Recommendations focus on treatment options

Osteoarthritis (OA) of the glenohumeral joint is one of the most common etiologies of shoulder pain. It is more common in women and appears to increase with age. The shoulder is, after the knee and hip, the third most common joint to require surgical reconstruction.

Many different options for treating glenohumeral OA exist. The treatment is dictated by patient age, severity of symptoms, radiographic findings, medical comorbidities, and patient characteristics. Most of the numerous nonsurgical treatment options have been extrapolated from the hip and knee OA literature. The surgical treatment of glenohumeral OA has seen tremendous growth in the last decade, with expanded surgical options and new surgical techniques to address the condition in young patients and to prevent various complications that can be associated with shoulder arthroplasty. Also, the controversy over whether total shoulder arthroplasty or hemiarthroplasty is the better treatment for patients with glenohumeral OA continues to be a hot topic.

Literature abounds, but little evidence is found
Although a large volume of literature exists on the nonsurgical treatment of OA in the hip and knee, questions remain about these treatments as applied to glenohumeral OA. Which ones have been thoroughly studied in the shoulder OA population? Which ones are most effective and have the best evidence supporting their use?

Likewise, when considering surgical treatment, what does the evidence show about the ongoing controversy of the use of hemiarthroplasty versus total shoulder arthroplasty? Does the literature support the use of some of the new procedures and surgical techniques to address glenohumeral OA? Where can orthopaedic surgeons go to review the evidence and apply it to clinical decision making?

To answer these and other questions, the AAOS has begun developing evidence-based clinical practice guidelines (CPGs). The purpose of any CPG is to assist the practitioner and help improve patient treatment by applying the current best evidence in making clinical decisions.

The newest CPG focuses on the treatment of OA of the glenohumeral joint. It is intended for use by orthopaedic surgeons and other qualified practitioners who treat patients with shoulder pain. (See “How the guidelines came to be,” below).

Sixteen recommendations
The CPG on the treatment of glenohumeral OA resulted in 16 recommendations that address nonsurgical treatment options—including physical therapy, pharmacotherapy, injectable corticosteroids, and viscosupplementation—as well a surgical

options such as arthroscopy, open débridement and nonprosthetic/biologic interposition arthroplasty, hemiarthroplasty, and total shoulder arthroplasty (Table 1).

The recommendations also cover treatment options for prevention of complications that can be associated with shoulder arthroplasty (deep vein thrombosis, glenoid loosening, pain associated with biceps disease, subscapularis insufficiency) and postsurgical rehabilitation.

Each recommendation is graded based on the total body of evidence available to recommend for or against the intervention (Table 2). No recommendations received a strong rating, and only one recommendation received a moderate rating.

Four recommendations had weak ratings, and nine recommendations were graded as inconclusive because evidence was insufficient or conflicting. In the absence of reliable evidence, the work group made two recommendations based on consensus, after considering the known harms and benefits associated with the treatment. A link to the summary of the recommendations, the full guideline, and supporting documents can be found on the AAOS Web site at www.aaos.org/guidelines

The work group strongly recommends that practitioners not rely solely on the summary, but that they consult the full guideline and evidence report as well. Treatment decisions for an individual patient depend on the individual patient’s circumstances and mutual communication between the patient and the treating practitioner.

Need for future research
After using evidence-based criteria to develop the guideline, the work group concluded that the quality of the scientific data on the management of the glenohumeral OA can be significantly improved. The fact that none of the recommendations were of strong strength indicates the need for future studies on the effectiveness of various treatment strategies. The role of nonsurgical modalities in the treatment of glenohumeral OA is unclear, and some of the new surgical techniques do not have much support in literature.

In particular, the following areas would benefit from high quality Level I or II studies:

• The role of physical therapy in nonsurgical treatment as well as in postsurgical rehabilitation of glenohumeral OA
• The role of pharmacotherapy in nonsurgical treatment of glenohumeral OA
• The role of injectable cortico-steriods in nonsurgical treatment of glenohumeral OA
• The role of injectable viscosupplementation in nonsurgical treatment of glenohumeral OA
• The role of arthroscopy in the treatment of glenohumeral joint OA
• The role of open débridement, nonprosthetic arthroplasty/interposition graft in the treatment of glenohumeral OA
• The risk of deep venous thrombosis (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

Better studies in these areas would significantly enhance our understanding of treatment options for glenohumeral OA and would enable stronger recommendations to be made in the future. Members of this work group hope that this guideline will identify and highlight the need for better quality studies and stimulate clinical and basic science researchers to address the deficiencies in current literature in the area of treatment for glenohumeral joint OA.

More information about guidelines is available at www.aaos.org/guidelines

Ilya Voloshin, MD, served as vice-chair of the work group that developed the Clinical Practice Guideline on the Treatment of Glenohumeral Joint Osteoarthritis. He reports the following disclosures: Arthrex, Arthrocare, Wyeth. He can be reached at ilya_voloshin@urmc.rochester.edu

How the guidelines came to be
The Clinical Practice Guideline on the Treatment of the Glenohumeral Joint Osteoarthritis, adopted by the AAOS Board of Directors at their December 2009 meeting, was developed by a multidisciplinary volunteer work group that included pediatric orthopaedic surgeons who practice in a variety of settings, along with assistance from the AAOS guidelines unit.

Members included Rolando Izquierdo MD, chair; Ilya Voloshin MD, vice-chair; Sara Edwards, MD; Michael Q. Freehill, MD; Walter Stanwood, MD; J. Michael Wiater, MD; William C. Watters III, MD, chair of the Guidelines and Technology Oversight Committtee (GTOC); Michael J. Goldberg, MD, GTOC vice-chair; Michael Keith, MD, chair of the Evidence Based Practice Committee; Charles M. Turkelson, PhD, director of the AAOS research and scientific affairs department; Janet L. Wies, MPH, manager, clinical practice guideline unit; Sara Anderson, MPH, lead research analyst; Kevin Boyer, Laura Raymond, MA, and Patrick Sluka, MPH, research analysts.

Funding was provided solely by the AAOS. The guideline is based on a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process included a review panel of internal and external committees, public commentaries, and final approval by the AAOS Board of Directors.

The methods used to prepare this guideline were rigorous, employed to minimize bias and to develop a set of reliable, transparent, and accurate clinical recommendations for treating osteoarthritis of the glenohumeral joint. These methods are detailed in the full guideline available at www.aaos.org/guidelines