Arthroscopic Debridement of Shoulder Osteoarthritis
abstract & commentary
Synopsis: Arthroscopic treatment of shoulder arthritis was effective at improving pain, motion, and function if there was still joint congruity and some joint space remained on an axillary radiograph.
Source: Weinstein DM, et al. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy 2000;16:471-476.
Osteoarthritis (oa) of the shoulder is common, even though it does not occur as frequently as in the hip or knee. In general, realignment or osteotomy techniques offer little compared to the hip or knee, so surgical treatment is limited to arthroscopic debridement or arthroplasty. Few papers in the literature address the outcome of arthroscopic debridement, so Weinstein and colleagues at Columbia Presbyterian analyzed their results with arthroscopic treatment of shoulder OA and tried to determine what characteristics led to better results.
Over a six-year period, Weinstein et al treated 25 patients with an average age of 46 arthroscopically for primary OA of the shoulder. All of the patients had failed at least three months of nonoperative treatment, including nonsteroidal anti-inflammatory drugs (NSAID’s), physical therapy and home exercises, with the average duration from initial visit to surgery being 23 months. No patient had severe loss of joint space with osteophyte formation and loss of concentricity between the humeral head and glenoid, which Weinstein et al considered a contraindication to arthroscopic treatment. Preoperatively, half of the patients had moderate to severe loss of motion, and about one-third had been misdiagnosed with impingement, frozen shoulder, etc., so that OA as the primary problem was only identified arthroscopically.
The operative technique included debridement of unstable chondral fragments or impinging osteophytes, labral tears (5), loose bodies (3), SLAP tears (2), and partial rotator cuff tears (2). A consistent finding was a thickened subacromial bursa that was removed in 23 of 25 patients; however, only two patients underwent acromioplasty. Also, only two patients underwent acromioclavicular (AC) joint resection.
Follow-up averaged 34 months with a minimum of one year. All of the patients experienced some pain relief initially, with 76% maintaining the improvement through final follow-up. Only two of 25 noted the pain had returned to the preoperative level. Ten of the 12 patients with stiffness improved their motion significantly with the procedure, and seven of 13 patients who had given up recreational sports preoperatively were able to resume these after surgery.
Comment by David R. Diduch, MS, MD
The knee literature has numerous articles regarding the expected outcome of arthroscopic debridement or chondroplasty for OA. Results generally show 40-70% improvement, with deterioration of outcome as length of follow-up increases. Prognostic factors that bode for a better result include normal alignment and early degenerative changes. Weinstein et al have effectively looked at their shoulder patients in retrospective fashion to try to determine which patients with OA would be more likely to have a better outcome with arthroscopic debridement, so that we can use their findings prognostically. All of the patients did better initially, and only 24% noted deterioration over time. This is encouraging. Better outcome was associated with less severe degenerative changes, although this did not reach statistical significance. Other factors such as age, gender, duration of symptoms, previous surgery, and radiographic stage did not correlate with the success rate.
What are we to make of these results? It would appear that arthroscopic debridement of shoulder OA offers a good outcome if the degenerative changes are not too advanced. Joint congruity must be preserved as well as some joint space visible on axillary radiograph. Patients are likely to improve their pain and motion and function for a moderate duration. Not doing an acromioplasty with the bursectomy may be important in minimizing the scar formation in the subacromial space and preserving motion. Admittedly, the follow-up in this paper is somewhat short at 34 months, but only one of the patients was worse to the point of going on to arthroplasty and 92% were satisfied with the procedure and would do it again. This is helpful prognostic information in the treatment of the young, active patient with shoulder OA.
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