Evaluation and Management of Chondral Lesions Affecting the Glenohumeral Joint

The Problem

For the purpose of this review, shoulder cartilage damage will be divided into two categories: diffuse joint destruction involving both the humeral head and glenoid (bipolar) or focal chondral defect (unipolar). In a young or high demand patient with diffuse bipolar shoulder arthritis where arthroplasty is undesirable, the surgeon must understand the role of arthroscopic treatment. Less commonly, a focal unipolar chondral lesion may require surgical treatment, and the surgeon must understand which treatment is most appropriate for the isolated chondral lesion. This review will discuss arthroscopic treatment of bipolar shoulder arthritis as well as treatment algorithms for focal chondral lesions.

Clinical Presentation

Focal chondral defect

Patients presenting with glenohumeral chondral defects will have a constellation of symptoms that are sensitive and rarely specific to this etiology. Pain will typically not localize to a specific region, and it is usually described as “deep”. The time of onset of symptoms is arguably one of the most important factors to take into account as literature on the knee has demonstrated that patients with prolonged symptoms (>1 year) have worse outcomes with surgical treatment. Acute onset of symptoms with an inciting factor (e.g., shoulder dislocation/impact) are more suggestive of improved outcomes with surgical management.

Typically patients will describe nocturnal pain when sleeping on the affected shoulder. They may also describe mechanical symptoms if the chondral or osteochondral fragment has become a loose body. Taking a thorough history is important, as these patients may develop chondral defects in the setting of avascular necrosis, which can occur through the following etiologies: chronic steroid use, HIV (secondary to pharmacologic treatment), sickle cell disease, cancer, and others.

Diagnostic information from prior glenohumeral injections should also be noted with the following questions asked if the treating physician did not perform the injection:

What direction was it given?

Was fluoroscopy or ultrasound used?

Did you benefit from the injection even temporarily the day it was given?

Which components improved with regard to pain, range of motion, and strength?

This information can help elucidate concomitant pathology and determine if the problem is intra-articular, as subjective swelling is not a common complaint of the shoulder patient.

Widespread glenohumeral arthritis

Patients with pathology beyond focal defects will typically have a more significant and telling history. This can include prior surgeries (stabilization/RF ablation), usage of intra-articular pain pumps, significant number of dislocations, or a septic joint to name a few. Patients will present not only with a pain component, but also with decreased range of motion. Understanding patients’ goals from treatment are key, as this patient population is one of the most difficult to treat when young and active.

Diagnostic Workup

Physical Exam

• Palpation and inspection are often normal.

• Pain with external rotation with the arm at the side.

• Glenohumeral crepitus with range of motion.

• The patient motioning to a “deep” pain with shoulder range of motion.

• Compression-rotation test: Lateral compression of the glenohumeral joint with internal and external rotation with the arm at the side which is painful both before and after a sub-acromial injection.

• Strength and motion testing are typically intact or limited only secondary to pain.

  In the setting of chondrolysis, range of motion will be significantly decreased and operative intervention will focus on improved motion and less reliably improved pain.

Radiographs

• Anteroposterior/Grashey/Scapular Y/Axillary.

  Evaluate for glenohumeral joint space narrowing/osteophytes.

  Humeral migration.

  Subchondral bone sclerosis/lucency.

  Mineralization.

  Glenoid bone loss.

• Stryker Notch/West Point Views.

  Hill-Sachs lesion.

  Osseous Bankart lesion.

MRI (with or without arthrogram)

• T2 series important to evaluate effusions/subchondral bone edema.

• Evaluate chondral surface, high percentage of false negatives due to thin nature of humeral cartilage.

• dGEMRIC analysis if available.

• Determine osseous involvement.

• Arthrogram has been shown to overestimate cartilage irregularities.

  Falsely increased thickness of normal cartilage.

  Falsely decreased thickness of thin cartilage.

  More accurate for glenoid.

• Rule out concomitant pathology.

Glenohumeral injection

• Can be combined with contrast before MRI for diagnostic and therapeutic benefit.

• Corticosteroids to decrease inflammation and pain component.

• Hyaluronic Acid, although off-label, may also be beneficial.

Non–Operative Management

Almost all glenohumeral chondral lesions should undergo a trial of non-operative management before proceeding with surgery, as many lesions are likely incidental. This trial includes activity modification, glenohumeral corticosteroid injections, physical therapy, and oral anti-inflammatories. Therapy should focus on rotator cuff strengthening and scapular stabilization and increased range of motion if limitations are present. The duration of non-operative management should be individualized with each patient. Surgical treatment is reserved for patients who fail a concerted effort of non-operative management.

Indications for Surgery

Bipolar arthritis

Arthroscopic surgery is indicated in patients who have failed conservative treatment but are inappropriate for shoulder arthroplasty due to patient young age, high demand or patient’s desire to avoid/delay arthroplasty. Arthroscopic treatment involves chondral debridement, synovectomy, osteoplasty, loose body removal, and when indicated, capsular release and treatment of additional shoulder pain generators.

When considering arthroscopic treatment of bipolar shoulder arthritis, the surgeon should evaluate for stiffness, associated shoulder pathology, and the severity of radiographic arthritis.

Stiffness

• A difference of 20 degrees range of motion from contralateral side in any plane is considered significant.

• Three etiologies exist for shoulder stiffness in the presence of bipolar arthritis.

  Capsular adhesions – this can be well addressed through arthroscopic capsular release.

  Bony blocks to motion from severe joint deformity – typically not amenable to arthroscopic treatment unless a focal osteophyte excision would re-establish motion.

  Post-surgical soft-tissue adhesions of the joint and subacromial space – may require capsular release as well as subacromial debridement.

Associated shoulder pathology

• Long head biceps tendinopathy requiring tenotomy in elderly or tenodesis in young.

• Subcoracoid impingement – requiring coracoidplasty.

• Subacromial bursitis, type III acromion – decompression with or without acromioplasty.

• AC arthrosis – distal clavicle excision.

• Rotator cuff pathology – debridement versus repair.

• Peripheral nerve entrapment – suprascapular, axillary (axillary nerve arthroscopic neurolysis has been reported as a surgical option for arthroscopic treatment of bipolar arthritis).

Severity of radiographic arthritis

• Results of arthroscopic treatment are better when 2mm of joint space are preserved on radiographs.

• More severe bony destruction is associated with inferior results.

• Posterior wear pattern with subluxation of the humeral head is also less likely to respond to arthroscopic treatment.

Focal lesions

Insufficient scientific evidence exists to precisely guide surgical treatment of focal unipolar cartilage lesions. Most recommendations are inferred from existing literature on the knee. In general the various surgical options for focal unipolar chondral lesions can be categorized as palliative, reparative, restorative, or reconstructive.

Palliative (Arthroscopic chondroplasty/Osteophyte excision)

• Best results in lower demand, older patients with contained chondral lesion <2cm2.

• Better outcomes if mechanical symptoms were due to loose chondral flap or osteophyte.

Reparative (Microfracture)

• Focal, contained Outerbridge Grade IV chondral defect with minimal/no bone loss with lesion <3-4cm2.

• No age data in shoulders, but improved if <40 years old based on knee data.

• In general, humeral head defect results better than glenoid defect or bipolar lesions.

• No role in chondral injury with bone loss, chondrolysis, or inflammatory arthritis.

Restorative

• Autologous Chondrocyte Implantation (also Matrix augmented)*

  Large unipolar lesions (>3-4cm2) with no appreciable bone loss.

• Osteochondral Autografts.

  For lesions <3 cm2 without significant bone loss.

  Revision treatment after failed microfracture.

• Osteochondral Allografts.

  For unipolar lesions >4cm2.

  Revision treatment after failed microfracture.

  Significant bone loss (associated with trauma or instability).

• Biologic Resurfacing or soft tissue interposition (Figure 1).

  Figure 1.

  Demonstrated here is a biologic resurfacing of the glenohumeral joint to treat chondrolysis. This was accomplished with a mushroom humeral head allograft (A) and a meniscal interposition (B). This case happened to be a discoid lateral meniscus.

  The authors believe there is currently no indication as published results are poor.

* Considered off-label usage in the shoulder

Surgical Technique

In order to optimize patient pain relief, it is important to always evaluate and address commonly associated shoulder pathology such as stiffness, biceps tendinopathy, subcoracoid impingement, subacromial bursitis, AC arthrosis, rotator cuff pathology, or suprascapular or axillary nerve entrapment.

Arthroscopy for bipolar arthritis

Utilizing a standard posterior viewing portal and anterior interval working portal, a diagnostic arthroscopy is first performed in the beach chair position. Lesions with a large chondral flap component or loose bodies may respond favorably to debridement alone. This can be performed with a small 4.5mm shaver. Performing an arthroscopic release in the setting of glenohumeral chondrolysis involves first establishing the patient’s preoperative range of motion to focus on specific deficits intra-operatively.

Decreased external rotation is typically addressed by completely releasing the tissue surrounding the subscapularis. This starts with the rotator interval tissue and leads to the subscapularis recess using a combination of an arthroscopic shaver and radiofrequency ablation, as the tissue can be highly vascularized. The subscapularis fossa can be elevated with an arthroscopic elevator with concomitant external rotation to decrease adhesions. After an adequate anterior release has been performed (i.e., subscapularis leading superior border well-defined as well as the plane anterior and posterior to the muscle with a complete capsulotomy including the axillary pouch), the camera should be switched to the anterior portal. If internal rotation deficit is present, then the posterior capsule can be released in a similar manner. The subacromial space should be entered as well to address any pathology present. The arthroscopy should end with an aggressive manipulation under anesthesia with the scapula stabilized in all planes of motion.

Reparative (Microfracture)

After performing a diagnostic arthroscopy in the beach chair position, where appropriate indications have been met for microfracture, one should first probe to assess unstable cartilage and do a simple debridement of the lesion, ensuring that it is contained. Defect preparation can be initiated with a small straight or angled curette which is used to further define the borders of the defect and initiate defect debridement. The goal is to create a vertical rim to help prevent lesion progression and to entrap the marrow clot. Any delaminated cartilage, especially at the periphery of the lesion, should be removed. The cartilage surface should be debrided with a curette and shaver such that the calcified cartilage layer is removed to allow integration of the fibrocartilage fill. Removal of this layer is confirmed by punctate bleeding and should not violate the integrity of the subchondral bone (Figure 2).

Before creating the microfracture defects, ensure that arm position allows for proper access to the lesions such that the awl perforates perpendicularly to the surface of the defect. For the glenoid this may include the use of a 7-o’clock portal for posterior lesions or a more lateral or distal anterior portal for anterior or inferior lesions, respectively. Humeral lesions are largely accessible through the standard anterior portal facilitated by internal and external rotation of the arm. The microfracture defects are classically created with a microfracture awl placed perpendicular to the subchondral surface starting at the periphery of the defect and working centrally in a spiral pattern. These defects should be spaced such that they do not converge. Generally, holes should be about 3-4mm apart and penetrate to a depth of 2-4mm (approximately the depth of the awl tip). Recent data may suggest that drilling may help avoid bone compaction that decreases access to marrow elements and heat generation is typically not a factor. After the microfracture holes have been completed, any bony remains on the rims of the holes should be removed by curettage or shaving. The irrigation pump pressure is then decreased, allowing the flow of marrow elements to be observed (Figure 3).

Figure 3.

Restorative/Reconstructive (Osteochondral auto/allograft, autologous chondrocyte implantation)

Osteochondral autograft

The goal is to transplant a full thickness osteochondral bone plug from an area of the knee that is non-weight bearing to the osteochondral defect of the shoulder. This is a single-stage procedure, most appropriate for smaller lesions.

Set-up and Equipment:

Beach chair position with both knee and shoulder prepped and draped is appropriate. Arthrex Osteochondral Autograft Transfer System (Arthrex, Inc., Naples, Florida), open shoulder tray.

Step 1: Shoulder Exposure and Defect Sizing

Shoulder surgical approach is a standard deltopectoral with subscapularis tenotomy and the knee graft harvest is through a mini-open incision. The shoulder osteochondral lesion size- depth, width, and number of plugs necessary should be determined after a debridement of superficial fibrocartilage and loose cartilage flaps.

Step 2: Knee osteochondral graft harvest

Through a mini-open incision, the superior medial aspect of the medial femoral condyle is exposed. The T-handle harvest instrument is sized based on the shoulder lesion and the depth is typically 10-15mm. The harvest tool is pressed firm to stay perpendicular to the articular surface. This can be performed arthroscopically; however, data suggests that contour matching with this method is less accurate.

Step 3: Recipient Site Preparation

The appropriately sized coring device is place over the shoulder osteochondral defect to a depth 1-2mm deeper than the harvest plug measures to avoid proud graft, shear stress, and early failure.

Step 4: Graft Implantation

Insert graft under direct visualization. May recess the graft a bit to avoid shear stresses. More frequent, lighter impaction techniques are safer for chondrocytes than fewer, more intense impactions.

Osteochondral allograft

Best reserved for larger osteochondral lesions, bone loss, or revision after failed microfracture or ACI. This requires a sized-matched donor typically based on MRI sizing. This is a single-stage procedure. The grafts are press-fit usually, however grafts larger than 18 x 18 may require fixation with absorbable pins or screws.

Set-up and Equipment:

Beach chair position, Arthrex osteochondral allograft tray (Arthrex, Inc., Naples, Florida), open shoulder tray.

Step 1: Exposure, Chondral Defect Preparation and Sizing

Standard deltopectoral approach with subscapularis tenotomy. Size the defect by selecting the cylindrical guide over the defect. Mark the 12 o’clock position with a marking pen. Place guide pin through the cylinder guide and penetrate to 2cm. Remove sizing cylinder and with appropriately sized reamer, ream over guide pin to desired depth, usually 6-8mm. This decreases the allogeneic load from implantation. Using a small ruler, measure the depth of the hole at 3, 6, 9, 12 o’clock positions to allow contouring of the allograft to prevent a prominent graft after implantation.

Step 2. Preparation of Donor Graft

Secure donor specimen to allograft workstation and use the cylinder guide to set the angle of donor graft harvest. Using an appropriately sized coring reamer in a similar manner to the recipient site preparation, core out the osteochondral plug. Trim the plug to appropriate depth by marking the 3, 6, 9, 12 o’clock positions with depth matching at each site. The graft is then irrigated with pulsatile lavage to flush out bone marrow elements (Figure 4).

Figure 4.

Step 3. Graft Insertion and Fixation

The graft is press-fitted into the recipient defect with the assistance of an oversized tamp. Make sure not to leave the graft proud as this will cause graft shear stresses and failure (Figure 5).

Autologous chondrocyte implantation (ACI)

The goal of ACI is to restore hyaline cartilage (>90%). Although very little evidence exists, ACI is best indicated for larger (>3 x 3 cm), unipolar, contained lesions of the humeral head. ACI requires two separate procedures. In the first procedure, a small biopsy of healthy articular cartilage is harvested and taken to a laboratory to undergo in vitro chondrocyte amplification in cell culture. After roughly 6 weeks, the second procedure is the implantation of the expanded autologous chondrocytes into the shoulder chondral defect with a tibial periosteal graft for coverage.

Stage 1: Chondral Biopsy and Cellular Amplification

The initial cartilage biopsy is performed arthroscopically in the non-weight bearing intercondylar region of the knee, similar to performing a notchplasty with a curette. The surgeon should err on the side of penetrating the subchondral bone to include deep chondrocytes. This biopsy should be approximately 200-300mg, which correlates with 200,000-300,000 cells. The cells are then sent to Genzyme Biosurgery (Cambridge, MA) or equivalent laboratory, for in vitro amplification, which requires 4-6 weeks on average.

Stage 2: Chondrocyte Implantation

Set-up:

Two assistants are recommended. Beach chair position is preferred. The shoulder is prepped and draped in a standard fashion. A pre-op regional block is used for analgesic purposes. Instruments: open shoulder tray, 18-gauge catheter tuberculin syringe, 6-0 vicryl sutures, mineral oil, and fibrin glue.

Exposure, Chondral Defect Preparation and Sizing:

An open surgical approach is used via the delto-pectoral interval with a subscapularis tenotomy and capsular arthrotomy. Once the humeral head defect is exposed, the defect must be prepared by removing all damaged or unhealthy-appearing cartilage, calcified cartilage and fibrocartilage. A #15 blade can be used to score the damaged cartilage, which is removed with a ring curette. The calcified cartilage should be gently removed to create punctate bleeding, but not overt subchondral bone penetration. To properly size the defect the surgeon can use sterile paper (obtained from the sterile gloves wrapping) and a marking pen to template the defect size and shape. In general it is advised to undersize the template by 1mm because type I/III collagen patch (off-label use) tends to expand when wet. One vial of cells should be applied to the patch prior to implantation to allow for cell adherence to the patch.

Patch Fixation and Sealing:

The collagen patch is aligned over the shoulder articular defect in the appropriate orientation. Suture the graft to the cartilage defect peripheral rim with 6-0 vicryl sutures using a P-1 cutting needle, tying simple interrupted knots placed on the periphery away from the patch. The knots can be placed 2mm apart and the suture can be primed with mineral oil to decrease suture patch friction. Suture the periphery in this fashion, but leave a 5mm opening superiorly to allow injection of the chondrocyte cells. The watertight integrity of the sutured periphery can be tested with saline from a tuberculin syringe 18-gauge angiocatheter placed through the small superior opening. Commercially available fibrin glue can be used to seal the sutured periphery.

Implantation of the Chondrocytes:

The autologous chondrocytes are aspirated from the vials through a tuberculin syringe in a sterile manner. Then the cells are introduced under the periosteal patch with an 18-gauge angiocatheter placed through the small superior opening. The superior opening is then closed with 6-0 vicryl and fibrin glue. The subscapularis tenotomy is closed with heavy nonabsorbable suture and the deltopectoral incision is closed in standard fashion. The patient is placed in an abduction brace.

Arthroplasty

Patients who have failed or are not indicated for the above procedures may benefit from glenohumeral arthroplasty. The details of this technique are not discussed in detail as they do not vary from typical primary arthroplasty techniques.

Pearls and Pitfalls of Technique

Arthroscopic release

• Allowing a 360 degree view of the subscapularis tendon anterior helps ensure that the interval, subscapularis recess, and inferior capsule are adequately released.

• Change the viewing portal to anterior to check for posterior capsular contracture.

• Arm positioning during surgery can tension structures that are limiting motion and aid in release.

Microfracture

• Utilize more lateral portals for glenoid defects and medial for humeral lesions.

• Focus on removing the calcified cartilage layer but do not over-penetrate the subchondral bone.

• Microfracture hole depth and spacing are important to avoid convergence and fracture.

Osteochondral allograft

• Avoid over-reaming the depth of the recipient site, increasing the allogeneic load.

• Copiously irrigate the marrow elements before implantation.

• Avoid fewer, more intense impacts if possible.

Osteochondral autograft

• Ensure harvest site is from non-articulating region to decrease the chance of donor site morbidity.

• Using a mosaicplasty technique can increase the risk of non-incorporation of central plugs and development of cystic changes.

Autologous chondrocyte implantation

• Using a collagen patch instead of periosteum decreases subsequent arthroscopy for hypertrophy.

• Obtain a proper seal with the overlying patch to ensure there is no cell leakage.

• Removal of the calcified cartilage layer is important; however, removing excessive bone will lead to subchondral bleeding that will dilute the expanded chondrocytes.

Potential Complications

Arthroscopic release

• Risks associated with this procedure are limited, beyond recurrence of pain/stiffness.

• Aggressive release medial to the coracoid places risks nerve injury.

• Humeral fractures can result from over-aggressive manipulation under anesthesia.

Microfracture

• Intra-lesional bone formation.

• Increased pain.

• Subchondral bone fracture during the technique.

Osteochondral allograft

• Disease transmission is possible even with newer screening techniques, though not probable.

• Failure of graft integration with recurrent effusions.

Osteochondral autograft

• Donor site morbidity.

• Cyst formation and lack of incorporation.

Autologous chondrocyte implantation

• Graft hypertrophy has essentially been resolved with collagen patch usage.

Post–operative Rehabilitation

As described by Salter et al. in the knee, motion is paramount for cartilage formation. However, shear stresses can also damage the cartilage repair tissue. While continuous passive motion is used frequently in the knee, we believe that it is unnecessary in the shoulder and prefer 2-4 weeks of sling use for comfort only. Patients begin passive and active-assisted range of motion immediately after surgery, including pendulums. Strengthening begins at 6 weeks which correlates with return of full passive motion. Recreational or non-athletes can return to all activities as tolerated by 4 months while high level or overhead athletes are restricted to return to sport until 6 months.

Outcomes/Evidence in the Literature

Millett, PJ, Horan, MP, Pennock, AT. “Comprehensive Arthroscopic Management (CAM) Procedure: Clinical Results of a Joint-Preserving Arthroscopic Treatment for Young, Active Patients with Advanced Shoulder Osteoarthritis”. Arthroscopy. vol. 29. 2013. pp. 440-8. (This is a retrospective review of 30 shoulders (avg patient age 52, mostly male) with bipolar arthritis undergoing arthroscopic treatment that included chondral debridement, synovectomy, osteoplasty, capsular release, long head of bicep tenodesis, subacromial decompression, and axillary nerve neurolysis. Results showed high pain relief and patient satisfaction with 20% progressing to arthroplasty at an average of 1.9 years. Patients with less than 2mm of joint space had a higher failure rate. Overall survivorship was 85% at 2 years.)

Gross, CE, Chalmers, PN, Chahal, J. “Operative treatment of chondral defects in the glenohumeral joint”. Arthroscopy. vol. 28. 2012. pp. 1889-1901. (This systematic review of previous studies assessed clinical outcomes of patients undergoing debridement, microfracture, OATS, and ACI. A review of debridement outcomes showed no correlation between age and sex with functional or pain outcomes. Patients with unipolar lesions showed a statistically significant improvement in validated outcome measures, while bipolar lesions were more likely to progress to arthroplasty in one study. Additionally, one study found that lesions greater than 2cm2 were a negative prognostic factor, with increased time to pain relief and increased failure rates.)

Frank, RM, Van Thiel, GS, Slabaugh, MA. “Clinical outcomes after microfracture of the glenohumeral joint”. Am J Sports Med. vol. 38. 2010. pp. 772-781. (This retrospective analysis of validated clinical outcome measures in 16 patients undergoing microfracture procedures showed statistically significant improvements in VAS, ASES, and SST scores post-operatively at an average of 27.8 months. Additionally, physical examination was performed on 57% of patients and showed significant improvements in shoulder abduction and external rotation post-operatively. Outcomes were not affected by patient age or sex. Mean follow-up was 27.8 months.)

Millett, PJ, Huffard, BH, Horan, MP. “Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture”. Arthroscopy. vol. 25. 2009. pp. 856-863. (An analysis of clinical outcome measures was performed on 25 patients undergoing microfracture procedure for full-thickness contained chondral lesions of the glenohumeral joint at an average of 47 months follow up. Outcomes were based on satisfaction, improvement of pain, and increased function based on the ASES score. Patients were shown to have statistically significant decreases in post-operative pain in addition to having improved ASES scores following treatment. However, treatment of bipolar lesions showed attenuated improvement in ASES scores. The greatest improvements in ASES scores were seen in patients with small, single humeral head lesions. A negative correlation between lesion size and ASES improvement was also found, though it was not statistically significant.)

Scheibel, M, Bartl, C, Magosch, P. “Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder”. J Bone Joint Surg Br. vol. 86-B. 2004. pp. 991-997. (This retrospective study of 8 patients with Outerbridge Grade IV lesions of the humeral head or glenoid greater than 100mm2 undergoing osteochondral autologous transplantation from the knee to the shoulder assessed clinical and radiological outcomes of the procedure at a mean of 32.6 months. Constant scores improved significantly, and all patients had a significant decrease in post-op pain. Additionally, there was a significant increase in mean ADL as well as a non-significant increase in range of movement and strength. Radiographs showed glenohumeral osteoarthritic changes at latest follow-up and inferior osteophyte formation in all patients, despite non-significant changes in glenohumeral distance. Despite the clinical improvements, it’s unclear if OATs may slow down the development of glenohumeral arthritis. Importantly, one patient suffered donor-site morbidity requiring two additional knee procedures that did not successfully resolve their pain and effusions.)

Kircher, J, Patzer, T, Magosch, P. “Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder-Results at nine years”. J Bone Joint Surg Br. vol. 91-B. 2009. pp. 499-503. (This follow-up of the previous study assessed clinical and radiographic outcomes of 7 patients previously assessed at a mean of 32.6 months who underwent osteochondral autologous transplantation (knee to shoulder) for Outerbridge Grade IV lesions of the glenohumeral joint. Mean follow-up for the current study was 8.75 years. While statistically significant improvements in the Constant score, pain level, and activities of daily living were seen from time of operation to the first follow-up, these were not significant between the first and second follow-ups. There was a significant increase in strength between the two follow-ups, however. Additionally, the significant increase in osteoarthritic grade between the time of operation to the first follow-up was not maintained between the first and second follow-ups. Radiographically, a relationship between the defect size or number of osteochondral cylinders and the development of osteoarthritis was not found, and it could not be determined if the arthritic changes were due to the procedure or reflected the natural course of the disease, instability, or initial trauma. Similarly in this study, one patient had significant donor site morbidity requiring two additional surgeries that did not resolve their pain.)

Chapovsky, F, Kelly IV, JD. “Osteochondral allograft transplantation for the treatment of glenohumeral instability”. Arthroscopy. vol. 21. 2005. pp. 1007.e1-1007.e4. (This is a case report of a 16 year old right hand dominant male with recurrent left shoulder instability at rest. Initial treatment included arthroscopic repair of a Bankart lesion and posterolateral humeral head defect. After one year free of dislocations, the patient returned following a post-traumatic recurrent instability episode and was found to have a large Hill-Sachs lesion. After one month of questionable compliance with a shoulder immobilizer, the patient experienced recurrent dislocation, and the Hill-Sachs lesion was repaired with an osteochondral allograft transplantation in addition to repair of the anterior inferior ligament and capsular shifting. There were no recurrent instability episodes at 1 year follow-up.)

Provencher, MT, LeClere, LE, Ghodadra, N. “Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibial allograft to the glenoid and a fresh allograft to the humeral head”. J Shoulder Elbow Surg. vol. 19. 2010. pp. e6-e11. (This is a case report of a 25-year-old right hand-dominant man with recurrent left shoulder pain and mechanical symptoms. Previous surgical history over the course of 7 years included open Bankart repair, debridement with anchor removal, and glenoid microfracture. Upon presentation to the authors, radiographs showed bipolar degenerative changes of the glenohumeral joint as well as an osteophyte and subchondral sclerosis. Repeat arthroscopy showed extensive bipolar Grade IV chondromalacia, and debridement and capsular release were performed. Despite initial symptom improvement, the patient returned to baseline several months later, at which point he underwent osteochondral allograft of a fresh distal tibia to the glenoid and fresh humeral head allograft with 2 plugs. Following 12 weeks of rehab, the patient returned to full duties at 7 months. At 16 month follow-up, the patient had full muscle strength in all muscle groups, nearly normal range of motion, and stated that he was nearly pain-free. Moreover, post-op imaging revealed complete incorporation of both allografts and excellent articular conformity without resorption.)

Buchmann, S, Salzmann, GM, Glanzmann, MC. “Early clinical and structural results after autologous chondrocyte transplantation at the glenohumeral joint”. J Shoulder Elbow Surg. vol. 21. 2012. pp. 1213-1221. (This retrospective evaluation of 4 patients undergoing autologous chondrocyte transplantation with collagen membrane seeding reported both validated clinical outcomes and radiographic outcomes of the procedure at an average of 41.3 months. Unipolar lesions were present in all patients, except one who had bipolar lesions. Post-operatively, VAS scores improved for all patients. Additionally, all patients had good to excellent scores for ASES, Rowe, and patient satisfaction. Radiographically, MRI showed integration as well as structural healing of the repair tissue in all patients but one.)

Strauss, EJ, Verma, NN, Salata, MJ. “The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. Article in Press”. J Shoulder Elbow Surg. 2013. pp. 1-11. (An analysis of clinical outcomes of 41 patients undergoing biologic resurfacing of the glenoid using lateral meniscus allograft or human acellular dermal tissue matrix was performed at a mean of 2.8 years follow-up. At this time, the clinical failure rate was 51.2% for both procedures, though patients treated with acellular dermal tissue matrix had both a higher rate of failure and a shorter time to failure than those treated with the lateral meniscus allograft. Clinical outcome measures showed ASES and SST scores improved significantly, and VAS pain scores decreased significantly in the overall cohort. Despite this improvement, overall outcome scores for each assessment were only fair, suggesting persistent symptoms and limited shoulder function.

Hasan, SS, Fleckenstein, CM. “Glenohumeral chondrolysis: part II–results of treatment”. Arthroscopy. vol. 29. 2013. pp. 1142-1148. (Forty patients with post-surgical glenohumeral chondrolysis were divided into two groups in this retrospective study. Half the patients had untreated chondrolysis, and half presented for evaluation or management of complications following treatment for chondrolysis. At least one arthroscopic debridement was performed in 75% of all patients, with 77% of those patients reporting poor symptom relief and requiring additional surgery. Sixty-two percent of patients underwent arthroplasty a mean of 13 months following initial debridement, suggesting poor responses to arthroscopic treatments. Nearly 68% of all patients underwent prosthetic shoulder arthroplasty at a mean of 32 months and entirely within 6 years of their index procedure. The mean time interval between the index procedure and arthroplasty was similar for both groups and the survival plots were not significantly different.)

Summary

Treatment of both focal and global glenohumeral arthritis requires taking into account several factors related to both the defect and the patient. Understanding patient goals and current symptomatology aid in directing management and increasing patient satisfaction. Avoiding non-linear thinking is crucial as young patients with bipolar arthritis may benefit from arthroscopic release and delaying arthroplasty. Cartilage restoration procedures, while well described in the knee, are still in their infancy in the shoulder and further research is required to determine if the same guidelines apply in this setting.

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