# Study Guide: Management of Glenohumeral Joint Osteoarthritis This study guide is based on the Evidence-Based Clinical Practice Guideline for the Management of Glenohumeral Joint Osteoarthritis, published by the American Academy of Orthopaedic Surgeons (AAOS) in 2020. It synthesizes current evidence and consensus-based clinical opinions regarding diagnostic and treatment strategies. --- ## Part 1: Key Concepts and Systematic Recommendations ### Overview of Glenohumeral Joint Osteoarthritis (GJO) * **Etiology:** Characterized by progressive loss of humeral head cartilage, adaptive changes to subchondral bone, and the development of inferior humeral head osteophytes. These changes lead to joint space narrowing, posterior humeral head subluxation, and progressive posterior glenoid bone loss. * **Epidemiology:** GJO is more common in women and increases in prevalence with age, particularly in patients over 60. Radiographic data shows a prevalence of 94% in women and 85% in men over the age of 80. * **Burden of Disease:** In 2016, a mean of 66,185 patients were discharged from U.S. hospitals with a primary diagnosis of GJO, with an average hospital charge of $64,332 per encounter. ### Summary of Graded Recommendations The AAOS assigns strength levels to recommendations based on the quality of available evidence. | Intervention/Factor | Strength | Summary of Finding | | :--- | :--- | :--- | | **Hyaluronic Acid (HA)** | **Strong** | Strong evidence supports that there is no benefit to using HA for GJO treatment. | | **Total Shoulder Arthroplasty (TSA)** | **Strong** | Anatomic TSA demonstrates better function and pain relief in short- to mid-term follow-up compared to hemiarthroplasty. | | **BMI** | **Strong** | Obese patients do not experience an increase in early post-operative complications compared to non-obese patients. | | **Gender/Sex** | **Strong** | Gender/sex is not associated with better or worse post-operative outcomes. | | **Comorbidities** | **Strong** | Patients with higher numbers of comorbidities experience higher rates of early post-arthroplasty complications. | | **Glenoid Components (Pegged/Keeled)** | **Strong** | Clinicians may use either; pegged components show fewer radiolucent lines, but clinical outcome differences are unclear. | | **Age** | **Moderate** | Older age at the time of surgery is associated with lower revision rates. | | **Smoking** | **Moderate** | Smoking is associated with inferior post-operative outcomes. | | **Pre-operative Function** | **Moderate** | Patients with higher pre-operative function may experience less functional improvement than those with lower baseline function. | | **Depression** | **Moderate** | Depression is associated with inferior post-operative outcomes. | | **Metal-Backed Glenoids** | **Moderate** | Surgeons should not use metal-backed cementless glenoid components. | | **Subscapularis Management** | **Moderate** | Surgeons can utilize subscapularis peel, lesser tuberosity osteotomy, or tenotomy during arthroplasty. | --- ## Part 2: Consensus Statements (No/Conflicting Evidence) In instances where reliable evidence is absent, the guideline provides recommendations based on the clinical opinion of the workgroup. * **Physical Therapy (PT):** May benefit select patients pre-operatively and is recommended for patients following shoulder arthroplasty. * **Injectable Biologics:** Stem cells or platelet-rich plasma cannot be recommended for GJO treatment due to a lack of evidence. * **Alternative Treatments:** The workgroup cannot recommend for or against acupuncture, dry needling, cannabis/CBD, capsaicin, shark cartilage, glucosamine/chondroitin, cupping, or TENS. * **Opioids:** Opioids should not be prescribed for routine, long-term pain management of GJO. * **Surgical Techniques:** * **Anatomic vs. Reverse TSA:** Either may be used for GJO in select patients with excessive glenoid bone loss or rotator cuff dysfunction. * **Tranexamic Acid (TXA):** May be used to reduce blood loss and transfusion risk during shoulder arthroplasty. * **Same-Day Discharge:** An option for select patients after shoulder arthroplasty. * **Pain Management:** Multimodal pain management or non-opioid individual modalities provide added benefits for post-operative recovery. --- ## Part 3: Short-Answer Practice Quiz **Q1: What is the primary finding regarding the use of Hyaluronic Acid for GJO?** *Answer:* Strong evidence supports that there is no clinical benefit to using Hyaluronic Acid for the treatment of glenohumeral joint osteoarthritis. **Q2: How does a high Body Mass Index (BMI) impact early post-operative complications in shoulder arthroplasty for GJO?** *Answer:* Strong evidence suggests that obese patients do not experience an increase in the rate of early post-operative complications compared to non-obese patients. **Q3: Which surgical option is preferred for short- to mid-term pain relief and function: Anatomic TSA or Hemiarthroplasty?** *Answer:* Anatomic Total Shoulder Arthroplasty (TSA) is preferred as it demonstrates more favorable function and pain relief. **Q4: What is the relationship between patient age at the time of surgery and revision rates?** *Answer:* Moderate evidence indicates that older age at the time of surgery is associated with lower revision rates. **Q5: Should surgeons use metal-backed cementless glenoid components? Why or why not?** *Answer:* No. Moderate evidence supports that surgeons should not use metal-backed cementless glenoid components. **Q6: What effect does smoking have on post-operative outcomes for GJO?** *Answer:* Smoking is associated with inferior post-operative outcomes (Moderate recommendation). **Q7: Is there a specific protocol for imaging patients with GJO undergoing arthroplasty?** *Answer:* Based on consensus, patients should be imaged with axillary and true AP (Grashey view) radiographs, with advanced imaging at the clinician's discretion. **Q8: What is the consensus on the use of opioids for GJO management?** *Answer:* Opioids should not be prescribed for routine or long-term management of glenohumeral osteoarthritis. --- ## Part 4: Essay Questions for Deeper Exploration 1. **Prognostic Indicators in Arthroplasty:** Discuss how pre-operative factors such as smoking, depression, and medical comorbidities influence the success of shoulder arthroplasty. Compare the strength of evidence for each of these factors according to the 2020 AAOS guidelines. 2. **Surgical Selection and Glenoid Fixation:** Analyze the evidence regarding glenoid component selection. Specifically, contrast the clinical findings for pegged versus keeled components and explain the guideline's stance on metal-backed cementless components. 3. **Non-Surgical Management Paradigms:** Evaluate the recommended non-surgical treatment path for a patient with GJO. Include a discussion on the role of physical therapy, the lack of efficacy for hyaluronic acid, and the consensus on injectable biologics. 4. **Advancements in Perioperative Care:** Describe the consensus-based recommendations for modern perioperative management of shoulder arthroplasty patients, focusing on Tranexamic Acid (TXA), multimodal pain management, and same-day discharge criteria. --- ## Part 5: Glossary of Important Terms * **Anatomic Total Shoulder Arthroplasty (TSA):** A surgical procedure where the glenoid and humeral head are replaced with prosthetic components that mimic normal anatomy. * **Bicep Tenodesis/Tenotomy:** Surgical procedures involving the long head of the biceps tendon, often performed concomitantly with shoulder arthroplasty to alleviate pain. * **Consensus Recommendation:** A recommendation based on the clinical opinion of the expert workgroup in the absence of reliable or consistent scientific evidence. * **Glenohumeral Joint Osteoarthritis (GJO):** A degenerative joint disease of the shoulder characterized by cartilage loss, bone changes, and functional decline. * **Grashey View:** A "true" anterior-posterior (AP) radiograph of the shoulder that provides a clear view of the glenohumeral joint space. * **Hemiarthroplasty:** A surgical procedure where only the humeral head is replaced, leaving the native glenoid intact. * **Lesser Tuberosity Osteotomy:** A surgical technique used during shoulder arthroplasty to gain joint exposure by detaching a small piece of bone where the subscapularis tendon inserts. * **Multimodal Pain Management:** The use of multiple types of pain-relief medications (e.g., non-opioid modalities) to improve post-operative recovery and reduce opioid dependence. * **Radiolucent Lines:** Lines visible on an X-ray that may indicate a lack of perfect integration or potential loosening between a prosthetic component and the bone. * **Reverse Total Shoulder Arthroplasty (RTSA):** A procedure where the ball-and-socket configuration of the shoulder is reversed, often used for patients with significant rotator cuff dysfunction or complex bone loss. * **Tranexamic Acid (TXA):** A medication used during surgery to reduce blood loss and decrease the likelihood of needing a blood transfusion.