- Email: [email protected]
Arthroscopic alternatives to total shoulder arthroplasty: You have got to be kidding
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E M I N A R S I N
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T H R O P L A S T Y
24 (2013) 2–6
Available online at www.sciencedirect.com
www.elsevier.com/locate/semvascsurg
Arthroscopic alternatives to total shoulder arthroplasty: You have got to be kidding Samuel Dubrow, MDa, Yousef Shishani, MDb, and Reuben Gobezie, MDc,n a
Cleveland Akron Shoulder and Elbow (CASE) Fellowship, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Cleveland, OH b The Cleveland Shoulder Institute, University Hospitals of Cleveland, Cleveland, OH c Division of Shoulder and Elbow Surgery, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Cleveland, OH
A RT I C L E IN F O
A BS T R A C T Shoulder arthroplasty is not an ideal surgical solution for young patients with arthritis of
Keywords:
the glenohumeral joint due to the concerns of long-term implant survival. Various open
glenohumeral arthritis
and arthroscopic procedures have been described for this patient population with varying
arthroscopy
results. Here we review current arthroscopic alternatives to total shoulder arthroplasty for
young patient
the treatment of glenohumeral arthritis. We also describe and present our outcomes of an
biologic resurfacing
all-arthroscopic technique, using fresh osteochondral allograft to correct bipolar glenohumeral arthritis in young patients. & 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Glenohumeral arthritis in young patients is a difficult problem to treat. A number of treatment options exist, including both open and arthroscopic procedures. Open surgical procedures include traditional total shoulder arthroplasty, hemiarthroplasty, arthrodesis, humeral head resurfacing, biologic glenoid resurfacing with or without humeral head replacement, autologous chondrocyte implantation, and osteochondral allograft resurfacing. Arthroscopic procedures include glenohumeral debridement, capsular release, chondroplasty, microfracture, humeral head osteoplasty, axillary nerve decompression, biologic and non-biologic glenoid resurfacing, and osteochondral allograft resurfacing. When multiple treatment options exist to treat the same problem, it is usually the case that none is considered a “universal ideal”
procedure. As such, no agreement exists regarding the optimal treatment for advanced glenohumeral arthrosis in the young patient [1]. Concern regarding the treatment of advanced glenohumeral osteoarthritis with bipolar chondral defects in young patients exists due to the expected failure of traditional shoulder arthroplasty within the patient's lifetime, and the subsequent need for revision surgery [2,3]. Shoulder arthroplasty can also have substantial risks and may require postoperative restrictions on patients which may impair lifestyle or job requirements in younger individuals, in order to minimize the risk of prosthetic loosening [4]. The purpose of this study was to review the arthroscopic alternatives for the treatment of glenohumeral joint arthrosis in the young patient, as well as to describe our technique of arthroscopic resurfacing using fresh osteochondral allograft.
Samuel Dubrow, MD and Yousef Shishani, MD has nothing to disclose. Reuben Gobezie, MD is a consultant and receives support from Arthrex, Naples, FL and Tornier, Edina, MN. n Address reprint requests to Reuben Gobezie, MD, Department of Orthopaedic Surgery, University Hospitals of Cleveland, 5885 Landerbrook Dr, Monarch Center, Mayfield Heights, OH 44124. E-mail address: [email protected] (R. Gobezie). 1045-4527/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.sart.2013.04.003
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M I N A R S I N
2.
Arthroscopic treatment options
2.1.
Debridement and capsular release
A
R T H R O P L A S T Y
Arthroscopy has greatly enhanced our ability to diagnose and treat various pathologies of the shoulder joint. Previous studies have shown arthroscopic debridement to be effective in treating osteoarthritis in select patient populations [4–6]. Arthroscopic debridement and capsular release can smooth cartilage lesions, eliminate or reduce mechanical symptoms, and release capsular contractures, thereby producing satisfactory outcomes when used to treat patients with early osteoarthritis of the shoulder [7]. Richards and Burkhart [8] believe that capsular release provides a reduction in joint contact pressures and a greater range of motion, thereby acting as the primary mechanism of pain relief in young, active patients with osteoarthritis. However, it has been shown that patients who undergo arthroscopic debridement and capsular release with osteochondral lesions greater than 2 cm2 have had poor outcomes [6]. Such arthroscopic procedures may provide improved symptoms and function, delaying the need for a more extensive operation, such as arthroplasty, but it may not prevent the further deterioration of the arthritic joint [8]. Millett and Gaskill [9] describe an arthroscopic technique that combines debridement and capsular release with inferior humeral osteoplasty and axillary nerve decompression. They refer to this technique as comprehensive arthroscopic management (CAM) of glenohumeral osteoarthritis [9,10]. The indications for this procedure include young patients (age o60 years) with glenohumeral osteoarthritis, and capsular contractures and inferior humeral spurs that have failed nonoperative methods [10]. The authors believe that inferior humeral osteophytes may compress the axillary nerve causing pain, weakness, and decreased range of motion, which osteoplasty (resection) of the inferior spur may relieve.
2.2.
Microfracture
Microfracture was first described by Steadman et al. [11] as a cartilage reparative strategy for the knee, by stimulating fibrocartilage growth within a contained chondral defect. This technique has also been applied to the glenohumeral joint. However, there are significant differences in articular cartilage between the shoulder and knee, which can impact results when applied to the glenohumeral joint [12]. The procedure involves first identification of the boundaries of the cartilaginous defect, followed by debridement with an arthroscopic shaver or curette to obtain a stable periphery with vertically oriented chondral walls. A curette is then used to remove the calcified cartilage layer of the defect. An awl is then used to penetrate the subchondral bone several times, approximately 2–3 mm apart, to produce bleeding bone [12]. Osteochondral lesions of the shoulder treated with microfracture have led to improvements in pain, activities of daily living, and the ability to participate in athletic activities [13]. Snow and Funk [14] showed that upon reoperation of patients that had undergone arthroscopic microfracture, there was good filling of the chondral defect with fibrocartilage. The authors conclude in their study that microfracture of the
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shoulder may be a useful technique to prevent further deterioration of grade IV chondral lesions; however longterm follow-up is necessary [14]. Millett et al. [13] showed the greatest improvements in those patients with microfracture of small unipolar humeral lesions, and the worst results in those with bipolar lesions.
2.3.
Biologic glenoid resurfacing
Several studies, with varying results, have looked at the results of biologic glenoid resurfacing with and without humeral head replacement for the treatment of arthritis of the glenohumeral joint in young patients [15–19]. These studies have looked at the use of Achilles tendon, anterior capsule, fascia lata, meniscus, and human acellular dermal tissue matrix to resurface the glenoid through open surgical techniques. Arthroscopic techniques of glenoid resurfacing have also been reported using the Restore Patch (Depuy, Warsaw, IN), an implant of porcine origin, and Graftjacket (Wright Medical, Arlington, TN), a regenerative tissue matrix made from human skin [20,21]. Pennington and Bartz [22] have also described an arthroscopic technique of glenoid resurfacing using meniscus allograft. Savoie et al. [20] showed that arthroscopic glenoid resurfacing provided statistically significant improvements in young patients with arthritis of the glenohumeral joint with a 3- to 6-year follow-up. Although few studies exist looking at the results of arthroscopic biologic glenoid resurfacing [20,21], they tend to have a more consistent and favorable result when compared to the results of open surgeries [17–19].
2.4. Biologic total shoulder resurfacing using fresh osteochondral allograft Gobezie et al. [2] were the first to describe an all-arthroscopic bipolar biologic shoulder resurfacing technique. The procedure involves the use of fresh osteochondral allografts, which are inserted entirely through the rotator interval under arthroscopic visualization, to replace the surfaces of the glenoid and humeral head; a cartilage transplant of the shoulder. Indications include a young patient (o50 years of age) with arthritis in the absence of a large inferior humeral osteophyte, an intact rotator cuff with at least 901 of forward elevation, and a centered glenohumeral joint (Fig. 1). The grafts are prepared first. Fresh osteoarticular allografts are taken from a cadaveric humeral head and medial tibial condyle or tibial plafond. The concavity of the medial tibial condyle and distal tibial plafond are similar to that of the glenoid. The Osteochondral Autograft Transfer System (OATS) platform (Arthrex, Naples, FL) is used to prepare the grafts. A 20-mm circular coring reamer is used on the tibial allograft for preparation of the glenoid resurfacing, which is centered over a portion of the articular surface. The core is then removed from the tibial allograft and cut to the desired thickness of 5 mm by use of a 5-mm deep cutting guide. This creates a graft of 20 mm in diameter and 5 mm in depth to be used on the glenoid. The same procedure is then carried out on the humeral allograft; however a larger graft can be prepared if desired, with a maximum diameter of 40 mm (Fig. 2).
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Figure 1 – (A) AP and (B) axillary x-rays of the right shoulder of a 48-year-old male candidate for arthroscopic total shoulder resurfacing with osteochondral allograft.
Arthroscopy is subsequently carried out with the patient in beach chair position. Standard posterior and anterior portals are made and a thorough inspection of the glenohumeral joint is undertaken. The biceps tendon is then released from the superior labrum in order to provide room for the passage of instrumentation and the grafts into the joint. A subpectoral biceps tenodesis is performed prior to the conclusion of the case. The entire rotator interval is then resected using an arthroscopic shaver and cautery device through the anterior portal, which is extended to 25–30 mm in length. This part is crucial in order to have enough room for passing instrumentation and graft into the joint through the anterior portal. Arthroscopic reaming of the humeral and glenoid surfaces, in preparation for the allografts, is conducted through the use of a transhumeral portal. In order to prepare this portal, a targeting guide is inserted through the anterior portal and centered over the humeral head. The targeting guide is employed much as an ACL guide is used to drill the tibial tunnel in arthroscopic anterior cruciate ligament reconstruction (Fig. 3). However, for the transhumeral portal, the drill entry point is on the lateral humeral cortex and is directed towards the center of the humeral head, where the targeting guide is placed. Next a circular 20-mm reamer is placed through the anterior portal and attached intra-articularly to a pin that enters the joint through the transhumeral portal. Once the reamer is connected to the pin, the humeral head is then reamed in retrograde fashion to a depth of 5 mm through the transhumeral portal. The glenoid is then reamed, again through the transhumeral portal, however this time in antegrade fashion. It is possible to ream the humeral
Figure 2 – Fresh cadaveric osteochondral allografts are prepared using the Osteochondral Autograft Transfer System (OATS) platform (Arthrex, Naples, FL). (A) A prepared 20 5mm tibial allograft used to resurface the glenoid. (B) A prepared 30 5-mm humeral head allograft to be used for humeral resurfacing. (Color version of figure is available online.)
Figure 3 – Targeting guide used to prepare the transhumeral portal. The circular guide is placed on the humeral head region to be resurfaced, which enters the joint through the rotator interval. The drill sleeve is then placed on the lateral humeral cortex and a wire is drilled directed towards the circular guide. A cannulated reamer is then used over the wire to prepare the transhumeral tunnel. (Color version of figure is available online.) head to a larger size (maximum of 40 mm) if indicated for a larger graft. The prepared glenoid graft is then inserted into the joint through the anterior portal. It is then positioned over the reamed glenoid surface and impacted into place. Chondral darts of 1.2 mm are then used to fix the graft in place, which are inserted through the transhumeral portal. Prior to insertion of the humeral graft a small drill hole is made through its center to allow for the passage of a strong suture. A large knot is tied on the articular side of the graft. This will then act as a traction suture for the seating of the graft onto the humeral head. A Nitinol wire is then fed through the transhumeral portal into the glenohumeral joint and is retrieved through the anterior portal. The free end of the suture, which was threaded through the humeral graft, is then placed through the loop of the Nitinol wire, which is then pulled back out of the transhumeral portal bringing the suture with it. The humeral graft is then inserted through the anterior portal and traction is applied to the attached suture through the transhumeral portal, seating the graft. The suture is then removed by grasping the knot on the articular surface of the humeral graft, through the anterior portal, and retrieving it from the joint. Additional pressure is applied to the humeral allograft by moving the shoulder through a range of motion to compress it against the glenoid (Fig. 4).
3.
Discussion
The procedure provides a biologic resurfacing of an arthritic glenohumeral joint, while preserving bone stock, thereby allowing for the possibility of later conversion to a standard
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Figure 4 – (A) Passage of the Nitinol wire through the transhumeral portal, exiting through the area of reamed surface in preparation for insertion of the humeral allograft. The glenoid graft was previously inserted and is visualized on the left side of the arthroscopic picture. (B) The humeral head allograft is being pulled into position via a “pull suture” that was brought through the transhumeral tunnel via the Nitinol wire. (C) Humeral allograft in position on the reamed surface with digital pressure applied to it. The knot from the “pull suture” will then be retrieved through the anterior portal. (D) Arthroscopic view of the articular surface after completion of the procedure. (Color version of figure is available online.)
total shoulder replacement if needed (Fig. 5). It also limits the damage to the surrounding structures including the subscapularis, as it is performed arthroscopically through the rotator interval. This greatly decreases the morbidity and rehabilitation required after surgery when compared to a standard total shoulder replacement [2]. The treatment of glenohumeral arthritis in the young patient remains a challenging issue. A recognized need exists for an alternative to the current treatment strategies in this patient population. A variety of arthroscopic options exist for the treatment of glenohumeral arthritis in the young patient, however no consensus exists as to which option provides the most reliable long-term outcomes. It appears that this arthroscopic technique of biologic total shoulder resurfacing using fresh osteochondral allograft can be an alternative and appropriate treatment strategy for glenohumeral arthritis in the young patient. Although long-term results of this procedure do not exist, we have obtained promising results in 1–2 year follow-up. The senior author (R.G.) has performed this procedure on 22 patients. There has been one failure of a humeral head graft, which was revised to a prosthetic humeral head resurfacing arthroplasty. Mean visual analog pain scores have improved
Figure 5 – Postoperative (A) AP and (B) axillary x-rays of the patient shown in Figure 1, showing increased glenohumeral joint space and a smooth articular surface.
from 6 to 1. The mean American Shoulder and Elbow Surgeons score has improved from 40 to 83. Range of motion in forward elevation has improved from 1281 to 1371. Our early results have been encouraging, but long-term follow-up is needed.
refere nces
[1] Kipp MA, Nguyen D, Bigliani LU. Surface replacement options in the young patient with advanced glenohumeral arthritis. Semin Arthroplasty. 2008;19:54–7. [2] Gobezie R, Lenarz CJ, Wanner JP, Streit JJ. All-arthroscopic biologic total shoulder resurfacing. Arthroscopy. 2011;27 (11):1588–93. [3] Cole BJ, Yanke A, Provencher MT. Nonarthroplasty alternatives for the treatment of glenohumeral arthritis. J Shoulder Elbow Surg. 2007;16:231S–40S. [4] Van Thiel GS, Sheehan S, Frank RM. Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthroscopy. 2010;26(11):1451–5. [5] Weinstein DM, Bucchieri JS, Pollack RG, Flatow EL, Bigliani LU. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy. 2000;16:471–6. [6] Cameron BD, Galatz LM, Ramsay ML, Williams GR, Iannotti JP. Non-prosthetic management of grade IV osteochondral lesions of the glenohumeral joint. J Shoulder Elbow Surg. 2002;11:25–32. [7] Van der Majien OA, Gaskill TR, Millett PJ. Glenohumeral joint preservation: a review of management options for young, active patients with osteoarthritis. Adv Orthop. 2012;2012: doi: 10.1155/2012/160923. [8] Richards DP, Burkhart SS. Arthroscopic debridement and capsular release for glenohumeral osteoarthritis. Arthroscopy. 2007;23(9):1019–22. [9] Millett PJ, Gaskill TR. Arthroscopic management of glenohumeral arthrosis: humeral osteoplasty, capsular release, and arthroscopic axillary nerve release as a joint-preserving approach. Arthroscopy. 2011;27(9):1296–303. [10] Millett PJ, Horan MP, Pennock AT, Rios D. Comprehensive arthroscopic management (CAM) procedure: clinical results of a joint-preserving arthroscopic treatments for young,
6
[11]
[12]
[13]
[14] [15]
[16]
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active patients with advanced shoulder osteoarthritis. Arthroscopy. 2013;29(3):440–8. Steadman JR, Rodkey WG, Rodrigo JJ. Microfracture: surgical technique and rehabilitation to treat chondral defects. Clin Orthop Relat Res. 2011;S391:362–9. Bhatia S, Hsu A, Lin E et al. Surgical treatment options for qthe young and active middle-aged patient with glenohumeral arthritis. Advances in Orthopedics. 2012:2012; doi:10. 1155/2012/846843. Millett PJ, Huffard BH, Horan MP, Hawkins RJ, Steadman JR. Outcomes of full-thickness articular cartilage injuries of the shoulder treated with microfracture. Arthroscopy. 2000;16 (5):471–6. Snow M, Funk L. Microfracture of chondral lesions of the glenohumeral joint. Int J Shoulder Surg. 2008;2:72–8. Burkhead WZ, Hutton KS. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg. 1995;4(4):263–70. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: two to fifteen year outcomes. J Bone Joint Surg Am. 2007;89(4):727–34.
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[17] Nicholson GP, Goldstein JL, Romeo AA, Cole BJ, Hayden JK, Twigg SL, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young patients with degenerative joint disease. J Shoulder Elbow Surg. 2007;16(S5):S261–6. [18] Elhassan B, Ozbaydar M, Diller D, Higgins LD, Warner JP. Soft tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am. 2009;91(2):419–24. [19] Verma NN, Strauss E, Salata M, McGill KC, Nicholson G, Cole BJ, et al. Failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. Arthroscopy. 2011;24(s5):e42. [20] Savoie FH, Brislin KJ, Argo D. Arthroscopic glenoid resurfacing as a surgical treatment for glenohumeral arthritis in the young patient: midterm results. Arthroscopy. 2009;25(8):864–71. [21] Bhatia DN, van Rooyen KS, du Toit DF, de Beer JF. Arthroscopic technique of interposition arthroplasty of the glenohumeral joint. Arthroscopy. 2006;22(5):570e1–5. [22] Pennington WT, Bartz BA. Arthroscopic glenoid resurfacing with meniscal allograft: a minimally invasive alternative for treating glenohumeral arthritis. Arthroscopy. 2005;21(12):1517–20.
E M I N A R S I N
AR
T H R O P L A S T Y
24 (2013) 2–6
Available online at www.sciencedirect.com
www.elsevier.com/locate/semvascsurg
Arthroscopic alternatives to total shoulder arthroplasty: You have got to be kidding Samuel Dubrow, MDa, Yousef Shishani, MDb, and Reuben Gobezie, MDc,n a
Cleveland Akron Shoulder and Elbow (CASE) Fellowship, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Cleveland, OH b The Cleveland Shoulder Institute, University Hospitals of Cleveland, Cleveland, OH c Division of Shoulder and Elbow Surgery, The Cleveland Shoulder Institute, Department of Orthopaedic Surgery, University Hospitals of Cleveland, Cleveland, OH
A RT I C L E IN F O
A BS T R A C T Shoulder arthroplasty is not an ideal surgical solution for young patients with arthritis of
Keywords:
the glenohumeral joint due to the concerns of long-term implant survival. Various open
glenohumeral arthritis
and arthroscopic procedures have been described for this patient population with varying
arthroscopy
results. Here we review current arthroscopic alternatives to total shoulder arthroplasty for
young patient
the treatment of glenohumeral arthritis. We also describe and present our outcomes of an
biologic resurfacing
all-arthroscopic technique, using fresh osteochondral allograft to correct bipolar glenohumeral arthritis in young patients. & 2013 Elsevier Inc. All rights reserved.
1.
Introduction
Glenohumeral arthritis in young patients is a difficult problem to treat. A number of treatment options exist, including both open and arthroscopic procedures. Open surgical procedures include traditional total shoulder arthroplasty, hemiarthroplasty, arthrodesis, humeral head resurfacing, biologic glenoid resurfacing with or without humeral head replacement, autologous chondrocyte implantation, and osteochondral allograft resurfacing. Arthroscopic procedures include glenohumeral debridement, capsular release, chondroplasty, microfracture, humeral head osteoplasty, axillary nerve decompression, biologic and non-biologic glenoid resurfacing, and osteochondral allograft resurfacing. When multiple treatment options exist to treat the same problem, it is usually the case that none is considered a “universal ideal”
procedure. As such, no agreement exists regarding the optimal treatment for advanced glenohumeral arthrosis in the young patient [1]. Concern regarding the treatment of advanced glenohumeral osteoarthritis with bipolar chondral defects in young patients exists due to the expected failure of traditional shoulder arthroplasty within the patient's lifetime, and the subsequent need for revision surgery [2,3]. Shoulder arthroplasty can also have substantial risks and may require postoperative restrictions on patients which may impair lifestyle or job requirements in younger individuals, in order to minimize the risk of prosthetic loosening [4]. The purpose of this study was to review the arthroscopic alternatives for the treatment of glenohumeral joint arthrosis in the young patient, as well as to describe our technique of arthroscopic resurfacing using fresh osteochondral allograft.
Samuel Dubrow, MD and Yousef Shishani, MD has nothing to disclose. Reuben Gobezie, MD is a consultant and receives support from Arthrex, Naples, FL and Tornier, Edina, MN. n Address reprint requests to Reuben Gobezie, MD, Department of Orthopaedic Surgery, University Hospitals of Cleveland, 5885 Landerbrook Dr, Monarch Center, Mayfield Heights, OH 44124. E-mail address: [email protected] (R. Gobezie). 1045-4527/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.sart.2013.04.003
SE
M I N A R S I N
2.
Arthroscopic treatment options
2.1.
Debridement and capsular release
A
R T H R O P L A S T Y
Arthroscopy has greatly enhanced our ability to diagnose and treat various pathologies of the shoulder joint. Previous studies have shown arthroscopic debridement to be effective in treating osteoarthritis in select patient populations [4–6]. Arthroscopic debridement and capsular release can smooth cartilage lesions, eliminate or reduce mechanical symptoms, and release capsular contractures, thereby producing satisfactory outcomes when used to treat patients with early osteoarthritis of the shoulder [7]. Richards and Burkhart [8] believe that capsular release provides a reduction in joint contact pressures and a greater range of motion, thereby acting as the primary mechanism of pain relief in young, active patients with osteoarthritis. However, it has been shown that patients who undergo arthroscopic debridement and capsular release with osteochondral lesions greater than 2 cm2 have had poor outcomes [6]. Such arthroscopic procedures may provide improved symptoms and function, delaying the need for a more extensive operation, such as arthroplasty, but it may not prevent the further deterioration of the arthritic joint [8]. Millett and Gaskill [9] describe an arthroscopic technique that combines debridement and capsular release with inferior humeral osteoplasty and axillary nerve decompression. They refer to this technique as comprehensive arthroscopic management (CAM) of glenohumeral osteoarthritis [9,10]. The indications for this procedure include young patients (age o60 years) with glenohumeral osteoarthritis, and capsular contractures and inferior humeral spurs that have failed nonoperative methods [10]. The authors believe that inferior humeral osteophytes may compress the axillary nerve causing pain, weakness, and decreased range of motion, which osteoplasty (resection) of the inferior spur may relieve.
2.2.
Microfracture
Microfracture was first described by Steadman et al. [11] as a cartilage reparative strategy for the knee, by stimulating fibrocartilage growth within a contained chondral defect. This technique has also been applied to the glenohumeral joint. However, there are significant differences in articular cartilage between the shoulder and knee, which can impact results when applied to the glenohumeral joint [12]. The procedure involves first identification of the boundaries of the cartilaginous defect, followed by debridement with an arthroscopic shaver or curette to obtain a stable periphery with vertically oriented chondral walls. A curette is then used to remove the calcified cartilage layer of the defect. An awl is then used to penetrate the subchondral bone several times, approximately 2–3 mm apart, to produce bleeding bone [12]. Osteochondral lesions of the shoulder treated with microfracture have led to improvements in pain, activities of daily living, and the ability to participate in athletic activities [13]. Snow and Funk [14] showed that upon reoperation of patients that had undergone arthroscopic microfracture, there was good filling of the chondral defect with fibrocartilage. The authors conclude in their study that microfracture of the
24 (2013) 2–6
3
shoulder may be a useful technique to prevent further deterioration of grade IV chondral lesions; however longterm follow-up is necessary [14]. Millett et al. [13] showed the greatest improvements in those patients with microfracture of small unipolar humeral lesions, and the worst results in those with bipolar lesions.
2.3.
Biologic glenoid resurfacing
Several studies, with varying results, have looked at the results of biologic glenoid resurfacing with and without humeral head replacement for the treatment of arthritis of the glenohumeral joint in young patients [15–19]. These studies have looked at the use of Achilles tendon, anterior capsule, fascia lata, meniscus, and human acellular dermal tissue matrix to resurface the glenoid through open surgical techniques. Arthroscopic techniques of glenoid resurfacing have also been reported using the Restore Patch (Depuy, Warsaw, IN), an implant of porcine origin, and Graftjacket (Wright Medical, Arlington, TN), a regenerative tissue matrix made from human skin [20,21]. Pennington and Bartz [22] have also described an arthroscopic technique of glenoid resurfacing using meniscus allograft. Savoie et al. [20] showed that arthroscopic glenoid resurfacing provided statistically significant improvements in young patients with arthritis of the glenohumeral joint with a 3- to 6-year follow-up. Although few studies exist looking at the results of arthroscopic biologic glenoid resurfacing [20,21], they tend to have a more consistent and favorable result when compared to the results of open surgeries [17–19].
2.4. Biologic total shoulder resurfacing using fresh osteochondral allograft Gobezie et al. [2] were the first to describe an all-arthroscopic bipolar biologic shoulder resurfacing technique. The procedure involves the use of fresh osteochondral allografts, which are inserted entirely through the rotator interval under arthroscopic visualization, to replace the surfaces of the glenoid and humeral head; a cartilage transplant of the shoulder. Indications include a young patient (o50 years of age) with arthritis in the absence of a large inferior humeral osteophyte, an intact rotator cuff with at least 901 of forward elevation, and a centered glenohumeral joint (Fig. 1). The grafts are prepared first. Fresh osteoarticular allografts are taken from a cadaveric humeral head and medial tibial condyle or tibial plafond. The concavity of the medial tibial condyle and distal tibial plafond are similar to that of the glenoid. The Osteochondral Autograft Transfer System (OATS) platform (Arthrex, Naples, FL) is used to prepare the grafts. A 20-mm circular coring reamer is used on the tibial allograft for preparation of the glenoid resurfacing, which is centered over a portion of the articular surface. The core is then removed from the tibial allograft and cut to the desired thickness of 5 mm by use of a 5-mm deep cutting guide. This creates a graft of 20 mm in diameter and 5 mm in depth to be used on the glenoid. The same procedure is then carried out on the humeral allograft; however a larger graft can be prepared if desired, with a maximum diameter of 40 mm (Fig. 2).
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Figure 1 – (A) AP and (B) axillary x-rays of the right shoulder of a 48-year-old male candidate for arthroscopic total shoulder resurfacing with osteochondral allograft.
Arthroscopy is subsequently carried out with the patient in beach chair position. Standard posterior and anterior portals are made and a thorough inspection of the glenohumeral joint is undertaken. The biceps tendon is then released from the superior labrum in order to provide room for the passage of instrumentation and the grafts into the joint. A subpectoral biceps tenodesis is performed prior to the conclusion of the case. The entire rotator interval is then resected using an arthroscopic shaver and cautery device through the anterior portal, which is extended to 25–30 mm in length. This part is crucial in order to have enough room for passing instrumentation and graft into the joint through the anterior portal. Arthroscopic reaming of the humeral and glenoid surfaces, in preparation for the allografts, is conducted through the use of a transhumeral portal. In order to prepare this portal, a targeting guide is inserted through the anterior portal and centered over the humeral head. The targeting guide is employed much as an ACL guide is used to drill the tibial tunnel in arthroscopic anterior cruciate ligament reconstruction (Fig. 3). However, for the transhumeral portal, the drill entry point is on the lateral humeral cortex and is directed towards the center of the humeral head, where the targeting guide is placed. Next a circular 20-mm reamer is placed through the anterior portal and attached intra-articularly to a pin that enters the joint through the transhumeral portal. Once the reamer is connected to the pin, the humeral head is then reamed in retrograde fashion to a depth of 5 mm through the transhumeral portal. The glenoid is then reamed, again through the transhumeral portal, however this time in antegrade fashion. It is possible to ream the humeral
Figure 2 – Fresh cadaveric osteochondral allografts are prepared using the Osteochondral Autograft Transfer System (OATS) platform (Arthrex, Naples, FL). (A) A prepared 20 5mm tibial allograft used to resurface the glenoid. (B) A prepared 30 5-mm humeral head allograft to be used for humeral resurfacing. (Color version of figure is available online.)
Figure 3 – Targeting guide used to prepare the transhumeral portal. The circular guide is placed on the humeral head region to be resurfaced, which enters the joint through the rotator interval. The drill sleeve is then placed on the lateral humeral cortex and a wire is drilled directed towards the circular guide. A cannulated reamer is then used over the wire to prepare the transhumeral tunnel. (Color version of figure is available online.) head to a larger size (maximum of 40 mm) if indicated for a larger graft. The prepared glenoid graft is then inserted into the joint through the anterior portal. It is then positioned over the reamed glenoid surface and impacted into place. Chondral darts of 1.2 mm are then used to fix the graft in place, which are inserted through the transhumeral portal. Prior to insertion of the humeral graft a small drill hole is made through its center to allow for the passage of a strong suture. A large knot is tied on the articular side of the graft. This will then act as a traction suture for the seating of the graft onto the humeral head. A Nitinol wire is then fed through the transhumeral portal into the glenohumeral joint and is retrieved through the anterior portal. The free end of the suture, which was threaded through the humeral graft, is then placed through the loop of the Nitinol wire, which is then pulled back out of the transhumeral portal bringing the suture with it. The humeral graft is then inserted through the anterior portal and traction is applied to the attached suture through the transhumeral portal, seating the graft. The suture is then removed by grasping the knot on the articular surface of the humeral graft, through the anterior portal, and retrieving it from the joint. Additional pressure is applied to the humeral allograft by moving the shoulder through a range of motion to compress it against the glenoid (Fig. 4).
3.
Discussion
The procedure provides a biologic resurfacing of an arthritic glenohumeral joint, while preserving bone stock, thereby allowing for the possibility of later conversion to a standard
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Figure 4 – (A) Passage of the Nitinol wire through the transhumeral portal, exiting through the area of reamed surface in preparation for insertion of the humeral allograft. The glenoid graft was previously inserted and is visualized on the left side of the arthroscopic picture. (B) The humeral head allograft is being pulled into position via a “pull suture” that was brought through the transhumeral tunnel via the Nitinol wire. (C) Humeral allograft in position on the reamed surface with digital pressure applied to it. The knot from the “pull suture” will then be retrieved through the anterior portal. (D) Arthroscopic view of the articular surface after completion of the procedure. (Color version of figure is available online.)
total shoulder replacement if needed (Fig. 5). It also limits the damage to the surrounding structures including the subscapularis, as it is performed arthroscopically through the rotator interval. This greatly decreases the morbidity and rehabilitation required after surgery when compared to a standard total shoulder replacement [2]. The treatment of glenohumeral arthritis in the young patient remains a challenging issue. A recognized need exists for an alternative to the current treatment strategies in this patient population. A variety of arthroscopic options exist for the treatment of glenohumeral arthritis in the young patient, however no consensus exists as to which option provides the most reliable long-term outcomes. It appears that this arthroscopic technique of biologic total shoulder resurfacing using fresh osteochondral allograft can be an alternative and appropriate treatment strategy for glenohumeral arthritis in the young patient. Although long-term results of this procedure do not exist, we have obtained promising results in 1–2 year follow-up. The senior author (R.G.) has performed this procedure on 22 patients. There has been one failure of a humeral head graft, which was revised to a prosthetic humeral head resurfacing arthroplasty. Mean visual analog pain scores have improved
Figure 5 – Postoperative (A) AP and (B) axillary x-rays of the patient shown in Figure 1, showing increased glenohumeral joint space and a smooth articular surface.
from 6 to 1. The mean American Shoulder and Elbow Surgeons score has improved from 40 to 83. Range of motion in forward elevation has improved from 1281 to 1371. Our early results have been encouraging, but long-term follow-up is needed.
refere nces
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