Date Published: March 22, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Sanjeev Bhatia, Andrew Hsu, Emery C. Lin, Peter Chalmers, Michael Ellman, Brian J. Cole, Nikhil N. Verma.
The diagnosis and treatment of symptomatic chondral lesions in young and active middle-aged patients continues to be a challenging issue. Surgeons must differentiate between incidental chondral lesions from symptomatic pathology that is responsible for the patient’s pain. A thorough history, physical examination, and imaging work up is necessary and often results in a diagnosis of exclusion that is verified on arthroscopy. Treatment of symptomatic glenohumeral chondral lesions depends on several factors including the patient’s age, occupation, comorbidities, activity level, degree of injury and concomitant shoulder pathology. Furthermore, the size, depth, and location of symptomatic cartilaginous injury should be carefully considered. Patients with lower functional demands may experience success with nonoperative measures such as injection or anti-inflammatory pharmacotherapy. When conservative management fails, surgical options are broadly classified into palliative, reparative, restorative, and reconstructive techniques. Patients with lower functional demands and smaller lesions are best suited for simpler, lower morbidity palliative procedures such as debridement (chondroplasty) and cartilage reparative techniques (microfracture). Those with higher functional demands and large glenohumeral defects will usually benefit more from restorative techniques including autograft or allograft osteochondral transfers and autologous chondrocyte implantation (ACI). Reconstructive surgical options are best suited for patients with bipolar lesions.
While the cause of primary glenohumeral osteoarthritis is largely unknown, secondary osteoarthritis is often due to trauma, acute or recurrent dislocation, or prior surgery. Primary glenohumeral arthritis typically results in posterior glenoid wear with posterior humeral head subluxation occurring in up to 50% of affected shoulders. Rotator cuff tears occur in less than 5–10% of cases of primary osteoarthritis. Joint space narrowing occurs with periarticular osteophyte formation most commonly on the inferior aspect of the humeral head. As a result, the anterior soft tissues such as the capsule and subscapularis become contracted and stiff, limiting external rotation . With the growing elderly population in the US, the number of total shoulder arthroplasties performed each year has doubled over the past decade to approximately 20,000 cases . While glenohumeral osteoarthritis typically affects older patients, in some cases it can affect younger, active patients causing significant pain and disability [3, 4].
A comprehensive Pubmed search was performed using the following Boolean search terms: glenohumeral arthritis, glenohumeral osteoarthritis, management, young patients. The yield of over 80 articles was examined carefully with emphasis placed on publications focusing on non-arthroplasty alternatives. These articles served as the basis for this paper in addition to our clinical experience.
As noted by Gartsman et al., patients with glenohumeral arthritis will generally reveal complaints of pain, disability, and loss of quality of life which may be common to many types of shoulder pathology . Patient symptoms are often of nonspecific shoulder pain and mechanical complaints . The examiner should elicit a history of glenohumeral trauma or instability, activities, and arm positions that cause pain, effusions, neurological complaints, and prior operative and nonoperative shoulder interventions . The examiner should have a general understanding of the demand a patient places upon their shoulder, including their athletic activities/aspirations and occupational demands. A history of instability may be particularly valuable given the connection between prior subluxation and dislocation events and the subsequent degeneration of the glenohumeral joint . Generally the diagnosis of a chondral injury is one of exclusion given its relative rarity in comparison to lesions of the biceps tendon, subacromial space, and capsulo-labroligamentous complex in younger patient cohorts [5, 9]. If prior surgery has been performed, a review of operative notes and intraoperative pictures may be helpful in determining the prior procedures performed and the status of the articular cartilage at the time of previous arthroscopy.
When treating patients with glenohumeral chondral pathology, identification of patients with symptomatic cartilaginous lesions and appropriate surgical decision making is paramount for success . Cartilage defects are frequently encountered on imaging or arthroscopic exam. At the outset, it is essential to identify those patients whose pain is generated by these lesions and differentiate incidental chondral lesions from symptomatic ones. Shoulder impingement, commonly seen in younger age groups, frequently mimics symptomatic glenohumeral chondral pathology but is frequently differentiated from chondral lesions with the help of the compression-rotation test . A history of shoulder trauma, previous shoulder surgery, recurrent subluxations or dislocation, mechanical symptoms (catching or clicking), and persistent pain after subacromial diagnostic injection are other clues that suggest symptomatic chondral pathology . In our experience, symptomatic chondral lesion should be considered a diagnosis of exclusion, with all other sources of shoulder pathology treated first, and most reparative procedures should be considered as a secondary option.
The mainstay of palliative surgical treatment is arthroscopic debridement and lavage (chondroplasty). Debridement acts to alleviate irritating mechanical symptoms that arise from edge instability. Additionally, arthroscopic debridement stabilizes cartilage lesions, thereby reducing the risk of further delamination.
For well-contained small unipolar cartilage lesions, marrow stimulation techniques are the next level of treatment that may be indicated beyond debridement. Microfracture, a cartilage reparative strategy popularized by Steadman et al.  in the knee, is a first-line technique for stimulating fibrocartilage growth in a chondral defect as a means of providing structural support to surrounding tissue [5, 9, 24]. The procedure can be performed arthroscopically in the humerus or glenoid and does not restrict opportunities for cartilage restoration in the future. However, differences in articular cartilage between the shoulder and knee are significant, which may impact results following microfracture. The thickness of the articular cartilage in the shoulder is much thinner than the knee, with maximum thickness of 1.5 mm tapering to less than 1 mm at the periphery of the humeral head and center of the glenoid . In addition, the convex shape of the humeral head and often peripheral location of articular defects on the glenoid may limit the ability to contain the initial clot.
The overall purpose of restorative surgery for glenohumeral chondral lesions is to anatomically reestablish damaged or missing cartilage. The primary surgical techniques are osteochondral grafting using autograft or allograft and autologous chondrocyte implantation (ACI). Both of these treatments necessitate open surgery and have potential complications such as donor site morbidity and the need for multiple surgeries (ACI) . Therefore, patient selection is critical to overall outcomes and patient satisfaction.
As opposed to restorative treatment options for smaller, superficial chondral defects, reconstructive cartilage surgery may be required for large and deep unipolar or bipolar defects. Reconstructive surgery is considered a “salvage” treatment option, with goals of restoring durable function to the shoulder and decreasing pain, typically as a final attempt before considering total shoulder arthroplasty (TSA) or glenohumeral arthrodesis. While reconstructive surgery technically includes hemiarthroplasty or TSA, we will focus on the prearthroplasty management for young and middle aged patients with significant chondral defects. Prearthroplasty reconstructive surgery includes resurfacing techniques to the humeral head and glenoid, as well as biologic or nonbiologic interpositional arthroplasty techniques using a variety of tissues, such as meniscal allografts, anterior capsule, fascia lata, Achillestendon allograft, and other specialized matrices. Suggested potential benefits of biologic glenoid resurfacing include pain relief and improved range of motion similar to TSA, without the well-known complications of polyethylene wear, cement fragmentation, and glenoid loosening or dissociation.
Resurfacing arthroplasty using interpositional graft offers potential advantages over conventional TSA, including the ability to biologically resurface the glenoid, in addition to biologic or nonbiologic resurfacing of the humeral head, thereby avoiding complications of TSA in cases of bipolar disease.
The postoperative regimen is important to the success of the cartilage repair process. With all procedures, early range of motion is encouraged to increase circulation and promote healing, but with some limits to protect the repair site. Patients who have undergone palliative treatment strategies should begin physical therapy immediately, with range of motion and strength exercises restricted only by pain. If a capsular release has also been performed, patients should receive physical therapy 3 times per week for 6 to 8 weeks.
Treatment of glenohumeral cartilage injuries in young patients continues to be a challenging issue. Surgeons must differentiate incidental chondral lesions from symptomatic lesions that are responsible for the patients’ pain. Even with appropriate imaging and a thorough patient history and physical examination, this remains difficult and often results in a diagnosis of exclusion that can only be verified on arthroscopy. After identification of a symptomatic patient, treatment depends on several factors, including the patient’s age, comorbidities, degree of injury, concomitant shoulder pathology, expectations, and activity level. Patients with lower functional demands may experience success with nonoperative measures such as medication and injections or arthroscopic surgery involving debridement and capsular release. Young patients with higher functional demands or extensive arthritis may require more aggressive surgical treatments that restore or reconstruct the cartilage. A variety of innovative nonarthroplasty procedures have been utilized for glenohumeral arthritis in the young patient, with promising short- to midterm success. However, long term outcomes or randomized trials are lacking, and future work is required to determine appropriate indications for each procedure and predictors for lasting success.