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Select Surgeons for Shoulder Instability Cautiously

Authors: Bruce Jancin

References: Rheumatology News, March 2004

Abstract
Shoulder stabilization surgery that's performed less than expertly constitutes a major risk factor for subsequent glenohumeral osteoarthritis, Dr. James S. Williams Jr. said at a symposium sponsored by the American College of Rheumatology.

Surgery to stabilize a shoulder prone to dislocation must restore normal joint forces. Too often the surgeon fails to do so, resorting instead to the quick fix of simply overtightening the shoulder, with resultant loss of external rotation.

“There are some of us who do a lot of this type of surgery, and other people who do it once in a while. If my sister dislocates her shoulder, I want her to go to somebody who does a lot of that surgery so she doesn't get overtightened. That can be a real problem,” said Dr. Williams, an orthopedic surgeon with a special interest in sports medicine at the Cleveland Clinic Foundation.

“If you see somebody in your office who has had previous surgery and he or she can't externally rotate even at 30 degrees, that person is going to develop arthritis in that shoulder down the road unless somebody helps get him stretched out anteriorly, either surgically or through physical therapy,” he added.

There is no classic presentation of glenohumeral osteoarthritis. Patients often first notice loss of range of motion. They may experience trouble tucking in their rear shirttail or fastening the back of a bra. Morning stiffness is common.

Pain is a relatively late finding. The nature of the pain, particularly while trying to sleep at night, can be useful in differentiating glenohumeral osteoarthritis from other shoulder pathologies.

“If they change position so that they're not on their shoulder, usually they can sleep. It's very different from impingement or bursitis or rotator cuff tendonitis or a rotator cuff tear; that's kind of a toothache pain that just doesn't let go, and you can't find a comfortable sleeping position,” Dr. Williams explained.

Incidentally, there's no association between rotator cuff injury or shoulder impingement syndrome and subsequent development of glenohumeral osteoarthritis. The pathologies are unrelated, the surgeon said.

Testing the shoulder's range of motion—external and internal rotation and elevation—is most easily done while the patient lies supine. It's important to check cervical range of motion, too, and to obtain a cervical x-ray if it's limited. Patients with glenohumeral osteoarthritis have an increased prevalence of asymptomatic osteoarthritis at C5 through C7, he said.

There's no reason to resort to MRI or CT scans in patients with glenohumeral osteoarthritis. All that's needed are plain films. A true anterior-posterior view is obtained to show the glenohumeral joint space and assess rotator cuff integrity, while an axillary, or West Point, view will demonstrate posterior erosion of the glenoid, Dr. Williams continued.

The natural history of glenohumeral osteoarthritis is gradual loss of range of motion and increasing pain, but there are things a patient can do to slow the process and delay or avoid shoulder replacement surgery. NSAIDs can help combat morning stiffness. Judicious physical therapy based upon x-ray findings can improve pain-free range of motion.

Activity modification is key. Activities that place stress on the shoulder joint, such as racquet sports or pumping iron, accelerate the degenerative process. Much as patients dislike hearing it, they need to give them up.

The jury is still out on the benefits of lubricant injections. A large clinical trial is in progress, but results remain a year and a half away. Cortisone injections are ineffective in patients with glenohumeral arthritis and merely increase risk of infection.

Glucosamine/chondroitin sulfate has anecdotally been of “tremendous benefit” in some of his patients, Dr. Williams said. “To my way of thinking, it really doesn't do any harm, and 30 cents/day to try and slow down arthritis isn't a lot of money to spend.”

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