What is the treatment approach for a degenerative glenoid rim?

Treatment Approach for Degenerative Glenoid Rim

Total shoulder arthroplasty (TSA) is recommended over hemiarthroplasty for patients with degenerative glenoid rim when conservative treatments have failed. 1

Initial Conservative Management

• Injectable viscosupplementation is an option for treating glenohumeral osteoarthritis (GH OA) with degenerative glenoid rim (Grade C recommendation, Level IV evidence) 1
• Viscosupplementation typically involves three weekly injections of hyaluronic acid preparations, with studies showing improvements in pain scores and function at 1,3, and 6 months after treatment 2
• There is insufficient evidence to support or refute the use of intra-articular corticosteroid injections for GH OA (Grade I recommendation, Level V evidence) 1
• Physical therapy focusing on rotator cuff strengthening and proprioceptive control should be the initial management for patients with glenoid dysplasia and instability symptoms 3

Surgical Management Algorithm

Step 1: Evaluate Patient Factors

• Age: Concern exists about performing shoulder arthroplasty in patients <50 years due to potential risks of increased prosthetic loosening and decreased survivorship 4, 2
• Severity of degeneration: Assess the extent of glenoid bone loss and retroversion using CT or MRI 3

Step 2: Consider Arthroscopic Options for Early Disease

• The evidence is insufficient to recommend for or against arthroscopic treatments for GH OA (Grade I recommendation, Level V evidence) 1
• Arthroscopic options may be considered for younger patients with early-stage OA who may not be candidates for arthroplasty 2
• For acute antero-inferior glenoid rim fractures, arthroscopic repair with ligamentotaxis technique can be effective 5

Step 3: Arthroplasty for Advanced Disease

• TSA and hemiarthroplasty are both options for treating GH OA (Grade C recommendation, Levels IV and V evidence) 1
• TSA is suggested over hemiarthroplasty (Grade B recommendation, Level II evidence) as it provides better outcomes in terms of pain relief, function, and quality of life 1, 2
• Hemiarthroplasty may be appropriate when the glenoid is naturally concentric or can be reamed to concentricity 2
• When performing TSA, keeled or pegged all-polyethylene cemented glenoid components are recommended 2
• In cases of severe glenoid bone loss, three-dimensional CT imaging and preoperative planning are essential to determine the optimal management strategy 6

Step 4: Management of Specific Scenarios

• For patients with GH OA and irreparable rotator cuff tear, TSA is not recommended (Consensus recommendation, Level V evidence) 1
• For severe glenoid dysplasia with bone deficiency and retroversion, bone grafts placed in a congruent position may decrease the risk of arthritis development 3
• In cases of posterior subluxation with glenoid deficiency, a bone block may be needed to augment reconstruction 7

Important Considerations and Pitfalls

• Surgeon experience is crucial: Surgeons who perform fewer than two shoulder arthroplasties per year should avoid performing these procedures to reduce immediate postoperative complications 2
• The quality of scientific data on management of GH OA is limited, with none of the recommendations receiving Grade A ratings 2
• There is insufficient evidence to recommend for or against a specific type of humeral prosthetic design or method of fixation when performing shoulder arthroplasty in GH OA (Grade I recommendation, Level V evidence) 1
• There is insufficient evidence to recommend for or against physical therapy following shoulder arthroplasty 1
• The combination of bone deficiency and retroversion in severe glenoid dysplasia makes glenoid osteotomy extremely challenging 3

By following this algorithm, clinicians can provide appropriate treatment for patients with degenerative glenoid rim, prioritizing conservative management initially and progressing to surgical options when necessary, with TSA being the preferred surgical approach for advanced disease.