TSA patients were available. The average (±SD) age at surgery was 65.7 ± 10.5 years and 66.2 ± 9.6 years for the HA and TSA groups, respectively ( P = .06). Average follow-up was 62.0 months and 61.1 months for the HA and TSA groups, respectively ( P = .52). Average American Shoulder and Elbow Surgeons scores improved from 36.3 to 70.2 for HA patients and from 34.0 to 78.5 for TSA patients ( P < .001 for both); final scores were not significantly different between groups ( P = .21). Average visual analog scale pain scores improved from 6.3 to 2.2 for HA patients and from 6.1 to 0.6 for TSA patients ( P < .001 for both). HA patients had significantly worse final visual analog scale scores compared with the TSA group ( P = .002). Significantly more TSA patients were satisfied with their surgery compared with HA patients (100% vs 70%) ( P = .01). Of both groups, 65.5% of HA patients (19 of 29) returned to at least 1 sport postoperatively compared with 97.3% of TSA patients (36 of 37) ( P < .001). Average timing for return to full sports was 5.5 ± 4.2 months and 5.4 ± 3.1 months for the HA and TSA groups, respectively ( P = .92). Significantly more TSA patients returned to higher upper extremity use sports ( P = .01). Conclusion: In patients with OA, rate of return to sports was significantly better after TSA compared with HA. HA patients had significantly more pain, worse surgical satisfaction, and decreased ability to return to high upper extremity use sports. For patients with OA who wish to return to sporting activities, these results help manage expectations.

Mr Davies and his colleagues conclude that, in a patient with Cushing's disease or avascular necrosis (AVN) at other sites, shoulder symptoms when crutch walking ‘should be enquired about and investigated radiographically’ (July 2001 JRSM, pp. 348-349). Crutch walking has wider relevance to AVN. In 1983 I reported the cases of two perhaps osteoporotic but otherwise healthy women aged 73 and 59 who developed AVN of the humeral head as a result of crutch walking following isolated femoral neck fracture treated by internal fixation1. In both cases the condition was self-limiting and in one it was detected only as a result of full examination for medicolegal purposes seven months after the injury. I presented also a third patient who had used a walking aid in the right hand for over 10 years after unsuccessful hip replacement and who had developed glenohumeral osteoarthritis, the appearances of which were suggestive of previous aseptic necrosis. I suggested that the condition probably was more common than appreciated because in those who use crutches for a limited period the symptoms were low-grade and spontaneous resolution takes place. With prolonged crutch walking, however, the condition might lead to glenohumeral osteoarthritis. Some support for this view was provided by a later paper reporting bilateral osteonecrosis of the humeral heads in a wheelchair-dependent T8 paraplegic2.