Clinical Presentation and Evaluation of Glenohumeral Arthritis.
Last updated Thursday, January 27, 2005
Degenerative joint diseasePrimary DJD In degenerative joint disease (DJD), the glenoid cartilage and
subchondral bone are typically worn posteriorly, often leaving intact
articular cartilage anteriorly (see figure 4). The cartilage of the
humeral head is eroded in a "Friar Tuck" pattern of central baldness,
often surrounded by a rim of remaining cartilage and osteophytes.
Degenerative cysts may occur in the humeral head or glenoid.
Osteophytes typically surround the anterior, inferior and posterior
aspects of the humeral head and the inferior and posterior glenoid. As
a result the humeral and glenoid articular surfaces have a flattened
configuration which blocks rotation. Loose bodies are often found in
the axillary or subscapularis recesses. The triad of anterior capsular
contracture, posterior glenoid wear and posterior humeral subluxation
is common in primary degenerative joint disease. Rotator cuff defects
are uncommon in primary degenerative joint disease.Secondary DJD In contrast to primary degenerative joint disease, secondary
degenerative joint disease arises when previous injury, surgery or
other condition affects the joint surface precipitating its
degeneration. In chronic, unreduced dislocations, (Hawkins, Neer,
Pianta, et al., 1987; Pritchett and Clark, 1987; Rowe and Zarins, 1982)
the humeral head may be indented and worn. The cartilage of the joint
surfaces may be replaced with scar, or the subchondral bone may be so
weakened by bone atrophy that it will collapse after reduction, leading
to an incongruous joint surface. Samilson (Samilson and Prieto, 1983)
identified seventy-four shoulders with a history of single or multiple
dislocations that exhibited radiographic evidence of glenohumeral
arthritis. The dislocations had been anterior in sixty-two shoulders,
posterior in eleven, and one had multidirectional instability. The
number of dislocations was not related to the severity of the
arthrosis. Shoulders with posterior instability had a higher incidence
of moderate or severe arthritis, as did shoulders with previous surgery
in which internal fixation devices intruded on the joint surface.
Hawkins and his co-workers (Hawkins, Neer, Pianta, et al., 1987) have
suggested hemiarthroplasty if the dislocation is greater than six
months old or if the humeral head defect involves more than 45% of the
articular surface. If the glenoid is destroyed, a total shoulder
arthroplasty may be indicated.
Tanner and Cofield reviewed twenty-eight shoulders with chronic
fracture problems requiring prosthetic arthroplasty. (Tanner and
Cofield, 1983) Sixteen had malunions with a joint incongruity, eight
had post-traumatic osteonecrosis, and four had nonunion of a surgical
neck fracture with a small, osteopenic head fragment.
Shoulders with secondary degenerative joint disease often present
complex pathology and difficult surgical management. (Huten and Duparc,
1986; Neer and Kirby, 1982) Difficulties may be related to a number of
factors: muscle contracture, scarring, malunion requiring osteotomy,
nonunion, or bone loss, especially humeral shortening. Dines et al
(Dines, Warren, Altchek, et al., 1993) recently reported their results
with shoulder arthroplasty in twenty patients with posttraumatic
changes. They emphasize the difficulty of these cases and the
advisability of avoiding tuberosity osteotomy. Other series of
arthroplasty for late sequellae of trauma include that of Norris et al
(Norris, Green, McGuigan, 1995), Habermeyer and Schweiberer (Habermeyer
and Schweiberer, 1992), and Frich et al (Frich, Sojbjerg and Sneppen,
1991).
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