Management of

Glenohumeral Arthritis
Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Postoperative rehabilitation
Figure 57

Figure 58

Continuous passive motion

Rehabilitation is started immediately following surgery in the recovery room with the
initiation of slow and gentle continuous passive motion (see figure 57).

For patients who have had an interscalene block prior to surgery this early motion is pain free.
Continuous passive motion (CPM) should be stopped and the wrist brace removed every two
to three hours for approximately 15 - 20 minutes to relieve any skin and nerve compression. A
sling is worn between exercise sessions until active muscle control is regained.

The patient-conducted rehabilitation program is started the day of surgery under the
instruction of the surgeon or therapist. While the program may vary with the details of the
surgery performed (see footnote 1), the following is a description of the basic program for
shoulder arthroplasty. The stretching exercises include

1. elevation
2. external rotation limited to 40 degrees
3. internal rotation
4. cross body adduction
5. grip strengthening
6. elbow range of motion
7. external rotator isometrics, and
8. anterior, middle and posterior deltoid isometrics.

The patient is instructed to perform a total of five exercise sessions spread evenly throughout
the day both while in the hospital as well as at home following discharge.
Charts are placed on the wall in full view from the patient's bed to graph the progress of
external rotation and elevation (see figure 58) as measured by the surgeon or therapist. This
provides positive feedback for rehabilitative progress.

For the routine arthroplasty, the range of motion goals to be achieved before discharge are
140 degrees of elevation, 40 degrees of external rotation, and functional internal rotation and
cross body adduction. These goals may be modified according to the specific surgical
procedure. Because the desired range has been achieved on the operating table, the patients'
task is simplified, they have only to maintain this range during the post operative period.
Exercises

Elevation (overhead reach) is performed in the supine Figure 59

position (lying flat on the back), grasping the wrist or
elbow of the operative shoulder with the hand of the
unoperated arm, pulling up toward the ceiling and
reaching overhead as high as possible to the goal of
140 degrees with the arm relaxed (see figure 59). A
pulley or the forward lean (see figure 60) may also be
useful in achieving elevation, especially if the
opposite shoulder is involved.

External Rotation (rotation away from the body) is

Figure 60
performed in the supine position (see figure 61), the
operative side elbow held against or close to the side
and flexed to 90 degrees. A stick is held in both hands
so that the unaffected extremity pushes on the
operative arm to externally rotate it to the goal of 40
degrees. Holding on to a door and turning away is
another useful way to stretch external rotation (see
figure 62).

Internal Rotation is performed by grasping the wrist

of the relaxed involved arm with the non-operative
side hand, the hands are lifted up the back as high as
possible. A towel can also be used to assist with
pulling the involved arm into internal rotation behind
the back (see figure 63).
Figure 61
Cross Body Adduction is performed sitting or
standing, grasping the elbow of the involved arm with
the other hand. The involved arm is relaxed with the
elbow extended and pulled across the body until a
stretch is felt (see figure 64).

Active Elbow Motion is performed standing in order

to allow unimpeded or unrestricted flexion/extension
and supination/pronation.

Grip Strengthening is performed to maintain forearm

tone and can be accomplished using a foam pad or
tennis ball.

External Rotator Isometrics are performed with the

forearm at neutral rotation. An attempt is made to Figure 62
move the wrist out to the side against the resistance of
the other hand or a fixed object (see figure 65).

Deltoid Isometrics are also performed standing or

sitting. The arm is held in a neutral position and
pushed forward, to the side and to the back to exercise the anterior, middle, and posterior
deltoid respectively.

Supine Presses are performed initially holding a cloth or stick between both hands with the
hands held close together (see figure 66). From a starting position with the elbows bent and
hands lying across the chest, the stick is pushed straight to the ceiling with both hands in a
slow and controlled manner and then slowly lowered back to the resting position at the chest.
The space between the two hands is progressively increased. As the shoulder becomes
stronger, the hands are pushed to the ceiling in a slow and controlled manner independent of
each other. With increasing strength, the exercise is conducted with a one pound weight
which is held in the involved hand as it is pressed to the ceiling. When that is comfortable the
incline is gradually increased to eventually reach the upright position. All presses should be
performed in a slow and controlledmanner; they are progressed to the next level only when 20
repetitions can be performed comfortably.

The patient is instructed in all these exercises on three occasions:

1. Prior to surgery,
2. Immediately after surgery, and
3. Prior to leaving the hospital. Before discharge, the goals of assisted external rotation to
40 degrees and assisted elevation to 140 degrees must be accomplished.

The patient is placed in charge of their own rehabilitation and taught to progressively return to
normal use of the shoulder. Typically, keyboarding and driving are achieved at two weeks,
swimming is started at six weeks, golf or tennis are started at three-six month and chopping
wood is precluded.

Footnotes

Footnote 1: For example if tuberosity or cuff fixation has been part of the procedure, external
rotation isometrics and active elevation may be delayed.

Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated August 27, 2001

Results
Hemiarthroplasty results

The results for the Neer design of hemiarthroplasty have been reported for osteonecrosis,
osteoarthritis, rheumatoid arthritis, and the residuals of trauma. When this procedure is
applied to the treatment of proximal humeral osteonecrosis, the pain relief has been quite
good, ranging from 91 to 100 per cent, and the range of motion of the shoulder approaches
normal. When this operation is applied to patients with rheumatoid arthritis, osteoarthritis, or
the residuals of trauma, satisfactory pain relief is less consistently achieved but, with the
exception of 3 of the 11 reported series, is still quite acceptable. Range of motion in these
latter patients tends to be less and is variable from series to series; average active abduction
ranged from one-third to three-quarters normal.

Total shoulder arthroplasty results

The most commonly used total shoulder arthroplasty has been the Neer design. Most patient
series contain a mixed diagnostic grouping, including patients with rheumatoid arthritis,
osteoarthritis, old trauma, and a variety of less common diagnostic categories. As can be seen
from the table, the percentage of patients achieving satisfactory pain relief is quite high, and,
quite typically, slightly greater than 90% of patients report no or only slight pain following
surgery. Motion data following surgery have not been as consistently reported as one might
desire, but the amount of motion regained seems variable and dependent on diagnostic
category. For example, in the series reported by Cofield, the mean active abduction following
surgery for the entire group of patients reported was 120 degrees. (Cofield, 1984) The average
return of active abduction varied greatly according to diagnosis: 141 degrees for osteoarthritis,
109 degrees for those with post-traumatic arthritis, and 103 degrees for patients with
rheumatoid arthritis. The return of movement in Cofield's series was not only dependent on
diagnosis but was also highly dependent on the condition of the rotator cuff and shoulder
capsule and on the avoidance of complications. (Cofield, 1984)

The largest series of total shoulder arthroplasties of this category has been reported by Neer.
(Neer, Watson and Stanton, 1982) He has suggested two systems for grading results. Patients
who received a full rehabilitation program were graded as excellent, satisfactory, or
unsatisfactory. To achieve an excellent result, the patient was enthusiastic about the operation,
had no significant pain, could use the arm without limitations, strength approached normal,
active elevation of the arm was within 35 degrees of the opposite normal side and external
rotation was 90 per cent of the normal side. In patients with a satisfactory result, there was no
more than occasional pain or aching with weather changes, good use of the shoulder for daily
activities, elevation of at least 90 degrees, and rotation to 50% of the normal side. Muscle
strength was at least 30% of the normal side, and the patients expressed satisfaction with the
operation. In an unsatisfactory result, the above criteria were not achieved. Neer has
suggested a separate evaluation category for patients who have total shoulder replacement but
whose muscles could be classified as detached and not capable of recovering function after
repair because of fixed contracture or denervation. Patients with substantial bone loss,
particularly bone loss in the proximal humerus, might also be included within this evaluative
category. In this setting, rehabilitation is aimed at achieving limited goals, the purpose being
to gain a lesser range of motion but maintain stability. Neer has suggested that this limited-
goals rehabilitation is successful when patients with these muscle or bone deficiencies achieve
90 degrees of elevation and 20 degrees of external rotation, maintain reasonable stability, and
achieve satisfactory pain relief. Other series of results with this type of prosthesis have been
reported. (Weiss, Adams, Moore, et al., 1990)

All series report lucent lines or lucent zones at the glenoid-bone cement junction. These vary
considerably in frequency among the different series, ranging from 30% to 93% of shoulders
reported. The keel portion of this implant serves as the significant means of attachment to the
scapula, and the lucent zones seen at the cement-bone junction surrounding the keel are of
great concern. The median percentage of the number of shoulders analyzed in which a lucent
line was identified at the bone-cement junction of the keel part of the component is 36. The
argument has been presented that when these lucent lines or zones are seen in patients they
are almost always present immediately postoperatively and clearly represent an error in
surgical technique. (Neer, Watson and Stanton, 1982) This may be the most common
sequence of events associated with roentgenographic lucent zones at the glenoid bone-cement
junction and speaks for the need for meticulous preparation of the bony bed and cementing at
the time of surgery. However, it has also been reported that these lucent zones have not been
present immediately after surgery but rather have developed over time. (Cofield, 1984) Green
and Norris(Green and Norris, 1994b) and Slawson et al (Slawson, Everson and Craig, 1995)
have recently provided a review of imaging techniques for evaluating glenohumeral
arthroplasty.

Franklin and co-authors have suggested a classification system for describing the radiographic
appearance of the glenoid component. (Franklin, Barrett, Jackins, et al., 1988) In Class 0,
there is no lucency. In Class 1, there is lucency at the superior or inferior flange only. In Class
2, there is incomplete lucency at the keel. In Class 3, there is complete lucency up to 2 mm
around the component. In Class 4, there is complete lucency greater than 2 mm around the
component. In Class 5A, the component has translated, tipped, or shifted in position. And in
Class 5B, the component has become dislocated from the bone.

In the series by Barrett (Barrett, Franklin, Jackins, et al., 1987) and Cofield, (Cofield, 1984)
analyses have also included a shift in glenoid component position relative to the position
achieved immediately following surgery. Analysis of component movement relative to the
bone requires the viewing of sequential x-rays over time because often a lucent zone is not
seen. This finding implies component loosening, but it can easily be overlooked if serial x-
rays are not studied.

Management of Glenohumeral Arthritis

Edited by Frederick A. Matsen, III, M.D.
Last updated January 9, 2002

Methods of assessing functional outcome

Ernest A. Codman will be remembered in the annals of orthopaedic history as a pioneer in the
study of shoulder disorders but few except the most ardent of his followers are familiar with
the role he played as a visionary and champion of what is currently described as outcomes
research. (Codman, 1934)

Evaluating success and failure

Central to what Codman described in the early 1900's as an "end-result" system was the
admonition that every patient should be followed to determine if the treatment was a success
and if not to determine the reasons for failure so that such occurrences could be prevented in
the future. Despite Codman's admonition nearly 100 years ago, there continues to exist a lack
of standardized methods for measuring results and reporting complications associated with
total shoulder implants. Unfortunately, the lack of a universally accepted outcome
measurement system for shoulder arthroplasty increases methodologic flaws in structured
literature reviews and often precludes meaningful retrospective or prospective comparisons
between various arthroplasty series. The desirability of research methodologies which will
improve the quality and comparability of multicenter studies is underscored by our review of
nearly fifty total shoulder replacement series. (Boyd, Thomas, Scott, et al., 1990; Brenner,
Ferlic, Clayton, et al., 1989; Brostrom, Kronberg and Wallensten, 1992; Brumfield, Schilz
and Flinders, 1981; Clayton, Ferlic and Jeffers, 1982; Cofield and Daly, 1992; Cofield and
Stauffer, 1977; Coughlin, Morris and West, 1979; Cruess, 1980; Engelbrecht, Siegel, Rottger,
et al., 1980; Faludi and Weiland, 1983; Fenlin, 1975; Fig.gie, Inglis, Fig.gie, et al., 1989;
Frich, Moller and Sneppen, 1988; Gristina, Romano, Kammire, et al., 1987; Gristina and
Webb, 1982; Hawkins, Bell and Jallay, 1989; Kelly, Foster and Fischer, 1987; Kolbel,
Rohlmann and Bergmann, 1982; Laurence, 1991; Lettin, Copeland and Scales, 1982;
Linscheid and Cofield, 1976; Martin, Sledge, Thomas, et al., 1995; Mazas and de la
Caffiniere, 1981; McCoy, Warren, Bade, et al., 1989; McElwain and English, 1987;
McKeeand Watson-Farrar, 1966; Neer and Morrison, 1988; Neer and Kirby, 1982; Pahle and
Kvarnes, 1985a; Pollock, Deliz, McIlveen, et al., 1992; Post, 1987; Post, Haskell and Jablon,
1980; Post and Jablon, 1983; Post, Jablon, Miller, et al., 1979; Roper, Paterson and Day,
1990; Torchia, Cofield and Settergren, 1994-1995; Warren, Ranawat and Inglis, 1982; Wilde,
Borden and Brems, 1984) The results of this review revealed that only thirty-three of these
reports assessed the outcome of treatment by applying a specific grading system. Moreover
there was a great lack of unanimity in regards to these evaluation schemes as twenty-two
different grading systems were utilized. Also disconcerting was the variability in reported
data, variations in terminology, and ill-defined standards of assessing complications which
made it difficult to systematically analyze many of these studies.

The necessity for improving study design, defining the important constituents of outcome
measurement, and increasing the validity of orthopaedic clinical research has been
emphasized by several authors. (Cowell and Curtiss, 1985; Cutler and Ederer, 1958; Gartland,
1988; Rudicel and Esdiale, 1985) It has been suggested that the current emphasis of
orthopaedic clinical studies should be directed toward outcome research which documents the
effect of treatment on the health of those treated and the subsequent quality of their lives.
(Gartland, 1988) Recently, the American Shoulder and Elbow Surgeons proposed a
standardized form for assessment of the shoulder which is applicable to all patients regardless
of diagnosis. (Richards, An, Bigliani, et al., 1994) Such standardized forms represent
assessment tools which will facilitate the analysis of multi-center studies, permit validity
testing of measurement tools and provide documentation of patient outcome in terms of
economics and improved quality of life.

Survivorship analysis

The validity of survivorship analysis in the evaluation of long-term clinical studies involving
total hip replacements is well established. (Cornell and Ranawat, 1986; Dobbs, 1980; Dorey
and Amstutz, 1986; Jinnah, Amstutz, Tooke, et al., 1986; Pavlov, 1987) Although non-
parametric estimates of survivorship based upon life tables and the Kaplan-Meier curve have
proven useful in predicting the longevity of hip arthroplasties, the application of these
instruments to total shoulder arthroplasty studies is limited to two series. (Brenner, Ferlic,
Clayton, et al., 1989; Cofield, 1993)

In 1983, Cofield performed a non-parametric estimation of survivorship in 176 unconstrained

total shoulder arthroplasties and predicated a 9.6 percent cumulative probability of failure at
five years. (Cofield, 1993) The criteria for failure was defined as the need for a major
reoperation which occurred in eight (4.5 percent) cases. The indication for reoperation
included early dislocation in three shoulders, glenoid component loosening in three shoulders,
and muscle transfer for axillary nerve paralysis and resectional arthroplasty for sepsis in one
shoulder each. In a more recent article by the same author, this Fig.ure did not significantly
change at an eleven year end point. (Torchia, Cofield and Settergren, 1994-1995) In 1989,
Brenner and colleagues (Brenner, Ferlic, Clayton, et al., 1989) analyzed the results of fifty-
three unconstrained total shoulder arthroplasties using the Kaplan-Meier survivorship curve.
Employing a more rigid definition that considered failure as not only the need for reoperation,
but also patient dissatisfaction with the degree of pain relief, the authors reported an eleven
year survival of only 73 percent.

In a large multi-center prospective study involving more than 470 unconstrained total
shoulder arthroplasties, the five year survival was estimated at 97 percent (95 percent
confidence interval). (Rockwood, 1990) A more rigid definition of failure, similar to the
criteria proposed by Brenner et al, (Brenner, Ferlic, Clayton, et al., 1989) was applied to a
subset of these patients whose diagnosis was restricted to osteoarthritis. For these patients,
failure was defined by one of two parameters. The first parameter, as with the two previous
studies, simply involved the need for reoperation following the index procedure. The second
parameter was based upon a patient self-assessment visual analog scale for pain. For this
analysis, failure was defined as the point in time at which the patient reported shoulder pain
which was equal or worse than the preoperative condition. For the osteoarthritis subgroup, the
probability of five year survival was 92 percent using the more stringent criteria.

Patient self-assessment

As a practical approach to effectiveness measurement which can easily be applied in an active

practice, one of us (FAM) has used patient self-assessment methods. Since January 1992, all
new shoulder patients have been asked to complete the Simple Shoulder Test (SST) (Lippitt,
Harryman and Matsen, 1993; Matsen, Lippitt, Sidles, et al., 1994) to define their pretreatment
shoulder function and the SF 36 to characterize there overall health status. The results from
these pre treatment questionnaires serve as the baseline on "INGO" for evaluating treatment
effectiveness from the perspective of the patient. Followup questions questionnaires reveal the
"outcome" of treatment from the patients' perspective. The difference between the outcome
and the ingo is the effectiveness of the treatment. Table 16-25 indicates some of these early
data for the effectiveness of total or hemi arthroplasty for each of the indicated diagnoses. The
preoperative scores are shown to the left of each arrow and the followup score to the right.
The data include the SF 36 parameters for total body physical role function and comfort as
well as the 12 SST parameters which are specific to the shoulder. The SF 36 scores are the
average of the scores of the patients. The SST scores are the percent of the patients answering
yes to the indicated question. While some of these numbers are too small for rigorous
comparison, in the future, data such as these will indicate the absolute and relative
effectiveness of different treatments for different types of glenohumeral arthritis. Dividing the
effectiveness by the cost of treatment will reveal the cost effectiveness for different diagnoses
by different programs.
Figure 60

Figure 61
Figure 62
Figure 63
Figure 64
Figure 65

Figure 66